sarah steverman: hello and welcome to the samhsa webinar, expanded support for medicaid health information exchanges. i am sarah steverman withsamhsa's office of policy, planning, and innovation. thank you so much for joining us today. today's webinar will provide an overview of the february 2016 state medicaid director's letter which updates the guidance for medicaid health information technology for economic and clinical health, the hitech act. furtherguidance in this letter, states are now permitted to use the 90% federal match to support both on-boarding and hie architecture that eligible medicaid providers need to connect to in order to demonstrate meaningful use. medicaid provider types such as mental health providers, substance abuse treatmentproviders and others can be supported for implementing hie or other interoperable systems, so long as such connections help eligible medicaid providers demonstrate meaningful use. of note, this guidance will facilitate data sharing and coordination between non-meaningful use and fees, including behavioral health providers with eligible medicaidproviders. for behavioral health clinics, including newly formed, certified community behavioral health clinics, this could be used to improve care coordination with partners in the community, including hospitals and emergency departments. it might help behavioral health clinics or bcdhds get data they need, not only for recording and quality measures but alsofor enabling care coordination in a more effective and timely fashion. thomas novak will be presenting today's webinar. we're really pleased to have him as he is the medicaid interoperability lead in the office of policy at the office of the national coordinator for health it, where he supports the advancement of medicaid interoperability andthe drafting and review of federal regulations. he is detailed part-time to the centers for medicare and medicaid services, medicaid data and systems group, where he provides direct support to state medicaid agencies and state governments on health information exchange, funding and strategy. before i turn over to tom, i justwant to give a couple housekeeping updates. we are recording this webinar and we'll have it available after the event for viewing. we have the option to provide question and answers. if you look at the q&a icon at the bottom of your screen, you can open that upand type your questions there at any time. we will have questions at the end of the presentation, but please feel free to ask questions throughout. and please note that we won't be opening up the line, so the q&a box is the only way to get those questions tous. at this point, i want to turn it over to tom. thank you so much, tom, for joining us. and thanks for all who are on the line, listening.
i'm going to turn it over to you, tom. thank you. thomas novak: thank you very much. i am tom novak with the centers for medicare and medicaid services dataassistant group, as well as the office of policy at the national coordinator for health it as was said. but thank you for that, sarah. that was very helpful. the thing we're going to talk about today is part of the recovery act. so, surprise, not an affordable care act presentation. way back to the recovery act. so the recovery act- and i apologize if this is sort of common knowledge to everybody, but it's good for level setting to do this sometimes so that people - the different levels of familiarity with some of this. so a little bit of a quick 101 on the hitech act. the hitech act was part of the recovery act in that it incentivized doctors andhospitals to use electronic health records. the program was administered either by medicare or by medicaid. the parts of the recovery act that were supported by medicaid allowed funding, administrative funding, to go to state medicaid agencies to support this ehr adoption. so these are not just any old electronichealth records, they're electronic health records that have to be good ones and meets the criteria established by the office of the national coordinator. so things that the ehr has to do are described in the meaningful use regulation, they'd have to do really good things, like e-prescribe,the public health data, check for medication reconciliation, medication allergies, transport data that includes things like problem lists, summaries of care, all those sorts of things you would need to coordinate care really well. so the administrative dollars that went to statemedicaid agencies allowed for the station-built systems to support the payment of the incentives for these electronic health records to the providers, the eligible providers who are generally acute care hospitals and primary care physicians. but it also includedmoney for health information exchange. it allowed state medicaid agencies to connect the incentive-eligible providers. and again, that's kind of a small universe of providers of acute care hospitals and primary care. so they absolutely wanted to be connected. they wantedhealth information exchanges and we gave out $350 million to that end for those health information exchanges that supported that smaller unit of providers. but even that, like $350 million is actually kind of a small number, in the fee mix world. that's not a lot for health information exchange, especiallywhen it's spread out over several years. and it doesn't hit a lot of providers. it doesn't hit the providers that do a great deal of care in the medicaid
continuum. so in any case, they wanted that money. it kept going up $45 million every year. it was supported greatly,but that guidance that limited it to incentive-eligible providers, the primary care and acute care hospitals, was written about meaningful use stage 1. notice it's about adoption, so it actually kind of made sense at the time, but as meaningful use stage 2 and stage 3 came tobe, there's greater emphasis on interoperability. so with that smaller universe of providers, it became more and more problematic because there was - requirements that they have this kind of interoperability, but no real financial support for a state medicaid agency to help out with that. so what we did atcms is we worked with the office of the general counsel, the white house, the office of management and budget, to push for an expanded definition that supported all medicaid providers so that a state medicaid agency could build health information exchanges, connecting anybody - those incentive-eligibleproviders who wanted to coordinate care with. so