Health Homes Technology Simulation Workshop

1. Health Homes Technology Simulation Workshop Ron Hendler Nish Thakker

2. Person-centered Medicaid systems Several Centers for Medicare and Medicaid Services (CMS) initiatives including: • Money Follows Person (MFP) • Balancing Incentive Program (BIP) • Health Homes -are prompting states to address requirements of “person-centered Medicaid systems” This has direct implications for HCBS programs.

3. Health Homes Information Requirements Describe the State’s methodology for tracking avoidable hospital readmissions to include data sources and measure specifications. Describe the State’s methodology for calculating cost savings that result from improved chronic care coordination and management achieved through this program, to include data sources and measures specifications. Describe the State’s proposal for using health information technology in providing health home services under this program and improving services delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider).

4. Significant Technical Challenges • These Affordable Care Act Programs encourage improvement in the delivery of Home and Community-based Long-term supports and services. • These Programs also present significant technical challenges associated with coordinating care across disconnected specialty providers and software platforms which can overwhelm staff responsible for designing and implementing the changes.

5. Heath Homes Technology Simulation Workshop This workshop will focus on demonstrating how standards and software, developed by CMS and ONC (Office of the National Coordinator), simplifies the interoperability required for sharing records across the Medicaid Enterprise These technologies enable states to: • Exchange clinical records between provider EHR systems • Capture performance metrics and quality measures.  • Achieve meaningful use incentive money eligibility • Manage consent and referrals using rigorous security standards Finally, a novel prototype system will be demonstrated that allows care coordinators to “actively” manage CMS Funded Health Home activities

6. Technology standards and systems enable health homes • Scenario describes a typical Health Home where a patient has 2 chronic conditions • Behavioral Health condition: Anxiety • Primary Care condition: Diabetes

7. Health HomesA Novel Prototype Person Centered Care Plan Thank You Next Slide

8. Existing Systems used by specialty Providers Providers and EHRs Long-Term Care/ HCBS Developmental Disabilities Primary Care BH Providers FQHCs Custom Queries Quality Measures

9. Existing Systems used by specialty Providers BH Providers • WITS System • Used by 28 States and Counties • Meaningful Use Certified • Over 2.3 Million Client Records Custom Queries Quality Measures

10. Existing Systems used by specialty Providers Long-Term Care/ HCBS • eLTSS System in production in MD • Recently chosen by Mississippi • Covers BIP requirements, waiver management, MFP, Electronic Visit Verification Custom Queries Quality Measures

11. Existing Data Standards: CCD Providers and EHRs Long-Term Care/ HCBS Developmental Disabilities Primary Care FQHCs BH Providers • The Continuity of Care Document (CCD) • XML document containing most common medical records elements • Vitals, demographics, lab tests, medications, encounters, etc. • Made Ubiquitous thanks to Meaningful Use CCD

12. Health Information Exchanges (HIE) Secure Record Sharing HIE Most States have HIEs and include: A Directory of Participating Care Provider Addresses Secure email (DIRECT) Compatible with EHRs

13. Health Information Exchanges (HIE) Secure Record Sharing HIE • Sending a DIRECT Message with a CCD attachment

14. HIE Standards Secure Record Sharing HIE An HIE transfers data using standards for: Messaging (DIRECT) http://wiki.directproject.org/ Secure Transmission of Interoperable Records (Encryption) Assured Record Authenticity (Digital Signing) Content (CCD) DIRECT CCD DIRECT

15. Sharing Confidential Information Across an HIE Secure Record Sharing Consent2Share 42 CFR pt2 HIE + • Consent2Share (C2S) • Bolt-on to an HIE for managing consent and privacy at the data element level • patient portal that enables patients to electronically provide and update their privacy preferences • Alleviates administrative burden placed on providers

16. Sharing Confidential Information Across an HIE Secure Record Sharing Consent2Share 42 CFR pt2 • Consent2Share (C2S) • Collaboration between VA and SAMHSA • Designed for very restrictive Substance Abuse Data Referral restrictions

17. Sharing Confidential Information Across an HIE Secure Record Sharing Consent2Share 42 CFR pt2 • Consent2Share (C2S) • Electronic Signature • Uses Adobe EchoSign

18. HIE & C2s Standards Secure Record Sharing Consent2Share 42 CFR pt2 HIE + • Uses: • CCD • DIRECT • And XACML • eXtensibleAccess Control Markup Language • HIEs can ask C2S patient’s privacy preferences permit sharing of a CCD • Providers only receive Patient Health Information when patient preferences “Permit” XACML XACML DIRECT CCD

19. Health Home Quality Measures • PopHealth • Open Source Project from MITRE and ONC • Takes CCD document to calculate required NQF Quality Measures • Used in CMS pilot “Value-based Purchasing” Program • Docs that report claims and QMs receive higher reimbursement • Perfect foundation for Pay for Performance Quality Measures popHealth

20. Health Home Quality Measures Quality Measures popHealth • PopHealth • Includes unique Quality Measures required for Health Homes

21. Quality Measures Standards: QRDA Quality Measures popHealth QRDA • QRDA • Quality Reporting Document Architecture • HL7 standard for transporting Quality Measures • http://wiki.hl7.org/index.php?title=Quality_Reporting_Document_Architecture XACML DIRECT CCD

22. Now Possible…. Billing Referrals Plans of Care Care Coordination The Home Health Dashboard • Integrated services require integrated software • Simulation only • Acts as the “Quarterback” instead of a separate EHR • Should use Open Systems • Federally-Funded Data Standards • Allows for Care Coordinators to “Actively” Manage a Patient’s care

23. ... with Open source Architecture Billing Referrals Plans of Care Care Coordination

24. Billing Referrals Plans of Care Care Coordination The Home Health Dashboard Secure Record Sharing Quality Measures Consent2Share 42 CFR pt2 HIE popHealth + Providers and EHRs Long-Term Care/ HCBS Developmental Disabilities Primary Care FQHCs BH Providers CCD DIRECT QRDA XACML