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State Medicaid Health Information Technology (HIT) Plan

Version 1.2

SFY 2011 to SFY 2014

Montana Department of Public Health and Human Services

Director’s Office

Revised August 18, 2011

Original Publication January 6, 2010

MONTANA DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICESState Medicaid Health Information Technology Plan (SMHP)

REVISION HISTORY

I-APDVERSION #

DATE SUBMITTEDTO CMS

CMS APPROVAL DATE

1.0 (original) January 6, 2011 January 6, 2011 April 4, 20111.1 June 30, 2011 June 30, 2011 Version Not Approved1.2 August 18, 2011 August 18, 2011

Revised August 18, 2011 Page 2 of 113 Director’s Office


Table of Contents

1.0 EXECUTIVE SUMMARY....................................................................................................................................6

2.0 THE STATE’S AS-IS HIT LANDSCAPE...........................................................................................................7

2.1 STAKEHOLDERS ENGAGED IN HIT/E ACTIVITIES WITHIN MONTANA...................................................................72.1.1 Federal Partners..........................................................................................................................................72.1.2 State of Montana..........................................................................................................................................92.1.3 HIE Designated Entity – HealthShare Montana (HSM)............................................................................112.1.4 Montana Regional Extension Center (REC)..............................................................................................132.1.5 Montana Exchange Networks.....................................................................................................................132.1.6 Tele-Medicine/Tele-Health in Montana.....................................................................................................182.1.7 Other entities engaged in HIT/E activities within the State of Montana...................................................19

2.2 CURRENT STATE ACTIVITIES THAT WILL FACILITATE HIE AND EHR ADOPTION..............................................202.3 OTHER ACTIVITIES THAT MAY INFLUENCE THE MPIP OVER THE NEXT FIVE YEARS.........................................22

2.3.1 Medicaid Health Improvement Program...................................................................................................222.3.2 MMIS Replacement....................................................................................................................................232.3.3 State Law or Regulation impact on EHR incentives..................................................................................232.3.4 State Broadband Access in Montana.........................................................................................................242.3.5 HIT Related Grants Awarded to the State..................................................................................................272.3.6 Medicaid Information Technology Architecture (MITA) Self Assessment.................................................282.3.7 State Systems..............................................................................................................................................30

2.4 AS-IS PROVIDER HIT/HIE..................................................................................................................................322.4.1 Montana Provider Practice Landscape.....................................................................................................332.4.6 Federally Qualified Health Centers (FQHC)............................................................................................452.4.7 Veterans Health Administration.................................................................................................................472.4.8 Indian Health Service (IHS) Clinical Facilities.........................................................................................47

3.0 THE STATE’S “TO-BE” LANDSCAPE............................................................................................................50

3.1 HIT/HIE GOALS AND OBJECTIVES.....................................................................................................................523.2 IT SYSTEM ARCHITECTURE................................................................................................................................523.3 MEDICAID PROVIDER INTERFACE WITH MPIP...................................................................................................543.4 HIE GOVERNANCE STRUCTURE.........................................................................................................................583.5 PROVIDER ADOPTION OF CERTIFIED EHR TECHNOLOGY....................................................................................583.6 FQHCS WITH HRSA HIT/EHR FUNDING..........................................................................................................593.7 TECHNICAL ASSISTANCE FOR MEDICAID PROVIDERS........................................................................................593.8 UNIQUE NEEDS POPULATION.............................................................................................................................593.9 LEVERAGING HIT GRANTS FOR THE MPIP........................................................................................................603.10 STATE LEGISLATION OUTLOOK FOR MPIP......................................................................................................603.11 OTHER ISSUES...................................................................................................................................................61

4.0 ACTIVITIES NECESSARY TO ADMINISTER AND OVERSEE THE MPIP...........................................61

4.1 PROGRAM ORGANIZATION..................................................................................................................................614.2 STAKEHOLDER COMMUNICATIONS.....................................................................................................................624.3 POLICY AND REGULATORY CHANGES................................................................................................................67

4.3.1 Policy Changes...........................................................................................................................................674.3.2 Privacy Regulatory Changes......................................................................................................................684.3.3. Other Regulatory Changes........................................................................................................................68

4.4 IMPLEMENTATION OF NECESSARY TECHNOLOGY..............................................................................................694.4.1 MPIP Technical Architecture.....................................................................................................................714.4.2 MPIP Provider and Hospital Adopt/Implement/Upgrade and Meaningful Use Workflows......................724.4.3 Participation in National Level Registry (NLR)........................................................................................79



4.4.4 Systems used to establish provider eligibility............................................................................................794.5 PROVIDER HELP DESK SUPPORT........................................................................................................................794.6 PROVIDER REGISTRATION PROCESS...................................................................................................................794.7 PROVIDER ELIGIBILITY FOR INCENTIVE PAYMENTS...........................................................................................80

4.7.1 Eligible Provider Types..............................................................................................................................804.7.2 Methodology for Patient Volume Determination.......................................................................................814.7.3 Assuring Providers are Not Hospital Based..............................................................................................834.7.4 Ensure Providers are Licensed, Not Sanctioned........................................................................................834.7.5 Provider and Hospital Attestation Process and Validation.......................................................................84

4.8 PROCESSING PAYMENTS TO PROVIDERS.............................................................................................................854.8.1 Provider Payment Request.........................................................................................................................854.8.2 Assignment of Payment..............................................................................................................................854.8.3 Provider Payment Calculations.................................................................................................................86

4.9 ADOPTION, IMPLEMENT OR UPGRADE TO CERTIFIED EHR TECHNOLOGY..........................................................914.10 VERIFICATION OF MEANINGFUL USE...............................................................................................................914.11 MEANINGFUL USE CRITERIA............................................................................................................................914.12 PROVIDER OUTREACH, EDUCATION AND ASSISTANCE....................................................................................924.13 APPEALS PROCESS............................................................................................................................................924.14 DATA COLLECTION AND REPORTING...............................................................................................................924.15 ASSUMPTIONS...................................................................................................................................................93

5.0 THE STATE’S AUDIT STRATEGY.................................................................................................................93

5.1 ADMINISTRATION...............................................................................................................................................935.1.1 Provider Enrollment...................................................................................................................................945.1.2 Prepayment Activities.................................................................................................................................945.1.3 Post-payment Activities..............................................................................................................................95

5.2 FRAUD AND ABUSE............................................................................................................................................965.3 OVERPAYMENTS.................................................................................................................................................975.4 ADMINISTRATION EFFICIENCIES.........................................................................................................................97

6.0 MONTANA’S HIT ROADMAP..........................................................................................................................99

6.1 MONTANA’S VISION FOR MOVING FROM “AS-IS” TO “TO-BE” LANDSCAPE....................................................996.2 ANNUAL BENCHMARKS FOR PROVIDER ADOPTION OF EHR TECHNOLOGY OVER TIME...................................1016.3 ANNUAL BENCHMARKS FOR DPHHS GOALS MEASURING MPIP PROGRESS....................................................102

APPENDIX A – HIT AND HIE ENVIRONMENTAL SCAN - JANUARY 2011..............................................104

APPENDIX B – MPIP STATE LEVEL REPOSITORY WORKPLAN AND SCHEDULE............................105

ACRONYMS.............................................................................................................................................................108

GLOSSARY...............................................................................................................................................................112

DOCUMENT REVISION HISTORY....................................................................................................................113



List of TablesTABLE 2.1 DPHHS PUBLIC HEALTH ORGANIZATIONS INVOLVED IN HIT/HIE ACTIVITIES........................................11TABLE 2.2 LEGACY HIT USED BY HEALTHCARE ORGANIZATIONS ASSOCIATED WITH HIEM......................................15TABLE 2.3 OTHER STAKEHOLDERS IMPORTANT TO MONTANA HIT/E ACTIVITIES......................................................19TABLE 2.4 BROADBAND GRANTS RECEIVED WITHIN THE STATE.................................................................................24TABLE 2.5 DPHHS EXECUTIVE GUIDING PRINCIPLES.................................................................................................29TABLE 2.6 CURRENT HIT LANDSCAPE FOR FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)...............................45TABLE 2.7 RECOVERY ACT FUNDING FOR COMMUNITY HEALTH CENTERS IN MONTANA (15)..................................46TABLE 2.8 CURRENT INDIAN HEALTH SERVICE, TRIBAL, AND URBAN NATIVE AMERICAN HEALTHCARE FACILITIES

IN MONTANA.......................................................................................................................................................48TABLE 4.1 QUALIFYING PATIENT VOLUME THRESHOLD FOR MPIP............................................................................81TABLE 6.1 ESTIMATED EHR INCENTIVE PROGRAM ENROLLMENT OVER FIVE YEARS.............................................101TABLE 6.2 HIT/HIE GOALS, OBJECTIVES, MEASURES, TARGETS, AND BASELINES.....................................................102

List of FiguresFIGURE 2.1 MONTANA EXCHANGE NETWORKS............................................................................................................14FIGURE 2.2 HEALTH INFORMATION EXCHANGE OF MONTANA....................................................................................15FIGURE 2.3 NORTH CENTRAL MONTANA HEALTHCARE ALLIANCE.............................................................................16FIGURE 2.4 ROCKY MOUNTAIN HEALTHCARE NETWORK............................................................................................17FIGURE 2.5 MONIDA HEALTHCARE NETWORK.............................................................................................................18FIGURE 2.6 INTERNET CONNECTIVITY OF PROVIDER’S PARTICIPATING IN MONTANA’S ENVIRONMENTAL SCAN........24FIGURE 2.7 ORGANIZATIONAL OWNERSHIP OF PROVIDER PRACTICES IN MONTANA....................................................33FIGURE 2.8 TYPES OF PROVIDER PRACTICES IN MONTANA..........................................................................................34FIGURE 2.9 PROVIDER PRACTICES WITH MULTIPLE SITES/LOCATIONS..........................................................................34FIGURE 2.10 INTEGRATION OF EHR WITHIN PRACTICE MANAGEMENT SYSTEMS USED BY MONTANA PROVIDERS....35FIGURE 2.11 EHR HARDWARE CONFIGURATION...........................................................................................................35FIGURE 2.12 PROVIDER PRACTICE METHODS FOR STORING MEDICAL RECORDS...........................................................36FIGURE 2.13 REASONS MONTANA PROVIDERS DO NOT CURRENTLY USE AN EHR SYSTEM.........................................36FIGURE 2.14 EXPECTED EHR DEPLOYMENT HORIZON FOR MONTANA PROVIDERS......................................................37FIGURE 2.15 TELEMEDICINE/TELEHEALTH SERVICES ACTIVELY USED BY MONTANA PROVIDERS...............................37FIGURE 2.16 BARRIERS TO USING TELEHEALTH/TELEMEDICINE BY MONTANA PROVIDERS........................................38FIGURE 2.17 PROVIDERS PLANNING PARTICIPATION IN MEDICAID OR MEDICARE INCENTIVE PROGRAMS.................39FIGURE 2.18 PERCENTAGE OF PROVIDERS SERVING 0-9%, 10-19%, 20-29%, AND GREATER THAN 30% MEDICAID

PATIENTS, RESPECTFULLY....................................................................................................................................40FIGURE 2.19 PERCENTAGE OF PROVIDERS SERVING 0-9%, 10-19%, 20-29%, AND GREATER THAN 30% MEDICARE

PATIENTS, RESPECTFULLY....................................................................................................................................40FIGURE 2.20 LABORATORY RESULTS DELIVERY METHODS USED BY PROVIDERS IN MONTANA...................................41FIGURE 2.21 MONTANA PUBLIC HEALTH ELR INITIATIVE..........................................................................................42FIGURE 2.22 MONTANA PROVIDERS WITH E-PRESCRIBING CAPABILITY.......................................................................43FIGURE 2.23 BARRIERS FOR USE OF E-PRESCRIBING BY PROVIDERS WHO HAVE E-PRESCRIBING FUNCTIONALITY......43FIGURE 2.24 PROVIDER IMPLEMENTATION PLANS FOR E-PRESCRIBING IN MONTANA..................................................44FIGURE 2.25 REASONS PROVIDERS IN MONTANA ARE NOT IMPLEMENTING E-PRESCRIBING........................................44FIGURE 2.26 MONTANA CITIES WITH VETERAN’S ADMINISTRATION FACILITIES.........................................................47FIGURE 2.27 MONTANA’S TRIBAL RESERVATIONS.......................................................................................................48FIGURE 3.1 DPHHS ENTERPRISE ARCHITECTURE........................................................................................................53FIGURE 3.2 MONTANA STATE LEVEL REPOSITORY – PROVIDER OUTREACH PAGE.....................................................55FIGURE 3.3 MONTANA STATE LEVEL REPOSITORY – ELIGIBLE HOSPITAL INITIAL REGISTRATION............................56FIGURE 3.4 MONTANA STATE LEVEL REPOSITORY – ELIGIBLE PROVIDER INITIAL REGISTRATION............................57FIGURE 4.1 MONTANA HIT/EHR PROVIDER OUTREACH PORTAL LANDING PAGE.....................................................63FIGURE 4.2 MONTANA DPHHS HIT/EHR WEBSITE....................................................................................................64FIGURE 6.1. HIT/MITA ROADMAP.............................................................................................................................100TABLE 6.2 MEDICAID EHR INCENTIVE PROGRAM SOLUTION IMPLEMENTATION SCHEDULE....................................102



1.0 EXECUTIVE SUMMARY

In this State Medicaid Health Information Technology Plan (SMHP), the Montana Department of Public Health and Human Services (DPHHS) has set forth a plan to achieve a sound and logical approach to health information exchange that enhances the ability of our healthcare providers to continue to deliver high quality, affordable health care for Montanans. Through the deployment of technology, our goal is to assist the provider community in their efforts to enhance patient safety and improved coordination of care by promoting the adoption of interoperable electronic health record systems and through the use of health information technologies meeting national standards. This is best accomplished through a public-private partnership, in collaboration with payers, providers, consumers, and health information technology partners.

To meet this ultimate goal, DPHHS has committed to three clear and obtainable objectives, ultimately leading to the development and deployment of a statewide HIT/EHR infrastructure that will facilitate our vision of future interoperability among all stakeholders.

Objective 1 – Survey and analyze the current conditions and capabilities of the HIT/EHR landscape in Montana

DPHHS lacked current and reliable information with regard to the readiness of Montana providers to participate in an electronic health record environment. Therefore, our first objective was to facilitate an environmental scan of the Montana healthcare provider community. To that end, DPHHS partnered with our state designated Health Information Exchange entity, HealthShare Montana (HSM), to conduct the first actual survey of the HIT/EHR landscape. The initial results of this process provided an interesting view into the capabilities of our providers and hospitals, and are included in this plan. DPHHS is working closely with our HIT Regional Extension Center (REC), the Mountain Pacific Quality Health Foundation (MPQHF). The REC is actively assisting providers in determining potential eligibility for Medicare and Medicaid Provider Incentive Programs. In addition, DPHHS has released a Request for Proposals for a new and improved MMIS. The RFP requires advanced HIT/EHR functionality, as well as system capacity and functionality to implement the Provider Incentive Payment Program.

Objective 2 – Develop a strategic plan for the promotion and development of the HIT/EHR infrastructure in Montana DPHHS, HSM, and the REC form an effective coalition capable of reaching out to a wide variety of HIT stakeholders including individual, group, and facility providers, as well as representatives of provider associations, state agencies, and state officials. Through strong partnerships with HSM in development of the statewide HIE, and with the REC in provider outreach and education, DPHHS is committed to the development of an HIT/EHR infrastructure that will be the foundation for the growth of EHR utilization across the entire spectrum of Montana



healthcare organizations. This includes not only providers, but all commercial and governmental payers, as well as Regional Health Information Organizations (RHIO) as well.

Our principal goal is to enable the Montana Health Care Program to drive a common vision of how the Medicaid Provider Incentive Payment Program will work in conjunction with the larger statewide HIT plan. The result will be a strategic and tactical plan that is the basis for the development and implementation of the activities that form Objective 3.

Objective 3 – Implement a Medicaid Provider Incentive Program (MPIP) for the State of Montana DPHHS will become a partner in the transformation of the State’s current HIT/EHR landscape into a technical infrastructure capable of supporting the meaningful use of EHR and similar data.

The State of Montana will develop an effective means of administering and distributing available federal incentive monies to eligible providers and hospitals, including establishing a process to determine eligibility, assure system certification, and create a method to track meaningful use. Steps to achieving this goal include: Implement a cost effective, fully automated, and auditable process to administer incentive

payments to eligible providers and hospitals, Develop incentive program rules designed to maximize the opportunity for Montana

Medicaid Providers to participate in the incentive program, Diligent oversight of the incentive program including routine audits and quality assurance

checks of meaningful use attestations and reporting mechanisms, Coordinate with community partners and encourage the adoption of certified EHR

technology that promotes health care quality and the exchange of health care information. Ensure the new Montana MMIS contains the functionality needed to support HIT and the

Montana MPIP upon deployment.

2.0 THE STATE’S AS-IS HIT LANDSCAPE

2.1 Stakeholders engaged in HIT/E activities within Montana1. What stakeholders are engaged in any existing HIT/E activities and how would the extent of their involvement be

characterized?2. Does the SMA have HIT/E relationships with other entities? If so, what is the nature (governance, fiscal, geographic

scope, etc) of these activities?3. Specifically, if there are health information exchange organizations in the State, what is their governance structure

and is the SMA involved? ** How extensive is their geographic reach and scope of participation?

2.1.1 Federal Partners

Federal partners engaged in HIT/EHR activities within Montana include: Centers for Medicare and Medicaid Services (CMS) Office of the National Coordinator (ONC) Indian Health Service (IHS)



Veteran’s Administration (VA) Centers for Disease Control (CDC)

2.1.1.1 Centers for Medicare and Medicaid Services (CMS)

CMS is a key federal stakeholder for the State of Montana. CMS established the Medicaid Incentive Payment Program (MPIP) via formal federal rulemaking, publishing the final rule in July 28, 2010. The final rule, establishes parameters and requirements for the MPIPs that States such as Montana will follow. CMS also assisted the ONC with the development of standards, implementation specifications, and certification criteria for EHR technology. In addition, CMS is working with the Office of Civil Rights (OCR) and ONC to ensure privacy and security precautions are addressed for the Medicaid Provider Incentive Program. Lastly, CMS provides oversight regarding the MPIP reviewing and approving the Implementation Advanced Planning Document (IAPD) for Health Information Technology (HIT) and the State Medicaid Health Information Technology Plan (SMHP).

2.1.1.2 Office of the National Coordinator (ONC)

The ONC is also a key federal stakeholder for the State of Montana. They are the principal federal entity coordinating efforts for the implementation and use of HIT and HIE. “ONC’s mission includes: Promoting development of a nationwide HIT infrastructure that allows for electronic use and

exchange of information that: Ensures secure and protected patient health information Improves health care quality Reduces health care costs Informs medical decisions at the time/place of care Includes meaningful public input in infrastructure development Improves coordination of care and information among hospitals, labs, physicians, etc. Improves public health activities and facilitates early identification/rapid response to

public health emergencies Facilitates health and clinical research Promotes early detection, prevention, and management of chronic diseases Promotes a more effective marketplace Improves efforts to reduce health disparities

Providing leadership in the development, recognition, and implementation of standards and the certification of HIT products;

Health IT policy coordination; Strategic planning for HIT adoption and health information exchange; and Establishing governance for the Nationwide Health Information Network [NHIN] (1)”



2.1.1.3 Indian Health Services (IHS)

The IHS is an important stakeholder in Montana; home to eleven federal or state recognized Tribal Nations. The IHS is involved in the following HIT efforts: Expand use of the IHS Resource and Patient Management System (RPMS) electronic health

record (EHR) including clinical care, support services, and practice management comprehensive health information, provider order entry, clinical decision support

Provide quality and performance reporting that is transparent and accessible to IHS consumers

Ensure RPMS meets national interoperability standards in order to participate in health information exchanges such as the National Health Information Network

Ensure the RPMS EHR receives certifications for ambulatory, inpatient, & behavioral health care

Continue to provide intensive support and training for deployment of the RPMS EHR. Adopt Personal Health Record technology to provide patients with tools to view and manage

their health information and promote self-management activities Improve telehealth and network infrastructure including upgrade of network routers, network

domain control, expansion of the storage area network, network security improvements (2)

2.1.1.4 Veteran’s Administration (VA)

The VA is an important federal stakeholder for several reasons. First, the VA is a leader is using EHR technology using information technology in their medical facilities since 1985 (3). Around 2008, the VA began moving from their Veterans Health Information Systems and Technology Architecture (VistA) to a new more modern HealtheVet health information technology solution. These VA solutions are available to use by States and other public stakeholders as a potential low-cost EHR solution. Second, “[n]early 80 percent of enrolled veterans have access to other health care coverage, and data from VHA indicate that most enrollees with other coverage rely on VHA for only part of their medical care (4).” This “dual use” of federal and non-federal providers may be problematic when it comes to coordinating care for these individuals. Under recent HIT Initiatives, however, the VA will exchange data on shared patients via the NHIN (4).

