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Session #313, February 22, 2017State Medicaid Agency Interoperability

Dave Hill, Anshuman SharmaHIMSS17 Presentation Preparation Resource

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Dave Hill Principal, The MITRE Corporation

Anshuman Sharma Entrepreneur in Residence, CMS

Session Facilitators

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• No conflicts to report

Conflict of Interest

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• Quick Introduction (10 minutes)

– Learning objectives and value of health steps

– MITA introduction

– State Medicaid Interoperability

– Modularity

– Why is interoperability and modularity important?

– Modular Pre-certification

– Elements of Interoperability

– Green Fields of Opportunity

• Discussion (45 minutes)

– Discussion Topics

• Summary (5 minutes)

– Contact info

Agenda

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• Examine what modularity and interoperability means in the current Medicaid environment

• Identify specific opportunities that can be fulfilled through State Medicaid Agency interoperability and modular pre-certification

• Develop specific next steps that can be taken today and going forward to help address those opportunities

Learning Objectives

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Interoperability and ModularityValue Towards Health STEPS• Treatment / Clinical

– Access to complete information improves care and reduces errors

• Patient Engagement / Population Management

– Access to data promotes engagement and better population management

• Savings

– Reuse of technology components, fewer costly errors

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MITA Introduction• An evolving initiative by the Centers for Medicare & Medicaid Services (CMS)

– Specifically under Center for Medicaid and Child Health Insurance Program Services (CMCS)

– Integrated business and IT transformation of the Medicaid Enterprise in all states

• Purpose

– Establish national level set of technologies and processes to improve program administration of State

Medicaid Agency (SMA)

– Promote use of newer technologies (Cloud computing, Service-Oriented Architecture (SOA), etc.)

– Provide opportunity for states to benefit from enhanced federal funding

• History

– Began in 2005 to move away from siloed design and development of typical Medicaid Management

Information Systems (MMIS)

– V3.0 released in March 28, 2012 to account for new legislative requirements and initiatives

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The MITA initiative includes

• An Architecture Framework

– Consolidation of principles, business and technical models

– Templates for use in the development of enterprise architectures

• 3 Interrelated Architectures to provide guidance to State

Medicaid Agencies (SMAs)

• Business and technical capabilities to define data strategy and

support design of services

Overall goal: aid transformation of the SMA to a business

driven enterprise utilizing mature information technology

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What is Modularity?• CMS has defined modularity as

“A packaged, functional business process or set of processes

implemented through software, data, and interoperable interfaces that

are enabled through design principles in which functions of a complex

system are partitioned into discrete, scalable, reusable components.”

- 42 CFR, Part 433.111(h)

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State Medicaid Agency Interoperability

• The ability of state Medicaid enterprise components to work together,

exchange and use information (clinical and administrative), within

and across organizational boundaries, to advance effective delivery

of healthcare.

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* Walker J, Pan E, Johnston D, et al. The value of health care information exchange and interoperability.

Health Affairs 2005

Why is Interoperability Important?

CMS States Vendors

• Sharing clinical and admin data

• Reducing cost and fraud

• Prevent medical errors*

• 18% due to lack of data

• Keep members engaged

• Coordinating care teams

• Accessing data at point of care

• Learning from health, admin data

• Clinical quality improvement

• Increase adherence to MITA

• Minimize customization

• Minimize configuration

• Improve system upgrade efficiency

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Someday,

you or a loved one

will be the patient

of an under-informed doctor.

Are you good with that?

We can change that for Medicaid!

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Why is Modularity Important?

CMS States Vendors

• Promote reuse

• Increase competition

• Increase adherence to MITA

• Minimize customization

• Minimize configuration

• Improve system upgrade efficiency

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• Develop a sustainable Pre-Certification process to assist State

Medicaid Agencies in their procurement of modular MMIS

solutions by providing, for their consideration, CMS evaluated

vendor solutions that are modular, reusable and have been

demonstrated to meet Medicaid business functions.

Modular Pre-certification

Goal

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Modular Pre-certification

Spur innovation and competition through a Medicaid IT marketplace

Reduce risk for states and CMS by encouraging state use of modular,

reusable CMS pre-certified solutions

Encourage modularity & interoperability among Medicaid systems

through open APIs and common, agreed-upon standards

Reduce burden on states and vendors for certification

Objectives

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Element Features or Capabilities Required

TransportProtocols (network, services/API, middleware)

Security (encryption, authentication, authorization, privacy)

SyntacticInformation model (objects, attributes, relationships, data types)

Wire format (message format, serialization)

SemanticCode systems (SNOMED CT, RxNorm, etc.)