long-term care providers, behavioral health providers, substance abuse treatment providers, correctional health providers, labs, pharmacies, home health, ambulances, really making sure we're reaching out to the entire continuum of care. so onfebruary 29, 2016, we released the state medicaid director's letter announcing it. this blog came out i think maybe the day before or the day after from dr. karen desalvo and andy slavitt announcing this new expanded funding to really complete the continuum of care. so thisnew funding that lays out some of the groundwork and it says that they can support health information exchange for eps and ehs as long as it helps those eps and ehs - i'm sorry, eps and ehs is the incentive-eligible providers, that's eligible professionals and eligible hospitals. just making sure i'mnot over-acronyming - but as long as it helps in reaching the meaningful use objective. so they're throwing the ball, they need someone to catch the ball. so if a state wants to build a system that connects substance abuse treatment providers to a health information exchange, as long as there's an incentive-eligibleprovider on the other end of that transaction, it's fine, it's within bounds for receiving this federal support. this federal support is a 90/10 federal support. so 90% of the cost is supported by cms. the 10%, the state still has to come up with. but the state can now find these activitiessupported as long as it's helping those eps and ehs achieve meaningful use. so if you look at the list of meaningful use objectives, it could be
medication reconciliation, transitions of care, secure messaging, other sorts of meaningful use objectives that rely on interoperabilitycan now be supported with 90/10 as well as those other medicaid providers who have kind of been left out on some of these recovery act support. so i want to go into - so the statute, we've got certain statutes written sort of broadly. so it's actuallykind of amazing to do that federally, to get something reinterpreted. so that's why it took, well, 14 months. so after we got that approved, we then needed to sort of start getting the word out, and we've had some good conversations with samhsa, who was involved in theclearance, as well as others at hhs, the office of civil rights, and whatnot. and i think what's worth flagging for this group is that we really wanted to emphasize the behavioral health and substance abuse treatment because this is what medicaid has wanted. medicaid wanted to include them in thecontinuum of care and now we can do it. so we've found the money for it. now we need to work together to find the legal path forward for some of these trickier questions about data segmentation, and part two, and hipaa and whatnot. so there are some rules around missing caveats and all that. this is actuallynot a new source of funding. we've changed the eligibility criteria for an existing source of funding, so all the original rules stay in place. so it's implementation only, so that's called ddi, so design, develop, implement. what that means is they can build something but it doesn'treceive operational support. so once they build whatever they build, the sort of maintenance and operation is not supported by this funding. the money is in place for 2021. so you cannot give ehrs away. you're onlydoing hie architecture and hie on-boarding, and i'll define both of those in a moment. and you do have to cost-allocate it, which i can go into it as well. so if you build something that's non-medicaid that payers and providers benefitfrom, we have to cost-allocate it. so the work you can do with this funding for the state medicaid director's letter really falls into two sort of big categories. the first is architecture, and i'm going to go into all these numbers in a little more detail, but it sort of means exactly what i'm saying.like you can build hie pieces. you can build various use cases, various pieces of software and technology that connects. so you can build the systems,
but you can also on-board to the systems. and on-boarding is maybe more immediate for this audience, because the state may already have ahealth information exchange or some amount of health information exchange activity. it might be more regional or not necessarily statewide and they just want to use this funding to add behavioral health providers or substance abuse treatment providers to health information exchange, they can do that as well.and what does on-boarding mean? it is a broad term, so i want to go into it. so there are two parts to on-boarding, there's a technical and the administrative part. so technically, we're talking about establishing a secure connection to the health information exchange. maybe you need to build an interface, aligningencryption standards, establishing the secure mailbox for coordinating care. so there's a technical component, but equally as important, if not more so, is the administrative work. you need someone to look at consent models, which is a very important flag for this audience to think these things throughin terms of businesses associated with hipaa consent models, encryption standards, looking at contracts, making a new contract, reference the right regulations to follow, and then everything is coordinated appropriately across these entities you might be adding to a health information exchange. so that's the process of on-boarding.that's how you get people actually to be interoperable with each other. and almost before you do the technical and administrative, there's this emphasis on workflow. if you look at ehr adoption, a lot of the complaints about ehr adoption are really complaints about workflow. clinicians who walk into an office on mondaymorning and they had a new ehr and they had no idea how to use it, they had no idea how it incorporated into the way they saw patients, because no one included the clinician in thinking through the workflow, thinking through how they room the patient now and check what box for some quality screening, or send the specimen to the lab and get the results,and when are you notified and when are you not notified, and what are the thresholds, and how do i follow up on referrals and really incorporating the ehrs in the workflow. these things are just as important with health information exchange. so that's a critical part of the on-boarding, is to use the 90/10 funding, which also can support this as part of on-boarding,that business process modeling, that planning, that workflow analysis to make sure whatever you're doing is done thoughtfully and well so that coordination of care can actually happen. so that's something else the state can support with it, and we encourage them. we look for very aggressive on-boarding practices.we want things to be truly implemented in a thoughtful manner. one more thought about that before i move on to architecture. the
