STATE OF INDIANA Family and Social Services Administration, Office of Medicaid Policy and Planning

Transcription

1 STATE OF INDIANA Family and Social Services Administration, Office of Medicaid Policy and Planning State Medicaid Health Information Technology Plan (SMHP) Annual Update June 2013 Status: FINAL

2 Revision History Version Number Date Revision Notes Author(s) /08/2010 Indiana HIT SMHP first draft submitted to OMPP for review Fox Systems /03/2011 Indiana HIT SMHP submitted to CMS Jared Linder /25/2011 Indiana HIT SMHP resubmitted to CMS based on feedback Jared Linder /15/2011 Indiana HIT SMHP resubmitted to CMS with required changes in accordance with CMS April 4, 2011 Letter and Enclosures A, B, and C sent to Pat Casanova, Indiana Medicaid Director. Pat Casanova received CMS approval of the IN HIT SMHP V1.10 by Rick Freidman via dated April 26, Jared Linder, Pat Casanova /30/2012 Indiana HIT SMHP developed as an annual update to be submitted to CMS; applied the State Medicaid HIT Plan (SMHP) Template to the Indiana 2012 Annual Update of the SMHP; and Applied the FSSA HIT Coordinator and HIT Project Manager changes to reflect document as the final version. Amie Redmon, Jared Linder, Pat Casanova SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 2 of 124

3 2.0 March 2013 and June 2013 Numerous minor updates across the entire document. Areas which changed most significantly include: - Update on Medicaid-related HIT activities (see section 1.2) - Update on as-is HIT landscape including adoption of e-prescribing and electronic transmission of continuity of care information (see sections 1.3; 2.1; 2.4) - Update on status of statewide HIE initiatives/activities (see section 2.6; 2.7; 2.9; 6.3) - Update on status of related initiatives such as the projects funded by Beacon grant awards and developments in statewide broadband-class communications deployment (see sections 2.5.3; 2.5.4) - Reaffirmation of Indiana s to-be vision and roadmap for HIT and HIE in support of its medical assistance programs (Indiana Health Care Programs) (see sections 3.2; 6) - Update on other Medicaid IT and IT-related initiatives such as MMIS, enterprise data warehouse and PBM with enhanced IT capabilities (see sections 2.1.3; 4.4; 6.4) - Update on EHR incentive program s administrative structure, system capabilities (the latter focused on MAPIR) and ongoing provider communication and outreach efforts (see sections 1.1; 4.6; ; ; 4.14) - Update on the EHR incentive program s Audit Strategy (also refer to the Audit Plan submitted to CMS) - Per feedback from CMS received in May 2013: added to sections 4.8, 4.12 and 4.13 and provided a completed 2013 State Medicaid Changes Checklist as an addendum - Indiana HIT SMHP Final update submitted to CMS Health Management Associates, Carenza Love SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 3 of 124

4 SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 4 of 124

5 Table of Contents 1. INTRODUCTION AND OVERVIEW EHR Incentive Program Overview Summary of HIT Activities Conducted During Year Summary of Indiana s HIT Future SECTION A: INDIANA S AS IS HIT LANDSCAPE Current HIT Environment - Overview HIT Activities Supporting Medicaid OMPP Quality Monitoring and Improvement Electronic Information Exchange Electronic Clinical Laboratory Ordering and Results Delivery E-Prescribing Exchange of Continuity of Care Information Electronic Public Health Reporting Immunization Registry HIT - HIE Capacity Broadband Internet Access and Telehealth Regional Extension Centers Grants to Expand HIT Adoption, HIE and Telemedicine in Rural and Underserved Regions Beacon Community Grant Statewide HIE Networks Current HIE Architecture/Structure Governance for State Health Information Exchange Current Statewide HIE Initiatives Veterans Administration and Indian Health Services Providers SMHP Updates Medicaid Information Technology Architecture (MITA) MMIS HIT/HIE Environment Summary of Medicaid Environmental As Is E-scan SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 5 of 124

6 Survey Strategy Survey Limitations As Is Professional Providers (Individual and Group Providers) E-scan As Is Hospital E-scan Future E-Scans SECTION B: INDIANA S TO BE HIT LANDSCAPE Participating Entities IHIT Governance Participation Board of Directors Advisory Councils Executive Leadership State HIT Coordinator Vision for HIT Environment SECTION C: ACTIVITIES NECESSARY TO ADMINISTER AND OVERSEE THE EHR INCENTIVE PAYMENT PROGRAM Program Administration Organization Concept of Operation Audit Work Group Audit Work Group Staffing Matrix Technology Work Group FSSA Technology Work Group Staffing Matrix Clinical Quality Work Group Communications Management Plan Scope Level 1 Basic OMPP-related Internal Communications Level 2 Advanced Internal OMPP-related Communications and External Communications Communications Standards, Processes, and Procedures Communication Principles Communication Considerations Document Control and the HIT Central Document Repository Communications Roles and Responsibilities SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 6 of 124

7 4.6.6 Communications Tools Project-Specific Communications Information Recent Changes in State Laws and Regulations Policy Changes HIE/HIT Activities across State Borders Privacy Regulatory Changes Provider Contract Changes Provider Eligibility Determination Eligible Providers Provider Registration Process Processing Payments to Providers Provider Payment Request Provider Payment Calculations Eligible Hospital (EH) Payment Calculation Eligible Professional (EP) Payment Calculation Provider NPI Role of Contractors in Indiana EHR Incentive Program Implementation Reporting Requirements Coordination with Medicare to Prevent Duplicate Payments Incentive Payment Recoupment Fraud and Abuse Prevention Data Sources Used for Verification A/I/U Verification Validating Meaningful Use Provider Appeals Coordination with IHIT Federal Financial Participation (FFP) Clinical Quality Data Clinical Data to Monitor Population-Based Outcomes Clinical Data to Monitor Performance SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 7 of 124

8 4.23 Meaningful Use and Patient Volume Criteria Patient Volume by Program Patient Volume Calculation Dependence upon Federal Initiatives SECTION D: THE STATE S AUDIT STRATEGY Category 1 Incentive Payment Audits Category 2 Administrative Expense Audits Audit Settings Audit Methodologies, Standards, Processes and Procedures Audit Periods Phase Phase 2 and Beyond Audit Planning Audit Preparation Desk Audit Procedures Proposed Desk Audit Procedures and Outcomes/Anomalies Matrix Field Audits Additional Information Audit Tools SECTION E: THE STATE S HIT ROADMAP Moving from As Is to To Be HIT Landscape - OMPP Initiatives Moving from As Is to To Be HIT Landscape IHIT Initiatives Core Interoperability Projects Other Initiatives State Participation in Health Information Exchange MMIS-Related Activities MMIS Replacement Implementation Participation in Statewide, Regional, and/or Local HIE Initiatives HIT Objectives for Meaningful Use of Clinical Data SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 8 of 124

9 List of Key Terms and Acronyms The following acronyms are used throughout this document: Acronym ADT A/I/U ANSA AR Definition Abstract Data Type Adopt/Implement/Upgrade Adults Needs and Strengths Assessment Accounts Receivable ARRA American Recovery and Reinvestment Act of 2009 CAH CCD CCHIE Critical Access Hospital Continuity of Care Document (format) Clark and Champaign Counties Health Information Exchange CHIP or SCHIP Children s Health Insurance Program or State Children s Health Insurance Program CHIPRA Children s Health Insurance Program Reauthorization Act of 2007 CHIRP CHPL CMO CMS CPOE CT DDI ED EH ehi EHR EMR EMS EP ephi EPSDT E-scan ESSENCE Children and Hoosiers Immunization Registry Program Certified Health IT Product List Care Management Organization Centers for Medicare and Medicaid Services Computerized Physician Order Entry Computed Tomography Design, Develop and Implement Emergency Department Eligible Hospital ehealth Initiative Electronic Health Record Electronic Medical Record Enterprise Medicaid System (Indiana s Replacement MMIS) Eligible Professional Electronic Protected Health Information Early Periodic Screening, Diagnosis, and Treatment Environmental Scan Electronic Surveillance System for the Early Notification of Community-based Epidemics SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 9 of 124

10 Acronym FA FAD FFP FFS FPL FQHC FSSA HEDIS HHS HIE HIO HIP HIT HL7 HP HPSA HRSA IAPD IAPD-U I-CANS IHCP IHIE IHIT IMMIS INPC INPIPS IRS ISDH IT IVR LEIE Definition Fiscal Agent Fraud and Abuse Detection Federal Financial Participation Fee-for-Service Federal Poverty Level Federally Qualified Health Center Family and Social Services Administration Healthcare Effectiveness Data and Information Set U. S. Department of Health and Human Services Health Information Exchange Health Information Organization Healthy Indiana Plan Health Information Technology Health Level Seven International Hewlett Packard Health Professional Shortage Areas as designed by HRSA Health Resources and Services Administration (an entity within HHS) Implementation Advance Planning Document Implementation Advance Planning Document-Update Integrated Curriculum for Achieving Necessary Skills Indiana Health Care Programs Indiana Health Information Exchange Indiana Health Information Technology, Inc. Indiana Medicaid Management Information System Indiana Patient Care Repository Indiana Provider Incentive Payment System Internal Revenue Service Indiana State Department of Health Information Technology Interactive Voice Response List of Excluded Individuals Entities SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 10 of 124

11 Acronym MAPIR MCE MCO MED MFCU MHIN MHS MIE MITA MOU MRI MU NAAC NCQA NEIMS NHIN NLR NPI NPPES OIG OMPP ONC PAPD PECOS PHA PI R&A REC RFP RHC Definition Medical Assistance Provider Incentive Repository Managed Care Entity Managed Care Organization Medicare Exclusion Database Medicaid Fraud Control Unit Michiana Health Information Network Managed Health Services Medical Informatics Engineering Medicaid Information Technology Architecture Memorandum of Understanding Magnetic Resonance Imaging Meaningful Use Net Average Allowable Cost National Committee for Quality Assurance National Environmental Information Management System National Health Information Network National Level Repository (see replacement term: Medicare & Medicaid EHR Incentive Program Registration and Attestation System (R&A)) National Provider Identifier National Plan and Provider Enumeration System Office of Inspector General Office of Medicaid Policy and Planning U.S. Department of Health and Human Services (HHS), Office of National Coordinator for Health Information Technology Planning Advance Planning Document Provider Enrollment, Chain, and Ownership Purdue Healthcare Advisors, Indiana Health Information Technology Regional Extension Center formerly known as I-HITEC Program Integrity Medicare & Medicaid EHR Incentive Program Registration & Attestation System Regional Extension Center Request for Proposal Rural Health Center SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 11 of 124

12 Acronym SHIECAP SMHP SUR TIN TPO WEDI Definition State Health Information Exchange Cooperative Agreement Program State Medicaid Health Information Technology Plan Surveillance Utilization Review Taxpayer Identification Number Treatment, Payment and (Health Plan) Operations Workgroup for Electronic Data Interchange The rest of this page is intentionally left blank. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 12 of 124

