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State of MontanaDepartment of Public Health and Human Services

State Medicaid Health Information Technology (HIT) Plan

Update

Version 1.3

SFY 2018 to SFY 2019

MONTANA DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES

Montana State Medicaid Health Information Technology (HIT) Plan

Table of ContentsEXECUTIVE SUMMARY........................................................................................................................................ 5

DOCUMENT PURPOSE......................................................................................................................................... 6

BACKGROUND.................................................................................................................................................... 6

A1 EXTENT OF PROMOTING INTEROPERABILITY ADOPTION...................................................................................................7A2 CHALLENGES OF BROADBAND INTERNET ACCESS..........................................................................................................16A3 FQHC FUNDING...................................................................................................................................................16A4 VA AND IHS EHRS...............................................................................................................................................17A5 HIT/E STAKEHOLDER ENGAGEMENT.........................................................................................................................18A6 SMA RELATIONSHIPS WITH OTHER HIT/E ENTITIES.....................................................................................................23A7 HIE ORGANIZATION GOVERNANCE STRUCTURE...........................................................................................................23A8 MMIS ROLE IN HIT AND COORDINATION WITH MITA................................................................................................23A9 PLANNING AND FACILITATION OF HIE AND EHR.........................................................................................................26A10 STATE RELATIONSHIP TO THE HIT COORDINATOR......................................................................................................28A11 ACTIVITIES INFLUENCING THE DIRECTION OF THE PROMOTING INTEROPERABILITY PROGRAM..............................................28A12 CHANGES TO STATE LAW OR REGULATIONS..............................................................................................................28A13 HIT/E ACTIVITIES THAT CROSS STATE BORDERS........................................................................................................28A14 INTEROPERABILITY OF THE IMMUNIZATION REGISTRY AND PUBLIC HEALTH SURVEILLANCE REPORTING DATABASE...................29A15 HIT-RELATED GRANTS..........................................................................................................................................31

SECTION B: THE STATE’S TO-BE LANDSCAPE....................................................................................................... 33

B1 HIT/E GOALS AND OBJECTIVES................................................................................................................................33B2 IT SYSTEM ARCHITECTURE......................................................................................................................................41B3 MEDICAID PROVIDER INTERFACES.............................................................................................................................44B4 FUTURE HIE GOVERNANCE.....................................................................................................................................45B5 SMA PLANNING OVER THE NEXT 12 MONTHS............................................................................................................45B6 LEVERAGING FQHC HIT/EHR RESOURCES AND EXPERIENCES.......................................................................................46B7 SMA SUPPORT FOR ADOPTION AND MEANINGFUL USE OF CERTIFIED EHR TECHNOLOGY..................................................46B8 ADDRESSING POPULATIONS WITH UNIQUE NEEDS.......................................................................................................47B9 LEVERAGING GRANTS FOR IMPLEMENTING PROMOTING INTEROPERABILITY PROGRAMS......................................................47B10 NEW STATE LEGISLATION NEEDS FOR PROMOTING INTEROPERABILITY PROGRAM IMPLEMENTATION...................................47

SECTION C: ACTIVITIES NECESSARY TO ADMINISTER AND OVERSEE THE PROMOTING INTEROPERABILITY PROGRAM........................................................................................................................................................ 48

C1 VERIFYING PROPERLY LICENSED/QUALIFIED PROVIDERS..................................................................................................48C2 VERIFYING HOSPITAL-BASED EPS..............................................................................................................................48C3 VERIFYING PROVIDER ATTESTATIONS..........................................................................................................................49C4 SMA COMMUNICATION WITH PROVIDERS..................................................................................................................50C5 CALCULATING PATIENT VOLUME...............................................................................................................................51

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C6 DATA SOURCES USED TO VERIFY PATIENT VOLUME FOR EPS AND ACUTE CARE HOSPITALS....................................................52C7 VERIFYING EPS AND FQHC/RHCS MEET THE PRACTICES PREDOMINATELY REQUIREMENT...................................................52C8 VERIFYING ADOPT, IMPLEMENT, OR UPGRADE OF EHR TECHNOLOGY...............................................................................53C9 VERIFYING MEANINGFUL USE OF EHR TECHNOLOGY FOR SECOND PARTICIPATION YEARS......................................................53C10 PROPOSED CHANGES TO THE MU DEFINITION...........................................................................................................53C11 VERIFYING USE OF CERTIFIED EHR TECHNOLOGY........................................................................................................53C12 SHORT-TERM AND LONG-TERM COLLECTION OF MEANINGFUL USE DATA.........................................................................54C13 PROCESS ALIGNMENT WITH OTHER QUALITY MEASURES..............................................................................................54C14 IT, FISCAL, AND COMMUNICATION SYSTEMS USED IN IMPLEMENTATION.........................................................................54C15 IT SYSTEMS CHANGES NEEDED TO IMPLEMENT THE PROMOTING INTEROPERABILITY PROGRAM...........................................54C16 IT TIMEFRAME FOR SYSTEMS MODIFICATIONS............................................................................................................55C17 NLR INTERFACE TESTING.......................................................................................................................................55C18 ACCEPTING REGISTRATION DATA FROM THE CMS NLR...............................................................................................55C19 WEBSITE FOR MEDICAID PROVIDERS.......................................................................................................................55C20 MODIFICATIONS TO THE MMIS.............................................................................................................................56C21 CALL CENTERS/HELP DESKS FOR PROMOTING INTEROPERABILITY PROGRAM INQUIRIES.....................................................56C22 PROVIDER APPEAL PROCESS...................................................................................................................................56C23 ACCOUNTING FOR FEDERAL FUNDING......................................................................................................................57C24 FREQUENCY OF EHR INCENTIVE PAYMENTS..............................................................................................................57C25 DIRECT PAYMENT PROCESS....................................................................................................................................58C26 MEDICAID PAYMENT DESIGNATION PROCESS.............................................................................................................61C27 MANAGED CARE PLAN PAYMENTS...........................................................................................................................61C28 ASSURING PAYMENT CONSISTENCY WITH STATUTES AND REGULATIONS..........................................................................61C29 CONTRACTOR ROLES IN IMPLEMENTING THE PROMOTING INTEROPERABILITY PROGRAM....................................................62C30 ASSUMPTIONS....................................................................................................................................................62

SECTION D: THE STATE’S AUDIT STRATEGY........................................................................................................ 63

SECTION E: THE STATE’S HIT ROADMAP............................................................................................................. 64

E1 MONTANA’S HIT PATHWAY....................................................................................................................................64E2 EXPECTATIONS FOR PROVIDER PROMOTING INTEROPERABILITY PROGRAM ADOPTION.........................................................68E3 PROGRESS BENCHMARKS........................................................................................................................................69E4 AUDIT AND OVERSIGHT BENCHMARKS.......................................................................................................................71

ACRONYMS....................................................................................................................................................... 72


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Revision History

VERSION # DATE SUBMITTED TO CMS CMS APPROVAL DATE

1.0 (original) January 6, 2011 January 6, 2011 April 4, 20111.1 June 30, 2011 June 30, 2011 Version Not

Approved1.2 August 18, 2011 August 18, 20111.3 June 1, 2018 June 4, 2018 September 18, 2018


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Executive SummaryMontana’s State Medicaid Health Information Technology Plan (SMHP) was approved by the Centers for Medicare and Medicaid Services (CMS) in 2011. The approved SMHP established Montana’s vision and plans to enhance the ability of healthcare providers to deliver high-quality, affordable healthcare for Montanans. Through the deployment of technologies, Montana endeavored to assist the provider community in efforts to enhance patient safety and improve coordination of care by promoting the adoption of interoperable electronic health record (EHR) systems in accordance with the American Recovery and Reinvestment Act (ARRA), Section 4201. Since 2011, there has been widespread adoption of various EHRs by providers, including practices, specialty providers, and hospitals in Montana, and progress on multiple health information exchange (HIE) fronts. In 2016, the Montana Department of Public Health and Human Services (DPHHS) began modularizing the Medicaid enterprise known as Montana’s Program for Automating and Transforming Healthcare (MPATH). As part of this modernization, Montana’s Medicaid Management Information System (MMIS) is being replaced with multiple components. For example, Population Health Management is one of the Medicaid enterprise components that aggregates patient data across multiple health information technology (HIT) solutions. The establishment of direct connections with EHRs aims to promote bi-directional data exchanges between DPHHS and providers and ultimately support the identification of quality measures and gaps in care. This component is targeted to be implemented in summer 2018. On a parallel HIE path, the Montana Medical Association (MMA) is leading a multi-stakeholder effort to establish a new statewide HIE for Montana named “Big Sky Care Connect”. As part of that effort a proof of concept pilot project in Billings, Montana, is working on conducting real-time exchange of health information and facilitating targeted clinical reporting for patients across participating pilot organizations. This work is being facilitated with assistance from Dr. David Kendrick and using the same technology solution as MyHealth Oklahoma. The MMA with assistance from various other groups and Dr. Kendrick has facilitated a HIE planning effort that included over one hundred stakeholders from health systems, clinics, hospitals, provider associations, government entities, and payers. The stakeholders formed five workgroups to discuss details of the new HIE related to governance, clinical quality measures, privacy & security, business-finance, and technology. While Montana lacks an operational statewide HIE platform, DPHHS is collaborating with this broad range of stakeholders to support internal departmental and statewide HIE efforts underway to serve as a launching pad for much broader use. Another consortium in Montana, the Health Information Exchange of Montana, Inc. (HIEM) is also leading an effort to support interoperability. HIEM is a non-profit 5Montana State Medicaid HIT Plan (SMHP) Update

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organization that includes hospitals, clinics and federally funded Community Health Centers in Northwest and Northcentral Montana. The HIEM is closely assessing efforts of the Lincoln County Health Alliance (LCHA) Project, an initiative to utilize a sustainable HIE to improve collaboration and coordination of health and information in pursuit of prioritizing community health needs and care.In this updated SMHP, DPHHS continues to promote its overall goal and has refined its objectives to influence Montana over the next five years based on progress and achievements made to date and future priorities. DPHHS’ overarching goal is to improve access to healthcare and treatment outcomes for Montanans. Four HIT and HIE objectives established to further shape Montana’s future landscape are based on common themes and priorities identified by DPHHS and stakeholders across the state and align with DPHHS’ broader goal. The objectives are:

Implement modular systems and services to modernize the Medicaid Enterprise.

Develop a sustainable statewide HIE solution for use by multiple stakeholders across the state.

Utilize data analytics to inform treatment, payment, and outcomes for healthcare.

Leverage HIE to encourage meaningful use of EHRs.

Document PurposeThe initial submission of the SMHP provided the State Medicaid Agency (SMA) and Centers for Medicaid and Medicare Services (CMS) with a shared understanding of activities relative to implementation of Section 4201 Medicaid provisions of the American Recovery and Reinvestment Act (ARRA) over a five-year period. The purpose of the SMHP Update is to provide CMS with updated information regarding activities the SMA has undertaken since submission of the initial plan in 2011. It also provides states the opportunity to develop lessons learned, course-correct, or further plan Health Information Technology/Health Information Exchange (HIT/E) initiatives.

BackgroundMontana DPHHS is responsible for the administration of Montana Healthcare Programs. DPHHS’ mission is to improve and protect the health, well-being and self-reliance of all Montanans. DPHHS is a diverse state department that provides services for people all over Montana. DPHHS has twelve divisions under its umbrella. Each division oversees numerous bureaus, programs, services, grants, and facilities. Montana’s small population, scattered over an immense area, poses challenges in delivering health care services. Geography and connectivity also 6Montana State Medicaid HIT Plan (SMHP) Update

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present challenges to ensuring continuity and care. With this in mind, the SMA continues to pursue opportunities to leverage health information technology and facilitate the exchange of health information on a statewide level to achieve their mission.


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Section A: The State’s As-Is HIT LandscapeA1 Extent of Promoting Interoperability Adoption1. What is the current extent of EHR adoption by practitioners and by hospitals? How recent is this data? Does it provide specificity about the types of EHRs in use by the State’s providers? Is it specific to just Medicaid or an assessment of overall statewide use of EHRs? Does the SMA have data or estimates on eligible providers broken out by types of provider? Does the SMA have data on EHR adoption by types of provider (e.g. children’s hospitals, acute care hospitals, pediatricians, nurse practitioners, etc.)?

Montana’s Department of Public Health and Human Services (DPHHS) captured data on provider and hospital EHR adoption by attestation through the State Level Repository (SLR). Program Year 2016 was the last year an eligible professional (EP) could begin participation in the Medicaid Provider Incentive Program (MPIP). The total number of providers and hospitals that received MPIP funding, both adopt, implement, and upgrade (AIU) and meaningful use (MU) since 2011 is 1,371. The table below includes the number and dollar amounts for Montana providers and hospitals that received payment for AIU and MU. Duplicate EPs and eligible hospitals (EHs) have attested in multiple years.

Table A1: Provider and Hospital Payments for AIU and MUNumber of Providers for both AIU and MU 1071

Number of Hospitals for both AIU and MU 149

Number of Providers for AIU 415

Number of Providers for MU 656

Number of Hospitals for AIU 34

Number of Hospitals for MU 115

Payment to Providers for AIU $8,718,170.00

Payment to Providers for MU $6,454,337.00

Payment to Hospitals for AIU $10,870,115.26

Payment to Hospitals for MU $18,039,919.93

Currently, the state lacks a comprehensive HIE platform that could foster further electronic health record (EHR) adoption by providers. DPPHS and other stakeholders 8Montana State Medicaid HIT Plan (SMHP) Update

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feel that a statewide HIE is needed to maximize EHR adoption. The statewide HIE that was formed, as described in the initial version of the SMHP, is no longer in place. The primary reason cited for this is a lack of sustainability. Also, the HIE solution failed during key integration efforts.Stakeholders in the Big Sky Care Connect project stated that providers support the implementation of a statewide HIE. One of the primary projects with stakeholder support is an HIE pilot project in Billings, Montana, among RiverStone Health, St. Vincent Health Care, Billings Clinic, and Blue Cross and Blue Shield (BCBS) of Montana. Additional information on the pilot project can be found in Section A9, Planning and Facilitation of HIE and EHR Adoption. The pilot project provides real-time exchange of health information and facilitation of targeted clinical reports to help doctors coordinate care among patients who cross over between their organizations. Montana Provider EHR Landscape

There has been widespread adoption of various EHRs by providers, including practices, specialty providers, and hospitals in Montana. Physician practices receive the greatest number of MU payments. This section includes data captured on EHR through several different sources, including the SLR and provider survey results provided by the Montana Medical Association (MMA) from the 2018 provider survey. Barriers to adoption noted by providers included detraction from patients and workflow issues. The absence of a statewide HIE also presents a significant barrier to realizing the full value of an EHR.Based on SLR data, a wide range of EHRs are in use by healthcare providers in Montana. eClinical Works had the highest volume of EHRs from 2012 through 2017, followed by Epic, Indian Health Services, NextGen, and Cerner. More than half of meaningful use payments were disbursed to physician practices and nurse practitioners, but a combination of inpatient and ambulatory payments have been made.The following series of figures details adoption, incentive payment, and vendor information for Montana EHR adoption.


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Institute for Health Metrics

Healthcare Management Systems, Inc.

Health Care Systems, Inc.

ExitCare, LLC

Emdeon Corporation

Design Clinicals, Inc.

Midas+ Solutions

CareCloud Corporation

MacPractice, Inc.

Sage

Vitera Healthcare Solutions, LLC

Tech-Time, Inc.

SOAPware, Inc.

Greenway Health, LLC

SuccessEHS

athenahealth, Inc.