Value sets

ProcessRoles and responsibilities

Business rules

Workflows

Elements of Interoperability

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Between Entity 1 And Entity 2 Transport Syntactic Semantic Process

Beneficiary (Web) Eligible Provider/Hospital W3C W3C W3C

Beneficiary (Web) Certified EHR W3C W3C W3C

Beneficiary (Web) SMA Patient Portal W3C W3C W3C

Beneficiary (Mobile) Eligible Provider/Hospital

Beneficiary (Mobile) Certified EHR

Beneficiary (Mobile) SMA Patient Portal

Provider Eligible Provider/Hospital ONC ONC MITAEligible Provider SMA Provider Portal ONC ONC MITACertified EHR HIE ONC ONC MITACertified EHR Registries ONC ONCCertified EHR eCQM System CEHRTRegistries HIE ONC ONCHIE SMA Patient Portal ONC ONC MITAeCQM System CMS ONC CEHRT

Provider DirectoryBeneficiary, EH/EP, Certified EHR,

HIE, SMA Portals, Registries, CMSONC ONC ONC

Master Patient IndexBeneficiary, EH/EP, Certified EHR,

HIE, SMA Portals, Registries, CMS

Identity Server Entity Authorization Server MITA

Green Fields of Opportunity

Legend

Good coverage

Partial coverage

Little coverage

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Between Entity 1 And Entity 2 Transport Syntactic Semantic Process

Beneficiary (Web) Eligible Provider/Hospital W3C W3C W3C

Beneficiary (Web) Certified EHR W3C W3C W3C

Beneficiary (Web) SMA Patient Portal W3C W3C W3C

Beneficiary (Mobile) Eligible Provider/Hospital

Beneficiary (Mobile) Certified EHR

Beneficiary (Mobile) SMA Patient Portal

Provider Eligible Provider/Hospital ONC ONC MITAEligible Provider SMA Provider Portal ONC ONC MITACertified EHR HIE ONC ONC MITACertified EHR Registries ONC ONCCertified EHR eCQM System CEHRTRegistries HIE ONC ONCHIE SMA Patient Portal ONC ONC MITAeCQM System CMS ONC CEHRT

Provider DirectoryBeneficiary, EH/EP, Certified EHR,

HIE, SMA Portals, Registries, CMSONC ONC ONC

Master Patient IndexBeneficiary, EH/EP, Certified EHR,

HIE, SMA Portals, Registries, CMS

Identity Server Entity Authorization Server MITA

Green Fields of Opportunity

Legend

Good coverage

Partial coverage

Little coverage

Focused

Opportunity

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• What is needed to make pre-certification of modules work? (10 minutes)

• What modules would be good candidates to address first? (10 minutes)

• How can MITA help and what changes are needed? (10 minutes)

• What MITA Governance Board working groups are needed to support modular interoperability? (10 minutes)

Discussion Topics

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• Treatment / Clinical

– Interoperability provides access to complete information to allow better care and fewer errors

• Patient Engagement / Population Management

– Members can engage more with better access to data

– Greater opportunity for learning from interoperable data

• Savings

– Greater competition and reuse of technical modules

– Greater opportunity for learning from interoperable data

Interoperability and ModularityValue towards Health STEPS

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• Dave Hill

– Principal, The MITRE Corporation

– dwhill@mitre.org

• Anshuman Sharma

– Entrepreneur in Residence, CMS

– Anshuman.Sharma@cms.hhs.gov

Contact Info

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Backup Slides

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How has CMS supported modular interoperability?

• CMS launched pre-certification page on Medicaid.gov

• Issued the Modularity Standard as one of the Standards and Conditions for Medicaid IT

• RFI released to gather industry feedback

• Presented MESC session on pre-certification

• SMDLs (COTS, APD Requirements, Modularity certification, Reuse)

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MITA Level 1

MITA Level 2

MITA Level 3

MITA Level 4

MITA Level 5

• Level 3 is the critical step for an effective interoperability strategy

• Well-designed Level 3 will dramatically simplify the transition to

Levels 4 and 5 in the future

• Interstate interoperability should be designed in as early as possible

• Design for the long-term; implement for the short-term

MITA Levels and Interoperability

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• ADT Events

• Advanced Directives

• Analytics

– Healthcare Assessments; Demographic Queries; eCQMs; Risk Assessment; Syndromic Surveillance

• Care Management

• Claim Submission

• Death Reporting

• Immunization Updates

• Lab orders

• Medication Reconciliation

• Patient Query

• Prescribed Medications

• Provider Access to Health Records

* Source: MITRE interviews with State Medicaid Agencies

Potential SMA / HIE Use Cases*

Current Initiatives

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Future Initiatives• Standard Health Record

• Analytics

– Cohort Analysis; Encounter Data Access; Fraud, Waste, and Abuse Monitoring; Patient Attribution; Population Health; Risk Assessment; SMA-Specific Reports; Social Determinants; Super-Utilizer Identification; Immunization Updates

• Behavioral Health Data

• Electronic Referrals

• Case Management

• Disease and Public Health Registry Updates

• Eligibility and Enrollment Verification

• Informed Consent

• ICOs/ACOs/MCOs

• Member Application for Medicaid Benefits

* Source: MITRE interviews with State Medicaid Agencies

• Mobile Access for Health Professionals of Health Record

• Patient Access to Health Record (Web and Mobile)

• Patient Identifiers / Patient Matching

• Patient Update

• Prescription Monitoring

• Provider Directory

• Relationship Management

Potential SMA / HIE Use Cases*

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Stakeholders

CMCS

Federal Partners

State Partners

Nonprofits

State

Marketplaces

Associations

Vendor Groups

MITA

Strategy

Enterprise

Challenges

Governance

Projects

Framework

Updates

Compliance

MITA Governance

Structure

Contribute

Ideas

Leadership

Board members

Working Group members

Focus Areas

MITA Governance

Board

How can you contribute?