13 1. Introduction and Overview The Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) is the State entity responsible for administering the Indiana Medicaid program, with approximately 1.1 million enrollees 1. FSSA is committed to improving the quality of care of Medicaid beneficiaries in the State and the health status of this population, and strongly believes that health information technology (HIT) can have a significant impact on health care quality, outcomes and health status. Thus, FSSA is committed to work with health care providers to better serve their patients through data sharing of electronic health information and meaningful use of HIT. The implementation of the Medicaid Electronic Health Record Incentive Payment Program initiative (hereafter referred to as the EHR Incentive Program or Program ) is a major cornerstone towards improving provider access to, and use of, electronic health information that should lead to improved health outcomes and status for Medicaid members. Since May 2, 2011, the State of Indiana has been operating its EHR Incentive Program per 42 CFR Parts 412, 413, 422, 495, et al. Funding for the Program is provided primarily by the Centers for Medicare & Medicaid Services (CMS); the State of Indiana provides matching funds for program administration activities. In order to participate in the EHR Incentive Program, a State Medicaid Health Information Technology Plan (SMHP) must be submitted and approved by CMS. Moreover, a Medicaid Health Information Technology (HIT) Implementation Advance Planning Document (I-APD) must be submitted by the State and approved by CMS before federal funding can be accessed for program administration and incentive payments to eligible professionals (EPs), eligible hospitals (EHs) and Critical Access Hospitals (CAHs). The State s first SMHP and Medicaid HIT I-APD were approved by CMS on April 26, In coordination with the abovementioned SMHP development process, Indiana developed the requirements needed to build the operations and IT infrastructure for operating the Program. While the IT infrastructure is substantially in place, the operations infrastructure continues to evolve particularly in response to the requirements in the Meaningful Use (MU) Stage 2 rule published in August of Additionally, in 2010 the Governor of Indiana established Indiana Health Information Technology, Inc. (IHIT) as the state entity to build on the established work of the five successful private sector health information organizations (HIOs) and named a Statewide HIT Coordinator to lead this effort. The five HIOs include: HealthBridge, HealthLINC, Indiana Health Information Exchange (IHIE) partnered with the Regenstrief Institute, Medical Informatics Engineering, and Michiana Health Information Network (MHIN). Since health information exchange (HIE) is a critical enabler of EHR meaningful use, the State incorporated many elements of the HIE Strategic and Operational Plan (SHIECAP) into its SMHP. The original SHIECAP was approved by the Office of the National Coordinator of Health Information Technology (ONC) on January 21, This SMHP update reflects the ongoing effort to ensure that the SMHP and SHIECAP remain aligned. 1 Based on information in statehealthfacts.org (a publication of the Kaiser Family Foundation) SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 13 of 124

14 During the latter part of 2011, Indiana determined a number of critical projects that had to be implemented for the EHR Incentive Program initiatives for Year 2. To this end, an IAPD-U was submitted on December 29, 2011 and approved by CMS on January 18, 2012 with funding expiring September 30, 2013, which supports the following key activities: Development and implementation of verification processes of EPs and EHs regarding their efforts to adopt, implement, or upgrade certified EHR technology and the Meaningful Use of said technology as a condition of receiving incentive payments, Implementation and ongoing support of the Medical Assistance Provider Incentive Repository (MAPIR) System, a multi-state collaborative effort that funded an EHR Incentive Program administration system that interfaces with Indiana s Medicaid Management Information System (MMIS), Development and implementation of program integrity procedures and related system changes, Development and implementation of the EHR Incentive Program Audit Plan, and Provider outreach, training and education on EHR Incentive Program rules and the meaningful use of CEHRT. 1.1 EHR Incentive Program Overview Implementation of electronic health records will improve access to health information for Hoosier Medicaid members and providers. EHRs facilitate easier coordination of care for the many providers who may be treating a Medicaid patient and provide patients with more readily accessible information needed to make important decisions about their health care. Indiana Medicaid will have access to clinical and administrative information for children, pregnant women, disabled, and adult populations and will use this information to improve coordination of care and health outcomes for those Hoosiers served. In preparing this update to the initial SMHP, Indiana closely followed the Final Rule, 42 CFR Parts 412, 413, 422, and 495 published July 28, 2010, the Correcting Amendment for the Final Rule, 42 CFR Parts 412, 413, 422, and 495 published December 29, 2010, and the American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L.111 5). The State of Indiana has adopted the national goals for EHR incentive programs; these include: 1) Enhance care coordination and patient safety; 2) Reduce paperwork and improve efficiencies; 3) Facilitate electronic information sharing across providers, payers, and state lines; and 4) Enable data sharing using state HIE and the Nationwide Health Information Network (NwHIN). Achieving these goals will improve health outcomes, facilitate access, simplify care, and reduce costs of healthcare nationwide. In accordance with provisions within the American Recovery and Reinvestment Act (ARRA), OMPP implemented a program to provide incentive payments to eligible EPs, EHs, and CAHs. Additionally, OMPP has worked SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 14 of 124

15 closely with federal and state partners to ensure the EHR Incentive Program aligns with the SHIECAP, thereby advancing state-level and national goals for HIE. The incentive payments directed to EPs, EHs, or CAHs are not reimbursement for services rendered by these providers. They are issued to incentivize provider adoption, implementation or upgrade (A/I/U) of certified EHR technology (CEHRT). Subsequently, these payments will be driven by the goal of promoting meaningful use of CEHRT as defined by CMS. OMPP elected to leverage business processes throughout the agency, and where feasible, integrate the Indiana EHR Incentive Program into the standard MITA business processes and OMPP s day-to-day operations. During the Implementation Phase, OMPP developed state-specific business processes where a MITA business or organizational process was not identified. Examples of these processes include Indiana EHR Incentive Program eligibility, Indiana Health Care Programs (IHCP) member volume, attestation receipt and validation, and provider registration and query to the Medicare & Medicaid EHR Incentive Program Registration & Attestation System (R&A), formerly referred to as the National Level Repository (NLR). During 2013 and into 2014, OMPP will transition the driver for incentive payments in accordance with the MU Stage 2 rule. As part of the MAPIR multi-state collaborative, all regulation changes for MU Stage 2 have been completed by HP and the implementation of the upgrade to MAPIR has commenced. Indiana is scheduled for its next MAPIR upgrade/update no later than June 30, Any future regulation changes that affect provider attestations will be handled in the same manner. 1.2 Summary of HIT Activities Conducted During Year 2 Major Program achievements in Year 2 include but are not limited to: - Transition from A/I/U to MU payments as follows: o May 2012: the State began making MU payments to EHs. o July 2012: the State began making MU payments to EPs. - Launch of the audit program per the Audit Plan submitted to CMS: o In 2012 the State completed 53 EP A/I/U audits. o During the same year the State completed 14 EH audits. - From an information systems perspective, the State continued to participate in the MAPIR collaborative. MAPIR now supports the Program s administrative requirements for meaningful use-based incentive payments: o Version 3.0 of MAPIR went live in May o Version 4.0 of MAPIR, which enable EH MU payments, went live in July Following (Table 1) are incentive payment statistics for EPs and EHs as of the end of SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 15 of 124

16 Table 1. Key EHR Incentive Program Statistics Type Amounts/Totals EP A/I/U Counts 1,341 EP A/I/U Paid Amount $28,319,175 EP MU Counts 203 EP MU Paid Amount $1,708,502 EH A/I/U Counts 86 EH A/I/U Paid Amount $51,465,637 EH MU Counts 26 EH MU Paid Amount $12,960,849 In the first three (3) Federal Fiscal Years (FFYs) of the EHR Incentive Payment Program, FSSA estimated that approximately 3,225 EPs and 76 EHs in the state of Indiana would receive $148 million in EHR Incentive Payments (covered at 100% FFP under ARRA). 1.3 Summary of Indiana s HIT Future OMPP recognizes that the Medicaid Program will play a significant role in transforming health care in Indiana and has developed its vision for HIT to address many of the challenges of integration with the HIO networks. Replacement of the MMIS is a priority project for OMPP. The new MMIS, currently planned to be fully in production by 2016, will provide improved functionality including Service Oriented Architecture (SOA), Enterprise Service Bus (ESB), a rules engine, and automated workflow functions that will support HIT/HIE efforts. The focus aimed at obtaining new technology and then leveraging this technology is an integral part of the statewide HIT solution. Implementation of electronic health records will improve access to health information for Hoosier Medicaid members and providers. EHRs facilitate easier and quicker coordination of care for the many providers who may be treating a Medicaid patient and provide patients with more readily accessible information needed to make important decisions about their health care. Indiana Medicaid will have access to clinical and administrative information for children, pregnant women, disabled, and adult populations and will use this information to improve coordination of care and health outcomes for those Hoosiers served. In the future, Indiana will need to maintain the sustainability of the HIO structure that has been in place over the past 15 years. Integration of the HIOs will be driven by the private sector needs and desire of Indiana health care providers for data sharing relationships to facilitate exchange of ephi for treatment, payment, and health plan operations and to monitor health care outcomes. OMPP participants in the state HIE will work with the Statewide HIT Coordinator and HIOs to define data standards and the integration timeline for the new MMIS into the statewide HIE framework. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 16 of 124

17 The State continues to deploy the infrastructure required to ensure health data exchange across health care entities as this continues to occur at a more expanded level; for instance: o o o o The Medicaid program is providing medical and pharmacy encounter data to a repository. Data use agreements between Medicaid and the substate HIO (Michiana) is in progress. A pilot data exchange project in the northern part of state is in progress; the interaction between claims and clinical data is still being worked out. Deployment of Direct and consolidated clinical care summaries is also in progress. OMPP will continue to transition to MU-based incentive payments in 2013 and into 2014, when the MU Stage 2 rule goes fully into effect. Activities surrounding MU Stage 2 and gathering Clinical Quality Measures (CQMs) are defined in later sections of this SMHP. To support the implementation of the EHR Incentive Program, OMPP has instituted or is in the process of instituting three work groups: 1) Audit Work Group established and operational. 2) Technology Work Group established and operational. 3) Quality Work Group under development at the time of this SMHP update. These work groups are designed to advise the core OMPP team managing the EHR Incentive Program. The scope of their advisory function includes but is not limited to: o o o o o Developing and reviewing existing policies (e.g. Audit, Program Integrity, Clinical Quality Review and Quality Improvement Measures, etc.); Building EHR Incentive Program-specific policies, procedures, and checklists; Ensuring that desk audits and field audits are conducted in a manner that has a defined criteria for selection; Results presentation and reportable opportunities for improvement; and Management of regulatory or financial infractions. As the EHR Incentive Program is further refined and improved upon within FSSA, and further defined by CMS with tools refined by the ONC, the State will update any changes necessary in regulations, policy, program, and/or processes. In addition to this updated SMHP, the necessary IAPD(s) will also be developed, updated, and submitted to CMS. Advancing Indiana s MITA maturity within each of the current MITA Business Areas will also continue. Following are just some of the initiatives designed to further the State s MITA capability maturity: o o o The new MMIS; A new Enterprise Data Warehouse (EDW); A new Pharmacy Benefits Management (PBM) solution; SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 17 of 124

18 o o A series of HIE initiatives including support of eprescribing, exchange of prior authorization data and clinical data exchange; and Design and deployment of an Integrated Eligibility Determination solution for the State s health care programs. The rest of this page is intentionally left blank. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 18 of 124

19 2. Section A: Indiana s As Is HIT Landscape Indiana completed an initial environmental scan (E-Scan) in 2010 as part of its initial SMHP plan to establish a baseline for assessing levels of provider EHR adoption and HIE connectivity. The E-Scan revealed widespread adoption of industry leading EHR products among providers primarily in urban areas, and interest from rural provider practices and clinics in how the EHR MU Incentive Payment Program might help them to acquire EHR capacity. At the time of the scan, Indiana was home to five (5) well-established Regional Health Information Organizations (HIOs). The Governor also established the Indiana Health Information Technology, Inc. (IHIT) in 2010 as the state s designated HIE entity to lead statewide HIE planning and coordination as part of the State HIE Cooperative Agreement Program (SHIECAP). Because of the state s robust HIO-HIE environment, already in percent (83 of 125) of acute care hospitals, representing 89 percent (16,027 of 18,018) of the state s acute care beds, and 70 percent (49 of 70) of independent laboratories servicing Indiana healthcare providers were connected to a HIO. Many providers, particularly in urban areas, were already able to send high-value data in categories such as encounters, admission, discharge and transfer (ADT) records, laboratory results, radiology results, and transcribed reports and dispensed medication. However, more variable were levels of individual provider EMR adoption and HIE connectivity, especially in rural areas. Considerable HIT and HIE development has occurred across the Indiana health care landscape as the EHR MU Incentive Payment Program implementation has progressed, and efforts of the HIOs and IHIT have expanded. Indiana has been ranked #1 for volume of query-based HIE transactions, and #3 for Direct enabled transactions. OMPP plans to conduct another comprehensive E-Scan in 2013 to establish a new baseline of information about provider adoption. Meanwhile, data is being compiled based on the outreach efforts of the REC, EHR Incentive Program implementation, and monitoring of performance measures linked to the SHIECAP strategic plan to understand where and how to continue to focus outreach efforts to support Medicaid providers in their HIT and HIE efforts. 2.1 Current HIT Environment - Overview Indiana s HIT environment is active with multi-faceted efforts to support provider HIT capacity and foster the sharing of clinical and administrative data to improve health care and support system improvements. The State has taken an active role through its state health agencies and Medicaid program to promote HIT adoption and HIE development, building upon its private health care marketplace. Indiana continues to be home to five well-established Health Information Organizations (HIOs), each functioning in different capacities for community partners. In addition to the HIO efforts with their providers, the State s two Regional Extension Centers are working with Medicaid providers to foster HIT adoption and engage them in the EHR incentive program; a Beacon Community initiative is working on targeted projects to expand the use of HIT and HIE for quality improvement. Moreover, IHIT has realized its role as a state level designated entity. IHIT s range of activities includes workgroups, educational forums, targeted activities related to the EHR Incentive Program, and convening activities to foster targeted strategic and tactical plans for expanding HIT and HIE capacity. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 19 of 124

