Together for Quality

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Together for Quality www.medicaid.alabama.gov
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Whats a poor stateto do?

• State Fund Budget need of 200 million state
  dollars (33 matching rate)
• General Fund growth of only 30 million
• No optional eligibility groups or optional
  benefit programs of any significance

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Transform!

• Utilize information technology to change the way
  Medicaid does business
• Can not raise reimbursement so lower the
  administrative barriers to participating in
  Medicaid
• Improve information flow to primary care
  providers (Medical Homes) to improve outcomes and
  services to Medicaid recipients

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Answer to the Question So What?

• Medicaid is very good at paying the right
  provider, the right amount (okay, maybe not
  enough but the set amount!), for the right
  recipient for the right service
• But SO WHAT?
• Together For Quality Alabamas Transformation
  Grant allows us to answer that question, reduce
  duplication of services and improve outcomes

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Medicaid Transformation

• Simplify provider access to information at the
  point of care
• Real-time, claims-based electronic health record
  to improve patient care
• Care management data to improve care choices and
  better manage patients

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Electronic Clinical Support Tool

• Formulary management
• Electronic claims based health record
• Drug risk management
• Profiling, scoring tool
• e-prescribing real time response

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Health Information System

• Create connectivity and interoperability among
  Alabamas state agencies and other providers
  beginning with the Department of Senior Services
• Establish efficient, electronic
  information-sharing that improves health and
  controls costs

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Chronic Disease Burden

• 7 out of 10 deaths
• 75 of all healthcare costs
• Chronic disabling conditions cause major activity
  limitations in 1 out of 10
• 1/3 of potential life lost before age 65

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Together For Quality

• Stakeholder Council Development

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Convening Stakeholders

• Achieve consensus
• Maintain participation
• develop a governance model
• safeguard privacy and security
• Achieve objectives
• demonstrate value
• create sustainability

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Stages

• Recognition of need for HIE among multiple
  stakeholders at various levels (how does TFQ
  relate to a statewide HIE, GC, NHIN
• Getting organized, defining shared vision, goals,
  and objectives (multiple inclusive workgroup
  meetings to address needs and frameworks)
• Transferring vision, goals and objectives to
  workplan defining needs and requirements
  (workgroup products)
• TFQ implementation

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Process

• February, 2007
• Convene Stakeholder Council to provide
  information and review status, reach consensus on
  foundational issues, form workgroups, prepare for
  visioning.
• Establish website link to workgroup materials and
  inform membership
• March, 2007
• Visioning session March 8th 9th including
  election of co-chairs and high level time line
• During March, workgroups continue formation and
  work as needed, incorporating AHIMA FORE workbook
  guidance as applicable
• Workplan, materials and meeting schedules posted
  on the website

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Success

• Identify the champions
• Create and maintain collaboration
• Create and maintain the vision
• Demonstrate value to continue collaboration and
  build trust
• Open communication among stakeholders to assure
  understanding and participation

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Potential Impact

• Improve health outcomes
• chronic disease case management
• reduce chronic disease burden
• prevent complications
• Improve health services coordination and reduce
  duplicative services
• electronic data use
• data-driven quality improvement

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Potential Impact

• Enhance public health, disease surveillance and
  disaster preparedness
• Advance healthcare research
• Control and reduce costs

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Quality Improvement

• Electronic health record
• Clinical support tool
• User support and resources
• training
• connectivity
• high risk case management support

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Health Information System

• Develop the enterprise architecture
• interoperability among multiple stakeholders
  databases
• develop the Patient Data Hub
• create stakeholder value through efficiencies

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Summary

• Claims based electronic health record
• Clinical support tool
• Health information system
• Quality Improvement
• Long term sustainability
• Roadmap AL, Gulf States, National

