AHCCCS - 2007 Medicaid Transformation Grant Final Report

Back to Table of Contents
Back to Section 3.5.13

3.6 Goals Achieved/Not Achieved

The original vision of the Health Information Exchange/Electronic Health Record Utility (HIeHR Utility) Project as stated in the grant proposal was:

... to develop and implement a web-based health information exchange (HIE) utility to achieve the goal of giving all Medicaid providers instant access to beneficiaries´ health records via electronic connection at the point of service. The electronic health record (EHR) available through this HIE utility will include patient demographics and eligibility information, patient problem lists, medications, lab tests orders/results, radiological results and images, inpatient discharge summaries, and clinical notes.

Implementing this HIE utility will transform the AHCCCS Medicaid program and the patient care process. Providing timely patient health information at the point of service will improve the quality, efficiency and effectiveness of Arizona´s Medicaid program. Real time health information access will result in reduction of medical errors, reduction of redundant testing and procedures, better coordination of care for chronic diseases, increased preventive interventions, reduction in the inappropriate use of the emergency room, and lower administrative costs. When aggregated, these benefits will save significant state and federal taxpayer dollars (in Medicaid, SCHIP, and IHS) as well as beneficiary and provider frustration.

The implementation of AMIE, demonstrated the ability to provide patient health information in close to real time at the point of care.

The high level of acceptance, and positive feedback by the provider community showed that the health care delivery community is ready for this change if managed and implemented properly.

The result of having access to patient information will realize an improvement of quality, efficiency and effectiveness of not just the Medicaid program, but the health care system in general.

Although AMIE was not able to reach a large number of providers, it demonstrated the concept of health information exchange, and educated with real world experience the stakeholders for HIE, including those with data to be shared, as well as those who would benefit from having access to the data. The result is a significant increase in momentum in the state helping to move the realization of health information exchange forward.

3.7 Lessons Learned

3.7.1 Importance of Managing Scope

Early research with our stakeholders helped identify what aspects of the HIE would deliver the most value early in the project. This helped to define the scope of the project. Attempting to solve all problems at once would have lead to failure.

By starting with a small number of record types, data providers, and practitioners accessing the data, we were able to successfully stand up a system, smooth out the glitches, and establish a platform upon which a large scale HIE could eventually be deployed.

3.7.2 Existing HIT Capability is Limited

There may be a perception outside of the health care system that much patient health information is already electronic and can easily be shared. The hospitals with the most resources are still struggling to integrate their own enterprise systems. The ability to share information outside of the enterprise presents many challenges.

3.7.3 Health Care Community and Public Level of Understanding

Only with the American Recovery and Reinvestment Act (ARRA) has the level of interest in electronic health information, and exchange increased. At the start of the Medicaid Transformation Grant (MTG) project, the IT, legal and compliance communities had little understanding of the mechanisms and safeguards being used in the sharing of electronic health information. Only those involved in the project or similar initiatives have developed a basic understanding. There is much ground yet to be covered. A conscious effort to continue to educate the following disciplines should be maintained:

Practitioners and the public understanding of which health information is electronic and what and how it is being shared is poor. With the high level of concern regarding the patient having control of their information, it is critical that there is a clear understanding of what, how and by whom information is being used, and what protections are in place in the event that privileges are abused.

3.7.4 Implementation Lessons
Standards
Standardization ensures that the system is able to meet all of the requirements placed upon it in many different categories:
Patient Identification
MPI algorithms differ, but none is perfect.
Without unique identifiers, there will always be challenges
Patient Consent
There are no clear regulations
Technology can support most consent models
Data is not easily identified on a level to be consent controlled
Provider relationships not centrally maintained to support consent by provider.
Security is paramount. A complete solution requires measures in a number of different areas:
Technical
Administrative
Policy
Procedural
User Training and Provisioning
User Authentication
Monitoring and Audits
Monitoring the system, usage, volumes and ensuring proper use is important for validation of value being delivered, and adherence to policies.
Regular Reports and Audits
Utilization Reports
Activity by User, Organization
Record Types
Users by Individual, Organization
Login Analysis
Audit Reports
Manual Review
Viewer Administration and Use
Ad hoc compliance requests
Penalties for violation of policy
Successful adoption depends heavily on understanding user needs and their environment.
Research through surveys and focus groups
Assessment and evaluation of adoption readiness
Environmental scan of existing infrastructure
Professional Forums with Organizations

3.7.5 Existing Regulations Not Written For the Digital Age

Privacy/Security rules and regulations can be a barrier. See the detailed discussion of regulations and policy in section 3.9, Policy Findings.

3.7.6 Leadership is Critical

Much of this project was accomplished by the project team forging ahead and then backtracking to incorporate leaders from the large range of stakeholders. As the objective of transforming health care to a digital age is continued, focused leadership is required to align the incentives and define roles and responsibilities of all participants. Duplication of services is a significant contributing factor to the increasing cost of health care, it would be a mistake to create duplication of infrastructure when implementing health information exchange.

