State of Wyoming
State Medicaid Health Information Technology Plan March 31, 2016 -Version 5
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Prepared by: Wyoming Department of Health With assistance from:
2030 Hoover Blvd. Frankfort, KY 40601
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Contents EXECUTIVE SUMMARY ................................................................................................................................................................................................... 7 History of HIT in Wyoming .......................................................................................................................................................................................... 7 Section A: The State “As Is” Landscape........................................................................................................................................................................ 10 Wyoming Healthcare Environment ......................................................................................................................................................................... 10 Wyoming eHealth .................................................................................................................................................................................................... 11 EHR Adoption and readiness................................................................................................................................................................................ 15 Wyoming EHR Incentive Program ........................................................................................................................................................................ 17 Environmental Scan ............................................................................................................................................................................................. 19 Broadband Internet Access ...................................................................................................................................................................................... 28 Federally Qualified Health Centers (FQHCs) ............................................................................................................................................................ 28 Veteran Administration and Indian Health Services ................................................................................................................................................ 28 Current State of HIT Relations within Medicaid and the Wyoming Department of Health .................................................................................... 29 SMA Relationships and Stakeholder Engagement ............................................................................................................................................... 30 Plans to Improve HIT/HIE Entity Relationships ........................................................................................................................................................ 31 Health Information Exchange .................................................................................................................................................................................. 31 Role of the MMIS in the Current HIT/E Environment .............................................................................................................................................. 34 Medicaid Information Technology Architecture.................................................................................................................................................. 34 States Activities Underway to Facilitate HIT/HIE Adoption ..................................................................................................................................... 37 States Role in Facilitating HIE and EHR Planning Adoption ..................................................................................................................................... 38 2
Direct outreach to providers who appear to be eligible for the Wyoming Medicaid EHR Incentive Program: .................................................. 39 Health IT Enhancements in Progress ....................................................................................................................................................................... 40 REC ....................................................................................................................................................................................................................... 40 Total Health Record ............................................................................................................................................................................................. 40 Wyoming Population Health Initiatives: Patient Centered Medical Homes ........................................................................................................ 41 Wyoming Data Repository and Data Analytics ................................................................................................................................................... 42 HIT/HIE Activities Crossing State Boarders .............................................................................................................................................................. 42 Public Health Reporting ........................................................................................................................................................................................... 43 State Laws or Regulations and HIT Related Grants.................................................................................................................................................. 44 Section B: The State’s “To-Be” Landscape ................................................................................................................................................................... 45 HIT and HIE Goals ..................................................................................................................................................................................................... 45 Medicaid EHR Incentive Program Goals: ................................................................................................................................................................. 45 Technical Support for the EHR Incentive Program providers .............................................................................................................................. 46 EHR Incentive Program over the next 12 months................................................................................................................................................ 46 IT System Architecture ............................................................................................................................................................................................. 47 Wyoming Providers Interfacing with Medicaid IT Systems ..................................................................................................................................... 50 Addressing the needs of unique patients through the EHR Incentive Program ...................................................................................................... 50 Anticipated state needs ........................................................................................................................................................................................... 50 Section C: Activities Necessary to Administer and Oversee the EHR Incentive Program ............................................................................................ 51 Introduction ............................................................................................................................................................................................................. 51
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Organizational Chart ............................................................................................................................................................................................ 52 EHR Incentive Staff ............................................................................................................................................................................................... 52 Existing Medicaid and WDH-IT Staff .................................................................................................................................................................... 55 EHR INCENTIVE PROGRAM OUTREACH ................................................................................................................................................................... 57 EHR Incentive Program Project Overview................................................................................................................................................................ 59 Preliminary Investigation and Analysis of EHR Incentive Program Requirements .............................................................................................. 59 Determination of Business Processes and Conceptual Design for Administration of EHR Incentive Program ................................................... 59 State Level Registry .................................................................................................................................................................................................. 60 State Level Registry—Design and Operation ....................................................................................................................................................... 60 State Level Registry – Business Processes and Conceptual Designs .................................................................................................................... 63 Eligible Professionals: Registration at the SLR ..................................................................................................................................................... 65 Eligible Hospitals: Registration at the SLR............................................................................................................................................................ 76 Adopt, Implement, or Upgrade Attestation......................................................................................................................................................... 82 Payment ................................................................................................................................................................................................................... 83 Determining Payment Amount ............................................................................................................................................................................ 83 Accounting for Incentive Payments to Professionals and Hospitals .................................................................................................................... 84 Pre-Payment Checks ............................................................................................................................................................................................ 84 Required Documentation to be uploaded to SLR ................................................................................................................................................ 85 Post-Payment Audits............................................................................................................................................................................................ 87 Payment Response File ........................................................................................................................................................................................ 88
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Communication of Payment Status with CMS Registration and Attestation System (NLR) .................................................................................... 88 Medicaid EHR Incentive Program Appeals Process ................................................................................................................................................. 88 Medicaid EHR Incentive Program Website .............................................................................................................................................................. 91 Medicaid EHR Incentive Program Provider Helpdesk Plan ...................................................................................................................................... 91 Section D: The State’s Audit Strategy .......................................................................................................................................................................... 93 Section E: The State’s HIT Roadmap ............................................................................................................................................................................ 94 Wyoming Medicaid EHR Incentive Program ............................................................................................................................................................ 94 Goals ........................................................................................................................................................................................................................ 96 Common Acronyms used in WDH HIT ......................................................................................................................................................................... 98 Appendix A: State Flexibility Rule .............................................................................................................................................................................. 101 State Medicaid Health Information Technology Plan Update Addendum ............................................................................................................ 101 1.1.1
SMA Policy Changes ........................................................................................................................................................................... 101
1.1.2
Provider Registration and Attestation ............................................................................................................................................... 102
1.1.3
Medicaid EHR Incentive Program Payment Administration .............................................................................................................. 103
1.1.4
Audit & Program Integrity .................................................................................................................................................................. 103
1.1.5
Outreach, Collaboration, Support ...................................................................................................................................................... 104
1.1.6
State-Based Performance Measures.................................................................................................................................................. 104
Appendix B: SLR Screen Shots .................................................................................................................................................................................... 105
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Wyoming SMHP Version History Date
Document Submission
Comments
November, 2011
Original SMHP Submission
March 2013
SMHP Update
Update of Audit Strategy, HIT Roadmap, ToBe, EHR Incentive Program, Broadband connection information
November 2014
Flexibility Rule Addendum
Included updated to the EHR Incentive Program Administration in regards to the Flexibility Rule
March 2016
SMHP Update
Re-aligning SMHP with SMHP Companion Guide, updates to As-Is, To-Be, EHR Incentive Program, Audit Strategy, and HIT Roadmap. Included new environment scan and updated SLR screens as addendum attachments.
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EXECUTIVE SUMMARY Before passage of the American Recovery and Reinvestment Act of 2009 (ARRA 2009), the Wyoming Department of Health (WDH) embarked on a strategy to promote the use of electronic health records and the exchange of health information among Wyoming healthcare providers. The Wyoming Medicaid program is a driver of this strategy within WDH. This State Medicaid Health IT Plan (SMHP) describes the history, current status and future vision for health information technology in the State of Wyoming. Although Wyoming Medicaid wrote this SMHP to satisfy the requirements of receiving federal financial participation for the state Medicaid EHR Incentive Program under ARRA, this SMHP also illustrates the interconnected pathways of government and private Wyoming healthcare stakeholders as they work “to promote a healthier Wyoming by developing a secure, connected and coordinated HIT system that supports effective and efficient health care.” To give context to the potential for health information technology to Wyoming’s health care system, this SMHP begins with a description of the geographic and demographic characteristics that affect healthcare delivery in Wyoming. The SMHP then discusses the current “As-Is” HIT landscape, as well as Wyoming Medicaid’s vision for the future “To-Be” HIT environment within the state. Both of these sections touch on the Total Health Record (THR), an electronic health record project that Wyoming Medicaid launched in 2011. The SMHP also describes Wyoming’s health information technology history and the current state of the IT systems supporting WDH, its provider network and its clients. After presenting the health IT environment, the SMHP then describes how Wyoming Medicaid administers and oversees the Wyoming Medicaid EHR Incentive Program. Finally, this SMHP contains a health IT roadmap for Wyoming Medicaid. History of HIT in Wyoming Wyoming is not approaching the health IT opportunities of ARRA completely devoid of experience with health information technology or health information exchange. Many stakeholders in the Wyoming health care system recognized the possibilities presented by technology to improve access to care. Wyoming began exploration of how technological advances 7
could benefit health care delivery with a 2004 directive from the Wyoming Legislature to the Wyoming Healthcare Commission. This legislation directed the Commission to conduct a study and develop a plan for establishing a statewide health information exchange network. After completing the study, the Commission recommended to the Governor and the Legislature that a self-sustaining Regional Health Information Organization (RHIO) be formed to facilitate three types of partnerships: intrastate partnerships, regional interstate partnerships and national/federal partnerships. These partnerships would provide for the rapid deployment of Wyoming’s health information infrastructure. The RHIO, named the Wyoming Health Information Organization (WyHIO), was formed in 2005. After formation of the WyHIO, various entities in Wyoming continued efforts to improve the state’s health IT environment and Medicaid and the e-Health Partnership built upon these existing activities during the current HIT and HIE planning processes. In 2006, WyHIO partnered with the University of Wyoming Center for Rural Health Research and Education to implement an online resource center for privacy and security, health information technology and exchange and telehealth. This work was conducted as part of the Health Information Security and Privacy Collaboration (HISPC) grant program funded by the Agency for Healthcare Research and Quality (AHRQ). Along with the HISPC work, in 2005 and 2006, the State initiated the development of a shared database using information from agencies that provide state-funded social services to Wyoming residents. The Wyoming Health Information Network (WHIN) coordinates collection and analysis of state benefit data from the Wyoming Department of Health, Wyoming Department of Family Services, Wyoming Department of Corrections and Wyoming Department of Employment. Using this data, the WHIN launched an initiative called Health Assist, a pilot program to help social service recipients identify, coordinate and use state and community services, understand health and medication issues and effectively communicate with medical professionals and service providers. In addition to the preliminary efforts resulting in the WyHIO and the WHIN, the Wyoming Legislature established the Wyoming Telemedicine/Telehealth Network Consortium in 2009 to facilitate the operation of a statewide, interoperable telemedicine/telehealth network. The Consortium spurred a tele-psychiatry initiative, which is being directed by two Wyoming hospitals and the state’s leading mental health facility. In addition to the work of the Consortium, the Wyoming 8
Department of Health recently entered into a partnership with the University of Washington to make a psychiatric evaluation available for each child who goes into custody of the Department of Family Services, prior to that child’s first MultiDisciplinary Team meeting where treatment, parenting and family reunification decisions will be made. An additional important component of Wyoming’s telehealth efforts is the 2009 Federal Communications Commission grant received by the University of Wyoming Center for Rural Health Research and Education. The purpose of the grant is to create a statewide high-speed telemedicine network. When the network is deployed, it will improve access to specialty care, especially in the state’s most underserved discipline, mental health, for residents of remote communities, as well as to provide educational resources for providers in those communities. As Wyoming pursues Health IT and HIE implementation, the highspeed telemedicine network, along with the other telehealth projects, will be a crucial part of state’s health technology infrastructure. Since Wyoming established their original Health IT initiatives described above and submitted its original SMHP in March 2011, existing health IT initiatives in the state has experienced a marked increase in attention allowing and existing programs to evolve, in additional to new health IT initiatives having commenced. The below sections provide insight into the current HIT environment in Wyoming and the activities that support the progression of the HIT initiatives and described in Wyoming’s first SMHP submission and additional activities from around the state.
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Section A: The State “As Is” Landscape Wyoming Healthcare Environment Covering nearly 98,000 square miles, Wyoming is the nation’s ninth-largest state measured by geographic area; however, with a population last estimated during the 2014 census at 584,153 it is one of the least populated states in the nation. Wyoming is one of only two states considered a “frontier state,” defined as a state with a population to land area ratio of less than six people per square mile. Wyoming has two metropolitan statistical areas and seven smaller micro-statistical areas. Seventythree percent of the state’s residents live in these nine communities and most of these communities are located near one of Wyoming’s borders. These demographics create unique healthcare challenges, including physician recruitment, maintaining an adequate emergency medical service (EMS) system and outmigration of residents who seek healthcare services in neighboring states. Resources for understanding the historic delivery of health care services in the state used a report done by the Wyoming Health Care Commission in 2007 and an environmental scan regarding HIT completed early in 2016. These resources consistently report the same challenges to delivery of high-quality healthcare services in the state: a small population spread over a large geographic area, difficulty in recruiting physicians and barriers to developing connections between healthcare delivery points. The studies and surveys have also proven useful for understanding the various forms of healthcare delivery organizations, whether those organizations are government, private, or hybrid entities. Wyoming Medicaid covers approximately 89,831 unduplicated individuals, or roughly 16% of Wyoming citizens. In addition to the individuals covered by Wyoming Medicaid, another 5,537 Wyoming children receive insurance through the Wyoming Kid Care CHIP program, a separate public-private partnership which shares its enrollment processes with Wyoming Medicaid, streamlining the application process. The Wyoming Medicaid program is currently growing with more than 90% of providers 10
in the state accepting Medicaid patients. Wyoming Medicaid pays providers on a fee-for-service basis--there is no Medicaid managed care in the state. Because of Wyoming Medicaid’s broad presence in the state, both in terms of covered persons and enrolled providers, Wyoming Medicaid is in a position to influence and assist the Wyoming health care stakeholders with the adoption of health IT and HIE initiatives. As with primary care practitioners, the number and geographic distribution of specialty providers is also inadequate in Wyoming. Other than radiology and orthopedic surgeons, specialists are in short supply and most are concentrated in the state’s two largest urban areas: Cheyenne (in the southeastern corner of the state) and Casper (in the center of the state). Wyoming residents often seek specialty care in other states, particularly in Denver, CO, Salt Lake City, UT and Billings, MT.
Wyoming eHealth The passing of the American Recovery and Reinvestment Act (ARRA) and the accompanying availability of federal funding streams reinvigorated Wyoming’s activities related to health information exchange. In the fall of 2009, Wyoming’s governor appointed a task force named the Wyoming e-Heath Partnership and asked that task force to examine and improve healthcare delivery for the citizens of the State of Wyoming. In March 2010, the Office of the National Coordinator for Health Information Technology (ONC) awarded the e-Health Partnership a cooperative agreement to fund development of a state HIE. The e-Health Partnership deployed health information exchange services in a phased approach, beginning with direct exchange services. However, this project failed to be self-sustaining and the ONC Funding that supported this project was returned in spring 2013 Using ARRA funds through the State Broadband Data and Development Grant Program, Wyoming completed the data collection and mapping of broadband capacity. Wyoming also developed a State Broadband Framework to guide the work of the State in expanding broadband capacity. One of the broadband opportunities identified in the State Broadband Framework includes advancing efficient access to health care information and health care services throughout the state. The actions 11
associated with this identified opportunity include (a) assess and address any connectivity gaps required to meet Wyoming Health Information Exchange objectives; (b) expand home telehealth and health monitoring use and innovations; and (c) establish partnerships between healthcare entities and public access computing centers (i.e. libraries) to provide training or resources to support access to health information and health care. A final area of ARRA funding related to the EHR Incentive Program affecting Wyoming’s health IT planning is ONC’s Health Information Technology Extension Program, which funds Regional Extension Centers. ONC awarded Mountain-Pacific Quality Health Foundation, the Quality Improvement Organization (QIO) for Montana, Wyoming, Hawaii and Alaska a cooperative agreement to serve as the Regional Extension Center for both Montana and Wyoming. The Wyoming Medicaid EHR Incentive Program successfully launched in December, 2011 and has registered 72 providers and 12 hospitals and paid out $5.9M as of June 18, 2012. Wyoming saw a surge in momentum in the fall of 2012 as it moved from planning to implementation activities. In accordance with its approved strategic and operating plans As of December 2015 Wyoming has made significant progress in administering the EHR Incentive Program. Table 1 below represents the total providers and amount paid broken out by provider type participating in the EHR Incentive Program between the start of the program in 2011 through December 31st, 2015.
