States making strides in technology, info exchange

States are making progress in implementing health information technology (HIT) and health information exchange (HIE) initiatives that have the potential to reduce health care costs resulting from inefficiency, medical errors, inappropriate care, and incomplete information, according to a new report from the Department of Health and Human Services' Office of Inspector General (OIG).

The OIG says 12 state Medicaid agencies (Florida, Iowa, Kansas, Louisiana, Mississippi, Missouri, Montana, Pennsylvania, Tennessee, Vermont, Wisconsin, and Wyoming) have implemented a variety of HIT initiatives, including claims-based electronic health records, electronic prescribing, remote disease monitoring, and personal health records initiatives. And many other state Medicaid agencies are in the process of developing similar initiatives.

Likewise, some 25 state Medicaid agencies (Arizona. California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, New Jersey, New York, Ohio, Rhode Island, Tennessee, Utah, Vermont, Washington, West Virginia, and Wisconsin) are involved in planning and developing statewide HIE networks that will allow for secure exchange of health care information. The networks' goal is to develop a statewide infrastructure to support widespread use of HIT and allow health care providers and payers in the states to securely exchange clinical information. Also, 13 state Medicaid agencies include Medicaid Information Technology Architecture (MITA) as part of their HIT and HIE planning. MITA is a framework developed by the Centers for Medicare & Medicaid Services to help states modernize their Medicaid information systems.

The OIG report says HIT is used to electronically collect, store, retrieve, and transfer clinical and administrative information. HIE is defined as sharing health care information electronically among disparate health care information systems. HIE requires each participant in an HIE network to agree to certain information-sharing policies and procedures. HIE is needed to make HIT, such as electronic health records and other technologies, become fully interoperable, meaning that health care providers can not only view or read data from another entity, but also can modify them and exchange them with other users.

Funding available

State Medicaid agencies can receive funding for HIT and HIE initiatives from Medicaid matching funds for administrative expenditures and from federal grants. The federal match for administrative expenditures is generally 50%, the OIG says, although it is higher for certain administrative functions.

Nine state Medicaid agencies (Iowa, Kansas, Louisiana, Missouri, Montana, Pennsylvania, Tennessee, Vermont, and Wisconsin) have implemented claims-based electronic health record initiatives for Medicaid beneficiaries. Some 27 additional Medicaid agencies are in the process of developing electronic health record initiatives. The nine current programs all rely on Medicaid claims data and contain clinical information about patients such as prior diagnoses, medical procedures performed, and prescription history. The information is derived from procedure and diagnosis codes contained in the Medicaid claims data. In all but one case, authorized health care providers access the information through a secure web portal. Four of the initiatives also have begun to incorporate a limited amount of data from other sources such as public health department immunization records.

Unlike interoperable electronic health records in which providers exchange clinical information, these initiatives enable providers to only view information derived from prior Medicaid claims. Providers cannot directly enter information into the record or exchange their clinical records with other providers.

The nine records initiatives are targeting different Medicaid populations and providers. Four have records available for the state's entire Medicaid population, three have records available for Medicaid beneficiaries participating in the state's fee-for-service program, one is limited to Medicaid beneficiaries participating in a managed care program, and one is limited to certain beneficiaries who are chronically ill. The initiatives also target different types of providers, with four of them allowing all enrolled providers to access beneficiaries' records, while the remaining five allow only specific types of providers to access the information, such as those in emergency departments.

State Medicaid directors told the OIG their primary goal in developing electronic health records was to improve quality of care by providing more information to clinicians about beneficiaries' medical histories. They believe that having access to a beneficiary's prior diagnoses and treatment history enables clinicians to provide better care. They also said the initiatives may prevent Medicaid fraud, waste, and abuse.

Security, privacy issues challenge

A major challenge in implementing electronic health record initiatives has been developing security and privacy policies, the directors said. In particular, notifying beneficiaries about how their information will be used and developing procedures to handle sensitive data, such as mental health, substance abuse, and HIV/AIDS information, have been challenging.