2.1.1.5 Centers for Disease Control (CDC)

The CDC is the liaison for the development and operations of Immunization Information Systems (IIS) for the U.S. Department of Health and Human Services. The CDC develops strategies and policies related to IIS as well as reviews funding requests, acquisition documents, and sponsors training, initiatives and programs.

2.1.2 State of Montana

In October 2008, Montana Health Care Program implemented an automated prior authorization application called SmartPA®. Affiliated Computer Services’ (ACS) proprietary electronic prior authorization application provides immediate adjudication and turnaround and enhances the



DPHHS’ prior authorization program by electronically processing the majority of PA requests at the pharmacy with fewer phone calls required from prescribers and pharmacies to the Drug Prior Authorization Unit.

In March of 2009 Montana Health Care Program implemented CyberAccess, a web-based, HIPAA-compliant portal that enables healthcare providers or their staff to have access via a web browser to the health care information of their patients who are enrolled in Medicaid. As a result, providers have the ability to view Electronic Health Records, obtain Prior Authorizations, and E-prescribe. Each of these functions is described in more detail below: Electronic Health Record

Download paid claim data submitted for patient by any provider of the past two years. This data includes drug claims, diagnosis codes, Current Procedural Terminology (CPT) codes, etc.

Identify clinical issues that affect the patients’ care. The drug history available for each patient includes drug alerts, a list of the prescriber’s

names, pharmacies used by the patient, the service date, drug name, quantity, supply, and refills.

The medical history contains the procedure code (e.g., CPT, HCPCS, and CDT), procedure description, dates of service, provider, place of service, International Classification of Diseases (ICD)-9 code, etc.

Prior Authorizations Electronically request a Prior Authorization or Clinical Edit override. Identify existing approved or denied Prior Authorizations or Clinical Edit overrides

issued for a patient. Determine if a drug is a preferred agent or requires edit override. Examine how specific Preferred Drug List (PDL) and Client Edit criteria would affect a

prescription of an individual patient and determine if a prescription meets the program’s requirements for payment.

Receive prescribing alternatives and best-practices information. Uses medical (ICD-9, CPT, etc.) and pharmacy data to determine the appropriateness of

medications. E-Prescribing

Search for a drug product. The e-prescribe function allows the provider to enter the patient, select the drug, quantity,

days’ supply, refills, provide directions for use, and indicate if a substitution is allowed. Print or transmit a prescription electronically to the recipient’s pharmacy of choice via

fax.

With the deployment of the new Montana MMIS in 2014, the functionality provided via Cyber Access will be replaced and expanded to allow clients in the Montana Health Care Program (i.e., Montana Medicaid) to have access to their data. Our goal is for Medicaid clients to have web-based access to most of the following data where practical: Access to claims based information, including: Drug claims, Diagnoses, Procedures, Lab

values, Biometrics Healthcare and disease education



Health/medication optimization Therapy follow-up recommendations Printable personal medical profile Health/wellness links

In addition, coordination and combined priority development by Medicaid with other public health authorities within the DPHHS such as those listed below will provide a key opportunity for accelerating implementation. As part of the SMHP, the DPHHS will assess where these entities are with respect to developing or implementing HIE and how that fits within the SMHP to ensure coordination and to provide for reduced costs and efficiencies when possible.

Table 2.1 DPHHS Public Health Organizations involved in HIT/HIE ActivitiesFederally Funded State Public Health Program Division within DPHHS/Contact person

Mental Health Data Infrastructure Grants for Quality Improvement (SAMHSA) Addictive and Mental Disorders Division

Epidemiology and Laboratory Capacity Cooperative Agreement Program (CDC) Public Health and Safety Division

Immunization Program Public Health and Safety Division

State Children’s Health Insurance Healthy Montana Kids Program

Substance Abuse, Mental Disorders, and Mental Health Facilities Addictive and Mental Disorders Division

Explain the SMA’s relationship to the State HIT Coordinator and how the activities planned under the ONC-funded HIE cooperative agreement and the Regional Extension Centers (and Local Extension Centers, if applicable) would help support the administration of the MPIP.

Reporting directly to the Director of the DPHHS, the State Health Information Technology Manager is involved in many aspects of planning and operations related to the State Medicaid Program. As a member of the DPHHS Director’s Office, the HIT Manager has daily access to and interaction with the State Medicaid Director and other Medicaid management team members. The HIT Manager will participate directly in the selection of the replacement MMIS, with special focus on evaluation of HIT/EHR functionality.

The State HIT Manager is also an ex-officio member of the Montana HIE Designated Entity –HSM Board of Directors representing state interests in HIE, and serves as the contracting officer for any HSM activities under contract with the State.

2.1.3 HIE Designated Entity – HealthShare Montana (HSM)

HSM started as a large health information technology stakeholder group convened by Senator Baucus in 2006. It formed into a formal nonprofit in the summer of 2007, with financial contributions from a large number of healthcare organizations. A technical plan for statewide HIE was completed in the winter of 2008 by a committee comprised of top health information



technology leaders. A committee of experts on healthcare privacy and security created a set of principles and standards adopted by the HSM Board.

HSM is among the broadest and most diverse organization of healthcare leaders and stakeholders in Montana. Its 23-member board includes representatives from state government, major payers, consumer groups, large and small healthcare facilities and individual physicians. There are 55 participating stakeholder organizations and HSM has received a resolution of support from the Montana Medical Association (MMA).

HSM’s mission is to support the health of all Montanans through the development of statewide HIE infrastructure. The infrastructure will have the capacity to: Support health information delivery to the point-of-care Enable point-of-care clinical decision support to assist with preventive care and management

of chronic illness Will allow performance reporting and will enable electronic prescribing with medication

reconciliation

On May 29, 2009, Montana Governor Brian Schweitzer authorized HSM to “act as the state designated HIE entity for Montana.” In addition, the 2009 Legislature granted funding to assist HSM in becoming fully operational through a contract with the DPHHS. As the SDE for Montana, HSM is tasked with the planning and coordination of the statewide HIE, including, coordinating and assisting the other ARRA, HITECH, and HIT projects being funded throughout the state including the Regional Extension Center (REC) recipient, Mountain Pacific Quality Health (MPQH), Montana Medicaid, and any Beacon grant sub recipients such as Montana Tech. In addition to HIE, HSM offers resources to help providers meet the requirements of meaningful use in the areas of electronic health record and electronic prescribing as well as providing a focused effort in the improvement of physician quality reporting (5 pp. 25-26). The DPHHS will be working very closely with HSM to ensure qualified Medicaid providers meet meaningful use and obtain incentive payments. Governance of HSM is through its Board of Directors as it deems appropriate; however, under their by-laws established in 2007, HSM must allow stakeholder participation both on the Board of Directors and any working committees for the HIE. As part of its by-laws, HSM has developed a succession plan for its board of directors consistent with the mission and vision of the HIE (i.e. including multi-stakeholder involvement).

The HSM Board of Directors is expected to act in a manner that assures transparency and accountability to the fullest extent possible, including regular communications with constituents, stakeholders and participants, via online, print and briefings for state leaders and others charged with oversight for the funded activities.

Governance for the HSM must reflect the interests of the varied stakeholders that will participate, due to the following facts:



Montana providers will receive ARRA incentive funding for adoption, implementation, or upgrade (A/I/U) of a certified EHR in their first incentive payment year, as well as for becoming meaningful users (MU) of a certified EHR system.

HSM will provide a subset of services that providers need to become Meaningful Users. HSM will assist in improving the quality and efficiency of healthcare delivered to

Montanans. There will be multiple stakeholders that benefit from the services provided by the HSM,

including consumers and patients.

2.1.4 Montana Regional Extension Center (REC)

Health Technology Services (HTS), a division of Mountain-Pacific Quality Health is the federally designated HIT REC for the states of Montana and Wyoming. As the State’s REC, MPQH offers technical assistance, guidance and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of EHR. They provide the following services: Implementation Assistance – from initial readiness & needs assessments to EHR

Implementation and Support Meaningful Use Assistance – leveraging a provider’s EHR potential and creating reporting

processes to support attestation and data submission Education – training on eligibility and incentive potential, privacy and security best practices,

vendor selection and data migration and exchange Project Management – services to ensure a provider’s project objectives are met, on time and

on budget, using provider staff in the most efficient and effective manner Vendor Selection – assist with selection of certified EHR vendors and group purchasing Privacy & Security Support – provide training and consulting on privacy and security best

practices

2.1.5 Montana Exchange Networks

Montana’s larger healthcare systems and hospitals have implemented a variety of systems that provide the capacity for the electronic exchange of health information (Figure 2.1). EHR is in place in many hospitals and clinics. A few of the efforts underway are described in Sections 2.1.5.1 – 2.1.5.5.



Figure 2.1 Montana Exchange Networks1

2.1.5.1 Health Information Exchange of Montana (HIEM)

The Health Information Exchange of Montana, Inc. (HIEM) is a rural health consortium of healthcare organizations in northwestern Montana who have formally come together to address their shared unique geographic and technological challenges in order to exchange basic medical information and expand telehealth applications in the region. It is a non‐profit organization comprised of “five independently owned and operated hospitals and two federal funded Community Health Centers (6).”

HIEM used the ICA (Informatics Corp of America) CareAlign Aggregation Platform to integrate the facilities comprising the area’s healthcare system that include: Glacier Community Health Center Health Center Northwest Kalispell Regional Medical Center Lincoln County Community Health Center North Valley Hospital Northern Rockies Medical Center St. John’s Lutheran Hospital, St. Luke Community Hospital

1 Lake, Missoula, and Cascade counties do not match legend colors because they are covered by multiple Health Exchange Networks (i.e., Lake [HIEM and Monida], Missoula [Monida and Rocky Mountain], and Cascade [Rocky Mountain and North Central]).



Figure 2.2 Health Information Exchange of Montana

Each of the facilities had disparate legacy healthcare information technology on various platforms and in different locations (Table 2.2).

Table 2.2 Legacy HIT used by healthcare organizations associated with HIEMAmicas PACS HealthPort Document Imaging Midas+ quality alerts

ChartBuilder EMR HealthWyse Home Health MIE WebChart EMR

DR PACS ImageNow document imaging PenRad mammo

eClinical Works EMR Keane long term care Pyxis pharmacyorders

FileMaker EMR MedHost ED SoftMed transcription

Fletcher-Flora LabPak Meditech Client Server abstracting, admission, lab, pharmacy Tech-Time ADT

GE Centricity Perinatal Meditech MAGIC admission planning, pharmacy, order entry departmental, lab Xcelera cath images

GE QS OB fetal monitoring Microsoft Word Clinical Documents

ICA developed a phased implementation approach that first integrated existing healthcare technology into vaulted data with patient matching capabilities, allowing the segregation of source data by participant while also enabling a longitudinal healthcare record to be generated for a patient at any of the facilities. This was accomplished by selecting critical feeding systems, piloting the approach and then expanding the aggregation phase throughout the community.



HIEM has identified “exchange with the State’s health exchange, HSM” as a goal. HIEM has received FCC funding for the expansion of fiber optic connectivity within the northwest portion of the state and is currently contracting with vendors to enhance broadband services in that region.

2.1.5.2 North Central Montana HealthCare Alliance

The North Central Montana Healthcare Alliance is a collaborative consortium of 15 healthcare facilities (Figure 2.3). The membership of the NMHA includes Montana’s largest tertiary hospital, a 49 bed rural hospital, a freestanding nursing home, two Indian Health Service facilities, and ten Critical Access Hospitals. The 13 counties served by the NMHA member hospitals encompass 31,828 square miles ‐ that is an area larger than the combined size of Vermont, New Hampshire, Connecticut, Delaware and Rhode Island.

Figure 2.3 North Central Montana Healthcare Alliance

Members of the NMHA and their communities are: Benefis Hospitals, Great Falls Big Sandy Medical Center, Big Sandy Blackfeet Community Hospital, Browning Central Montana Medical Center, Lewistown Fort Belknap Hospital, Fort Belknap Liberty County Hospital, Chester Marias Medical Center, Shelby Missouri River Medical Center, Fort Benton



Mountainview Medical Center, White Sulphur Springs Northern Montana Healthcare, Havre Northern Rockies Medical Center, Cut Bank Phillips County Hospital and Medical Center, Malta Pondera Medical Center, Conrad Teton Medical Center, Choteau Wheatland Memorial Healthcare, Harlowton

2.1.5.3 Rocky Mountain Health Network

Established in 1991, the Rocky Mountain Health Network is a 500 member provider hospital organization based in Billings, MT that delivers healthcare services and solutions throughout Montana and northern Wyoming. Rocky Mountain Health Network serves 14 counties throughout Montana (Figure 2.4).

Figure 2.4 Rocky Mountain Healthcare Network

2.1.5.4 Monida Healthcare Network

As a Physician Hospital Organization, the Monida Healthcare Network is a regional association of healthcare providers, governed by member physicians and hospitals serving residents of Montana and Idaho. Monida Healthcare Network is a not‐for‐profit association consisting today of more than 550 providers, seven hospitals, and other healthcare providers in Montana and Idaho. Monida Healthcare Network serves seven counties in western Montana (Figure 2.5).



Figure 2.5 Monida Healthcare Network

2.1.5.5 Montana Frontier Healthcare Network

Critical access hospitals in Deer Lodge, Granite, Prairie, and McCone counties using a centralized ambulatory care information system approach that allows population health, quality reporting, and information exchange; vendor DocSite.

2.1.6 Tele-Medicine/Tele-Health in Montana

2.1.6.1 Montana Healthcare Telecommunication Alliance (MHTA)

MHTA is a national model recognized for collaboration and innovation. The MHTA, which includes healthcare organizations across Montana, works to promote advancements in telecommunications using video‐teleconferencing and telemedicine. MHTA is a network of networks: Eastern Montana Telemedicine Network METNET – State of Montana Partners in Health Telemedicine Network Realizing Education and Community Health, REACH - Montana, a service of Benefis Healthcare, Great Falls St. Patrick Hospital FORTH (Fiber Optic Rural Telehealth) Montana Advanced Telecommunications Alliance



2.1.6.2 REACH Montana Telehealth Network

Promoting telehealth for north central Montanans through the activities of the REACH MontanaTelehealth Network. This Great Falls based IP televideo network serves thecommunities of White Sulphur Springs, Choteau, Conrad, Cut Bank, Shelby, Chester, Fort Benton, Big Sandy, Rocky Boy, Havre and Chinook.

Inter‐network connections via private communications lines link RMTN with telehealth networks in Billings, hospitals in Kalispell, Butte, and Missoula, and connections to the capitol city of Helena via METNET (the State of Montana’s Televideo arm), and MHA, an Association of Montana Health Care Providers.

2.1.6.3 Montana Frontier Healthcare Network

Operates a web‐based telemedicine network currently comprising critical access hospitals inDeer Lodge, Granite, Prairie and McCone counties and a consulting hospital in Missoula County.

2.1.7 Other entities engaged in HIT/E activities within the State of Montana

Several other entities are engaged and/or are important stakeholders regarding HIT/E activities within the State of Montana (Table 2.3)

Table 2.3 Other Stakeholders important to Montana HIT/E activitiesOrganization Role/Activities

National Center for Health Care Informatics (NCHCI)

NCHCI, located in Butte, is a nonprofit organization organized to support the development of HIT. Recently NCHCI worked with San Diego-based Crossflo Systems to provide the state with its Data Exchange server software. The purpose was to facilitate data sharing to detect outbreaks associated with bioterrorism. A pilot project demonstrated the ability to rapidly develop and deploy health information for the purpose of detecting naturally occurring or bioterroists’ pathogens in their pre-epidemic phases (syndromic surveillance). NCHCI states in a news release that this system has the capacity to support other HIE.

Montana Medical Association (MMA)

The Montana Medical Association (MMA) represents Montana physicians regarding important issues that concern them.

Montana Primary Care Association (MPCA)

The Montana Primary Care Association (MPCA) represents Federally Qualified Health Centers (FQHCs) regarding important issues that concern them.

Montana Dental Association (MDA)

The Montana Dental Association (MDA) represents dentists regarding important issues that concern them.

City/County Health Departments

The state of Montana and the network of city and county health departments collect and share extensive data, including communicable diseases, vital statistics, Medicare and Medicaid.

Urban Indian Health Clinics

Approximately 45% of the UIHPs receive Medicaid reimbursement as Federally Qualified Health Centers (FQHC) and others receive fees for service under Medicaid for allowable



Table 2.3 Other Stakeholders important to Montana HIT/E activitiesOrganization Role/Activities

services, i.e. behavioral services, transportation, etc

State Alliance for e-Health’s Regional Health IT Consultation

Collaborative established to assist states in coordination with CMS and ONC

2.2 Current State activities that will facilitate HIE and EHR adoptionWhat State activities are currently underway or in the planning phase to facilitate HIE and EHR adoption? What role does the SMA play? Who else is currently involved? For example, how are the regional extension centers (RECs) assisting Medicaid eligible providers to implement EHR systems and achieve meaningful use?

State HIT activities supporting the facilitation of HIE and EHR adoptions include: Planning Advanced Planning Document (PAPD) development and approval As-Is Surveys Environmental Scan State Medicaid Health Information Technology Plan (SMHP) Implementation Advanced Planning Document (IAPD) development and approval Coordination with the:

CMS ONC REC HSM

In June 2010, the DPHHS released a series of questionnaires to State stakeholders (Table 2.1) to address the HIT landscape. These stakeholders were not requested to conduct formal outreach to providers. Instead, these organizations were engaged to offer their perspective of the HIT/EHR capabilities representative among the provider community with whom they are engaged on a daily basis. The DPHHS followed up these questionnaires with a series of interview sessions with the same and extended set of stakeholders.

The formal statewide outreach activity designed to assess the Montana HIT landscape was achieved through a formal survey process known as the Environmental Scan. The DPHHS contracted with HSM to perform the State’s Environmental Scan, which was completed in January 2011. The results from the internal assessment and the Environmental Scan were used to develop the SMHP, and are presented in part in Section 2.4.1 as well as other areas of the SMHP. The final findings of the Environmental Scan are presented in its entirety in Appendix A of this document found on page 97.

Other roles and responsibilities of the DPHHS as related to the facilitation of EHR and HIE include: Oversight of Eligible Provider (EP) and Eligible Hospital (EH) Registration, Attestation,

Audit, and Payment activities associated with the MPIP Participation in formal monthly meetings with MPQH, HSM



Attendance at all meetings with ONC and CMS Conducting status meetings with MPQH and HSM Conducting status meetings with internal stakeholders Participation in monthly board meetings with HSM Oversight of HSM’s Environmental Scan Establishing policy as it relates to the Medicaid Agency’s use of EHR

Other entities involved in State activities to facilitate HIE and EHR adoption includes: HSM MPQH

HSM is the State’s Designate Entity for HIE. As the State’s HIE Designated Entity, HSM has been involved in the planning, development and implementation activities for a statewide HIE. Activities to date include: Formation of HIE Workgroups

Technology Public Interest Finance Clinical Legislative Governance

Submission of the Strategic and Operational Plans for the statewide HIE Piloting a project with DocSite, a HIE vendor. The project is testing DocSite’s functionality

and ability to provide HIE to a variety of provider types including large urban hospitals, small rural hospitals, community health centers, and established regional HIE networks.

Development of a comprehensive, statewide Environmental Scan in coordination with the DPHHS, Montana Tech, Montana’s Regional Extension Center, Montana Primary Care Association, Montana Hospital Association, MPQHF, and Eastern Montana Telehealth Network.