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Resources

• http//ehealthinitiative.org/
• EHealthInitiative, includes directory of HIE
  initiatives and toolkit of model policies,
  agreements, forms, and other HIE resources
  Connecting Communities Toolkit (http//toolkits.eh
  ealthinitiative.org/ ) is on this site
• http//www.staterhio.org/
• Development of State Level Health Information
  Exchange Initiatives workbook by Foundation of
  Research and Education (FORE) of American Health
  Information Management Association (AHIMA)
• http//healthit.ahrq.gov/
• Agency for Healthcare Research and Quality
  information from AHRQ-funded health IT projects,
  including a list of AHRQ-funded health
  information exchange (HIE) projects

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Resources

• http//hhs.gov/healthit/
• US Department of Health and Human ServicesPortal
  to federal health IT efforts
• http//www.cms.hhs.gov/MedicaidSCHIPQualPrac/01_Ov
  erview.asp
• Medicaid and SCHIP Quality Practices
• http//www.ahima.org/hie/links.asp
• Contains several links to resources
• http//www.connectingforhealth.org/
• Connecting for Health, Markle Foundation,
  includes links to resources and reports as well
  as link to Common Framework video clip

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Operating Rules for Steering Committee

• Decisions may be made by a vote of the majority
  present for a meeting.
• Each steering committee member will have one
  vote ex-officio members will not be voting
  members.
• If steering committee members cannot attend a
  meeting, they should send an informed
  representative as proxy.
• Steering committee will meet when needed to hear
  concerns/receive questions and make
  recommendations to Medicaid Commissioner.
• Legal counsel should be present at meetings to
  offer guidance as needed.

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Structure of the Steering Committee

• Representative of HHS state agencies to include
  ADPH, MH/MR, DHR, Senior Services, Rehab
  Services, Medicaid
• Physician representative
• Hospital representative
• Pharmacy representative
• Long-term care representative
• Primary care center representative
• Ex-officio members
• Governors office
• Academic representative
• Payer representative
• AQAF representative
• Alabama Information Systems Division
• Co-chairs from each work group

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Policy Workgroup Charter

• The policy workgroup has been chartered to
  recommend policies and organizational structure
  to support the development and implementation of
  a shared vision and plan for addressing health
  care quality and cost through health information
  technology (HIT) and health information exchange
  (HIE) in Alabama. For the purposes of the grant
  period, a steering committee will be established
  to review policies developed by the workgroup and
  make recommendations to the Medicaid
  Commissioner. Following the grant period, it is
  anticipated that a separate, independent
  governing body will be necessary to continue the
  work of the grant and expand it as needed.

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Policy Workgroup Mission

• Provide leadership, encourage collaboration/coordi
  nation, and ensure broad-based representation of
  interested parties and the ability for these
  parties to share ideas freely.
• Make policy recommendations to the steering
  committee.
• Assist other workgroups as necessary in
  developing policies.
• Support/facilitate adoption of HIT, to include
  clinical support tool and state agency
  interoperability
• Promote equitable and ethical approach to HIE
• Encourage policies that ensure a uniform approach
  and compliance with applicable state and federal
  laws and regulations.
• Promote use of existing resources
• Assist in developing business plan for project to
  include marketing/communications
• Recommend policies for an independent audit
  (e.g., for security, access issues)
• Promote transparency and accountability

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Policy Committee Scope and Boundaries

• All discussions/communications will be
  transparent and open to diverse opinions.
• All recommendations during the grant period will
  be purely advisory in nature. The Alabama
• Medicaid Commissioner will have the final
  authority for grant decisions.
• The policy workgroup members shall agree to
  operate within the boundaries of the policy it is
  to establish regarding conflict resolution.

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Policy Committee Constraints

• Credibility, trust, willingness to share
  information
• Possible turf issues
• Reluctance to change
• Consumer fears regarding privacy
• Need for quick decision making due to aggressive
  time frame and need to balance this with time
  necessary to ensure stakeholder education and
  constituent buy in.
• Steep learning curve

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Summary

• Claims based electronic health record
• Clinical support tool
• Health information system
• Quality Improvement
• Long term sustainability
• Roadmap AL, Gulf States, National

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Clinical Workgroup Mission

• The Clinical Workgroups mission is to improve
  the care and outcomes of patients within the
  state of Alabama by facilitating access to the
  information needed to make informed healthcare
  decisions.