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Provider Type
Total Providers
Total Payments
Acute Care Hospitals
57
$ 15,975,697.62
Certified Nurse Midwife
2
$ 29,750.00
Dentist
18
$ 382,500.00
Nurse Practitioner
33
$ 561,000.00
Pediatrician
82
$ 1,269,333.34
Physician
94
$ 1,627,750.00
Physician Assistants (FQHC/RHC)
1
$ 21,250.00
Totals
287
$ 19,867,280.00
Table 1: Total Numbers by Provider Type
To coordinate these varied efforts and ensure consistent communication about HIT and HIE projects funded by ARRA, Wyoming and Montana stakeholders created the Northern Rockies HIT Coalition. Representatives from the joint Regional Extension Center, both states’ HIE cooperative agreement awardees, both states’ Medicaid agencies and both states’ HIT Coordinators meet regularly to discuss their respective progress and planned outreach activities. The Coalition demonstrates the commitment of all the parties to leverage resources toward the common goal of promoting HIT and HIE adoption and supporting both the Medicare and Medicaid EHR Incentive Programs. In addition to ARRA funds granted to Wyoming under the EHR Incentive Program and the State Broadband Data and Development Program, in the summer of 2010 the Wyoming Department of Health Immunization Section applied for and was awarded ARRA grant funds from the Centers for Disease Control for activities designed to increase the interoperability 13
between EHRs and Immunization Information Systems (IIS). The WDH Immunization Section will use the grant funds to increase the number of immunizations reported to Wyoming’s IIS (the Wyoming Immunization Registry, or WyIR) directly from provider EHR systems, as well as decrease the time between the administration of the immunization and the reporting of the immunization to the registry. The objectives of the grant will be achieved through a combination of making direct connections from specific providers’ EHR systems to the WyIR and making connections from EHR systems to the Total Health Record (THR) Gateway and then extracting and forwarding immunization information from the THR Gateway to the WyIR. Within WDH, Medicaid and the Immunization Section are working cooperatively to make immunization connections in the most efficient manner so as to maximize the exchange of information and minimize costs to the Department and to providers. The objective of enhancing the interoperability of EHRs with Immunization Information Systems promotes overarching objectives of encouraging the exchange of healthcare information in electronic format. These immunization connections will help the State report more accurate immunization statistics, give doctors real-time patient immunization histories and add one more data element in the health IT progression in the State of Wyoming. The Wyoming Department of Health Immunization Section applied for this funding with the specific objectives of the grant and the overarching objectives for improving healthcare provided by WDH and the State of Wyoming in mind. The work in the telecommunications sector necessary to support widespread adoption and use of health IT and health information exchange continues in Wyoming under the ARRA State Broadband Data and Development Program grant. While these grant funds will not be used for any procurement or capacity build-out, the funds are supporting wide-scale analysis of the broadband needs and capacity in the State, with a focus on the State’s smaller communities that has not before been possible. This grant also enabled the State of Wyoming to hire a Broadband Coordinator position, which sits in the State’s Office of the CIO, along with the HIT Coordinator. The close proximity of these two positions facilitates communication and collaboration between these two closely-related grants and systems. In addition to those grant opportunities identified in Wyoming’s SMHP in 2011, the Wyoming State Legislature authorized a
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state-funded grant opportunity for the state’s critical access hospitals. This grant opportunity provides funding for those facilities who need assistance in acquiring (or upgrading) the certified electronic health record technology necessary to meet Meaningful Use. These grant awards were announced June 30, 2012. Another component of Wyoming’s HIT landscape was the work that was completed with the Children’s Health Insurance Program Reauthorization Act (CHIPRA) Demonstration Grant awarded in 2010 to the State of Maryland in partnership with Wyoming and Georgia. The grant will be used to improve the quality and cost of care for Wyoming Medicaid and S-CHIP children with serious behavioral health disorders by implementing or expanding a Care Management Entity provider model and employing health IT to support clinical decision making. Under the terms of the grant, Wyoming will use health IT systems to improve timeliness and access to care, support provider efforts in quality improvements and improve prescribing and monitoring of psychotropic medication use by children. The objectives of this grant was closed and phased into another program in 2015. EHR Adoption and readiness
Over the last 10 years, a number of HIT surveys and studies have been conducted in Wyoming. Previously the comprehensive analysis completed at the request of the Wyoming Health Care Commission in 2007 by the Wyoming Survey and Analysis Center (WYSAC) at the University of Wyoming, in cooperation with the WyHIO. This survey concluded that significant progress had been made in HIT since an earlier survey in 2005, finding that electronic medical records software was in place in 44% of clinics and private physician offices and 64.5% of the reporting hospitals. In addition, billing and administrative functions were automated in at least 84% of clinics and private physician offices and all but one reporting hospital. Nearly all locations surveyed had some form of Internet access.1 In anticipation of development of this SMHP, WDH hired Public Consulting Group (PCG) to complete an environmental scan of provider HIT adoption in the state. The environmental scan, conducted in January through March of 2016, asked Wyoming
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individual and institutional providers to describe their current and planned use of health IT. The scan had the following purposes: ● Update select information from previous scans conducted in the state; ● Validate the underlying planning assumptions for the state’s HIT planning; ● Better inform the state’s activities related to HIE, the administration of the Medicaid EHR Incentive Program and the activities of the state’s Regional Extension Center; and ● Ensure conformance of the HIE and State Medicaid Strategic Plans to the guidance issued by ONC and CMS, respectively. The original environmental scan results focused on providers that met the CMS Medicaid incentive eligibility definition in the Final Rule: physicians, dentists, certified nurse midwives, nurse practitioners, physician assistants and hospitals. Complete scan results were made available to the Wyoming e-Health Partnership, Wyoming Medicaid and the Regional Extension Center. Most recently, WHD continued their partnership with PCG to complete the new and updated environmental scan using the email survey tool Survey Monkey, PCG and WDH developed a nineteen-question survey aimed at understanding the provider community’s adoption and use of Health Information Technology (HIT) throughout the state. The survey included a combination of multiple choice and open response questions. PCG and WDH collaboratively determined a key Healthcare Provider Stakeholder distribution list of approximately 1,444 providers. The survey link was distributed to this group on February 2, 2016 and remained open through February 19, 2016, with one reminder email sent out on February 16, 2016. The PCG and WDH team also attended a provider workshop in Wyoming, and encouraged providers to participate in the survey by both handing out survey links as well as having available iPads with the online survey available. A total of 307 responses were received, which yielded a 21.3% response rate. The web survey conducted in 2010 yielded a total of 108 responses. The following sections describe PCG’s findings regarding Wyoming providers’ HIT and HIE landscape and readiness.
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Wyoming EHR Incentive Program
As mentioned above, Wyoming has had substantial growth in the adoption and retention of eligible professionals in the EHR Incentive Program. The table below details the total number of eligible providers and eligible hospitals counts and payments broken down into AIU and MU as well as program year. Table 2 allows for a comprehensive overview of EHR adoption and engagement in the Wyoming EHR Incentive Program from the beginning of the program to current. EP/EH
Total AIU
Total Paid AIU
Total MU
Amount Paid MU
Total Paid
Amount Paid
Hospitals 2011
0 $0.00
0 $0.00
0 $0.00
Providers 2011
0 $0.00
0 $0.00
0 $0.00
Total for 2011
0 $0.00
0 $0.00
0 $0.00
Hospitals 2012
15 $5,944,662.24
6 $2,320,620.94
21 $8,265,283.18
Providers 2012
48 $1,005,833.34
4 $34,000.00
52 $1,039,833.34
Total for 2012
63 $6,950,495.58
10 $2,354,620.94
73 $9,305,116.52
Hospitals 2013
6 $1,726,703.11
3 $822,717.45
9 $2,549,420.56
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Providers 2013
56 $1,190,000.00
9 $76,500.00
65 $1,266,500.00
Total for 2013
62 $2,916,703.11
12 $899,217.45
74 $3,815,920.56
Hospitals 2014
1 $336,706.21
13 $2,209,506.91
14 $2,546,213.12
Providers 2014
26 $552,500.00
22 $187,000.00
48 $739,500.00
Total for 2014
27 $889,206.21
35 $2,396,506.91
62 $3,285,713.12
13 $2,614,780.76
13 $2,614,780.76
Hospitals 2015
0 $0.00
Providers 2015
17 $361,250.00
48 $484,500.00
65 $845,750.00
Total for 2015
17 $361,250.00
61 $3,099,280.76
78 $3,460,530.76
Hospitals 2016
0 $0.00
0 $0.00
0 $0.00
Providers 2016
1 $21,250.00
0 $0.00
1 $21,250.00
Total for 2016
1 $21,250.00
0 $0.00
1 $21,250.00
Table 2: Total EPs/EHs Paid by Payment Year
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Environmental Scan
The majority of provider respondents were individual providers (47.1%). Respondents who specified “Other” included public health offices, dental offices, skilled nursing facilities, long term care facilities, nursing homes, etc. (Figure 1). The majority of responses were collected from Natrona County (19.4%), Laramie County (13.7%), Sheridan County (9.0%), and Fremont County (8.7%) which are four of the five most populated counties in Wyoming.
Figure 1: Organization Types
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EHR Incentive Program Findings According to the survey, the knowledge, use, and adoption of HIT seems to vary substantially across Wyoming providers. When providers were asked to rate their level of knowledge regarding the Medicare / Medicaid EHR Incentive Programs, the average rating was 2.59 on a 5-point scale. A majority of the respondents (62.9%) stated that they have never participated in an EHR Incentive Program.
Figure 2: Knowledge of Medicare/Medicaid Incentive Programs
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Of the respondents who stated that they had participated in an EHR Incentive Program, the majority (46.2%) of these providers have achieved Stage 2 of Meaningful Use (Figure 3)
Figure 3: Stage of MU Achieved
When asked about the level of support providers had received from their EHR vendor, the mean rating was 3.40 on a 5-point scale, 1 being no support and 5 being very supportive (Figure 4).
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Figure 4: EHR Vendor Support Meeting MU
When respondents were asked if they have received support from an organization other than their EHR vendor to achieve MU, 34.2% stated that they have utilized Health Technology Services Regional Extension Center (REC). Providers who specified “Other” (55.3%) included responses such as: · · · · ·
Medicare Indian Health Services Billing Clinics Professional Organizations None/not applicable 22
EHR Status Approximately 63.8% of the providers that responded to this survey stated that they have an EHR. Of those respondents with an EHR, the majority (74.2%) do not use any software to assist with care coordination. Common responses for organizations that do use software to assist with care coordination included Dentrix Dental System, Therapy Notes, and the Wyoming Immunization Registry, among other programs. Positively, a notable percentage of respondents (32.4%) indicated that they had experienced no barriers with the adoption and use of an EHR. However, the remaining respondents indicated experiencing technical, financial, operational, and other barriers. Common themes in the open responses included an EHR not being able to meet specific or nuanced needs, physician and staff resistance to change, lack of support, adopting an EHR being a time-consuming process, lack of communication with other EHRs, poor connections, etc. The majority of respondents (48.8%) indicated that they are not currently sharing clinical data electronically. However, a number of providers indicated various methods of clinical data exchange (Figure 5). The majority of respondents (79.8%) do not have a Direct Trust secure message account. As WDH has a limited number of Direct Secure Messaging (Direct Trust) accounts that can be provided to the provider community for free, identifying providers who are interested in DSM (Direct Trust) and want an account is a key next step (Figure 5).
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Figure 5: Clinical Data Shared Electronically
HIE Participation When asked about their level of interest / need in participating in an Exchange across provider networks both in and out of Wyoming, the average rating was 2.82 on a 5-point scale (Figure 6). 24
Figure 6: Interest/Need in Participating in an HIE
There seemed to be provider interest across the spectrum of services that could be provided by an HIE. Respondents indicated that medication history, downloadable clinical summaries, and test results would be most valuable, in addition to other HIE services such as referrals, lab results, and immunization history (Figure 7).
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Figure 7: Most Valuable HIE Services
When asked about what gaps an HIE could fill, providers indicated that an HIE would be useful for a variety of reasons including continuity of care, discharge summaries, faster speed and ease of acquiring information, referrals and exchange of information between facilities, medical history, radiology and lab testing done by other providers, and reduced paperwork. Importantly, 24 of 76 providers who responded to this question indicated that there were no gaps an HIE could fill or they were unsure. These data points speak to the Wyoming providers’ lack of education or exposure to the services that an HIE could provide. It will be critical to understand Wyoming providers’ preferences for a sustainable model for a statewide HIE. The majority of respondents preferred a usage fees sustainability model, or a model based on the actual volume of usage (53.3%). When asked about preference of a governance structure for a statewide HIE, the majority of respondents indicated that they had no preference (80.4%). 26
However, a recurring theme for the respondents that indicated a preference was that the HIE governance should be administered by a private non-profit organization to lead with state participation on the Board of Directors (or non-state participation at all). Conclusions and Limitations While the survey yielded a significant amount of responses from a wide range of Wyoming providers, responses were obtained from a low percentage of the entire Wyoming provider community, and as such, the analyses from this survey are not representative of the Wyoming provider population. Thus, the results are planned to be used for informative and descriptive purposes, rather than predictive and representative analysis. The Environmental Scan importantly also will include supplemental findings from the Focus Groups and Targeted Interviews in the sections below, which support a more holistic representation of the Wyoming provider community’s use and adoption of HIT. Some limitations of conducting a web survey can be attributed to several causes listed below.
Time constraints and resource availability – The time, costs and resources required to conduct a survey representative of an entire population can be significant, especially when it comes to successfully marketing the survey and engaging participant interest. In conjunction with WDH, key groups of providers were included in the web-survey to determine the need and value of an HIE in Wyoming.
Unique population – The State of Wyoming’s unique geographical landscape make it difficult to target a certain population.
Limited distribution channels – The survey’s primary source of distribution was electronically through an email distribution list. As a result, providers without internet access were excluded from participation. This limitation may have been exacerbated because of Wyoming’s sparsely populated rural areas that are faced with broadband challenges. Additional distribution channels, such as mail and phone, would have increased the sample size, but the team concluded that focus groups and targeted interviews will be conducted to further explore survey findings and mitigate the risk of the sample size not being representative. 27
Survey length and complexity – The survey set out to capture much information about Wyoming’s HIT landscape. Working alongside WDH, PCG attempted to create a survey that had the right balance between user friendly and too detailed.
