IME Att 3 MITA

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  • In Iowa, we have implemented a new business model for the administration of the state’s Medicaid program. It is called the Iowa Medicaid Enterprise, or IME for short. As we reviewed the MITA concepts and materials we were struck by the similarities and became an early adopter state not really knowing what that might mean for the IME or for MITA. We have begun to discover what MITA can do for the IME, and we are in the process of documenting our progress and our plans using the MITA framework. We would like to share with you where our MITA journey in Iowa has taken us, and where we plan to go with MITA providing guidance and tools for achieving our shared goals.
  • I’ll tell you a little bit about Iowa and our Medicaid program, then introduce the concepts behind the IME. After reviewing how our plans align with MITA’s goals, I’ll summarize how we approached implementing our vision. Our transition to operations occurred June 30, so I’ll tell you what we’re planning next, and offer some lessons we learned along the way. Then Erin Harris, our MITA Coordinator will talk about MITA-sizing the IME.
  • Iowa’s population is estimated to be about 2.9 million, ranking 30 th in population and 25 th in land area among the states. Along with other states our Medicaid budget has increasingly been dominated by the costs of the Medicaid program. Faced with the challenge of finding cost effective measures in administration and benefits, Iowa chose to seek a solution that gave more control to the State in production of better health outcomes and administration of the Medicaid program.
  • Prior to the IME, Iowa had a traditional Fiscal Agent MMIS solution. As is common, the one-size-fits-all approach functioned well for some services, not so well for others. The technical staff and infrastructure were mainly remote from Iowa, and operational staff across town from the Medicaid administrative staff. The ability to adapt to changes was frequently constrained.
  • We envisioned a different solution – one that would modularize our business operations and employ “best practices” in each service area. This would help to provide flexibility and the ability to adapt to change. We wanted a solution that would focus on effective delivery of medical services to the members, based in data collection and analysis that would empower our program administration to do a better job of controlling costs and defining benefits. We were also determined that we would improve our member and provider services by using performance standards to measure success. We wanted to increase accountability throughout the operations of the Iowa Medicaid program, in keeping with Iowa’s initiative for “Results-Based Accountability” in state government.
  • The RFP for the IME was released in 2003. MITA’s Framework 1.0 was published in January of 2004, after the IME project was already underway. While we could not change our DDI schedule to incorporate all aspects of MITA into the project because of our set operations date, we could run a parallel project to determine if MITA could add value to the IME and to what extent Iowa was moving in the MITA direction. As an early adopter state we have documented the IME in terms of shared goals with MITA and the value MITA adds to Iowa’s vision.
  • Iowa issued a single RFP, with multiple components that aligned with major business functions. Separate responses were required, and a single vendor could respond to any or all of the components. In the end eight vendors were selected for the nine components. The IME is also supported by other State services including the housing of the MMIS and Data Warehouse on state data center equipment.
  • Our plans included transferring a copy of the production MMIS to state-owned hardware then enhancing it for use in the IME. A Medicaid data warehouse was built on a state data center platform and operated by the Department’s Data Management Division. All Contractors were given a common set of tools including a common state facility, common data sources and a workflow process management system. Systems brought by Contractors were integrated into the IME model as additional tool sets. All Contractors share a common basic contract with the entire set of report card measures for the IME as part of that contract.
  • The IME turned to operations as scheduled. Two units went live earlier than our June 30 th date. Our first payment cycle occurred on schedule and the IME paid all claim types and all provider types in that payment cycle. Sixty days prior to our implementation date of June 30, the Iowa legislature passed Medicaid reform. Phase 1 became effective July 1. Because most of the players involved in making reform happen now resided in the IME facility all policy, waivers, rules, system changes were able to be in place by the required effective date. This was able to be accomplished because of the flexibility of the IME model.
  • Thanks for coming to hear about our MITA activities for the IME in Iowa. I will tell you what we initially planned to accomplish with our MITA activities, and highlight some of the IME’s opportunities for enterprise architecture. Then we’ll look at some of the MITA and enterprise architecture tools we have employed to prepare for the MITA self-assessment, and see how these activities have contributed to the IME’s ability to perform strategic planning that is focused on our business.