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Clinical Workgroup Scope and Boundaries

• Share information to facilitate improved outcomes
  and foster effective resource utilization
• Using evidence-based quality measures, identify
  and prioritize clinical data elements
• Identify algorithms and tools (including case
  management) for quality improvement
• Develop promotional and distribution plan for
  increasing the use of the clinical support tool
• Integrate user feedback and concerns into
  continuous refinement of the clinical support
  tool
• Advise policy group on issues relating to a
  promotional / distribution plan
• Collaborate with technical group on issues
  relating to user functionality of the clinical
  support tool
• Manage the functional specification of the
  clinical support tool

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Clinical Workgroup Scope and Boundaries

• The Clinical Workgroup Will involve
• All care settings
• All relevant users of clinical information,
  including patients and caregivers
• The Clinical Workgroup will NOT focus on
• Clinical outcomes for which the health
  information exchange CANNOT be a contributor to
  success
• Incorporating financial information into the data
  exchange
• The infrastructure upon which the HIE will be
  built
• The resolution to privacy and security issues in
  compliance with HIPAA the assigned workgroup
  will provide direction
• Vendor solution recommendations

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Finance Workgroup Mission

• The Finance Workgroup has been chartered to
  evaluate existing HIE financial models, make
  recommendations for a financial model that will
  achieve long term HIE sustainability for the
  State of Alabama, and provide input for TFQ
  grant-related budget activities.

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Finance Workgroup Scope and Boundaries

• Assist in the preparation of the RFI that
  includes technological costs and benefits
  thereof.
• Identify costs present in current system of
  health information exchange in Alabama
• Review existing financial models of operational
  HIEs
• Review cost information for cross-section of
  local and national HIEs.
• Identify potential savings associated with HIE
  (ROI)
• Identify barriers that may exist to identifying
  the cost and measurable financial savings through
  HIE
• Collaborate with the other Workgroups to provide
  relevant financial information to clarify the
  costs and benefits of HIE
• Provide additional financial advisory resources
  to the TFQ project management

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The Finance Workgroup will NOT focus on

• Identification of the clinical outcomes
  associated with data exchange
• Incorporating financial information into data
  exchange
• Technical infrastructure upon which data exchange
  could be built
• Resolution to privacy and security issues in
  compliance with HIPAA the assigned workgroup
  will provide direction
• Vendor solution recommendations
• Constraints
• Privacy/HIPAA Issues/Inter agency sharing (Policy
  Privacy WGs)
• Trust This will be improved if we can increase
  transparency
• State vendor list needs to be completed
• Agency streamlining (or lack of it) relative to
  development of the PDH may hinder process

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Privacy Workgroup Mission

• The Privacy Workgroup has been chartered to
  understand the impact of legal and regulatory
  mandates as it relates to the implementation of
  Together for Quality (TFQ), Alabama Medicaid
  Agency (ALMA) transformation grant. This groups
  mission is to provide interpretation of the laws
  and regulations such as HIPAA privacy and
  security rules and to provide general guidelines
  and recommendations that should be followed in
  implementing the technology solution.

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Privacy Workgroup Scope and Boundaries

• Provide clear and accurate interpretation of the
  HIPAA privacy regulations.
• Document the risks associated with implementing
  the technology for a statewide, dynamic,
  interoperable enterprise database (PDH) and
  health information system (HIS). Especially
  ensure appropriate recognition is given to
  consumer perspectives on privacy, as well as
  impact on provider relationships.
• Provide general privacy policy review and
  interpretation including state and national
  regulations.
• Review, provide feedback, and make
  recommendations on data sharing agreements
  including inclusion of business associate
  agreement language when appropriate. In the
  future will be asked to focus on disclosure
  guidelines, data sharing between entities (state
  agencies, providers, and public health purposes,
  etc.

