The Centers for Medicare and Medicaid Services plans to revamp its computer systems starting in 2011 with a project designed to eliminate or control duplicate data collection in Medicaid and the Children's Health Insurance Program (CHIP).
CMS also will develop the Medicare Encounter Data Processing System, to encourage the re-use of information and flexibility through a technical architecture that is based on sharing software services.
With these projects, the agency aims to accelerate improvements in how it delivers health care based on patient outcomes, as called for under the health reform law, according to an agency report.
It will need to re-engineer its systems and coordinate its programs in order to better mine patient information that can be re-used across the agency, so it can transform from being "a passive payer of claims to an active purchaser of quality health care," according to the CMS report published Dec. 23.
As an example of the agency's challenges, the report said CMS holds various pieces of information about healthcare providers in 25 different databases all used for different program purposes. CMS computer systems are also outdated and its data-processing capacity is overworked, according to the report, "Modernizing CMS Computer and Data Systems to Support Improvements in Care Delivery."
"CMS systems are focused on paying claims, not providing better care," the report said, adding that limited capabilities exist to accept and process clinical data for decision support.
To change that, the agency will have to break down existing information silos, consolidate current data and acquire new data, such as quality of care assessments and clinical records.
The agency will focus on obtaining better analytics for quality of care in new delivery models, and drive quality improvements by rewarding healthcare providers based on quality performance metrics that are called for in the Affordable Care Act.
It will modernize its enterprise data environment over several years, starting with the two new projects. As a result, Medicaid and CHIP will share a single source of data across the enterprise, which will also strengthen program integrity and transparency to reduce waste and fraud.
Currently, CMS approves the federal financial participation in 51 different state Medicaid and CHIP systems, which do not include common structures for effective communications and comparison of data. The enterprise data environment that CMS is establishing will enable integrated infrastructure for Medicaid and CHIP programs and state partners.
CMS will build on work already underway to develop a comprehensive Medicaid and CHIP data dictionary, business rules for eligibility and enrollment data model. The agency will also establish a master database and an enterprise index of providers with the states, the report said.
It will create a state advisory panel to begin meeting in April 2011 to consider methods to improve Medicaid and CHIP data processing, submission and sharing. The panel will produce recommendations for CMS by October.
For the Medicare Encounter Data Processing System, providers will submit claims to CMS for patient visits in the X12-837 electronic transaction format, a Health Insurance Portability and Accountability Act (HIPAA) standard. The system will receive the data and apply common edits from software modules so it can be processed and reused. Eventually, the edits will be incorporated into the software services, according to the report.