  • MITA activities at the IME were conducted in parallel to the DDI phase of the IME project, and commenced in late July of last year. Plans included assessing the MITA framework for its applicability to the IME business model, and contributing whenever possible to the definition of MITA. We also wanted to find out if MITA principles could be applied to the IME. This proved to be problematic within the compressed timeframe of the DDI phase since MITA was continuing to develop and change, and because plans and contracts were already in place for the IME. So we decided to focus on MITA’s potential impact for future planning for the IME. We wanted to validate and pilot MITA and its enterprise architecture methods to develop a business process model and collect and organize the IME’s architectural elements and artifacts being produced as a part of DDI.
  • Many of the activities required in the DDI phase of the IME project provided key components for building an enterprise architecture. Because the IME was transforming the business operations for Iowa Medicaid, new business processes were developed and documented in required deliverables, and used as design criteria for the workflow process management system to be implemented. All the IME contractors were also required to develop operational procedures manuals, and points of process flow integration with other business units were documented along with internal processes. All contracts specified performance measures associated with each contractor’s responsibilities, and these are being mapped to specific business processes. Another team extracted and documented the business rules embedded in the MMIS system that had been transferred to state hardware. The technical environment built for the IME during DDI was adapted to meet specific business needs, combining COTS, custom development, and contractor-owned and operated components interfaced with the mainframe-based MMIS. Continued development of systems integration will provide greater operational efficiency and flexibility based on business drivers in the IME.
  • So, the question was: “How to MITA-size the IME?” How could the EA underway in the DDI phase be used in validating and piloting MITA? The MITA lifecycle represented here has matured over the last year, but its essential components remain the same. Ideally, it would be entered from the left, with all incoming products in place (strategic plan, state enterprise architecture, MITA framework and capability matrix, and MITA Medicaid EA guidelines). But the IME was in the midst of an implementation, MITA products were under development or revision, and the state EA pre-dated plans to transfer the MMIS. In reality, we have found ourselves all over this map of the iterative process that is MITA and enterprise architecture development.
  • Since MITA’s EA guidelines were still under development, the MITA team suggested that we take a look at other views of enterprise architecture such as the NASCIO (National Association of State CIOs) EA toolkit, the FEA (Federal Enterprise Architecture), and other EA models. Each has a different perspective on the detailed dimensions of an enterprise architecture. This model, for example, is an IT view that represents a desirable alignment of information and applications architectures with the technical infrastructure layers of an enterprise architecture, all supporting a common user interface. The top-down view (in the upper right) shows equally important aspects of security and systems management supporting the architecture. However, just as we have found with pyramid structures around the world that appear to be similar, there are critical internal differences that correspond to the purposes for which they were built. Where is the business?
  • The multiple dimensions of enterprise architecture must focus on the business of the enterprise. Here, this business centric focus is illustrated in the context of MITA and its EA dimensions. A business process is shown as it matures over time and the MITA maturity model. There are four dimensions that characterize the business process over any particular instance in time: the capability or competency with which the process is performed, and the data, application, and technical architecture used to support that level of competency. There are business drivers from various sources that stimulate changes and improvements in capabilities. Picture each of the four dimensions connected by a stretchy membrane, like a piece of balloon, so that any movement or change in one dimension has a tendency to pull along the others, but not in a solid “lock-stepped” way. One dimension can advance, and it can take some time before all the others catch up. Forcing one up will not necessarily cause the others to also advance – planning coordinated advances in each dimension will provide smoother transitions for the enterprise’s business processes.
  • MITA and enterprise architecture introduce new perspectives in thinking about the way we do business. As we approached EA modeling in the IME, we found it helpful to apply a means of breaking down the what from the who, how, when and where. This was very valuable both in business process modeling and in building our traceability matrix.