This provider survey will serve as a foundation for future data gathering. Understanding Wyoming’s unique provider landscape is a challenging task that will require more focused questioning to smaller, more targeted populations.
Broadband Internet Access Lack of broadband access does not appear to present a barrier to HIT adoption in Wyoming. More than 97% of physician practices reported having broadband access to the Internet, while only two practices reported having only dial-up capability. The widespread availability of broadband access will facilitate the state’s efforts to promote the use of HIE. With broadband actions identified the current broadband coverage can be viewed at the following website http://www.broadbandmap.gov/summarize/state/wyoming. Wyoming plans to stay active in addressing the remaining broadband challenges through.
Federally Qualified Health Centers (FQHCs) In October 2010, Wyoming Primary Care Association (WYPCA), an advocacy group for Wyoming health centers, surveyed the FQHCs regarding their HIT adoption. All five Wyoming FQHCs have an EHR in place, with Allscripts used most commonly. None of the Wyoming FQHCs applied for HIT/EMR funding from the Health Resources Services Administration (HRSA).
Veteran Administration and Indian Health Services In addition to the state’s 27 acute care hospitals mentioned above, Wyoming providers also practice in federal health care locations, including two Veteran’s Administration (VA) hospitals and two Indian Health Services (IHS) clinics. The Wyoming VA hospitals use the VistA Computerized Patient Record System and are positioned to use this technology in a meaningful way. The IHS facilities 28
utilize the RPMS EHR system, an adaptation of VistA. Wyoming does plan to pursue interoperability with both the VA and HIS, however there is no definite date on when the connections will take place.
Current State of HIT Relations within Medicaid and the Wyoming Department of Health Overall IT Environment The health information architecture of Wyoming Medicaid has evolved over the years along a traditional pathway combining multiple approaches to software development, system operation and functional oversight. The result is a loosely integrated environment where the system components and functional units come together to manage the health care services provided to Medicaid clients. Medicaid is developing additional health IT systems which promise to move the Medicaid enterprise into a more client-centric and integrated environment which will share information across the care continuum. Wyoming Medicaid and other WDH personnel are involved in many of these efforts. These activities will support the Wyoming EHR Incentive Payment Program both directly and indirectly, as the WDH compiles data sources available to the EHR Incentive Payment Program for verification purposes and creates infrastructure to facilitate sharing of the data across organizational and geographical boundaries. The health IT systems currently supporting Medicaid is quite functional with MMIS providing relatively strong functionality. Some specialized applications to augment the MMIS have been developed in-house; others are the product of third-party vendors. Some of the application systems are hosted within the State of Wyoming’s information technology infrastructure and some are hosted by private contractors. The application systems have been adapted to coordinate activities through a combination of on-line and batch processes. All are managed through the coordinated efforts of several State of Wyoming agencies which are mutually dependent on each other for information and data sharing. The overall system is successful because the core MMIS is solid and the Medicaid program has historically enjoyed strong support and collegial relationships with these other agencies. The respective responsibilities of these agencies are summarized below.
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SMA Relationships and Stakeholder Engagement
All of the organizations below are entities that the SMA has relationships with that include a focus for improving HIT/HIE. Some are at the county level, university level, or at the state government level. WY Department of Health The WDH provides and manages healthcare benefits which are the responsibility of the State of Wyoming. These programs include Medicaid and Kid Care CHIP (the Children’s Health Insurance Program) and Medicaid eligibility is determined by the WDH Customer Service Center. They take applications via walk-in, mail-in, fax, phone and online. The WDH also administers state and federal funds to support the state’s public health programs, including mental health and substance abuse, developmental disabilities, aging, rural and frontier health, preventive health and safety and community and public health programs. Because the state’s medical assistance programs and public health programs operate within the same agency, these programs develop collaborative working relationships focusing on how best to leverage resources and serve the state’s citizens. In the case of the EHR Incentive Program, Medicaid staff have taken the lead in education and promotion of the WDH’s planning and execution of activities designed to support Wyoming professionals and hospitals seeking incentive payments. While Wyoming Medicaid operates the Wyoming EHR Incentive Program independently, Medicaid anticipates the need for the WDH to develop and implement policies and initiatives to ensure the continued cohesive transition from paper to electronic health information. State Auditor’s Office The State Auditor’s Office (SAO) makes all cash disbursements from the State of Wyoming treasury. Upon determination that a covered service has been provided to an eligible beneficiary and the extent to which the State of Wyoming shall pay for such service, the SAO will disburse funds to the provider. The EHR Incentive Payment Program will use the SAO to undertake disbursement of incentive payment funds to providers who qualify for incentive payments.
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Institute for Population Health The formation of the Institute was to centered around the goal of providing Wyoming communities and their healthcare providers develop strategic platforms for taking a more proactive approach to patient care and population health management – reaching out to the residents beyond the traditional four walls of a hospital or a clinic to address the challenges of caring for frail or vulnerable populations; rising chronic disease rates; and delivering evidence-based preventive health services. The Institute plays a key role in the alignment of CQMs for both the EHR Incentive Program in and the Patient Centered Medical Home (PCMH), a population health initiative that promotes a pay for quality program for providers in the state. PCMH is discussed in further detail later in this section.
Plans to Improve HIT/HIE Entity Relationships The SMA communicates frequently with all of its stakeholders to ensure it is communicating its vision, priorities and provides resources if possible to ensure its providers can be successful in adopting and implementing health IT and reaching MU milestones. The agency is transparent in its dealings with all participants.
Health Information Exchange Governance Structure Wyoming does not currently have a functioning statewide HIE, However the state is currently contracting with Public Consulting Group (PCG) to provide HIE planning oversight in preparations of issuing an RFP for Statewide HIE Solution in early 2017. The state does however have a Medicaid specific HIE through the Total Health Record (THR) Gateway. As a component of the Total Health Record and the heart of the system for Medicaid’s purposes, the THR Gateway is the health information exchange component that receives feeds from the Medicaid MMIS and the Medicaid PBM system and incorporates the information from those claims databases (such as diagnosis codes and prescriptions filled) into a Continuity of Care Document (CCD). The THR Gateway also has 31
the capability to pull information from the Total Health Record Electronic Health Record (EHR), further discussed below, and deduplicates the information appropriately to add to the Medicaid only patient’s C/CDA. Current Plans to use HIE to meet MU and how HITECH systems will achieve state health goals Wyoming worked with other HIT stakeholders to ensure coordination and develop strategies that meet the evolving business needs of HIT/HIE environment, as well as supporting the continued adoption of health technologies by physicians and other providers. To warrant the HIEs adoption by Wyoming’s health care population, alignment with public health reporting was established for Meaningful Use. Submission to state public health registries will be achieved through a making direct connections from specific providers’ EHR systems to the Total Health Record Gateway and then extracting and forwarding it to the registries (Figure 8).
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Figure 8: THR Gateway
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Role of the MMIS in the Current HIT/E Environment Currently, the MMIS is the de facto Health IT environment for Medicaid programs. The data warehouse which stores information from the MMIS is Wyoming Medicaid’s definitive source of information for client and provider demographics and can be queried to glean information from claims data. When WDH programs seek information about utilization of services or quality of care, the typical approach is to look to the MMIS, either by running a stand-alone query or developing an application to support ongoing monitoring of the desired information. Medicaid implemented its cornerstone health IT project known as the Total Health Record (THR) in 2009. The MMIS supports the Total Health Record Gateway by sending a feed of claims data to the Total Health Record Gateway module in order to populate the master patient index and the provider index within the THR Gateway module. In addition, the THR Gateway uses MMIS insurance coverage and claims data when responding to a request for a Continuity of Care Document (CCD) to populate insurance and clinical fields of that CCD. The design of the THR Gateway also contemplates using MMIS claims data to support a clinical rules engine within the THR Gateway to offer physicians limited clinical decision support. As currently designed, these data exchanges will flow only unidirectional from the MMIS to the THR Gateway; however, WDH will continue to seek opportunities to enhance interoperability between the MMIS and THR Gateway in later stages of the project. The current capabilities of the MMIS also will support the Wyoming Medicaid EHR Incentive Program. This support will consist of matching provider enrollment data from the CMS Registration and Attestation System (NLR) to data in the MMIS and for supplying the provider’s information for payment processing. In addition to providing this administrative data, the MMIS will verify substantive requirements of the EHR Incentive Program, including Medicaid patient volume and the provider’s type. Medicaid Information Technology Architecture
Medicaid has completed its internal Medicaid Information Technology Architecture (MITA) assessment in 2015. A HIT MITA assessment is scheduled to be completed in 2016. 34
The plan to move Wyoming into alignment with the MITA Maturity Levels and Seven Standards and Conditions will be done through continued emphasis on improving operations of the Medicaid programs. MITA SS-A included a five-year roadmap or transition plan described the details of how to move from the “As-Is” to the “To-Be”. Below illustrates the identified components of the “As-Is” and “To-Be” as it concerns Wyoming’s concepts of operation (Figure 9).
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Figure 9: As-Is/To-Be
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States Activities Underway to Facilitate HIT/HIE Adoption Current Contracted Services The SMA has contracted for the following services to support the adoption of HIT/HIE activities comprising the operation and administration of the EHR Incentive Program (Table 3).
Activity
Description
Contractor
IAPD Status
SLR Reporting
Development of detailed reports for the state to identify populations and providers to extend outreach. Additionally the development of financial reporting Implementation of Modified Stage 2 for Program Year 2015 and 2016, the development of Stage 3 requirements. Ongoing maintenance of SLR system Provide full range auditing procedures for the Meaningful Use Develop, distribute and provide detailed environmental scan report of the HIE/HIT landscape.
HealthTech Solutions
Included in FFY 20152017
HealthTech Solutions
Included in FFY 20152017
Myers & Stauffer
Included in FFY 20162017
PCG
Included in FFY 20142016
Development of the HIE Strategic Plan, HIE Sustainability Plan, HIE
PCG
Included in FFY 20152017
SLR Development and Maintenance
EHR Incentive Program Auditing Services Environmental Scan
Statewide Health Information Exchange Planning
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Internal HIT Training
Total Health Record Gateway
Business Plan, and HIE IAPD for preparations of a statewide HIE. The development of training modules and education material centered on the EHR Incentive Program and how HIT is part of Medicaid. The development of training is for the purpose of internal Wyoming Medicaid staff. The development and expansion of activities including clinical alerts with access to the Medicaid CCD, and connection/ onboarding of providers for Wyoming Public Health Reporting for MU.
Brijent
Included in FFY 20152017
Xerox
Included in FFY 20152017
Table 3: Contracted Services
States Role in Facilitating HIE and EHR Planning Adoption Wyoming Medicaid is the strategic driver in facilitating provider adoption of health IT. To encourage and facilitate provider adoption of HIT, Medicaid a vital role in HIT adoption across the state. The Following details Wyoming’s scope in planning and aiding in EHR adoption. Administering CMS Medicaid EHR incentives and Maintaining State Level Registry System: Medicaid is responsible for administering the Wyoming Medicaid EHR Incentive Program for eligible professionals, eligible hospitals and CAHs. Medicaid has contracted an incentive program administrative system to be accessible to providers and to 38
contain the appropriate controls required by CMS. This design for the incentive program administrative system is described more fully in the Section C of the SMHP. Low-cost EHR alternative: WDH recognized the aggressive timing of the EHR Incentive Program coupled with the cost barrier to EHR adoption as challenging for Wyoming providers. In response, WDH accelerated adoption of EHR technology by offering the Total Health Record Electronic Health Record component, a state funded ONC Certified product. WDH’s THR EHR technology for Medicaid providers, allows for the eligible provider population to access a certified EHR technology free of charge will mitigate both the timing and cost challenges providers face. As an ONC-certified product, the THR EHR qualifies as “certified EHR technology” and provides functionality capable of meeting the Stage 1 and 2 measures and objectives of meaningful use. The THR EHR has provided a solution that gives providers experience with health IT, and has also given providers the tools needed to achieve meaningful use and thereby to qualify for the EHR incentive payments.
Direct outreach to providers who appear to be eligible for the Wyoming Medicaid EHR Incentive Program:
Through continued analysis of MMIS claims data, the results of the environmental scan and the current Medicaid high volume incentive program, Medicaid continues to analyze and identified Wyoming providers who are likely to be eligible for the Wyoming Medicaid EHR Incentive Program. Medicaid will contact these providers in a variety of ways, including in-person visits. Contact with providers also allows for an initial assessment of their EHR adoption status. Data Availability for decision-making The ability of the Total Health Gateway to generate a Continuity of Care Document (CCD) provides a snapshot of a patient’s health, including demographics, primary diagnosis, secondary diagnosis, allergies and current medications, and also a source of data for quality reporting. In addition to the CCD, the Wyoming PCMH and Data Repository, discussed in further detail below, allow for population and or patient specific analysis of CQMs, claims, and clinical data analytics.
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Health IT Enhancements in Progress REC
The Wyoming REC Program continues to work with Wyoming providers to implement and use certified EHR technology in their practices. Mountain-Pacific Quality Health is a nonprofit corporation that strives to be the “go-to” resource for driving innovation in health care systems in the states and territories we serve. They first began partnering with providers, practitioners and patients in Montana in 1973. With four decades of experience, they now support the health care communities of Montana, Wyoming, Hawaii, Alaska, Guam, American Samoa and the Commonwealth of the Northern Mariana Islands. Total Health Record
WDH implemented a significant HIT initiative in 2010 that was designed to increase HIT functionality. This initiative is known as the Total Health Record (THR). The THR is a web based system consisting of two components: an ONC certified Electronic Health Record offered at no cost to Wyoming Medicaid providers to assist them with meeting MU requirements. This system is 100% state funded. The THR Gateway which provides a single connection point for Wyoming providers to electronically submit Public Health data to be in compliance with MU. The THR Gateway also hosts connections with other program within the WDH which provides a C/CDA on Medicaid beneficiaries.
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Wyoming Population Health Initiatives: Patient Centered Medical Homes
Wyoming Medicaid is actively pursuing the meaningful use of technology to improve healthcare quality and outcomes. With the passage of the Affordable Care Act, Wyoming Medicaid began thinking strategically of how it could support the National Strategy for Quality Improvement in Health Care and pursue the goals of quality health care with measured improvement in care outcomes for the overall health of Wyoming residents. The National Quality Strategy focuses on six priorities, each of which is supported by a series of quantitative goals and measures: ● Patient Safety ● Care Coordination ● Efficient Use of Healthcare Resources ● Patient and Family Engagement ● Population and Public Health ● Clinical Processes/Effectiveness To achieve the quality improvements envisioned by the National Quality Strategy, the Strategy calls for “data on care delivery and outcomes [that can] be measured using consistent, nationally-endorsed measures in order to provide information that is timely, actionable, and meaningful to both providers and patients.” Wyoming Medicaid has identified nine Clinical Quality Measures (CQMs) addressing Population and Public Health and Clinical Processes/Effectiveness to be the focus of the Wyoming Quality Care Coordination Program. The use of CQMs aligns with The Centers for Medicare/Medicaid Services use of CQMs in a variety of quality initiatives that include quality improvement and public reporting. The CQMs, which are designed to capture the degree to which a provider delivers appropriate clinical services in an optimal timeframe, address: 1. Tobacco use assessment and tobacco cessation intervention 2. Breast cancer screening 3. Cervical cancer screening 4. Colorectal cancer screening 5. Childhood immunization status 6. Diabetes hemoglobin A1c control 41
7. Diabetes blood pressure management 8. Diabetes low density lipoprotein (LDL) management and control 9. Follow-up care for children prescribed ADHD medication To reward primary care providers who participate in the Wyoming Quality Care Coordination Program (WYQCCP), Wyoming Medicaid is using a “pay-for-quality” program that will financially incentivize primary care providers to report the nine CQMs through the Wyoming Electronic Health Record (EHR) Incentive Program State Level Repository web portal manually from the provider’s electronic health record (EHR). QCCP and popHealth systems are tools for Clinical Quality Measure reporting. These tools are vendor hosted a maintained by Healthtech Solutions (HTS).