Hosting monthly Board of Director’s meetings to discuss progress

MPQHF has been offering technical assistance, guidance and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of EHR.



2.3 Other activities that may influence the MPIP over the next five years

2.3.1 Medicaid Health Improvement Program

In 2009, Montana designed a new statewide Health Improvement Program as an enhancement to Passport to Health, Montana Health Care Program’s Primary Care Case Management (PCCM) Program. This enhanced PCCM is operated through a network of Passport providers consisting of 14 Community Health Care Centers (CHCC) statewide who receive an enhanced case management fee to work with on average a total of 3,000 to 3,500 Passport eligible clients a month who have been identified as high risk, high cost through predictive modeling, or have been referred by a primary care provider. In addition to location, coordination and monitoring of primary health care services, enhanced services include the following: Conduct patient health assessment within 30 days of State referral of patient to Provider.

Patients who cannot be reached or who prefer not to participate in an assessment initially are placed in “on demand” status and additional contact attempts are made at least twice during the following 12 months.

Provide initial and ongoing clinical assessment at pre-determined intervals such as 30, 60, 90 days and one year, depending on diseases and risks.

Tailor a holistic treatment/action plan for each enrolled patient in consultation with patient’s primary care provider.

Manage patients as indicated—in person, telephonically, or other means suited to the individual.

Provide group appointments for education and prevention when appropriate. Monitor and remind patients about routine testing; provide follow-up education regarding

tests. Coordinate services with existing partners and form new partnerships (examples—hospitals,

community primary care providers, specialists, social service and non-profit programs). Participate in multi-disciplinary hospital pre-discharge planning and counseling. Provide post hospital discharge visits, in-person and/or telephonic. Educate and support patients in self-management of health conditions. Be familiar with and refer patients to available local resources that can help patients with

social services, housing, and other life problems that could prevent patients from paying attention to medical conditions.

Track patient data—enrollment status, diseases, risks, interventions, and outcomes—and report to the State.

In conjunction with the State, incorporate new methods such as remote disease monitoring or virtual video visits as technology is available and appropriate.

Monitor patient progress and determine criteria for completion/graduation.

Currently, the CHCC’s and the State use a combination of internal software products (e.g., Commercial of the Shelf (COTS) case management systems such as Daphne and Pathways Compass), paper files, and MS Excel spreadsheets to manage the program. The current process is both time consuming and prone to error, in part because staff must enter the same information



into multiple information management systems. As HIT/HIE initiatives move forward, the State looks forward to improving the processes and tools that support the MHIP to enable the DPHHS to meet the following objectives: Improve the collection of health outcome information for Medicaid clients enrolled in the

MHIP Improve the consistency of data collected from each CHCC Consistently track interventions and help determine which intervention are most successful

by population type Compare programs across state based on numbers of clients serviced, time spent with clients,

client health outcomes, and cost Measure client satisfaction related to the involvement with the program. More efficiently compare historical predicted patient risk scores and costs with actual health

outcomes and costs to determine cost savings

2.3.2 MMIS ReplacementWhat other activities does the SMA currently have underway that will likely influence the direction of the MPIP over the next five years?

On December 3, 2010, Montana DPHHS released a Request for Proposals for the Design, Development, Implementation, and Operation of a new MMIS. This project has an anticipated completion date of April 2014.

In addition to advanced capabilities related to the handling of standard electronic health record data, DPHHS has also included the scope and functionality of the MPIP into the requirements of the new MMIS. Our goal is to fully integrate the administration of the incentive program with our MMIS in order to take advantage of advanced provider management functionality that will be incorporated in the new Medicaid processing system. This process will allow Montana to further our goals of offering seamless interaction to providers for all Medicaid related activities via a single web interface. Through this process, our intent is to reduce the overall burden and impact on providers for not only traditional provider enrollment and credentialing activities, but also the attestation and meaningful use requirements related to compliance with the rules of the incentive program.

2.3.3 State Law or Regulation impact on EHR incentivesHave there been any recent changes (of a significant degree) to State laws or regulations that might affect the implementation of the MPIP? Please describe.

No significant changes in Montana laws or regulations have been identified that would impact our MPIP.



2.3.4 State Broadband Access in MontanaTo what extent does broadband internet access pose a challenge to HIT/E in the State’s rural areas?

Broadband penetration across Montana is similar to that in all states, with greater access in more urban areas than in small and rural parts of the State. While any individual provider can implement an EHR system internal to the organization, the ability to participate in an exchange network is limited or impossible if broadband access is unavailable or unreliable. Montana’s Environmental Scan indicated higher than expected levels of access to high-speed internet connectivity (Figure 2.6).

No Internet access0.6% Dial Up

1.3%

DSL47.1%

Broadband58.0%

Other 14.0%

Figure 2.6 Internet connectivity of provider’s participating in Montana’s Environmental Scan

Did the State receive any broadband grants?

There are numerous federal funding agencies for broadband efforts and Montana stakeholders have applied for and received grants under several funding sources. Seven broadband grants (Table 2.4) have been awarded to State government and private entities within the State.



Table 2.4 Broadband Grants received within the State

Granting Organization Project Type Receiving Organization Description of Project/Effort Award

Amount

The National Telecommunications and Information Administration (NTIA

Mapping and Planning Activities

Department of Commerce2

The broadband mapping portion of this project will consist of data collection, development of a statewide broadband availability map, transmission of that data to NTIA for the development of its national broadband map, and the long-term maintenance of these data by the state.

The planning portion of this project will focus on outreach and facilitation to identify and prioritize broadband access needs and solutions in local communities and across the State. (7)

$2.086 Million3

$300,0004

$3.221 Million5

2 Governor Brian Schweitzer specifically designated the Montana Department of Commerce as the agency to apply for and receive these funds for the purposes of expanding health, education, and economic development throughout Montana.3 Grant award amount in federal dollars4 Funding leveraged by the Department of Commerce that was appropriated in the Montana Reinvestment Act (HB 645) for broadband mapping5 In-kind services from the existing Montana Cadastral Mapping Program as the state match for the federal grant





Amount

Department of Commerce Broadband Technology Opportunities Program (BTOP) Awards

Expanding Infrastructure and Services

University Corporation for Advanced Internet Development

“The project proposes a large-scale, public-private partnership to interconnect more than 30 existing research and education networks, creating a dedicated 100-200 Gbps nationwide fiber backbone with 3.2 terabits per second (TBps) total capacity that would enable advanced networking features such as IPv6 and video multicasting. The project plans to connect community anchors across all disciplines into virtual communities with shared goals and objectives, including colleges, universities, libraries, major veterans and other health care facilities, and public safety entities, with additional benefits to tribes, vulnerable populations, and government entities.

$62,540,162.00

Department of Commerce BTOP

Public Computer Centers

Montana State Library

By investing in public libraries, our project will make sustainable broadband enhancements available to 86% of the Montana population. It will increase average facility broadband speeds at participating libraries to 21 mbps, while cutting wait times in half by increasing the total number of computers. It will extend health, education, and job services to vulnerable populations in most need.

$ 1,829,473

Department of Commerce BTOP

Sustainable Broadband Adoption

Communication Service for the Deaf, Inc.

This project intends to expand broadband adoption among people who are deaf and hard of hearing and provide them with online tools to more fully participate in the digital economy. The project proposes to employ a combination of discounted broadband service and specialized computers, technology training from an online state-of-the art support center customized to the community’s needs, public access to videophones at anchor institutions

$14,988,657





Amount

from coast to coast, and a nationwide outreach initiative. Thousands will gain online access to all the Internet has to offer, including sign language interpreters, captioned video services, and other content and functionalities designed especially to advance their educational, employment, and healthcare interests.”

United States Department of Agriculture (USDA) Broadband Initiative Program (BIP)

Last Mile Non-Remote Area

Reservation Telephone Cooperative

This project, using Fiber-to-the-Home technology, brings affordable and reliable broadband access and video services to underserved rural areas in western North Dakota and eastern Montana communities in and around the Fort Berthold Indian Reservation, including the remote Squaw Gap service area and the partially remote Mandaree, New Town, Parshall and Roseglen service area.

Grant request$ 10,950,000Loan request $ 10,950,000

USDA BIP Last Mile Project Telephone Company

The project will expand high-speed Internet service on the Crow Indian Reservation in southeastern Montana, providing broadband access to approximately 1712 locations.

Grant Request:$11,662,109.00Loan Request:$3,887,370.00Other Funding:$165,000.00

USDA BIP Last MileNemont Telephone Co-Operative, Inc.

This project will provide Fiber to all locations within the Fort Peck Indian Reservation exchanges of Brockton, Froid Rural, North Poplar, North Wolf Point, and Frazer that do not currently have access to 5Mbs (up and down combined). This project will also bring Fiber to the exchange of Poplar which is the headquarters of the Fort Peck Assiniboine-Sioux Tribes. It is estimated that approximately 7,250 people, 200 businesses, and 40 other community institutions will benefit from this project and create more than 280 jobs. (8)

Grant Request: $23,394,510.00Loan Request:$2,599,390.00Other Funding: $566,000.00Total:$26,000,000.00 (9)





Amount

USDA BIP Last Mile Montana Opticom, LLC

This project will expand high-speed broadband to rural communities and rural areas within Gallatin County, Montana. More than 18,500 people, approximately 4,100 local businesses and 58 community institutions stand to benefit from this improved service. Montana Opticom, LLC estimates that this project will directly create at least 650 jobs. (8)

Grant Request: $32,000,000.00Loan Request:$32,127,322.00Total: $64,127,322 (9)

2.3.5 HIT Related Grants Awarded to the StateIf the State was awarded an HIT-related grant, such as a Transformation Grant or a CHIPRA HIT grant, please include a brief description.

2.3.5.1 Medicaid Transformation Grant

The DPHHS received two transformation grants from the CMS. On January 25, 2007, the CMS awarded the DPHHS a $1,481,152 Medicaid Transformation Grant for Enhancing EHR – Clinical Decision Making during the first grant selection period (10). The purpose of this grant was to enhance its maintenance of EHR by expanding the capacity of its secure Web-based system to house information about the overall health status of each Medicaid recipient, as monitored against published national disease guidelines (11). On September 28, 2007, CMS awarded the DPHHS a $601,126 Medicaid Transformation Grant to improve Lien and Estate Recoveries. (10) The purpose of this grant was to automate the existing manual system of identifying claims for lien and estate recovery and improve the lien and estate recovery system in the collection of nursing home recipient personal needs accounts/burial accounts.

2.3.5.2 Children’s Health Insurance Program (CHIPRA) Grant

The DPHHS received a CHIPRA Grant of $907,868 for Federal Fiscal Year 2010. However, the primary goal of this grant was to assist families in applying and obtaining health care coverage for children through various outreach activities (12).

2.3.6 Medicaid Information Technology Architecture (MITA) Self AssessmentHas the State coordinated their HIT Plan with their MITA transition plans and if so, briefly describe how?



MITA's goals of seamless, integrated systems and the provision of timely, accurate, and easily accessible data received a considerable boost with the inclusion of the HITECH provisions in the ARRA. HITECH's emphasis on standardization and simplification of health information exchange via EHRs shared across HIEs underscores the MITA principles of transparency, interoperability and accountability. MITA guidelines provide a framework for States to use as they modernize their MMIS, and develop systems whose interoperability with other government and industry health systems and data repositories will facilitate the HITECH goal of expeditious health information reciprocity among Medicare, State Medicaid Agencies, and providers of health services. With MITA’s promotion of IT that smoothly spans enterprises and HITECH’s directive for health information exchange across different provider entities, both MITA and HITECH forecast a soon-to-be realized future where expansive IT is positioned to meet business needs, in place of the current era where health system activities are too often shaped and proscribed by IT limitations.

MITA has, from its inception, been characterized by providing a long-range vision of how States will mature their MMIS and Medicaid programs over a period of five to ten years. This model is embodied in the MITA concept of operations and demonstrated through the "to-be" vision of Medicaid operations that States document using the MITA State Self-Assessment (SS-A). Through HITECH, State Medicaid Agencies now have an opportunity to apply this MITA vision to developing an HIT/E landscape that will support the broad transformation of Medicaid’s administrative, clinical and IT enterprise. Development and implementation of the State Medicaid HIT plan and subsequent meaningful use of EHRs by Medicaid providers are in direct alignment with MITA maturity level 4, which calls for the integration of clinical data into the MMIS work flow to help monitor quality and improve the outcomes of Medicaid beneficiaries.

On December 3, 2007, the State of Montana MMIS Management Group held an Executive Visioning Session facilitated by FOX. The vision statements from that session were cross-walked to the MITA goals to produce the following guiding principles were established for the project:

Table 2.5 DPHHS Executive Guiding PrinciplesMITA Goal DPHHS Guiding Principle

Integration and Interoperability

Medicaid eligibility determination is not in scope for this project, but the eligibility systems must interface with the MMIS and provide all data required to administer the health care programs

Need interoperability to share data with public health

Flexibility to respond rapidly to change

MMIS capability and staff need to support exchange of EHRs

MMIS capability must include a way to calculate cost sharing and benefit limits so providers obtain current information

Enterprise view to align technology and business needs

Data from silo systems must be integrated for an enterprise look at programs and other agency data

The MMIS must meet federal/state Medicaid and HIPAA standards and be



Table 2.5 DPHHS Executive Guiding PrinciplesMITA Goal DPHHS Guiding Principle

certified

Privacy and security of health information is critical while enabling the sharing of information across agencies and systems.

Business functions must drive technical solutions and the MMIS capability must be flexible to meet future needs including new regulations and innovations.

Look at ways to automate manual processes.

Business rules in the MMIS must be in sync with administrative rules and State plan.

Both MMIS and DSS must support benefit designs for multiple programs including other state healthcare programs

Budget constraints will be a factor in determining the feasibility of new MMIS functionality

Business rules in the MMIS must be in sync with administrative rules and State plan.

Data that supports analysis and decision-making

MMIS capability must be able to support the use of clinical data, such as lab test results

MMIS capability must be able to support information needed to measure the outcome of treatment and the changing health status of recipients

Performance measurement for accountability and planning

MMIS capability must be able to support new reimbursement methodologies

Coordinate with Public Health and other partners to improve overall health

The MMIS capability needs to focus on the needs of the recipient

Care coordination/disease management will require additional clinical data for high cost and high risk beneficiaries

MMIS capability must be able to support all types of external interaction with providers, based on the capabilities of the provider

Coordination of benefits between plans requires cooperation between Medicaid and other health plans

In 2010, the DPHHS completed the development of its MMIS and Fiscal Agent Re-Procurement RFP. In preparation for this re-procurement, DPHHS completed a MITA SS-A, and then focused on gaps identified by business users where newer technologies, automation, and higher MITA maturity level capabilities are needed to fulfill the “To Be” vision of the business users. The DPHHS business users and Technology Services staffs reviewed the MPIP Final Rule for administration of the Incentive Program and collection of Meaningful Use measures from eligible providers, and then revised the MMIS requirements for HIE/HIT section of the RFP to include known MMIS changes necessary to administer the MPIP such as: issue payments to providers; audit attestation, Medicaid thresholds; check sanctions and licensing databases, etc.).



In preparing the SMHP, the State included MMIS HIT/HIE related efforts aligned with regulatory requirements and DPHHS’ desire to implement the MPIP by mid 2011.

2.3.7 State SystemsPlease describe the role of the MMIS in the SMA’s current HIT/E environment.

2.3.7.1 Medicaid Management Information System (MMIS)

Although the current MMIS environment makes very limited use of EHR, Medicaid does deploy a variety of applications and processes related to the transaction of electronic records containing healthcare related information. Examples of these electronic transactions are eligibility, claims, and prior authorizations. The following summary outlines the basic framework of the electronic environment related to the MMIS.

Montana’s current MMIS system is a mainframe based CICS/VSAM application using COBOL and has been in operation since 1985. The core MMIS resides on the ACS mainframe located in Pittsburgh, Pennsylvania. Montana uses several subsystems to expand the functional capability of the core MMIS. The subsystems include the Pharmacy Benefits Management System (PDCS); Drug Rebate Analysis and Management System (DRAMS), Data Warehouse and Decision Support System (DSS); Advance Fraud Detection support (OmniAlert); a HIPAA EDI Translator solution and a Provider Web Portal, including a Claims-Based Medical History component.

The Pharmacy Benefits Management system is an on-line real time system used by enrolled pharmacy providers to submit pharmacy claims to the Montana Health Care Program and MHSP program. The system electronically verifies recipient eligibility, product coverage status, applicable co-pay requirements, and adjudicates the claim. Also integrated into the system are prospective drug utilization review edits. The PDCS and DRAMS systems are owned and operated by the existing MMIS Fiscal Agent, with the State being one of several government and private users of the system.

The State maintains ownership of the Data Warehouse used in support of the current DSS solution, but licenses the query tool used to access the data.

Recently, additional applications have been deployed to enhance management of Montana’s Medicaid programs. Impact PRO is a predictive modeling application used by Montana Medicaid for care management activities. Cyber Access is a web-based application that enables healthcare providers or their staff to access Electronic Health Records, obtain Prior Authorization, and E-prescribe.

The State licenses a HIPAA EDI translator solution from the existing MMIS Fiscal Agent. This translator allows the processing of electronic claims and other standard ANSI X12 transactions as required by HIPAA.



The Montana Web Portal provides static content (such as provider manuals, notices, and newsletters), and dynamic content (ANSI X12 transactions, both real-time and batch) to all authorized providers. In addition, the Montana Web Portal provides secure Medical Claims History functionality. The Medical Claims History portion of the Montana Web Portal assists providers in the treatment of patients by allowing them to access a client’s medical claims history interactively. For example, a primary care provider can view information related to emergency room visits for their Care Management clients. Providers can inquire on up to three years of patient claims history. The information returned is from claims data processed by Medicaid and includes the name of the provider who rendered the service, diagnosis codes(s), service(s) delivered by procedure/revenue/NDC code, service description(s) (office visit, lab, etc.), and prescribed drug information. Effective March 1, 2007, providers were able to enroll in Medicaid or HMK using the enrollment capability built into the Web Portal. The information is typically updated weekly.

As discussed earlier in this document, Montana will replace our existing MMIS in April 2014.

2.3.7.2 Immunization Information SystemWhat is the current interoperability status of the State Immunization registry and Public Health Surveillance reporting database(s)?

The State Immunization Information System (IIS) currently receives batch files from a small number of providers. These files are then translated by a programmer to an appropriate file that then can be loaded into the registry. There is limited standardization from the vendor file which requires a significant amount of staff time to set up, however once the batch file has been made there is little maintenance to the file transfer. In December 2010, the DPHHS awarded a contract to Scientific Technologies Corporation (STC) to replace its legacy IIS with the Maine version of the Wisconsin Immunization Registry (WIR). The new system, imMTrax, will provide the framework to increase provider participation via electronic interfaces and increase public health’s role in Federal and State HIT initiatives.

As part of this effort, the DPHHS, in partnership with STC, will be making necessary enhancements to imMTrax to adhere to the changing national data exchange standards (upgrading from HL7 2.3 to HL7 2.5), in addition to identifying and assisting providers and their Electronic Health Record (EHR) vendors to exchange data with imMTrax.

2.3.7.3 Public Health Surveillance

There are two types of public health surveillance systems – general reportable conditions surveillance and syndromic surveillance. The current general reportable conditions surveillance system (Montana Infectious Disease Information System – MIDIS) is a NEDSS compatible system with PHIN compliant components. This system is in the testing phase for receipt of electronic laboratory reporting from commercial, hospital and public health laboratories. The syndromic surveillance application, developed by Northrop-Grumman, has been non-operational since 2009. Due to the small size of Montana and its emergency department encounter dataset,



the system was found not to be useful for syndromic surveillance. In addition, when the state of Montana switched to Oracle 10G, a major software development effort for the system was deemed not to be financially or operationally feasible. Syndromic surveillance data from Montana healthcare facilities will need to be received into a different data system in the future, if deemed necessary for meaningful use requirements.