  • The fundamental framework of the IME’s business process model was laid out in the requirements and the organization of the RFP. The separate functional areas for RFP responses constituted business units in the IME, and laid the groundwork for defining the business areas in the BPM. Requirements were massaged into business capabilities. The drafts of the IME business units’ operational procedures were used to develop an outline of business processes. These were then organized into MS Excel spreadsheets used as input for Visio organizational charts which served as models. These were then used to further refine the business processes by inspecting them for redundancies in processes, examining the functional hierarchy that was presented in graphical format, and analyzing trigger events for the processes.
  • Here are some high level examples of the models produced. The first is the overall IME business model, showing our business areas. The second model shows the Medical Services business area model, and the functional areas it encompasses. Each functional area then has associated business processes that appear in lower level models.
  • Next, we crosswalked the IME business process model to the latest version from MITA. It revealed that our IME BPM went to a finer degree of granularity in the business processes, partly due to the fact that some MITA business processes cross business and functional areas in the IME business model. Gaps in our BPM were also revealed, as was expected, since not all processes were documented in detail in the DDI phase, only those performed by contractors. When multiple IME processes mapped to a single MITA process, that highlighted areas for procedural and systems integration across our business areas. The crosswalk provides the basis for comparison with the MITA capability matrix when we perform our MITA self-assessment. It also permits us to maintain an IME business process model that remains relevant to the way we operate and to the business people within the IME.
  • Here is a sample from our crosswalk, with the MITA BPM shown in greens on the left, and the IME in blues on the right. The base business processes are in the two middle columns, with up to two intermediate levels (functional areas) and the business areas shown in the outer columns. Here, the MITA Member Management business area corresponds to functions and processes in DHS Eligibility Administration, Member Services, and Medical Services business areas within the IME.
  • Now, recalling our EA questions a few slides back, here is an example of our initial traceability matrix for the IME, which is still a work in progress. For each business and functional area, such as the Medical Support functions of our Member Services area, we have business processes going down the left side, with columns for pre-IME “as is” capabilities, new IME “to be” capabilities, the gaps between them, and the who – stakeholders, the business value of the added capabilities, as well as alignment with the IME’s goals. This shows assessing the degree of alignment with specific goals as a measure of progress. We expect our traceability matrix to become a living document, although by preserving versions at pre-determined timeframes we will be able to track changing directions and priorities.
  • We then extended the concept of the traceability matrix to begin capturing other dimensions of the enterprise architecture. Applications related to the “to be” capability were specified and documented in DDI requirements and design deliverables produced by the contractors, and high level details about the associated technical and data architectures were also captured. We can use this to know what IT components may be affected by changing a business process capability. It also permits us to know what business processes and capabilities may be impacted when a technical component is changed.
  • From there, additional details and artifacts for each of the EA dimensions can also be associated with each capability. Illustrated here are the “qualities” associated with the capability, from the new MMM and MITA capabilities matrix. This also shows collecting the performance measures linked to a particular business capability. As these details are extended and captured for each EA dimension for each business process, the information needed to complete the IME’s MITA self-assessment will be compiled.
  • What we have learned at the IME by piloting the MITA lifecycle is that the process of preparing for the MITA self-assessment also provides an opportunity to begin documenting the architecture for our enterprise. The BPM we developed provided input for our traceability matrix and its extensions. By applying our crosswalk, we will be able to compare our implementation with the MITA capabilities matrix to perform the self-assessment. We have discovered that these tools and processes have helped us collect and organize our EA artifacts, and provide a roadmap for future change within the enterprise. We can better understand the scope and impact of changes in the business, and its supporting architecture, by using the information organized in the extended traceability matrix. MITA and EA are an on-going effort that is incremental and iterative. More value can be gained, and more detail and increased granularity can be documented with each iteration. These techniques will permit a variable focus, from the level of changing business process steps all the way up through re-engineering the enterprise.