money is for implementation only, but again, just like we sort of take a broad definition of on-boarding, we also want a really thoroughdefinition of implement. so when we say you actually on-board it to a health information exchange, so if you're on-boarding behavioral health providers to an existing health information exchange for example, implements them and on-board them isn't just establishing that connectionand getting it set up. we also want testing. we want testing of multiple use cases, of how the data might flow, and we want a production date. we want it to actually work. so we want states to really make sure this works so that there's really data flowing because it's all about meaningful use. if you can get it so that it'ssupporting meaningful use, get it all the way so that you can show that it does do that. so that's an important emphasis that we make on this. so even though the money is only for implementation, take a long time doing implementation to get it right, like design a thorough process that is comprehensive and really makes sure that you are connecting theincentive-eligible medicaid providers to the other medicaid providers that any state medicaid agency may want to connect with. i'm going to go into some of the more popular architecture specifics. this is not an exhaustive list, but it's a bit high level, but i want to dig down a bit into some of thesespecifics as to what we can support with this 90/10 fund. so provider directories, apologies to any of my technical colleagues who are on the phone, but it's a bit of an oversimplification, but it's kind of like a whitepages. it's kind of like a whitepages where one clinician can go look up another clinicianthat he or she may wish to coordinate care with and look up the other clinician and send structured data, send secure messages to that other clinician that might contain medication history, problem lists, treatment notes, various structured data that can help meet meaningful useobjectives that will include the summary of care and things like that. and it's a very basic and very natural – first thing you build when you build a health information exchange. not always the first thing you build, but it's one of the more prominent features of a healthinformation exchange. and it's something, if you were, as a state, were going to add on other medicaid provider types such as behavioral health and substance abuse, that's likely a first area you would go, where you would add to your provider directory long-term care providers, behavioral health providers, substance abuse treatment providers in such a mannerthat they can now be part of that whitepages where they would have the functionality to send secure data back and forth to the incentive-eligible providers, the primary care and acute
care hospitals. so you would create the linkages with a provider directory. and we sort of go into this, and so states - this is less relevant here, but statescan fund that through a few different buckets of money. now, if we were talking to a state, we would give them counsel on what the best way forward would be for that. and you all have these slides, i'm going through a few examples. these are a little more directed towards state medicaid agencies, but we talked about the variousmeaningful use objectives and examples of meaningful use objectives a provider directory might support. so secure messaging is that layer that is underneath a provider directory, but you can have secure messaging outside of a provider directory. it's any sort of connection, so you might have other systems you're creating inthe state that can have secure messaging, that layer underneath that allows for hipaa compliance, transactions to go back and forth from provider to provider that coordinate care in a secure way. and there is support, sort of under meaningful use for that secure messaging. so whatever a state is thinking of doing, sometimes a first stepis just getting everybody establishing secure messaging statewide for purposes of meeting meaningful use. so i want to be clear that that one's allowed. encounter alerting – a little bit of acronym tutorial here. and this is known by a few different things, so you might have also heard of something called adt alerting, that'sadmit, discharge, transfer alerting. or you might have also heard of ens, which is event notification service. they are all kind of the same thing. it is a system that can go from hie to hie or health center to health center, health system to health system that lets a pushnotification go out, letting some sort of care team, or social worker, or care manager, or medical home know that a patient is moving from setting to setting. so maybe they were admitted to an emergency room. maybe they were discharged to a post acute care facility and they had dischargeinstructions. various change in status often require some sort of follow-up. so if they're discharged from the hospital, you need to connect them to a specialist or a primary care to give proper follow-up to make sure you don't have a readmission. this really moves the needle on a lot ofthings. so if you look at any of the groups out there, building acos - i think they just had something published three days ago that showed how encounter alerting really moves the needle on cost and quality metrics, that lowers readmission rates, lowers cost. the acos builtit first, to just let you know. if an aco is out there, they know which things you build actually work, and even though the published