2.4 As-Is Provider HIT/HIE1. Does the SMA have data on EHR adoption by types of provider (e.g. children’s hospitals, acute care hospitals,

pediatricians, nurse practitioners, etc.)?2. What is the current extent of EHR adoption by practitioners and by hospitals?

a) How recent [are these] data? b) Does it [Do the data] provide specificity about the types of EHRs in use by the State’s providers? c) Is it specific to just Medicaid or an assessment of overall statewide use of EHRs?

3. Does the SMA have data or estimates on eligible providers broken out by types of provider? 4. Are there any HIT/E activities that cross State borders? Is there significant crossing of State lines for accessing health

care services by Medicaid beneficiaries? Please describe.

As discussed earlier, HSM is the state designated Health Information Exchange organization. In the fall of 2010, DPHHS commissioned HSM to conduct an extensive survey of the Montana healthcare provider environment. The HSM Environmental Scan was designed to achieve several goals relative to the current landscape of HIT/EHR in Montana: To determine the extent to which Montana providers use EHR technology in their existing

practices, To ascertain information related to EHR planning, both strategic and tactical, across the

entire spectrum of healthcare providers, To determine the level of information technology resources available to providers in the form

of organizational IT staff, or contracted IT support, To determine the real and perceived barriers to the implementation of meaningful EHR

technology faced by Montana providers.

The survey was completed in December 2010. The results are extremely enlightening, and provide an intriguing view into the HIT/EHR readiness of the providers in our state. Many of those findings are presented in following sections. The complete Environmental Scan is available in Appendix A on page 103.

2.4.1 Montana Provider Practice Landscape

The Montana healthcare provider environment reflects many of the unique characteristics of Montana and Montanans. Among those characteristics is a deep sense of community, as well as a profound sense of self reliance and individualism. For example, the Environmental Scan indicated that almost 90% of respondents were affiliated with a privately owned practice (Figure 2.7). Only 7.8% indicated participation with a hospital-owned organization (Figure 2.7).



Privately owned practice

87%

Hospital-owned practice8%

Other5%

Figure 2.7 Organizational ownership of provider practices in Montana

In addition, over 72% of respondents indicated they were part of a solo or partnership practice, versus a group or other type of practice arrangement (Figure 2.8). Almost 70% of respondents reported their organization had a single site (Figure 2.9). This result presents a very clear picture of the practice landscape in Montana, which is marked by smaller, more community focused entities.

Single/Solo53.8%

Partnership18.5%

Group21.5%

Other6.2%

Figure 2.8 Types of provider practices in Montana



No67.5%

Yes32.5%

Figure 2.9 Provider practices with multiple sites/locations

2.4.2 Montana Provider EHR Landscape

The Environmental Scan reflected that an encouraging number of Montana providers, nearly 30%, have an integrated EHR component (Figure 2.9). While more than 40% of respondents indicated the deployment of a stand-alone practice management system, many vendors have developed available add-on modules that provide EHR functionality and would eliminate the need for the provider to implement a new management system (Figure 2.10). DPHHS, HSM, and the REC will use this data for initiating provider outreach activities statewide, particularly in anticipation of the launch of the Medicaid MPIP in Fall 2011. Concerted provider outreach activities including web-based seminars and public meetings will begin in July 2011.

13.3%

45.3%

29.3%

4.7%7.3%

Do not have oneStand-alone-systemIntegrated with EHRNot applicableUnsure

Figure 2.10 Integration of EHR within Practice Management Systems used by Montana providers



Among those providers with EHR capable or EHR ready systems, half of the respondents indicated the use of a self contained system operating within the practice’s own IT infrastructure. Only 14% of those surveyed indicated the use of an external IT vendor or ASP to support and operate EHR hardware (Figure 2.11).

50.0%

14.6%

22.9%

12.5% Self-contained system operating within the provider's business.

Application Service Provider (ASP) Vendor hosts the system

EHR system is owned by another healthcare provider (hospital, clinic, or Federally designated network organization)

Other

Figure 2.11 EHR hardware configuration

Although this information is encouraging, a disappointing number of respondents indicated a continued reliance upon traditional paper files for short and long-term storage and access to patient information, reinforcing the concept that old habits are hard to break (Figure 2.12).

61%

6%

33%

Paper medical records/charts filed in a cabinet.

Computer-based system in which paper records/charts are scanned and stored electronically. This system can also be described as a document imag-ing management system (DIMS).

An electronic health record (EHR) system that stores patient medical and demographic informa-tion in a computer database that is accessed by computer terminals or other electronic means. (An EHR may also include or be connected to a DIMS.)

Figure 2.12 Provider practice methods for storing medical records



Montana providers overwhelmingly point to the initial cost of functional EHR systems as the single largest barrier to deployment, followed distantly by the perception of insufficient return on such an investment in their practice (Figure 2.13).

Initial cost

Insufficient return on investment

Confusing number of EHR choices

Currently available EHR products don't satisfy our needs

Staff does not have the expertise to use an EHR

EHRs lack interoperability with other information sys-tems resulting in high interface costs

Decreased office productivity during implementation resulting in decreased revenue

Concern that EHR choice will quickly become obso-lete

Staff is satisfied with paper-based records system

Other (please specify)

75%

36%

34%

16%

28%

26%

24%

22%

28%

31%

Figure 2.13 Reasons Montana providers do not currently use an EHR system

Based on the preceding data, it is easy to understand the reluctance of providers to invest in EHR functionality in spite of the obvious benefits such technology could bring to a healthcare organization. Only 42% of surveyed providers indicated certain intent to deploy EHR technology within the next two years (Figure 2.14).

24.0%

18.0%

12.0%

35.0%

11.0%

Within 1 yearWithin 2 years3 years or longerNo plansOther (please specify)

Figure 2.14 Expected EHR deployment horizon for Montana providers



Today, the Montana provider community, in general, widely uses telemedicine and telehealth processes. Geographic dispersion accounts for much of this use, with provider indicating a strong preference for telemedicine in the areas of continuing medical education for themselves and staff, as well as the effectiveness of telemedicine for treatment (Figure 2.15).

Providing patient care

Consults to other providers about patient care

Receiving information from home monitoring equipment

Videoconferencing

Nursing call centers

Continuing medical education

Grand rounds

Distance learning

Other

42.7%

35.9%

5.8%

59.2%

2.9%

65.0%

21.4%

68.0%

10.7%

Figure 2.15 Telemedicine/Telehealth services actively used by Montana providers

Although widely used in Montana, telemedicine has unique barriers among the provider community (Figure 2.16).

Cost of equipment

Lack of communication connection (Internet)

Cost of communication connection (Internet)

Physician credentialing and privileging issues

Lack of clinical resources

Lack of technical resources

Reimbursement issues

Other

66.4%

6.9%

20.7%

25.0%

19.0%

34.5%

44.8%

19.8%

Figure 2.16 Barriers to using Telehealth/Telemedicine by Montana providers



2.4.3 Potential for Montana Providers to Participate in State Medicaid Provider Incentive Program

Results of the Environmental Scan present a sobering view of the degree to which providers regard participation in available EHR incentive programs, and clearly reflects a lack of full understanding and/or information regarding the available programs. Although only 9% of providers indicated that they would definitely pursue participation in the state MPIP, 30% indicated they were unsure at this point (Figure 2.17). This is a clear indication that additional outreach and education is necessary in order for providers to more accurately determine the appropriate track to follow.

Beginning in the summer of 2011, DPHHS and the REC, in conjunction with other stakeholders, will begin a series of public meetings and informational sessions designed to educate and inform providers with respect to the incentive program. These activities will continue throughout the time period leading up to the anticipated launch of the program in November 2011. Section 3.3 starting on page 51 contains more details regarding provider outreach via the MPIP State Level Repository website.

Medicare16.1%

Medicaid9.0%

Both Medicare and Medicaid

18.7%No26.5%

Unsure29.7%

Figure 2.17 Providers planning participation in Medicaid or Medicare Incentive Programs

One of the greatest areas of concern for both Montana DPHHS and the provider community is the patient volume qualifications required to participate in the state’s MPIP. Due to the very rural nature of our state, as well as the dispersion of our population (i.e., Montana ranks third lowest in population per square mile among the 50 states), many providers simply do not serve the level of Medicaid patients that is currently required under the final rule. The Environmental Scan reflects very discouraging results related to this factor, with nearly 40% of respondents indicating a total Medicaid patient load of less than 10% and only 20% reporting a Medicaid patient load of greater than 30%. While this result includes both hospital and physician respondents, it clearly indicates that many Montana provider organizations will struggle to demonstrate patient volume required to participate in the MPIP, and will be forced to pursue the reduced funding available through Medicare.





Figures 2.18 and 2.19 illustrate the disparity of Medicaid versus Medicare patient volumes among Montana providers.

39%

20%

20%

20%

0-9%10-19%20-29%Greater than 30%

Figure 2.18 Percentage of providers serving 0-9%, 10-19%, 20-29%, and greater than 30% Medicaid patients, respectfully

14%

14%

12%

59%

0-9%10-19%20-29%Greater than 30%

Figure 2.19 Percentage of providers serving 0-9%, 10-19%, 20-29%, and greater than 30% Medicare patients, respectfully



2.4.4 Use of Electronic Lab Records in Montana

Per the 2010 Environmental Scan, Montana providers still rely predominantly (approximately 80%) on paper records for the delivery of lab results (Figure 2.20).

Fax63.1%

Proprietary lab system15.5%

Mail4.8%

Other16.7%

Figure 2.20 Laboratory results delivery methods used by providers in Montana

The DPHHS in cooperation with providers is working on initiatives to increase capabilities for the transmission of electronic laboratory records (Figure 2.21 page 41). In 2010, the DPHHS received Epidemiological Laboratory Capacity (ELC) funding from the CDC. The DPHHS is exchanging electronic data with the Public Health Laboratory Interoperability Project (PHLIP). In addition, the Montana Public Health Laboratory (MTPHL) and Mayo Laboratory are sending test results of reportable conditions to DPHHS’ MIDIS Surveillance System. The DPHHS is also working with Hospital Laboratories statewide to facilitate Electronic Laboratory Reports (ELR) data exchange.

MTPHL will directly transmit daily HL7 messages of Influenza laboratory test results from the Laboratory Information System (LIS) to the CDC Influenza Branch. This will replace the current web based manual data entry that DPHHS performs weekly. The PHLIP project is currently in production.

MTPHL directly transmits test results of reportable conditions from the LIS to the MIDIS. MTPHL developed a customized interface, which is ready to send test messages from LIS to MIDIS.

As funding and resources allow, these projects will be expanded to additional laboratories, targeting the larger laboratories that are more likely to have reportable conditions or use the MTPHL as a reference laboratory.



Figure 2.21 Montana Public Health ELR Initiative



2.4.5 E-Prescribing in Montana

Although on the rise, utilization of e-prescribing functionality among Montana healthcare providers remains very low. In fact, Montana ranks 48th out of the 50 states plus the District of Columbia with respect to the total volume of e-prescribing activity. Total prescriptions routed electronically continue to grow considerably from 9,467 in 2007 to 294,231 in 2009. In addition, more than 90% of Montana pharmacies are equipped to accept electronic prescriptions. However, that process is hampered considerably when only 18% of Montana physicians were routing prescriptions electronically as of 2009 (14) (14).

The Environmental Scan sought to gather information related to providers capabilities, plans, and perceived barriers regarding the implementation of e-prescribing functionality. A majority of Montana providers view e-prescribing as a very low priority within their organizations, with nearly 70% indicating no e-prescribing functionality within their organizations, and more than 50% indicating no plans to implement e-prescribing (Figures 2.22 thru 2.24).

Uses a stand-alone e-prescribing tool5.4%

E-prescribing is a component of EHR

25.7%

No e-prescribing solution68.9%

Figure 2.22 Montana providers with e-prescribing capability

Pharmacies in area don't partic-ipate in e-prescribing

30.4%

Provider's prefer to fax pre-scriptions

13.0%

Miscellaneous other reasons including immature process

56.5%

Figure 2.23 Barriers for use of e-prescribing by providers who have e-prescribing functionality



Implementing in 2010-201122.8%

Considering Implementation af -ter 2011

25.7%

Not considering implementation51.5%

Figure 2.24 Provider implementation plans for e-prescribing in Montana

Per the Environmental Scan, a significant percentage of providers (48.5%) noted that the initial cost of implementing e-prescribing was a barrier (Figure 2.25).

Initial cost

Insufficient return on investment

Shortage of available IT staff

Competing priorities

Local pharmacies don't participate in e-prescribing

Not reason provided

Other

48.5%

24.2%

33.3%

21.2%

18.2%

42.4%

9.1%

Figure 2.25 Reasons providers in Montana are not implementing e-prescribing



2.4.6 Federally Qualified Health Centers (FQHC)Does the State have Federally-Qualified Health Center networks that have received or are receiving HIT/EHR funding from the Health Resources Services Administration (HRSA)? Please describe.

Does the SMA have data on EHR adoption by types of provider (e.g. children’s hospitals, acute care hospitals, pediatricians, nurse practitioners, etc.)?

The State of Montana has 15 Community Health Care Centers of which 13 have and EHR (Table 2.6).

Table 2.6 Current HIT Landscape for Federally Qualified Health Centers (FQHC)

Facility City Provider Type EHR Software Deployed

Ashland CHC Ashland Physician Assistants (PA), Physician one day a month

eClinical Works (eCW)

Bullhook CHC Havre Nurse Practitioner (NP), Dentist EHS

Butte CHC Butte Physician, Dentist, PA, NP Currently do not have an EHR

Central Montana CHC Lewistown Physician, NP eCW

Community CHC Great Falls Physician, Dentist, PA, NP Sage

Community Health Partners Livingston Physician, Dentist, PA, NP Next Gen

Cooperative Health Center Helena Physician, Dentist, PA, NP eCW

Custer County CHC Miles City NP eCW

Flathead CHC Kalispell Physician, Dentists, NP eCW

Glacier County CHC Cutbank Physician, Dentists, NP eCW

Northwest CHC Libby Physician, Dentists, NP, PA eCW

Partnership Health Center Missoula Physician, Dentists, NP, PA eCW

River Stone Health Billings Physician, Dentists, NP, PA eCW

Sweet Medical Center Chinook Physician, NP, PA EHS

Montana Migrant and Seasonal Farm Workers Council Billings NP, others on contract Currently do not have

an EHR

In 2008, five of the 15 centers received HIT related funding to set-up a network (Table 2.7).

During 2009 – 2010, six of the 15 centers used stimulus funding to help with hardware & software needs.



Table 2.7 Recovery Act Funding for Community Health Centers in Montana (15)

Health Center Grantee Name City Project Type Award Amount

Ashland Community HC Ashland Capital Improvement Construction Program $293,820

Bullhook Community HC, Inc Havre Capital Improvement Construction Program $332,110

Butte Silver-Bow Primary Health Care Clinic Butte Capital Improvement Construction Program $784,170

Cascade City-County Health Department Great Falls Capital Improvement Construction Program $438,020

Central Montana Community HC Lewistown Capital Improvement Construction Program $251,610

Community Health Partners, Inc. Livingston Capital Improvement Construction Program $559,295

Custer County Community HC, Inc Miles City Capital Improvement Construction Program $268,657

Flathead City - County Health Dept Kalispell Capital Improvement Construction Program $241,438

Glacier Community HC, Inc. Cut Bank Capital Improvement Construction Program $336,625

Lewis & Clark City-Co. Health Dept. Helena Capital Improvement Construction Program $469,345

Lincoln County Community HC Libby Capital Improvement Construction Program $435,220

Missoula City/County Health Dept/Partnership HC Missoula Capital Improvement Construction Program $571,545

Montana Migrant Council, Inc. Billings Capital Improvement Construction Program $433,855

Sweet Medical Center, Inc. Chinook Capital Improvement Construction Program $333,300

Yellowstone City & County Health Department D/B/A Riverstone Health Billings Capital Improvement

Construction Program $951,680

Total $6,700,690



2.4.7 Veterans Health Administration1. Does the State have Veterans Administration or Indian Health Service clinical facilities that are operating EHRs?

Please describe.

The Veteran’s Administration (VA) Montana Health Care System consists of facilities that provide services to veterans in 13 cities across the State (Figure 2.26).

Figure 2.26 Montana cities with Veteran’s Administration facilities

2.4.8 Indian Health Service (IHS) Clinical Facilities

As of August 6, 2010, there were 14 Indian facilities that serve the State’s Tribal Nations (Figure 2.27). Montana is home to seven tribal reservations:

Blackfeet Tribe of the Blackfeet Reservation Chippewa Cree Tribe of the Rocky Boy's Reservation Confederated Salish & Kootenai Tribes of the Flathead Reservation Crow Tribe of the Crow Reservation Gros Ventre and the Assiniboine Tribes of the Fort Belknap Reservation Sioux and Assiniboine Tribes of the Fort Peck Reservation Northern Cheyenne Tribe of the Northern Cheyenne Reservation



These IHS facilities use the IHS’ RPMS EHR (Table 2.8). Ten of these facilities are affiliated with the Indian Health Service and two are directly affiliated with the tribes. The RPMS was originally based on the VHA EHR. However, the IHS contracted with Medsphere Systems Corporation to develop a Graphical User Interface (GUI) for the RPMS.

Montana IHS and Tribal related clinics are reimbursed in accordance with federal IHS guidelines, and are not reimbursed at Medicaid FQHC rates. Montana’s five “urban” Native American health facilities are reimbursed in accordance with state reimbursement policies that govern other Federally Qualified Health Centers located in Montana.

Figure 2.27 Montana’s Tribal Reservations

Table 2.8 Current Indian Health Service, Tribal, and Urban Native American Healthcare Facilities in Montana

Facility Name City Provider Type

Affiliation EHR Usage

Crow/Northern Cheyenne Hospital

Crow Agency Hospital IHS Use EHR in an inpatient and outpatient

setting and also use Vista Imaging

Crow/Northern Cheyenne Hospital - Lodge Grass Clinic

Lodge Grass Clinic IHS Use EHR in an outpatient setting and also use Vista Imaging

Crow/Northern Cheyenne Hospital - Pryor Health Clinic

Pryor Clinic IHS Use EHR in an outpatient setting and also use Vista Imaging



Table 2.8 Current Indian Health Service, Tribal, and Urban Native American Healthcare Facilities in Montana

Facility Name City Provider Type

Affiliation EHR Usage

Fort Peck – Verne E. Gibbs Health Center Poplar Clinic IHS Use EHR in an outpatient setting and

also use Vista Imaging

Fort Peck – Chief Redstone Health Center Wolf Point Clinic IHS Use EHR in an outpatient setting and


Blackfeet Community Hospital Browning Hospital IHS Use EHR in an outpatient setting and


Blackfeet Community Hospital - Heart Butte Health Station

Heart Butte Clinic IHS Use EHR in an outpatient setting and also use Vista Imaging

Lame Deer Health Center Lame Deer Clinic IHS Use EHR in an outpatient setting and


Fort Belknap Hospital and associated Eagle Child Health Station

Ft. BelknapHays Hospital IHS Use EHR in an outpatient setting and


Rocky Boy Tribal Health Center Box Elder Clinic Tribal Use EHR in an outpatient setting and


Flathead Tribal Health Center and associated Health Stations

St. IgnatiusElmoRonanArleeHot SpringsPolson

Clinic Tribal Use EHR in an outpatient setting and also use Vista Imaging

Helena Indian Alliance - Leo Pocha Memorial Clinic

Helena FQHC Urban Unknown

Indian Family Health Clinic Great Falls FQHC Urban Unknown

Indian Health Board of Billings Billings FQHC Urban Unknown

Missoula Indian Center (Outreach Facility) Missoula FQHC Urban Unknown

North American Indian Alliance Butte FQHC Urban Unknown



3.0 THE STATE’S “TO-BE” LANDSCAPE

Montana is a frontier state with a small population (44th in USA – est. 975,000) dispersed over avast geographic region (4th largest state in USA – 145,552 sq. miles) and ranks 48th in the USA for population density. HIT exists throughout the state and is well developed in some locations. In addition, regional and system exchanges exist, or are in development. In smaller practices and healthcare organizations in many rural and frontier areas lack fundamental HIT software, hardware, and personnel. Broadband access is improving, but may still be a challenge in some areas.

A collaborative structure for statewide health information exchange (HIE) exists in the form of HealthShare Montana (HSM), the state’s designated HIE development entity. HSM was formed to develop and support widespread adoption of electronic health record technology and health information exchange across Montana.