20 With leadership from the State s HIT coordinator, IHIT is supporting coordination and collaboration among the HIOs and OMPP to foster data sharing among Medicaid providers to promote heath care quality and efficiency. OMPP is contracting with IHIE to aggregate Medicaid claims with medical and pharmacy data in its repository to create a CCD record that can be shared between Medicaid providers. OMPP is also in the planning phase of a similar initiative with the Michiana HIE. E-prescribing is increasing, as evidenced by dramatic increases in the numbers of pharmacies connected to the Allscripts network and E-prescribing rates among providers that have risen exponentially year after year since In line with the State s SHIECAP targets, at the end of the first quarter of 2013, the HIOs will have implemented standardized CCDs via Connect gateways to increase hospital s ability to access clinical care summaries. A consumer engagement strategy is being implemented to expand use of PHR portal and access to immunization records. For Medicaid providers in particular, as of early 2013 statistics from Indiana s EHR Incentive Program show that 1,882 EP s have started the process, 1,793 EP s have successfully submitted their registration, and 116 hospitals have started and successful submitted registrations. Payment has been issued to 1,406 of the registered 1,793 EP s state, and 88 of 116 hospitals have received payment. Table 2 (below) provides a view of the HIT environment in the State as of 2010; OMPP in partnership with IHIT will conduct an updated environmental scan in Moreover, section contains additional information specific to e-prescribing. Table 2. HIT Environmental Information (2010). Functionality Level of Adoption among Providers* Adoption Scale: 1=Low, 5=High Laboratory ordering 1 Laboratory results delivery 4 Clinical messaging and results delivery for care coordination (HL7) 5 Clinical summary exchange for care coordination (CCD/CCR) 1 Clinical repository services 2 Electronic prescribing and refill requests (SureScripts or HIO) 4 Queries for medication fill history 2 Electronic Public health reporting 3 Quality reporting 2 Eligibility and claims transactions HIT Activities Supporting Medicaid Within Indiana s executive branch, two agencies administer Medicaid and other health care programs. The Indiana Family and Social Services Administration (FSSA) and its Office of Medicaid Policy and Planning (OMPP) are responsible for the Medicaid program as the designated state agency under the federal Medicaid statute. The Indiana State SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 20 of 124

21 Department of Health (ISDH) is the public health agency for the state and oversees the local health departments. ISDH is responsible for most of Indiana s health programs. The Executive Board of ISDH, the agency s ultimate authority, and the State Health Commissioner are appointed by the governor. The State Health commissioner is the secretary of the Executive Board and the chief executive of ISDH. By law, the commissioner must be licensed to practice medicine in Indiana. The Secretary of FSSA and the Commissioner of ISDH are required by statute to coordinate related programs, including the Medicaid program. The Secretary of FSSA is accountable for formulating overall policy for family, health, and social services in Indiana, including the resolution of administrative, jurisdictional, or policy conflicts between a division of FSSA and ISDH. By statute, FSSA must advise the Commissioner of ISDH of proposed rules affecting common areas of interest, including Medicaid, and obtain comments from ISDH on the proposed rule. Indiana has multiple health services programs with overlapping constituencies in both FSSA and ISDH. Other divisions in FSSA with Medicaid responsibilities include the Division of Aging (DA), Division of Disability and Rehabilitative Services (DDRS), which administers Medicaid waivers for home-based, long term care for the elderly, disabled and other special populations, and the Division of Family Resources (DFR) which has eligibility determination responsibilities in programs for children, pregnant women and low income families, and the Division of Mental Health and Addiction (DMHA). The Children s Health Policy Board, comprised of the Secretary of FSSA, the State Health Commissioner, the Insurance Commissioner, the State Personnel Director, the Budget Director, the State Superintendent of Public Instruction, and the Director of the Division of Mental Health, directs policy coordination for Indiana s children's health programs, including Children s Health Insurance Program (CHIP). Under the auspices of OMPP, the Hoosier Healthwise Program provides health care services to Indiana s children, low income families and pregnant women. Individuals who enroll in Hoosier Healthwise are eligible for either Medicaid benefits or benefits through the Children s Health Insurance Program (CHIP). The State contracts with MCOs to provide services to Hoosier Healthwise enrollees through a medical home and a committed provider network throughout the State. Indiana Care Select is an enhanced Primary Care Case Management (PCCM) Program provided through OMPP, which contracts with two Care Management Organizations (CMOs). Medicaid HIT related activities are overseen by both FSSA - through OMPP - and ISDH. The State HIT Coordinator plays a coordination role between the agencies and with the range of external entities who participate in aspects of the Medicaid program that rely upon sharing electronic health data. Figure 1 (next page) depicts the relationship amongst the many entities involved in Medicaid HIT in Indiana. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 21 of 124

22 Figure 1. Medicaid HIT Program Relationships IN STATE GOVERNMENT EHR INCENTIVE PROGRAM WORK GROUPS State HISP IN PRIVATE-PUBLIC COLLABORATIVE PROJECT COLLABORATIONS - Beacon - MyVaxIndiana - Organ Procurement Entity Integration - BlueButton - Others Family and Social Services Administration Office of Medicaid Policy and Planning Traditional Medicaid Care Select M.E.D. Works Hoosier Healthwise Indiana Health Plan STATE HIT COORDINATOR BOARD OF DIRECTORS ADVISORY COUNCILS RECs RHIOs DIRECT PROGRAM 2.3 OMPP Quality Monitoring and Improvement The overarching mission of the Indiana Office of Medicaid Planning and Policy (OMPP) is to improve the health and quality of Hoosier lives through positive outcomes from a value driven health care system. The Indiana OMPP works to achieve this mission through a strategy that involves data driven decision making, implementation of evidence based practices, fiscal responsibility, and active engagement with providers, members, health plans, and state and local governments. OMPP supports a multi-faceted program of value-based contracting to serve Indiana s Medicaid and CHIP populations, including a strategy for ongoing quality improvement relying upon HIT supported quality reporting and analysis. As part of Hoosier Healthwise risk-based contracting that began in 2007, OMPP implemented a quality strategy that mandated Hoosier HealthWise MCOs to submit clinical quality measures. These happen to now be consistent with the core measures now mandated for EHR Incentive Payments. OMPP began collecting quarterly reports from the MCOs on a SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 22 of 124

23 variety of quality indicators for preventive health, for children and adolescents, and for pregnant women, and newborns. This increased access to data allowed the OMPP to begin to track and monitor performance on key quality indicators and steer the focus toward improvement activities. Effective January 1, 2008, the Healthy Indiana Plan (HIP) benefits became available through private insurers. The State contracts with two insurance carriers for the HIP program to ensure comprehensive and committed health networks across the State are offering a choice of plans to Medicaid enrollees. HIP insurance carriers are required to submit claims/encounter-based, outcomes measures to assess the provision of various screening and prevention measures, as well as immunizations. OMPP also administers the Indiana Care Select Program, an enhanced Primary Care Case Management (PCCM) Program, which contracts with two Care Management Organizations (CMOs), to assist with care coordination, provider relations and member services. Care Select care management services for special populations with disabilities and chronic illnesses. Care Select contracts include incentives and reporting requirements for addressing conditions amenable to care management, reflecting the unique needs of the disabled and wards/fosters population. OMPP has been able to incrementally raise performance benchmarks, such as a recent example that moved the required rate of members 18 or older diagnosed with a new episode of major depression, treated with an anti-depressant and who remained on antidepressant for x days to the NCQA Medicaid HEDIS 75th percentile. Over time, OMPP has gathered and evaluated clinical quality measures based on paid claims/encounters stored in the MMIS to monitor Medicaid utilization and quality variables. Within the State government, electronic data sharing was instituted between the OMPP and the Division of Mental Health and Addiction (DMHA) as well as the Indiana State Department of Health (ISDH), including county level data, to monitor and improve the quality of care for pregnant women, children, and those with serious mental illness. Standardized assessments (CANS and ANSA) of persons receiving care at the State s Community Mental Health Centers are received by DMHA and linked to Medicaid claims data in order to better understand total utilization of mental health services. Health information exchange activity in the state and several HIT initiatives, both internal and external to the OMPP, are now in place to strengthen and expand OMPP efforts to gather and evaluate quality measures. As part of the Quality Health First program, (QHF), OMPP shares claims/encounter data with the Regenstrief Institute, a research agency. Through Regenstrief one of the State s HIOs - the Indiana Health Information Exchange (IHIE) - aggregates these data with that from health plans, hospitals, labs, and other providers of healthcare throughout Indiana or in the nine county area including and surrounding Indianapolis, using claims/encounters and clinical data to calculate quality measures. OMPP staff support IHIE by helping inform the selection and implementation of quality measures. The State is also an active partner in other regional health information exchange programs, including partnering with the Michiana HIE to conduct pilots using Medicaid claims data. On an ongoing basis, OMPP is participating with IHIE and other HIOs to explore options to expand its strategy for quality data reporting and analysis from providers and managed care entities participating in HIE networks, targeting OMPP priorities for Medicaid quality improvement. Having accomplished operational implementation of the EHR Incentive Program, OMPP is in the process of re-aligning its internal and external quality oversight and improvement processes to integrate reporting of Clinical Quality Measures SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 23 of 124

24 (CQMs) and other measures of health care provider performance, update quality improvement strategies with its partner HIOs, and identify the most productive way in which OMPP staff can utilize these measures and capabilities. This includes bi-monthly OMPP quality strategy committee meetings. 2.4 Electronic Information Exchange OMPP administers the Medicaid Program in Indiana and is the largest payer in the State. The State s Fiscal Agent (HP) processes a monthly average of over 4 million claims/encounters, of which 97 percent (including pharmacy claims) are submitted as electronic transactions or entered directly via the Internet Electronic Clinical Laboratory Ordering and Results Delivery Across Indiana, laboratories and providers are primarily using Directed Exchange to support electronic clinical laboratory results delivery. Currently, over 1200 organizations and 4600 individual providers are enabled for directed exchange including 9 laboratories, with almost 53,000 directed transactions for results delivery from laboratories during the third quarter of 2012 alone. Seventy-five percent of hospital laboratories are enabled for ELR. Historically, providers have used the electronic order entry hosted by laboratory providers outside of HIO web portals or EMR interfaces. However, the state s major HIOs are evolving with their architectures to begin to serve as hubs for lab ordering and results delivery; integration has been completed to enable results sharing between sub-state HIOs, and increased capacity to support ELR with public health. IHIT is offering incentive payments for rural hospitals and clinics (FQHC/RHC/CHC) to connect to HIE infrastructure, either through sub-state HIOs or via direct messaging, to send and receive lab results. With approximately one third of independent laboratories connected to HIE, IHIT is also working to assist independent labs with incentive payments for establishing connectivity with the state s HIE infrastructure, including public health ELR E-Prescribing Indiana is well above nationwide goals for e-prescribing: close to 98 percent of active Indiana pharmacies participate in e-prescribing, exceeding the 2012 National Goal of 94 percent. As of December 31, 2012, there were over 10,000 e- prescribing providers and 1.86 million monthly transactions at 1,180 pharmacies in the state. Year to year, the number of providers e-prescribing continues to grow exponentially - based on data obtained from SureScripts and its nationwide e-prescribing network, the number of participating Indiana providers grew from approximately 1,800 to over 10,000 between 2008 and the end of There was a 19 percent increase in e-prescribers between 2011 and 2012 alone. At this time, over half of Indiana physicians are now actively e-prescribing Exchange of Continuity of Care Information Efforts are currently underway to drive interoperability between the sub-state health information organizations (HIOs) and expand the ability to deliver results and messages to any provider connected to one of the sub-state HIOs. All five of the HIOs accomplished this by launching shared provider directories and Direct-compliant transport by implementing Health Information Service Provider (HISP) protocols. As part of statewide interoperability initiatives, the sub-state HIOs SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 24 of 124