data is just now starting to come in, this one is effective. you can say somewhat without ambiguity that if you have patients whohave multiple chronic conditions or patients who have high cost, the super utilizer types, encounter alerting is very critical. and it's kind of cheap, actually, if you look at some of the statewide systems. it's not particularly expensive and it's not particularly difficult, technology-wise, to build that.it can be like a bell that goes off, so then the bell is followed by some transactions that have data. so you get an alert that that patient has been discharged and then you might follow it up with summary of care and discharge instructions and whatever you need to do the proper case management for that patient. so it's a very gooduse case that does a lot for the more complicated patients, and those more complicated patients are almost always having some sort of exposure to substance abuse or behavioral health concerns. if you look at it, i think about three or four most expensive medicaid categories, ithink four or five of them, it intersects with that area. care plan exchange goes nicely with encounter alerting. care plan, in the event you're unaware, is an editable, dynamic plan that is shared electronically. so we have them in a (technicaldifficulty) but even then, they're not optimized as much, it could be electronically, or in some cases they are, but generally not. where there's a shared care plan that many providers have access to, which is really critical for these patients with multiple chronicconditions. as an example, i think, it's helpful to think of like maybe a non-compliant diabetic where you maybe have an ophthalmologist, an endocrinologist, a cardiologist, all the care supplies. maybe there's depression in the past. maybe there's home dialysis supply, so you have home care.you have all of these various providers and then you have shared goals, like maybe there's a goal around a1c for that patient. so you can use this money to support systems that help coordinate that care. so all of the care team can go in, and the care team is a part of meaningful use, so the careteam can go in and look at the shared care plan, make changes, provide updates, coordinate together on the treatment of this patient. and if you look at the patients who are of concern to samhsa, this is very, very important. this is something that everybody can get involved in. everybody is coordinating together,particularly looking at medication, because if you're trying to coordinate, you need medication history. this is very, very important. this is something that also can be supported by
the 90/10 match. i'm going to go a little bit into some of the standards here because it's sort of worth knowing a bit about that, and that's, again, maybe a little more of aconversation with state medicaid agencies, but it is helpful to make sure we're doing this in a way that is interoperable, and you do need that sort of standard-based approach for a care plan to be interoperable. i think i'll go a little bit even into the ccbhc possibilities there, whichwe can go into more detail later. so a hisp, so a little bit similar to some of the activities i described with on-boarding. hisp has that governance function interoperability, so the coordinating entity that makes sure that thedata actually moves. so it's maybe a behind-the-scenes entity that does a lot of coordination, but that had not been explicitly called out before as being supported by medicaid, so we wanted to explicitly call it out, that that function can be supported. because sometimes,the state medicaid agency would take on the hisp-like activities which they can do but it can be a lot. so if you're a statewide hie for example, you probably have a hisp role. or some states could use the hisp financial support to unite various regional health informationorganizations. let's say you're a pennsylvania, for example, that has activity in philadelphia, activity in pittsburgh, you've got guys in the middle and you have various other health systems scattered throughout, the hisp activity can also sub-connect those nicely. so thehisp activity can make sure you have statewide governance that maybe even includes a shared service layer that goes statewide to make sure that you allow your state to build various smaller hies within the state that respond to the geographic and demographic needs of thoseareas. but if you also have statewide needs that you want for quality reporting or other things that you can use the hisp as your carrot or as your stick to do some of that work for you and support it with a 90/10 support. so that's something that's helpful in establishing some statewidegovernance for a health information exchange. and just a little more information on that as to the kinds of things that they do as governance activities. query exchange is a sort of what it sounds like but it doesn't fall into sort of as tidy a box as some of this other work. soquery exchange has some more complicated governance requirements, so i wanted to call that out. a lot of state medicaid agencies
want to do query exchange because they're probably already getting a lot of quality data either through encounter data or like a37s from claims or managedcare encounters. so they already have this clinical data warehouse, a good repository of data. and then adding on the query front end to it where you would ask people data warehouse questions. it's a short walk for them, so a lot of states wanted to call that as something that could be supported. and the query exchange,as long it supports meaningful use objectives, is a-okay, so that's something that we wanted to call out specifically and that's more of a design question that is helpful, so. public health systems, that might seem less relevant to this group but i'm going to convince youthat it is not. so public health systems in meaningful use are important. we want all of our providers to be doing all their work with immunization registries, syndromic surveillance registries and whatnot. the state can now use the 90/10 support to connect the medicaid providers to those systemswhere they really couldn't connect architecture or they couldn't pay for architecture before. now they can pay for architecture. but what i want to flag is specialty registries. so specialty registries were a part of meaningful use stage 2. so a quick little history lesson here. meaningful usestage 1, you may be surprised to hear that occasionally we receive negative comments on federal regulations. and meaningful use stage 1 requires public health reporting but the provider is included in meaningful use. so if i was a dentist - sometimes providerswho have different scopes of practice and those providers were like - why am i being required to report these public health registries in order to receive my incentive payment? and it makes no sense for the kind clinician i am. in response, because we are receptive, we created meaningfuluse stage 2, the option for a state to create a specialty registry. so rather than make a provider report through a registry that is outside his or her scope of practice, we wanted to let a state set their own priorities and look at the scopes of practice of their medicaid providers to create whateveris appropriate. so we gave a lot more state autonomy there. and then with the release of the letter, not only did they - did it allow this specialty registry reporting for purposes of awarding incentive payments but now they can also build them. so what we're finding is we sort of accidentally- we'll stay with the schedule. we intentionally created a lot of innovation. states are looking at this as an opportunity to really build the systems that
