With Medicaid system "transformation" grants and other federal health IT matching funds now flowing, some states are beginning to consider their Medicaid Management Information Systems (MMIS) as more than back-end data processing systems.
Instead, across the country, states are envisioning their MMIS as fledgling health information exchanges (HIE), de facto networks for sharing health information across their state Medicaid provider community.
Few states, however, view the nascent Medicaid HIEs as precursors of mainstream statewide HIEs that aim to also extend data sharing across the state to non-Medicaid commercial providers and other health care organizations.
But that's exactly what New Jersey health care officials are planning. It's currently a pilot program, but a year from now they expect to mount a full-fledged Medicaid HIE, offering an "Expedia for health care" for the state's 1.3 million Medicaid clients, using repurposed MMIS data. Based on the concept of the popular Expedia travel site, the Medicaid HIE would allow Medicaid providers to access clinically relevant information about any of their Medicaid patients, even if they hadn't seen them before.
As with Expedia, to do this doctors would need to make a simple query"even just the name of the patient"through a Web portal, and in near real-time they'd get back a single page containing the patient's disease and treatment history.
That would save doctors time they now spend scrolling through screens of MMIS data to locate those records. It would also cut state Medicaid costs by eliminating redundant testing and ultimately improving patient care.
After the Medicaid HIE goes into operation, a statewide HIE could be built on the back of the Medicaid HIE to cater to New Jersey's other 6.7 million residents.
"The funding is there now for us to do this," said Michele Romeo, chief information officer for the New Jersey division of medical assistance and health services in the Department of Human Services (DHS), and the person responsible for all New Jersey Medicaid IT. "We are going to buy the software and hardware, and we've developed a Master Client Index (MCI) that all the other (regional) HIEs that Medicaid does business with will be able to use."
Under New Jersey's health IT operational plan, filed in August with the Office of the National Coordinator for Health IT (ONC), Medicaid is a key partner with the state in delivering on this vision, with the state leveraging Medicaid funding to help build the infrastructure for the statewide HIE.
The MCI, which will link the Medicaid program with the state's immunization and lead screening registries, is crucial to the development of the statewide HIE. It will also be a key element of the eventual NJ health information network (NJHIN).
Empty HIE syndrome
Given the lessons from HIEs already operating in the state and around the country, the technology used to build HIEs seems well understood, according to Colleen Woods, who has been the state's HIT coordinator since July, and before that was Romeo's predecessor at the New Jersey DHS. As far as getting the support for going ahead with the statewide HIE, what's needed now is the "value balance" to the equation, she said.
"The insurance industry is looking for the value they would get out of this, providers are looking for value, pharma is looking for value," she said. "Ultimately, people have to be convinced by this."
And the key to that could be how those parties see the ultimate effectiveness of the Medicaid HIE. Or, said Vik Kheterpal, a principal at CareEvolution, which is providing the software that will derive the clinical data and provide identity and security services for the Medicaid HIE, how well it can avoid "empty HIE syndrome."
"You can create the best tools for accessing and sharing the information, but that means nothing if there's no data in the HIE once it's running," he said. "As with most HIE efforts, it's about the data and not the technology."
For instance, you can't start with just a narrow sliver of data in the exchange, he said, because that won't get people excited. You need to provide information on a critical subset of patients so the doctors who will be using the data know there's something useful for them and won't forget it's there and stop using the exchange. And Medicaid claims data is very effective for that, according to Kheterpal.
In that model, then, data on the 1.3 million Medicaid recipients in the Medicaid HIE would "seed" the eventual statewide HIE, he said, and that will be populated over time with data from other sources. If all of the HMOs and providers that Medicaid deals with in the state were included, along with the state employees' health plan, virtually the entire 8 million population of New Jersey would be covered, according to Romeo.
The other side of getting people to use the Medicaid HIE, and by extension the statewide HIE once it's operating, is designing a system from which doctors can get immediate value. A traditional portal approach would have doctors logging-in to a site only to be faced with navigating a complex series of icons and tabs, and then parsing the stream of data once they did get to a page they were interested in.
Expedia for health care
That's where the analogy to Expedia comes in. That system for travelers provides a series of distinct choices of airlines, hotels and other resources they can choose from, in response to a simple query about flight dates, origin and destination.
Likewise, CareEvolution's Web-based Expedia for health care model would bring up information about a patient filtered from the Medicaid claims data, stripped of financial details and ordered by clinical relevance, showing, for instance, the timeline of the care that patient has received.
The idea, said Kheterpal, is to provide a 30 second snapshot of a patient that provides a complex medical history on a single screen, and that doesn't overwhelm the physician.
"We want to organize a story of the patient that actually goes beyond the kind of thing that Expedia for travelers produces," he said. "The physician wants to know things like a trend line of patient disease, and to be able to pick from a list of potential diagnoses."
In contrast, the traditional portal method would involve scrolling through pages and pages of information, which isn't useful, he added.
The CareEvolution approach is an automated system that operates on demand in near real-time by matching the doctor's unique patient record with the HIE's Master Client Index. Given that most patients call ahead of time for an appointment, that gives plenty of time for the system to spool requests so that the data is ready for the doctor to access when the patient arrives.
Even emergency responders calling in to a hospital from an ambulance about the patient they are carrying usually do so a few minutes ahead of when they arrive, "and from an information systems perspective that's tons of lead time," said Kheterpal.
EHR calling card
This Medicaid electronic health record will also act as an introduction to EHRs for doctors that haven't adopted them yet, Romeo said. "Over 50 percent of our providers are more than a little skeptical of EHRs," she said. "This will be a way of easing them into it."
The information derived from the Medicaid HIE, knowing the doctors who are accessing the system and who aren't, will also provide a better way of identifying those providers who are candidates for the federal incentive programs for adopting meaningful use of EHRs, she said.
A statewide HIE might arrive a little later only because the players in that effort have to be organized, and the requisite governance has to be put in place, Romeo said.