LSS Data Systems

Practice Fusion

Cerner Corporation

Indian Health Service

eClinicalWorks, LLC

0 20 40 60 80 100 120 140 160 180

AmbulatoryInpatient

Figure A1. EHR System by Vendor as Reported by the SLR

In dollars, Epic and Cerner systems received the greatest payment amounts, as these systems were more often associated with inpatient hospital settings. However, payments for providers in an ambulatory setting are just as prevalent in Montana.


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2011 2012 2013 2014 2015 2016 2017 $-

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

$3,000,000.00

$3,500,000.00

$4,000,000.00

$4,500,000.00

$5,000,000.00

AmbulatoryInpatient

Figure A2. Payments by Year

2012 had the largest total dollars paid for meaningful use. The number of payments to providers in ambulatory settings has steadily increased since 2015, resulting in an overall increase in the number of payments and dollars paid.


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Physician33%

Nurse Practitioner29%

Dentist13%

Acute Care Hospitals11%

Physician’s Assistant Practice

6%

Unknown5%

Nurse Midwife3%

Hospital2%

Figure A3. Payments by Provider Type

As shown in Figure A3 above, over half of MU payments have gone to physician practices and nurse practitioners as reported through the SLR. A large majority of payments have gone to providers providing services in an ambulatory setting.


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In addition to the SLR data, the Montana Medical Association (MMA) surveyed Montana providers during the first quarter of 2018. The following charts summarize the EHR/MU questions for PCPs and non-PCPs. Figure A4 shows that more than 90% of PCPs have an EHR. The same holds true for other providers surveyed through the MMA as shown in figure A5. The percentages are anticipated to reach closer to 100% in the next five years.

Yes91%

No9%

PCPs – Have an EHR? (n=451)

Figure A4. MMA Survey – PCPs – Have EHR?

Yes93%

No7%

Non-PCPs – Have an EHR? (n=264)

Figure A5. MMA Survey – Non-PCPs – Have EHR?


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Just under two-thirds of surveyed Montana PCPs have received Meaningful Use (MU) payments, as shown in figure A6 below. Anticipated MU payments through year five can be found in Section B. About half of other providers surveyed received meaningful use payments.

Yes64%

No36%

PCPs – Receive Meaningful Use Payments? (n=332)

Figure A6. MMA Survey – PCPs – Receive Meaningful Use Payments

Yes51%

No49%

Non-PCPs – Receive Meaningful Use Payments? (n=191)

Figure A7. MMA Survey – Non-PCPs – Receive Meaningful Use Payments


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Patients Notes

Managing Lab Results

Track & maintain Demos

Utilize E-prescribing

Utilize Computerized Provider Order Entry

Conduct Billing

Conduct Info. Exchange w/ patients

To be alerted or flagged

Provide Patient Support Info.

Conduct Internal Reporting

Conduct Info. exchange w/ partners

Use Clinical Decision Support

0% 20% 40% 60% 80% 100%

PCPs – How EHR is Used?

Yes NoFigure A8. MMA Survey – PCPs – How EHR is Used?

The MMA survey revealed that PCPs use EHRs for a broad range of clinical and administrative functions. More than 90% of PCPs report using EHRs to take patient notes, manage labs, track demographics, and utilize e-prescribing.


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Patients Notes

Track & maintain Demos

Utilize E-prescribing

Managing Lab Results

Conduct Billing

Utilize Computerized Provider Order Entry

To be alerted or flagged

Conduct Internal Reporting

Conduct Info. Exchange w/ patients

Provide Patient Support Info.

Conduct Info. exchange w/ partners

Use Clinical Decision Support

0% 20% 40% 60% 80% 100%

Non-PCPs – How EHR is Used?

Yes NoFigure A9. MMA Survey – Non-PCPs – How EHR is Used?

As shown in Figure A9, non-PCPs also use an EHR for a broad range of functions and have similar trends to PCPs. Less than 50% of non-PCPs reported using an EHR for clinical decision making and conducting information exchange with partners. Comparatively, more than 60% of PCPs reported using EHRs to support information exchange with partners. Based on survey results, non-PCPs lag behind PCPs with regard to using EHRs to support administrative functions.


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A2 Challenges of broadband internet access2. To what extent does broadband internet access pose a challenge to HIT/E in the State’s rural areas? Did the State receive any broadband grants?

Broadband penetration in Montana is among the worst in the nation. Approximately 28% of the population does not have access to 25mbps coverage. This is due to Montana’s small population and large land mass area. The largest Montana cities have the best access with rural areas having the most limited; this is especially true in eastern Montana. If providers are unable to connect to broadband internet or have unreliable coverage, this can impede statewide HIT and HIE initiatives. Broadband access in Montana is improving. In October 2017, the Montana Public Service Commission secured over $100 million in federal funds to support increasing broadband access in rural areas. One of the component requirements for federal funding support is that it must support rural healthcare. The State Information Technology Services Division (SITSD) included improving broadband access across the state in their most recent five-year plan.

A3 FQHC Funding3. Does the State have Federally-Qualified Health Center networks that have received or are receiving HIT/EHR funding from the Health Resources Services Administration (HRSA)? Please describe.

When Montana submitted the initial SMHP in 2011, there were 15 Federally Qualified Health Centers (FQHCs). That number increased to 17 and recently decreased to 16 as one FQHC acquired another earlier this year.Montana Primary Care Association (MPCA) is the recipient of a Health Center Controlled Network (HCCN) grant to support the adoption, use, and optimization of HIT by FQHCs in Montana. Fifteen of the 16 FQHCs in Montana are part of this network. Only Southwest Montana Community Health Center (CHC) is a part of the Oregon Community Health Information Network (OCHIN). MPCA receives $625,000 annually under this grant and has since December 2012.The HCCN grant includes goals targeting increased adoption of ONC certified EHRs and increasing the number of providers receiving payments for MU. To address these goals, the HCCN:

works to build internal HIT workforce capacity supports privacy and security knowledge provides workflow assessments to meet MU objectives provides assistance in understanding MU objectives and attestation

requirements17Montana State Medicaid HIT Plan (SMHP) Update

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monitors and participates in state and local HIE efforts Currently, all 16 CHCs have an ONC-certified EHR in place. Also, the HCCN supports use of care coordination and reporting tools to meet internal quality improvement needs as well as various state and federal requirements, including MU, uniform data system (UDS), and patient-centered medical home (PCMH) requirements.The table below provides an updated roster of FQHCs in Montana.

Table A2. Federally Qualified Health Centers

Facility City

Bighorn Valley Health Center HardinBullhook CHC HavreSouthwest Montana CHC ButteCentral Montana CHC LewistownCommunity CHC Great FallsCommunity Health Partners LivingstonPureView HelenaFlathead CHC KalispellGlacier CHC Cut BankMarias Health Services ShelbyNorthwest CHC LibbyPartnership Health Center MissoulaRiverStone Health BillingsSapphire CHC HamiltonSweet Medical Center ChinookAg Workers Health & Services Billings

A4 VA and IHS EHRs4. Does the State have Veterans Administration or Indian Health Service clinical facilities that are operating EHRs? Please describe.

The Montana Veterans Health Administration uses VistA as their EHR. This system was implemented in 2008. Indian Health Services (IHS) continues to promote the


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Meaningful Use of EHRs in their facilities. The VA and IHS efforts are described in detail in Section A5.

A5 HIT/E Stakeholder Engagement5. What stakeholders are engaged in any existing HIT/E activities and how would the extent of their involvement be characterized?

Federal Partners

Federal partners engaged in HIT/EHR activities within Montana include: Centers for Medicare and Medicaid Services (CMS) Office of the National Coordinator (ONC) Indian Health Service (IHS) Veteran’s Administration (VA) Centers for Disease Control (CDC)

Centers for Medicare and Medicaid Services (CMS)

CMS is a key federal stakeholder for the State of Montana. In 2011, CMS established the Medicare and Medicaid Promoting Interoperability Programs to encourage EPs, eligible hospitals (EHs), and Critical Access Hospitals (CAHs) to adopt, implement, upgrade and demonstrate meaningful use of certified EHR technology (CEHRT). CMS also assisted the ONC with the development of standards, implementation specifications, and certification criteria for EHR technology. CMS continues to work with the Office of Civil Rights (OCR) and ONC to ensure privacy and security precautions are addressed for the MPIP. Lastly, CMS provides oversight regarding the MPIP reviewing and approving the Implementation Advanced Planning Document (IAPD) for HIT and the SMHP.Office of the National Coordinator (ONC)

The ONC is a key federal stakeholder for the State of Montana. They are the principal federal entity coordinating efforts for the implementation and use of HIT and HIE in Montana. ONC is at the forefront of the federal administration’s HIT efforts and is a resource to the entire health system to support the adoption of health information technology and the promotion of nationwide health information exchange to improve health care. ONC is organizationally located within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS). The position of National Coordinator was created in 2004, through an executive order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009.Indian Health Services (IHS)


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The IHS is the principal federal health care provider and health advocate for Indian people, and its goal is to raise their health status to the highest possible level. The IHS provides a comprehensive health service delivery system for approximately 2.2 million American Indians and Alaska Natives who belong to 567 federally recognized tribes in 36 states. Montana has seven federally recognized tribal nations and one state recognized tribal nation (see http://tribalnations.mt.gov/ for more information). IHS is a key federal stakeholder for the State of Montana in the coordination of HIT and HIE initiatives including the:1. Continued expansion of the framework for comprehensive management of

health information and its secure exchange between consumers, providers, government and quality entities, and insurers.

2. Expansion and improvements to the IHS clinical information system, Resource and Patient Management System (RPMS) for the management of clinical and administrative information in IHS healthcare facilities. RPMS enables IHS facilities large and small to work independently and within the larger network of the Indian Health system, and, are an integral component for providing the best and most effective healthcare to individual patients and the community as a whole.

3. Continued connectivity and coordination of healthcare information between internal IHS facilities and external agencies for the secure exchange of relevant patient data. This includes gathering patient history documents from a variety of sources such as facilities of different types or in varying locations.

4. Continued alignment of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) between the OIT, clinical, and business disciplines within the Indian Health Service/Tribal/Urban (I/T/U) community for the benefit of patients.

5. Continued promotion of meaningful use of EHR in which patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities.

6. Continued promotion of the National Data Warehouse (NDW), an enterprise-wide data warehouse environment for the IHS national data repository. The NDW gathers, stores, reports, and allows easy access to accurate historical data. It is custom designed to meet the administrative and clinical needs of Indian health end users nationwide. It includes a national enterprise-level database that provides a relatively complete, historical repository of patient registration and encounter information dating back to October 2000.


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http://tribalnations.mt.gov/



The Indian Health Service has long been a pioneer in using computer technology to capture clinical and public health data. The IHS clinical information system is called the Resource and Patient Management System (RPMS). The RPMS EHR graphical user interface represents the next phase of clinical software development for the IHS. In April 2011, the IHS Resource and Patient Management System (RPMS) was certified according to standards established by the Office of the National Coordinator for Health Information Technology (ONC). This accomplishment allowed Eligible Professionals (EPs) and Eligible Hospitals (EHs) to participate in the Centers for Medicare and Medicaid Services (CMS) Promoting Interoperability Program. With the release of the 2014 ONC Rule and the 2014 CMS Stage 2 Rule, the scope of requirements for demonstrating Meaningful Use were greatly increased, and new certified electronic health technology (CEHRT) became necessary. As of August 22, 2014, the 2014 RPMS EHR was certified according to the 2014 ONC standards.

Table A3. EHR Deployment StatusLocation City Type Usage

Crow Indian Hospital Crow Agency

Hospital Inpatient federal and tribal hospitals & VistA Imaging sites

Lodge Grass Clinic Lodge Grass Clinic EHR VistA Imaging sitesPryor Health Clinic Pryor Clinic EHR VistA Imaging sitesPoplar Health Center Poplar Clinic EHR VistA Imaging sitesWolf Point Health Center

Wolf Point Clinic EHR VistA Imaging sites

Browning Indian Hospital

Browning Hospital Inpatient federal and tribal hospitals & VistA Imaging sites

Heart Butte Health Station

Heart Butte Clinic EHR VistA Imaging sitesLame Deer Health Center

Lame Deer Clinic EHR VistA Imaging sitesHarlem Indian Hospital (Fort Belknap)

Harlem Hospital Inpatient federal and tribal hospital & VistA Imaging sites

Hays Health Station Hays Clinic EHR VistA Imaging sitesRocky Boy Health Center

Box Elder Clinic UnknownFlat Head Health Center

Flat Head Clinic UnknownIndian Family Health Clinic

Great Falls Clinic Unknown

Veteran’s Administration (VA)


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The VA Montana Health Care System provides a VA presence in every major city in the state through a series of community-based clinics, a community living center, and an acute care medical center.Fort Harrison (Helena) is a 34-bed acute care, medical-surgical facility that offers a broad range of acute, chronic, and specialized inpatient and outpatient services for both male and female Veterans. Specialty care includes internal medicine, gerontology, neurology, dermatology, cardiology, palliative care, pain management, medical oncology, surgery (general, vascular, laparoscopic, endoscopic), urology, orthopedics, plastic, ophthalmology, ENT, podiatry, gynecology, chiropractic care, psychiatry (including outpatient substance abuse treatment and PTSD and MST specific care), and ambulatory care (primary care). Radiology Service provides a broad range of diagnostic and interventional care provided on a full-time basis. Pathology Services are available on site also provided on a full-time basis. Telemedicine services are available for psychiatry, radiology, gynecology, primary care, ophthalmology, and tele-home health. The 24-bed residential rehabilitation facility serves patients needing treatment for PTSD and Substance Abuse.A 30-bed Community Living Center (CLC) that provides general and ventilator dependent care is located in Miles City. Primary care is provided at Anaconda, Billings, Bozeman, Cutbank, Glasgow, Glendive, Great Falls, Havre, Kalispell, Lewistown, Miles City, and Missoula. Primary Care Telehealth Outreach Clinics are located in Hamilton and Plentywood. Staff and contract specialists visit the clinics regularly and provide access to specialty care as needed.Montana is the fourth largest state geographically and has one of the largest per capita Veteran populations. To augment mental health services in the outbased clinics, VA Montana Health Care System contracted mental health care outside Lewis and Clark County (location of Fort Harrison) to reduce Veteran travel. This allowed the VA to provide for local care while maximizing funding in rural areas without making the Veteran travel.Montana has two state Veterans' homes located in Columbia Falls (northwest) and Glendive (east). The VA also uses contract arrangements with private nursing homes to allow Veterans to be placed in long-term care facilities closer to their families.The VA has used health information technology in their medical facilities since 1985. Part of the current EHR solution includes a state-of-the-art patient portal known as My HealtheVet. My HealtheVet engages Veterans as an integral part of their care team enhancing patient-centric care. The Veterans Health Information Systems and Technology Architecture (VistA) has served as the backbone of the VA EHR system for many years but plans are underway to modernize the VA health information technology infrastructure. The VA has recently announced their plan to implement a new EHR solution nationwide, beginning as early as 2018-19. 22Montana State Medicaid HIT Plan (SMHP) Update

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The Veterans Health Information Exchange (VHIE) began in 2009, as part of the Virtual Lifetime Electronic Record (VLER) initiative. VHIE is a national query-based exchange designed to share Veterans’ health information electronically, safely, and privately between VA, Department of Defense (DoD), and selected private health care facilities that are members of the secure Nationwide Health Information Network. VHIE has over 150 community partners nationwide and is growing. VA Montana has local community partner presence in the Missoula and is looking to gain additional partners in 2018.The Department of Veterans Affairs announced a major upgrade to its electronic health record system. The upgrade will shift the VA from an in-house legacy architecture to a commercial solution set, bringing it in line with DoD practices.In addition to integrating with DoD systems, the VA needs to coordinate with academic affiliates and community partners, while also engaging VA clinicians in the implementation of the new system. Enhanced interoperability is essential to a seamless experience for Veterans whenever and wherever they receive care. All VA Montana Community-Based Outpatient Clinics use the VA EHR system. Centers for Disease Control (CDC)