respond to their state level needs. so we are getting states requesting funding support for things like zikaregistry, a lead registry in michigan, washington, dc wants to have a homelessness registry. they are doing - we approved an advance directive registry in colorado. so these are things that as an incentive-eligible provider can report to this specialized registry andmeet their requirements for meaningful use. so it's working exactly as planned and we're getting a lot more inventive ideas from state medicaid agencies on this. so we're really excited. and prescription monitoring programs count as specialized registries. they counted before the letter came out and they still count. so the states can nowuse incentive money to build a prescription drug monitoring program. and they can build - like that - and i want to say on top of that, but i think probably people on the call know that just having a pdmp doesn't assure you're going to manage your state opioid situation. you need to use that data in a meaningfulway and sometimes that requires a more dynamic system. so you can build a pdmp that we can build and you can build a good one that has a large interoperable component. links to your pharmacy system, links to your case management. maybe can send push notifications,can coordinate with care plans. it can have a lot of other functionality with e-prescribe systems or whatnot. so you can really get dynamic with some of the things you do here. or if you're going to do a registry that's unrelated to pdmp, but is exactly related to behavioral health orsubstance abuse treatment, you could absolutely build a behavior health statewide registry that's - was used for case management - patients of behavioral health medicaid patients, under the care of behavioral health providers. so you could build some sort of registry that was - that was helpful, that contain helpfuldata. we have - some states that are onboarding ems providers, so adding those providers to statewide systems. so let's think that through, right? so if you are a state having ambulance providers to a statewide health information exchange, you could also connect the said ems providersto a registry that will let that ems provider know if they were picking up a patient with unknown substance abuse treatment problem or behavioral health problem and maybe even result in some correctional diversions. so we don't send the people to jail that we can know right away that theyare off their meds, they need to loop in a case manager, or social worker, or connect them to whatever resources we have that we can connect them to. we can
build these dynamic systems. so we can do really cool things if the state - the state medicaid agency is a willing partner. so thinking through - i probablyspent more time on this one tiny bullet than many of those slides combined. but you can do a lot of cool stuff with specialty registry. so you could do a lot for these particular groups of medicaid patients, so we want to really flag that as an opportunity for innovation here. i guess i get so excited aboutspecial registry. so, obviously, this is always important to be standards-based. that's how you get to operability. i won't go through much into medicaid's governance models. it's in our medicaid systems the medicaid enterprise, prioritizes some of the principles. things need to interoperable, thingsneeds to be reusable. so if state medicaid agency is going to build something, they want to use over and over and over again. so if the state medicaid agency onboards behavioral health providers, onboards substance abuse treatment providers, they absolutely want those roads they build tobe driven on over and over again by medicaid acos, by medicare acos, by auxiliary admission programs, by 1115 waivers in the state, or state-planned amendments, or any other sort of innovative program that the state might be thinking of. so we're really - so we emphasized that a lot to medicaid, thatthis is very important to us at the state level. and then we sort of - this is more about the aligning of some of the standards to make sure that data does flow within the medicaid enterprise in a standards-driven away. so i want to go through cost allocation a little bit because this couldbe important basically in states that maybe didn't expand medicaid. so the 90/10 funding supports medicaid providers. what that means is that if you are a state medicaid agency that wants to support something and non-medicaid payers and providers benefit, that's the costallocated. so if you are building a statewide let's say a provider directory for example. so we talked about provider directory. if a state is building a statewide provider directory and only 70% of the providers in that directory are medicaid providers, then you can only use90/10 funding for 70%. the acronym - or it's not an acronym here - the way we describe it is medicaid is completely willing to be the macy's of the mall, but we will not be the whole mall. we need other payers and providers to standby. they don't need to necessarily even have a contract but we need to have memorandumof understanding that there's other - the other payers and providers who are not medicaid are going to be at the table, they're going to be contributing. so if you have a statewide hie we can't