HSM has presented a strategic approach to CMS for facilitating the state’s “To-Be” HIE landscape. This approach has been approved, and the following characteristics will provide the backbone of Montana’s HIE:1. The implementation of a comprehensive strategy to improve EHR adoption statewide.

HSM’s approach includes the selection of Covasint as an HIE partner to provide the necessary infrastructure and EHR products necessary to support Montana’s healthcare providers.

2. A plan for improving coordination with Medicaid, Medicare, and other state and federal level stakeholders including improved communication and relationships with key administrators.

3. Development of a productive and collaborative relationship with the Mountain-Pacific Quality Health Foundation, Montana’s Regional Extension Center for HIT/EHR activities.

Long term sustainability of the statewide HIE is of particular concern. To that end, HSM is developing “value added” services that may provide additional support and revenue for the HIE moving forward, including:1. Continuity of Care Record (CCR)/Continuity of Care Document (CCD) Exchange –

summary information available to providers when needed via query of CDR, charged on a per inquiry or annual fee basis

2. Physician Quality Reporting Initiative (PQRI) and other pay for performance incentives separate from one-time ARRA or HITECH incentives – charge fees to handle required data reporting to allow providers to earn increased reimbursement and avoid eventual penalties.

3. Provider/Patient Portal – charge to providers to maintain secure provider-patient messaging including on-line consultation, online services such as registration or bill pay, access to personal health records, low-cost provider websites with provider-selected third party educational content, and other material.

4. Population health data uses – charge for de-identified and identified data reporting for state (i.e. Diabetes Quality Care Monitoring System or DQCMS), public health (i.e. immunization registries), private insurer (i.e. Healthcare Effectiveness Data and Information Set [HEDIS]), provider/patient reporting for disease management and other practice functions, clinical research, etc.



5. Clinical Groupware/EHR Lite – (including eRx and targeted Clinical Decision Support System [CDSS]) – competitively priced turn-key option for providers wishing to implement focused and inexpensive ambulatory care HIT/HIE that would meet “meaningful use” criteria and qualify provider for HITECH/ARRA incentives.

6. Telemedicine – charge for web-based telemedicine services with link to CCR/CCD data.

A major goal for DPHHS is to significantly improve the current level of interoperability between providers, existing regional exchanges, the statewide Montana HIE, and national information exchanges. To that end, the Montana HIE will leverage existing HIT/EHR capabilities of hospitals, health systems, and regional exchanges to reach out to a broader base of providers interested in developing and/or improving their HIT capabilities via the HIE.

The future HIE landscape in Montana will not ignore the importance of privacy and security. Montana’s HIT technical framework will be marked by extensive documentation and enforcement related to HIPAA requirements, breach notification and mitigation, and increased coordination with national privacy and security initiatives.



3.1 HIT/HIE Goals and ObjectivesLooking forward to the next five years, what specific HIT/E goals and objectives does the SMA expect to achieve? Be as specific as possible (e.g., the percentage of eligible providers adopting and meaningfully using certified EHR technology, the extent of access to HIE, etc.)

The DPHHS’ specific HIT/HIE goals, objectives, measures, targets, and baselines are outlined in Table 6.2. They are broken down into the following four main goals and their supporting objectives:Goal 1 – Encourage Medicaid providers to adopt, implement, or upgrade to certified EHR technology

Objective 1.1 – Encourage Medicaid providers to take first steps towards adoption by phasing out paper-based processes; this will help encourage adoption for Meaningful Use stage 2 as well as provide efficiency and reduction in administrative expenses.

Objective 1.2 – Encourage Medicaid providers to take first steps towards adoption of e-prescribing

Objective 1.3 – Encourage Medicaid providers to adopt, implement, or upgrade by leveraging and expanding the current MPQH REC scope of efforts for outreach, education, and technical support in Montana

Goal 2 – Obtain a solution for incentive program administration

Objective 2.1 – Obtain an efficient and economical solution to administer the incentive program for Montana. 6

Objective 2.2 – Use existing DPHHS tools and methods to support audit and oversight requirements

Goal 3 – Support implementation and sustainability of the statewide HIE

Objective 3.1 – Provide outreach to providers to encourage participation in the HIE.

Goal 4 – Leverage MITA

Objective 4.1 – Include the HIE in planning for statewide sharing of health information, including access to State government assets such as immunization registry, syndromic surveillance, and state labs

Objective 4.2 – Initiate efforts from the MITA-SSA to develop the required Service Oriented Architecture (SOA) based services

3.2 IT System Architecture1. *What will the SMA’s IT system architecture (potentially including the MMIS) look like in five years to support

achieving the SMA’s long term goals and objectives? a) Internet portals? - Provider portal and client portal in new MMISb) Enterprise Service Bus? - Yesc) Master Patient Index? – Yes, the client file will control more functionality, limits, eligible services, will have its

own eligibility filed) Record Locater Service? – NA?e) Business Rules Enginef) Case Management/Workflowg) Single Sign-on/Security

The DPHHS is in the process of replacing several of the Department’s largest systems that have reached the end of their life. These legacy systems do not possess the modern IT design and

6 Given the State’s current budget constraints and the fact that the new MMIS will incorporate the MPIP functionality, the DPHHS explored both internal and external options for timely and cost effective implementation of MPIP.



technology features that allow them to readily share information or change to comply with ever-changing federal and state policies. As part of this process, the DPHHS intends to leverage modern information technologies such as Service Oriented Architecture (SOA) to promote interoperability between systems.

These system replacement efforts will establish the foundation for an Enterprise Architecture (EA) that aligns with MITA. The next generation of DPHHS systems must: Improve the integration of services to customers using more than one of the Department’s

programs. Improve the quality, integrity, and reliability of data used to administer the Department’s

programs and provide benefits to customers. Increase the value and lower the risk of the Department’s investment in information

technology by providing a framework of components and data that can be shared and reused by many systems.

Implement the appropriate security and confidentiality safeguards for the Department’s information systems and data.

The EA will allow the separate, standalone systems to communicate using exposed, shared services to support the interoperable requirement for MMIS; the DPHHS will integrate MMIS with the following capabilities (Figure 3.1): Service-Oriented Architecture Enterprise Service Bus Web Portal Single Sign-On Shared Information and Web Services, including a Common Client Index (CCI) Intersystem Navigation

Figure 3.1 DPHHS Enterprise Architecture

The Department has made significant strides with the implementation of its new Medicaid Eligibility system, CHIMES-Medicaid. This system was built using modern web-based



technologies that include the use of a business rules engine that functions as the main driver for eligibility determination. The next phase of our eligibility modernization will commence January 2011 with the development of the other two eligibility systems: Supplemental Nutrition Assistance (SNAP) and Temporary Assistance for Needy Families (TANF) effort. This project will include the implementation of SOA technology that will link all three eligibility systems together and provide the foundation for DPHHS’ envisioned EA. In tandem with this effort, the development of a new MMIS will begin in 2011 that also possesses modern web technologies and a business rules engine within the framework of MITA.

3.3 Medicaid Provider Interface with MPIPHow will Medicaid providers interface with the SMA IT system as it relates to the MPIP (registration, reporting of meaningful use data, etc.)?

Limiting or eliminating changes to existing DPHHS IT systems is a primary goal of the MPIP project. Likewise, the DPHHS will be transitioning to a new MMIS in April of 2014. The DPHHS foresees that because of this transition, the provider registration and attestation interface may change during the life of the MPIP.

To reduce the impact on state IT systems during initial implementation of the Montana MPIP, DPHHS will deploy a software service to be provided by ACS, our current MMIS and Medicaid Fiscal Agent vendor. This system is described in depth in Section 4.4 of this document. The ACS State Level Repository (SLR) solution provides an interactive registration and attestation process that will serve as a single point of service for providers with respect to all aspects of the incentive program.

Providers will register for the incentive program via a portal that is separate from, but linked to, the current Medicaid provider portal and MMIS. The portal will start on a general provider outreach and informational page shown in Figure 3.2. Providers will be able to access a variety of sources of information including CMS, ONC, DPHHS, and other valuable points of reference.



Figure 3.2 Montana State Level Repository – Provider Outreach Page



EPs and EHs will select specific paths through the portal that are designed for ease of registration. Representations of the initial registration pages related to eligible hospitals and eligible professionals are in Figures 3.3 and 3.4 respectively.

Figure 3.3 Montana State Level Repository – Eligible Hospital Initial Registration



Figure 3.4 Montana State Level Repository – Eligible Provider Initial Registration



The linkage to the current Montana MMIS will provide access to MMIS-based Medicaid provider enrollment information that will be used to assist with validating provider eligibility. This information includes the provider’s current Medicaid enrollment status, critical identifier information, as well as relevant contact information.

The SLR will use automated notices/e-mails to providers, as well as a process to allow direct messaging from DPHHS staff to participating providers. Direct messaging will be used to allow for more detailed communication to providers regarding status such as approvals, denials, or requests for additional provider information.

Provider payments will be processed via the MMIS, using current procedures in place to monitor Medicaid provider payments. The incentive payments will receive a designated fund code, allowing the DPHHS Fiscal Division’s Statewide Accounting, Budgeting and Human Resource System to track incentive payments separately from other provider payments, and facilitate reporting.

As the DPHHS transitions to the new MMIS, it is possible that all MPIP functionality will be integrated into the MMIS. The requirements for the new Montana MMIS include all functionality inherent to the ongoing administration of the MPIP, including all attestation processes and audit capability required to validate the achievement of meaningful use measures required for ongoing participation.

3.4 HIE Governance Structure Given what is known about HIE governance structures currently in place, what should be in place by 5 years from now in order to achieve the SMA’s HIT/E goals and objectives? While we do not expect the SMA to know the specific organizations will be involved, etc., we would appreciate a discussion of this in the context of what is missing today that would need to be in place five years from now to ensure EHR adoption and meaningful use of EHR technologies.

Moving forward, all State agencies that interact with health information will be required to participate in the HIE to the extent possible. The method of enforcing this participation from state agencies will need to be determined by the State and is not in the jurisdiction of the HSM Board of Directors.

The State will need to consider updating its policy and procedures and/or enter into formal contractual agreements to clearly delineate roles and responsibilities of the various entities involved in HIE efforts and the processes that must be followed to maintain security, consistency, and quality.

3.5 Provider adoption of certified EHR technology

In the next 12 months, the DPHHS and other stakeholders are planning a coordinated provider outreach and education program through HSM, MPQH, and Medicaid. Montana’s adoption strategy will be to partner with the MPQH for provider outreach, education, and technical support. MPQH will be the direct line to providers. The DPHHS will also include information



regarding the MPIP in the Medicaid Newsletters, on the State Medicaid, HIT, and the Montana Access to Health Web Portal websites, and provider training.

3.6 FQHCs with HRSA HIT/EHR Funding** If the State has FQHCs with HRSA HIT/EHR funding, how will those resources and experiences be leveraged by the SMA to encourage EHR adoption?

The DPHHS will work with MPQH to encourage and support the FQHCs to use HRSA HIT/EHR funding through the selection and purchase of certified EHR systems. If resources are available, the DPHHS may also send field representatives to the FQHCs to assist with this process.

3.7 Technical Assistance for Medicaid Providers** How will the SMA assess and/or provide technical assistance to Medicaid providers around adoption and meaningful use of certified EHR technology?

The DPHHS has limited resources to provide technical assistance to Medicaid providers, however, the DPHHS will provide Medicaid providers access to current HIT/EHR information via newsletters, training, and via the internet (including providing links to ONC and CMS resources). In addition, the DPHHS will work closely with MPQHF and HSM to ensure provider’s needs are being addressed.

The MPIP services will include technical call center assistance to providers who need information regarding registration in the incentive program, guidance with respect to meaningful use criteria, assistance with documentation requirements, and other aspects of the MPIP.

3.8 Unique Needs Population** How will the SMA assure that populations with unique needs, such as children, are appropriately addressed by the MPIP?

The new Montana MMIS will incorporate advanced features related to EHRs. The MMIS and other closely aligned applications, such as our predictive modeling software, are widely used by Montana Medicaid’s Care Management Team in the evaluation and active health management activities on behalf of Medicaid members. The new MMIS will contain additional functionality designed to enhance the ability of our Care Management team to gain a broader perspective of an individual’s health than that available from claims history alone. For example, the new MMIS EHR functionality will include the capability to: provide the ability to incorporate narratives from external clinical information as free text present data captured externally, such as on-line provider entry and notes capture laboratory and radiology results retain key dates that are related to beneficiary’s history and physical, such as date of

diagnosis for a chronic disease (i.e., diabetes) or life-changing operational procedures (i.e., transplants)



maintain all beneficiary information, identified by information source, regarding allergies, medical conditions, and drug intolerances

summarize, filter, and facilitate searching through large amounts of data, including claims data, data entered by a provider, and data entered by a beneficiary during the delivery of beneficiary care

capture beneficiary vital signs through direct provider input to include height/weight, blood type, blood pressure, pulse, and oxygen level

provide a medication profile for each beneficiary allow beneficiaries to input information into their own health records

The goal of DPHHS is to work in tandem with providers, Medicaid members, and perhaps most importantly the new statewide HIE (HealthShare Montana) to capture the most complete and useful set of health information available for patients, particularly those with multiple chronic illnesses or those at high risk.

The DPHHS will maintain operational efforts that focus resources on various care management endeavors related to populations with unique needs. The DPHHS has structured programs to address behavioral health issues of both adults and children. Care management programs address high-risk obstetrics (OB), ER over-utilization, breast and cervical cancer, transplants, medically fragile, chronic diseases, and other special circumstances. By enhancing providers’ access to EHRs, and widening the availability of that data to appropriate parties through HIEs, the care coordination opportunities become increasingly advantageous.

3.9 Leveraging HIT Grants for the MPIPIf the State included in a description of a HIT-related grant award (or awards) in Section A, to the extent known, how will that grant, or grants, be leveraged for implementing the MPIP, e.g. actual grant products, knowledge/lessons learned, stakeholder relationships, governance structures, legal/consent policies and agreements, etc.?

Coordinated planning for the SMHP with HSM, MPQH, and broadband entities helps to leverage efforts. Many of the same stakeholders are involved in many of these efforts and the DPHHS will leverage the relationships, governance structures, and products from these efforts for the MPIP.

3.10 State Legislation Outlook for MPIPDoes the SMA anticipate the need for new or State legislation or changes to existing State laws in order to implement the MPIP and/or facilitate a successful MPIP (e.g. State laws that may restrict the exchange of certain kinds of health information)? Please describe.

The DPHHS does not anticipate the need for new or State legislation or changes to existing State laws in order to implement the MPIP and/or facilitate a successful MPIP because we are following the federal guidelines for implementation of the program. If there is a need the DPHHS would adapt its policies to facilitate the program.



3.11 Other IssuesPlease include other issues that the SMA believes need to be addressed, institutions that will need to be present and interoperability arrangements that will need to exist in the next five years to achieve its goals.

The State of Montana considers the protection of an individual’s personal health information to be one of the most fundamental responsibilities for all parties involved in the exchange of health data. In addition, Montana recognizes that the ultimate success of the meaningful use of EHR technology will be reliant upon the degree to which participants agree to share critical medical data.

Prior to the deployment of the CyberAccess medical record and e-prescribing solution for Medicaid providers, DPHHS legal counsel determined that the disclosure of Medicaid data to healthcare providers was allowed under all Federal (HIPAA) and state laws. DPHHS proactively withholds some diagnostic information deemed to be too sensitive for release. This data includes any information regarding behavioral health including chemical dependency, sexually transmitted diseases, HIV/AIDS information, and potentially other information deemed sensitive by DPHHS. However, most physical health diagnostic information is available. Montana will follow the same approach with respect to data that will be made available via the statewide HIE. All Medicaid data will be made available to healthcare providers deemed covered entities by HIPAA. This will not include information in the possession of any state agency or government entity, including DPHHS, and considered protected against any disclosure under any existing state or federal laws. In this respect, Montana will follow an “opt out” policy related to the disclosure of information, and will require patients to submit a written request for exclusion of their information from the HIE.

4.0 ACTIVITIES NECESSARY TO ADMINISTER AND OVERSEE THE MPIP

4.1 Program Organization1. What IT, fiscal and communication systems will be used to implement the MPIP?2. What will be the role of existing SMA contractors in implementing the MPIP – such as:

a) MMISb) pharmacy benefit managers (PBM)c) fiscal agentd) managed care contractorse) etc

The DPHHS will establish oversight in the following functional areas to support the HIT effort. Additional resources in the areas of policy/rule development, provider communication, technical architecture, and legal support will be provided as required:

Executive Oversight – The DPHHS HIT Manager is responsible for overall direction of the project, monitoring progress and status, and for providing timely and accurate information to DPHHS leadership regarding the MPIP. The HIT Manager is also responsible for any



coordination with CMS, ONC, and other Federal stakeholders on behalf of the state of Montana.

Provider Outreach, Education, and Information – Provides recommendations and direction on the outreach, education, and communications to Medicaid EPs and EHs, other Medicaid providers, MPQH, Montana professional associations, and Montanans to inform these stakeholders on progress and all aspects of the MPIP.

Provider and Business Operations – Identification of impacts to Medicaid providers and DPHHS business operations and makes recommendations and provides direction for planning and implementation regarding provider relations, provider services, and business operations of the MPIP

Technical Interfaces and Specifications – Provides recommendations and direction on integration of the MPIP business requirements into MMIS; resolves technical issues and identifies and plans for system modifications to support capabilities identified by the other functional area representatives.

4.2 Stakeholder CommunicationsLimited outreach activities have occurred in the form of web-based provider training offered by DPHHS, as well as extensive outreach conducted statewide by the Regional Extension Center field staff. Provider outreach activities have been minimal to date due to issues surrounding the approval of the Medicaid incentive program by the Montana Legislature. With approval of both the legislature and the governor in May 2011, the state budget legislation provided the fiscal authority necessary for the Montana MPIP to move forward to the next phase.

On September 1, 2011, Montana DPHHS will launch two HIT/EHR websites dedicated to educating the Montana health care provider community.

The first is the Medicaid HIT/EHR Provider Outreach Portal or POP. The POP is the gateway to the State Level Repository, a sophisticated interactive provider portal that will walk participants through every step of the registration and attestation process.

The design of the POP provides easy access to valuable resources that will assist EPs and EHs throughout the registration and attestation process. Via the POP, participants can access eligibility wizards, critical CMS sites including Frequently Asked Questions and the most up to date news regarding EHR initiatives, as well as a direct link to the Health Technology Services Regional Extension Center.

The REC is a critical partner to DPHHS with respect to the communication of critical information to the provider community. With field staff currently canvassing the state working with providers on all aspects of EHR selection and implementation, the REC is capable of reaching providers where DPHHS’ limited resources inhibit such outreach. Although to date our agreement with the REC is informal, this critical resource is our best source of information regarding the preparedness of the Montana provider community, and the issues organizations face in the deployment of electronic health record technology.



Figure 4.1 on the following page illustrates the form and content of the Provider Outreach Page to be deployed on September 1.

Figure 4.1 Montana HIT/EHR Provider Outreach Portal Landing Page



Also on September 1, 2011, DPHHS will launch a revised HIT/EHR website that provides critical information regarding the Medicaid Incentive Program, including links to valuable resources and critical information. The Montana Medicaid SLR logo in the middle of the page is a direct link to the POP.

Figure 4.2 Montana DPHHS HIT/EHR Website



Guidelines will be developed outlining the detailed procedures for communicating all facets of the MPIP including eligibility, attestation, payment, recoupment, appeals.

The Department will develop a planned approach for internal and external communications to ensure all stakeholders are adequately informed on progress made toward the implementation of the MPIP. The DPHHS is responsible for all aspects of information sharing, and works closely with all stakeholders to ensure that appropriate information is shared, and that it is shared in a consistent manner.

The DPHHS will develop a Communications Plan for informing providers, the public, external agencies, the media on progress made toward implementation of the MPIP, and for sharing communications internally within the DPHHS. The final plan includes the following components:1. A statement of objective, including a commitment to support the implementation of the

provisions of the Recovery Act that provide incentive payments to EPs and EHs for the meaningful use of certified EHR technology.