The CDC is the liaison for the development and operations of Immunization Information Systems (IIS) for the U.S. Department of Health and Human Services. The CDC develops strategies and policies related to IIS as well as reviews funding requests, acquisition documents, and sponsors training, initiatives, and programs.State Partners

State partners engaged in HIT/EHR activities within Montana include: Health Technology Services (HTS) North Central Montana HealthCare Alliance (NMHA) Monida Healthcare Network Montana Primary Care Association (MPCA)

Health Technology Services (HTS)

Health Technology Services, a department of Mountain-Pacific Quality Health (MPQH). Provides technical assistance, guidance, and information on best practices to support and accelerate health care providers' efforts to become meaningful users of EHRs help with meaningful use.Northcentral Montana Healthcare Alliance (NMHA)

Northcentral Montana Healthcare Alliance is a collaborative consortium of 14 healthcare facilities located in northcentral Montana. Members of the alliance include Montana’s largest tertiary hospital, a 49-bed rural hospital, a freestanding 23Montana State Medicaid HIT Plan (SMHP) Update

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nursing home, two Indian Health Service facilities, and ten Critical Access Hospitals (CAHs). The NMHA mission is to collaboratively develop strategies, synergies, relationships, products, and services, that will improve delivery, access, and quality, while controlling the cost, of not-for-profit healthcare in all Alliance member communities. Network partners include:

Montana Health Network Health Information Exchange of Montana, Inc. Monida Healthcare Network Montana Office of Rural Health/Area Health Education Montana Performance Improvement Network (PIN) Mountain-Pacific Quality Health

Monida Healthcare Network

The Monida Healthcare Network is a regional association of healthcare providers, governed by member physicians and hospitals serving residents of Montana and Idaho. Formed in 1996, the Monida Healthcare Network is a not-for-profit association consisting today of more than 550 providers, nine hospitals, and other healthcare providers in Montana and Idaho. Monida specializes in the recruitment and placement of healthcare professionals.Montana Primary Care Association (MPCA)

The MPCA is a non-profit organization dedicated to improving access to high-quality, community based, affordable primary health care in Montana. MPCA is the association of Montana’s community health centers, and works to support and increase Montanans’ access to excellent, patient-centered health care. MPCA provides training and technical assistance to health centers and works to improve access to health care for all, especially for underserved and vulnerable populations.

A6 SMA Relationships with other HIT/E Entities6. Does the SMA have HIT/E relationships with other entities? If so, what is the nature (governance, fiscal, geographic scope, etc.) of these activities?

Montana Medical Association (MMA)

The MMA is Montana's largest organization of physicians dedicated to improving patient care. MMA's mission is to serve their members as an advocate for the medical profession, quality patient care and the health of all Montana citizens. In February 2018, MMA released an HIE Feasibility Study Final Report and Articles of Incorporation and Bylaws for a proposed new HIE organization called “Big Sky Care Connect”. In late April 2018, the new organization was officially formed and registered with the Montana Secretary of State. The new organization is working on formally adopting the by-laws and setting up the permanent governing board. The 24Montana State Medicaid HIT Plan (SMHP) Update

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organization is working on establishing an agreement with DPPHS regarding the HIE work. The next step is the development of a sustainable formal HIE business plan. Behavioral Health Alliance of Montana (BHAM)

The BHAM unites addiction, mental health, and tribal behavioral health organizations as providers and reinforces behavioral health as a foundational component of Montana's healthcare system. The alliance meaningfully embraces the alignment and unification of behavioral health in Montana's greater health system and promotes availability and access to quality behavioral health education, prevention, treatment, recovery support and related services to people, families, and communities in need. The BHAM founding board consisting of two representatives from the children’s, adult, substance use and Native American groups.

A7 HIE Organization Governance Structure7. Specifically, if there are health information exchange organizations in the State, what is their governance structure and is the SMA involved? ** How extensive is their geographic reach and scope of participation?

A functional HIE does not exist in the State of Montana at this time. DPHHS, MMA, and other stakeholders are pursuing planning activities for the establishment of an interoperable statewide HIE. Please refer to Section B4 for additional information on the To-Be governance structure.

A8 MMIS Role in HIT and Coordination with MITA8. Please describe the role of the MMIS in the SMA’s current HIT/E environment. Has the State coordinated their HIT Plan with their MITA transition plans and if so, briefly describe how.

In 2010, Montana DPHHS released a Request for Proposal (RFP) for development and implementation of a new Medicaid Management Information System (MMIS). After three years, the project remained in DDI. In October 2015, the MMIS contractor announced that they would no longer be implementing an MMIS in Montana and the scope of their contract was reduced to implementation of the Pharmacy Benefits Management System (PBMS). Currently, the state MMIS consists of 48 legacy systems working with the previously referenced PBMS, and the recently implemented Premium Billing and Collections solution (which was procured to address a specific subset of requirements for financial services.) To address Montana’s continued need for a replacement MMIS, and CMS guidance for modular system implementations, Montana submitted an IAPD in September of 2016, outlining a series of procurements positioned to replace the current system 25Montana State Medicaid HIT Plan (SMHP) Update

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using a modular approach, known as Montana’s Program for Automating and Transforming Healthcare (MPATH). The plan outlined nine module procurements with additional components and services procurements to address the state’s needs. As of March 2018, the MPATH program procured a Premium Billing and Collections solution, a Population Health (Data Analytics and EDW) solution, a Provider solution in collaboration with the National Association of State Procurement Officers (NASPO), and has procurements in progress for Systems Integrator Services, Provider Services, and Electronic Visit Verification (part of the Care Management module). The Population Health Data Analytics component includes services that would replicate, on a small scale, HIE functionality to serve the SMA. The Population Health component, provided by Cerner Corporation, will aggregate provider and patient information from 27 data sources across the state, furthering the SMA’s ability to support timely, accurate information for improving access to healthcare and treatment outcomes for Montanans. Project kickoff for the Population Health Data Analytics component occurred March 6, 2018. The intention of DPHHS is to connect the Population Health component to a new statewide HIE when that is ready.Alignment with the MITA 3.0 SS-A

CMS released the initial MITA framework in 2005, to support states in improving their Medicaid programs, and has since refined the original process, adding assessment of the SMA’s maturity and capability in adherence with the Seven Standards and Condition in 2011. The MITA framework allows states to assess their current business processes and evaluate the level of automation and incorporation of technologies across the SMA. In early 2016, the SMA conducted a MITA 3.0 SS-A, with primary participation of the MPATH Program team, DPHHS program SMEs, and Public Knowledge. The State Self-Assessment and Roadmap were submitted to CMS in October 2016.As part of the MMIS Replacement procurement planning, the project team mapped the base and module-specific requirements to the MITA business areas, confirming consistency between the To-Be maturity scores and the requirement language. The intent is to transform the current Concept of Operations, one which is defined by the many siloed processes and data stored in disparate systems to one characterized by automation, coordination of processes, and data that is accessed from a central location.While the MITA SS-A progressed, DPHHS leadership participated in a series of planning sessions for the MPATH Program, developing and defining the vision, goals, and objectives of the modularity effort. From these sessions, guiding principles were captured for consideration throughout the modular replacement projects.

Table A4. Montana Healthcare Programs Enterprise Guiding Principles26Montana State Medicaid HIT Plan (SMHP) Update

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Montana Healthcare Programs Enterprise Guiding PrinciplesFlexible Enterprise Technology Platform

Implement flexible, rule-based, configurable systems/services to enhance decision-making, increase management efficiency and promote agile adaptability for new and evolving regulations, programs and initiatives.

Centralized Data Repository

Implement a centralized data warehouse and associated data analytics tools to enable real-time or near-time access to data, including clinical data and enhanced reporting, that meets changing business and management needs.

Business-driven Enterprise transformation

Business functions must drive technical solutions and the modular MMIS capability must be flexible to meet future needs, including new regulations, legislation, and innovations.

Process Automation

Automate manual processes and eliminate human intervention wherever possible. Utilize workflow tools to standardize business processes that guide internal and external users through process steps, activities, and tasks.

Data Integration and Interoperability

Promote reusable components by using open architecture, and adopting industry and national standards for interoperability, integration, and data exchange.

Data Consistency Across the Enterprise

Utilize a comprehensive data governance process to ensure consistent data management processes and policies across the Montana Healthcare Programs Enterprise. Provide data that is timely, accurate, usable, and easily accessible, to support analysis and decision making for healthcare management and program administration.

Progressive Technology

Implement services that will allow Montana to take advantage of progressive technology (access via mobile devices, mobile apps, instant messenger, etc.) to improve how they interact and communicate with members, providers, and contractors.

Member and Provider Centric Focus

Implement solutions that provide an easy to access and comprehensive portal for providers, members, and other stakeholders, and promote self-service functionality. For example, claims status and member eligibility inquiries. The solution would leverage role-based security to ensure that stakeholders have access to only the information required for their needs.

Cost Efficiency and Effectiveness

Implement a solution that supports future DPHHS desire to pay providers based on the quality of


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services, rather than the number of services, focus on the member outcomes, and efficiently process fee-for-service claims.

A9 Planning and Facilitation of HIE and EHR Adoption9. What State activities are currently underway or in the planning phase to facilitate HIE and EHR adoption? What role does the SMA play? Who else is currently involved? For example, how are the regional extension centers (RECs) assisting Medicaid eligible providers to implement EHR systems and achieve meaningful use?

DPHHS is facilitating HIT and EHR adoption in multiple ways. DPHHS has paid over $40,000,000 to providers and hospitals for initial adoption and meaningful use through MPIP. Also, DPHHS is modularizing the Medicaid enterprise. As part of this modernization, the MMIS is being replaced with multiple components. Interoperability is fundamental to the success of modular solutions. Population Health Management is one of the Medicaid enterprise components that aggregates patient data across multiple HIT solutions.DPHHS is leveraging a Cerner solution called Health-e-intent for integrating provider EHRs with the Medicaid enterprise. The direct connections between DPPHS and provider EHRs, using Cerner, are a subset of providers in Montana, but could eventually reach 45,000 members. DPHHS will establish direct connections with EHRs. DPHHS can leverage these interfaces to support the immunization registry and public health registries, among other benefits. The solution will have the ability to do bi-directional data pushes with DPHHS and will help support identifying quality measures and gaps in care. The intention of DPHHS is to connect the Population Health component to a new statewide HIE when that is ready.Currently, Montana lacks a statewide platform for HIE. Also, integration issues caused system issues. Internal stakeholders and providers have noted that a lack of HIE is a significant barrier to EHR adoption. However, several local HIEs are developing regional solutions to remove these barriers, including hospital networks. Both DPHHS and external stakeholders uniformly stated that a statewide HIE is a valuable proposition. A pilot effort is underway to serve as a launching pad for much broader use. A proof of concept pilot in Billings, Montana, among RiverStone Health, St. Vincent Health Care, Billings Clinic, and BCBS of Montana is gaining buy-in across the state. This pilot provides exchanging of patient information for care coordination across organizations. The Montana Medical Association supports this effort, and the 28Montana State Medicaid HIT Plan (SMHP) Update

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Montana Health Care Foundation contributed funding for planning. DPHHS leadership have been involved with planning efforts. Over one hundred stakeholders have been involved with planning efforts for a larger statewide HIE effort, including health systems, clinics, hospitals, provider associations, government entities, and payers. Stakeholders formed five workgroups in 2017: Governance, Clinical Quality, Privacy & Security, Business-Finance, and Technology. The group identified establishing a governing board as a crucial next step. The Billings pilot enables real-time exchange of health information and facilitating targeted clinical reports for patients across these organizations. These efforts are further described in the To-Be Vision section of this plan.HIEM is also exploring options for HIE. HIEM was formed as a not-for-profit corporation in 2006 by the following health care organizations:

Kalispell Regional Healthcare, Kalispell (Founding Member) Northern Rockies Medical Center, Cut Bank (Founding Member) Glacier Community Health Center, Cut Bank (Founding Member) Cabinet Peaks Medical Center, Libby (Founding Member) Northwest Community Health Center, Libby (Elected Member) St. Luke Community Hospital, Ronan (Founding Member) North Valley Hospital, Whitefish (Elected Member)

Initially, HIEM invested in a planned statewide HIE platform that eventually dissolved due to sustainability and other solution issues. HIEM’s mission is to advance the delivery of healthcare and education for Montana communities through partnerships and technological infrastructure. HIEM’s vision is to be a leading regional health information organization in the areas of connectivity, infrastructure, innovation and sustainability.One of HIEM’s first major projects was the development of a dedicated fiber optic healthcare network. HIEM received a $13.6M award through the Federal Communication Commission’s Rural Health Care Pilot Program in November 2007, and dedicated the first 185-mile fiber optic network over the Continental Divide in August 2012. In 2014, this award, along with a $2.4M (15%) required cash match provided by network partners, provided 425 miles of new fiber optics. HIEM is assessing efforts of the Lincoln County Health Alliance (LCHA) Project, which is funded by the HRSA Rural Health Network Development Planning Program Grant. HIEM will engage in strategic planning in support of leveraging a proven HIE solution in the future.LCHA’s mission is to improve population health in Cabinet Peaks Medical Center’s service area by creating a strategic plan that identifies and prioritizes the health needs of the community and the necessary steps to improve collaboration and coordination of HIE in Lincoln County. Planning meetings to explore HIE options are scheduled for June 2018. LCHA’s goals are to:29Montana State Medicaid HIT Plan (SMHP) Update

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Improve access to health information to better serve rural patients in the community in order to achieve population health.

Increase efficiency by aligning resources and strategies within the network to improve HIE across healthcare organizations and to expand telehealth services in the rural community.

Enhance care coordination and collaboration among members to move toward achieving the Triple Aim: Improving population health, improving patient experience of care, and reducing the per capita cost of healthcare.

Health Technology Services (HTS), a department of Mountain-Pacific Quality Health (MPQH), provides guidance and information on best practices to support and accelerate health care providers' efforts to become meaningful users of EHRs.

A10 State Relationship to the HIT Coordinator10. Explain the SMA’s relationship to the State HIT Coordinator and how the activities planned under the ONC-funded HIE cooperative agreement and the Regional Extension Centers (and Local Extension Centers, if applicable) would help support the administration of the Promoting Interoperability Program.

The State HIT Coordinator continues to direct providers to HTS. At this level of program maturity, HTS provides guidance and information on best practices to support and accelerate health care providers' efforts to become meaningful users of EHRs.

A11 Activities influencing the direction of the Promoting Interoperability Program11. What other activities does the SMA currently have underway that will likely influence the direction of the Promoting Interoperability Program over the next five years?

Montana is committed to the modularization of the Medicaid enterprise to promote interoperability across HIT solutions and integration of EHR into the Medicaid enterprise. DPHHS will also support MMA and others in their planning efforts to determine the feasibility and sustainability of a statewide HIE platform. These major tasks are key factors that will influence the direction of the EHR program over the next five years.


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A12 Changes to State law or regulations12. Have there been any recent changes (of a significant degree) to State laws or regulations that might affect the implementation of the Promoting Interoperability Program? Please describe.

No significant changes in Montana laws or regulations have been identified that would impact the MPIP.

A13 HIT/E Activities that Cross State Borders13. Are there any HIT/E activities that cross State borders? Is there significant crossing of State lines for accessing health care services by Medicaid beneficiaries? Please describe.