25 are leveraging Direct messaging as well as NwHIN s Connect software standards to actively exchange consolidated care summaries using a continuity of care document (CCD) format. Using Connect gateways, they are able to query other data sources to identify if additional information exists on a patient. Patient information is merged into a single document by the HIO initiating the query then delivered to the point of care via Direct messaging. Indiana is significantly ahead of other states in terms of meeting ONC program goals for direct and query-based transactions: currently a little over half of Indiana s hospitals are electronically sharing care summaries with unaffiliated hospitals and providers, and this percentage is expected to increase to up to 70 percent by the end of Electronic Public Health Reporting Indiana s Public Health Emergency Surveillance System (PHESS) was established almost a decade ago by the Indiana State Department of Health (ISDH) in partnership with the Regenstrief Institute. Today it electronically links 116 of Indiana s 119 hospital emergency departments to the ISDH to create a statewide, standards-based public health surveillance system. A component of PHESS, the Electronic Surveillance System for the Early Notification of Communitybased Epidemics (ESSENCE), is used by healthcare providers for reporting specific cases of communicable diagnosis to health departments. PHESS is supported as a public health surveillance system by Indiana law; action taken in 2011 required reporting of Public Health Reportable conditions. The reliability of the PHESS has been tested by public health staff who, since the time of its inception, have learned how to use the system to process and interpret the data for statistical as well as practical public health significance. Access to PHESS is from EHRs through the Internet to Regenstrief Institute. When ISDH epidemiologists identify alert data that merit further investigation, data is relayed to an ISDH field epidemiologist for follow-up with the hospital and local health departments. As additional hospitals and local health departments have obtained access to PHESS and ESSENCE, field epidemiologists are now able to send secure data links to them via , vastly improving the investigation process. As additional users view data through ESSENCE, surveillance analysis and response time will continue to be enhanced. Discussions regarding the potential evolution of the State s ambulatory surveillance systems are in progress Immunization Registry The Children and Hoosier Immunization Registry Program (CHIRP) was established in 2002 under Indiana Codes IC as a database to collect immunization records for individuals of all ages in Indiana. By centralizing immunization records, individuals in the state now have access to their records through private providers, local health departments and schools. Originally, records maintained in the registry could be released to both schools and Indiana Medicaid, but efforts are underway to make a determination of what if any changes will be necessary to allow the Immunization Registry database to be used to meet Meaningful Use reporting requirements as part of the Medicaid EHR Incentive Program. As of early 2013, CHIRP is currently able to accept unidirectional data using HL7 standards enabling Indiana providers to interface with ISDH for unidirectional reporting to the immunization registry. IHIE and OMPP are partnering with SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 25 of 124

26 vendors to implement bi-directional HL7 messaging between medical providers and CHIRP. This query based exchange will enable Indiana providers to receive and view a thorough immunization history for their patients prior to administration of immunizations, and submit the required immunization records to the registry using existing (or new) EMR systems. The registry will also provide a suggested immunization schedule. OMPP is working with ISDH to implement My VaxIndiana, an initiative allowing parents using a PIN to access their child s immunization record. Part of this initiative involves linking My VaxIndiana to HIO-sponsored PHRs via Direct Messaging. 2.5 HIT - HIE Capacity A number of initiatives have contributed to building overall HIT-HIE infrastructure and supports for Medicaid providers who deliver health care services to enrollees and participate in Indiana s EHR Incentive Program Broadband Internet Access and Telehealth Indiana received $16 million from the Federal Communications Commission's (FCC's) Rural Health Care Pilot Program, and as a result created the Indiana Telehealth Network. The Telehealth Network aims to improve the health and wellbeing of Indiana residents, particularly those in rural areas, through the utilization of a dedicated broadband health network to deliver Telehealth applications including but not limited to telemedicine, health information exchange, distance education and training, public health surveillance, emergency preparedness, and trauma system development. The Indiana Telehealth Network (ITN) formed an FCC Rural Health Care Steering Committee, which is made up of representatives from healthcare providers, telecommunication companies, representatives from the Indiana Office of Community & Rural Affairs, and representatives from the Indiana Rural Health Association, the lead entity for the ITN. Currently, OMPP has no representatives or role regarding the FSS Rural Health Care Steering Committee. There are 35 Critical Access Hospitals, six not-for-profit rural hospitals (under 100 beds) and 15 Urban Partner Hospitals that were included in the Telehealth Network RFP. Of these hospitals, 28 are participating in the Indiana Telehealth Network and are in the process of Phase I of the grant. The Telehealth Network intends to build fiber optic cable directly in the hospitals and lighting the building with Gigabit Ethernet switches. Some healthcare participants may elect to connect to the public internet via their local Post Office Protocol (POP) server The connection speeds will be 10, 50, and 100 Mbps handed off via 10/100 Ethernet connections. Final bandwidth determinations have not been made by all hospitals. The Telehealth Network had made progress toward its target to construct approximately 125 miles of fiber with approximately 93% of that being buried cable. Grant funding under the pilot program is used to support 85% of the costs of constructing the dedicated broadband network, the remaining 15% matched through participating critical access and rural hospitals. Construction for the initial projects began in the 2nd quarter of The rollout is continuing over a five year period. Table 3 (next page) presents a summary of the rollout for this project in three phases. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 26 of 124

27 Table 3. Broadband Network Five Year Rollout Phase 1 Phase II Phase III Reduced bandwidth costs Reduced Primary Rate Interface (PRI) 23 costs Double the speed of existing broadband connections 85% funding for construction of fiber to their hospitals Ability to transmit images Improved economic opportunities Administrative assistance Ability to conduct Telehealth encounters over a dedicated health care network Disaster Recovery E-Learning Internet Access Videoconferencing Seamless interfaces with the Indiana Health Information Organizations (HIOs) Regional Extension Centers Indiana has two regional extension centers that contract with ONC: - HealthBridge, which operates the Tri-State HIT Regional Extension Center (REC) serving 19 counties in Indiana, 37 counties in Kentucky, and 11 Ohio counties. - Purdue Healthcare Advisors (PHA, formerly known as I-HITEC), operated by Purdue University. More than 90% of the cost of this REC is federally subsidized. Through grant funding and a $250 per provider fee, PHA is guiding eligible primary care physicians and nurse practitioners through to EHR meaningful use compliance process. The scope of PHA also includes supporting providers with direct, individualized, and on-site education, outreach, and technical assistance Grants to Expand HIT Adoption, HIE and Telemedicine in Rural and Underserved Regions Despite the barriers to HIE adoption that exist in rural and underserved areas of the State, particularly in southern Indiana, access to EMRs, HIE connectivity and telemedicine has increased over several years due to a series of targeted 2 Primary Rate Interface (PRI) is a standardized telecommunications service level within the Integrated Services Digital Network (ISDN) specification for carrying multiple DS0 voice and data transmissions between a network and a user. Wikipedia, December Primary Rate Interface (PRI) is a standardized telecommunications service level within the Integrated Services Digital Network (ISDN) specification for carrying multiple DS0 voice and data transmissions between a network and a user. Wikipedia, December SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 27 of 124

28 grant-funded efforts. In some rural counties, 54 to 76 percent of physicians are now using EMRs or HIO web portals to access HIE services. 4 In 2005 Riley Connections obtained a HRSA Rural Health Network grant which paid for a large percentage of the onetime associated costs to expand connectivity to its telemedicine network serving specialty healthcare to children. This expanded connectivity facilitated virtual consultation services in adolescent psychiatry, pediatric urology, pediatric endocrinology, pediatric dermatology, oncology, cystic fibrosis related diabetes, and diabetes disease management. File transfer services became available for pediatric EEGs and pulmonary sleep studies. Another HRSA grant in 2005 to the Health and Hospital Corporation of Marion County enabled virtual access to radiology images and reports by providers in twelve Health Professional Shortage Ages served by Wishard Health Services (WHS). Enhanced access was provided to a Picture Archive Communications System (PACS) for providers, staff and patients including computerized tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, ultrasound and diagnostic x-ray. Through a $1.3 million CMS Medicaid Transformation Grant in 2008, OMPP contracted with IHIE to extend HIE infrastructure and capabilities to the southwest region of Indiana. Several hospital-based health systems, public health departments and clinics agreed to participate in this initiative Beacon Community Grant In May 2010, Indiana received $16 million in grant funding for the Beacon Communities Cooperative Agreement Program administered by U.S. Department of Health and Human Services (HHS) and Office of the National Coordinator for Health Information Technology (ONC). Indiana s Beacon Communities grant was awarded to a consortium led by the IHIE - a wide range of hospitals, physician groups and patients across Central Indiana encompassing the cities of Anderson, Bloomington, Carmel, Columbus, Fishers, Indianapolis, Kokomo, Noblesville, Plainfield and Richmond. The consortium committed to enhance information connectivity, reduce unnecessary tests and hospital visits, and improve preventive care for such chronic conditions as diabetes and coronary artery disease through the meaningful and secure use of electronically communicated and privacy protected patient information. Specific goals for the Beacon program included: Reduce the number of preventable hospital admissions and emergency department visits that are related to ambulatory care by 3%, Reduce the number of ambulatory care re admissions by 10%, Reduce the number of redundant radiologic studies by 10%, Increase the proportion of patients screened for colorectal and cervical cancer by 5%, Increase the data available for adult immunizations by 5%, Improve by 10% the proportion of patients whose diabetes is under control, as evidenced by HbA1C levels below 9%; and 4 Indiana Health Information Technology Board (IHIT). Survey of HIE Adoption and HIO Interviews, May 2010 SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 28 of 124

29 Improve by 10% the proportion of diabetic patients whose cholesterol is controlled, as evidenced by achieving risk adjusted LDL targets. Over the three years of the Beacon program, efforts have been closely aligned with the projects supported through the SHIECAP program. Activities have included: 1. Expanding clinical data sources to enhance the electronic record and data exchanged with the HIE. 2. Broaden and deepen its Quality Health First Program ( by adding new disease and wellness measures and functionality, while broadening provider participation in order to more fully address the challenges of efficiency, quality and public health. 3. Focusing on rural physicians, working with Indiana s Regional Extension Centers to achieve electronic health record adoption and meaningful use in at least 60 percent of primary care providers in the Indiana Beacon Community area. 2.6 Statewide HIE Networks There are five established exchange networks operated by Health Information Organizations (HIOs) that currently serve Indiana and, in some cases, border-states. These HIE networks developed initially with a majority of hospital participation, although they continue to expand their provider outreach efforts especially in the context of the Program. Each network has distinct characteristics in terms of their geographic region, participants, and business model. Networks currently in existence in Indiana are listed in Table 4, below. Table 4. Major Indiana Regional Health Information Organizations/Networks Regional Network Providers Covered Status HealthBridge Greater Cincinnati tri-state area physicians. Operational HealthLINC Physicians in Lawrence, Monroe, Orange and Owen counties. Operational Indiana Health Information Exchange Michiana Health Information Network The Med-Web 13 institutions representing hospitals, healthcare providers, researchers, public health organizations and economic development groups. Over 1,000 physicians in northern Indiana and southwestern Michigan. Clinical messaging of lab and radiology reporting in north eastern Indiana counties. Operational Operational Operational SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 29 of 124