shoulder it all ourselves. we could definitely - we definitely front load some activities that are medicaid heavy activities, then onboarding is almost always going tobe medicaid only to the medicaid providers but we can't go beyond medicaid payers and providers in terms of paying for it all. so that's - and that's an important flag especially if you're a state that maybe didn't expand medicaid and maybe don't have as big a medicaid footprint. so we can - and if you're wanting to work in that area, cometalk to me. we have approaches you can do that are maybe sort of more medicaid upfront loaded where you can sort of maybe get more built sooner that would add value to all of your efforts, but just know that that cost allocation is a federal requirement. so again it needs to be connected for meaningfuluse objectives. the state defines the benchmarks. what i mean by that is - recall that i said it's for implementation only. the state defines what that is though so, if the state says we want to onboard behavioral health providers to our statewide hie. and we will considerour benchmark to be - we will consider ourselves implemented when 95% of behavioral health providers are onboard per our very robust definition of onboard. 95% is a huge number. that's going to take a long time. it could take 18 months. it could take two years. that's fine. again we want really thorough, really good definitions but thestate supplies that benchmark. and then the state should know that we're going to make sure that these things really do the things they say they're going to do. so we're going to be checking up on that and the state should use standards whenever standards are appropriate. some cases they are, some cases they are not but they should always usethe meaningful use as their yardstick, like does wherever they build, whoever they onboard, help somebody achieve meaningful use if yes. we have support. there's other things out there that we supported in the past that we continue to support but it's sort of worth flagging. i mentioned planning and workflow andbusiness process modeling. states can get 90/10 support for that but that kind of changes now, right? because now that the state can support these new kinds of providers the things they might model for their business processes they might look at are going to be new and different. so then you sort of go back to the drawing board in a few cases if the state medicaid agencywants to support some of these things, they can do that. it's sort of a reminder that not only is there new money but you might want to relook at the old money and spend some of it again in a different way. you might want to rethink, okay, what's the workflow for incorporating behavioral health data into my health information exchange. so that planning money - statesused a lot of it in 2009, 2010 and 2011 but now they can vary - they can go back to it. they've always been able to go back to it, but i wanted to flag it so the states
knew that they could think through some of these things thoughtfully to make sure that they're really doing a good job, making sure that thesystems we're building were done in an efficient way that really helps the medicaid patients. this is all related to the research reform, of course. here's where we do intersect with the affordable care act, even though we're funded by the recovery act. so it all really ties together. so if you're building these systems, youcreated systems that allow acos, allow medical home pilots and state innovation models and 1115 waivers. that you've created all the foundation you need to a lot of these things. so you have a broader continuum of care supported by health information exchange. and one quick note, so i do say health information exchange a lot, itdoesn't necessarily need to be health information exchange you're supporting. it could be any interoperable systems. so as you're creating one standalone system that may be not necessarily what someone would call a health information exchange but it connects incentive-eligible providers then it's - that it's stillavailable for support. the letters (technical difficulty). you change the email address? that's fine, email them or email me or if you email them, they'll email me if you have any questions about this. sometimes you might find - you may find that you don't know who the medicaid people are in the state you want to work with. ican make those introductions, we work very close to the state medicaid agencies and the state medicaid agencies who control this funding. so the money always goes to the state medicaid agency. and then the state medicaid agency will work with the health information exchange, we'll hire somebody to do onboarding support for providers, but it alwaysstarts with the state medicaid agency and then it comes out, and they can request the money at any time to a document called an iapd. it's an implementation and advance planning document which is - it follows my favorite federal acronym papd, the planning advance planning document. andthen that is done at least annually, but there's need to be at least quarterly, just whenever the state sort of organizes their hie activity they can submit that to their regional cms people. and in this group, you may not know those people, you may have known the rightpeople to be connected with and i'm happy to make those connections especially because i think the ccbhc work is hot, like there's a lot of cool stuff we can do here. and i have - i took the - maybe it was naive of me to try to be this aggressive. but let's just say,medicaid directors all right, we try to make a very clear pathway to - okay now we're giving you the money to build hies
for behavioral health and substance abuse. let's also quickly show you a legal path forward. though it was adorably naive of me to think i could quickly show youa legal path forward. so, it's better to do those sort of as one offs, it seems like with the state so lucia savage, the chief policy officer, ocr, any other agency that we need to pull in to help you think through some of these. we don't want any state to say no because they can't figure out the regulation. we can't figureout the path forward legally. so, we've taken away the money excuse and we're trying to take away the sort of legally excuse that they don't know how to do it. they don't have to do data segmentation or what have you. so, reach out to us, please, please, please, and we will figure out how the state can build it. so, let's always err on theside of we can probably do it. let's just - reach out to us and we'll find a path forward to yes. that said i think - i think we're right on time. we have about 15 minutes for question. to go through some of these - are there comments from the box or are you going to handle those? sarah steverman: yeah,i can. thank you, tom, very much. this is incredibly - very useful information. i am happy to ask you some questions that i think are rising to the top here. and i wanted to start out with getting back to the example of the certifiedcommunity behavioral health clinics that have - you know, we're looking at those demonstration programs