DPHHS supports efforts to establish HIEs with the potential to grow into a statewide solution. DPHHS will enter into reciprocal data exchange agreements with surrounding states when necessary to promote compilation of complete patient health information records. DPHHS will reevaluate the need for these agreements in the future.Also, providers serving in Montana may include Medicaid patients from border states in determining MPIP eligibility. Similarly, states bordering Montana will have access to Medicaid eligibility and patient volume information to verify corresponding data for providers relying on Montana’s Medicaid information for their MPIP. There are some bordering state providers that may cross state boundaries, including northern Wyoming and parts of Idaho.

A14 Interoperability of the Immunization Registry and Public Health Surveillance reporting database14. What is the current interoperability status of the State Immunization registry and Public Health Surveillance reporting database(s)?

The State Immunization Information System (IIS), imMTrax provides the framework to increase provider participation via electronic interfaces and increase public health’s role in federal and State HIT initiatives. The imMTrax system receives batch files from providers that are subsequently loaded into the registry. Currently, imMTrax supports 48 active interfaces, including 13 hospitals and 146 clinic locations. All but two interfaces are compliant with HL7 Messaging Standards Version 2.5.1, for electronic data exchange in healthcare. In 2016, DPHHS was awarded the Capacity Building Assistance for Infrastructure Enhancements to Meet Interoperability Requirements grant.


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The DPHHS Immunization Program will coordinate efforts to continue its expansion of health information exchange under the direction of Dr. Gregory Holzman, State Medical Officer.Public Health Surveillance

DPHHS has several public health surveillance systems that help support provider EHR meaningful use payments:

National Electronic Disease Surveillance System (NEDSS) Immunization Registry Cancer Registry Syndromic Surveillance

National Electronic Disease Surveillance System (NEDSS)

DPHHS works with hospitals, clinics, and laboratories to report diseases that are mandated. All disease information is entered into a database at the local level and electronic laboratory reports (ELR) are captured through the National Electronic Disease Surveillance System (NEDSS). ELR results are sent to the CDC. The State reports that 60% of hospitals utilize electronic reporting. In addition, large reference labs use ELR.Below is the list of laboratories that are sending ELR to the Montana Infection Disease Information System (MIDIS). Thirty-three are live out of an estimated 65 on DPHHS’s ‘target list.’ However, with the exception of St. Peters, Kalispell Regional Medical Center (KRMC), and Community, DPHHS has captured most of the large hospitals in population centers. The three remaining are currently testing with the goal to reach go-live in 2018.

Table A5. Healthcare Providers Utilizing ELRHospitals and Clinics Laboratories

Barrett HospitalBeartooth Billings ClinicBenefisBillings ClinicBozeman HealthClark Fork Valley HospitalCommunity Hospital of AnacondaDaniels Memorial HealthcareDeer Lodge Medical CenterGlendive Medical CenterHoly Rosary HealthcareLivingston HealthcareMarcus Daly MemorialPioneer Medical Center

ARUPLabCorpMayoMTPHLPAMLQuestSanford Laboratories


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Hospitals and Clinics LaboratoriesPoplar CommunityRoundup MemorialSheridan MemorialSidney Health CenterSt. James HealthcareSt. Joseph Medical CenterSt. Patrick HospitalSt. Vincent HealthcareStillwater CommunityTrinity HospitalWheatland Memorial

Immunization Registry

The State Immunization Registry, imMTrax, is Montana-specific. The system will be upgraded to a national solution in approximately four months. The solution is used to support meaningful use reporting for providers. The solution maintains records on over one million Montanans. To date, DPHHS has 48 unique interface connections that include 179 provider sites sending immunization data. There are 44 remaining organizations in the queue that are at different points in the onboarding process. DPHHS plans to use the Cerner Health-e-intent solution to facilitate population of the immunization registry with participating provider EHR data.Cancer Registry

DPHHS uses a program called Rocky Mountain Data Systems. Meaningful use requires that physicians’ offices report through the registry. DPHHS has experienced challenges getting providers connected to this system. Currently, there is one physician group with a secure connection to the registry. DPHHS is also gathering cancer registry information from cancer centers and labs. If a provider uses a system separate from the State, they must submit information through the Montana file transfer system utilizing a set data layout and must do so on a monthly basis. The CDC provides a portal, the Public Health Information Network Messaging System (PHIN-MS), for all labs and states to use to collect and upload information to the cancer registry.Syndromic Surveillance

DPPHS obtains data from the Syndromic Surveillance reporting system. Facilities in Montana, Critical Access Hospitals, and some of the larger hospitals share de-identified visit data. This solution supports MU for hospitals. Syndromic surveillance data are anonymous and sent to DPHHS on a daily basis from 34 facilities in Montana. Due to the pre-diagnostic and real-time nature


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of syndromic surveillance, public health events of interest can potentially be identified before other surveillance methods. DPHHS estimates that they collect information from 50% of desired facilities, which comprise approximately 90% of state ER visits due to their size.

A15 HIT-related Grants15. If the State was awarded an HIT-related grant, such as a Transformation Grant or a CHIPRA HIT grant, please include a brief description.

In Montana’s previously approved SMHP, version 1.2, DPHHS described several HIT grants received. DPHHS has since been awarded the State Innovation Model Grant and the Transformation Grant. These grants are described in this section. State Innovation Model Grant

In December 2014, the State was awarded a State Innovation Model (SIM) Grant through CMS to engage a diverse group of stakeholders, including Medicaid, private payers, providers, and citizens, to develop a State Health Care Innovation Plan. One of the planning deliverables for this Grant was a HIT Transformation Plan. The SIM Grant prioritized HIT and HIE development. Transformation Grant

From 2011-2014, DPHHS Chronic Disease Prevention and Health Promotion Bureau was awarded a Community Transformation Grant (CTG) through the CDC. This five-year grant focuses on community-level efforts to reduce chronic diseases by promoting healthy lifestyles. Montana’s designation for this grant is 'rural' and is focused on the following areas:

Tobacco Free Living Active Living and Health Eating Clinical and Other Preventive Services Healthy and Safe Environment

DPPHS is focusing on the current HIT infrastructure within the Medicaid enterprise, leveraging federal funding through CMS to support the MPIP and MPATH programs. In addition, federal funding is available to support statewide HIE efforts as described in Section 3. HIT implementation and MPIP grant funds are listed in the table below. HIT Implementation grant funding is for administrative costs associated with the MPIP.

Table A6 – DPHHS HIT Implementation and Administrative Grant fundsHIT Implementation HIT Incentive FFY 2017 Grants Awards $ 449,388 FFY 2017 Grants Awards $5,916,846 FFY 2017 Spent - Qtr 1 FFY 2017 Spent - Qtr 1


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HIT Implementation HIT Incentive $106,110 $454,711

FFY 2017 Spent - Qtr 2

$105,200 FFY 2017 Spent - Qtr 2

$936,735


$188,860 FFY 2017 Spent - Qtr 3

$1,446,326


$49,218 FFY 2017 Spent - Qtr 4

$3,079,074

$449,388

$5,916,846 FFY 2018 Grants Awards (to date)

$393,000

FFY 2018 Grants Awards (to date)

$ 787,000


$87,112 FFY 2018 Spent - Qtr 1

$420,194

FFY 2018 Spent - Qtr 2not yet

reported FFY 2018 Spent - Qtr 2not yet

reportedFFY 2018 Spent - Qtr 3 FFY 2018 Spent - Qtr 3 FFY 2018 Spent - Qtr 4 FFY 2018 Spent - Qtr 4

$87,112 $ 420,19

4


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Section B: The State’s To-Be LandscapeDPHHS’s overall goal is to improve access to healthcare and treatment outcomes for Montanans. Based on stakeholder interviews, DPHHS identified four HIT and HIE objectives for the To-Be Landscape that align with this broader goal. DPHHS HIT and HIE goal, vision, and objectives are based on common themes and priorities identified by DPHHS and stakeholders across the state.High-level HIT and HIE Vision: Leverage HIT to improve the healthcare and treatment outcomes for Montanans.

Table B1 – State-Level HIT ObjectivesState-Level HIT Objectives

Objective 1: Implement modular systems and services to modernize the Medicaid Enterprise. Objective 2: Develop a sustainable statewide HIE solution for use by multiple stakeholders across the State.Objective 3: Utilize data analytics to inform treatment, payment, and outcomes for healthcare.Objective 4: Leverage HIE to encourage meaningful use of EHRs.

This section provides details of the HIT and HIE vison for the state based on these priority objectives. Montana aims to improve healthcare outcomes across the state by achieving these objectives. DPHHS is both a facilitator and key participant in meeting statewide HIT and HIE objectives.

B1 HIT/E Goals and Objectives1. Looking forward to the next five years, what specific HIT/E goals and objectives does the SMA expect to achieve? Be as specific as possible; e.g., the percentage of eligible providers adopting and meaningfully using certified EHR technology, the extent of access to HIE, etc.

DPHHS is collaborating with a broad range of stakeholders to support HIT and HIE objectives for internal department efforts, and statewide efforts. This section provides the details of these objectives, including those that are led by DPHHS.Objective 1: Implement modular systems and services to modernize the Medicaid Enterprise. DPHHS is adopting a modular approach to deploying new systems and services for Medicaid modernization efforts. DPHHS is procuring best of breed solutions and 36Montana State Medicaid HIT Plan (SMHP) Update

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services to meet the “To Be” business objectives defined in the Montana MITA 3.0 SS-A. DPHHS believes this approach expands the pool of Medicaid Enterprise system vendors as opposed to the traditional “big-bang” MMIS implementations. The modularity component/services blend approach is also aligned with CMS Standards and Conditions. The Medicaid enterprise modernization program for the DPPHS, MPATH, is positioned to achieve the following objectives:

An enterprise system that is flexible to quickly adapt to the dynamic, evolving needs of existing programs and support new regulations, policies and innovations

An enterprise system founded on business-driven technical solutions An enterprise system where business processes are automated wherever

possible An enterprise system that provides centralized access to data An enterprise system that includes data analytics tools to support the use of

clinical data to measure treatment outcomes and the changing health status of members.

An enterprise system that includes standardized and automated electronic communication and data exchange capabilities

An enterprise system that includes a Master Client Index (MCI) An enterprise system that integrates data from disparate systems to enable

enterprise wide-program managementDPHHS developed an MPATH modularity blueprint as a result of strategic planning sessions with stakeholders, guidance received from CMS, discussions with industry vendors, and a view of the national landscape. This blueprint is shown in figure B1 below. In addition, a description of key modular solutions and services follow the blueprint.


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Figure B1 – MPATH Modularity Blueprint

The MPATH program modules and module components are described below.Provider Services (PS): DPHHS will obtain a Provider Services module. The Provider Services vendor will provide a modern, web-based self-service solution that allows healthcare providers (which includes but is not limited to; physicians, hospitals, nursing homes, pharmacies and durable medical equipment) to enroll with Montana Healthcare Programs to provide healthcare services to thousands of Montanans covered by these programs. The solution will also allow providers to view and maintain their information on file (e.g., address, licensure and group affiliations) and revalidate their enrollment details online.Enterprise Data Warehouse (EDW): DPHHS will implement an EDW for the Montana Healthcare Programs enterprise. The EDW will serve as a central repository for all Montana Healthcare Programs Enterprise data and provide decision makers with timely access to accurate and consistent information. The EDW will provide integrated program data which will provide the State's Medicaid Program with enhanced abilities to gain insights into outcomes and anticipate future needs.Data Analytics Services and Tools (DA): DPHHS will obtain DA Services and Tools for integration with the centralized EDW repository. It will enable the creation of comprehensive statistical profiles of healthcare delivery and utilization by both 38Montana State Medicaid HIT Plan (SMHP) Update

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providers and members. These tools and services will facilitate comprehensive analytical reporting, budgeting, forecasting, and daily program monitoring.Financial Support Services (FSS): DPHHS will obtain an FSS module. This will translate information received from the various Montana Healthcare Programs systems (including multiple payer systems) and assign DPHHS-defined account coding for integrated financial reporting. It will serve as an intermediary between the department’s payment systems and the State of Montana’s Statewide Accounting, Budgeting and Human Resource System (SABHRS) and Accounts Receivable Management System (ARMS). It will support financial transaction processing and reconciliation for both claims and non-claims expenditures.Claims Processing and Management Services (Claims): DPHHS will obtain a Claims Processing and Management Services module. This module will support the receipt, adjudication and editing, pricing (using Montana Healthcare Programs approved reimbursement methodologies), and payment for health care claim types including (but not limited to): physician, hospital, outpatient, nursing home, dental, vision, transportation, disability services, mental health, and waiver services. During claims adjudication, this module will also process service authorizations, third party insurance liability, and calculate member liabilities including cost share and cost share coordination between multiple payers. This module will be configurable and flexible to support claims processing for multiple programs. Claims will be adjudicated in “real-time” and process payments and remittance advice daily (or at an interval determined by the state).Care Management Services (CM): DPHHS will obtain a CM services module. This module will support activities to improve member healthcare outcomes and reduce healthcare costs for Montana Healthcare Programs by helping members and caregivers manage health conditions effectively. The care management module will include workflow to identify members for specific programs, coordinate care for members enrolled in individual or multiple care management programs and collect and report on treatment outcomes. The solution will need to support member outreach, configurable development of assessments, capturing and monitoring assessments and screenings, treatment plans, authorize services, and incident management and reporting. It will provide comprehensive case management and workflow to track a member’s care from inception to conclusion with the tracking of key events being triggered based on the member’s condition or type of services required.Customer Care Services (CCS): DPHHS will obtain a CCS module. This module encompasses all aspects of the customer care experience for Montana Healthcare Programs providers and members before or following their enrollment in the department's healthcare programs. The Contractor is expected to provide a comprehensive suite of services, tools, and systems necessary to promote a 39Montana State Medicaid HIT Plan (SMHP) Update

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positive customer care experience. Provider and member self-service supplemented by call center support is key to a successful and positive customer experience. Provider and member data will be available through a variety of secure customer self-service options such as website, mobile apps, and social media. Real-time account information will be accessible securely using various devices such as computers, tablets, and smartphones. Provider and member self-service options will be available across all platforms and provide a positive, comprehensive and seamless experience for all users.Pharmacy Claims Processing and Management Services (PBMS): FlexibleRx, the PBMS module is an online, real-time pharmacy claims adjudication system. FlexibleRx was implemented December 2015, as the first legacy replacement module within the Montana Healthcare Programs enterprise. CMS certified FlexibleCMSRx on February 15, 2017. FlexibleRx receives member eligibility and provider information from the legacy MMIS. Adjudicated claims are sent to the MMIS for payment generation to providers.Quality Assurance/Quality Control Testing Services (QA/QC): DPHHS will obtain a QA/QC testing services vendor for comprehensive functional and non-functional testing, integration testing, parallel testing, and user acceptance testing support throughout each phase of the system development lifecycle for each module. The QA/QC testing services vendor will utilize testing tools and testing databases provided by the module contractors for concurrent testing and other activities throughout the project.Pharmacy Support Services (PSS): The PSS module encompasses two objectives. DPHHS will procure new components to replace the legacy Drug Rebate Analysis and Management System (DRAMS) and Retrospective Drug Utilization Review (RetroDUR) systems. To reduce the dependency on FlexibleRx, the pharmacy claims processing and management system on the existing legacy MMIS, the current pharmacy claims processing and management services contractor, Conduent will complete enhancements to integrate multiple services including member eligibility, provider, financial transaction processing, and centralized data storage and reporting into the MPATH integration platform.Objective 2: Develop a sustainable statewide HIE solution for use by multiple stakeholders across the State.DPHHS and external stakeholders believe a statewide HIE will promote further adoption of EHR and other HIT across the state. Stakeholders anticipate that EHR adoption could grow to close to 100% with the implementation of a statewide HIE. However, the HIE must be self-sustaining to achieve long-term success and to fully realize EHR benefits. There are four major initiatives noted by DPHHS and stakeholders for HIE:


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HIE pilot ("Billings Pilot"): This proof of concept project is a private venture pilot involving three healthcare providers and one payer in Billings, Montana. This two-year proof of concept HIE focused on five quality measures and super-utilizers.