30 HealthBridge has offered operational health information exchange since Its mission is to build a collaborative network of organizations and technology to improve the quality and efficiency of health care delivery. With 33 full-time employees, HealthBridge serves a primary service area in the Greater Cincinnati tri-state area that includes four Indiana counties. HealthBridge has more than 10,000 physicians in its provider directory and 2.5 million patient records in a population area of 2.2 million people. HealthBridge serves approximately 5,500 physicians in the tri-state area, of which physicians (with an estimated 80,000 patients) practice in Southeast Indiana and the surrounding counties. HealthBridge also serves as a consultant and collaborative partner to many other HIEs around the country. Through its partnership with HealthLINC, HealthBridge also serves a multi-county area centered in Bloomington and operates the Tri-State HIT Regional Extension Center (REC) serving 19 counties in Indiana, 37 counties in Kentucky, and 11 Ohio counties. HealthBridge is one of the nation s leaders in HIE sustainability, with less than 3 percent of its operating revenues over 10 years coming from grants or charitable sources. For the last several years, HealthBridge has recorded revenue exceeding expenses while growing its operations and service area significantly and making key investments and upgrades in its technology infrastructure. HealthLINC is a community-based organization that has offered operational health information exchange since 2007 to healthcare stakeholders in Lawrence, Monroe, Orange and Owen counties. Headquartered in Bloomington, HealthLINC is proud to have more than 200 South Central physicians actively using the system; 175,000 patient records in a population area of 367,000 people; and 130,000 exchange results per month. HealthLINC has developed expertise in running a self-governed HIE that benefits from outsourced technology infrastructure and selected business operations in a pre-franchise model. This model gained national attention when it received an award (with its partners HealthBridge and Clark and Champaign Counties Health Information Exchange in Ohio) from the e-health Initiative in This approach is beginning to demonstrate that semi-rural communities can operate and sustain an HIE based upon regionally generated revenue. Indiana Health Information Exchange (IHIE) is a tax-exempt, nonprofit corporation founded in 2004 by a unique collaboration of 13 institutions representing Indiana hospitals, healthcare providers, researchers, public health organizations, and economic development groups. IHIE is a leading provider of scalable health information exchange services with demonstrated and sustainable technologies and processes. IHIE s vision is to use information technology and shared clinical information to: (i) improve the quality, safety, and efficiency of health care; (ii) create unparalleled research capabilities for health researchers; and (iii) exhibit a successful model of health information exchange for the rest of the country. In recognition of this success, the ONC awarded IHIE a $16 million Beacon Community Cooperative Agreement Program grant to build and strengthen central Indiana s HIT infrastructure and exchange capabilities. Through this cooperative agreement program IHIE has worked diligently to build upon a vision where hospitals, clinicians, and patients are meaningful users of HIT, and together the community achieves measurable improvements in health care quality, safety, efficiency, and population health. Michiana Health Information Network (MHIN) was formally established in 1999 with the mission to provide single source, secure access and delivery of medical information leading to the care and quality of a person. MHIN serves over 1,000 physicians and 400,000 patients across northern Indiana and southwestern Michigan. In addition, MHIN has significant technical resources in the areas of database administration, in particular Oracle and MS-SQL networking and SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 30 of 124

31 technology planning. MHIN s management team has experience in building operations for large-scale capabilities to deliver service to the ambulatory environment, consolidated to support over 20,000 ambulatory sites. MHIN also offers national scale in product and market planning and business modeling. With nearly 10 years of historical results, the MHIN community data repository is deeply threaded into all aspects of care in the medical community and will continue to grow as MHIN continues to work with other HIOs in both Indiana and Michigan to facilitate the exchange of medical information across medical service areas. The Med-Web, created in 1995 by Medical Informatics Engineering (MIE), delivers approximately 1.5 million secure clinical messages each month, including more than 225,000 monthly diagnostic reports and nearly 15,000 radiology studies. The Med-Web includes a directory of participating stakeholders, and intelligently delivers information in the format required by each provider. The success of this network led to development of a full portfolio of electronic health record products including EMR, Document Management and Radiology Information System/Picture Archiving and Communication System solutions and is used by physician practices, clinics, and Fortune 500 Companies. 2.7 Current HIE Architecture/Structure The current As Is HIE architecture is depicted below and identifies the five HIOs participating in statewide HIE and data sharing within the State of Indiana. Figure 2 (next page) also represents the complex relationships between the data users and HIE service entities. The foundation (blue ellipses) of the HIE model is the data service users. There are three types of users represented: physicians/clinics, hospitals and payers. The mezzanine is supported by five exchange network s infrastructure. HealthBridge and HealthLINC are illustrated as one support because HealthBridge provides the infrastructure and connectivity for HealthLINC. CMS and IHIT are represented outside of the structure illustrating their regulatory and standard-setting functions. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 31 of 124

32 Figure 2. Indiana HIE Network Structure 2.8 Governance for State Health Information Exchange To carry out its leadership and coordinating role for the state, as designated by the Governor, IHIT has developed a governance model and instituted a formal governance structure that leverages private sector HIE development while ensuring strong state direction and multi-stakeholder collaboration. Indiana s statewide HIE governance leverages the HIE governance structures and processes that are well-established by its five major private sector HIOs, an infrastructure that is already overseeing stakeholder involvement and the provision of many of the required HIE services. IHIT plays a strong governance role to foster the implementation of the state s HIE strategic priorities, agreed to by stakeholders and elaborated in the state s Strategic and Operations Plans as part of the SHIECAP. IHIT is focusing and directing the efforts of the HIE stakeholders - Indiana HIOs, state agencies, HIT vendors, providers and consumers - in four strategic areas: Connecting Data Sources, Interoperability, Improving Outcomes, and Federal/State Initiatives. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 32 of 124

33 The state s integrated HIE governance structure is important for OMPP to support the Medicaid and CHIP programs, and to enable all Indiana healthcare stakeholders to enjoy the benefits of secure intrastate and interstate health information exchange. The relationships depicted below between Medicaid, Statewide HIT Coordinator, Medicaid HIT Coordinator, and the Advisory Councils, serve to structure productive collaboration between agencies and sectors, engage stakeholders in meaningful ways, and leverage the most streamlined and coordinated efforts to build a robust statewide HIT and HIE infrastructure. The membership of the IHIT Board of Directors and its four (4) Councils provide strong state government oversight through the senior leadership of key state agencies, including FSSA, along with representation from all HIE stakeholder groups in Indiana. The Board of Directors consists of twelve (12) directors, four (4) of whom serve by virtue of their office (designated directors), and eight (8) of whom are appointed by the Governor (appointed directors) and represent various stakeholder groups and geographic areas. Of the eight governor appointees, one half is from within government and the other half is external to government. Figure 3 (below) depicts the roles and relationships of the HIE governance body described above. Figure 3. HIE Governance Structure Roles and Relationships SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 33 of 124

34 2.9 Current Statewide HIE Initiatives Several longstanding programs and organizational efforts are leveraging HIE to support priorities for greater administrative efficiency and value-based performance among providers and health plans. The Quality Health First (QHF) program is a collaborative initiative between IHIE and the Employers Forum of Indiana, a statewide collaborative of large public and private employers, physicians, hospitals, public officials, insurers, health plans and other stakeholders that seeks to develop solutions to challenges inherent in the local healthcare marketplace. IHIE combines information collected from providers through the HIE with a multi-carrier claims information to support a payfor-performance program. Using community-wide claims/encounters and clinical data at the level of the individual practitioner, providers receive reports, alerts and reminders to help monitor patients' health and wellness, and to improve the care of their patients, including the management of common, chronic diseases. Approximately 1,200 providers participate in the Quality Health First program. In addition to IHIE s QHF program, health plan eligibility inquiry services are provided for 114 physician practices through HealthBridge, HealthLINC, and MHIN. RealMed, a top ranked Indiana claims and clearinghouse company acquired by Availity, LLC, provides advanced, online, automated transactions processing between healthcare providers and all payers. RealMed and other national clearinghouse organizations provide eligibility checking and claims processing to virtually all Indiana providers, allowing HIOs to develop higher value added administrative HIE services Veterans Administration and Indian Health Services Providers There are two federal health care delivery systems in Indiana. The Richard L. Roudebush VA Medical Center in Indianapolis, Indiana, is a part of the Veterans in Partnership integrated healthcare network delivery system providing primary care, specialty care, extended care, and related services to veterans. The Camp Atterbury Medical Treatment Facility (MTF), a user of VISTA EHR technology, is located near Edinburg, Indiana. Under a pilot project between IHIE and the US Department of Veteran Affairs, the NwHIN gateway was used to share information electronically to support health care services provided both at Roudebush and by private health care providers in Central Indiana who signed up on a voluntary basis for the HIE service. Subsequently, the five Indiana HIOs also established connections via the Nationwide Health Information Network using the Connect Gateway. Indiana has no enrolled Indian Health Services (IHS) providers at this time. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 34 of 124

35 2.11 SMHP Updates The SMHP was developed by leveraging content from a variety of sources. A MITA SS-A update was conducted to document any change to existing standard MITA business processes and provide insight into future business process as well as document technical resources. These and new state-specific business processes are the basis for the on-going Indiana EHR Incentive Program operations. Indiana solicited feedback from providers regarding the likelihood of their participation as well as barriers to participation on two separate occasions: one while constructing the State HIT Plan (SMHP), and again during the Indiana Medicaid EHR Incentive Program planning. In addition, Medicaid has been involved with HIT planning with the statewide designated entity and participates in ongoing discussions between Indiana s five HIOs, the Beacon awardees and the RECs. Indiana sought guidance from the Indiana State Department of Health, as well as provider associations including the Indiana State Medical Association, and incorporated into the plan suggestions for hospital payments from the Indiana Hospital Association. Indiana will continue to periodically meet with these and other outside entities and solicit feedback regarding the challenges providers face and will work to help incorporate further enhancements that will both help providers meet meaningful use and increase access to information. To further outline a plan for stakeholder involvement, OMPP actively participates in HIT functions and solicits information from stakeholders to continually improve the Indiana EHR Incentive Program and increase the adoption of meaningful use. OMPP is and will be represented at IHIT Inc. board meetings and will participate on councils where appropriate with the HIOs, ISDH, and other entities. OMPP plans to continue to solicit feedback from the provider community using additional periodic vehicles like E-scans. Future conversations will focus on additional barriers to adoption, preparation and challenges with meeting appropriate stages of meaningful use, as well as focusing on how to assist providers who have or are having technical or may have future planning challenges or concerns. OMPP participates in ongoing provider workshops which are currently conducted quarterly by Indiana s Fiscal Agent, HP. This will provide an open forum to solicit feedback and answer provider and stakeholder questions and issues. The team developing this SMHP participated in regular CMS and ONC sponsored teleconference opportunities, the Multi-State Collaborative monthly teleconference to understand the EHR Provider Incentive Payment Program and the requirements of the SMHP. The State is also very active in the MAPIR Collaborative, the CMS Region 5 Medicaid HITECH workgroup, and the Communities of Practice sponsored by CMS and facilitated by the Medicaid EHR Team (MeT) Medicaid Information Technology Architecture (MITA) During preparation of the initial SMHP, the OMPP business areas participated in intensive review sessions to identify the Indiana EHR Incentive Program s impact on IHCP, reviewed the regulatory requirements for submission of the SMHP published in the Final Rule at and the CMS guidance for revisions to the SMHP published on April 29, The business areas then reviewed each business process that has been and will continue to be implemented to develop a SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 35 of 124