2. A statement of strategies. Strategies include identification of EPs and hospitals; education of EPs and EHs to adopt, implement, upgrade, and meaningfully use EHR technology; and provision of educational information for both providers and all interested stakeholders. Strategies will be implemented after obtaining input via surveys, web input, training events, telephone, public hearings, and meetings with professionals and organizations. Activities will be conducted through training events, multimedia presentations, and messages on the web site, informative emails, articles, and news releases, partnering with various agencies, direct contact with EPs and EHs, and using social media to share information.

3. A statement of research and planning. Research and planning includes preparing and mailing survey questions, gathering input via stakeholder meetings, using surveys on the internet, and analyzing and using the data gathered.

4. A statement about audiences. The key audiences are EPs and EHs, and affected stakeholders (interested parties, HIT work groups, consumers, vendors, and Medicaid members). The value of reaching out to EPs and EHs is to assist them with obtaining patient data and making the best possible healthcare decisions for their patients. Barriers that might be expected with EPs and EHs include cost, security/privacy issues, technical knowledge of providers, infrastructure issues, mindset, lack of knowledge, and time concerns. The value of reaching out to stakeholders is that the stakeholders will benefit from a multitude of health professionals being able to access health records needed to ensure informed and efficient delivery of appropriate care. Barriers that might be expected with stakeholders include lack of access, privacy issues, fear and perception of “government,” generational gaps, technical knowledge, literacy issues, language issues, cultural barriers, and lack of resources.

5. A statement of measurements of success. To timely measure whether EPs and EHs successfully adopt, implement, upgrade, and meaningfully use certified EHR technology, appropriate tracking and counting must be done. This measurement includes a comparison against a goal of reaching 100 percent of professionals and hospitals to identify their current As Is use of certified EHR technology, a goal of reaching 100 percent of professionals to determine eligibility, a goal of commitment from 90 percent of professionals and hospitals to



participate in the MPIP, and a goal of using 100 percent of allocated funds to reduce costs to EPs and EHs to adopt, implement upgrade, or meaningfully use certified EHRs.

6. A summary statement. The summary statement includes the commitment of the DPHHS to distribute information in a timely manner to EPs, EHs, internal and external stakeholders, and interested parties. Ultimately, the key for a successful implementation of the MPIP is for EPs and EHs to meaningfully use certified EHR technology to improve the healthcare outcomes for Montanans.



4.3 Policy and Regulatory Changes

4.3.1 Policy Changes

DPHHS policy staff will conduct a comprehensive review of new policy required to implement the MPIP. At this time, DPHHS expects to create a new section of policy dedicated solely to the governance of these programs. Within this new section, the agency will address administrative processes, provider eligibility rules, and reimbursement criteria and procedures. Specifically, DPHHS will address policy on issues related to Medicaid patient volume standards, the definition of pediatrician, and meaningful use criteria and payment to EPs. Where there is no specific written policy, DPHHS will defer to the Final Rule issued by CMS.

DPHHS will develop a legal opinion regarding the sharing of Medicaid claims data over exchange networks. It is the goal of the DPHHS to provide access to patient medical information in order to further the medical treatment of members whose medical providers participate with the statewide HIE. Pursuant to the provisions of HIPAA, found at 45 CFR § 164.502(a)(1)(ii) and 45 CFR § 164.506, a covered entity, such as the DPHHS, may use and disclose protected health information (PHI) for treatment, payment, or healthcare operations. Specifically, 45 CFR § 164.506(c)(2) states that a covered entity, such as DPHHS, may disclose PHI for the treatment activities of a healthcare provider. Pursuant to 45 CFR § 164.502(b) the “minimum necessary” requirement does not apply to disclosures or requests for treatment by a healthcare provider. This legal opinion will set a foundation for DPHHS participation in, and exchange of, data using an HIE.

Policy changes necessary to support a comprehensive vision for statewide HIT/HIE is not available at this time because the HSM Strategic and Operational Plans are not yet complete and the statewide effort is still in the early stages. Thus, DPHHS is submitting partial completion of this section of the SMHP, which will be updated after further collaboration and HSM and statewide plans are available. DPHHS plans to align its policies with the statewide vision once developed.

4.3.1.1 Recent Changes in State Laws or Regulations

Minimal regulatory changes and no new state laws are expected at this time.

4.3.1.2 HIE/HIT Activities Crossing State Boundaries

The Montana HIE will participate in the NHIN; however, there may be a need to develop specific State to State data exchanges. The DPHHS will support efforts by the HIE to enter into reciprocal data exchange agreements with surrounding states when necessary in order to facilitate the compilation complete patient health information records. DPHHS will reevaluate the need for these agreements in the future should this information become available through the national HIE infrastructure.



In addition, providers serving in Montana may include Medicaid patients from border states in determining MPIP eligibility. Similarly, states bordering Montana will have access to Medicaid eligibility and patient volume information to verify corresponding data for providers relying on Montana’s Medicaid information for their MPIP.

4.3.2 Privacy Regulatory Changes

At this point, only minimal changes and no new state laws are expected at this time. The DPHHS will fully comply with all applicable HIPAA and ARRA privacy regulations.

4.3.3. Other Regulatory Changes

At this point, no new state laws are expected.



4.4 Implementation of Necessary Technology5. What IT systems changes are needed by the SMA to implement the MPIP?6. What is the SMA’s IT timeframe for systems modifications? 7. What kind of website will the SMA host for Medicaid providers for enrollment, program information, etc?8. Does the SMA anticipate modifications to the MMIS and if so, when does the SMA anticipate submitting an MMIS I-

APD?

Montana Medicaid plans for minimal changes to the existing legacy MMIS. Instead, the agency will deploy a software service offering from ACS, Montana’s current MMIS Fiscal Agent. ACS will deploy a web-based attestation collection and monitoring system capable of providing the level of automation and technical support requirements necessary to support the Montana Medicaid EHR Incentive Program.

The service will: 9. Document, track and attest provider usage including the ”meaningful use” of electronic

health records 10. Ensure providers meet or exceed minimum Medicaid patient and other thresholds 11. Process provider payments according to program guidelines 12. Document and validate payment for certified systems 13. Audit, reconcile, and report provider and program compliance 14. Coordinate overlapping program (Medicare/Medicaid) and multi-state claims to prevent

duplicate or over payments 15. Maintain an active data repository with history 16. Receive from and provide data to NLR in accordance with CMS interface specifications

This service will provide the State with a web-based application that delivers portal access to a Master State Provider Repository (MSPR). This repository will be useful for two purposes. First, the MSPR will house all information required for Meaningful Use eligibility, tracking, attestation and payment. Second, it will serve as the foundation of a Master Provider Index for the State’s health information exchange (HIE) network. The web-portal will allow both providers and State users to access, provide and maintain information in accordance with their security role.

Features of the provider portal include: 17. Allow secure provider log-in (optional SSO from an MMIS Portal) 18. Allow providers to review and edit their demographic information 19. Allow for role-based screens (EP or EH) 20. Allow providers to complete meaningful use attestation forms 21. Allow submission of completed forms to State Medicaid entities 22. Allow provider messaging from State Medicaid entities 23. Provide a payment history log 24. Allow provider to initiate an appeal 25. Allow providers to upload Meaningful Use quality metrics in approved XML format 26. On-Line help and User Manual

Features of the State user portal include: 27. Allow secure role-base log-in by State approved users



28. Provide work queues for users based upon role or department 29. Provide for provider registration information to be routed and approved 30. Allow State users to message or comment to providers on approval, denial or request

additional information 31. Allow inactivation of eligibility upon removal from program 32. Allow State users to review and approve attestation information 33. Provide payment calculation function 34. Initiate payment cycle 35. Manage appeals 36. Review quality metrics 37. On-line help and User Manual

The Montana Medicaid EHR Incentive Program database and state level registry will also maintain the following information and functionality:38. Receive required provider data from MMIS and licensing entities 39. Send Master Medicaid Provider File to HIE 40. Establish and maintain records for providers requesting payment from State Medicaid agency 41. Receive batch files from NLR for new providers that signed up for HITECH Medicaid

incentives (20-30 fields per record) 42. Match NLR file to MMIS provider data (audit step) 43. Send batch files to NLR with eligibility approval notification 44. Receive attestation information submitted to CMS by eligible hospitals 45. Request Prior Payment Information from NLR (duplicate check) 46. Receive Prior Payment Information from NLR (duplicate check) 47. Provide payment information to NLR 48. Receive Program Switch Notifications 49. Receive notifications that a provider has switched state. 50. Send removal notifications to NLR 51. Receive hospital cost report information from NLR 52. Calculate or receive provider specific information from claims information such as:

a) Number of unique State Medicaid patients b) Number of Medicaid encounters c) Number of adjudicated prescription d) Number of controlled prescriptions e) Number of non-controlled prescriptions with “electronic” as the origin code

The workplan and schedule for the design, development , and implementation of the MPIP SLR are contained in Appendix B on page 103. November 7, 2011 is the current scheduled SLR launch date for provider registration. Initial provider payments will begin approximately December 5, 2011.

MMIS modifications required to support this service should be minimal, and are included in the costs for implementing this service.



4.4.1 MPIP Technical Architecture



4.4.2 MPIP Provider and Hospital Adopt/Implement/Upgrade and Meaningful Use Workflows












MONTANA DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES

State Medicaid Health Information Technology Plan (SMHP)




4.4.3 Participation in National Level Registry (NLR)When does the SMA anticipate being ready to test an interface with the CMS National Level Repository (NLR)? What is the SMA’s plan for accepting the registration data for its Medicaid providers from the CMS NLR (e.g. mainframe to mainframe interface or another means)?

Montana’s selected MPIP administration partner, ACS, completed initial testing of the bi-directional interface between the Montana MPIP State Level Repository and the NLR in March 2011. Montana providers will select one NPI number with which to register in the NLR and one TIN. The NLR will transmit Montana provider registrations to the SLR daily using an ACS Gentran mailbox. This data transfer between CMS and ACS mainframes uses XML.

4.4.4 Systems used to establish provider eligibility

Montana Medicaid will rely on the MMIS system to provide basic demographic information to assist with determining eligibility. The provider will be required to verify their information contained within the MMIS. The MPIP through an automated interface will verify the provider is a Montana Medicaid provider in good standing (i.e., provider is not deceased, provider is appropriately licensed, and there are no sanctions against the provider) at the time of registration and payment.

4.5 Provider Help Desk Support1. What kinds of call centers/help desks and other means will be established to address EP and hospital questions

regarding the incentive program?2. How will the SMA communicate to its providers regarding their eligibility, payments, etc?

The DPHHS will use the following methods for assisting providers with questions regarding the incentive program:53. The DPHHS will provide a point of contact along with the main number and email address

for which all application questions will be directed. 54. The DPHHS has established a website for individuals seeking general information about the

EHR program (17).Additional MPIP information will be provided in the Medicaid Provider monthly newsletter, electronic remittance advices or provider notices to keep providers updated.

4.6 Provider Registration Process

Providers (EPs and EHs) contacting DPHHS regarding the MPIP will be directed to the DPHHS provider web site for detailed information on participation in the MPIP in Montana. Providers will be instructed to register in the NLR. Once registered in the NLR, the DPHHS will validate the Medicaid provider enrollment and the NLR record, affirming that the provider has selected Montana Medicaid participation. Once a provider has registered in the NLR, the provider will need to go to Montana’s MPIP site to complete their registration.




DPHHS currently requires that all providers submit a valid TIN and National Provider ID (NPI) as a condition of Medicaid provider enrollment. Each EP or EH will be enrolled as a DPHHS Medicaid provider and will therefore, without change in process or system modification, meet the requirement to supply a TIN.

The TIN will be used to identify the providers on IRS Form 1099 and allow IRS reporting based on the appropriate TIN where providers have received an EHR Incentive payment from DPHHS. Current business and system processes support the use of TIN to identify provider payments.TINs are validated with the IRS annually. When DPHHS submits a 1099 file to the IRS, the IRS will respond to DPHHS Finance Department with a letter including a list of incorrect TINs. DPHHS Finance will send this list to Provider Enrollment to follow up by contacting the provider for the correct information. If the provider does not respond, DPHHS finance places the provider on payment hold until the correct TIN is submitted.

4.7 Provider Eligibility for Incentive Payments

4.7.1 Eligible Provider Types

DPHHS will qualify providers as defined in the Final Rule Medicare and Medicaid Programs; EHR Incentive Program. As specified under section 1903(t)(2)(A) of the Act, Medicaid participating providers who wish to receive a Medicaid incentive payment must meet the definition of a “Medicaid Eligible Professional’’ or “Medicaid Eligible Hospital.”

The EP definition (1903(t)(3)(B) of the Act) lists five types of Medicaid professionals: Physicians Dentists Certified nurse-midwives Nurse practitioners Physician assistants (i.e., when practicing in an FQHC or RHC that is so led by a physician

assistant)

Montana acute care and critical access hospitals may also be eligible to participate in the Medicaid incentive program. Montana has no children’s hospitals.

Eligible professionals practicing in Indian Health Services/Tribal facilities/Urban Indian Clinics (I/T/U) and who meet the eligibility criteria and all other program requirements may also participate in the program.




4.7.2 Methodology for Patient Volume Determination1. What data sources will the SMA use to verify patient volume for EPs and acute care hospitals?2. What methodology will the SMA use to calculate patient volume?

The DPHHS will allow clinics and group practices to use the practice or clinic Medicaid patient volume (or needy individual patient volume, insofar as it applies) for Montana and any additional State7 and apply it to all EPs in their practice under three conditions: 1. The clinic or group practice's patient volume is appropriate as a patient volume methodology

calculation for the EP (for example, if an EP only sees Medicare, commercial, or self-pay patients, this is not an appropriate calculation),

2. There is an auditable data source to support the clinic's patient volume determination, and 3. The practice and EPs decide to use one methodology in each year (in other words, clinics

could not have some of the EPs using their individual patient volume for patients seen at the clinic, while others use the clinic-level data) (18).

The clinic or practice must use the entire practice's patient volume and not limit it in any way. EPs may attest to patient volume under the individual calculation or the group/clinic proxy in any participation year. Furthermore, if the EP works in both the clinic and outside the clinic (or with an outside group practice), then the clinic/practice level determination includes only those encounters associated with the clinic/practice.

Table 4.1 Qualifying Patient Volume Threshold for MPIP

Eligible Professional Type

Minimum 90-day Medicaid PV Threshold

Comments Calculation

Physicians 30% Must be non-hospital based PV ≥ 0.30( Medicaid Encounters

Total Encounters)

Pediatricians 20% Must be non-hospital based PV ≥ 0.20( Medicaid Encounters

Total Encounters)

Dentists 30% Must be non-hospital based PV ≥ 0.30( Medicaid Encounters

Total Encounters)

Certified nurse mid-wives 30% Must be non-hospital

based PV ≥ 0.30( Medicaid EncountersTotal Encounters

)

Physician Assistant whenpracticing at an FQHC/RHC ledby a physician assistant

30% For Medicaid EP practicing predominately (50% of patient volume over a six month period) in an FQHC or RHC a minimum of 30% of

PV ≥ 0.30( Medicaid EncountersTotal Encounters

)

PV ≥ 0.50( FQHC∨RHC Medicaid EncountersFQHC∨RHC Total Encounters

)

7 For the purposes of determining Medicaid patient volume, providers must include patient encounters from Montana and may also include any other State Medicaid patient encounters. If a provider claims Medicaid patient encounters from multiple states, the provider must include the provider’s total patient encounters (i.e., Medicaid and Non-Medicaid) in those states in the calculation and identify all states included in the volume threshold calculation.




Table 4.1 Qualifying Patient Volume Threshold for MPIP

Eligible Professional Type

Minimum 90-day Medicaid PV Threshold

Comments Calculation

their patient volume must come from “needy individuals”

Nurse Practitioner 30% Must be non-hospital based PV ≥ 0.30( Medicaid Encounters

Total Encounters)

Acute care and Critical Access hospitals

10%

The MPIP will utilize the MMIS Master Provider File NPI/TIN data to identify registered hospitals as acute care or CAH.

PV ≥ 0.10( Medicaid EncountersTotal Encounters

)

Children’s hospital No threshold identified

To substantiate the EP’s attestation for meeting PV the DPHHS will use the following data as a benchmark: Paid claims from MMIS (used to validate provider attestations). Such paid claims data will

include encounter claim information used to substantiate the provision of services to any Medicaid client. This data will not include capitated payments for the Primary Care Case Management (PCCM) program or any program payments that do not represent the provision of actual services rendered for Medicaid clients.

Montana will request paid claims data or verification of patient volume from other states if such volume is claimed by a provider in order to meet volume threshold. Data from other states will not be requested if the provider can qualify based exclusively on Montana Medicaid patient volume.

Number of Medicaid visits from the most recent UDS/4 (used to validate FQHC attestations) Total visits from most recent UDS/4 (used to validate FQHC attestations) Total visits from the most recent Medicare Cost Report (used to validate RHC attestations)

To substantiate the EH’s attestation for meeting PV the will use the following data as a benchmark: Total Discharges from Medicare Cost Report S-3 Part 1 (line 12 column 15) Total Medicaid discharges from MMIS




4.7.3 Assuring Providers are Not Hospital BasedHow will the SMA verify whether EPs are hospital-based or not?

To verify that the EP is not hospital based Montana Medicaid will capture Medicaid claims information from the MMIS system using the formula below to make the initial determination if a provider qualifies for the MPIP. Upon the EP’s request for payment the EP will certify they meet this criterion. The following is the calculation for determining that the EP is providing less than 90% place of service (POS) in a hospital setting:

Paid Claims with POScodes 21∧23Total Paid Claims for all Services

=X %(less than90 %qualifies)

The hospital-based exclusion does not apply to the Medicaid-EP qualifying based on practicing predominantly at a FQHC or RHC (18 p. 44483).

4.7.4 Ensure Providers are Licensed, Not SanctionedHow will the SMA verify that providers are not sanctioned, are properly licensed/qualified providers?

Montana Medicaid will qualify providers as defined in the Notice of Proposed Rule Making (NPRM) rule for Medicaid EPs and EHs. As specified in the Act, Medicaid participating providers who wish to receive Medicaid incentive payments must meet the definition.

Upon receipt of notification from the NLR that a provider has selected to participate in the Montana MPIP, the following will be verified: The EP or EH has no sanctions preventing them from participating, The EP is not deceased The EP is not hospital based Confirm that the provider is eligible (e.g. Physician, dentist, NP, acute care hospital). Is appropriately licensed (e.g. NP is a licensed NP not an RN) [and] Is listed on the NLR correctly

Montana Medicaid will verify by using the Montana MMIS. The MPIP will interface with the MMIS to complete the initial verification and validation of the provider for licensure and sanction. The MPIP will verify with the Montana Death Registry System (MDRS) to validate the provider is not deceased. The provider type eligibility will be based on the provider type and specialty associated with the provider in the MMIS; specifically, limited to the following MMIS provider types: Physicians = provider type 27 Pediatrician = provider type 27/specialty 37 Mid-level practitioners = provider type 44 Certified Nurse Midwife = provider type 44/specialty 77 Nurse Practitioner = provider type 44/specialty 92 Physician Assistant (PA) = provider type 44/specialty 51 Dentist = provider type 18




Acute Care Hospital: provider type 01 with CCNS in the range of 0001-0879 or provider type 74 with CCNs 1300 – 1399

A PA is considered to be leading an FQHC or RHC under any of the following circumstances:55. When a PA is the primary provider in a clinic (e.g., when there is a part-time physician and

full-time PA, we would consider the PA as the primary provider),56. When a PA is a clinical or medical director at a clinical site of practice, or,57. When a PA is an owner of an RHC

FQHCs and RHCs that have PAs in these leadership roles are considered "PA-led." Since RHCs can be practitioner owned (FQHCs cannot), we will allow ownership to be considered "PA-led” (18).

The provider must be actively enrolled in Medicaid in order to apply for the Medicaid Provider Incentive Payment. If the provider is not listed in the MMIS the provider will need to enroll with Medicaid provider enrollment prior to applying.

4.7.5 Provider and Hospital Attestation Process and ValidationHow will the SMA verify the overall content of provider attestations?How will the SMA verify that EPs at FQHC/RHCs meet the practices predominately requirement?

