In the past two years, communities and states have begun building health information exchanges (HIEs) to improve the quality, efficiency and cost-effectiveness of health care, but one obvious area for improvement seems to have been overlooked: Medicaid.
If today’s trends continue, Medicaid will absorb about a third of the lifetime federal taxes paid by males born in 2025. Yet Medicaid was a stakeholder in fewer than 20 percent of the 101 HIEs that had been established by 2005, according to a study conducted for the Agency for Healthcare Research and Quality.
Fortunately, there are signs that Medicaid is getting more involved. In January, the Health and Human Services Department awarded $103 million in Medicaid Transformation Grants to 27 state agencies. HHS Secretary Mike Leavitt said the grants were designed to help states “implement innovative systems to get more value out of the money they spend providing health care to their low-income elderly, children and disabled citizens.”
Some states are using the money to target specific populations or tinker with the mammoth Medicaid Management Information System (MMIS). Among the smaller projects, North Dakota is using $75,000 to develop a Web-based interface for Medicaid pharmacy claims. That’s hardly enough to transform its system, but observers say all such efforts are steps in the right direction.
“They’re useful even if for no other reason than that it’s recognizing that there is a larger health [information technology] market out there besides MMIS and Medicaid,” said Gino DeMarco, vice president of HHS account management at CNSI, a large IT solutions provider. “They offer an opportunity for a state to think outside the box, get it funded and then implement it, such that if it’s successful, it will illustrate a different model than the way things have always been done.”
Other grant winners have more ambitious goals, which include linking Medicaid to statewide information exchanges, electronic health records (EHRs), e-prescribing and one-stop physician-credentialing services. Arizona will receive nearly $12 million in the next two years to develop an EHR/HIE utility, and Kentucky is using its grant of nearly $5 million to develop a Web-based HIE as the foundation for a statewide e-health network.
Arizona’s network catalyst Some Medicaid programs sought grants to develop an EHR system or an HIE, but the Arizona Health Care Cost Containment System, the state’s Medicaid agency, has chosen to do both — at the same time.
Two years ago, the health care industry in Arizona set a goal of creating a statewide HIE that would give all Arizonans access to EHRs within five years. The agency is the state’s largest insurer, providing coverage to more than 18 percent of the population, and it wanted to play a major role in the project as the logical champion and catalyst for a statewide HIE.
“The underlying driver with us is a transformation of the health care delivery system,” said Tony Rodgers, director of the state’s Medicaid agency. “We believe that we cannot sustain the current inefficient system and add populations, expand coverage to children and keep costs down unless we have the ability to get physicians to practice with a single view of the health information.”
The state’s Medicaid HIE Utility Project seeks to launch a Web-based system that will provide instant access to Medicaid patients’ records whenever they receive care. The network would span Arizona’s public/private health care community, including authorized Medicaid clinics, hospitals, long-term care providers, community-based care programs and managed care plans.
Standardizing access to Medicaid Under Arizona’s plan, providers would be required to exchange data in a format that meshes with the new Medicaid system. Initially, they would participate on a voluntary basis because only 15 percent of Arizona’s physicians have EHR systems, and many rura
l hospitals have only the most rudimentary information systems.
However, the new network promises to reduce the cost of participating in the HIE to less than $1,000 per client terminal for Medicaid providers.
“We decided that by providing easy and affordable access to a common EHR, we could enhance providers’ ability to provide quality health care for our members,” Rodgers said.
Ultimately, the plan calls for adding tools that support clinical decision-making and Web-based learning.
Rodgers said he would like to see more than 90 percent of providers connected by the end of 2011. Even so, the biggest challenge will be getting them to change their business practices. “This will require physicians to be interactive,” Rodgers said, because all the Medicaid drug formularies, reference guidelines for best practices and decision support will be online.
“That’s going to be a challenge for some providers who simply are not comfortable with computer technology,” he said. “But if they don’t fully interact with it, they’re not going to get the full value of it.”
The project is scheduled for a pilot test in January 2009, with statewide operation beginning that summer. The return on investment The Medicaid project will have a number of benefits, Rodgers said. Real-time access to updated patient information will mean fewer medical errors, a reduction in redundant tests and procedures, better coordination of care for chronic diseases, higher quality, and increased patient confidence in the health care system.
In addition, planners estimate that the project will lead to an annual 3 percent decrease in acute-care and long-term medical costs and an annual 2 percent decrease in overall administrative costs for the Medicaid program.