36 concept of operations for the Indiana EHR Incentive Program. Where feasible the approach adopted was to integrate the Indiana EHR Incentive Program business process into OMPP s corresponding standard MITA business process. The State plans to conduct a MITA self-assessment once the MITA 3.0 business process model and related self-assistance guidance are finalized (at the time of this SMHP update, MITA 3.0 is not finalized; there are several business process areas for which capability expectations have not been defined). 5 The current MMIS project demonstrates the State of Indiana s commitment to move its Medicaid enterprise systems up the MITA capability maturity ladder and line up the State s Medicaid enterprise systems more closely with the Seven Standards and Conditions for IT development (modularity, industry standards, reuse/leverage, business results, etc.) promoted by CMS. Moreover, the State s commitment to leveraging IT capabilities across programs and even states is illustrated by the adoption of MAPIR. Table 5 (next page) contains information on MITA guiding principles and objectives and how they impact the current design of IHCP and the Medicaid EHR incentive program. The rest of this page is intentionally left blank. 5 Per the rule update issued in April 2011, states are expected to update their MITA assessments within twelve months of the finalization of MITA 3.0. In their assessments states must include a roadmap for how they will push their business processes and information systems, in particular their MMIS but not only their MMIS, up the capability maturity ladder incorporated into MITA. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 36 of 124

37 Table 5. Current MITA 2.0 Guiding Principles and Objectives MITA Goal OMPP Guiding Principle Objective/Actions Integration and Interoperability Promote efficient and effective data sharing to meet stakeholder needs. Document Management Integration of the imaging system with the MMIS for improved access to information and operational efficiency. Enhance and introduce up-to-date management information and communication systems through the MMIS Re-procurement project. Letter Generation Implement a flexible and configurable system component to improve operational efficiency and enhance member and provider communication. Care Select Program Enhancement of the Care Select Case Management system and further integration with the MMIS will allow a broader spectrum of OMPP staff to utilize the system more effectively. Promote reusable components and modularity. Claims/Encounter Processing Implementation and integration of the existing Business Rules Engine into the MMIS for enhanced claims processing. Promote efficient and effective data sharing to meet stakeholder needs. Secure Provider Portal This enhancement will allow providers real-time online access to view and change their account information, saving significant staff time in data entry and phone inquiries. General System Functionality Enhancement of Data Warehouse capabilities (Data Cubes) for analyzing and reporting of data. It will also include the creation of Dashboards for management decision-making and access to data by the public. Integration and Interoperability Promote efficient and effective data sharing to meet stakeholder needs. Drug Rebate Automate the process and provide online access for invoices and payments to suppliers. Drug Utilization Review Reference data file enhancement. Asset Verification Electronic data exchange with financial institutions for asset verification of Dual Eligible. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 37 of 124

38 MITA Goal OMPP Guiding Principle Objective/Actions Provide a beneficiary-centric focus. Implement an online enrollment and eligibility system that will integrate with the MMIS to provide enhanced accessibility and eligibility and benefit determination for members. Flexibility to respond rapidly to change Identify, qualify, and manage a costeffective, efficient, and flexible Medicaid program. Indiana Health Information Organization Through participation in this statewide initiative, the OMPP commits to promoting a comprehensive approach to accelerating the exchange of health information by involving providers and consumers, establishing State agency trust, developing sustainable funding sources, providing capable business services and operations, developing technical capabilities and consulting with State officials. Implement an online enrollment and eligibility system that will integrate with the MMIS to provide flexibility in response to program and policy changes. Adopt data and industry standards. HIPAA 5010 and International Classification of Diseases (ICD)-10 The system enhancements to comply with these federally mandated data formats will be included in the MMIS Re-procurement project. Support integration of clinical and administrative data. Work with MCOs and HIOs to establish a method to collect, trade, and report clinical data. Promote secure data exchange. Health Information Exchange (HIE) Implementation of the initial infrastructure to provide the capability to exchange health information between State entities and the public. Flexibility to respond rapidly to change Promote secure data exchange. Secure Member Portal Indiana to support implementation a portal to provide members the ability to view and manage their information and eventually the capability for Personal Health Records SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 38 of 124

39 MITA Goal OMPP Guiding Principle Objective/Actions Electronic Provider Referral Online access to information for providers to refer members to a specialist. Enterprise view to align technology and business needs Sustain and maximize available funds. Program Integrity (PI) The PI system will integrate new technologies with fraud detection and case tracking systems to improve the effectiveness and efficiency of fraud and abuse investigations. Ongoing review of reimbursement rates and methodologies to ensure that provider payments are consistent with efficiency, economy, and quality of care. Simplify the claim/encounter process, through collaboration with providers. Claims Resolution Implementation of automated workflow for MMIS claims resolution. Claims/Encounters Processing Implementation and integration of the Business Rules Engine into the MMIS to provide efficiency and flexibility in the processing of claims/encounters or data warehouse. Break down artificial boundaries between systems, geography, and funding. Support HIOs in sharing data across the state HIE as well as in other states. Data that supports analysis and decisionmaking Seek to greatly improve the status of health care across the State Continue to monitor quality of care and update the Quality Strategy Plan annually. Support further development of statewide immunization registry. Ensure accuracy and correctness of payments Program Integrity (PI) Implement a comprehensive PI system consisting of a Fraud and Abuse Component, a Medical Surveillance Utilization Review System (SURS) Component, a Case Tracking System, and Data Management for the OMPP s Program Integrity and Accountability Unit. Data that supports analysis and decision- Ensure accuracy and correctness of payments Program Integrity Support mechanisms to enhance sharing sanction, audit, and licensure information. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 39 of 124

40 MITA Goal OMPP Guiding Principle Objective/Actions making Enhancement of the edit and audit functions for MMIS claims/encounters processing including CCI edits. Finance Enhancements to the Financial system for management of payments and adjustments and reporting. Performance measurement for accountability and planning Improve the effectiveness and efficiency of the delivery of medical services. Maximize revenue by containing costs, eliminating duplication, and using all sources of funds. Enhancement of MCO, CMO and FFS performance measures to include data for Indiana EHR Incentive Program and mandated measures for CHIP. Provide continuous improvement/utilization review by evaluating service outcomes, program costs, and provider participation to maximize and effectively manage resources. Enhancement of MCO, CMO and FFS performance measures to include data for Indiana EHR Incentive Program and mandated measures for CHIP. Coordinate with Public Health and other partners to improve overall health Attract and maintain a strong network of service providers by continuously evaluating and implementing programs that strengthen the reimbursement process. Enhancement of CHIRP system to be bi-directional Coordinate with Public Health and other partners to improve overall health OMPP is committed to developing a health care partnership with policy makers, beneficiaries, providers, and stakeholders from the community to provide maximum health care benefits to qualified individuals through innovative and cost effective programs. Enhancement of CHIRP system to be bi-directional to ensure that EPSDT clinical data is available. Enhancement of MCO, CMO and FFS performance measures to include data for Indiana EHR Incentive Program and mandated measures for CHIP. The following MITA 3.0 framework highlights are included for informational purposes for this SMHP update: This version takes into account the new legislative requirements outlined in the Health Information Technology for Economic and Clinical Health Act, the Children s Health Insurance Program Reauthorization Act, and the Patient Protection and Affordable Care Act (P.L ), as amended by the Health Care and Education SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 40 of 124

41 Reconciliation Act of 2010 (P.L ), together referred to as the Affordable Care Act, all of which went into effect since publication of MITA 2.0 in In addition, MITA 3.0 reflects the use of newer technologies such as cloud computing and our recent policies described in Guidance for Exchange and Medicaid Information Technology (IT) Systems, version 2.0 and the Enhanced Funding Requirements: Seven Conditions and Standards, Medicaid IT Supplement, (MITS v1.0). New sections to the Framework include assistance to states in the preparation of the MITA State Self- Assessment, as well as Advanced Planning Documents (APDs) that are used by states to obtain Federal Financial Participation (FFP) to match state expenditures on eligible Medicaid systems, and a reference guide listing locations of topics of interest throughout the Framework. Lastly, the MITA 3.0 Framework is consistent with the final rule entitled, Medicaid Program; Federal Funding for Medicaid Eligibility Determination and Enrollment Activities (Federal Register, Vol. 76, No. 75) effective April 19, 2011, which provides states with the authority to receive enhanced federal funding to achieve a higher degree of interaction and interoperability across the Medicaid enterprise and the Health Insurance Exchanges (HBEs). Because the Final Rule regarding the Medicaid Eligibility Changes under the Affordable Care Act of 2010 was released on March 16, 2012, the MITA 3.0 framework does not at this time, include member eligibility and enrollment business processes or capability matrices. CMS is updating MITA 3.0 to include this information and additional information is forthcoming. The requirement to prepare the State Self-Assessments within twelve (12) months of release of MITA 3.0 remains in effect; however, the time period for preparing the State Self- Assessment (SS-A) will not begin until CMS has released the member eligibility and enrollment business processes or capability matrices MMIS HIT/HIE Environment Indiana s current MMIS is built on a nearly twenty-year old platform known as IndianaAIM. The current system uses batch processing and flat-file data transfers for interoperability, and does not perform real-time transactions. The current system lifecycle is in the planning and re-procurement phase and OMPP plans to replace the existing MMIS with new technology capable of enhanced automation and more efficient/economical processing capabilities in the future. Technical capabilities anticipated to be provided by the system will include: enhanced workflow, web services, a rules engine, and an enterprise service bus. The new system will have an inherent EHR capability to enhance and/or streamline many functions currently performed including care management and prior authorizations. OMPP s timeline is to have the replacement MMIS in production by OMPP will share services in a standard format when the data is used to promote care coordination for Hoosier members and/or transmitted to achieve EP or EH Meaningful Use requirements. Maintenance of the Health Insurance Portability and Accountability Act (HIPAA) and the ARRA security standards for receipt and transmission of the health information is a priority for OMPP, IHIE, and stakeholders participating in the statewide HIE network. Data will be exchanged for SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 41 of 124

42 purposes of treatment, payment and program operations in accordance with HIPAA requirements Summary of Medicaid Environmental As Is E-scan In November 2010, OMPP conducted an Environmental-scan of enrolled Medicaid program providers to determine the following: Current physician usage of EHRs Identification of the EHR systems in use in the State Interest by non-users in adopting EHRs Identification of barriers to adoption Survey Strategy Two scans were developed to communicate with specific provider groups: one for health professionals (individual and group practitioners) and one for hospitals. Initially participants of the As Is E-Scan intensive work session were provided with sample scans from three states. The participants discussed the Indiana environment, identified providers, and leveraged questions from the samples to compose questions specific to Indiana. It was determined by OMPP staff that all Indiana enrolled professional providers would be solicited to respond to the E-scan. The participants then identified the survey tool as Survey Monkey, targeted provider organizations for outreach and posted notice to providers using the Indiana Fiscal Agent, HP s MMIS Provider Notification tools. The questions were divided into two survey tools: one for hospitals and another for eligible professionals Survey Limitations Given the small sample size, data from the Medicaid E-scan has been compared to the Indiana HITECH scan from May The original E-scan breakdown was by provider type: Physician (MD, DO), Pediatrician, Dentist, Hospital, Advanced Practice Nurse, Ophthalmologist, Psychiatrist, and Others including physician assistants operating in an FQHC/RHC. The E-scan captured the total number of Medicaid-enrolled providers who received the survey, the number of respondents and the survey participation rate. OMPP worked with the hospital association to assist hospitals in determining potential dual eligibility status. OMPP has not performed any comparisons between the numbers extracted under Plan on Participating and the percentage of hospitals that will in fact qualify under each provider type. However, using data from the Rate Setting Contractor, OMPP data show 64% Medicaid eligibility, which is consistent with that shown in the survey responses. OMPP will research data from Survey for eprescribing to determine validity for reporting in future iterations of the SMHP. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 42 of 124