to expand services and connect behavioral health with primary care and other providers in the community to improve health coordination. anothertenet of it is quality measures and they're all thinking about how do we improve quality and how do we measure quality. is there - can you talk a little bit more about - and maybe there's an example of how this has been used toimprove care coordination, and is there or any quality measure recording functions that the hies can serve as well? thomas novak: yeah, and thanks for flagging that because i sometimes forget to mention that because those are actually something very - they always enable a support so it'ssort of not a new thing but it's something maybe worth mentioning because maybe it's not as obvious and not as known outside the incentive-eligible provider world that states are absolutely using these funds to build very robust quality reporting systems. so, that is very state to state. otherwise, those come out on themedicaid side, they can be more and more aligned. they have a new statewide or a nationwide quality reporting initiative that medicare is rolling out,
they've got close to 20 states live now under the code key [answers] and that is the way that the state medicaid agencies are aggregating or reporting qualitydata to medicare or i'm sorry, the medicaid. but they have a very robust quality reporting system in place. we've been doing a lot of work on aligning quality metrics. so, state medicaid agencies absolutely can use these funds to support collecting quality data and they are. sometimes, it mightseem more appropriate, given what they're doing to use a different bucket of money. it might be the mmis support which is the state medicaid systems that pay claims, check eligibility and manage the new enrollment and things like that. these are - so multiple avenues. so that'sbeen definitely being done. and if any of your colleagues want to learn about that or have ideas for at state by state level, you can talk to any state that wants to make use of some good ideas there. and in terms of the ccbhc in coordinated care, really, anything that'swithin the parameters of meaningful use are on the table. so transitions of care is the sort of most obvious one where one provider will send a transition of care to another provider which includes a summary of care and a summary of care has various data components such as the medication history, the problem list, thecare - and the care team, immunization history, sort of all the things you hoped to have, right? so that is the most obvious one but there are some less obvious ones that i think are appropriate here. so medication reconciliation is important. and especially, remember we're medicaid, right? so we're thinking about foster care for children, so children whoare maybe on psychotropic drugs so wandering through foster care system. no one's really doing a great job of managing their medication history because it's like attribution. it's difficult as they move from being wards of the state to foster parents, to biological parents and going back and forth, keeping track of these things is difficult.we can now (inaudible) and support systems that track things like that. so, we have that flexibility. so, medication history is another one that i think is huge for our intersection between medicaid and samhsa. i think we can do a lot there. and we don't - we have been talking to some state medicaid, see pharmacy medical directors aboutthat very thing and it's - it only came out in february, so we only have a few states that have pulled together some cohesive requests but there are a lot in the planning stages now. so, you're not too late for the party. like there are states taking through these things and interested in those paths forward.so that's really something we care a lot about on the medicaid side of things. sarah steverman: great. to drill down to kind of
what states are doing, there's a question from the state department of behavioral health, they're in the process of implementing meditechat psychiatric hospitals, nursing facilities and intermediate care facilities, and the question is whether or not this funding would be eligible for those activities? thomas novak: no. so, meditech isn't ehr. so it cannot provide ehrs. meditech, however,is - well, many of the meditech products are certified electronic health records so whereas we can't pay for the ehrs, - those ehrs are going to have the ability to connect to hie because the way they are certified allows for them to - requires them to do certainthings. i'm assuming that's the kind of meditech products that they would have, that they can take, maybe not for themselves. so that means there's a short walk to connect those products to any sort of the statewide hie and that you could support. so if you're building all of these, you're - it sounds like you did a goodjob in buying the right kind of ehr that is going to be able to plug into some of these health information exchanges rather seamlessly. there might be some interface cost, but not a lot. if a vendors you there's a lot, you pull it in, we'll help - we'll help sort that out, so the vendors are sometimes going to tell you or often will tell you they cost mostthan they do. so that's going to be practice by practice. then we have various sort of characteristics there that we can use to help, of course, reducing those interface cost to connect and onboard. but the systems like - those ehrs have an hie layer behind them. so that we build and then the connections to build and wecan build on the onboarding to those hies, we can build. but we can't buy ehrs. but you know what, that is reminding me of one thing. so the thing we almost always hear. we talked to behavioral health providers or substance abuse providers but we don't haveehrs, right? because that's - we know that. which is true. it's a group that has a lot of - there's a lot of working paper or doesn't have very good ehrs. so, what the state medicaid agencies can do is - they can also look at solutions that are web based. so, if there -the meaningful use objectives are really about the eps and the ehs. so (inaudible) providers, to keep their hospitals in primary care. so, whereas their ehrs have to connect to something, so say a web-based provider directory, so they have to connect directly to it and i say it can be aportal to there, but for - they have to have a certified ehr for purposes of the program. but, okay, for throwing the ball and catching the ball?