Providers and hospitals will provide the following attestations or certifications to verify the following (18):1. Patient volume: For the first year, a continuous 90-day or greater (up to the maximum of the

EP calendar year or the EH fiscal year) period may be used to calculate patient volumes. Both the numerator and denominator of the equation must use the same period. EP or EH will submit the time period for when the patient volume was measured; and will identify the source the information was taken from; the numerator, denominator and resulting percentage for either Medicaid or Needy Individual volume.

2. Hospital Average Length of Stay (ALOS): Upon initiation of the MPIP SLR, hospitals will be required to attest to the facility’s ALOS, and this information will be validated using a report that calculates the ALOS based on the demographic data entered by the hospital as part of the payment calculation. The MPIP is scheduled for enhancement in January 2012, at which time the system will calculate the ALOS for the hospital based on the total patient bed days and total discharges. The SLR currently validates that the hospital’s ALOS is less than or equal to 25 days as part of the eligibility as defined in the Final Rule, although Children’s Hospitals are considered eligible regardless of their ALOS (Montana has no children’s hospitals). Acute care and CAHs with an ALOS of 25.01 or greater are not eligible and will be prevented from continuing the application process, as they do not meet the requirements.

3. EP practicing predominantly at an FQHC or RHC: EP will certify they meet this requirement by submitting the following—clinic location, the needy patient encounters at the location along with his or her total patient encounters and the percentage and the six month period used to determine the percent.




4. Other non-state or local funds received for EHR: EP or EH will certify if they have or have not received non-State or local funds for an EHR. If funds have been received the EP will indicate the amount for the coinciding payment year.

5. Adopt, Implement or Upgrade (AIU): For their first year the EP or EH will attest that they have Adopted, implemented or upgraded, identify the certified system and date of AIU.

6. Certified EHR: This will be checked on the ONC website which will list all certified EHRs.7. EP will identify the specific board certified specialty for quality measure purposes.

All information submitted by providers will be subject to audit. The overall content of the provider attestations will be verified prior to any payment being made. If a provider omits any information necessary for the eligibility determination or to make a payment, the provider will be notified.

4.8 Processing Payments to Providers

4.8.1 Provider Payment Request

The provider will be directed to the Montana secure attestation page to enter their NLR registration number. The attestation process will search for the NLR Registration number in the NLR table. The attestation process will automatically compare the provider type, NPI, and payee TIN to the information from the NLR. If these do not match, the user will receive an error message on the screen on how to receive further assistance. The attestation process will compute the current participation year based on the most recent NLR Registration record participation year and the number of participation/payment years recorded in the Montana MPIP solution.

Prior to making the payment the DPHHS will notify the NLR that the payment is ready to be made and the NLR will lock the provider’s applicant record to prevent duplication of payment and ensure the provider is unable to switch programs or states. Upon approval for payment, transactions will be processed through Montana’s MMIS and will appear as an item on the provider’s standard statement of remittance received from Montana Medicaid. Payment transactions will be processed as they are approved, the result being that approved provider incentive payments will be processed as a component of Montana Medicaid’s standard weekly payment cycle.

4.8.2 Assignment of Payment1. What will be the process to assure that Medicaid provider payments are paid directly to the provider (or an employer

or facility to which the provider has assigned payments) without any deduction or rebate? 2. What will be the process to assure that Medicaid payments go to an entity promoting the adoption of certified EHR

technology, as designated by the state and approved by the US DHHS Secretary, are made only if participation in such a payment arrangement is voluntary by the EP and that no more than 5 percent of such payments is retained for costs unrelated to EHR technology adoption?

EPs will choose direct or assigned payments. In the case where the provider is a member of a group and chooses to assign the incentive payment to the group, these payments will be made to a group consistent with existing MMIS capabilities. In the case where the provider who is a member of a group chooses to retain the incentive payment, the payment will be made directly to the provider through an existing process in the MMIS. Due to existing MMIS limitations,




Montana Medicaid will not make direct incentive payments to any entity that is not recognized as a Montana Medicaid provider.

The NLR Registration transaction to the State will include not only the EP’s Personal TIN, but also the Payee TIN. DPHHS plans to assign the payment at the state level, as the national level has no way to validate the payee TIN/EP TIN combination. The Montana MPIP Registration and Attestation function will list the valid individual and group NPIs, names, State provider IDs, and TINs associated with the EP who is registering at the state level. The EP will have the opportunity to choose which of these valid entities, to assign his/her EHR Incentive payment. The valid choices will be the groups the providers are associated with, as well as the individual provider.

4.8.3 Provider Payment Calculations

4.8.3.1 Eligible Professionals (EP) Payment CalculationWhat is the SMA’s anticipated frequency for making the EHR Incentive payments (e.g. monthly, semi-monthly, etc.)?

Montana anticipates making EHR incentive payments on a monthly basis. Montana Medicaid will ensure that payments do not exceed the maximum amount of $21,250 for year 1 and $8,500 for years 2 through 6 (18 p. 44492).

Payment after the first year may continue for a maximum of five years. Medicaid EPs may receive payments on a non-consecutive, annual basis. No payments may be made after September 30, 2021. In no case shall a Medicaid EP participate for longer than six years or receive payment in excess of the maximum $63,750 (17 p. 44492).

EPs that meet the State definition of Pediatrician and carry between 20 to 29 percent Medicaid patient volume will have their payment reduced by one-third. The Pediatrician will not receive more than $14,167 in the first year and not more than $5,667 for subsequent years. The total allowable for six years will not exceed $42,500. All other requirements noted above for an EP remain the same (18 p. 44492).

What will be the process to assure that all hospital calculations and EP payment incentives (including tracking EPs’ 15% of the net average allowable costs of certified EHR technology) are made consistent with the Statute and regulation?

To assure that all incentive payment calculations are made consistent with all statutes and regulations, the MPIP payment calculation process will be automated and based on calculations contained in the final rule. An output report will show the breakdown of the calculated payment and all payments will be reviewed for accuracy.




4.8.3.2 Eligible Hospital (EH) Payment CalculationWhat will be the process to assure that all hospital calculations and EP payment incentives (including tracking EPs’ 15% of the net average allowable costs of certified EHR technology) are made consistent with the Statute and regulation?

The MPIP hospital aggregate incentive amount calculation will be a one-time, up front calculation using the equation outlined in the Final Rule. The aggregate EHR incentive amount is the total amount the hospital could receive in Medicaid payments over a theoretical four years of the program. It is the product of two factors:

1. The overall EHR amount2. The Medicaid Share

The overall EHR amount is based upon the sum over a theoretical four years of payment where the amount for each year is the product of three factors: 1. An Initial Amount2. The Medicare Share [and] 3. A Transition Factor applicable to each of a theoretical four years

4.8.3.2.1 Initial Amount Initial Amount is equal to a base amount of $2,000,000, plus a discharge-related amount.

The Initial Amount is the sum of a base amount and a discharge-related amount. The base amount is $2,000,000, and the discharge-related amount provides an additional $200 for estimated discharges between 1,150 and 23,000 discharges. No payment is made for discharges prior to the 1,150th discharge or for discharges after the 23,000th discharge.

For the first payment year, data on hospital discharges from the hospital fiscal year that ends during the federal fiscal year prior to the hospital fiscal year that serves as the first payment year will be used as the basis for determining the discharge-related amount. To determine the discharge-related amount for the three subsequent payment years that are included in determining the overall EHR amount, the number of discharges will be based on the average annual growth rate for the hospital over the most recent three years of available data. The SLR captures 4 years of discharge data for the hospital (most recent year plus 3 years back). The growth rate is calculated as defined by CMS by determining the difference in discharges from year to year and converting to a percent increase/decrease. The three years are averaged together to determine the average annual growth rate. If a hospital’s average annual rate of growth is negative over the three-year period, the rate will be applied as such. Montana will use hospital cost reporting for validation.

The Medicare Share portion of the Medicaid hospital overall EHR amount is set at 1 by the statute.




4.8.3.2.2 Transition Factor

This factor in the formula determines the Medicaid incentive payment to an eligible hospital. For each of the four years of theoretical payment, a different transition factor applies, as demonstrated in Table 1. Note that for the Medicaid Program, an aggregate EHR amount is calculated only once, and this amount is then spread over all years of a hospital’s payments. Therefore, the transition factors in Table 1 are used to calculate the aggregate EHR amount but do not indicate that the hospital’s payment will be calculated anew on a yearly basis.

4.8.3.2.3 The Medicaid Share

The second step in determining the aggregate EHR amount for a meaningful user of certified EHR technology is to calculate the Medicaid Share. The Medicaid Share is essentially the percentage of a hospital’s inpatient, non-charity care days that are attributable to Medicaid inpatients.

The numerator of the Medicaid Share is the sum of: 1. The number of Medicaid inpatient-bed-days and 2. The number of Medicaid managed care inpatient-bed-days.

The denominator of the Medicaid Share is the product of: 1. The total number of inpatient-bed-days for the eligible hospital during that period and 2. The total amount of the eligible hospital’s charges during that period, not including any

charges that are attributable to charity care divided by the estimated total amount of the hospital’s charges during that period.

Please note that the removal of charges attributable to charity care in the formula, in effect, increases the Medicaid Share resulting in higher incentive payments for hospitals that provide a greater proportion of charity care.

The following table illustrates the hospital calculation described above:

EH Payment=Overall EHR Amount × Medicaid Sharewhere

Overall EHR Amount=¿

and

Base Amount=$ 2,000,000.00

and

Discharge related information8 for 12 month period (FFY) prior to payment year is the sum of: 1 through 1,149 discharge = $0




1,150 through 23,000 discharged = $ 200 For discharges greater than 23,000 = $09

The formula for calculating the discharge related amount by year is as follows: Year 1: (Total discharges from most recent cost report capped at 23,000 – 1149 disallowed

discharges)*$200 Year 2: ((Year 1 discharges * Average annual growth rate capped at 23,000) – 1149

disallowed discharges)*$200 Year 3: ((Year 2 discharges * Average annual growth rate capped at 23,000) – 1149

disallowed discharges)*$200 Year 4: ((Year 3 discharges * Average annual growth rate capped at 23,000) – 1149

disallowed discharges)*$200

The transition factor for each year equals (18 p. 44498): Year 1=1.0 Year 2=0.75 Year 3=0.50 Year 4=0.25

Therefore, the overall EHR amount is summarized as follows:

Year 1= ($ 2,000,000+Discharge Related Amount )× 1.0Year 2=($ 2,000,000+Discharge Related Amount )× 0.75Year 3=($ 2,000,000+ Discharge Related Amount ) ×0.50Year 4=($2,000,000+Discharge Related Amount )× 0.25Overall EHR=Totalof all four years

and

Medicaid Share=¿ [ Medicaid inpatient bed days+Medicaid managed care inpatient bed days

{( total inpatient bed days )× total charges−charity care chargestotal charges } ]

What will be the process to assure that there are fiscal arrangements with providers to disburse incentive payments through Medicaid managed care plans does not exceed 105 percent of the capitation rate per 42 CFR Part 438.6, as well as a methodology for verifying such information?

At this time Montana does not have any managed care entities.

What is the SMA’s anticipated frequency for making the EHR Incentive payments (e.g. monthly, semi-monthly, etc.)?

8 The State will use data on the hospital discharge from the hospital fiscal year that ends during the Federal fiscal year prior to the fiscal year that serves as the first payment year.9 Discharge Related amount × (1+3 year average annual growth rate) × 200




Montana intends to pay the aggregate hospital incentive payment amount over a four year period, contingent on the hospital’s annual attestations and registrations for the annual Montana Medicaid payments. The EH will receive the following percent of their Aggregate Overall EHR amount over the four years as follows: Year 1: 50% (Aggregate EHR Payment X .50)Year 2: 30% (Aggregate EHR Payment X .30)Year 3: 10% (Aggregate EHR Payment X .10)Year 4: 10% (Aggregate EHR Payment X .10)

Payments can be made to an EH on a non-consecutive annual basis. However, if an EH registers after September 30, 2017 they will not be eligible to receive the Aggregate Overall EHR Incentive amount. No incentive payments may be made after September 30, 2021.

4.8.4 Accounting for 100% federal fundingWhat will be the process to assure that all Federal funding, both for the 100 percent incentive payments, as well as the 90 percent HIT Administrative match, are accounted for separately for the HITECH provisions and not reported in a commingled manner with the enhanced MMIS FFP?

Cost centers will be set up for the provider payments with the funding set to 100% federal funds. When an EP or EH is paid the cost center associated with the provider incentive payment program will be charged. This will allow the DPHHS to track on a monthly basis the total amount paid. The State accounting system also allows for information to be downloaded at any point in time to determine the total payments made to date.

4.8.5 Accounting for 90/10 fundingWhat will be the process to assure that all Federal funding, both for the 100 percent incentive payments, as well as the 90 percent HIT Administrative match, are accounted for separately for the HITECH provisions and not reported in a commingled manner with the enhanced MMIS FFP?

The DPHHS’ Business and Financial Services Division, which oversees the Cost Allocation Plan, established a process for tracking and monitoring to ensure the funding relating to the ARRA HIT is funded at the 90/10 ratio and to ensure the funding is tracked separately from other funds. Divisions with staff participating in the MPIP project have worked with their individual fiscal and budget staff to establish cost centers with the appropriate fund mix. For employees who directly charge their time or do not fill out an activity report the time is tracked by pay period and the hours are entered in the time system and allocated to the cost centers. For individuals whose time is indirectly charged their time is tracked on the monthly activity report and cost allocated to cost centers based on that information.




4.9 Adoption, implement or upgrade to certified EHR technologyHow will the SMA verify adopt, implement or upgrade of certified electronic health record technology by providers?

A provider who adopts, implements, or upgrades a certified EHR during their first year will need to upload documentation (e.g., ONC Certification number, purchase order) substantiating their acquisition of the certified EHR technology. During the first year, the provider will not need to demonstrate meaningful use to receive payment. During the second payment year they would demonstrate meaningful use for a 90 day period only. For payment years three and up, providers must demonstrate meaningful use over a continuous 12-month period.

4.10 Verification of Meaningful Use1. How will the SMA verify providers’ use of certified electronic health record technology?2. How will the SMA verify meaningful use of certified electronic health record technology for providers’ second

participation years?

The DPHHS will conduct selected compliance reviews of EPs and EHs who register for the incentive program and of recipients of incentive payments for the meaningful use of certified EHR technology. The reviews will validate provider eligibility through their meaningful use attestations including verification of meaningful use and would also review components of the payment formulas. Montana’s MPIP solution will be able to accommodate different requirements depending on the attestation year and the meaningful use measures collected.

4.11 Meaningful Use CriteriaWill the SMA be proposing any changes to the MU definition as permissible per rule-making? If so, please provide details on the expected benefit to the Medicaid population as well as how the SMA assessed the issue of additional provider reporting and financial burden.

The SMA will not be proposing any changes to the Meaningful Use definition as permissible per rule making. Montana will adopt the Medicaid Meaningful Use definition and no additional measures will be added at this time. As such, during the second and subsequent years EPs will attest through submission of defined objectives and clinical quality measures using the certified EHR for the calendar year for each stage (i.e., Stages 1 – 3) of Meaningful Use:

Stage 1 Stage 2 Stage 3

Capture health information in a coded format,

Use the information to track key clinical conditions,

Communicate captured information for care, coordination purposes,

Report clinical quality measures and public health information.

Disease management, Clinical decisions support, Medication management, Support for patient access to

their health information, Transitions in care, Quality measurement, research,

and Bi-directional communication

with public health agencies.

Achieving improvements in quality, safety and efficiency,

Focus on decision support for national high priority conditions,

Patient access to self-management tools,

Access to comprehensive patient data, and

Improve population health outcomes.




4.12 Provider Outreach, Education and Assistance

The DPHHS will use the following avenues to provide outreach, education, and assistance to providers and hospitals. Provider organizations such as HSM, MPQH, Montana Medical Association, Montana

Dental Association, Montana Hospital Association and Montana Primary Care Association will be used to assist the state in communicating information to and receiving input from providers and hospitals

The monthly Medicaid provider newsletter Targeted provider notices Banner messages on remittance advices or other brief notices when payments are made The DPHHS ARRA HIT Website

4.13 Appeals Process58. What will the SMA establish as a provider appeal process relative to:

a) the incentive paymentsb) provider eligibility determinations c) demonstration of efforts to adopt, implement or upgrade and meaningful use certified EHR technology

Montana Medicaid will use the existing provider appeal process used within the Medicaid Program to govern appeals related to incentive payments, provider eligibility determination, and efforts to adopt or upgrade and meet meaningful use of certified EHR technology. Initiation of the formal appeal process assumes that all informal administrative reviews and resolution steps typically observed by Montana Medicaid in the administration of disputes are exhausted, and the provider wishes to escalate the issue and receive a binding decision. Such informal processes include follow-up communication with the provider regarding the issue, as well as research and analysis into possible avenues of correction that may be taken on the part of both the provider and DPHHS.

If at any time a provider is denied participation, for any reason, per the final rule, the State will use the process already established for Medicaid provider appeals. The State will notify the provider of their appeal rights at any denial in this process: a) incentive payments, b) provider eligibility determinations, and c) demonstration of efforts to adopt, implement or upgrade and meaningful use certified EHR technology.

4.14 Data Collection and Reporting1. How will the SMA collect providers’ meaningful use data, including the reporting of clinical quality measures? Does

the State envision different approaches for the short-term and a different approach for the longer-term?2. How will this data collection and analysis process align with the collection of other clinical quality measures data,

such as CHIPRA?

In order to receive Medicaid incentive payments, providers will be required to demonstrate (and Montana will track and validate) meaningful use, as described in section II.A.2. of the final rule. Beginning in 2012, Montana will receive clinical quality measures data from participating MPIP providers. To the extent possible, DPHHS will coordinate the collection of clinical quality measures in order to minimize the impact on participating providers. The Montana MPIP will




share any such reported data with CMS in an aggregated, de-identified manner, on an annual basis or as otherwise required by CMS. Montana will submit an updated SMHP outlining the methodology for collecting Meaningful Use data and other required information outlined in the final rule, as required by the CMS.

4.15 Assumptions1. States should explicitly describe what their assumptions are, and where the path and timing of their plans have

dependencies based upon:a) The role of CMS (e.g. the development and support of the National Level Repository; provider outreach/help desk

support)b) The status/availability of certified EHR technologyc) The role, approved plans and status of the Regional Extension Centersd) The role, approved plans and status of the HIE cooperative agreementse) State-specific readiness factors

Montana is making the following assumptions: 59. HSM strategic and operational plans are approved without major change.60. A vendor is selected in early January 2011 to develop the State MPIP solution.61. NLR is available for interface testing with Montana by the vendor by 2nd Qtr of CY 2011.62. Montana’s MPIP solution is available for NLR interface testing by 2nd Qtr of CY 2011.63. SMHP and IAPDs are approved in a timely manner with minimal need for revisions.64. Federal sources will provide communication materials/fact sheets for the state to use for

outreach.65. Affordable certified EHR solutions will be accessible to Montana providers66. The DPHHS will need to make only minimal changes to the existing MMIS67. The replacement MMIS will contain functionality that will allow the migration and

administration of the MPIP process68. The State will have sufficient financial and human resources to support the MPIP

5.0 THE STATE’S AUDIT STRATEGY NOT INCLUDED FOR PUBLIC VIEW
















6.0 MONTANA’S HIT ROADMAP

69. *Provide CMS with a graphical as well as narrative pathway that clearly shows where the SMA is starting from (As-Is) today, where it expects to be five years from now (To-Be), and how it plans to get there.

70. Describe the annual benchmarks for each of the SMA’s goals that will serve as clearly measurable indicators of progress along this scenario.

71. Discuss annual benchmarks for audit and oversight activities.CMS is looking for a strategic plan and the tactical steps that SMAs will be taking or will take successfully implement the MPIP and its related HIT/E goals and objectives. We are specifically interested in those activities SMAs will be taking to make the incentive payments to its providers, and the steps they will use to monitor provider eligibility including meaningful use. We also are interested in the steps SMAs plan to take to support provider adoption of certified EHR technologies. We would like to see the SMA’s plan for how to leverage existing infrastructure and/or build new infrastructure to foster HIE between Medicaid’s trading partners within the State, with other States in the area where Medicaid clients also receive care, and with any Federal providers and/or partners.