  • IME Att 3 MITA

    1. 1. MITA Case Studies: Which came first – the enterprise or the architecture? Presented to: MMIS Conference 2005: Big Sky, MT August 14 - 18, 2005 Mary Tavegia – IME Project Director, State of Iowa DHS Erin Harris – IME MITA Coordinator, Software Engineering Services
    2. 2. The Iowa Medicaid Enterprise <ul><ul><li>Iowa Facts and Figures </li></ul></ul><ul><ul><li>IME Vision </li></ul></ul><ul><ul><ul><li>Similar to MITA Goals </li></ul></ul></ul><ul><ul><li>Implementing the Vision </li></ul></ul><ul><ul><ul><li>RFPs, Contracts, and Performance Measures </li></ul></ul></ul><ul><ul><ul><li>DDI – Building the IME </li></ul></ul></ul><ul><ul><li>The Enterprise is Live! </li></ul></ul><ul><ul><ul><li>Initial Results </li></ul></ul></ul><ul><ul><ul><li>What’s Next </li></ul></ul></ul><ul><ul><li>“ MITA-sizing” the IME </li></ul></ul>
    3. 3. Medicaid in Iowa <ul><li>Iowa </li></ul><ul><ul><li>Population – 2.9 million </li></ul></ul><ul><ul><li>Currently 10% of population Medicaid eligible </li></ul></ul><ul><ul><li>Medicaid impacts one out of every three Iowans </li></ul></ul><ul><li>Dramatic Medicaid Cost Increases </li></ul><ul><ul><li>Average Monthly Eligibility (> 39% in 5 years) </li></ul></ul><ul><ul><li>Average Monthly Total Payments (> 69% in 5 years) </li></ul></ul><ul><li>Results-based Accountability in Iowa </li></ul><ul><ul><li>Performance measurement </li></ul></ul><ul><ul><li>Cost-effective healthcare </li></ul></ul>
    4. 4. MMIS in Iowa <ul><li>Last procurement in 1995 </li></ul><ul><ul><li>Fiscal agent customized MMIS </li></ul></ul><ul><ul><li>Pharmacy Point of Sale (POS) </li></ul></ul><ul><ul><li>Decision Support System (DSS) </li></ul></ul><ul><ul><li>Medically Needy </li></ul></ul><ul><ul><li>Managed Care </li></ul></ul><ul><ul><li>Operated on Contractor hardware in Pennsylvania and Georgia </li></ul></ul><ul><ul><li>Professional Services and operational support by Fiscal Agent </li></ul></ul><ul><ul><li>Interfaces with state-operated Medicaid eligibility systems (Title XIX, ISIS) </li></ul></ul><ul><li>Ability to adapt to change constrained </li></ul>
    5. 5. Iowa Medicaid Enterprise (IME) <ul><li>The Vision </li></ul><ul><ul><li>Improve service to Iowa Medicaid members, providers, and partners </li></ul></ul><ul><ul><li>Shift control from Contractor to the State </li></ul></ul><ul><ul><ul><li>Increase accountability throughout Medicaid operations </li></ul></ul></ul><ul><ul><ul><li>Enhance decision making ability </li></ul></ul></ul><ul><ul><li>Implement “Best practices” in key Medicaid business functions </li></ul></ul><ul><ul><ul><li>State management with “Best of Breed” Contractors </li></ul></ul></ul><ul><ul><ul><li>Improve health outcomes for members </li></ul></ul></ul><ul><ul><ul><ul><li>Enhanced primary care case management </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Initiate disease management program </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Collect and analyze cost and outcome information </li></ul></ul></ul></ul><ul><ul><ul><li>Collaboration rather than competition </li></ul></ul></ul><ul><ul><li>Increase flexibility and adaptability </li></ul></ul><ul><ul><li>Leverage state IT infrastructure </li></ul></ul>