how the ball is caught is sort of less important. they get the meaningful use credit by doing that transition of care. it is okay if they saidit's transition of care that then ticked off via a web portal. so, if somebody asks if you have behavioral health or substance abuse provider who needs to go on a web portal to do a transition of care, that's fine. it's accessed and it's connected to an incentive- available provider. that is with in-bound. so, that's veryimportant to understand. i'm embarrassed i forgot to mention that for these kinds of providers. so that's something that is a known problem with this group that we can help with. sarah steverman: great. do you have any state examples that you can provideor a place where the audience can go to look at a few example of how states are using hitech to engage behavioral health and kind of connect all of - fully utilize the options that you describe?are there - is there a particular state that you can provide us an example of? and then, i guess the follow-up is if you have - if there's anywhere that cms is tracking these efforts and if there's any state examples that can be accesseddown the line? thomas novak: so, i think no. no, i don't actually, right? because there's not - it's relatively young, the program, so new york is probably the closest but theirs isn't even approved. so, there are states - well, colorado is onboarding providers. so, it hassort of like - the things that we're most commonly seeing which is just add behavioral health providers through existing systems. so, colorado is doing that. other states are in the planning stages but in terms approved funding, we probably only have three to four states total with easilyanother 20 in the planning stages. so i don't have a lot of great examples, which is sort of good because it's better to get to this sooner rather than later and plug you into the various states as they plan these things. so, it's sort of easiest for a state to just do onboarding to add these providers to - that's going tobe the first way behavioral providers get in before we've been to architecture because it's sort of easier. you're just adding them to an existing structure and not building something new. so, that's what we're most likely seeing in terms of some the planning ideas. and then i think new york and a few other places are lookingat various architectural options. sarah steverman: will the approved plans be posted for other states to see or is that - are there –
between cms and the states? thomas novak: it depends. it's actually the state call. it's what they do. but it's very collegialso if you want to see a certain state's plan, we can sort of access the intermediary and sometimes a state may just need to redact their dollar amount of the contracts referenced in there, so they might need to just redact a bit of it. but states are usually very willing to share those. so we can disseminate those.there are a lot of state post them on line anyway. so it's sort of state by state and it's a state call. but if the state doesn't and you want to know, based on my conversation to others, what states are doing, just reach out to us and we can try to facilitate that. sarah steverman: okay. are states generally, obviously,that's housed within the medicaid department where most of the activities are originating and they're reaching out to partners in the state? thomas novak: i'm sorry. what was the question? sarah steverman: i'm assuming for those on the line who would like to see what's going ontheir state, they should probably reach out to either you or to - or to ask or - so we can connect them but it's probably - i'm guessing their medicaid agency would be the place to go to see what they're up to? thomas novak: yeah, it's always - it's always the medicaid agency. it will be - there's like some statewide hieactivity with the help of the - but the purse strings are really controlled by the state medicaid agency so they're going to have the most current information. sarah steverman: okay, and then one final question, i think, before we end. we have a question and i think this is probably on a lot ofpeople's mind regarding consent and whether or not considerations of consent and sharing patient records is something that's built in and whether that's part of what can - part of the interoperability, the hie or some partof ehr system and kind of where that whole consent for hecfr part 2 to authorization requirements, where that comes in to play. thomas novak: right. that's a - yes. so, yeah, when i said that we support onboarding and (inaudible), thatincludes sort of the whole work, the higher consent. so, the state needs to figure out what the rules are. what the part 2 might affect or how it might intersect with state things. and some states might find themselves - actually some states - oh, (technical difficulty).i'm looking at building a consent management registry. so, they can use the - and we haven't been able to prove yet but that's interesting idea that we
sort of technically support bringing a little more information about it but, let's say, i want to build something like that to help managesome of the consent that might be relevant to states. so you can use it in various ways. it doesn't need to fit into the meaningful use mold but it is something we support in various functions and so, either the hist can coordinate it in terms of consent management or maybe it'son the onboarding process as we look at the consent models and the contracts or maybe it's also something that's electronically, maybe it's a consent management registry or a system that has a single sign on that looks at data segmentation or user-based authority and those kindof things. sarah steverman: great, great. this has been a lot of information and i hope that has been helpful for everyone. tom, i want to thank you for partnering with samhsa and helping us out by providing all of this, the information today on the hitech accesson how behavioral health can engage in our states. i want to thank everyone on the line who listened in and provided questions. please feel free to follow up to the email on the screen. well, come to us here in at samhsa and we can get questions to tom or -tom, do you want to provide your email? i think it's just tom. novak - was is it thomas. novak - thomas novak: yes, thomas. novak. (technical difficulty)that is it. yeah. sarah steverman: yeah, great. so, thank you, tom. thank you all for joining us and pleasekeep us updated on how you're working in your states to get this done. thanks so much. thomas novak: thank you so much everyone.
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