The document discusses Medicaid IT architecture and interoperability. It provides background on Medicaid spending and beneficiaries. It then describes the Medicaid IT Architecture (MITA) framework, which aims to make Medicaid systems more patient-centric, interoperable, and based on industry standards. The framework is a roadmap to guide states in building their own customized IT solutions over 5-10 years. Finally, the document discusses three scenarios for funding collaborative environments and electronic health initiatives like e-prescribing through the existing Medicaid Management Information System (MMIS) funding structure.

1. HIMSS – National Capitol Area Rosslyn, VA October 16, 2008 Medicaid IT Architecture and Interoperability Rick Friedman, Dir. Division of State Systems CMSO, CMS richard.friedman@cms.hhs.gov

2. Medicaid Background Information

3. Growth in Medicaid Beneficiaries Millions of Medicaid Beneficiaries 0 10 20 30 40 50 60 1965 1975 1985 1995 2008

4. Medicaid Summary Percentage of Total 55.2 Million $326.4 Billion IT Spending as a Percent of Total Medicaid Less than 1 Percent – FY 2007 FY 2007 Eligibles and Spending Claims Processing Engine Fraud Detection (SURS) Mgmt + Admin (MARS) 3 rd Party Liability (TPL) Provider Subsystem Reference Subsystem Six Original MMIS Subsystems CURRENT PRIOR APPROVAL PROCESS State Submits Plan/APD, RFP and Contract to CMS for IT Funding CMS Approves Project: …90% FFP for MMIS Development …75% FFP for MMIS Operations …50% FFP for all other IT/Admin CMS Certifies MMIS

5. MEDICAID: People and Money *About 7 million duals have been subtracted from the total to avoid double-counting Source: Kaiser Commission, 2007 $623 billion 90 million* Medicaid and Medicare $ 297 billion 42 million Medicare $326 billion (1 of every 5 health care $s ) 55 million (1 out of every 6 Americans) Medicaid $1.54 trillion 325 million U.S. Totals Money People

6. CMS’ Perspective 1.Medical information follows the consumer; i.e., they are at the center of their care 2. Consumers chose providers based on clinical performance results 3. Clinicians have complete patient history, computerized ordering and electronic reminders 4. Quality initiatives measure performance and drive quality-based competition 5. From transactions to actions-- machines talk to machines; people focus on services; goal is health outcomes improvement

7. CMS Places a High Value On Cross-Agency Data Sharing Medicaid administrators lacked a comprehensive view of their world -- MMIS was not keeping pace with their rapidly changing world CMS decided to re-tool the MMIS into MITA -- the Medicaid IT Architecture Web-based, patient-centric, interoperable system based on industry IT standards Enterprise-oriented, rather than organization Data shared across boundaries Provides basis for HIT/E -- EHR, eRx, PHR

8. Medicaid Information Technology Architecture (MITA)

9. What Is MITA? MITA is a FRAMEWORK MITA is a TOOL KIT MITA is a ROAD MAP NOTE: MITA is NOT a one-size-fits-all approach Each State builds its own IT solution based on standards, models and processes contained within the MITA Framework that have been developed with the help of all States and the IT industry

10. Key Principles--MITA Support State-driven program requirements as well as Federal Provide Medicaid managers at all levels with robust data sets that significantly enhance their ability to focus on outcomes Business-driven enterprise architecture Commonalities and differences co-exist peacefully Standards first Built-in Security and Privacy Data consistency across the enterprise

11. MITA’s Goals Provide State Medicaid agencies with a powerful analytical tool Improve health care outcomes Align with Federal Health Architecture Ensure patient-centric views not constrained by organizational barriers Make use of common IT and data standards

12. MITA’s Objectives Foster interoperability between and within State Medicaid organizations Provide web-based access and integration while respecting patient privacy and confidentiality concerns Support software reusability with commercial off-the-shelf (COTS) software Integrate seamlessly clinical and public health data

13. MITA’s Orientation Business-driven service oriented architecture solution (focus on supporting biz not tech) Firmly grounded in enterprise architecture principles ( in use by many other industries ) Defines a business transformation over a five year and long-term (10 years and greater) timeframe Includes a technical architecture and a transition strategy to enable the business transformation

14. How Would CMS Handle Funding in a Collaborative Environment that Focuses on Interoperability? Three Scenarios and e-Rx Data Flow

15. E-Health (e.g., eRx) Schematic Note: The following discussion is a conceptual analysis of how CMS may be able to support e-Health activities using MMIS funding. While some of this thinking has been approved at various levels, final decisions will depend upon specific conditions yet to be determined DW HW/SW WEB PORTAL Examples eRx EHR/EMR PHR

16. NON-MEDICAID AGENCY DW HW/SW ACTIONS: Medicaid Agency builds a data warehouse (DW) and web portal (WP) as a part of its MMIS. Non-Medicaid agency builds its own DW and WB. Both parties agree to build an electronic bridge linking both DWs and WPs CURRENT FFP AVAILABILITY: Medicaid Agency receives 90% FFP to build the DW/WP, and 75% FFP to operate them Non-Medicaid Agency uses own funds to build and operate DW/WP Jointly built electronic bridge is paid for by both parties per Federal CAP Principles. Medicaid receives enhanced 90/75 FFP rates for its share of costs. MEDICAID AGENCY Scenario 1: Medicaid Agency and Non-Medicaid Agency Both Build Their Own E-Health Hardware/Software Facilitators DW HW/SW Data WEB PORTAL M M I S WEB PORTAL

17. Other State Agency DW HW/SW ACTIONS: Medicaid Agency builds a data warehouse (DW) and web portal (WP) as a part of its MMIS. Non-Medicaid agency/provider buys own equipment to access web as well as trains staff on its use. CURRENT FFP AVAILABILITY: Medicaid Agency receives 90% FFP to build the DW/WP, and 75% FFP to operate them Non-Medicaid Agency/provider uses their own funds for their access ramps to DW/WP MEDICAID AGENCY Scenario 2: Medicaid Agency Builds and Operates E-Health Hardware/Software Facilitators and Permits Access by Others Data M M I S WEB PORTAL Provider

18. Other State Agency DW HW/SW ACTIONS: Medicaid Agency accesses DW/WP through its MMIS Changes/enhancements may be necessary to enhance use of DW/WP within MMIS. CURRENT FFP AVAILABILITY: Medicaid Agency receives 90% FFP to enhance, 75% FFP to operate its internal requirements with outside DW/WP Changes to the outside DW/WP specific to Medicaid matched at 50% because it’s not part of the MMIS Provider/Other Users costs not matched with MMIS FFP MEDICAID AGENCY Scenario 3: Entity Not Under Medicaid Builds and Controls DW/WP MMIS WEB PORTAL Provider Data Data

19. E-Prescribing Data Flows Physician’s Office Electronic Switch Pharmacy State Medicaid Agency MMIS Claims Engine Rx Claims 1. Eligibility Inquiry and Drug History 2. Rx sent to Pharmacy $ $ Office Visit Claim Pharmacy Claim 3. Drug/drug interaction