Wyoming Data Repository and Data Analytics
HTS recently implemented its Data Repository and Data Analytics solution in WY. The data repository accepts feeds from Xerox MMIS claims data to optimize Wyoming’s reporting capabilities in addition to colleting data from the popHealth tool in the SLR portal. The Implementation of the Data Repository brings together clinical and claims information to provide meaningful views of the quality data and state specific reporting. The reports are created in such a way that they allow WDH to have filtering options and date parameters so reports can be recreated by WDH on demand to fit their needs.
HIT/HIE Activities Crossing State Borders Wyoming does have a high referral pattern across state lines. There are connections currently in place with Colorado and Utah being the most common. Wyoming continues to coordinates with bording states to promote interoperability and accommodate patient referrals
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Public Health Reporting Immunization Registry The Wyoming Department of Health Immunization Section received a grant from the Centers for Disease Control (CDC) to increase the interoperability between EHRs and Immunization Information Systems in the summer of 2012. Connections with four certified EHR products was undertaken to establish a connection to the Wyoming Immunization Registry (WyIR) through the Total Health Record (THR) Gateway. Once the initial connection was established, additional Public Health reporting could be completed through the same interface. The Wyoming Immunization Registry (WyIR) is a secure, confidential, Internet-based immunization database containing the electronic vaccination records of Wyoming residents. The WyIR system is administered and maintained by the Immunization Unit within the Wyoming Department of Health. The WyIR may be accessed at https://wyir.health.wyo.gov/wysiis/login.jsp In addition to providing a method by which to access and update a patient’s vaccination history, the database assists the provider in managing vaccine inventory as well as generating immunization forecasts and sending reminder/recall alerts to patients. Cancer Surveillance The Wyoming Cancer Surveillance Program (WCSP) is a statewide population-based cancer incidence, follow-up, treatment and mortality monitoring system that collects, analyzes and disseminates information on all new cancer cases in Wyoming. In operation since 1966, the WCSP has been collecting cancer data on all cancer cases diagnosed or treated in Wyoming since 1962. The WCSP monitors cancer incidence through pathology reports and uniform reporting of information by health care providers in Wyoming. In 1977, a law was passed requiring reporting by all entities detecting, diagnosing and treating cancer cases in Wyoming (statute 35-1-240[b] and public law 102-515). Submission to the WCSP is done through the THR Gateway similar to the WyIR. Healthcare providers including, but not limited to, hospitals, ambulatory surgery centers, laboratories, radiation therapy facilities, oncology facilities and physician
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offices are required to report cancer cases to the Wyoming Cancer Surveillance Program. Hospitals need to abstract and/or report inpatient and outpatient cancer cases. Electronic Lab Reporting The THR Gateway enables electronic lab reporting for Wyoming providers through an HL7 interface to the Wyoming the Infectious Disease Epidemiology Program. In addition to reporting to the program providers can use this submission to meet compliance of reporting to specialized registry for meaningful Use. Syndromic Surveillance Registry The Wyoming Department of Health uses Health Monitoring Systems (HMS) EpiCenter for all syndromic surveillance activities and disease reporting. The Department requires Wyoming hospitals and non-hospital eligible providers to contract with HMS for submission of syndromic surveillance data to meet Meaningful Use criteria.
State Laws or Regulations and HIT Related Grants No regulations or grants that currently affect the EHR Incentive Program in the state of Wyoming
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Section B: The State’s “To-Be” Landscape Medicaid continues with other stakeholders in Wyoming to develop a statewide interoperable health care network that will be capable of sharing data both in state and across state lines. . Wyoming’s vision for health information technology is ’To promote a healthier Wyoming by developing a secure, connected and coordinated HIT system that supports effective and efficient health care”
HIT and HIE Goals In the next 5 years Wyoming plans to have a functional and sustainable statewide HIE that will support referral patterns and electronic data exchange across state borders. The goal of interoperability is the key to the successes to determine the HIE needs for the state. Wyoming Medicaid plans to conduct targeted interviews and focus groups with stakeholders. Additionally Wyoming will continue to leverage an existing contract with PCG to complete the HIE planning work. Upon completion of requirements gathering the state will procure the statewide HIE solution. Wyoming hopes to select a vendor and implement a HIE solution by the end 2018. Wyoming also plans to utilize existing Medicaid systems, including but not limited to the MMIS, THR, popHealth, SLR, Eligibility, and Data Repository to extract the data in a manner to promote better patient outcomes and drive public health policies.
Medicaid EHR Incentive Program Goals: Figure 10 identifies the attestation rate of providers based on current registrations in the State Level Repository. As of calendar year 2015, 73 % of registered EP’s have attested with the Medicaid EHR Incentive Program. Returning EP’s to continue with MU attestation is at 56%. The goal for the EHR Incentive Program is to increase the return to 80% while also increasing the attestations of registered EPs to 90%. The EH percentages are expected to remain the same due to all Wyoming hospitals are dually eligible and have registered as such. Due to low volume and no Medicaid bed days, 3 of the 27 hospitals are not currently eligible for participation.
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Outreach continues to review and follow up with these EH’s regularly to assist as needed. Of the remaining EH’s participating, 50% have received full pay out for this program. Considering that there are newly eligible providers in the state every year, Wyoming continues to review claims data to identify providers with a high Medicaid volume. Once identified outreach to those specific provider types are performed.
OUTCOMES Performance Metric
CY 2015 Target
CY 2016 Target
CY 2011
CY 2012
CY 2013
CY 2014
CY 2015*
% of First Year attestations based on registrations (cumulative)
77%
83%
N/A
43% EP 83% EH
67% EP 88% EH
73% EP 85% EH
73% EP 85% EH
% Returning to Attest for Meaningful Use (cumulative)
92%
96%
N/A
8% EP 4% EH
12% EP 43% EH
27% EP 54% EH
56% EP 88% EH
(-) Indicates data not yet available N/A indicates data not yet available due to the creation of a new metric * As of July 31, 2015
Figure 10: EHR Incentive Program Outcomes and Targets
Technical Support for the EHR Incentive Program providers
Wyoming Medicaid offers a variety of solutions for providers. Collaboration with the regional extension center, working with provider’s vendors, targeted outreach, and one-on-one technical assistance with providers in regards to attestations and the SLR system. Additionally Wyoming’s SLR vendor can provide additional system technical support as needed. EHR Incentive Program over the next 12 months
Considering that there are newly eligible providers in the state every year, Wyoming continues to review claims data to identify providers with a high Medicaid volume. Once identified, outreach to those specific provider types is performed. In program year 2016, Wyoming is planning on focusing AIU outreach activities specifically for dental provider community, as it has been identified that a 46
majority of them meet the patient volume criteria as well as use ONC Certified EHR software. Outreach is performed through phone call and one-on-one education sessions with the providers to complete the attestations. Moving forward Wyoming plans to maximize participation in the EHR Incentive Program and continue to encourage EHR adoption within the states by provide a statewide HIE solutions to meet the needs of providers. Additionally, the state will continue to cover the cost of on-boarding to the THR Gateway for the purpose of public health reporting. There is no plan currently for Medicaid Expansion that would affect the EHR Incentive Program. It has been identified that if Medicaid expansion occurred in the state it would impact Eligible Providers and potentially Eligible Hospitals in the state.
IT System Architecture Wyoming is currently underway of re-procuring their MMIS. The procurement and implementation process is planned to stretch over a 3-4 year time frame where there will be a complete MMIS replacement in addition to the implementation of a Master Patient Index, Enterprise Service Bus, and a Data Warehouse. Wyoming has opted for a modular MMIS replacement so the RFP and implementation of the different components of the MMIS will phased in. Below illustrates the states MMIS replacement vision (Figure 11).
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Figure 11: MMIS Replacement Vision
As Wyoming looks to procure a MMIS replacement that will utilize a modular approach, connections between the different systems will enable multiple programs to use an assortment of data to assist with identifying gaps and resources available to address health disparities across the state. The illustration below depicts Wyoming’s IT Architecture goals over the next 5 years. The environment centers around interoperability with a specific focusing on data exchange between systems (Figure 12).
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Figure 12: IT Architecture
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Wyoming Providers Interfacing with Medicaid IT Systems Wyoming Medicaid is hoping to achieve certification as a PQRS registry. This is part of the overall strategy to eventually become a Qualified Clinical Data Repository (QCDR) to enable all Wyoming providers the ability for single log on to report CQMs for different programs. As part of the state Medicaid Payment Reform, a Patient Centered Medical Home model was launched in January 2015. This program is the beginning of CQM alignment with other state agencies as well as providing additional incentives for Wyoming providers that participate and provide regular CQM data. Additionally, Wyoming currently has 23 active connections with the THR Gateway for the purpose of public health reporting. Connection is established at the vendor level to off-set cost to the EPs and EHs. State funds cover the connection to the Gateway on the state side. Limited additional internal connections have been established with the Early Hearing Detection and Intervention Program, newborn screenings and Medicaid Waivers. All programs within the division do utilize the CCD viewer to access Medicaid patient data available through the THR Gateway.
Addressing the needs of unique patients through the EHR Incentive Program Wyoming has implemented a data repository to allow for the identification of unique populations with specific needs of care. The data repository is populated by a variety of means including, THR Gateway, SLR, and PCMH.
Anticipated state needs Since 2011 the state has been very supportive of the EHR Incentive Program and 10% match of HITECH funds to allow Wyoming to have a successful program. Currently the state does not anticipate the needs for any additional legislation
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Section C: Activities Necessary to Administer and Oversee the EHR Incentive Program Introduction In contrast to larger states, Wyoming anticipated a straightforward pathway toward implementation of the Wyoming Medicaid EHR Incentive Program. Although the work is complex, the numbers are small. Based on claims data, Wyoming Medicaid believes around 250 Eligible Professionals (EPs) working in less than 60 practice locations will have the required 30 percent Medicaid or Medicaid plus needy individual patient encounter volume. With respect to Eligible Hospitals (EHs), Wyoming Medicaid projects that 26 of the state’s 27 hospitals will meet the 10 percent Medicaid patient encounter threshold. Due to this small population, Wyoming Medicaid developed a cost-effective plan for the EHR Incentive Program that maximizes resources while providing the services and resources needed to support Wyoming providers.
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Organizational Chart
Figure 13: Organization Chart
EHR Incentive Staff
The Health Information Technology (HIT) Systems Manager, the HIT Outreach Coordinator and the EHR Program Specialist. Make up the EHR Incentive Program staff for Wyoming. A HIT Legal and Policy Advisor is available for staff as well.
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Health IT Outreach Coordinator The HIT Outreach Coordinator developed the Outreach strategy described in this SMHP. In addition to producing content over appropriate media, the HIT Outreach Coordinator conducts follow-up with Wyoming providers who request additional information about the EHR Incentive Program. The HIT Outreach Coordinator spearheads outreach and education efforts regarding the Wyoming Medicaid EHR Incentive Program. The HIT Outreach Coordinator focuses on Wyoming health care eligible professionals who are likely to qualify for EHR Incentive Program payments. The HIT Outreach Coordinator communicates with the statewide HIE entity staff, as well as directly with Wyoming professional organizations such as the Wyoming Medical Society, the Wyoming Hospital Association and the Wyoming Primary Care Association. The HIT Outreach Coordinator represents Medicaid in a collaborative effort with the Regional Extension Center. This position is also responsible for maintaining a http://wyomingincentive.wyo.gov/ As the EHR Incentive Program matures, the EHR Incentive Program Outreach Coordinator will assist with continued promotion of the incentive payment program, as well as other initiatives undertaken by Medicaid to promote the adoption and use of EHR systems among Wyoming health care providers. HIT Systems Manager The HIT Systems Manager is responsible for gathering business requirements and assisting with the design of an electronic system for administering the Wyoming Medicaid EHR Incentive Payment Program. This position manages the business processes of the EHR Incentive Payment Program and works with the WDH-IT division as well as with Medicaid’s MMIS contractor to incorporate the specifications of existing systems into this project.
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The Medicaid HIT Systems Manager serves as a point of contact for health IT projects both within WDH and between WDH and other stakeholders in the Wyoming health care system. This position interacts with WDH Senior Management as well as with program leaders within the Medicaid office. The HIT Systems Manager solicits and reviews proposals for vendor services regarding the Wyoming Medicaid EHR Incentive Program, monitors day to day operations of the program and assumes primary responsibility for creating and submitting required documents to CMS, including this SMHP and the accompanying I-APD. The HIT Systems Manager contributes expertise regarding the requirements for Meaningful Use and how CQM data submitted by eligible hospitals and providers can be leveraged to improve outcomes across the state. The HIT Systems Manager and the HIT Outreach Coordinator collaborate to publicize the EHR Incentive Program and the benefits of health IT adoption. EHR Program Specialist The EHR Program Specialist assists with prepayment review auditing in the EHR Incentive Program and will perform internal workflow checks in the SLR. The EHR Program Specialist also provides outreach and guidance to eligible professional’s one on one. Additionally, the EHR Program Specialist will serve as a data specialist to pull analytical reporting from the SLR, PCMH, and Data Repository to allow for complete population health analysis across the Wyoming Medicaid population. Health IT Legal and Policy Advisor The Health IT Legal and Policy Advisor is an attorney position created by Medicaid to advise the Medicaid office and other WDH entities about privacy and security concerns arising from the adoption and use of Health IT systems. This position also advises Medicaid about the formation of appropriate policies with respect to connecting Medicaid’s electronic health information with other WDH health IT systems and granting or limiting access to WDH personnel based on the minimum necessary information required for them to perform their job functions.