    6. 6. IME Similar to MITA Goals <ul><li>RFP for IME released in 2003 </li></ul><ul><li>MITA Framework 1.0 published in January 2004 </li></ul>MITA Goals <ul><li>Integration and interoperability </li></ul><ul><li>Flexibility to respond rapidly to change </li></ul><ul><li>Enterprise view to align technology and business needs </li></ul><ul><li>Data that supports analysis and decision making </li></ul><ul><li>Performance measurement for accountability and planning </li></ul><ul><li>Coordination with partners to improve overall health </li></ul>IME Strategy <ul><li>Co-location state, contractors </li></ul><ul><li>Integrate contractor systems </li></ul><ul><li>Modular business units </li></ul><ul><li>Begin technology migration </li></ul><ul><li>Collaborative business model </li></ul><ul><li>Workflow integration </li></ul><ul><li>Collect clinical data </li></ul><ul><li>Improve DSS capabilities </li></ul><ul><li>Performance-based contracts </li></ul><ul><li>Enhanced monitoring and reporting of trends, costs </li></ul><ul><li>Enhanced case and disease management </li></ul><ul><li>PDL, pharmacy/clinical coordination </li></ul>
    7. 7. Implementing the IME Vision <ul><li>Single RFP, multiple components </li></ul><ul><ul><li>Systems </li></ul></ul><ul><ul><li>Professional Services </li></ul></ul><ul><li>Contract with “Best of Breed” service providers </li></ul><ul><ul><li>8 Systems and Professional Services Contractors </li></ul></ul><ul><ul><li>Operational support from the State </li></ul></ul><ul><ul><ul><li>Department’s Division of Data Management (DDM) </li></ul></ul></ul><ul><ul><ul><ul><li>Network Support </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Data Warehouse </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Other Medicaid State Systems </li></ul></ul></ul></ul><ul><ul><ul><li>Department of Administrative Services </li></ul></ul></ul><ul><ul><ul><ul><li>Iowa Technology Enterprise (ITE) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Printing and Mailing Services </li></ul></ul></ul></ul><ul><li>Separate Responses </li></ul><ul><ul><li>MMIS administration, Workflow, Imaging </li></ul></ul><ul><ul><li>Pharmacy POS </li></ul></ul><ul><ul><li>Medical Services </li></ul></ul><ul><ul><li>Pharmacy Medical Services </li></ul></ul><ul><ul><li>Member Services </li></ul></ul><ul><ul><li>Provider Services </li></ul></ul><ul><ul><li>SURS </li></ul></ul><ul><ul><li>Provider Cost Audits and Rate Setting </li></ul></ul><ul><ul><li>Revenue Collection </li></ul></ul>
    8. 8. DDI – Building the IME <ul><li>One-year timeframe </li></ul><ul><ul><li>IV&V and PMO contract services </li></ul></ul><ul><ul><li>Early transfer MMIS to state hardware </li></ul></ul><ul><ul><li>Build and transfer Medicaid Data Warehouse </li></ul></ul><ul><li>Shared Data and Tools </li></ul><ul><ul><li>Co-location </li></ul></ul><ul><ul><li>Common data sources for all IME staff </li></ul></ul><ul><ul><ul><li>MMIS </li></ul></ul></ul><ul><ul><ul><li>Medicaid Data Warehouse </li></ul></ul></ul><ul><ul><ul><li>Workflow Process Management System </li></ul></ul></ul><ul><ul><li>Integrate on- and off-site contractor systems with MMIS </li></ul></ul><ul><ul><li>Performance based contracts and Report Cards </li></ul></ul>
    9. 9. The Enterprise is Live! <ul><li>Initial Results </li></ul><ul><ul><li>Preferred Drug List 1-15-05 </li></ul></ul><ul><ul><li>Pharmacy Point Of Sale 6-25-05 </li></ul></ul><ul><ul><li>MMIS, Workflow & Contractor systems 6-30-05 </li></ul></ul><ul><ul><li>Began Paying claims with Payment Cycle 7-11-05 </li></ul></ul><ul><ul><li>Phasing in Medicaid Reform: IowaCare Phase 1 </li></ul></ul><ul><li>Next Steps </li></ul><ul><ul><li>Medicaid Reform: Next phases IowaCare </li></ul></ul><ul><ul><li>Better integration, expand SOA capabilities </li></ul></ul><ul><ul><li>Monitor performance and fine tune collaboration </li></ul></ul><ul><ul><li>Continue MITA-sizing and enterprise architecture development </li></ul></ul>