Big Sky Care Connect: This is the new organization working towards establishing a new statewide sustainable interoperable HIE. The planning of the organization and the model for the new HIE is patterned on the successful MyHealth Oklahoma HIE.

DPHHS Health-e Intent: This is a solution procured by DPHHS as part of a broader scope of work for data analytics (Population Health) as described in Objective 3 of this section. DPHHS intent is to eventually leverage a statewide HIE as the point of integration for providers. The Health-e Intent solution will have the ability to do bi-directional data exchanges with DPHHS and will help support identifying quality measures and gaps in care.

HIEM: HIEM’s vision is to be a leading regional health information organization in the areas of connectivity, infrastructure, innovation and sustainability. HIEM is interested in strategic planning in support of leveraging a proven HIE solution. HIEM is closely watching efforts out of the Lincoln County Health Alliance (LLCHA)) Project, which is funded by the HRSA Rural Health Network Development Planning Program Grant.

These four efforts are described in further detail below.HIE Pilot ("Billings Pilot")

Private entities have started forming local HIEs within the State. The Billings Clinic, St. Vincent Healthcare, RiverStone Health, and BCBS focused on specific use cases with the potential to expand into a statewide HIE. The pilot enables real-time exchange of health information and facilitating targeted clinical reports for patients across these organizations. Big Sky Care Connect

The Montana Medical Association led an effort starting in 2017 to reform a statewide HIE. The effort had assistance and guidance from Dr. David Kendrick and is modeled on the process that Oklahoma went through to re-establish their statewide HIE after the first one was not successful. The MMA formed a working group of stakeholders from various providers, organizations, and the state. The stakeholders then formed five workgroups to work through various aspects of establishing a new HIE. These workgroups were Governance, Clinical Quality, Privacy & Security, Business-Finance, and Technology. The stakeholder group then identified establishing a governing board as a crucial next step. A new entity from this effort was formed in late April 2018 called “Big Sky Care Connect”41Montana State Medicaid HIT Plan (SMHP) Update

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Based on a market analysis that was done as part of the stakeholder group research, the business-finance workgroup believes the HIE could be sustainable through a subscription-based HIE. The initial sustainability target is approximately three million with an estimated market potential of around 22 million. The overall stakeholder group identified the following key value propositions for providers:

New Revenues: closing care gaps; market analytics to optimize service delivery; quality track/report for value-based payment models; access to alternative payment models; better infrastructure for at-risk payment models; enhanced provider recruitment and retention.

Cost and Loss Avoidance: reduce 30-day readmit penalties; avoid costly patient safety penalties; avoid unnecessary/costly duplication; reduce HIT costs; integrate medication reconciliation/prescription drug registry; business continuity/disaster recovery resource; community health needs assessment.

Better Care: behavioral health integration; empower telehealth; coordinate social determinants; better emergency response; reduced radiation exposure; natural disasters/emergencies; avoidable adverse drug events; closed care gaps; better care coordination; public health improvements.

DPHHS Health-e-intentHealth-e-intent is a solution from Cerner procured through DPHHS as part of a broader scope of work for data analytics (Population Health) as described in Objective 3 of this section. DPHHS is leveraging the Health-e-intent solution for integrating provider EHRs with the Medicaid enterprise. The direct connection between DPPHS and provider EHRs supports a subset of Montana providers with the potential to eventually reach 45,000 members. The direct connection eliminates the need to rebuild interfaces to support the immunization registry and public health registries. The solution will also have the ability to facilitate bi-directional data exchanges with DPHHS and help support the identification of quality measures and gaps in care. The initial implementation is planned for July 1st of 2018, for providers already using a Cerner EHR solution with integration of all participating providers over a period of 12 months. 40% of the hospitals use the Cerner solution and five additional solutions we will be connecting for an additional 15-20 entities. DPHHS intention is to connect the Health-e-intent platform to the new statewide HIE when that is available. With funding for provider EHRs to drop over the next three years, DPHHS will be poised to encourage EHR adoption through Health-e-intent and coordination with the new statewide HIE. Changes to policy will be required to support electronic reporting of clinical quality measures through provider EHRs. This arrangement positions DPHHS to leverage electronic quality measures in support of value-based payments.42Montana State Medicaid HIT Plan (SMHP) Update

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Objective 3: Utilize data analytics to inform treatment, payment, and outcomes for healthcare.DPHHS released an RFP in August of 2017, to obtain Population Health Data Analytics Services and Tools (Population Health) to support predictive modeling and to identify member risk for care management related activities. The Population Health Data Analytics Services and Tools is one of multiple COTS solutions planned to support multi-dimensional data analytics necessary as part of Medicaid modernization efforts. The data analysis solutions will support statistical profiling of healthcare delivery and utilization for both providers and members for population health management. Additionally, these tools and services will provide comprehensive analytical reporting, budgeting, forecasting, and daily program monitoring. The project kicked-off in March 2018. DPHHS intends to release one or more RFPs for the remaining Data Analytic Components in January 2019, and anticipates project kickoff in June 2019.Initially, the Population Health Data Analytics solution will receive data files from the Montana Healthcare Programs Legacy system. Providers that leverage Cerner's EHR solution can integrate with the Health-e-intent solution. At a later date, the Population Health Data Analytics solution will be integrated with the EDW, Montana Healthcare Programs centralized data repository. It will also be integrated with the new statewide HIE when that it available. Population Health Data Analytics solution will replace existing legacy components and services including a Windows server/workstation-based application used to analyze Montana Healthcare Programs claims data for predictive modeling and to identify member risk for care management related activities. The Population Health Data Analytics services and tools will provide Montana Healthcare Programs Administration with information necessary to improve the overall health and quality of care for Montana Healthcare Programs members while identifying opportunities to lower costs. The solution shall be configurable to accommodate standardized, proven, and nationally accepted population health measures. The solution shall allow measures to be retired and accommodate new measures. The Population Health Data Analytics Contractor will provide a comprehensive population health management solution that includes standard and configurable quality measures, utilization statistics, provider and member profiles, and other required criteria. The solution will exchange healthcare, prevention, prescription drug, disease management, behavioral and mental health, and substance abuse data with a variety of sources (e.g., Enterprise Data Warehouse, Provider EHRs, and statewide HIE). The Population Health Data Analytics solution will also have the ability to perform complex analytical reporting and analysis through a collection of 43Montana State Medicaid HIT Plan (SMHP) Update

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standardized reports as well as ad hoc reporting. The solution will be able to identify gaps in patient care and send notification to the appropriate MPATH module (e.g., care management).The Population Health Data Analytics services and tools will provide Montana Healthcare Programs Administration with information necessary to improve the overall health and quality of care for Montana Healthcare Programs members while identifying opportunities to lower costs. The solution shall be configurable to accommodate standardized, proven, and nationally accepted population health measures. The solution shall allow measures to be retired and accommodate new measures. HIEM

The HIEM Network connects over 20 hospitals and clinics to medical technology networks in Montana. In addition, it expands connectivity for professional healthcare education through the University of Montana, Salish Kootenai College, Flathead Valley Community College, and Montana State University College of Nursing. HIEM also has a high priority for increasing access for telemedicine and professional education programs to rural and frontier communities and partners with KRMC to provide telehealth services using the network.With a secure, fiber optic network infrastructure in place, HIEM is now focusing on new initiatives such as offering commodity internet service to members. With the advances in interoperability technology, HIEM hopes to explore new initiatives to improve health information exchange in the future. In collaboration with LCHA stakeholders, HIEM is planning meetings to explore HIE options are scheduled for June 2018. LCHA plans to instill a sustainable model for improving frontier population health by:

Building committed partnerships Achieving optimal patient experiences and outcomes Advancing access to secure health information Enhancing care coordination and collaboration Utilizing technology to enhance access to care Improving efficiency by aligning resources and strategies

Objective 4: Leverage HIE to encourage meaningful use of EHRs.Within the next five years, DPPHS and external stakeholders would like EHR adoption by providers and hospitals to be close to 100%. The focus on statewide HIE efforts and integration of EHRs with public registries should promote further adoption across the state.


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By enhancing the State’s HIT and HIE infrastructure and interoperability, this provides a foundation for providers across the state for meeting meaningful use. Additional tasks to support this include the following:

Continue to conduct provider outreach, including MPIP Provider Outreach website updates and communications.

Encourage providers to participate in current HIE planning efforts, such as the Billings Pilot, the Big Sky Connect HIE, and the Health-e-intent project.

Support the creation of a governance structure, business plan, and communication plan for statewide HIE.

Provide technical assistance to assist Medicaid providers seeking to create interoperable connections.

While a wide range of hospitals and providers, especially rural providers, have not fully adopted EHRs, stakeholders suggest that all hospitals will meet MU, and the broad majority of provider practices will adopt EHRs.

B2 IT System Architecture2. What will the SMA's IT system architecture (potentially including the MMIS) look like in five years to support achieving the SMA's long-term goals and objectives? Internet portals? Enterprise Service Bus? Master Patient Index? Record Locater Service?

DPHHS’ vision for information technology is outlined in Section 4, IT Principles, of the Information Technology (IT) Plan published in 2016 (IT Plan). The IT Plan states:

The department is moving away from monolithic and outdated legacy systems toward a vision of web-based, people-friendly, and interoperable systems. Enterprise Service Oriented Architecture (SOA) is the centerpiece of this shift from the present to the future. This architecture will allow separate, standalone systems to communicate using exposed, shared services through a common shared architecture and service bus. Users will be able to seamlessly access data from multiple systems, and errors associated with redundant data entry will be reduced. Enterprise SOA is reshaping and improving the way the department serves Montanans and does business.The department employs SOA for system interoperability that takes advantage of Commercial Off-The-Shelf (COTS) products and allows for the reuse of system components across business functions as services. SOA is an approach to loosely coupled, protocol independent, standards-based distributed computing where software resources expose their functionality as services and are available across the network. The department has implemented a data exchange service bus that provides interoperability that makes use of multiple industry standards, including ASC X12, HL7 (V 3), XML,


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XSLT, WS-I, WSDL, SOAP, UDDI, and WS-BPEL. The department’s current and future system replacement projects will be required to align with these standards. The department will also require third-party contractors to exchange data with the department via web services using the appropriate standards like ASC X12.The department also plans to collect and store data from multiple systems for decision support. The department is working on an enterprise data warehouse and data marts that will allow data mining and analytics. This service is essential in the assessment of program performance and efficacy, particularly for evaluating the impact and correlation of services from multiple programs and agencies over time, as it affects a single client or a population. Accordingly, internally and externally hosted systems will have the capability to transmit data to a data warehouse and other databases within the department using the department's Enterprise Data Exchange. A data mart and basic data analytics service has been implemented as part of the department's enterprise services. Finally, for future healthcare systems, the department follows the federal guidance on the Medicaid Information Technology Architecture (MITA) principles that are associated with high-quality software systems (e.g., scalability, adaptability, securability, availability, manageability, and interoperability) as the basis for the system architecture. To this end, the department is currently replacing its legacy Medicaid Management Information System (MMIS) with one that is fully aligned with the MITA standards and the new CMS Modular rules and guidance. The department intends to continue to adhere to the MITA roadmap for controlled and strategic transformation for all programs and systems where appropriate.


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Figure B2 – Montana Enterprise Service Bus Vision

Systems Integration ServicesA systems integration services contractor is being procured to support interoperability and enterprise integration, technical coordination of component implementations, and data management for Montana Healthcare Programs. The Systems Integration Services Contractor will establish the MPATH integration platform and the integration framework for standards established by the DPHHS Enterprise Architecture Committee. The integration framework will enable the seamless integration of various modularity components including COTS software, Software as a Services (SaaS) solutions, and other modules. The integration framework will include the configuration, support and maintenance of an enterprise service bus (ESB), transformational services, and protocol services. The systems integration services contractor will assist with the development of standards for architecture, interfaces, and data for each modularity project, including the data coming in through the ESB into the operational data store and


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eventually transformed into the EDW and other modules. The high-level scope of the systems integration services contractor includes the following components:

Systems Integration and Oversight: The systems integration services contractor will coordinate and oversee architecture planning, development, and testing efforts across the various components of the modularity project, including the integration of healthcare data (e.g., member, provider, and claims data) from MPATH modules and other Montana Healthcare Programs enterprise systems.

Enterprise Service Bus: The MPATH integration platform will include an ESB to serve as the primary gateway to access services and data from other modules/module components. The ESB is needed to support interactions among the modularity components to intelligently route data flowing through enterprise components, adapting and transforming that data as required by various systems. The ESB will provide an SOA and standards approach that promotes data sharing and interoperability.

Operational Data Store (ODS): The operational data store will provide a central repository of Montana Healthcare Programs data to serve day-to-day operational needs. Data sharing will be brokered through the ODS.

Interface Integration: The systems integration services contractor will design, develop and maintain standardized enterprise interfaces that require minimal customization that enhance the ability to rapidly deploy applications, integrate legacy applications and share data across multiple Montana Healthcare Programs enterprise components. The contractor’s systems integration services will provide composite business service and process orchestration via the MPATH integration platform.

Additionally, the systems integration services solution will create, send, receive and process a number of standard transaction types (e.g., X12, FIRE, HL7, and NCPDP D.0) to support the exchange of data between MPATH modules/module components via the MPATH integration platform. The systems integration services contractor will provide integration planning and technical services to support the transition of legacy services and components to MPATH. DPHHS, the systems integration services contractor and the legacy fiscal agent contractor will work collaboratively to plan the integration of new modules while retiring the corresponding legacy functionality (e.g., the implementation of the Care Management module will require strategic coordination and timing to ensure the MPATH Integration Platform can provide data to the legacy system necessary to support claims processing and the fiscal agent can make the necessary modifications to the legacy MMIS to receive care management data from the MPATH Integration Platform and disable legacy functions that will be performed in the new module).


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Other functionally provided by the systems integration services contractor are described below. Single Sign-On/Identity Access Management: The Systems Integration Services Contractor will provide a product solution for the authentication and authorization component of the MPATH Integration Platform. This will include exposing a bi-directional interface between the authentication service and the authorization product so that user information can flow between the two components. The Systems Integration Services Contractor will also expose a bi-directional interface between each of the other modules so that authorization information can flow between the components. The authorization product shall store user role information as defined by DPHHS. The Systems Integration Services solution will need to maintain and synchronize this information with the other Module Contractors. Other MPATH Module Contractors will be responsible for storing, maintaining, and synchronizing user role information in their systems; the source of that user role information will be the authorization product.Integrated Customer Access Portal: The Systems Integration Services solution will provide a comprehensive Integrated Customer Access Portal (ICAP). The ICAP will facilitate authentication and authorization (using Single-Sign-On/Identity Access Management described below) of MPATH users and provide centralized navigation to all MPATH module components, assigned work, project dashboards, and notifications/system messages. Electronic Signatures Acceptance and Management: An electronic signature acceptance and management process will be integrated into the system. This process should be automated and may include a software component that enables the association of an “electronic signature” to an action, document, or record that is verifiable and adheres to Montana security requirements.Master Client Index (MCI): The System Integration Services solution will provide a Master Client Index (MCI) The MCI will accept eligibility from various sources and will support the receipt and creation of eligibility transactions (e.g., X12 834). Member eligibility data stored in the MCI will be exchanged with MPATH modules to facilitate Montana Healthcare Programs business processes. Master Provider Index (MPI): The solution is also expected to include a Master Provider Index (MPI) that includes standardized unique identifiers for providers across the Montana Healthcare Programs enterprise that prevents the creation of duplicate records and includes interfaces to easily match providers from other systems.Business Rules Engine: A business rules engine is anticipated to be included with System Integration Services and the claims processing solution.