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Existing Medicaid and WDH-IT Staff
In addition to the Health IT positions added to the Medicaid office for the purpose of several existing staff members within Medicaid and the WDH-IT division operation of the Wyoming Medicaid EHR Incentive Program. These staff members include the Wyoming State Medicaid Agent (Medicaid Director), the Medicaid Medical Director, the WDH-IT division administrator and staff overseeing the Total Health Record project. In addition to these staff members who primarily advise the EHR Incentive Staff with respect to implementation and integration of the system for administering the EHR Incentive Program, staff from the Medicaid fiscal, program integrity and medical policy groups assists with administering the EHR Incentive Program within the Medicaid office. Medicaid Fiscal Group The Medicaid fiscal group assisted the EHR Incentive Staff in gathering business requirements related to issuing the incentive payments to eligible professionals and hospitals. This group also establishes the budget strings for the state funds and the enhanced federal financial participation funds expended over the life of the Wyoming Medicaid EHR Incentive Payment Program. This group will support the Wyoming Medicaid EHR Incentive Payment Program by assisting with processing payments to qualifying professionals and hospitals and accounting for the federal funds received by Medicaid Medicaid Program Integrity Group The Medicaid program integrity group offered the EHR Incentive Staff insights into the methods by which the EHR Incentive Program payments could be audited in compliance with the Final Rule. This group monitors providers who are enrolled in Medicaid for initial and continued compliance with eligibility requirements and monitors submission of claims for medical services for overpayments, fraud and abuse. The program integrity staff will provide expertise regarding the appeals process if a provider wishes to appeal a decision regarding eligibility or satisfaction of meaningful use requirements.
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Medicaid Medical Policy Group The Medicaid medical policy staff includes eight staff positions and is led by the Medicaid Medical Director, a physician who advises Medicaid in aspects of policy related to medical services. The remaining staff includes a medical care coordinator (a registered nurse), two provider services managers, a facilities manager, a mental health/substance abuse manager, a dental manager and the Medicaid Dental Officer. Because this group has a great deal of direct interaction with providers, they will be able to reinforce outreach and training efforts of the EHR Incentive Program. Medicaid Director/State Medicaid Agent The Medicaid Director is the State of Wyoming Medicaid Agent and is the direct supervisor of the Medicaid program EHR Incentive Program Systems Manager. This position also supervises the day-to-day operations of the Wyoming Medicaid program. The Medicaid Director spearheaded the Total Health Record project and remains the owner of that project within WDH. Medicaid Medical Director The Medicaid Medical Director advises Medicaid about the clinical aspects of medical and provider policy. As the EHR Incentive Staff gathered requirements for the EHR Incentive Program, the Medical Director provided insights into workflow and clinical implications of providers’ transition to EHR systems. This position also helps the Health IT Outreach Coordinator to determine and design effective messages about the incentive payments and the benefits of health IT. In addition to advising the day-to-day operations of Medicaid and the EHR Incentive Program, the Medical Director, along with the Medicaid Director, was an early advocate for and designer of Medicaid’s Total Health Record project. The Medical Director also works closely with other health IT initiatives within WDH including a telehealth project for psychiatric consults and evaluations and a CHIPRA grant project to use health IT to improve outcomes for children with severe emotional disturbances who may be cared for within and between multiple WDH divisions and offices. 56
WDH Information Technology Staff In addition to existing Medicaid staff, the EHR Incentive Staff will request significant support from the WDH Information Technology Division (WDH-IT) during the design, implementation and operation of the Wyoming Medicaid EHR Incentive Program. The WDH IT staff supports the entire Department of Health, of which Medicaid is a part. This gives the WDH-IT staff a broad view of the technology initiatives being undertaken within WDH and how those initiatives might be connected to or leveraged to benefit all the clients WDH serves. State Hit Coordinator In the fall of 2011, the governor’s office and the Office of the Chief Information Officer agreed to create a state position solely for the duties of the State HIT Coordinator required under the terms of the ONC State Cooperative Agreement for Health Information Exchange. The State HIT Coordinator sat in the Office of the CIO and in addition to carrying out the terms of the Cooperative Agreement, the State HIT Coordinator worked across state agencies to assess IT systems and needs related to health and social services programs. In the realm of HITECH activities, the State HIT Coordinator facilitated communications between Medicaid, public health, and the REC, as well as with other stakeholders within the Wyoming health care delivery system. This position is currently vacant. As the State Cooperative Grant ended, the position was not re-staffed therefore there is currently no State HIT Coordinator
EHR INCENTIVE PROGRAM OUTREACH The Wyoming Medicaid EHR Incentive Program Outreach Plan complements and interacts with a statewide outreach plan for health IT in Wyoming. The broader communication plan incorporates the state designated entity for health information exchange (the e-Health Partnership), the Regional Extension Center and the Total Health Record system developed by
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Medicaid for Medicaid providers and patients. While Medicaid will focus on the Medicaid EHR Incentive Program, the Medicaid EHR Incentive Staff recognizes that health IT efforts by providers will require support from the e-Health Partnership and the Regional Extension Center. The State HIT coordinator also schedules a call monthly for collaboration with EHR Incentive Staff to coordinate communication and outreach activities As a result, the statewide outreach plan will require all interested entities to work together to help providers understand the complete health IT environment in Wyoming. Medicaid developed a website, www.wyomingincentive.wyo.gov, for the purpose of providing a central resource about health IT activities in the state. The website describes the roles of Medicare and Medicaid EHR Incentive Programs, and Medicaid EHR program staff contract with Briljent to provide HIT Computer Based Training (CBT) for all aspects of the EHR Incentive Program Wyoming outreach plan was originally comprised of three structured phases of outreach. Phase I focusing on raising awareness and evaluating support of the EHR Incentive Program. Phase II of the incentive program outreach plan will involve new tools, new target audiences and message content with more specificity. A key element in Phase II communication and outreach will be the identification of and communication with those providers and hospitals with significant Medicaid patient volume, as well as those providers and facilities indicating an interest in participating in the CMS EHR Incentive Program during the course of the environmental scan. Lastly Phase III consists of one-on-one support and outreach to provider in assisting them with registration and attestations for the EHR Incentive Program. Currently in Wyoming, Phase I Outreach has wrapped up and the state is consistently practicing outreach tools and techniques associated with Phases II and III.
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EHR Incentive Program Project Overview Preliminary Investigation and Analysis of EHR Incentive Program Requirements
The Medicaid EHR Incentive Staff gathered requirements for the Wyoming Medicaid EHR Incentive program from the EHR Incentive Program Final Rule, with assistance from the HITECH Act Systems Interaction and Interface Control Document Version 3.0 and the CMS template for State Medicaid HIT Plans. The staff organized these requirements into a plan for leveraging existing database structures to create a system centering around five main components: provider registration, provider attestation and requesting payments, approval and issuance of payments, appeal processes and accounting for the federal financial participation amounts. Determination of Business Processes and Conceptual Design for Administration of EHR Incentive Program
This section of the SMHP describes how Medicaid will approach the tasks necessary to accept a provider’s registration in the Wyoming Medicaid EHR Incentive Program, verify hospital and professional eligibility and satisfaction of program requirements and issue payments. Wyoming Medicaid plans to use as many resources as possible to verify eligibility before allowing the hospital or professional to proceed to the attestation phase in order to minimize the potential for discovering a provider is not eligible after incentive payments have been issued. Medicaid will use a variety of existing IT, fiscal and communication systems to implement the Wyoming Medicaid EHR Incentive Program. Existing systems include the CMS Provider Registration and Attestation System (NLR) established by CMS, the HITECH Research and Support User Interface, the Business Intelligence Report, the Medicaid MMIS and the State of Wyoming Online Financial Systems (WOLFS). Medicaid developed a web-based registration and attestation portal supported by a data warehouse to collect and organize the information necessary to administer the program. There is currently a Medicaid provider portal for enrollment with the Wyoming Medicaid program; however, it does not have the capability to
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support the attestation requirements. Along with a user friendly format for providers to encourage participation, a new portal designed specifically for the EHR Incentive Program was the best option for Wyoming. Medicaid EHR Incentive Staff have foregone the procurement and contract process with a vendor-offered solution after weighing the costs of adopting such a system. Wyoming Medicaid has acquired software developed by the Kentucky CHFS agency for its Medicaid EHR Incentive Payment Program to implement an electronic system to support the process of reviewing applications for incentive payments and issuing those payments to qualified providers and hospitals. This database has been modified to become the State Level Registry (SLR) for the Wyoming Medicaid EHR Incentive Payment Program.
State Level Registry Wyoming assessed Medicaid’s technical and business needs pertaining to the Wyoming Medicaid EHR Incentive Program and elected to obtain the system code for AIU as well as Phase One of Meaningful Use from the State of Kentucky for the electronic system to support administration of the EHR Incentive Program. The State of Wyoming used in house resources to manipulate Kentucky’s AIU code to work for Wyoming. For phase one of the Meaningful Use code, that was obtained from Kentucky free of charge. Since obtaining the original code Currently the system functions to accept attestations for both Meaningful Use Stages 1 and 2. The SLR screens providers are required to complete to receive payment in from the Wyoming Department of Health are illustrated in Appendix A for reference. The next phase to incorporate the final rule for April 2016. State Level Registry—Design and Operation Eligible Professionals (EPs) Registration and Attestation Process Flow
The flow of the first year’s attestation for eligible professionals and hospitals will begin with registration with CMS. An electronic file, B6, will be sent to the Wyoming SLR for state verification of eligibility. Once a provider/hospital is
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determined eligible, an electronic notification will be sent with a link to the Wyoming SLR to the EP or EH. With this notification being sent a B-7 will also be sent back to the NLR indicating whether or not the provider is eligible. The provider/hospital will then be able to complete attestation and upload all required documentation by following the link. Once all documentation has been submitted, the Wyoming EHR staff will verify all the information. If the eligible provider/hospital has submitted adequate verification of adopt, implement, upgrade of an ONC certified EHR and meets the required Medicaid patient volume for the practice type, a D16 will be sent to the NLR to verify no payment has been made the EP or EH from another state. Once the NLR has verified no other payments made, a response D16 will be sent and received by the SLR. Payment will then be approved for the appropriate year and reported to CMS in a D18. The State of Wyoming has contracted the work to develop the second phase of the SLR, meaningful use and deployed the second phase August 2012. The SLR will capture attestations regarding the professional’s meaningful use data as well as require a re-attestation to the professional’s eligibility for the Medicaid EHR Incentive Payment Program. Eligible Hospitals and Critical Access Hospital (CAHs) Registration and Attestation Process Flow
The flow of the first year’s attestation for eligible hospitals is detailed in the page flow diagram below. As depicted in the diagram, 2011 attestations will be limited to a hospital’s eligibility for the Medicaid EHR Incentive Payment Program and whether a hospital has adopted, implemented, or upgraded certified EHR technology. Late summer 2012, the SLR will capture attestations regarding the hospital’s meaningful use data (Figure 14).
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Figure 14: SLR Attestation Workflow
Attestation to Adoption, Implementation, or Upgrade
As permitted by the Final Rule, Medicaid will require only that eligible professionals, eligible hospitals and CAHs attest that they adopted, implemented, or upgraded certified EHR technology.
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In an eligible professional’s or eligible hospital’s second payment year, Medicaid will require proof of EHR certification in addition to patient volume methodology to establish eligibility. The eligible professional or hospital will also be required to attest that during the EHR reporting period, the professional or hospital satisfied the required meaningful use objectives and associated measures in the Final Rule. In addition, Medicaid will require the eligible professionals to report the result of each applicable meaningful use measure for all patients seen during that EHR reporting period. Finally, Medicaid will require eligible professionals and hospitals to report ambulatory or hospital clinical quality measures (as applicable) electronically. In the event that a provider switches EHR products at a single location during the EHR reporting period, they will have the flexibility to count a patient as unique on each side of the switch and not across it (for example, 1 patient seen before the switch and after the switch could be counted once or twice). EPs in these scenarios must choose one of these methods for counting unique patients and apply it consistently throughout the entire EHR reporting period. Medicaid intends to leverage reporting and data capture capabilities of the Total Health Record system to receive eligible professionals’, eligible hospitals’ and CAHs’ reports of meaningful use measures and of ambulatory or hospital clinical quality measures. To do so, Medicaid envisions access to the Total Health Record so that provider information flows seamlessly from the provider’s EHR to the Total Health Record and then to the State Level Registry, where an eligible provider or hospital can then attest to the pre-populated meaningful use and clinical quality measures. State Level Registry – Business Processes and Conceptual Designs Interface with CMS Registration and Attestation System (NLR)
Eligible professionals and eligible hospitals must register with the CMS Registration and Attestation System (NLR) before they will be allowed to access the Medicaid SLR. The Medicaid registration process assumes that the CMS Registration and Attestation System will capture the professional’s or hospital’s registration information, eliminate duplicate registrations and check the registrations against CMS exclusion lists. After CMS validates a registration record, the SLR is capable of receiving the record from CMS (through a B-6 transaction) and performing certain validations at the state level. For the initial 63
validations at the state level, Medicaid verifies only Medicaid EHR Incentive Program eligibility factors related to the professional’s provider type before returning the registration record response to CMS through the B-7. Verification of other eligibility factors (including patient volume and factors having to do with the professional’s practice locations) will occur after the professional supplies additional information to the SLR. After performing the initial verification of the professional’s registration record from the CMS Registration and Attestation System (NLR), the SLR will transmit a response back to CMS to indicate that the professional is eligible for the Wyoming Medicaid EHR Incentive Program (through a B-7 transaction). Because Medicaid will perform additional eligibility verification steps after this initial B-7 transmission back to CMS, Medicaid will verify a professional’s eligibility status by sending a new B-7 if the professional is found to be ineligible in one of the later eligibility determinations. For hospitals, the Medicaid SLR receives a B-6 transaction from the CMS Registration and Attestation System (NLR), verify that the hospital is eligible for the Medicaid EHR Incentive Program by confirming that the facility is an acute care or children’s hospital and transmit a B-7 transaction back to CMS. As with professionals, the SLR will only verify the hospital’s initial eligibility factor of hospital type. If Medicaid discovers that the hospital does not meet the Medicaid patient encounter threshold later in the registration process, the SLR will transmit an updated B-7 transmission to CMS modifying the hospital’s status to ineligible. In addition to the B-6 and B-7 transactions between the CMS Registration and Attestation System (NLR) and the SLR on the eligibility side, the Medicaid SLR is capable of transmitting payment information back to CMS (through D-16 and D-18 transactions). This transaction will indicate that the professional’s receipt of a payment, allowing CMS to reconcile the professional’s payment year in the event a professional moves between the Medicare and Medicaid EHR Incentive Programs or between different state Medicaid EHR Incentive Programs.