    10. 10. Enterprise Architecture: MITA-sizing the IME <ul><ul><li>MITA activities for the IME </li></ul></ul><ul><ul><ul><li>Opportunities for Enterprise Architecture (EA) </li></ul></ul></ul><ul><ul><li>MITA Tools for the IME EA </li></ul></ul><ul><ul><ul><li>Business Process Model </li></ul></ul></ul><ul><ul><ul><li>Capabilities and the Traceability Matrix </li></ul></ul></ul><ul><ul><li>EA and IME Strategic Planning </li></ul></ul><ul><ul><ul><li>MITA self-assessment </li></ul></ul></ul><ul><ul><ul><li>Business–focused IT planning </li></ul></ul></ul>
    11. 11. MITA for the IME <ul><li>MITA Activities in Parallel to DDI at the IME </li></ul><ul><ul><li>Track and assess MITA framework </li></ul></ul><ul><ul><ul><li>Contribute to MITA definition </li></ul></ul></ul><ul><ul><li>Apply MITA principles to the IME </li></ul></ul><ul><ul><ul><li>Current DDI recommendations </li></ul></ul></ul><ul><ul><ul><ul><li>Problematic in timeframe </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>MITA continuing to evolve </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Plans and contracts for the IME already underway </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Assess MITA impact for future planning </li></ul></ul></ul><ul><ul><li>Validate/pilot MITA and enterprise architecture </li></ul></ul><ul><ul><ul><li>Business process modeling </li></ul></ul></ul><ul><ul><ul><li>Collect architectural elements, artifacts </li></ul></ul></ul>
    12. 12. IME’s Opportunities for Enterprise Architecture <ul><li>Redesign of business operations </li></ul><ul><ul><li>Document business processes </li></ul></ul><ul><ul><ul><li>Workflow </li></ul></ul></ul><ul><ul><ul><li>Operational procedures </li></ul></ul></ul><ul><ul><ul><li>Cross-functional integration </li></ul></ul></ul><ul><ul><li>Planning for quality by measuring performance </li></ul></ul><ul><ul><li>Extract and document business rules from transferred MMIS </li></ul></ul><ul><li>Technical environment adapted to business needs </li></ul><ul><ul><li>Configured for operational efficiency </li></ul></ul><ul><ul><li>Flexible, adaptable modularity </li></ul></ul>
    13. 13. MITA Lifecycle
    14. 14. IT View: Enterprise Information Architecture Where is the Business? Richard Watson, Lawrence Livermore National Laboratory csdl2.computer.org/comp/proceedings/hicss/2000/0493/07/04937059.pdf
    15. 15. Business-centric Focus <ul><li>Multiple dimensions of MITA EA </li></ul>Business Process Capability Data Application Technical Time MITA Maturity Business Drivers
    16. 16. EA Modeling Questions <ul><li>What? – the process </li></ul><ul><ul><li>Verb + Object (Process Claims) </li></ul></ul><ul><li>How? – the capability/competency </li></ul><ul><ul><li>Qualities: </li></ul></ul><ul><ul><ul><li>Timeliness </li></ul></ul></ul><ul><ul><ul><li>Accuracy </li></ul></ul></ul><ul><ul><ul><li>Efficiency </li></ul></ul></ul><ul><ul><ul><li>Quality </li></ul></ul></ul><ul><ul><ul><li>Cost-effectiveness </li></ul></ul></ul><ul><ul><ul><li>Value </li></ul></ul></ul><ul><li>Who? – stakeholders, actors, customers </li></ul><ul><li>What information? – the data </li></ul><ul><li>With what? – the application(s) </li></ul><ul><li>With who, when, where? – the technical infrastructure </li></ul>
    17. 17. IME Business Process Model <ul><li>Functional framework in IME RFP </li></ul><ul><ul><li>Business units </li></ul></ul><ul><ul><li>Requirements   capabilities </li></ul></ul><ul><li>IME operational procedures manuals </li></ul><ul><ul><li>Decompose and recombine chronological events </li></ul></ul><ul><ul><li>Develop outline of business processes (table) </li></ul></ul><ul><ul><li>Create graphical representation (model) </li></ul></ul><ul><ul><li>Review/Assess/Modify – visual aid to refine model </li></ul></ul><ul><ul><ul><li>Functional hierarchy, redundancy, trigger events </li></ul></ul></ul>