The majority of the 27 state Medicaid agencies with planned electronic health record initiatives will develop claims-based programs similar to those already in existence. In a few cases, the OIG reports, Medicaid agencies are attempting to develop more interoperable records that will rely on HIE networks. And in two cases, the agencies are planning to replace their claims-based initiative with more interoperable records that will include data from other sources and allow providers to exchange a wider range of clinical information.

Five states (Florida, Kansas, Mississippi, Missouri, and Tennessee) have developed e-prescribing initiatives and another 21 states are in the process of developing programs. The current efforts allow providers to electronically prescribe medications and to view beneficiaries' prescription histories derived from Medicaid claims data. They also give providers information about the states' Medicaid drug formulary and potential drug interactions. Providers can access the systems through web portals or through hand-held personal digital assistants.

Medicaid directors said their goals for e-prescribing included avoiding adverse events due to drug interactions or errors, limiting drug-seeking behavior by enabling physicians to view medication histories, increasing adherence to the Medicaid formulary by enabling providers to view formulary information, and monitoring physician prescribing behavior.

The directors said they ran into security and privacy problems similar to those experienced with electronic health records. Two directors reported difficulty expanding their initiatives because some pharmacies don't have the capability to receive prescriptions electronically.

Remote monitoring initiatives

The state Medicaid agencies in Missouri and Wyoming have implemented remote disease monitoring initiatives for selected Medicaid beneficiaries and three additional states are in the process of developing such initiatives. In Missouri and Wyoming, beneficiaries have been provided an electronic telemonitoring device for use in their homes. The devices collect health information and monitor beneficiaries' vital signs and other medical statistics daily. In Missouri, the device is a central processing unit that can incorporate an array of technologies such as an automated blood pressure cuff or a scale. The Wyoming device asks beneficiaries questions about their health status such as weight changes or test results. In both initiatives, the information gathered by the units is transmitted through telephone lines to providers who are charged with monitoring beneficiaries' health status. When problems are detected, the monitoring team follows up with the beneficiary's primary care provider.

Both initiatives are available primarily to chronically ill beneficiaries who might benefit from daily monitoring. The beneficiaries commonly have conditions such as diabetes, asthma, and chronic heart failure. The directors of the two agencies said their goal for the program is to improve patient outcomes and reduce emergency care and hospitalizations. They also think the initiatives could reduce the total cost of care for participating beneficiaries.

In terms of implementation challenges, one agency director cited the difficulty in maintain current telephone numbers for participating beneficiaries, while the other referred to challenges in measuring the initiative's impact.

No state Medicaid agency now provides personal health records to Medicaid beneficiaries, although 13 agencies reported they are planning to develop such initiatives. Most are expected to be claims-based, much like the electronic health records, although these records will be maintained by beneficiaries, usually through a portable computer drive or a web portal.

Some 25 state Medicaid agencies are planning and developing statewide HIE networks to allow for the secure exchange of health care information. The networks' main goal is to develop a statewide infrastructure to support widespread use of interoperable electronic health records and other health information technology. The networks intend to allow most, if not all, health care providers and payers in the state to securely exchange clinical information.

In all 25 states, the Medicaid agencies are working with multiple public and private entities to plan and develop statewide HIE networks. The entities typically form advisory boards or nonprofit organizations charged with overseeing development of the networks.

In 13 states, the Medicaid agencies are incorporating MITA into their HIT and HIE planning. The report says state Medicaid directors report that MITA provides useful guidance that will help modernize states' Medicaid management information systems and will lead to more efficient administration of their Medicaid programs. The directors in the 13 states also said implementing MITA will increase the interoperability of their management information systems and increase the possibility of Medicaid participation in future HIT and HIE initiatives.

Based on findings from surveying all state Medicaid programs, the Inspector General recommended that CMS: 1) continues to support MITA goals; 2) collaborates with other federal agencies and offices to assist state Medicaid agencies in developing privacy and security policies; and 3) continues to work with the Office of the National Coordinator for HIT to ensure that state Medicaid initiatives are consistent with national goals.

CMS concurred with the recommendations. The agency reported it supports the goals of the recommendations and already has taken steps to implement them.

Download the OIG report at