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Eligible Professionals: Registration at the SLR
After a professional registers with CMS and receives a Registration Identifier, the professional may register with the Wyoming Medicaid SLR through the public home page at http://wyomingincentive.wyo.gov/. At the public home page, the provider will enter her National Provider Identifier (NPI) and her Registration Identifier from the CMS registration. Once a professional enters this data into the SLR public home page, the SLR will confirm that it matches a record received from the NPI and if a there is a match, will pre-populate the provider’s data from the NPI in the next screen of the SLR. In any case when the provider is not the individual registering or attesting, a provider authorization letter must be submitted prior to any individual working on behalf of the EP. This letter can be found on http://wyomingincentive.wyo.gov. The letter indicates who has permission to act on behalf of the provider as well as informing the provider they are solely responsible for the information attested to. Verification of Eligibility: EP Provider Type
Pursuant to the Final Rule, five provider types are eligible for the Wyoming Medicaid EHR Incentive Program: ● ● ● ● ●
Physicians Physician Assistants practicing in a FQHC or RHC led by a PA Nurse Practitioners Certified Nurse Midwives Dentists
In addition to determining baseline eligibility, a professional’s provider type designation also affects that professional’s required Medicaid encounter volume if the professional is a pediatrician. After the SLR matches the professional’s registration record from the NPI, Program Integrity will match the professional to the Wyoming MMIS system and use the provider type on record in the MMIS as the professional’s provider designation. For professionals who are matched as pediatricians, a Medicaid patient enrolled encounter volume of 20% will be required instead of the volume of 30% required for other provider 65
types. The Wyoming MMIS does not allow more than one provider type designation or a subspecialty designation, therefore pediatricians with sub-specialties must be registered in the MMIS as a pediatrician in order to be eligible for the 20% patient enrolled encounter volume requirement. Residents practicing in the State of Wyoming will not be eligible for the EHR Incentive Program due to the fact that they do not directly bill Medicaid; their bills are submitted through their supervising physician’s Medicaid number. This results in not having an auditable data source required by the eligibility criteria stated in the Final Rule 495.304. Attestation for EP’s is based on the calendar year, the cut off to attest for a program year is 31 December; the state of Wyoming has approved a tail (grace) period to extend this to the 31st of March. Verification of Eligibility: EP “Practices Predominantly” and PA “So Led”
Medicaid’s EHR Incentive Staff will determine whether an EP practices predominantly in a FQHC or a RHC. If the EP is a Physician’s Assistant (PA), whether they practice in a FQHC or RHC that is “so-led” by a PA. The EHR Incentive Staff has identified all FQHCs, RHCs and Tribal clinics in the state of Wyoming using the Wyoming Healthcare Facility Directory maintained by the Wyoming Department of Health. Each identified clinic is sent a worksheet to assist in determining provider/provider types practicing at each location and aggregate patient volume methodology to submit to the EHR staff prior to registration and attestation. Once the determination is made that an EP practices predominantly or that the clinic is PA “so led,” an email from the Medicaid EHR staff is sent to notify all eligible providers with a link to the National Level Registry. They will need to register on there first, to have access to the Wyoming incentive website to begin the registration/attestation process. A PA is eligible for incentive payments only if the PA practices in a FQHC or RHC where the PA leads or the FQHC or RHC is “so led” by the PA. This is described in more detail below.
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Eligible Professionals identified as “Practices Predominantly” and PA “So Led” are eligible to count “needy individuals” to meet the required 30% Medicaid patient enrolled encounter threshold. Per the Final Rule 495.302 Definitions, please see 5.5.2.4 for definition of Needy Individuals EP Practices Predominantly
Per the Final Rule: 495.302 Definitions: Practice Predominantly means an Eligible Professional for whom the clinical location for over 50% of his or her total patient encounters over a period of 6 months in the most recent calendar year occurs at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). After the Medicaid EHR Incentive Staff determines whether the professional practices predominantly at an FQHC or RHC, during attestation, each eligible professional will include needy individuals, based on the definition in the Final Rule 495.302, in their Medicaid patient encounters Claims submitted to Medicaid by FQHCs and RHCs are typically submitted under the facility’s provider number rather than under the provider number of the professional performing the services. At best, MMIS claims data can gauge only the reasonableness of a professional’s declaration by reviewing the number of services the provider performs outside of an FQHC or RHC and determining whether that number would reasonably constitute less than 50% of a typical professional’s practice. However, even this review is skewed due to the fact that a professional may submit no Medicaid claims from practice locations other than an FQHC or RHC. In the absence of clear-cut available data, Medicaid will rely on random audits of professionals who declare they practice predominantly in an FQHC or RHC to verify this determination. These types of practices will also be determined as a high-risk in the risk profile auditing strategy. PA So Led
With respect to physician assistants, the professional’s practice location is relevant because physician assistants may only participate in the Medicaid EHR Incentive Program if they lead an FQHC or RHC or practice at an FQHC or RHC where the
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practice is “so-led” by a physician’s assistant. Medicaid will adopt CMS’s guidance in the Final Rule and consider a FQHC or RHC to be led by a physician assistant if: 1. The physician assistant is the primary provider in a clinic; 2. The physician assistant is a clinical or medical director at a clinical site of practice; or 3. The physician assistant is an owner of an RHC. As mentioned above, every FQHC, RHC and Indian Health Clinic will be sent a worksheet prior to any registrations to assist in determining practice types, names of providers and aggregate patient volume methodology; this form is to be submitted to the EHR staff prior to initial approval in the SLR by program integrity. This worksheet will also be required to be submitted at the time of each provider’s attestation. Using this worksheet and the MMIS, the EHR staff will determine each PA’s eligibility. Verification of Eligibility: EP Medicaid Patient Enrolled Encounter Volume
After the Medicaid SLR captures relevant characteristics of the eligible professional, including whether the professional is a pediatrician or a physician assistant and whether the professional practices at a FQHC or RHC, the SLR will capture and calculate the professional’s patient volume and Medicaid enrolled encounter volume to determine whether the professional meets the required threshold for receiving an incentive payment. Any clinic that has providers that are not enrolled in Wyoming Medicaid, however bill under the clinic Medicaid number will be required to complete a group practice information form. This instance can refer to but not limited to: Indian Health Service (IHS), Federally Qualified Health Centers (FQHC) or Rural Health Clinics (RHC). The form will need to be completed and sent to the EHR Incentive Staff before preliminary checks are completed. Once the form is received the review process can begin, the clinic/provider will however still need to attest with the information provided on the form in the SLR.
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The Program Integrity Office of Wyoming Medicaid will verify the following information to ensure the state does not pay providers that are not eligible. This information will be verified and housed in the SLR and the individual verifying the questions will “sign off” to validate eligibility. In the SLR the first questions verified of the provider by Program Integrity are: 1) Is the provider an actual Wyoming provider? Is the provider licensed in Wyoming? The Program Integrity section of Wyoming Medicaid will verify this information with the Wyoming Licensing Board (to check that licensure is current) and the Wyoming Medicaid MMIS (to check that the provider is enrolled). 2) Is the provider type eligible? The EHR Incentive staff will verify the provider type is an eligible provider type to participate in the EHR Incentive Program using the provider’s taxonomy code from the MMIS. 3) Have you verified there are no sanctions against the provider? The Program Integrity section of Wyoming Medicaid will verify this information in the MED system. 4) The Program Integrity section of Wyoming Medicaid will also utilize the List of Excluded Individuals/Entities (LEIE) as well as Excluded Parties List System (EPLS). 5) At least one of the clinical locations used for the calculation of an EP's patient volume have CEHRT during the payment year for which the EP is attesting to adoption, implementation or upgrade or meaningful use. This address must be provided at the time of attestation. Medicaid Patient Enrolled Encounter Volume: Individual or Group Level
Because an eligible professional may report either individual patient volume or at the practice’s group level volume for purposes of meeting the 30% Medicaid patient enrolled encounter threshold, or 20% for Pediatricians. The Medicaid SLR page will accommodate either reporting method. For eligible professionals who practice predominantly at a FQHC or RHC, “needy individual” encounters will be entered in the patient volume field and verified using the group practice information form in determining the aggregate patient volume methodology submitted during attestation.
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Medicaid Patient Enrolled Encounter Volume: 90-day Reporting Period
The Medicaid SLR will capture the 90-day reporting period the professional enters for measuring patient enrolled encounters. From the Final Rule, the reporting period for determining Medicaid patient enrolled encounters is to be a consecutive 90-day period in the previous calendar year. Entry of a period that is less than 90 days or that falls outside of the previous calendar year will trigger an error message. If the volume entered is below the required 30% the system will not allow the provider to continue the attestation. For providers that are not hospital based and do not have more than 90% hospital encounter: if a provider has enrolled encounters at multiple places of service they can count these in the 90-day period, or they can leave them out. However, this calculation has to be all or none, either all the enrolled encounters from the other places of service or none. For example: An OB/GYN pulls call at the local hospital, they bill for their services through their practice as well as services provided in their practice. They can count the hospital enrolled encounters, but they must count all of them to include Medicaid or none of them. Medicaid Patient Enrolled Encounter Volume: Pediatricians
The business rules for the Medicaid SLR will reflect the reduced Medicaid volume threshold for pediatricians. If the professional is enrolled with the Medicaid MMIS as a pediatrician, the SLR will require 20% of the pediatrician’s enrolled encounters to be attributable to Medicaid patients. Like all other professionals, pediatricians may use either their individual patient volume or their group practice level patient volume. Other than the volume requirement changing from 30% to 20% and the payment difference, the Medicaid SLR’s business rules and operational procedures will be identical for pediatricians and non-pediatricians. EP Patient Enrolled Encounter Volume—Defining Medicaid and Needy Patient Encounters
In the Final Rule 495.306 (e) CMS defines ‘Medicaid encounters’ and ‘needy patient encounters’ differently. A Medicaid encounter means services rendered to an individual on any one day where: (I) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service 70
(ii) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual’s premiums, copayments and cost-sharing. (iii) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project under section 1115 of the Act) at the time the billable service was provided Needy Individuals mean individuals that meet one of following: For the purposes of calculating needy individual patient volume, a needy patient encounter means service rendered to an individual on any 1 day if any of the following occur: (i) Medicaid or CHIP (or demonstration project approved under section 1115 of the Act) paid for part or all of the service; (ii) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid all or part of the individual’s premiums, co-payments, or cost-sharing (iii)The individual was enrolled in a Medicaid program (or (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided. (iv) The service was furnished at no cost; and calculated consistent with 495.310(h); or (v) The services were paid for at a reduced cost based on a sliding scale determined by the individual’s ability to pay. According to the Final Rule: In determining the ‘‘needy individual’’ patient volume threshold that applies to EPs practicing predominantly in FQHCs or RHCs, section 1902(t)(2) of the Act authorizes the Secretary to require the downward adjustment to the uncompensated care figure to eliminate bad debt data. We interpret bad debt to be consistent with the Medicare definition, as specified at § 413.89(b)(1). In order to remain as consistent as possible between the Medicare and Medicaid EHR incentive programs, States will be required to downward adjust the uncompensated care figure. Under Medicare, bad debts are amounts considered to be uncollectible from accounts and notes receivable that were created or acquired in providing services. 71
‘‘Accounts receivable’’ and ‘‘notes receivable’’ are designations for claims arising from the furnishing of services and are collectible in money in the relatively near future." To further explain, if a patient has an agreement with the provider before the services are rendered, on a sliding scale or charity case, the encounter can be counted. If the patient does not have an agreement and does not pay for services rendered, the encounter cannot be counted in the 30% patient volume, due to this encounter being considered “bad debt.” Eligible professionals reporting needy patient encounters are required to downwardly adjust uncompensated services to eliminate bad debts. Wyoming EHR Incentive staff will validate whether this adjustment has been made. In the final rule, CMS provides two methodologies for calculating patient volume: Wyoming Medicaid will use the fee-forservice methodology. EP Patient Enrolled Encounter Volume—Individual Level Calculation
When an eligible professional is attesting to their individual Medicaid patient enrolled encounters, the Medicaid SLR will capture the professional’s entry for Medicaid patient enrolled encounters and total patient encounters and then calculate the percentage of Medicaid patient enrolled encounters. If the calculated total is 30% or greater (or 20% or greater if the professional is a pediatrician), the professional will be allowed to proceed with attestation. If the calculated total is under 30%, (or 20% for a pediatrician) the payment calculator will indicate zero payment. Medicaid EHR staff will contact the professional to review methodology and assist as needed. For professionals who practice predominantly in an FQHC or RHC, the Medicaid patient enrolled encounters plus CHIP, sliding scale and uncompensated encounters will be entered in the Medicaid enrolled encounters field in the Medicaid SLR. The SLR will use that total as the numerator for calculating whether the professional has met the 30% threshold (or 20% threshold if the professional is a pediatrician).
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The Medicaid SLR will prompt the user to enter the professional’s total volume of patient encounters and volume of Medicaid patient enrolled encounters and will provide a calculation for the professional. Professionals that are eligible to include patient enrolled encounters that include Medicaid patients covered through another state, CHIP patient's, sliding scale encounters and uncompensated encounters, they will be required to upload a spreadsheet identifying the total of each of these encounters individually. This will allow Wyoming Medicaid EHR staff to verify the professional’s patient volume attestation information by comparing the professional’s entries with information from disparate sources, as reflected in table 4: Category
Validation Method
Medicaid Patient Enrolled Encounters
Query claims history using Medicaid data warehouse.
Wyoming Kid Care CHIP Encounters
Review quarterly Kid Care CHIP FQHC/RHC Encounters report.
Out-of-State Medicaid and CHIP Encounters
Contact the other state’s Medicaid program if the volume of encounters exceeds 10% of the total Medicaid (or Medicaid/needy) encounters and the state is one of the six bordering Wyoming.
Uncompensated Care and Sliding Scale Encounters
Wyoming EHR Incentive staff will work directly with the FQHC or RHC. Table 4: SLR Individual Patient Volume
Outreach/communication has been established with Colorado, South Dakota, Nebraska, Utah, Idaho and Montana. Wyoming extended the offer to share any data needed by neighboring states to assist with their EHR Incentive program for purposes of verifying providers’ eligibility (i.e. 30% Medicaid patient volume). A contact e-mail address was given; as well, Wyoming
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asked for a contact individual to send our data requests to, in the event we need to validate enrolled encounters attributable to Medicaid clients covered by other State Medicaid programs. If the accuracy of the professional’s patient volume data cannot be confirmed, the Medicaid EHR Incentive Staff will try to resolve the discrepancy by contacting the professional. If the discrepancy can be resolved, the Medicaid EHR Incentive Staff may return the professional’s attestation for correction. If the discrepancy cannot be resolved, the Medicaid EHR Incentive Staff will deny the professional’s attestation. The Notice of Denial will include a description of Medicaid’s appeal process. The Medicaid SLR will calculate the totals for the professional using the formulas described below. EP Patient Enrolled Encounters – Medicaid only ● Total Medicaid Enrolled Encounters = Medicaid Patient Enrolled Encounters for Each Location + Out-of-State Medicaid Patient Enrolled Encounters for Each Location ● Total Encounters = Sum of Total Patient Encounters for All Locations ● Percentage of Medicaid Enrolled Encounters = Total Medicaid Enrolled Encounters / Total Encounters * 100 EP Patient Enrolled Encounters – Medicaid plus Needy Individuals ● Total Medicaid/Needy Encounters = Medicaid Patient Enrolled Encounters for Each Location + Needy Patient Encounters for Each Location + Out-of-State Medicaid Patient Enrolled Encounters for Each Location ● Total Encounters = Sum of Total Patient Encounters for All Types and All Locations ● Percentage of Medicaid/Needy Encounters = Total Medicaid/Needy Encounters / Total Encounters * 100 The professional may continue with the attestation only if the Percentage of Medicaid (or Medicaid/Needy) Enrolled Encounters is 30% or greater (or 20% or greater for a pediatrician). Wyoming Medicaid will use basic math rules when determining patient volume calculations. Percentages at 0.5 or greater will be rounded up to the next whole number.