    18. 18. IME BPM Models
    19. 19. MITA - IME BPM Crosswalk <ul><li>Revealed </li></ul><ul><ul><li>Gaps in IME BPM </li></ul></ul><ul><ul><li>Differences in granularity of BPMs </li></ul></ul><ul><li>Multiple IME BPs map to a MITA BP </li></ul><ul><ul><li>BPs that cross IME business areas </li></ul></ul><ul><ul><li>Highlights areas for BP and/or system integration </li></ul></ul><ul><li>Provides roadmap for self-assessment </li></ul><ul><li>Keeps IME BPM relevant to IME business model </li></ul><ul><ul><li>No “forcing the framework” onto the enterprise </li></ul></ul>
    20. 20. Crosswalk Sample Medical Services Lock-in   Lock-in Enrollment         Medical Services Disease Management   Enroll Selected Members and Providers for Disease Management Program         Medical Services Enhanced Primary Care Case Management (EPCCM)   Enroll Selected Members and Providers for EPCCM         DHS Eligibility Administration     Enroll Member for Waiver, Mental Health         Member Services     Enrollment Broker for Managed Health Care Enroll Member                   Enrollment   DHS Eligibility Administration     Determine Medicaid Eligibility Determine Eligibility                   Eligibility Determination                 Member Management Business Area Intermed 1 Intermed 2 Business Process Business Process Intermed 2 Intermed 1 Business Area       IME Business Model       MITA Business Model v21b
    21. 21. Initial Traceability Matrix Example Capabilities/Goals/Business Value Medical Director Med Srv Unit Mgr Med Srv Ops Mgr Policy Rep Retro Review Sprvsr Medical Director Med Srv Unit Mgr Med Srv Ops Mgr PA Supervisors Policy Rep Provider Srv Rep Member Srv Rep Medical Director Med Srv Unit Mgr Med Srv Ops Mgr Claim Rev Suprvsr Policy Rep Elig Rep Atty Gen, Rep Stakeholders Improved payment accuracy and monitoring of utilization. Improved response time and accuracy of prior authoriza- tions improves provider and patient relations, and increases accuracy of billing. Partner w/local medical community to ensure fair review using established standards of care. Business Value Perform medical review of 10% of all claims. Initiate revenue adjustments as needed. Accept electronic PAs. Provide medical consulting services to DHS regarding policy changes, and to providers regarding policy for PAs and billing. Track all communications with providers regarding policy electronically. Provide well-qualified Medical Director (MD/OD) and professional staff or consultants for medical review functions.     &quot;To be&quot; IME Capability #1 Improve service – L (1) #2 State control - M (2) #3 Best Practices - H (3) Total Goal Alignment = 6 #1 Improve service – H (3) #2 State control - L (1) #3 Best Practices - H (3) #4 Flexibility/Adapt - M (2) #5 Leverage state IT–L (1) Total Goal Alignment = 10 #1 Improve service – H (3) #3 Best Practices - H (3) Total Goal Alignment = 6 Goal Alignment Dispersed clinical review services with limited staffing. Increasing program focus on claims quality.   Retrospective Inpatient and Outpatient Review Limited legacy system EDI capabilities. Dispersed clinical review services with limited staffing. No automated CRM or Document management systems. Process paper or fax PAs and requests for exception to policy. Pre-procedure/Pre- admission Review Dispersed clinical review services with Limited staffing. Increasing Program focus on health outcomes. Review claims for administrative and Judicial appeals. Request additional information from providers as needed. Claim Review     Medical Support     Medical Services &quot;As is&quot; -> &quot;To be“ Gap Description &quot;As is&quot; Current Capability IME Business Area/Key Process