3.8 National Implications

Since electronic health information exchange is still in its infancy, there is much to be gained by others from lessons learned. AHCCCS has consistently strived to share what we´ve experienced and learned through this journey of developing a working HIE, as well as learning from others, and adapting their teachings to our initiatives. Whenever mankind endeavors to achieve new horizons, it is only done by standing on the accomplishments of others.

Through the NASMD Medicaid Transformation Collaborative, participation in numerous presentations and webinars such as the AHRQ Health Care Innovations Exchange (http://www.innovations.ahrq.gov/content.aspx?id=2599), the use of open source development, the publishing of this report and other documentation from our project, we hope the progress of health information exchange will be advanced nationally.

Over the two years of the project, Director Rodgers presented to over 60 different audiences across the country sharing the vision of health information technology, both from a Medicaid perspective as well as a health care system wide perspective.

3.9 Policy Findings

Through the contract with AzHeC, a Legal Working Group was assembled, led by Beth Schermer and Kristen Rosati of Coppersmith Schermer & Brockelman PLC a leading Phoenix, Arizona law firm providing widely-recognized legal knowledge and skill to clients in Arizona and across the nation, primarily in the areas of health care, employment, litigation, corporate and real estate transactions, and investigations and criminal defense.

The Legal Working Group involved many individuals from a wide array of perspectives, including representatives from consumer organizations, hospitals, physician groups, long term care, health plans, various state agencies and the Arizona Attorney General´s Office, universities and colleges, large employers, IT vendors, private law firms, and organizations planning HIOs.

The Legal Working Group developed a model HIO participation agreement (contract) and HIO policies that integrate responsibilities for the HIO and the participating health care providers to rigorously protect the health information handled through the HIE process. This model contract was used and adapted by the AMIE project for use with its data partners and data users.

Also performed was a close evaluation of existing federal and Arizona statutes and regulations, to determine whether those laws may pose barriers to electronic health information exchange and to determine what "gaps" need to be filled to ensure rigorous privacy and security of health information in HIE. The Legal Working Group encountered a wide variety of federal and state laws that already protect patient health information and provide substantial penalties for the misuse of that information for individual and entities subject to those laws. These federal and state statutes and regulations include:

As we move to exchanging health information electronically, we are encountering a number of medical records laws that were clearly designed for the paper world and that cannot accommodate the migration to electronic health records. For example, the proposed statutory and regulatory amendments:

Barriers to electronic health information exchange were identified in the following statutes:

  1. General Medical Records, A.R.S. § 12-2291, et seq.
  2. Clinical Laboratory Disclosures of Lab Results, A.R.S. § 12-2294 and A.R.S. § 36-470
  3. Genetic Testing Information: A.R.S. § 12-2801, et seq. and A.R.S. § 20-448.02, et seq.
  4. Computer Tampering Laws, A.R.S. § 13-2301, et seq.,
  5. Immunization Information, A.R.S. § 36-135 and A.A.C. R9-6-708
  6. Mental Health Information: A.R.S. § 36-501, et seq.
  7. Communicable Diseases: A.R.S. § 36-661 et seq. and A.R.S. § 20-448.01
  8. Health Care Directives, A.R.S. § 36-3295

Proposals for amendments to these statutes were documented in the memos from Kristen Rosati to the Legal Working Group, which are included with this report.

3.10 Impact to Medicaid

The Medicaid population in Arizona tends to be very mobile and transient. Electronic health information to support continuity of care across care settings has proved to be invaluable to practitioners when made easily available.

The potential of health information exchange for Arizona, the Medicaid program in Arizona and across the nation has been demonstrated as achievable through this project. The value model as discussed earlier in this report goes into great detail regarding where cost avoidance can be found, efficiencies can be gained, and safety can be improved through HIE.

3.11 Cost Efficiencies and Savings

Although the scope of the AMIE rollout was limited as was stated in the project evaluation reports, the value to clinicians of the information AMIE made available, and the ease and efficiency of accessing this information was validated by the feedback we received. Clearly if AMIE were to be expanded to encompass a larger number of data providers and clinicians, the financial, quality and safety gains indicated in the value model and anticipated in the original vision of the initiative could easily be realized.

3.12 Sustainability

Business models for health information exchange are in development all across the country. The focus of the AMIE project was to develop and demonstrate the technology to help educate the health care community in Arizona on the concept of health information exchange, and to start the cultural change towards the use of electronic health information.

The challenge for health information exchange is to properly scope the services an exchange would provide, balanced against the cost and the derived value of delivering those services. An HIE can serve as only the conduit or network through which health information can be delivered at a minimal cost, or provide aggregation and clinical decision support services at significantly greater cost. There is a broad array of services that could be provided.

AMIE has been transitioned to a not for profit organization which is working on developing a business model for statewide health information exchange. It is believed that a sustainable business model is achievable on a statewide basis as opposed to a regional or community scope. The AMIE not for profit, working with other organizations within Arizona will be developing a sustainable business model during 2010.

To Section 4.0