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EP Patient Volume—Group Level Calculation
The Final Rule gives professionals working in group practices or clinics the choice of reporting patient enrolled encounters at the group or individual level. In the Final Rule 495.306(h) Group Practices: Clinics or group practices will be permitted to calculate patient volume at the group practice/clinic level, but only in accordance with all of the following limitations: 1. The clinic or group practice’s patient volume is appropriate as a patient volume methodology calculation for the EP. 2. There is an auditable data source to support the clinic’s or group practice’s patient volume determination. 3. All EP’s in the group practice or clinic must use the same methodology for the payment year. 4. The clinic or group practice uses the entire practice or clinic’s patient volume and does not limit patient volume in any way. 5. If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those enrolled encounters associated with the clinic or group practice and not the EP’s outside enrolled encounters. Wyoming Medicaid will use data from the MMIS to verify that professionals who register using their group practice level enrolled encounters register consistently within their group practices and to verify the numerator of the patient volume calculation for that group practice. If a professional indicates reporting patient volume at practice group level, the Medicaid SLR will capture patient volume in the same manner as if the professional was reporting individual patient volume. A professional who practices at multiple practice groups may only choose one practice for reporting patient volume. Upon submission of an EP attestation of patient volume at a group level, the Medicaid EHR Incentive Staff, as part of its overall review, will validate the volume of Medicaid (or needy) patients using the following methods shown below in table 5:
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Category
Validation Method
Medicaid Patient Enrolled Encounters
Query claims history using Medicaid data warehouse.
Kid Care CHIP Encounters
Review quarterly Kid Care CHIP FQHC/RHC Encounters report.
Out-of-State Medicaid and CHIP Encounters
Contact the other state’s Medicaid program if the volume of encounters exceeds 10% of the total Medicaid (or Medicaid/needy) encounters and the state is one of the six bordering Wyoming.
Uncompensated Care and Sliding Scale Encounters
Wyoming EHR Incentive staff will work directly with the FQHC or RHC.
Table 5:SLR Group Patient Volume
Eligible Hospitals: Registration at the SLR
After a hospital registers with the CMS Registration and Attestation System (NLR) and receives a Registration Identifier from CMS, the hospital may register with the Medicaid SLR through the public home page www.wyomingincentive.wyo.gov. At the public home page, the hospital will enter its NPI and Registration Identifier from CMS. Once a hospital enters this data into the SLR public home page, the SLR will confirm that it matches a record received from CMS and if a there is a match, will pre-populate the hospital’s data from CMS in the SLR.
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Verification of Eligibility: EH Medicaid Patient Enrolled Encounter Volume
To participate in the Medicaid EHR Incentive Program, 10% or more of a hospital’s total encounters in any representative 90day period in the previous fiscal year must have been attributable to Medicaid patients. For hospitals, the Final Rule 495.306(e) defines a Medicaid patient enrolled encounter as: (2) For the purposes of calculating hospital patient volume, the following definitions of this section may apply: (i) A Medicaid encounter means services rendered to an individual per inpatient discharge when any of the following occur: (A) Medicaid (or a Medicaid demonstration project approved under section 115 of the Act) paid for part or all of the service; or (B) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual’s premiums, co-payments and/or cost sharing (C) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided. (ii) A Medicaid encounter means services rendered in an emergency department on any 1 day if any of the following occur; (A) Medicaid (or a Medicaid demonstration project approved under section 115 of the Act) paid for part or all of the service; or (B) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual’s premiums, co-payments and/or cost sharing
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(C) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided. Pursuant to the Final Rule, children’s hospitals are not required to meet the 10% Medicaid patient enrolled encounter threshold; however, because Wyoming has no children’s hospitals, this exception will not be built in to the Medicaid SLR system. Using the hospital’s self-report, the SLR will capture the hospital’s 90-day reporting period, the hospital’s volume of total inpatient discharges and the hospital’s volume of total emergency department enrolled encounters. The SLR also will capture the volume of inpatient discharges and emergency department encounters attributable to Medicaid patients (including Wyoming Medicaid patients and those patients insured by Medicaid programs of other states). The SLR will capture inpatient discharges and emergency department encounters based on the hospital’s self-report. Before authorizing payment, Medicaid will validate the hospital’s self-reported encounters using cost report data and claims data collected by MMIS. The following table sets out the sources of data for verifying eligibility and amount of the EHR Incentive Payments for Wyoming hospitals. Data
Needed to Calculate:
Source
Medicaid Discharges
Whether hospital meets 10% minimum Medicaid patient volume for eligibility
Medicare Cost Report
Dual Eligible Discharges
Whether hospital meets 10% minimum Medicaid patient volume for eligibility
NCI could determine this from claims data
Worksheet S-3 Part I
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Comment NCI routinely receives Worksheet S-3
Total Discharges
● Whether hospital meets 10% minimum Medicaid patient volume for eligibility ● Discharge-related portion of EHR amount for Incentive Payment
Medicare Cost Report
NCI routinely receives Worksheet S-3
2552-96: Worksheet S-3, Part I, Column 15, line 12 2552-10: Worksheet S-3, Part I, Column 15, line 14
Medicaid ER Enrolled Encounters (Note: an enrolled encounter is services rendered on one day)
Whether hospital meets 10% minimum Medicaid patient volume for eligibility
NCI could determine this from claims data
An encounter is services rendered on one day. NCI assumes this means ER visits for which services are rendered on an outpatient basis and does include visits for patients who are admitted as inpatients through the ER
Dual Eligible ER Encounters
Whether hospital meets 10% minimum Medicaid patient volume for eligibility
NCI could determine this from claims data
An encounter is services rendered on one day. NCI assumes this means ER visits for which services are rendered on an outpatient basis and does include visits for patients who are admitted as inpatients through the ER
Total ER Encounters
Whether hospital meets 10% minimum Medicaid patient volume for eligibility
NCI knows of no source other than hospital records for this
An encounter is services rendered on one day. NCI assumes this means ER visits for which services are rendered on an outpatient basis and does include visits for patients who are admitted as inpatients through the ER
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Medicaid Inpatient Days (newborns and observation days excluded)
Medicaid Share for Incentive Payment
Medicare Cost Report
NCI routinely receives Worksheet S-3
2552-96: Worksheet S-3, Part I, column 5, sum of lines 1, 6-10 2552-10: Worksheet S-3, Part I, column 7, sum of lines 1, 8-12
Total Inpatient Days (newborns and observation days excluded)
Medicaid Share for Incentive Payment
Medicare Cost Report
NCI routinely receives Worksheet S-3
2552-96: Worksheet S-3, Part I, column 6, sum of lines 1, 6-10 2552-10: Worksheet S-3 Part 1, Column 8, Line 1, 2 + Lines 8 - 12
Total Charges
Medicaid Share for Incentive Payment
Medicare Cost Report
NCI routinely receives Worksheet C
2552-96: Worksheet C, Part I, column 8, Line 101 2552-10: Worksheet C, Part I, column 8, Line 200
Charity Care Charges
Medicaid Share for Incentive Payment (Note: Although it is to a hospital’s advantage to report
Medicare Worksheet S-10 2552-96: Line 30 (Other uncompensated care charges from hospital
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● NCI routinely requests Worksheet S-10 from the Medicare Intermediaries, but not all hospitals complete the worksheet ● In FY 2008 and/or 2009, 14 WY hospitals completed some portion of the Worksheet S-10, but only 9 completed Line 30
charity care charges, because it will increase its Medicaid share, the Medicaid share can still be calculated without it.)
records) 2552-10: Worksheet S10, column 3, line 20
● In the absence of sufficient charity care data, uncompensated care data with a downward adjustment for bad debts may be used to estimate charity care ● WY’s Medicaid DSH Qualification Worksheet, Low-Income Utilization Rate has IP hospital charges attributable to charity care; but this worksheet has been eliminated for years after FY 2008
Table 6: EH Encounters
Wyoming Medicaid developed a hospital calculator available on the http://wyomingincentive.wyo.gov/ website also Exhibit A. This calculator establishes the calculation methodology Medicaid will use after validating the hospital’s numbers. The Medicaid patient volume is then calculated using the formulas below: ● Total Medicaid Enrolled Encounters = Inpatient Medicaid Discharges + Inpatient Out-of-State Medicaid Discharges + Medicaid ED Enrolled Encounters + Out-of-State Medicaid ED Enrolled Encounters ● Total Encounters = Total Inpatient Discharges + Total ED Encounters ● Percentage of Medicaid Enrolled Encounters = Total Medicaid Enrolled Encounters / Total Encounters Wyoming Medicaid will use basic math rules when determining patient volume calculations. Percentages at 0.5 or greater will be rounded up to the next whole number. If the accuracy of the hospitals patient volume data cannot be confirmed, the Medicaid EHR Incentive Staff will try to resolve the discrepancy by contacting the hospital. If the discrepancy can be resolved, the Medicaid EHR Incentive Staff may return the hospital’s attestation for correction. If the discrepancy cannot be resolved, the Medicaid EHR Incentive Staff will deny the hospital’s attestation. The Notice of Denial will include a description of Medicaid’s appeal process. Attestation for EH’s is based on federal fiscal years, the cut off to attest for a program year is 30 September, the state of Wyoming has approved a tail (grace) period to extend this to the 31st of December.
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Adopt, Implement, or Upgrade Attestation
After determining that a registered provider is eligible for the Wyoming Medicaid EHR Incentive Program, Medicaid will require eligible professionals and hospitals to attest to their adoption, implementation or upgrade of certified EHR technology. For 2011, Medicaid will allow only attestation of adoption, implementation or upgrade; Medicaid will not permit hospitals or professionals to attest to meeting the meaningful use requirements of the Final Rule. For 2012, Medicaid will implement a method to allow providers to attest to meaningful use by late summer. The Medicaid SLR will collect a hospital or professional’s attestation to adoption, implementation, or upgrade of certified EHR technology by asking the hospital or professional to provide the following information: ● Affirm that the hospital or professional adopted, implemented, or upgraded certified EHR technology. ● For professionals, designate the practice location where the certified EHR technology was adopted, implemented, or upgraded. ● Enter the CMS certification number for the certified EHR technology. ● Provide (either by uploading, emailing, or faxing) documentation supporting the hospital or professional’s affirmation of adoption, implementation, or upgrade of certified EHR technology. Acceptable documentation will include name and version of EHR, proof of licenses for each provider or hospital, binding documentation to an EHR vendor, such as a purchase agreement, license agreement, or other evidence of the hospital or professional’s acquisition of certified electronic health record technology in accordance with the Final Rule. A vendor letter may be submitted for informational purposes; however it does not qualify by itself as binding documentation. After collecting this information, the Medicaid SLR will require the hospital or professional to indicate attestation to the accuracy of the collected information. The Medicaid SLR will then verify the hospitals or professional’s attestation by checking the CMS certification number with the CHPL web service established by ONC. 82
If Medicaid’s review of a hospital’s or professional’s attestation indicates the attestation is accurate, the EHR Incentive Staff will verify the content of the provider’s attestation before approving it for payment.
Payment Determining Payment Amount
For eligible professionals who meet the 30% threshold of Medicaid patients (or 20% threshold if the professional is a pediatrician) and attest to the adoption, implementation, or upgrade of certified EHR technology, the Medicaid SLR will determine the professional’s payment based on the professional’s year of participation in the Medicaid EHR Incentive Program. The Medicaid SLR will use information gathered from the professional’s registration record at the CMS Registration and Attestation System (NLR) NPI to determine the professional’s year of participation. Medicaid anticipates this will be a fairly straightforward process, facilitated primarily by the communication between the SLR and CMS. For eligible hospitals, the EHR Incentive Program Final Rule requires state Medicaid agencies to choose an auditable data source to calculate Medicaid EHR Incentive Program payments for hospitals. Medicaid will use Medicare cost reports submitted to Medicaid by participating hospitals for this auditable data source. The Medicaid SLR will capture from the hospital user the hospital’s fiscal year, total discharges, inpatient days (excluding nursery days), total charges and uncompensated care charges of the most recent cost report. When a hospital attests, it is required that they use the most recent cost report that was filed, not the most recent settled report ending in the previous fiscal year of the payment year. Payments will not be recalculated each year; the payment will be based off of the initial calculation. The only time a payment would be recalculated is if the hospital receives the settled cost report back and changes had been made to the pertinent fields that were used for the incentive calculation; the hospital will be required to send the cost report to the EHR Incentive Staff. At that time the EHR Incentive Staff will review the settled cost report and the incentive calculator used to arrive at the initial payment. They will recalculate the payment with the settled
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report, if the total payment changed more than 5% negative or positive, payment adjustments will be made on the next hospital payment year. The results of the review will be sent to the hospital by the EHR Incentive Staff. Accounting for Incentive Payments to Professionals and Hospitals
Medicaid will issue incentive payments through the State Auditor’s Office (SAO). Medicaid decided to use the SAO rather than its MMIS based on the following considerations: ● In Wyoming, the MMIS does not generate hardcopy checks or electronic funds transfers. All payments to Medicaid providers are issued by the SAO, including those resulting from claims processed by the MMIS. ● The EHR Incentive Staff tasked with managing development of the State Level Registry already has experience generating electronic payment requests to the SAO. All payments are traceable on the SAO website by EFT number. When Medicaid sends a payment request to the SAO, it will include an accounting code specific to incentive payments. This is in recognition of the need to track the federal match for incentive payments separately from administrative costs. After payment is made, the EFT number is documented along with the date of payment. Pre-Payment Checks
Two pre-payment checks will be performed prior to generating a payment request to the SAO. The checks will include querying the CMS Registration and Attestation System (NLR) for a duplicate payment or a new federal exclusion and verifying the accuracy of the amount to be paid. Querying the CMS Registration and Attestation System for a duplicate payment or a new federal exclusion will be accomplished through the D-16 Duplicate Payment/Exclusion Check interface. The D-16 will be generated by the SLR upon approval of a hospital’s or professional’s attestation by the EHR Incentive Staff. If CMS’s response indicates the hospital or professional has already been paid or that a new exclusion was found, the EHR Incentive Staff will deny the attestation. The
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Notice of Denial sent to the professional or hospital will include a description of Medicaid’s appeal process. If the CMS response indicates no prior payment and no new federal exclusion, the final pre-payment check is performed. The final pre-payment check is to verify the accuracy of the amount to be paid. For professionals, the EHR Incentive Staff will verify the amount based on the type of professional, the professional’s participation year and the total cumulative payments made to the professional so far.