    22. 22. Traceability Matrix – EA Example EA Dimensions MQUIDS > VB.NET using Visual Studio 2003 > 2-tier environment > SQL Server 2000 > Crystal reports > ADO.NET object model MQUIDS > VB.NET using Visual Studio 2003 > 2-tier environment > Crystal reports > ADO.NET object model OnBase Tech Env. ELVIS Tech Env MMIS Tech Env MQUIDS > VB.NET using Visual Studio 2003 > 2-tier environment > Crystal reports > ADO.NET object model Technical Solutions Notes > SQL Server 2000 > MMIS Claims History > SQL Server 2000 > MMIS Prior Auth Master > SQL Server 2000 > MMIS Claims History Data Architecture Notes > Requirements Confirmation Workbook – FINAL > SRS061.000 Medical Support > Requirements Confirmation Workbook – FINAL > SRS061.000 Medical Support > Requirements Confirmation Workbook – FINAL > SRS061.000 Medical Support     Related IME Requirements Documents > MQUIDS DSD 3-3-05 Perform medical review of 10% of all claims. Initiate revenue adjustments as needed. Retrospective Inpatient and Outpatient Review > MQUIDS DSD 3-3-05 > WDS915.2_Prior Authorization > WDS913_Workview > WDS907.2_Medical Services Accept electronic PAs. Provide medical consulting services to DHS regarding policy changes, and to providers regarding policy for PAs and billing. Track all communications with providers regarding policy electronically. Pre-procedure/Pre- admission Review > MQUIDS DSD 3-3-05 Provide well-qualified Medical Director (MD/OD) and professional staff or consultants for medical review functions. Claim Review     Medical Support     Medical Services Related IME Design Documents &quot;To be&quot; IME Capability IME Business Area/Key Processl de
    23. 23. More EA/MITA Details in Extended Traceability Matrix <ul><li>Extend details captured in matrix for each EA dimension: </li></ul><ul><ul><li>Capability/competency definition (MMM qualities, performance measures, etc.) </li></ul></ul><ul><ul><li>Application architecture (COTS, legacy systems, subsystems, etc.) </li></ul></ul><ul><ul><li>Data architecture (files, locations, formats, . . ., metadata repository) </li></ul></ul><ul><ul><li>Technical architecture (hardware, telecomm, operating systems, integration, services, etc.) </li></ul></ul><ul><li>EA details collected in matrices provide information to perform MITA self-assessment </li></ul>MITA Maturity Model (MMM) Qualities/Performance Measures Cost- Effective- ness Quality Value Efficiency Performance Measures     Timeliness Provide well-qualified Medical Director (MD/OD) and professional staff or consultants for medical review functions. Claim Review     Medical Support     Medical Services Accuracy &quot;To be&quot; IME Capability IME Business Area/Key Process
    24. 24. EA and IME Strategic Planning <ul><li>MITA self-assessment </li></ul><ul><ul><li>BPM  extended traceability matrix + crosswalk  self-assessment </li></ul></ul><ul><li>Business–focused IT planning </li></ul><ul><ul><li>Traceability matrix collects EA artifacts </li></ul></ul><ul><ul><li>Provides process change roadmap </li></ul></ul><ul><ul><ul><li>Gaps, goals, stakeholders, data, applications, technical infrastructure </li></ul></ul></ul><ul><ul><ul><li>Scope and impact of change </li></ul></ul></ul><ul><ul><li>Incremental </li></ul></ul><ul><ul><ul><li>Iterative process </li></ul></ul></ul><ul><ul><ul><li>Granularity </li></ul></ul></ul><ul><ul><ul><li>Focus: business process, functional area, business area, enterprise </li></ul></ul></ul>
    25. 25. Questions Mary Tavegia, [email_address] , (515) 725-1110 Erin Harris, [email_address] , (615) 293-2993

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