43 As Is Professional Providers (Individual and Group Providers) E-scan The Eligible Professional E-scan was designed to collect baseline information, determine which providers had previously implemented any components of an electronic EHR system, estimate potential eligibility based upon provider type and patient volume, and gauge EP interest in participation in the Indiana EHR Incentive Program. OMPP encouraged providers to participate in the E-scans through a variety of mechanisms including: attendance at Rural Health Clinic Association meetings; Claims Banner Message; and outreach to professional associations. Indiana has implemented a web site for providers at provide educational information, responses to frequently asked questions, and a telephone line for providers to ask questions about the E-scan or the Indiana EHR Incentive Program. A notification about the E-scan effort including the location of the online survey was ed to provider organizations and posted to the Indiana Fiscal Agent, HP s MMIS Provider Notification tools. Indiana providers are in various stages of automation, with larger, more urban organizations generally more automated than smaller, rural practices. Many of Indiana s smaller agencies and clinics have expressed interest in the Indiana EHR Incentive Program, but will require assistance and support to adopt and implement EHR MU capability. Table 6 (below) contains the general characteristics related to EHR adoption reported across the different professional provider groups responding to the E-scans. Presumed eligible providers were those that self-reported that they met the patient volume requirements established in the proposed rule (Medicare and Medicaid Programs; Electronic Health Record Incentive Program). Table 6. Eligible Professional Survey Information Survey Areas Minimum Medicaid Patient Volume Use of EHRs and eprescribing Barriers to participation in the Indiana EHR Incentive Payment program Implement, Upgrade and Replace Response Results 44.0% of the respondents reported as eligible for the Indiana EHR Incentive Program based on patient volume. 53% of the respondents determine the patient volume using patient encounters. 53.7% of respondents currently have EMR systems and would check the Medicaid formulary and eprescribe if available. Respondents ranked the barriers to participation as: 1. Low Medicaid patient volume 2. Cost/Effort to buy and use an EMR system 3. Training and staff workload Responses are: 26.9% will be implementing an EMR; 23.7% will be upgrading a current system; and 4.5% will be replacing a system. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 43 of 124

44 The OMPP E-scan inquired about the functionality of the EHR systems in use. Almost 65 percent of the features required by the final rule appear to be met within the existing systems and appear to be leveraged by respondents using those systems. More than 96 percent of respondents reported using industry standard EMR solutions. Information from the E-scan regarding how certain EMR/EHR features had been deployed by professionals is presented in Figure 4, below. Figure 4. Provider Meaningful Use Statistics (based on most recent E-scan) SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 44 of 124

45 As Is Hospital E-scan All Indiana hospitals were targeted with a 16-question scan to collect baseline information and document the EMR systems and capabilities currently in place. OMPP encouraged hospitals to participate in the E-scans through a variety of mechanisms including: outreach to the Indiana Hospital Association Claims Banner Message; a web site for hospitals at: responses to frequently asked questions, and a telephone line for hospitals to ask questions about the E-scan or the Indiana EHR Incentive Program. A notification about the E-scan effort including the location of the online survey was ed to provider organizations and posted to the Indiana Fiscal Agent, HP s MMIS Provider Notification tools. Notably, the responses to the Medicaid scan mirrored that of the Statewide Environmental scan responses. OMPP also acknowledged the statewide finding that unconnected providers are concentrated in the in rural portions of the state. The map of acute care hospitals below (Figure 5, next page) demonstrates that those connected are concentrated in the largest population centers (blue), with most of the unconnected acute care hospitals (red) occurring in rural portions of the state. The statewide survey returned a similar geographic connection imbalance for CAHs, FQHCs, and RHCs. Just 5 percent of rural health clinics and 11 percent of 56 FQHCs are connected electronically to a HIO. Only 29 percent (10 of 35) critical access hospitals are connected to HIE services and are able to send high value data. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 45 of 124

46 Figure 5. Indiana Hospitals with HIE Connectivity Initially Indiana s acute care hospitals indicated considerable interest in the EHR Incentive Program, with 65.1 percent indicating intent to enroll is indicated - refer to survey responses in Table 7, next page. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 46 of 124

47 Table 7. Indiana Facility HIT Survey Areas Plan on Participating Use of EHRs and eprescribing Implement, Upgrade, Replace Connected to HIE Sending high value data Response Results 65.1% plan on participating in both Medicaid and Medicare. 14.0% in Medicare only and 2.3% in Medicaid only. 80% reporting have a currently EMR 25.7% plan on implementing an EHR/EMR, while 45.7% plan on upgrading a current system, no replacements were noted. Responses to this portion of the survey were significantly low, less than 36% of acute care facilities responded to the Medicaid scan. However, the statewide scan reported 66% of the acute facilities were connected to HIE. OMPP recognizes that more than 60% (83 of 125) report sending data such as, admission, discharge, transfer (ADT) records, laboratory results, radiology results, and transcribed reports and dispensed medications. As noted in the Eligible Hospital E-scan, the features required by the final rule appear to be met within the existing hospital systems and appear to be leveraged by respondents using those systems. Figure 6 (next page) indicates the Hospital Reporting Usage of EHR Features as captured through the E-scan. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 47 of 124

48 Figure 6. HIT Survey Hospital EMR/EHR Features Future E-Scans In the 2013 program year, OMPP will complete two new provider surveys. The first survey will be sent to providers who are currently enrolled in the EHR Incentive Payment Program and have received payment for A/I/U. The goal of this survey will be to gage provider satisfaction with the incentive program and to capture the level of understanding around meaningful use reporting. The second survey will be aimed at potential providers who have not yet enrolled in the incentive program or who have registered but have not yet submitted their attestation for A/I/U. These surveys are discussed in more detail in Section 4 of this document. The results of these 2013 surveys will be included in the 2014 SMHP update. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 48 of 124

49 3. Section B: Indiana s To Be HIT Landscape Indiana is working from a clear vision for how the implementation of electronic health records and widespread, robust health information exchange will improve health and health care for Indiana. This vision, and the roadmap to achieve it, was crafted based on an appreciation for the Indiana culture of marketplace innovations, and broad stakeholder input about the role of the state for guiding and overseeing the pathway to statewide information system implementation. The early direction for Indiana s HIT development was shaped by the private sector, forged by the successful efforts of the nation s leading HIOs, IHIE and HealthBridge. The HITECH Act and the SHIECAP provided the impetus to coalesce Indiana s vision into a strategic plan and operational pathway toward the future To Be HIT landscape, building on a foundation of HIE business acumen, and policy leadership provided by FSSA. The designation of Indiana Health Information Technology, Inc. (IHIT) as the leading governance entity for Indiana s HIT and HIE efforts provided a formal bridge between sectors, and a venue for collaborative, negotiated HIT and HIE solutions. The Indiana Strategic and Operational Plans submitted to ONC under SHIECAP, represent a comprehensive approach to link HIT and HIE capacity development to goals for improving health care, including for those served by Medicaid and other public programs. OMPP and other key division staff members participated in intensive planning sessions to identify its vision for the future and continue as integral partners in the governance, development and operations of Indiana s developing statewide health information system. Additionally, beginning in 2013 Indiana is implementing a new MMIS; this implementation will be guided by how its capacities support the State s management of its public programs in conjunction with the HIT and HIE assets developing across the broad landscape. The next phase of work over the next two to three years to realize the To Be HIT Landscape will involve efforts outlined in the Strategic and Operational Plans, MMIS re-procurement, and the further refinement of EHR Incentive Program operations. Continued provider adoption of certified electronic health records will improve point of care access to health information for Indiana Medicaid members and providers. Expanded HIE capacity through Direct Secure Messaging as well as more robust query based exchange will facilitate greater streamlining and coordination of care. Enhanced access to clinical data and analytics will improve the quality and cost-effectiveness of health care provided for individuals and families and of the Indiana health care system as a whole. 3.1 Participating Entities The key to implementing Indiana s vision for HIT is an effective governance structure that is viewed as credible by stakeholders, and is effective at meaningfully engaging diverse sectors and interests to negotiate collaborative solutions and investments of time and resources. Indiana Health Information Technology, Inc. (IHIT) plays this critical role to ensure that all stakeholders participate and are served by HIT and HIE services. As a non-profit, state-level governance and coordinating entity, IHIT builds on the experiences of previous HIT stakeholder collaborations. These include: the Indiana Health Informatics Corporation (IHIC), a public instrumentality created in 2007 under statute by the State of Indiana to guide and promote health information exchange within the State; the State HIE Collaboration which began in SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 49 of 124

50 2008; and the Exhibit Indiana initiative coordinated by BioCrossroads, to establish a convening and coordination structure and governance processes for generating multi-stakeholder buy-in and the trust necessary for effective publicprivate collaboration. IHIT captured lessons learned from these efforts as its formal structures and processes were crafted. Most significantly, IHIT provides a venue that blends strong public and private sector representation, and uses a distributed approach to governance that builds on the well-established HIE governance structures and processes of Indiana s 5 HIOs IHIT Governance Participation The IHIT governance structure consists of a Board of Directors and four Advisory Councils representing stakeholder groups. As noted in the incorporation documents Board of Directors A. IHIT Board Stakeholders are either mandated or appointed a. Mandated i. Secretary of the Indiana Family and Social Services Agency or the Secretary's designee ii. Indiana Secretary of Commerce or the Secretary's designee iii. Indiana State Health Commissioner or the Commissioner's designee iv. Director of the Indiana Office of Management and Budget or the Director's designee b. Appointed by Governor i. A representative of the interagency state council on black and minority health established under Indiana Code (or any successor statute) ii. A representative of a statewide organization representing the interests of Indiana hospitals or a chairperson, chief executive officer or other senior executive of an Indiana based hospital iii. A physician licensed under Indiana Code (or any successor statute) iv. A representative of an Indiana hospital that serves a disproportionate share of indigent or underinsured patients; (v) A representative of a statewide organization representing the interests of rural health in Indiana or a chairperson, chief executive officer or other senior executive of a rural health entity v. A patient/consumer representative vi. A data privacy and security expert vii. A research scientist with expertise in medical informatics SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 50 of 124

51 Advisory Councils Stakeholders are involved in various workgroups or councils that are charged to provide expertise and perspective to inform the Board decision-making, and to ensure the continued support for Indiana s HIT vision, strategies, and implementation plans. The leaders of the five major Indiana HIOs are each directly engaged as the HIE Policy and Technical Advisory Council; refer to Table 8 (below). Table 8. HIE Policy and Technical Advisory Council Representation HIO Organization HealthBridge HealthLINC Indiana Health Information Exchange Michiana Health Information Network The Med-Web Greater Cincinnati tri-state area physicians. Representation Physicians in Lawrence, Monroe, Orange and Owen counties. 13 institutions representing Indiana hospitals, healthcare providers, researchers, public health organizations, and economic development groups. Over 1,000 physicians in northern Indiana and southwestern Michigan. Clinical messaging of lab and radiology reporting in north eastern Indiana counties. The other three groups are collaborative efforts comprised of a mix of representation from the following institutions or groups; refer to Table 9 (below). Table 9. Participation in Other State HIE Advisory Councils Research and Education Council Data Provision and Use Council Patient Advocacy Council Indiana University School of Medicine Indiana Family and Social Services Medicaid Director or designee Ambulatory Care Purdue University Health insurance providers Drug Treatment University of Notre Dame Employers Ethics Other purchasers of health coverage Regenstrief Institute, Inc. Health care providers Home Health & Hospice Other health professional schools TBD Allied health professionals Provider support and clerical staff Care coordination staff Hospital Privacy Officer/ Representative Other research organizations TBD Clinical laboratories Insurance Company Other representative groups TBD Pharmacies IN Primary Care Assn. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 51 of 124