* Where the State is deferring some of its longer-term planning and benchmark development for HIT/E in order to focus on the immediate implementation

6.1 Montana’s Vision for Moving from “As-Is” to “To-Be” Landscape

At this time, DPHHS is embarking on a system modernization effort that includes replacing several of the Department’s largest systems that have reached end-of-life. They are monolithic in nature and difficult and expensive to maintain. They do not possess the modern IT design and technology features that allow them to readily share information or change to comply with ever-changing federal and state policies. These facts led to long-range appropriations in the 2007 and 2009 Legislative Session to replace key human service systems. These system replacement efforts will put in place the next generation of IT systems. The next generation of DPHHS systems must be built to: Improve the integration of services to customers using more than one of the Department’s programs. Improve the quality, integrity, and reliability of data used to administer the Department’s programs and provide benefits to customers. Increase the value and lower the risk of the Department’s investment in information technology by providing a framework of components and data that can be shared and reused by many systems. Implement the appropriate security and confidentiality safeguards for the Department’s information systems and data.

Our system modernization efforts will also incorporate enterprise architecture and accompanying technologies such as business rules engine, web services and Service-Oriented Architecture into its plans for replacing its legacy set of human service systems. This enterprise architecture will support the Director’s initiative to operate the Department as an enterprise, rather than a collection of unrelated programs and services. The goal of this initiative is to foster holistic service delivery where programs collaborate and cooperate with each other in meeting the needs of individuals and families. This collaboration is currently being supported by the use of tools we have recently put in place such as WebEx and SharePoint, which assist our 3,100 employees located statewide communicate more regularly and more effectively without traveling long distances.

Current DPHHS IT Initiatives include: Improving our alignment with MITA standards The deployment of initial EHR functionality in the DPHHS




Updating existing technologies and policies that prohibit or hinder HIT/HIE strategy Coordination of statewide HIE efforts

The DPHHS recently completed its MITA SS-A. These MITA concepts, principles and tools were used to assessing the current “As-is” HIT Landscape to the desired “To-be” HIT Landscape and in the development of the MMIS replacement RFP. The DPHHS leveraged and integrated the results of the MITA SS-A into the statewide IT Initiative planning where feasible.

In 2009, DPHHS in conjunction with ACS deployed a web-based medical record and e-prescribing tool. CyberAccess is designed to provide access to medical claims information to enhance a provider’s efforts in diagnosing and treating Medicaid patients. The tool also provides e-prescribing functionality. The DPHHS is currently in the process of procuring a implementation vendor to replace the DPHHS’ legacy IIS with an IIS with modern architecture and HL7 messaging capability.

DPHHS has initiated a project to replace the existing legacy MMIS with a modern relational database system. It is the vision of the DPHHS that the technical architecture of the new MMIS will facilitate the DPHHS’ ability to deploy advanced EHR functionality to ensure the DPHHS can share health information efficiently with the State’s Medicaid providers.

DPHHS has identified the MMIS changes needed to solve the immediate need to implement the MPIP within the MMIS. DPHHS is deferring some of its longer-term planning and benchmark development for HIT/HIE since the HSM Strategic and Operational Plans are not complete at this time. DPHHS dialog with the Department of Commerce, BTOP, BIP, and FCHCC grantees is also underway. When details of these projects are fully understood, including a timeline for projects, this SMHP will be updated and a separate IAPD to request funding will be submitted.

Figure 6.1. HIT/MITA Roadmap




6.2 Annual Benchmarks for provider adoption of EHR technology over timeWhat are the SMA’s expectations re provider EHR technology adoption over time? Annual benchmarks by provider type?

The DPHHS recognizes the effort and resources required to implement and administer the Medicaid Electronic EHR Incentive Program as described in the previous sections. In an effort to monitor, track, and adjust DPHHS’s strategy, DPHHS has set goals and benchmarks for provider enrollment and participation, and will monitor progress toward these goals. These benchmarks, reflected in Table 5, include estimates of the providers and hospitals that will enroll in the Medicaid EHR Incentive Program over the next five years. DPHHS anticipates that in the second year of the program, when meaningful use must be demonstrated, enrollment and eligibility for incentives will not increase significantly from enrollment under Adopt, Implement and Upgrade requirements. In addition, because hospital incentives are significantly larger than those for physicians, DPHHS estimates higher enrollment for eligible hospitals.

Table 6.1 Estimated EHR Incentive Program Enrollment Over Five Years

Provider TypeEligible Providers

& Hospitals (Estimated)

Medicaid EHR Incentive Program Enrollment(Projected)

Year 1 Year 2 Year 3 Year 4 Year 5

Eligible Professionals

Physician 1537 769 922 1076 1230 1383

Pediatrician 424 212 254 297 339 382

Certified Nurse Midwife/Nurse Practitioner 324 162 194 227 259 292

Dentists 295 148 177 207 236 266

FQHC/RHC 19 10 11 13 15 17

Eligible Hospitals

Acute Care Hospitals 10 6 8 9 10

Children’s Hospitals NA

Critical Access Hospitals 35 21 25 28 32 33

The DPHHS will create and implement the appropriate EHR incentive payment system that is described in Section 3, and processes outlined in Sections 4 and 5. As part of this implementation plan, a number of dependencies have been identified, such as: the requirement that states must have approved SMHP and IAPD documents; end-to-end NLR testing; attestations must be accepted within 90 days of program launch; and payments must be made with 45 days of successful attestation. DPHHS is incorporating these dependencies into planning activities to ensure program launch by July 2011 (Figure 6.2).




Table 6.2 Medicaid EHR Incentive Program Solution Implementation Schedule

6.3 Annual benchmarks for DPHHS goals measuring MPIP progress

Table 6.2 HIT/HIE goals, objectives, measures, targets, and baselinesGoal 1 – Encourage Medicaid providers to adopt, implement, or upgrade to certified EHR technology

Goal 2 – Obtain a solution for incentive program administration.

Objective 2.1 – Obtain an efficient and economical solution to administer the incentive program for Montana. 10

By 2010, the DPHHS will procure an MPIP solution

By 2011, the DPHHS will implement an MPIP solution

Objective 2.2 – Use existing DPHHS tools and methods to support audit and oversight requirements. By 2011 prepare audit program to perform:

Eligibility audits Patient volume audits Meaningful Use and Annual Incentive Payment

audits From 2011 - 2015 perform audits to verify Eligibility Patient volume Meaningful Use and Annual Incentive Payments

From 2012 – 2015, 10% (X) of the estimated program population will be audited each year.

Goal 3 – Support implementation and sustainability of the statewide HIE

Objective 3.1 – Provide outreach to providers to encourage participation in the HIE. HSM/MPQH/DPHHS will provide outreach to providers to encourage HIE participation from 2010 – 2015.

Outreach activities are expected to result in 10% of eligible providers to participate in the HIE by 2012 and then 10% per year thereafter

Goal 4 – Leverage MITA

10 The State will use the revised Medicare 2552-10, Worksheet 2-10 to determine the charity care portion of the formula.




Objective 4.1 – Include the HIE in planning for statewide sharing of health information, including access to State government assets such as immunization registry, syndromic surveillance, and state labs. DPHHS will collaborate with HSM to provide

capability for interoperability and exchange of health information between EPs, hospitals, FQHCs/RHCs, IHS and Tribes, and other Medicaid enrolled providers responsible for delivery of health care services, and third-party payers throughout Montana.

Objective 4.2 – Initiate efforts from the MITA-SSA to develop the required Service Oriented Architecture (SOA) based services. The DPHHS plans to deploy a SOA-based

MMIS in line with the State’s IT Initiatives




APPENDIX A – HIT AND HIE ENVIRONMENTAL SCAN - JANUARY 2011

Montana EHR Environmental Scan.pdf




APPENDIX B – MPIP STATE LEVEL REPOSITORY WORKPLAN AND SCHEDULE

KEY MPIP SLR IMPLEMENTATION SCHEDULE DATES

July - Oct – MPIP Implementation (approximately 120 days) July 6 – MPIP SLR DDI Kickoff July 7 – Sept 1 Provider Outreach Page July 15 – Sept 6 Provider Master File Construction July 19 – Oct 24 State Level Registry (SLR) Configuration Sept 1 – Oct 24 State Dashboard Configuration Oct 24 – Oct 28 SLR and State Dashboard UAT Oct 24 – Oct 31 SLR and State Dashboard Implementation

Sept 1 – Launch Provider Outreach Page and updated State EHR/HIT Website Nov 7 – Begin Montana Provider SLR Registration Dec 5 – Targeted first incentive payment

Montana SLR Workplan and Schedule.pdf




Bibliography1. The Office of the National Coordinator for Health Information Technology. About ONC. The Office of the National Coordinator for Health Information Technology (ONC). [Online] U.S. Department of Health and Human Services, August 13, 2010. [Cited: 10 07, 2010.] http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__onc/1200.2. Indian Health Service. American Recovery and Reinvestment Act, HITECH Act, EHR Certification, and Meaningful Use. IHS Recovery. [Online] [Cited: October 14, 2010.] http://www.ihs.gov/recovery/index.cfm?module=dsp_arra_meaningful_use.3. Department of Veterans Affairs Office of Enterprise Development. VistA-HealtheVet Veterans Affairs (VA's) Current and Future Computerized Patient Record System. VISTA Monograph. [Online] July 2008. [Cited: October 14, 2010.] http://www4.va.gov/VistA_MONOGRAPH/index.asp.4. Congressional Budget Office. Quality Initiatives Undertaken by the Veterans Health Administration. Congressional Budget Office Health Publications. [Online] August 2009. [Cited: October 14, 2010.] http://www.cbo.gov/ftpdocs/104xx/doc10453/08-13-VHA.pdf.5. Johnson, Marcy. HealthShare Montana Operational Plan. Operational plan for implementing a statewide health information exchange for the State of Montana. Billings, MT : HealthShare Montana, August 2, 2010.6. Health Information Exchange of Montana. Health Information Exchange of Montana, Inc FCC Rural Health Care Pilot Project . Health Information Exchange of Montana. [Online] [Cited: October 14, 2010.] http://hiemontana.org/fcc.html.7. Hultin, Chad. Montana Broadband Projects. Department of Commerce. [Online] 2010. [Cited: 08 18, 2010.] http://recovery.mt.gov/commerce/broadband/default.mcpx.8. Kendrick, Bart. News Release: Agriculture Secretary Vilsack Announces Over 120 Recovery Act Broadband Projects to Bring Jobs, Economic Opportunity to Rural Communities. United States Department of Agriculture, Rural Development. [Online] August 4, 2010. [Cited: August 31, 2010.] http://www.rurdev.usda.gov/STELPRD4005543.html.9. Rural Utilities Service. Rural Utilities Service Broadband Initiatives Program Round Two Application Directory. Rural Development United States Department of Agriculture. [Online] June 2, 2010. [Cited: August 31, 2010.] http://www.broadbandusa.gov/BIPportal/files/Broadband-R2%20SEARCHABLE%20PDFwPNR-2010-06-01.pdf.10. Kahn, Jessica. Medicaid Transformation Grants Fact Sheet. Mediciad Transofrmation Grants. [Online] January 12, 2009. [Cited: September 9, 2010.] https://www.cms.gov/MedicaidTransGrants/Downloads/Medicaid_Transformation_Grants_FactSheet.pdf.11. Montana Department of Public Health and Human Services. State Gets $1.5 Million Medicaid ‘Transformation’ Grant. Montana Department of Public Health and Human Services. [Online] February 13, 2007. [Cited: September 9, 2010.] http://www.dphhs.mt.gov/newsevents/newsreleases2007/february/medicaidgrant.shtml.12. Centers for Medicare & Medicaid Services. Childrens Health Insurance Program Reauthorization Act (CHIPRA) of 2009 Outreach and Enrollment Grants. FY 2010 CHIPRA Outreach Grantees Summaries. [Online] July 7, 2010. [Cited: August 27, 2010.] http://www1.cms.gov/CHIPRA/Downloads/Grantees.pdf.13. Zufeldt, Camie. Montana As-Is HIT Assessment - Question Series # 10. Helena, July 2010.




14. surescripts. Top States for Electronic Prescribing. Surescripts. [Online] [Cited: November 29, 2010.] http://www.surescripts.com/media/668581/fifth%20annual%20safe%20rx%20state%20rankings.pdf.15. U.S. Department of Health & Human Services. HHS.gov/Recovery. Recovery Act Funding for Community Health Centers in Montana. [Online] 30 June, 2009. [Cited: August 27, 2010.] http://www.hhs.gov/recovery/programs/hrsa/montana.html.16. Hayes, Howard. IHS EHR GUI Deployment Status. Indian Health Service. [Online] Indian Health Service, August 6, 2010. [Cited: August 18, 2010.] http://www.ihs.gov/CIO/EHR/index.cfm?module=gui_facilities.17. Preshinger, Duane. Montana Medicaid Health Information Technology Initiative. Department of Public Health & Human Services . [Online] September 10, 2010. [Cited: September 10, 2010.] http://medicaidprovider.hhs.mt.gov/providerpages/ehrincentives.shtml.18. Medicare and Medicaid Programs;Electronic Health Record Incentive Program; Final Rule. s.l. : Federal Register 42 CFR Parts 412, 413, 422 et al., July 28, 2010. Vol. 75, 144, p. 44483. RIN 0938–AP78.19. Office of Inspector General. OAS RAT-STATS Software. Office of Inspector General (OIG), U.S. Department of Health and Human Services. [Online] [Cited: September 14, 2010.] http://oig.hhs.gov/organization/oas/ratstats.asp.20. Montana Department of Public Health and Human Services. Administrative Rules of Montana Chapter 85 General Medicaid Services. [Online] October 13, 2009. [Cited: September 14, 2010.] http://dphhs.mt.gov/legalresources/administrativerules/title37/chapter85.pdf.21. Medicare and Medicaid Programs; Electronic Health Record Incentive Program. s.l. : Federal Register 42 CFR Parts 412, 413, 422 et al., July 28, 2010. Vol. 75, 144, p. 44489. RIN 0938–AP78.22. Department of Public Health and Human Services. Administrative Review and Fair Hearing Process for Medical Assistance Providers. Montana Secretary of State. [Online] March 31, 2007. [Cited: September 14, 2010.] http://www.mtrules.org/gateway/ruleno.asp?RN=37%2E5%2E310.




ACRONYMS

Acronym Description

A/I/U Adopt, Implement, and Upgrade

AP Accounts payable

AR Accounts receivable

ARRA American Recovery and Reinvestment Act of 2009

BTOP Department of Commerce Broadband Technology Opportunities Program

BIP US Department of Agriculture Broadband Initiative Program

CAH Critical Access Hospital

CCHIT Certification Commission for Health Information Technology

CDC Centers for Disease Control

CHIP Children’s Health Insurance Program

CIO Chief Information Officer

CMS Centers for Medicare & Medicaid Services

COB Coordination of Benefits

CPOE Computerized Physician Order Entry

CPU Central Processing Unit

CSR Customer Service Representative

DME Durable Medical Equipment

DRG Diagnosis-related Group

DSS Decision Support System

DW Data Warehouse

EDI Electronic Data Interchange

EFT Electronic Funds Transfer

EHR Electronic Health Record

EH Eligible Hospital

ELR Electronic Laboratory Reports or Reporting

EMR Electronic Medical Records

EP Eligible Professional

EPE Electronic Provider Enrollment

ePHI Electronic Protected Health Information




Acronym Description

EPSDT Early Periodic Screening, Diagnosis, and Treatment Program

ER Emergency Room

FEIN Federal Employer Identification Number

FFP Federal Financial Participation

FQHC Federally Qualified Health Center

FTTP fiber-to-the-premises

HAN Health Access Network

HCPCS Healthcare Common Procedure Coding System

HEDIS Healthcare Effectiveness Data and Information Set

HIE Health Information Exchange

HII Health Information Infrastructure

HIIAB Health Information Infrastructure Advisory Board

HIPAA Health Insurance Portability and Accountability Act

HISPC Health Information Security and Privacy Collaborative

HIT Health Information Technology

HITECH Health Information Technology for Economic and Clinical Health Act

HITRC Health Information Technology Research Center

HL7 Health Level Seven

HMIS Health Management Information System

HMP Health Management Program

HRSA Health Resources and Services Administration

IAPD Implementation Advance Planning Document

ICD-9 International Classification of Diseases and Related Health Problems, 9th Revision

ICD-10 International Classification of Diseases and Related Health Problems, 10th Revision

IDN Integrated Delivery Network

IDS Integrated Delivery System

IFR Interim Final Rule

IHS Indian Health Services

IO Insure Oklahoma

IRS Internal Revenue Service

IT Information Technology




Acronym Description

I/T/U Indian Health Services, Tribal facilities/Urban Indian Clinics

MAR Management and Administrative Reporting System

MED Medical Exclusion Database

MFCU Medicaid Fraud Control Unit

MITA Medicaid Information Technology Architecture

MMIS Medicaid Management Information System

MU Meaningful Use

NHIN National Health Information Network

NLR National Level Registry

NPI National Provider Identifier

NPPES National Plan and Provider Enumeration System

NPRM Notice of Proposed Rule Making

NTIA National Telecommunications and Information Administration

OEI Outreach, Education, and Information work group

OIG Office of the Inspector General

ONC Office of the National Coordinator for Health Information Technology

PA Physician Assistant

PCMH Patient Centered Medical Home

PCP Primary Care Provider

PDI Planning, Development, and Implementation work group

PHR Personal Health Record

PI Program Integrity

POS Point-of-Sale

PQRI Physician Quality Reporting Initiative

PRU Performance and Reporting Unit

QA/QI Quality Assurance/Quality Improvement

REC Regional Extension Center

RFI Request for Information

RFP Request for Proposal

RHC Rural Health Clinic

RHIO Regional Health Information Organization




Acronym Description

RPMS Resource and Patient Management System

SCHIP State Children’s Health Insurance Program

SMHP State Medicaid Health Information Technology Plan

SMM State Medicaid Manual

SS-A State Self-Assessment

SURS Surveillance Utilization Review System

TIN Taxpayer Identification Number

VA Veterans Affairs

VFC Vaccines for Children

VistA Veterans Health Information Systems and Technology Architecture

X12 Accredited Standards Committee X12




GLOSSARY

Electronic Health Record (EHR)

A subset of each care delivery organization’s EMR, presently assumed to be summaries, like the Continuity of Care Record or the Continuity of Care Document, is owned by the patient and has patient input and access that spans episodes of care across multiple care delivery organizations within a community, region, or state (or in some countries, the entire country). The EHR in the United States use the proposed National Health Information Network (NHIN).

Electronic Medical Record (EMR)

An application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications. This environment supports the patient’s EMR across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and manage healthcare delivery within a care delivery organization. The data in the EMR is the legal record of what happened to the patient during their encounter at the care delivery organization and is owned by the care delivery organization.

Healthcare Provider

includes a hospital, skilled nursing facility, nursing facility, home health entity or other long term care facility, health care clinic, community mental health center (as defined in section 1913(b)(1)), renal dialysis facility, blood center, ambulatory surgical center described in section 1833(i) of the Social Security Act, emergency medical services provider, Federally qualified health center, group practice, a pharmacist, a pharmacy, a laboratory, a physician (as defined in section 1861(r) of the Social Security Act), a practitioner (as described in section 1842(b)(18)(C) of the Social Security Act)." (NOTE: According to CMS under Medicaid these institutional providers are acute care hospitals and children's hospitals. Further information is available at: http://ehr.healthcareitnews.com/priming_pump_QA.html. One important exception is if the physician is employed by a hospital; in that case, the hospital, not the physician, is eligible for the reimbursement.)

Health Information Exchange (HIE)

The mobilization of healthcare information electronically across organizations within a region, community or hospital system. HIE provides the capability to electronically move clinical information among disparate healthcare information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care. HIE is also useful to multiple public health authorities to assist in analyses of the health of the population and the effectiveness of treatments.

Health Information technology (HIT)

Encompasses a broad array of technologies involved in managing and sharing patient information electronically, rather than through paper records and non-standard transmittals.




DOCUMENT REVISION HISTORY

Version Date Description1.0 January 6, 2011 Original document1.1 June 30, 2011 Minor revisions requested

by CMS as condition of approval of SMHP