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B3 Medicaid Provider Interfaces3. How will Medicaid providers interface with the SMA IT system as it relates to the Promoting Interoperability Program (registration, reporting of MU data, etc.)?

The DPHHS provider outreach homepage serves as the Medicaid providers' primary Promoting Interoperability Program interface tool for applying for the provider incentive payment and obtaining supportive resources throughout HIT transition. The provider outreach home page provides accurate, consistent information to providers and centralizes the national, state, and regional links for additional program information. It also serves as the provider portal to access the Montana SLR. In support of Montana DPHHS vision to improve access to health care and quality of health care for Montanans, the provider outreach home page offers the following:

A centralized “one-stop” launching pad of available tools for managing eligible provider and hospital Promoting Interoperability Program information

A secure portal to access the MT SLR Organized information offering real-time feeds of current HIT news and

updates from other federal organizations such as CMS Notification of planned changes associated with the Promoting

Interoperability Program

B4 Future HIE Governance4. Given what is known about HIE governance structures currently in place, what should be in place by five years from now in order to achieve the SMA's HIT/E goals and objectives? While we do not expect the SMA to know the specific organizations will be involved, etc., we would appreciate a discussion of this in the context of what is missing today that would need to be in place five years from now to ensure EHR adoption and meaningful use of EHR technologies.

One of the primary objectives for the state is to establish a statewide HIE. For the Big Sky Connect organization, champions helped to establish a non-profit, multi-stakeholder framework. One of the primary next steps is to develop a sustainable business plan and governance framework. In parallel, the Population Health solution is a potential launching pad for broader connectivity in the State. For either initiatives or other regional HIE, stakeholders must be thoughtful in establishing a sustainable HIE framework.A critical success factor for a successful HIE is to establish a multi-stakeholder governance structure to include payers, providers, and some citizen representation. DPHHS’s guidance to developing the governance framework has been to start 50Montana State Medicaid HIT Plan (SMHP) Update

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simple and build out the framework in an iterative way as additional use cases are identified. Given the pilot approach to the forming HIEs, nimble governing bodies could encourage efficient decision-making. Stakeholder roles in the governance framework should focus on use cases, such as hospital admits and discharges. Stakeholders should be able to join the governance structure quickly, but also be released if a use case becomes obsolete. Following a successful business model like Oklahoma is a key factor in the potential success of a new statewide HIE.

B5 SMA Planning over the next 12 Months5. What specific steps is the SMA planning to take in the next 12 months to encourage provider adoption of certified EHR technology?

DPHHS will continue to promote the adoption of certified EHR technology through their program website, http://mt.arraincentive.com. The provider outreach home page provides accurate, consistent information to providers and centralizes the national, state, and regional links for additional program information. It also serves as the provider portal to access the Montana SLR. Additionally, the following outreach methods are commonly used for encouraging adoption of EHR technology:

Professional associations including but not limited to, Montana Medical Association, Montana Dental Association, Montana Hospital Association and the Montana Primary Care Association will be used to assist the state in communicating information to and receiving input from providers and hospitals

The monthly Medicaid provider newsletter Targeted provider notices Banner messages on remittance advices or other brief notices

B6 Leveraging FQHC HIT/EHR Resources and Experiences6. If the State has FQHCs with HRSA HIT/EHR funding, how will those resources and experiences be leveraged by the SMA to encourage EHR adoption?

MPCA is currently participating in the statewide HIE efforts, including participation as part of the board for the new 501c3 entity (Big Sky Connect). Through this work, they will share information with the State Medicaid Agency regarding EHRs of member health centers, allowing Big Sky Connect to leverage experiences and resources previously obtained by FQHCs.


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http://mt.arraincentive.com/



B7 SMA Support for Adoption and Meaningful Use of Certified EHR Technology7. How will the SMA assess and provide technical assistance to Medicaid providers around adoption and meaningful use of certified EHR technology?

DPHHS provides outreach to Medicaid providers through a Provider Outreach Page and electronic newsletters. More information regarding provider outreach can be found through the Provider Outreach Page at http://mt.arraincentive.com. The site includes:

A centralized “one-stop” launching pad of available tools for managing Provider Promoting Interoperability Program information

A secure portal to access Montana’s SLR Organized information offering real-time feeds of current HIT news and

updates from other federal organizations such as CMSAdditional provider support includes a technical call center for providers who need information on attestation requirements, guidance with respect to meaningful use criteria, assistance with documentation requirements, and other aspects of the MPIP.DPHHS also refers providers to Health Technology Services (HTS), for guidance and information on best practices to support and accelerate health care providers' efforts to become meaningful users of EHRs help with meaningful use.

B8 Addressing Populations with Unique Needs8. How will the SMA assure that populations with unique needs, such as children, are appropriately addressed by the Promoting Interoperability Program?

DPHHS will continue to coordinate with its federal and state stakeholder partners to identify and support populations with unique needs. For example, DPHHS coordinates with the Behavioral Health Alliance of Montana (BHAM) to embrace alignment, unification and representation of behavioral health services in Montana’s greater health system and promote access to the Promoting Interoperability Program for this community.

B9 Leveraging Grants for Implementing Promoting Interoperability Programs9. If the State included in a description of a HIT-related grant award (or awards) in Section A, to the extent known, how will that grant, or grants, be leveraged for 52Montana State Medicaid HIT Plan (SMHP) Update

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implementing the Promoting Interoperability Program, e.g. actual grant products, knowledge/lessons learned, stakeholder relationships, governance structures, legal/consent policies and agreements, etc.?

A description of HIT-related grants awarded and federal funding leveraged to support DPHHS HIT activities is presented in Section A15.

B10 New State Legislation Needs for Promoting Interoperability Program Implementation10. Does the SMA anticipate the need for new State legislation or changes to existing State laws in order to implement the Promoting Interoperability Program and facilitate a successful Promoting Interoperability Program (e.g., State laws that may restrict the exchange of certain kinds of health information)? Please describe.

No significant changes to Montana laws or regulations have been identified that would impact our MPIP. Current state law describing Montana’s EHR rule is presented at http://www.mtrules.org/gateway/ruleno.asp?RN=37%2E85%2E1101


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http://www.mtrules.org/gateway/ruleno.asp?RN=37.85.1101



Section C: Activities Necessary to Administer and Oversee the Promoting Interoperability Program

C1 Verifying properly licensed/qualified providers1. How will the SMA verify that providers are not sanctioned, are properly licensed/qualified providers?

The Promoting Interoperability Program Payment Coordinator has documented and implemented standards of conduct and proper use policies for the Promoting Interoperability Program. The method for verifying that providers are not sanctioned and is properly licensed/qualified is presented in detail in Appendix A and Appendix B, of the SMHP Section D: State’s Audit Strategy Update document, version 1.0.Approve or Deny Attestations for Payments

In summary, the Promoting Interoperability Program Payment Coordinator validates a provider does not have federal or state sanctions or exclusions in the OIG database by navigating to http://exclusions.oig.hhs.gov/ and entering the provider's name in the Search field. If there are no results matching the provider name, a screenshot is taken of the results. If results indicate a sanction, a verification match of the provider’s social security number is performed. If results reveal a match, the Promoting Interoperability Program Payment Coordinator’s supervisor is notified and the Montana Surveillance and Utilization Review (SURS) program is contacted for subsequent review. To verify providers are properly licensed/qualified, a query is made with the Department of Labor and Industry by navigating to https://ebiz.mt.gov/pol/. The Promoting Interoperability Program Payment Coordinator clicks on the “Licensee Lookup/Search For A Licensee” and enters the first, middle, and last name of the provider. If the license is in good standing, a screenshot is taken of the results as needed. If the license is not in good standing, the provider is notified and a request is made for a current copy of the license.

C2 Verifying hospital-based EPs2. How will the SMA verify whether EPs are hospital-based or not?


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https://ebiz.mt.gov/pol/

http://exclusions.oig.hhs.gov/



To verify that the EP is not hospital-based Montana Medicaid will capture Medicaid claims information from the MMIS system using the formula below to make the initial determination if a provider qualifies for the MPIP. Upon the EP's request for payment, the EP will certify they meet this criterion. The following is the calculation for determining that the EP is providing less than 90% place of service (POS) in a hospital setting:

Paid Claims with POS Codes 21 and 23 = X% (less than 90%

qualifies)Total Paid Claims for all Services

C3 Verifying provider attestations3. How will the SMA verify the overall content of provider attestations?

The Promoting Interoperability Program Payment Coordinator has documented and implemented standards of conduct and proper use policies for the Promoting Interoperability Program. The method for verifying the overall content of provider attestations is presented in detail in Appendix A and Appendix B, of the SMHP Section D: State’s Audit Strategy Update document, version 1.0.Approve or Deny Attestations for Payments

In summary, the Promoting Interoperability Program Payment Coordinator reviews content submitted by providers and hospitals to verify the following:

Patient volume: A continuous 90-day or greater (up to the maximum of the EP calendar year or the EH fiscal year) period may be used to calculate patient volumes. Both the numerator and denominator of the equation must use the same period. The EP or EH submits the time period for when the patient volume was measured; identifies the source the information was taken from; the numerator, denominator and resulting percentage for either Medicaid or Needy Individual volume.

Hospital Average Length of Stay (ALOS): Hospitals are required to attest to the facility’s ALOS. This information is validated using a report that calculates the ALOS based on the demographic data entered by the hospital as part of the payment calculation. The SLR currently validates that the hospital’s ALOS is less than or equal to 25 days as part of the eligibility as defined in the Final Rule, although Children’s Hospitals are considered eligible regardless of their ALOS (Montana has no children’s hospitals). Acute care and CAHs with an


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ALOS of 25.01 or greater are not eligible and are prevented from continuing the application process, as they do not meet the requirements.

EP practicing predominantly at an FQHC or RHC: EPs certify they meet this requirement by submitting the following—clinic location, the needy patient encounters at the location along with his or her total patient encounters and the percentage and the six-month period used to determine the percent.

Other non-state or local funds received for EHR: EPs or EHs certify if they have or have not received non-State or local funds for an EHR. If funds have been received the EP indicates the amount for the coinciding payment year.

Adopt, Implement or Upgrade (AIU): For their first year, the EP or EH attests that they have Adopted, implemented or upgraded, identify the certified system and date of AIU.

Certified EHR: This is verified on the ONC website which lists all certified EHRs.

EPs identify the specific board-certified specialty for quality measure purposes.

All information submitted by providers is subject to DPHHS audit process. The overall content of the provider attestations are verified before any payment being made. If a provider omits any information necessary for the eligibility determination or to make a payment, the provider is notified.

C4 SMA communication with providers4. How will the SMA communicate to its providers regarding their eligibility, payments, etc.?

Eligibility Notification

The Promoting Interoperability Program Payment Coordinator facilitates mass email communications to providers notifying them of their eligibility status and program participation information. Providers are directed to Montana’s secure attestation page, through the Montana State Level Registry, https://mt.arraincentive.com/ .Payment Notification

A notice is not distributed to providers ahead of payment. Prior to making the payment, DPHHS will notify the NLR that the payment is ready to be made and the NLR will lock the provider's applicant record to prevent duplication of payment and ensure the provider is unable to switch programs or states. Upon approval for payment, transactions will be processed through Montana’s MMIS and will appear as an item on the provider’s standard statement of remittance received from Montana Medicaid. Payment transactions will be processed as they are approved. The approved provider incentive payments are processed as a component of Montana Medicaid’s standard weekly payment cycle.56Montana State Medicaid HIT Plan (SMHP) Update

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https://mt.arraincentive.com/



EPs will receive direct or assigned payments. In the case where the provider is a member of a facility and chooses to assign the incentive payment to the facility, these payments are made to a facility consistent with existing MMIS payment processes. In the case where the provider who is a member of a facility chooses to retain the incentive payment, the payment will be made directly to the provider through an existing process in the MMIS. Due to existing MMIS limitations, Montana Medicaid will not make direct incentive payments to any entity that is not recognized as a Montana Medicaid provider.The NLR Registration transaction to the State will include not only the EP’s Personal TIN, but also the Payee TIN. DPHHS assigns the payment at the state level, as the national level has no way to validate the payee TIN/EP TIN combination. The Montana MPIP Registration and Attestation function lists the valid individual and group NPIs, names, State provider IDs, and TINs associated with the EP who is registering at the state level. The EP has the opportunity to choose which of these valid entities, to assign his/her EHR Incentive payment. The valid choices will be the facilities the providers are associated with, as well as the individual provider.

C5 Calculating patient volume5. What methodology will the SMA use to calculate patient volume?

The Promoting Interoperability Program Payment Coordinator has documented and implemented standards of conduct and proper use policies for the Promoting Interoperability Program. The method for calculating patient volume is presented in detail in Appendix E of the SMHP Section D: State’s Audit Strategy Update document, version 1.0.Calculate Patient Volume Procedure

In summary, providers determine patient volume by including patient encounters from Montana Medicaid and may also include any other State Medicaid patient encounters. If a provider claims Medicaid patient encounters from multiple states, the provider must include the provider’s total patient encounters (i.e., Medicaid and Non-Medicaid) in those states in the calculation and identify all states included in the volume threshold calculation.

Table C1 – Qualifying Patient Volume Threshold for MPIP

EP Type PV Comments Calculation

Physicians 30% Must be non-hospital based PV ≥ 0.30( Medicaid Encounters

Total Encounters)

Pediatricians 20% Must be non-hospital based PV ≥ 0.20( Medicaid Encounters

Total Encounters)


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EP Type PV Comments Calculation

Dentists 30% Must be non-hospital based PV ≥ 0.30( Medicaid Encounters

Total Encounters)

Certified nurse mid-wives

30% Must be non-hospital based PV ≥ 0.30( Medicaid Encounters

Total Encounters)

Physician Assistant (practicing at an FQHC/ RHC ledby a PA)

30%

For Medicaid EP practicing predominately (50% of patient volume over a six-month period) in an FQHC or RHC a minimum of 30% of their patient volume must come from “needy individuals”

PV ≥ 0.30( Medicaid EncountersTotal Encounters

)

PV ≥ 0.50( FQHC∨RHC Medicaid EncountersFQHC∨RHC Total Encounters

)

Nurse Practitioner 30% Must be non-

hospital based PV ≥ 0.30( Medicaid EncountersTotal Encounters

)

Acute care and CAHs 10%

The MPIP will utilize the MMIS Master Provider File NPI/TIN data to identify registered hospitals as acute care or CAH.

PV ≥ 0.10( Medicaid EncountersTotal Encounters

)

Children’s hospital

No threshol

d identifie

d

C6 Data sources used to verify patient volume for EPs and acute care hospitals6. What data sources will the SMA use to verify patient volume for EPs and acute care hospitals? 58Montana State Medicaid HIT Plan (SMHP) Update

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The Promoting Interoperability Program Payment Coordinator uses the State Level Registry Dashboard, MMIS, and hospital cost reports to verify patient volume for EPs and acute care hospitals.

C7 Verifying EPs and FQHC/RHCs meet the practices predominately requirement7. How will the SMA verify that EPs at FQHC/RHCs meet the practices predominately requirement?