52 Research and Education Council Data Provision and Use Council Patient Advocacy Council Vendors - Pharmaceutical products and medical devices Vendors - Data security and privacy services Vendors - HIE goods and services Other representative groups TBD Juvenile Diabetes or Cancer Mental Health Nursing Home/Seniors Research Physician Smaller Hospitals Executive Leadership State HIT Coordinator The state HIT Coordinator also serves as the executive director of IHIT. This role embodies a collaborative multi-sector approach. The IHIT Executive Director/HIT Coordinator brings sectors and interests together to consider policy goals for improving health care including for Medicaid and CHIP, and continuously focusing and facilitating the efforts of the five Indiana HIOs, providers, vendors, agencies and stakeholders at large on the four strategic pillars of Indiana s Strategic and Operational Plans: connecting data sources, fostering interoperability, improving outcomes, and leveraging Federal/State Initiatives. 3.2 Vision for HIT Environment In its Strategic and Operational Plans, Indiana lays out four (4) strategic pillars that serve as the vision and pathway for the state s HIT environment: connecting data sources, fostering interoperability, improving outcomes, and leveraging Federal/State Initiatives. As national standards further develop and through the various targeted projects underway, IHIT is working with the HIOs to foster increased interoperability, data standardization and security. Building from efforts being driven by private market trading partner agreements, IHIT and its partners are leveraging additional open source tools and specifications (e.g. Direct and the Connect Gateway) developed as part of the Nationwide Health Information Network (NwHIN). According to the strategies being pursued by IHIT and its partners, EPs and EHs (including CAHs) will continue to gain and expand connectivity and the ability to exchange health information within and outside their HIO for the purposes of treatment, payment, and health plan operations (TPO). A comprehensive strategy for expanding interoperability through the HIOs is designed to ensure that the adoption of certified EHR technology will target eligible professionals and hospitals but encompass other health care providers and the industry at-large. Interoperability for individual providers outside of an HIO ecosystem will be accelerated by providing secure HIE messaging for clinical information between health care providers, enable the capture of core information to facilitate care coordination and point of care SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 52 of 124

53 decision making, and will foster more timely access to care for Hoosiers without delays while reducing the administrative burden of paper-based exchanges. As the majority of providers are gaining active status as participants in the EHR incentive program, demonstrating meaningful use and the reporting of Clinical Quality Measurements (CQM) will continue to be the prevailing priorities as Stage 2 and Stage 3 requirements are instituted. Organizing and integrated quality reporting strategy is an important ongoing focus, seeking to build upon developing cross-hio querying of repositories and other strategies currently in play to expand and enhance interoperability of clinical data. The public health opportunities associated with building the capacity of the statewide HIE network are immense. The State Immunization registry and public health surveillance reporting database are two examples of databases that can be populated with information that is gathered through the HIOs. Many providers are already required to submit multiple files for secondary uses by public health officials for monitoring and reporting purposes. IHIT is working closely with ISDH to plan and fund further expansion of the Indiana Immunization Registry capabilities through the SHIECAP. Medicaid has prepared and released an RFP and will seek a contractor to replace the existing MMIS system to be in production by The new MMIS will contain an enterprise service bus, a rules engine, and workflow management components. Provider and member portal capabilities will continue and provide stakeholders with a mechanism for managing their demographic information and the capability to obtain access to Medicaid policy rules and submit claims/encounters. Both Indiana Health Information Exchange (IHIE) and HealthBridge currently have connections to the National Health Information Network (NwHIN). In the future Indiana will need to maintain the sustainability of the HIO structure that has occurred over the past 15 years. Integration of the HIOs will be driven by the private sector needs and desire of Indiana health care providers for data sharing relationships to facilitated exchange of ephi for TPO and to monitor health care outcomes. Indiana has been successful in obtaining funding under the ARRA. These funds are intended to provide the necessary technical assistance for providers to become meaningful users of EHRs, coordinate the state s efforts with regard to the electronic exchange of health information, and provide the needed training and education to increase the health IT workforce. FSSA recognizes that the agency will play a significant role in transforming health care in Indiana and has developed its vision for HIT to address many of the challenges of integration with the HIOs. Obtaining and leveraging new technology is a key component. Therefore re-procurement of a new MMIS is a major priority for providing improved functionality that will support OMPP and statewide HIT/HIE efforts. Indiana s vision for HIT also relies heavily on utilizing meaningful use of clinical information obtained through adoption, implementation and upgrade of certified EHR systems by providers and facilities and leveraging HIO technologies currently in place in Indiana. Through the use of EHR systems, HIE and other technologies described in the following sections, OMPP is positioned well over the next three to five years to significantly impact the following shared goals, initially established in IHIT s Strategic Plan: SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 53 of 124

54 1. Connect Data Sources. 2. Interoperability. 3. Improve Outcomes. 4. Establish secure statewide and interstate HIE. 5. Focus on prevention - not just clinical preventive services for individuals, but public health community-based policies and programs - to support improved health status and control costs by reducing the burden of preventable illness and injury. Realizing these broad goals for IHIT and its stakeholders includes the following six components and related strategies: 1. Simplified access to Health Care Information and Services for Beneficiaries. a. Enhance secure web-based Beneficiary information, communication, outreach and tracking b. Provide enhanced provider on line search capabilities c. Improve service delivery through Interactive Voice Response (IVR) and VOIP (Voice Over Internet Protocol) technologies where possible d. Design and implement on line capabilities to enhance quality consumer directed access to care e. Development of strong Medical Home model delivery system f. Increase collaboration between all state payer and provider g. Streamline Point of Service functions (e.g., Smart Cards) h. Fully develop e-prescribing functionality 2. Simplified interaction with the Health Care infrastructure for Providers a. Credentialing: i. Single credentialing organization and standard forms for all payers for the State of Indiana ii. Adopt nationally recognized provider credentialing process iii. Interface to the NPI database b. Web-based Access: i. Enhance secure web-based provider enrollment, maintenance, communication and tracking that is available for provider self-service ii. Provide online data submission with real-time claims/encounters tracking of approvals, denials, and other status reporting iii. Provide web based physician/provider quality and cost reporting iv. Provide a secure web-based care management systems options v. Enhance web-based prior authorization (PA) function SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 54 of 124

55 vi. Enhanced web-enabled claims/encounters processing functionality vii. Improve eligibility coordination and knowledge sharing between agencies and business partners c. Enhanced Technology Supports: i. Streamline Point of Service functions (e.g., Smart Cards) ii. Support and accommodate electronic signatures iii. Provide for data interchange with Data Warehouse iv. Facilitate move to total electronic claims/encounters v. Interface with future EHR and PHR system functionalities vi. Fully develop e-prescribing functionality 3. Improved Health Care Outcomes - measured by increased usage of performance criteria a. Create clear outcomes and expectations for providers to address pay for performance and quality of care b. Incentivize providers to use quality preventative care c. Utilizing HIE/HIT to improve health care Quality and Safety. d. Develop and expand innovative approaches to prevention. e. Develop a comprehensive statistical profile for delivery and utilization patterns 4. Evolving use of modern information technology to improve the delivery of health care and outcomes, identify administrative efficiencies, coordination and optimization of care. a. Administrative Efficiencies: i. Improve contract administration ii. Provide automated federal reporting iii. Enhance automated reporting capabilities iv. Improve financial reporting capacity including data pulls, details, and definitions v. Simplify and automate creation and management of edits and audits vi. Develop and Automate the Rate Setting process vii. Support and enhance capabilities to access federal rebate programs viii. Provide for data interchange with Data Warehouse ix. Develop and expand innovative approaches to prevention. x. Reduce duplication of effort regulatory vs. contract monitoring xi. Develop webcasts and other on line accessible training for MMIS users xii. Enhance web-based prior authorization (PA) function SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 55 of 124

56 xiii. Facilitate move to total electronic claims/encounters xiv. Enhanced web-enabled claims/encounters processing functionality xv. Automate TPL functionality xvi. Fully develop e-prescribing functionality xvii. Enhance pre-payment and post-payment pattern analysis xviii. Provide Contractor system supports (Contract Management system) to improve efficiency of contracting process b. Coordination of Care i. Develop enhanced interfaces to existing registries ii. Development of strong Medical Home model delivery system iii. Interface with future EHR and PHR system functionalities iv. Optimization of Care v. Provide secure, web-based assessment tool for Waiver, Senior and disability functions vi. Improve service delivery through IVR (Interactive Voice Response) and VOIP (Voice Over Internet Protocol) technologies where possible vii. Provide clear and accurate EPSDT services and tracking viii. Explore health care literacy program to reduce ER use by Medicaid population ix. Implement Statewide HIE to improve episode of care management x. Develop and expand innovative approaches to prevention 5. Integrated medical service delivery model that includes high quality Medicaid providers a. Encourage and promote retention of quality Medicaid providers b. Explore health care literacy program to reduce Emergency Room use by Medicaid population c. Implement Statewide HIE to improve episode of care management d. Improve eligibility coordination and knowledge sharing between agencies and business partners 6. Move from client focus to family or community based health care. a. Development of strong Medical Home model delivery system OMPP, together with the Medicaid Fiscal Agent, are actively encouraging provider adoption of certified EHR technology through regularly scheduled quarterly provider workshops, presentations to professional associations, visits to physician s offices by provider service representatives, provider newsletters and claims banner messages. Providerfocused outreach, training, and education will continue to be a primary focus to support full implementation of the EHR Incentive Program during 2013 and beyond. SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 56 of 124

57 HIE To-Be Projects MMIS Replacement (Enterprise Medicaid HITECH HIT EHR Incentive Payments Federal Mandates State of Indiana OMPP will leverage work with the Regional Extension Centers and HIOs to support EPs and EHs in response to technical questions about certified EHR technology and integration with the HIOs. Additionally, Indiana s HIT Roadmap includes the following projects Figure 7, below - over the next few years; together these projects are intended to fully leverage HIT and HIE to impact the health status of Indiana s population and, in particular, the Medicaid population. Figure 7. Key State Medicaid HIT/HIE Initiatives Projects X and NCPCP Transactions ICD-10 Planning ICD-10 Implementation ICD-10 Maintenance & Operations Health Care Reform (HCR) Enhancements Project Planning Strategic Plan (SMHP) Development Initial SMHP Development and Submit to CMS IAPD Development and Submit to CMS IAPD Update and Submit to CMS Develop Core Systems Reqs Develop Indiana Systems Reqs Build/Test Core System MAPIR Incentive Attestation Software NLR Interface EHR Provider Outreach and Training EHR Auditing Annual Update to SMHP and Submit to CMS MMIS RFP State Review MMIS RFP Released MMIS RFP Evaluation MMIS Contract Negotiations/Approval IV&V Activities MMIS Implementation MMIS Certification and Prepare for CMS Visit Enterprise Data Warehouse (DW) SFY2010 SFY2011 SFY2012 SFY2013 SFY2014 SFY2015 SFY2016 SFY2017 SFY2018 SFY2019 SFY2020 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Correct Coding Initiative - Expansion HIE eprescribe - SMA Drug Formulary HIE Prior Authorizations HIE Clinical Data Exchange CHIRP Pharmacy Benefits Management System (PBM) Integrated Eligibility Determination Services Systems (IEDSS) RFP Developed and Released IEDSS RFP Evaluation IEDSS IAPD Development and Submit to CMS IEDSS Contract Negotiations/Approval IEDSS Implementation IV&V RFP Developed and Released IV&V RFP Evaluation IV&V Contract Negotiations/Approval IEDSS included in MMIS Certification SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 57 of 124

58 4. Section C: Activities Necessary to Administer and Oversee the EHR Incentive Payment Program This section includes a description of the business processes OMPP will employ to ensure that eligible professionals and eligible hospitals have met Federal and State statutory requirements to receive the EHR Provider Incentive Payments. OMPP plans to use their standard MITA business processes where feasible, and integrate the Indiana EHR Incentive Program into day-to-day operations in partnership with HP where appropriate. Examples of new state-specific business processes to be developed include: Provider registration Provider eligibility determination and verification Medicaid patient volume verification Provider attestation verification A/I/U Query to the Medicare & Medicaid EHR Incentive Program Registration & Attestation System (R&A) 4.1 Program Administration Organization Figure 8. EHR Incentive Program Administration - Organizational Chart SMHP ANNUAL UPDATE State of Indiana FSSA CONFIDENTIAL Page 58 of 124