Rodgers said that although the HIE project will initially focus on serving the Medicaid population and improving health care in Arizona, it is being built with an eye toward eventually connecting with the National Health Information Network (NHIN). Therefore, the state’s program will comply with national standards and function as the point at which all state data is standardized and exchanged, with the goal of being able to share information beyond Arizona’s borders.
“If one of our members is in New York and has to go to the ER, that provider can access all the relevant health information needed to treat them successfully,” Rodgers said. “But we also want that care information to be sent back to Arizona and included in the permanent health record so physicians back here will know about the treatment the person received in New York. That’s a continuity of care we’ve never had before and definitely want.” Kentucky’s HIE foundation When Kentucky passed legislation two years ago that called for creating a statewide e-health network, Medicaid was the obvious place to start.
Kentucky’s Medicaid program has 710,000 enrollees. “We are one of the largest purchasers of health care and one of the largest employers in the state,” said Trudi Matthews, senior policy adviser for e-health at the Kentucky Cabinet for Health and Family Services. “We can’t just sit on the sidelines and wait for other people to make this happen. We want to be the leader in this.”
The state’s project — the Kentucky Health Information Partnership (K-HIP) — revolves around a single-sign-on Web portal for payer/provider communications. Initially, it will allow providers to view claims-based patient health summaries and conduct certain administrative transactions, such as verifying eligibility and benefits, submitting claims, and requesting prior authorization for treatment.
Matthews said officials chose the portal technology in part because they wanted to achieve quick results and thereby encourage stakeholders to participate.
The portal was the least expensive, least complicated and fastest route to interoperability and operation, she said.
Kentucky officials also believe that building claims-based patient health summ
ries is easier than trying to create full-blown medical records from scratch.
Mixed-payer system Unlike other grant projects, K-HIP is a mixed-payer system. Although led by the Medicaid program, it also involves Anthem Blue Cross and Blue Shield, Bluegrass Family Health, Humana, the Kentucky Employees Health Plan and Passport Health Plan. Having those health plans involved means that millions of Kentucky residents — as much as 60 percent of the state’s population — will be part of the initiative from the start.
Working cooperatively with public and private payers is likely to be one of the project’s biggest challenges, Matthews said. “E-health is naturally collaborative, and the technology requires collaboration, which means that partners have to lay down their proprietary interests and their natural competitive suspicions of others in the health care arena in order for us to collaborate effectively,” she said. “Those business relationships will be the biggest difficulties for us, and they’ll be ongoing.”
The technology challenges, by contrast, are relatively simple. Kentucky has already upgraded its MMIS to integrate claims data with information from public sources, clinical partners, the agency’s data warehouse and Medicaid eligibility systems. Those upgrades have streamlined claims processing and enhanced the system’s reporting capabilities.
“Because it is so state-of-the-art now, the data that Medicaid will be sharing and providing through the statewide e-health portal will be as up-to-date and as near to real time as any private payer can provide,” said Sandeep Kapoor, chief technology officer at the Kentucky Cabinet for Health and Family Services. “Under the old legacy system, the claims data could be rife with holes and as much as a month old.”
The new MMIS is critical to Kentucky’s ability to go forward with the e-health network. “Honestly, if we still had the old legacy system, we wouldn’t be having this conversation,” Kapoor said.
Matthews said the state anticipates that K-HIP will reduce costs, increase administrative efficiency, enhance patient care and improve health outcomes.
The system will also ease providers’ transition to electronic health care because they only need to have a computer and a high-speed Internet connection to access it. Currently, 80 percent of claims in Kentucky are submitted electronically, Matthews said, but if another 3 percent to 5 percent of providers start submitting claims via the portal, “it will save us enough money to pay for the system itself.”
Like their colleagues in Arizona, Kentucky officials are anticipating an eventual link to NHIN. In the meantime, K-HIP is scheduled for a pilot phase in early 2008 and a statewide deployment in early 2009.
“We expect this to be the essential backbone for e-health in Kentucky while allowing enough flexibility for community exchanges to tailor services for their own areas,” Matthews said.
From the battlefield to the home front: Managing medical data
Government Health IT presents Col. Claude Hines Jr., program manager for the Defense Health Information Management System, in this recent InSight eSeminar. Col. Hines discusses the health information technology and tactical challenges faced by the military medical community in Iraq, Afghanistan and other areas of conflict. In doing so, he describes the current information technology solutions for transferring clinical data between battlefield care givers to health care personnel at military treatment facilities worldwide.