To verify that EP’s meet the practices predominantly requirement, DPHHS uses the following data as a benchmark:

Paid claims from MMIS (used to validate provider attestations). Such paid claims data includes encounter claim information used to substantiate the provision of services to any Medicaid client. This data does not include capitated payments for the c(PCCM) program or any program payments that do not represent the provision of actual services rendered for Medicaid clients

Montana requests paid claims data or verification of patient volume from other states if such volume is claimed by a provider in order to meet volume threshold. Data from other states will not be requested if the provider can qualify based exclusively on Montana Medicaid patient volume

Number of Medicaid visits from the most recent query run in the MMIS (used to validate FQHC attestations)

Total visits from most recent query run in the MMIS (used to validate FQHC attestations)

C8 Verifying adopt, implement, or upgrade of EHR technology8. How will the SMA verify adopt, implement or upgrade of certified electronic health record technology by providers?

At this phase of the Promoting Interoperability Program, DPHHS is no longer verifying A/I/U; rather, providers must demonstrate meaningful use over a continuous 12-month period.


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C9 Verifying meaningful use of EHR technology for second participation years9. How will the SMA verify meaningful use of certified electronic health record technology for providers’ second participation years?

The Promoting Interoperability Program Payment Coordinator conducts selected compliance reviews of EPs and EHs who register for the incentive program and of recipients of incentive payments for the meaningful use of certified EHR technology. The reviews validate provider eligibility through their meaningful use attestations in the SLR, including verification of meaningful use and verifies components of the payment formulas. An EP that does not meet meaningful use measures will not complete Medicaid attestation in the SLR. Montana’s MPIP accommodates different requirements depending on the attestation year and the meaningful use measures collected.

C10 Proposed changes to the MU definition10. Will the SMA be proposing any changes to the MU definition as permissible per rule-making? If so, please provide details on the expected benefit to the Medicaid population as well as how the SMA assessed the issue of additional provider reporting and financial burden.

DPHHS will not be proposing any changes to the Meaningful Use definition as permissible per rule-making. Montana has adopted the Medicaid Meaningful Use definition and no additional measures will be added at this time. Current EP Medicaid Promoting Interoperability Program objectives and measures are available at https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2018ProgramRequirementsMedicaid.html

C11 Verifying use of certified EHR technology11. How will the SMA verify providers’ use of certified electronic health record technology?

The Promoting Interoperability Program Payment Coordinator verifies providers use of certified EHR technology by accessing the Certified Health IT Product List page at: https://chpl.healthit.gov/#/resources/cms_lookup. A search on the provider ID is conducted to retrieve the EHR technology edition information. A screenshot is taken of the results as needed. 60Montana State Medicaid HIT Plan (SMHP) Update

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https://chpl.healthit.gov/#/resources/cms_lookup

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2018ProgramRequirementsMedicaid.html

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2018ProgramRequirementsMedicaid.html



C12 Short-term and long-term collection of meaningful use data12. How will the SMA collect providers’ meaningful use data, including the reporting of clinical quality measures? Does the State envision different approaches for the short-term and a different approach for the longer-term?

Montana receives clinical quality measures data from participating MPIP providers through the attestation process. To the extent possible, DPHHS coordinates the collection of clinical quality measures in order to minimize the impact on participating providers.

C13 Process alignment with other quality measures13. * How will this data collection and analysis process align with the collection of other clinical quality measures data, such as CHIPRA? Currently, DPHHS does not coordinate the collection of clinical quality measures with other entities or programs.

C14 IT, fiscal, and communication systems used in implementation14. What IT, fiscal and communication systems will be used to implement the Promoting Interoperability Program? This question is no longer applicable based on the maturity level of the Promoting Interoperability Program.

C15 IT systems changes needed to implement the Promoting Interoperability Program15. What IT systems changes are needed by the SMA to implement the Promoting Interoperability Program? Future changes that must be made to Montana Medicaid’s IT systems are submitted to the contractor, Conduent, through the Request for Modification (RFM) process. RFMs are assessed and incorporated into a queue based on priority level and guidance from the State. System change requests that are initiated as a result of changes to federal program requirements are incorporated at the direction of CMS.


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C16 IT timeframe for systems modifications16. What is the SMA’s IT timeframe for systems modifications? The RFM implementation timeframe is established on a case-by-case basis. RFMs are jointly reviewed and approved for processing by Montana and Conduent, based on a prioritization scheme approved by the State.

C17 NLR interface testing17. When does the SMA anticipate being ready to test an interface with the CMS National Level Repository (NLR)? Bi-directional interface testing between the Montana MPIP State Level Repository and the NLR was completed in March 2011, during the implementation phase of the Promoting Interoperability Program.

C18 Accepting registration data from the CMS NLR18. What is the SMA's plan for accepting the registration data for its Medicaid providers from the CMS NLR (e.g., mainframe to mainframe interface or another means)?DPHHS leverages the MMIS system to obtain basic demographic information to support eligibility determination. Providers are required to verify their information contained within the MMIS. The MPIP, through an automated interface, verifies that the provider is a Montana Medicaid provider in good standing (i.e., provider is not deceased, provider is appropriately licensed, and there are no sanctions against the provider) at the time of registration and payment.

C19 Website for Medicaid providers19. What kind of website will the SMA host for Medicaid providers for enrollment, program information, etc.?

DPHHS provides program information to Medicaid providers through a Provider Outreach Page at http://mt.arraincentive.com. The site includes:

A centralized “one-stop” launching pad of available tools for managing Promoting Interoperability Program information

A secure portal to access Montana’s SLR Organized information offering real-time feeds of current HIT news and

updates from other federal organizations such as CMS


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C20 Modifications to the MMIS20. Does the SMA anticipate modifications to the MMIS and if so, when does the SMA anticipate submitting an MMIS I-APD?

The MPATH project is currently underway. The MPATH Program submitted their initial IAPD in September 2016 and submitted an IAPD-U in February 2018.The MPATH process and planning project is described in Section B1, HIT/E Goals and Objectives.

C21 Call Centers/Help Desks for Promoting Interoperability Program inquiries21. What kinds of call centers/help desks and other means will be established to address EP and hospital questions regarding the Promoting Interoperability Program?

DPHHS provides Promoting Interoperability Program information and support to Medicaid providers through the following communication and outreach channels:

The Promoting Interoperability Program Payment Coordinator provides technical support to providers requesting information or support on attestation requirements, guidance with respect to meaningful use criteria, assistance with documentation requirements, and other aspects of the MPIP.

A Provider outreach page, http://mt.arraincentive.com. The site includes:o A centralized “one-stop” launching pad of available tools for managing

Promoting Interoperability Program informationo A secure portal to access Montana’s SLRo Organized information offering real-time feeds of current HIT news and

updates from other federal organizations such as CMS. DPHHS also refers providers to Health Technology Services (HTS). HTS

provides guidance and information on best practices to support and accelerate health care providers' efforts to become meaningful users of EHRs help with meaningful use.

C22 Provider appeal process22. What will the SMA establish as a provider appeal process relative to: a) the incentive payments, b) provider eligibility determinations, and c) demonstration of efforts to adopt, implement or upgrade and meaningful use certified EHR technology?


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DPHHS utilizes the provider appeal process established by the Medicaid Program to govern appeals related to incentive payments, provider eligibility determination, and efforts to adopt or upgrade and meet meaningful use of certified EHR technology. Initiation of the formal appeal process assumes that all informal administrative reviews and resolution steps observed by Montana Medicaid in the administration of disputes are exhausted, and the provider wishes to escalate the issue and receive a binding decision. Such informal processes include follow-up communication with the provider regarding the issue, as well as research and analysis into possible avenues of correction that may be taken on the part of both the provider and DPHHS.If at any time a provider is denied participation, for any reason, per the final rule, the State shall notify the provider by a formal denial letter of their appeal rights at any point in the process at which they are denied: a) incentive payments, b) provider eligibility determinations, and c) demonstration of efforts to adopt, implement or upgrade and meaningful use certified EHR technology.

C23 Accounting for federal funding23. What will be the process to assure that all Federal funding, both for the 100 percent incentive payments, as well as the 90 percent HIT Administrative match, are accounted for separately for the HITECH provisions and not reported in a commingled manner with the enhanced MMIS FFP?

Budget allocation accounts are established and maintained for provider payments with the funding set to 100% federal funds. When an EP or EH is paid the budget allocation account associated with the provider incentive payment program is charged. This enables DPHHS to track on a monthly basis the total amount paid. The state accounting system also allows for information to be downloaded at any point in time to determine the total payments made to date. The Business and Financial Services Division (BFSD), which oversees the Cost Allocation Plan, maintains a budget-tracking and monitoring process to ensure the funding relating to the ARRA HIT is funded at the 90/10 ratio and to ensure the funding is tracked separately from other funds. Divisions with staff participating in the MPIP project work with their individual fiscal and budget staff to establish budget accounts with the appropriate fund mix. For employees who directly charge their time or do not fill out an activity report, the time is tracked by pay period and the hours are entered in the time system and allocated to the budget account. For individuals whose time is indirectly charged, their time is tracked on the monthly activity report and cost allocated to budget accounts based on that information.


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C24 Frequency of EHR incentive payments24. What is the SMA's anticipated frequency for making the EHR Incentive payments (e.g., monthly, semi-monthly, etc.)?

Montana administers EHR incentive payments on a weekly basis, every Monday. Montana Medicaid ensures that payments do not exceed the maximum amount of $8,500 for years 2 through 6. Payment after the first year may continue for a maximum of five years. Medicaid EPs may receive payments on a non-consecutive, annual basis. No payments may be made after January 2023. In no case shall a Medicaid EP participate for longer than six years or receive payment in excess of the maximum $63,750.EPs that meet the State definition of Pediatrician and carry between 20 to 29 percent Medicaid patient volume will have their payment reduced by one-third. Pediatricians do not receive more than $14,167 in the first year and not more than $5,667 for subsequent years. The total allowable for six years will not exceed $42,502. All other requirements noted above for an EP remain the same.DPHHS pays the aggregate hospital incentive payment amount over a four-year period, contingent on the hospital’s annual attestations and registrations for the annual Montana Medicaid payments. The EH receives the following percent of their Aggregate Overall EHR amount over the four years as follows:

Year 1: 50% (Aggregate EHR Payment X .50) Year 2: 30% (Aggregate EHR Payment X .30) Year 3: 10% (Aggregate EHR Payment X .10) Year 4: 10% (Aggregate EHR Payment X .10)

Payments cannot be made to an EH on a non-consecutive annual basis.

C25 Direct payment process25. What will be the process to assure that Medicaid provider payments are paid directly to the provider (or an employer or facility to which the provider has assigned payments) without any deduction or rebate?

To assure that all incentive payment calculations are made consistent with all statutes and regulations, the MPIP payment calculation process is automated and based on calculations contained in the final rule. An output report shows the breakdown of the calculated payment and all payments are reviewed for accuracy.EH Payment Calculations


June 1, 2018



The MPIP hospital aggregate incentive amount calculation occurs on a one-time, up front calculation using the equation outlined in the Final Rule. The aggregate EHR incentive amount is the total amount the hospital could receive in Medicaid payments over a theoretical four years of the program. It is the product of two factors:

The overall EHR amount The Medicaid Share

The overall EHR amount is based upon the sum over a theoretical four years of payment where the amount for each year is the product of three factors:

An Initial Amount The Medicare Share [and] A Transition Factor applicable to each of a theoretical four years

Initial Amount Initial Amount is equal to a base amount of $2,000,000, plus a discharge-related amount.The Initial Amount is the sum of a base amount and a discharge-related amount. The base amount is $2,000,000, and the discharge-related amount provides an additional $200 for estimated discharges between 1,150 and 23,000 discharges. No payment is made for discharges prior to the 1,150th discharge or for discharges after the 23,000th discharge. For the first payment year, data on hospital discharges from the hospital fiscal year that ends during the federal fiscal year prior to the hospital fiscal year that serves as the first payment year was used as the basis for determining the discharge-related amount. To determine the discharge-related amount for the three subsequent payment years that are included in determining the overall EHR amount, the number of discharges is based on the average annual growth rate for the hospital over the most recent three years of available data. The SLR captures four years of discharge data for the hospital (most recent year plus three years back). The growth rate is calculated as defined by CMS by determining the difference in discharges from year to year and converting to a percent increase/decrease. The three years are averaged together to determine the average annual growth rate. If a hospital’s average annual rate of growth is negative over the three-year period, the rate is applied as such. Montana uses the hospital cost reporting for validation.The Medicare Share portion of the Medicaid hospital overall EHR amount is set at one by the statute.Transition Factor 66Montana State Medicaid HIT Plan (SMHP) Update

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This factor in the formula determines the Medicaid incentive payment to an eligible hospital. For each of the four years of theoretical payment, a different transition factor applies, as demonstrated in Table 1. Note that for the Medicaid Program, an aggregate EHR amount is calculated only once, and this amount is then spread over all years of a hospital’s payments. Therefore, the transition factors in Table 1 are used to calculate the aggregate EHR amount but do not indicate that the hospital’s payment is calculated anew on a yearly basis.The Medicaid Share

The second step in determining the aggregate EHR amount for a meaningful user of certified EHR technology is to calculate the Medicaid Share. The Medicaid Share is essentially the percentage of a hospital’s inpatient, non-charity care days that are attributable to Medicaid inpatients. The numerator of the Medicaid Share is the sum of:

The number of Medicaid inpatient-bed-days and The number of Medicaid managed care inpatient-bed-days.

The denominator of the Medicaid Share is the product of: The total number of inpatient-bed-days for the eligible hospital during that

period and The total amount of the eligible hospital’s charges during that period, not

including any charges that are attributable to charity care divided by the estimated total amount of the hospital’s charges during that period.

The removal of charges attributable to charity care in the formula, in effect, increases the Medicaid Share resulting in higher incentive payments for hospitals that provide a greater proportion of charity care. The following illustrates the hospital calculation described above:

EH Payment = Overall EHR Amount x Medicaid SharewhereOverall EHR Amount ¿¿andBase Amount = $2,000,000.00andDischarge related information1 for 12-month period (FFY) prior to payment year is the sum of:1 The State uses data on the hospital discharge from the hospital fiscal year that ends during the Federal fiscal year prior to the fiscal year that serves as the first payment year.67Montana State Medicaid HIT Plan (SMHP) Update

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EH Payment = Overall EHR Amount x Medicaid Share1 through 1,149 discharge = $01,150 through 23,000 discharge = $ 200For discharges greater than 23,000 = $02

The formula for calculating the discharge related amount by year is as follows:Year 1: ((Total discharges from most recent cost report capped at 23,000) – 1149 disallowed discharges)*$200Year 2: ((Year 1 discharges * Average annual growth rate capped at 23,000) – 1149 disallowed discharges)*$200Year 3: ((Year 2 discharges * Average annual growth rate capped at 23,000) – 1149 disallowed discharges)*$200Year 4: ((Year 3 discharges * Average annual growth rate capped at 23,000) – 1149 disallowed discharges)*$200Overall EHR=Totalof all four yearsand

Medicaid Share=¿ [ Medicaid inpatient beddays+Medicaid managed care inpatient bed days

{( total inpatient bed days )× total charges−charity care chargestotal charges } ]

C26 Medicaid payment designation process26. What will be the process to assure that Medicaid payments go to an entity promoting the adoption of certified EHR technology, as designated by the state and approved by the US DHHS Secretary, are made only if participation in such a payment arrangement is voluntary by the EP and that no more than 5 percent of such payments is retained for costs unrelated to EHR technology adoption?