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Privacy Workgroup Scope and Boundaries

• Assist in the development of a universal consent
  form/language that will allow for sharing of
  patient data across healthcare entities.
• While the work group will make recommendations on
  implementation, it will not be responsible for
  actual implementation.
• In the second year determine any common policies
  that need to be developed for violations of
  patient privacy.
• Review, provide feedback and make recommendations
  regarding the process for granting access (e.g.
  who should have access and for what data and for
  what period of time, address access for job
  changes, termination of access) to patient data.
• Review, provide feedback and when appropriate
  make recommendations to the technical and
  clinical work groups on issues such as
• emergency access procedure, authorization
  authentication models, integrity control
  guidelines, access to HIS information, etc.

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Privacy Workgroup Scope and Boundaries

• Address provider or facility management that
  allow for exceptions to consent form policy
• Identify protected patient populations and
  methods for data management within the exchange.
  Delineate how restrictions to PHI,
• amendments to PHI, and accounting of disclosures
  will be handled. (Participation Functionality
  issues)
• This group shares work with the Technology Work
  Group to address security issues where overlap
  may occur.
• Responsible for bringing and representing
  stakeholder privacy related concerns to
  appropriate parties (e.g. ALMA Project Sponsor
• Team, Advisory Council, other work groups)

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The Privacy Workgroup will NOT focus on

• The identification of the clinical outcomes and
  interventions of the clinical data exchange
• The identification of costs or benefits related
  to the implementation of the regional data
  exchange
• The infrastructure upon which the data exchange
  will be built
• Individual institutions privacy and security
  policies
• Enforcing recommendations
• Vendor solution recommendations
• Specific legal advice opinion or documentation
• Constraints
• Too large dont do it all at once
• Doesnt include BCBS and others
• Perceptions of public and provider
• Trust
• Focus on patient care

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Technical Workgroup Mission

• The Technical Workgroup has been chartered to
  represent and address the IT related issues to
  implement a statewide HIS. A robust technical
  model is required for effective health
  information exchange. It is imperative to
  leverage currently available HIT capabilities and
  build upon technical successes from other
  implementations to address HIE and business
  needs. This Workgroup will develop the consensus
  to ensure appropriate technical standards are
  applied for TFQ.

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Technical Workgroup Scope and Boundaries

• Identify technical barriers related to exchanging
  data between hospitals, physicians, ancillaries,
  and other stakeholder entities.
• Make technical recommendations for the roles and
  responsibilities for those participating in HIE
  leveraging existing national standards,
  approaches, and models.
• Assessment of existing and planned HIE projects
  underway in Alabama including an assessment of
  underlying HIT capabilities.
• This project will include review and assessment
  of the inventory of existing state of Alabama
  technical infrastructure resources and
  determination of what infrastructure resources
  can be leveraged.

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Technical Workgroup Scope and Boundaries

• Identify technical barriers related to exchanging
  data between hospitals, physicians, ancillaries,
  and other stakeholder entities.
• Make technical recommendations for the roles and
  responsibilities for those participating in HIE
  leveraging existing national standards,
  approaches, and models.
• Assessment of existing and planned HIE projects
  underway in Alabama including an assessment of
  underlying HIT capabilities.
• This project will include review and assessment
  of the inventory of existing state of Alabama
  technical infrastructure resources and
  determination of what infrastructure resources
  can be leveraged.

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The Technical Workgroup will NOT focus on

• Vendor solution recommendations.
• The detailed design of edge solutions.
• The resolution to privacy and security issues in
  compliance with HIPAA the assigned workgroup
  will provide direction.
• Constraints
• Medical Liability Government
• Turf needs to change to trust
• Reluctance of providers to change
• Reward system for those willing/keep paying those
  who do not change
• Willingness to share info/trust
• Credibility issues
• Trust issues
• Consumer fears/Privacy