The Promoting Interoperability Program Payment Coordinator reviews payment information and specifically looks at the payee National Provider Identifier (NPI) in the CMS Data for Provider file as well as who the payment is assigned to on the attestation agreement to assure that payments are going to the facility or to whom the EHR vendor contract is with. Providers that show a payee NPI matching their

2 Discharge Related amount × (1+3 year average annual growth rate) × 20068Montana State Medicaid HIT Plan (SMHP) Update

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own personal NPI will be queried to determine the reason for payment going to them. This will assure that payments are being made to support EHR costs.

C27 Managed care plan payments27. What will be the process to assure that there are fiscal arrangements with providers to disburse incentive payments through Medicaid managed care plans does not exceed 105 percent of the capitation rate per 42 CFR Part 438.6, as well as a methodology for verifying such information?

At this time, Montana does not have any managed care entities.

C28 Assuring payment consistency with statutes and regulations28. What will be the process to assure that all hospital calculations and EP payment incentives are made consistent with the Statute and regulation?

The MPIP payment calculation process is automated and based on calculations presented in the final rule. An output report shows the breakdown of the calculated payment and all payments are reviewed for accuracy.

C29 Contractor roles in implementing the Promoting Interoperability Program29. What will be the role of existing SMA contractors in implementing the Promoting Interoperability Program – such as MMIS, PBM, fiscal agent, managed care contractors, etc.?

This question is no longer applicable based on the maturity level of the Promoting Interoperability Program.

C30 Assumptions30. States should explicitly describe what their assumptions are, and where the path and timing of their plans have dependencies based upon: • The role of CMS (e.g., the development and support of the National Level

Repository; provider outreach/help desk support• The status/availability of certified EHR technology • The role, approved plans, and status of the Regional Extension Centers • The role, approved plans, and status of the HIE cooperative agreements • State-specific readiness factors *May be deferred


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This question is no longer applicable based on the maturity level of the Promoting Interoperability Program. However, DPHHS maintains the following assumptions with regard to ongoing program support:

CMS continues to serve as a key federal partner. DPHHS does not anticipate major changes by CMS to program requirements for EP’s, Groups, or EH’s attesting in PY2018 and beyond.

Affordable certified EHR upgrades shall continue to be accessible to Montana providers.

HTS will continue to be a valuable resource for Montana providers seeking meaningful use clarification and assistance.

DPHHS SMHP updates and IAPDs shall be reviewed and approved by CMS promptly.


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Section D: The State’s Audit StrategyDPHHS to determine whether they want to pare this section back. Montana’s audit strategy describes the pre-payment and post-payment audit functions that may lead to the detection of fraud or abuse of the Promoting Interoperability Program. The audit strategy shall be maintained and updated along with this SMHP as required by CMS.


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Section E: The State’s HIT RoadmapE1 Montana’s HIT Pathway1. *Provide CMS with a graphical as well as narrative pathway that shows where the SMA is starting from (As-Is) today, where it expects to be five years from now (To-Be), and how it plans to get there.

As mentioned in Section B.1 above, DPHHS is adopting a modularity approach to deploying new systems and services for Medicaid modernization efforts. The narrative pathway for the following Objectives 1 and three are shown in Figure E1 below. The Systems Integration Contractor will coordinate architecture planning, development, and testing efforts across the various components shown in the figure below, including data analytics.Objective 1: Implement modular systems and services to modernize the Medicaid Enterprise. Objective 3: Utilize data analytics to inform treatment, payment, and outcomes for healthcare.


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Figure E1: MPATH Roadmap

There will be a distinct roadmap for the statewide HIE objectives, which is described at a high-level below.Objective 2: Develop a sustainable statewide HIE solution for use by multiple stakeholders across the State.Objective 4: Leverage HIE to encourage meaningful use of EHRs.

Initial planning efforts have been identified for the statewide HIE. A non-profit designation was received, and a Board has been formed. We identified initial and longer-term tasks needed to support the sustainability of an HIE as shown in Figure E2 below and the action plan in Table E1. governance and data governance model. 73Montana State Medicaid HIT Plan (SMHP) Update

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Given the early stages of planning, we feel an initial and long-term governance structure are needed to accommodate the initial use cases and expanded use cases over time. The timeline is provided as a sample since HIE planning efforts are in the early stages.

Figure E2: Representative HIE Structure Roadmap

Short-term startup tasks for HIE governance and use case planning are presented in Table E1 below.

Table E1: HIE Governance and Start-up Tasks

# Activity Estimated Timeframe1. Engage additional HIT and HIE

stakeholdersImmediately

2. Establish Guiding Principles 3-6 months

3. Create an initial project charter to clearly describe: HIE scope and timelines HIE use cases Preliminary roles and responsibilities Defines authority of the HIE Board

3-6 months

4. Define use cases, contract, and SOW Technical Requirements Business Requirements Service Level Agreements (SLAs) Deliverables

4-8 months


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# Activity Estimated Timeframe

5. Develop initial HIE artifacts Sustainability Plan Legal agreements Policy and statute seeds Backup and disaster recovery

procedures Security and Privacy Plan

4-8 months

6. Create initial legal framework: Master End-User License Agreement HIPAA compliant Business Associates

Agreement (BAA) Data Sharing Agreement

8-12 months

7. Establish Implementation Guides: Use case development request

templates Testing plan and test script templates Training guides and material

templates Issue remediation process Service support standards Entrance and Exit Criteria to

determine readiness

8-12 months

8. Define backup and disaster recovery procedures

8-12 months

9. Develop Privacy and Security Plan Within first three months of contract execution

10. Establish Communication Plan and reporting

6-8 months

11. Establish Data Governance Committee 4-6 months

12. Determine long-term governance structure and functional roles: Decision-making Hierarchy of decision-making Issue Resolution processes Roles & Responsibilities

12-15 months

13. Develop transition strategy and Transition Plan

8-12 months


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# Activity Estimated Timeframe

14. Establish data quality standards 8-12 months

E2 Expectations for Provider Promoting Interoperability Program Adoption2. What are the SMA’s expectations re provider EHR technology adoption over time? Annual benchmarks by provider type?

Interviewed stakeholders anticipate most healthcare providers will adopt EHRs within the next five years. A statewide HIE should provide additional value proposition for provider adoption. We identified estimated Medicaid payments for the Promoting Interoperability Program in Table E2 below.

Table E2: Estimated Provider and Hospital Provider Incentive Payments

Total Estimated Provider

Payments:

Year 2 – 264 providers - total payment amount possible $2,244,000.00Year 3 – 383 providers - total payment amount possible $3,255,500.00Year 4 – 486 providers - total payment amount possible $4,131,000.00Year 5 – 541 providers - total payment amount possible $4,598,500.00Year 6 – 578 providers - total payment amount possible $4,913,000.00

Estimated Hospital

Payments:

Year 4 – $30,150.00 (Hospital 1)Year 2 – $65,700.00 (Hospital 2)Year 4 – $186,394.82 (Hospital 3)Year 4 – $33,800.00 (Hospital 4) Year 3 – $21,900.00 (Hospital 2)Year 4 -– $21,900.00 (Hospital 2)Total: $259,844.82


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Estimated Certified Nurse

Midwife Payments

7 that can attest for Year 2 at $8,500.00 a year = $59,500.0012 that can attest for Year 3 at $8,500.00 a year = $102,000.0015 that can attest for Year 4 at $8,500.00 a year = $127,500.0015 that can attest for Year 5 at $8,500.00 a year = $127,500.0015 that can attest for Year 6 at $8,500.00 a year = $127,500.00

Estimated Dentist Payments

72 can attest for Year 2 at $8,500.00 a year = $612,000.0086 can attest for Year 3 at $8,500.00 a year = $731,000.0097 can attest for Year 4 at $8,500.00 a year = $824,500.0099 can attest for Year 5 at $8,500.00 a year = $841,500.0099 can attest for Year 6 at $8,500.00 a year = $841,500.00

Estimated Nurse

Practitioner Payments

96 can attest for Year 2 at $8,500.00 a year = $816,000.00127 can attest for Year 3 at $8,500.00 a year = $1,079,500.00146 can attest for Year 4 at $8,500.00 a year = $1,241,000.00157 can attest for Year 5 at $8,500.00 a year = $1,334,500.00168 can attest for Year 6 at $8,500.00 a year = $1,428,000.00

Estimated Physician Payments

122 can attest for Year 2 at $8,500.00 a year = $1,037,000.00169 can attest for Year 3 at $8,500.00 a year = $1,436,500.00232 can attest for Year 4 at $8,500.00 a year = $1,972,000.00265 can attest for Year 5 at $8,500.00 a year = $2,252,500.00285 can attest for Year 6 at $8,500.00 a year = $2,422,500.00


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Estimated Physician Assistant

Practicing in FQHC

9 can attest for Year 2 at $8,500.00 a year = $76,500.0019 can attest for Year 3 at $8,500.00 a year = $161,500.0026 can attest for Year 4 at $8,500.00 a year = $221,000.0031 can attest for Year 5 at $8,500.00 a year = $263,500.0032 can attest for Year 6 at $8,500.00 a year = $272,000.00

E3 Progress Benchmarks3. Describe the annual benchmarks for each of the SMA’s goals that will serve as clearly measurable indicators of progress along this scenario.

Benchmarks for each of the SMA’s goals are included in Tables E3 and E4 below.Table E3 – Annual Benchmarks for Objectives 1 and 3

Objective 1: Implement modular systems and services to modernize the Medicaid Enterprise.Objective 3: Utilize data analytics to inform treatment, payment, and outcomes for healthcare.

SFY19 Benchmarks:

Contractor selection for System Integrator Services procurement; Contractor selection for multiple modules including Provider Management.

Design, Development and Implementation of Data Warehouse solution

Initial Design, Development and Implementation of System Integration Services

SFY20 Benchmarks:

Design, Development, and Implementation of Data Analytics Solution

Initial Design, Development, and Implementation of Care Management Services

Ongoing Design, Development and Implementation of System Integration Services

SFY21 Benchmarks:

Systems Integration of modular solutions Population Health/Enterprise Data Warehouse Operations Provider Management Operations Procurement of Claims Processing Services


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SFY22 Benchmarks:

Systems Integration of modular solutions Design, Development and Implementation of Claims

Processing Services

SFY23 Benchmarks:

Systems Integration of modular solutions Operations of Claims Processing Services

Table E4 – Annual Benchmarks for Objectives 2 and 4

Objective 2: Develop a sustainable statewide HIE solution for use by multiple stakeholders across the State.Objective 4: Leverage HIE to encourage meaningful use of EHRs.

SFY19 Benchmarks:

Establish Board of Directors/Steering Committee Establish HIE Charter Define the scope of use cases AI and MU Payments Provider Payment Audits

SFY20 Benchmarks:

Develop Sustainability Plan AI and MU Payments Provider Payment Audits DDI of HIE Use Case(s) Establish Data Governance Framework

SFY21 Benchmarks:

AI and MU Payments Provider Payment Audits DDI of HIE Use Case(s) Operations of initial HIE Use Case(s)

SFY22 Benchmarks:

AI and MU Payments Provider Payment Audits DDI of HIE Use Case(s) HIE Operations

SFY23 Benchmarks:

DDI of HIE Use Case(s) HIE Operations


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E4 Audit and Oversight Benchmarks4. Discuss annual benchmarks for audit and oversight activities

Monitoring activities are conducted to ensure that policies and procedures in place are followed. An ongoing oversight effort remains part of the daily procedures performed by the Promoting Interoperability Program payment coordinator. The payment coordinator conducts various types of reviews, such as:

A prepayment review Verification of payment accuracy Verification of non-duplication of EHR payments Review reports for outlier information

The Audit Bureau retrieves a sample for each payment year using a combination of methodologies. DPHHS maintains its detailed audit strategy in a separate stand-alone document. The audit strategy is maintained and updated along with this SMHP as required by CMS.


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AcronymsAcronym Description

AR Accounts receivableARRA American Recovery and Reinvestment Act of 2009BIP US Department of Agriculture Broadband Initiative ProgramCAH Critical Access HospitalCCHIT Certification Commission for Health Information TechnologyCDC Centers for Disease ControlCHIP Children’s Health Insurance ProgramCIO Chief Information OfficerCMS Centers for Medicare & Medicaid ServicesCOB Coordination of BenefitsCPOE Computerized Physician Order EntryCPU Central Processing Unit CSR Customer Service RepresentativeDME Durable Medical EquipmentDRG Diagnosis-related GroupDSS Decision Support SystemDW Data WarehouseEDI Electronic Data InterchangeEDW Enterprise Data WarehouseEFT Electronic Funds TransferEHR Electronic Health RecordEH Eligible HospitalELR Electronic Laboratory Reports or ReportingEMR Electronic Medical RecordsEP Eligible ProfessionalEPE Electronic Provider EnrollmentePHI Electronic Protected Health InformationEPSDT Early Periodic Screening, Diagnosis, and Treatment Program



Acronym Description

ER Emergency RoomFEIN Federal Employer Identification NumberFFP Federal Financial ParticipationFQHC Federally Qualified Health CenterFTTP fiber-to-the-premisesHAN Health Access NetworkHCPCS Healthcare Common Procedure Coding SystemHEDIS Healthcare Effectiveness Data and Information SetHIE Health Information ExchangeHII Health Information InfrastructureHIIAB Health Information Infrastructure Advisory BoardHIPAA Health Insurance Portability and Accountability ActHISPC Health Information Security and Privacy CollaborativeHIT Health Information TechnologyHITECH Health Information Technology for Economic and Clinical Health Act HITRC Health Information Technology Research Center HL7 Health Level SevenHMIS Health Management Information System HMP Health Management ProgramHRSA Health Resources and Services AdministrationIAPD Implementation Advance Planning DocumentICD-9 International Classification of Diseases and Related Health Problems, 9th

RevisionICD-10 International Classification of Diseases and Related Health Problems,

10th RevisionIDN Integrated Delivery NetworkIDS Integrated Delivery SystemIFR Interim Final Rule


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Acronym Description

IHS Indian Health ServicesIO Insure OklahomaIRS Internal Revenue ServiceIT Information TechnologyI/T/U Indian Health Services, Tribal facilities/Urban Indian ClinicsMAR Management and Administrative Reporting SystemMED Medical Exclusion DatabaseMFCU Medicaid Fraud Control UnitMITA Medicaid Information Technology ArchitectureMMIS Medicaid Management Information SystemMPATH Montana’s Program for Automating and Transforming HealthcareMPCA Montana Primary Care AssociationMPIP Medicaid Provider Incentive ProgramMU Meaningful UseNEDSS National Electronic Disease Surveillance SystemNHIN National Health Information NetworkNLR National Level RegistryNPI National Provider IdentifierNPPES National Plan and Provider Enumeration System NPRM Notice of Proposed Rule MakingNTIA National Telecommunications and Information AdministrationOCHIN Oregon Community Health InformationOEI Outreach, Education, and Information workgroupOIG Office of the Inspector GeneralONC Office of the National Coordinator for Health Information TechnologyPA Physician AssistantPCCM Primary Care Case Management


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Acronym Description

PCMH Patient-Centered Medical HomePCP Primary Care ProviderPDI Planning, Development, and Implementation workgroupPHR Personal Health RecordPI Program IntegrityPOS Point-of-SalePQRI Physician Quality Reporting Initiative PRU Performance and Reporting Unit QA/QI Quality Assurance/Quality ImprovementRFI Request for InformationRFP Request for Proposal RHC Rural Health ClinicRHIO Regional Health Information OrganizationRPMS Resource and Patient Management SystemSITSD State Information Technology Services DivisionSMHP State Medicaid Health Information Technology PlanSMM State Medicaid ManualSS-A State Self-AssessmentSURS Surveillance Utilization Review SystemTIN Taxpayer Identification NumberVA Veterans AffairsVFC Vaccines for ChildrenVistA Veterans Health Information Systems and Technology ArchitectureX12 Accredited Standards Committee X12


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