Figure 14:Pre-payment Workflow
For hospitals, the amount and the participation year will be compared to payment projections the EHR Incentive Staff have produced for each Wyoming hospital. In the event the system-calculated payment is found to be inaccurate, the problem will be immediately referred to IT and the payment request held until the problem is resolved. Required Documentation to be uploaded to SLR
For providers the required documentation is required to be uploaded to the SLR: ● Patient volume methodology: explain and show calculations. This needs to include how the clinic/provider came to the number they are attesting to (30% or 20% for Pediatricians). This could be a billing system that was used to pull the number of Medicaid claims, an appointment book that was counted. Anything to show the methodology of how the number was determined. ***Note - no PHI should ever be uploaded to the SLR
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● EHR documentation: license, invoice or contract (something binding clinic/provider to vendor). The EHR Incentive Staff need to see something that binds the clinic/provider to the vendor. This could include an invoice or contract. ● If more than one provider in a practice, please provide information concerning number of licenses acquired from EHR vendor. ● Screen shot of the EHR version is helpful to the Wyoming Incentive Staff. The staff must arrive at the same certified technology number that is attested to in the SLR by the provider. Most times this requires the version of technology that is being used. Most of the EHR’s have a tab that says ABOUT, this is where the version can be found. ● If available a vendor letter is helpful as well, however, this cannot be used by itself for EHR documentation. Vendors will provide letters stating their technology is certified, this letter is very useful to the EHR Incentive staff, however the letter alone cannot be used. It must be accompanied with a contract, invoice or license agreement. For hospitals the required documentation is required to be uploaded to the SLR: ● Patient volume methodology: explain and show calculations. This needs to include how the hospital came to the number they are attesting to (10%). This could be a billing system that was used to pull the number of Medicaid claims or the electronic health record report; anything to show the methodology of how the number was derived. ***Note-no PHI should ever be uploaded to the SLR ● EHR documentation: license, invoice or contract (something binding hospital to vendor). The EHR Incentive Staff need to see something that binds the hospital to the vendor. This could include an invoice or contract. ● Screen shot of the EHR version is helpful to the Wyoming Incentive Staff. The staff must arrive at the same certified technology number that is attested to in the SLR by the hospital. Most times this requires the version of technology that is being used. Most of the EHR’s have a tab that says ABOUT, this is where the version can be found.
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● If available a vendor letter is helpful as well, however, this cannot be used by itself for EHR documentation. Vendors will provide letters stating their technology is certified, this letter is very useful to the EHR Incentive staff, however the letter alone cannot be used. It must be accompanied with a contract, invoice or license agreement. ● Most current complete cost report, to include S-10 if applicable. If S-10 was not required, upload your methodology and figures for uncompensated care ● Three previous years’ worksheet S-3, Part 1 EP’s and Hospitals will keep all documentation available in the event of an audit by EHR Staff. Post-Payment Audits
Once payment has been made, it is verified on the State Auditor's website and the EFT number is annotated. Verification with the HITECH Research and Support User Interface is also used to ensure the D18 transmitted and the information was updated appropriately. As part of its audit strategy, the EHR Incentive staff will conduct random, post-payment audits based on risk assessment of hospital and professional attestations. The audits will include independent verification that payments were calculated accurately based on the payment caps and formulas described in the Act and expounded upon in the Final Rule. In the event during the post payment audit, an Eligible Professional or Hospital is unable to provide the requested documentation to confirm Medicaid eligibility per the requirements set by the Final Rule 495.8, 495.306 and 495.308. This can include, however not limited to, proof of adopt, implement or upgrade to a certified EHR, patient volume calculations and any other information the EP or EH attested to on the state level registry. The incentive payment will be recovered by Wyoming Medicaid if these requirements are not met. The EP or EH can appeal the process per the State Medicaid HIT Plan, section 5.6.
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Payment Response File
After processing a payment request, the SAO will send a payment response file, D18, to the SLR. The payment response file confirms a payment was issued. It will include the amount paid, date of payment, method of payment and check or EFT number. Once payment is confirmed, Medicaid will notify CMS through the CMS Registration and Attestation System (D-18) and the EHR Incentive staff will notify the provider through an email. The final steps in the payment process involve delivery of the payment to the provider. If a provider has already elected to receive Medicaid payments through electronic funds transfer, the incentive payment will be transmitted by the SAO to the provider’s bank. If the provider or clinic requests a payment to go to an entity at not enrolled in the SAO database, they will be required to submit a WOLFS Form prior to EFT payment. The EHR Incentive Staff will then query the HITECH Research and Support User Interface to ensure the payment was received without error to the NLR.
Communication of Payment Status with CMS Registration and Attestation System (NLR) As indicated above in the SMHP, Medicaid understands the business requirements of the Medicaid EHR Incentive Program include the ability for the Medicaid SLR to communicate a hospital’s or professional’s payment status to the CMS Registration and Attestation System (NLR). This means that in addition to the B-6 and B-7 transactions between CMS and the SLR on the eligibility side, the Medicaid SLR is capable of transmitting payment information back to CMS (through a D-18 transaction). This transaction will indicate the professional’s receipt of a payment, allowing CMS to reconcile the professional’s payment year in the event a professional moves between the Medicare and Medicaid EHR Incentive Programs or between different state Medicaid EHR Incentive Programs.
Medicaid EHR Incentive Program Appeals Process 42 CFR 495.370 and 495.334 requires that Wyoming Medicaid have a process in place for providers to appeal the following issues related to the Medicaid EHR Incentive Program:
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(1) Incentive payments. (2) Incentive payment amounts. (3) Provider eligibility determinations. (4) Demonstration of adopting, implementing and upgrading and meaningful use eligibility for incentives under this subpart. Wyoming Medicaid anticipates providers seeking the incentive payments may appeal the following specific decisions: ● Denial of eligibility based on provider type, status as a hospital-based provider or status of practicing predominantly in a FQHC or RHC. ● Denial of eligibility based on Medicaid volume or Medicaid plus needy individual volume. ● Denial of payment based on non-use of certified electronic health record technology. ● Denial of payment based on non-satisfaction of the “adopt, implement, or upgrade” requirement for first year payment. ● Denial of payment based on non-satisfaction of Stage 1 meaningful use requirements for second year payment. Wyoming Medicaid anticipates that hospitals seeking incentive payments may appeal the following decisions: ● Denial of eligibility based on the hospital’s Medicaid patient volume. Denials of Incentive Payments: During the initial registration process, if a provider is determined by the system to be ineligible for the Wyoming Medicaid EHR Incentive Program, the system will not allow the provider to complete registration. For example, if a provider answers “yes” to the question which asks whether more than 90% of the provider’s enrolled encounters occur in a hospital setting, the 89
business rules for the system will indicate that the provider may not continue the registration. When the system makes this determination, the provider will encounter a screen stating that the provider is not eligible and may not continue with the registration process. The EHR Incentive Staff will send an electronic communication to the address specified by the provider, stating the reason that the registration process could not be completed. The electronic communication to the provider will specify a process for the provider to request more information from Wyoming Medicaid about the determination. The electronic communication will also provide additional documentation or information to the EHR Incentive Staff. The information received will warrant an administrative review of that documentation or information. The review will be conducted by the EHR Incentive Staff and will result either in a confirmation of the denial of eligibility or a decision that the provider is eligible and instructions for the provider to return to the registration process. This review will be considered a request for reconsideration under the Wyoming Medicaid rules and regulations and if the denial is confirmed, the provider will be notified of his or her right to an administrative hearing consistent with the Wyoming Medicaid rules and regulations. The process described above will also apply to situations where a provider successfully registers with the Medicaid SLR, but later is determined not to qualify for an incentive payment. The electronic communication to the provider will state the particular reason that the provider does not qualify, describe the process for the provider to request additional information and to submit additional documentation and information in support of the provider’s application for that year’s incentive payment. In cases where there is no denial or determination that the provider does not qualify, but the provider believes there is an error, instructions on the Wyoming Medicaid EHR Incentive Program website will instruct the provider to contact the EHR Incentive Staff to resolve the issue. In these cases, the EHR Incentive Staff will initiate the electronic communication advising the provider of the process for receiving administrative review of the issue. Medicaid will use its existing administrative appeal process to resolve disputes with providers about incentive payments, eligibility determinations and providers’ qualification for incentive payments. The existing administrative appeal process is governed by Chapters 1 and 16 of the WDH Medicaid regulations. In addition, Chapter 3 of the WDH Medicaid regulations governs provider participation in the Medicaid program. The program’s administrative appeals process is also governed by the 90
Wyoming Administrative Procedure Act, W.S. 16-3-101 et seq. and the regulations promulgated by the Office of Administrative Hearings (OAH Rules Chapters 1-7).Although new rules may be promulgated to specifically address the Wyoming Medicaid EHR Incentive Program, Medicaid is committed to using the same appeals process for disputes in the incentive program that it uses for other disputes between the agency and providers, in order to maintain a consistent process.
Medicaid EHR Incentive Program Website The Wyoming Medicaid EHR Incentive Program website (http://wyomingincentive.wyo.gov/ ) was completed in early January 2011. The website provides: a link to the secure registration and attestation portal, an avenue to e-mail the EHR Incentive Staff, information about eligibility guidelines, resources to assist providers with determining their patient volume, a Medicaid EHR incentive calculator for hospitals, links to relevant CMS and ONC websites and Wyoming and national news regarding the Wyoming Medicaid EHR Incentive Program. Changes to the website will include integration of the user interfaces for accessing the secure portal and posting of tutorials that will demonstrate, step-by-step, how to complete the attestation forms. The website will be updated as needed with pertinent information regarding the incentive program as well as the amount that has been paid out by the Wyoming Medicaid Incentive Program.
Medicaid EHR Incentive Program Provider Helpdesk Plan Because the number of eligible professionals, eligible hospitals and CAHs in Wyoming is limited, a full-fledged help desk is not reasonable. The EHR Incentive Staff has and will continue to disseminate contact information for the HIT Systems Manager and Health IT Outreach Coordinator to eligible professionals, eligible hospitals and CAHs. These two staff members will act as a Provider Helpdesk and respond to provider questions regarding certification, claims and eligibility determinations. The hours of operation will be normal business hours (0800-1700). These two members will respond to inquiries within three business days. An internal tracking system will be developed to track contacts and to route questions to the appropriate person to resolve any issues or concerns in relation to the Wyoming Medicaid EHR Incentive Program.
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Development and dissemination of a Wyoming Medicaid EHR Incentive Program Provider Manual has been completed and uploaded. This manual contains information about the incentive program, as well as instructions for navigating the Medicaid SLR system. The manual is available on the http://wyomingincentive.wyo.gov/ website and the State Level Registry and updated as necessary at those locations.
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Section D: The State’s Audit Strategy Please see Wyoming’s Audit Strategy for all information concerning auditing and oversight activities.
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Section E: The State’s HIT Roadmap This HIT Roadmap indicates Medicaid’s anticipated activities involving health IT systems and initiatives in Wyoming, including the collaborative activities with other stakeholders engaging in health IT projects, the administration and supervision of the Wyoming Medicaid EHR Incentive Program, the Total Health Record project and planned Medicaid program and system initiatives to leverage the abilities of health IT systems for purposes of operating the Wyoming Medicaid program more efficiently and effectively and facilitating WDH’s mission of improving the health of Wyoming’s citizens. Collaborative health IT activities described in this section of the HIT roadmap focus on Medicaid’s efforts to coordinate projects and programs established by the ARRA funds of the HITECH Act with the State Designated Entity.
Wyoming Medicaid EHR Incentive Program In this section of the HIT Roadmap include those tasks necessary to design, acquire, implement and maintain an administrative system for purposes of making incentive payments to eligible professionals and hospitals that use certified EHR technology in accordance with the measures and objectives established by the Final Rule. This section includes activities relating to provider communication which is specific to the EHR Incentive Program, updates and maintenance development of a State Level Repository (“SLR”) system to administer the incentive payments during the first and all consecutive year, as well as the expansion of the SLR to accommodate additional functionality as required my CMS to enhance patient outcomes.
Activity Participate in educational opportunities presented by CMS (i.e. All-States HITECH call) and ONC (conferences, Community of Practice groups). Participate in Region 8 CMS calls
2016
2017
2018
2019
2020
2021
Q1, Q2, Q3, Q4
Q1, Q2, Q3, Q4
Q1, Q2, Q3, Q4
Q1, Q2, Q3, Q4
Q1, Q2, Q3, Q4
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Q1, Q2,
Q1, Q2,
Q1, Q2,
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Q1, Q2,
Q1, Q2,
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Participate in meetings of RO#8 Collaborative facilitated by CMS Complete and submit State Medicaid HIT Plan; revise and update as necessary. Complete and submit Implementation Advanced Planning Document; revise and update as necessary. Conduct direct outreach to professionals and hospitals eligible for Wyoming Medicaid EHR Incentive Program Conduct analysis of Medicaid volume for practices and hospitals as appropriate to assist with determination of percentage of enrolled encounters attributable to Medicaid patients. Present EHR Incentive Program information to Medicaid Physician Advisory Group to generate awareness and solicit provider feedback about health IT issues, meaningful use questions and awareness of health IT resources. Develop outreach material for continued education for providers Continue developing SLR system. Enhance SLR capability QRDA submissions of CQMs for Meaningful Use Maintain up to date auditing procedures to reflect program year requirements Increase return rate of providers coming back for MU 56% to 80% Increase Dental provider participation in
Q3, Q4 Q1, Q2, Q3, Q4 As needed
Q3, Q4 Q1, Q2, Q3, Q4 As needed
Q3, Q4 Q1, Q2, Q3, Q4 As needed
Q3
Q3
Q3
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As requested
As requested
As needed Q1 Q2, Q3, Q4
As needed
Q1 Q2, Q3, Q4 Q1 Q2, Q3, Q4 Q1 Q2,
Q1 Q2, Q3, Q4 Q1 Q2, Q3, Q4 Q1 Q2,
As required Q4
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Q3, Q4 Q1, Q2, Q3, Q4 As needed
Q3, Q4 Q1, Q2, Q3, Q4 As needed
Q3, Q4 Q1, Q2, Q3, Q4 As needed
As requested
As requested
As requested
As requested
As needed As Required Q1, Q2, Q3, Q4 Q1 Q2, Q3, Q4 Q1 Q2, Q3, Q4 Q1 Q2,
As needed As Required
As needed As Required
As needed As Required
Q1 Q2, Q3, Q4 Q1 Q2, Q3, Q4 Q1 Q2,
Q1 Q2, Q3, Q4 Q1 Q2, Q3, Q4 Q1 Q2,
Q1 Q2, Q3, Q4 Q1 Q2, Q3, Q4 Q1 Q2,
the EHR Incentive Program by 10% Complete revamp of audit strategy Revised and developed new risk criteria
Q3, Q4 Q2 Q3 Q2 Q3
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Goals This section of the HIT Roadmap includes Medicaid’s vision for using HIT, with electronic health records and health information exchange as a vital component, to implement programmatic policies and initiatives designed to improve the efficiencies of the Medicaid program and to improve the health of Wyoming citizens. Activity
2016
2017
Want all 64 CQMs available in the PCMH system for providers to report
Q4
Q1, Q2, Q3,Q4
Original 29 targeted clinics enrolled and reporting by the end of 2016
Q4
Q1, Q2, Q3,Q4
Q1, Q2, Q3,Q4
2018
2019
2020
2021
Q1, Q2, Q3,Q4
Q1, Q2, Q3,Q4
Establish CQM Benchmarks for PCMH Program to promote improve in patient outcomes Identify realistic statewide HIE needs
Q3
Release RFP for Statewide HIE Solutions
Q4
Q1
Explore initiatives to promote transparency of data and appropriate data-sharing between providers, payers and patients for purposes of improving outcomes and reducing inefficiencies. Continue to develop enhancements to Total Health Record with a focus on data
Q1, Q2, Q3, Q4
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utilization and decision support. Have all providers who desire to report to the available public health registries connected through the THR Gateway Leverage Data Repository reporting to identify gaps in patient care
Q1, Q2, Q3, Q4
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Q1, Q2, Q3, Q4
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On-going
Ongoing Q1, Q2, Q3, Q4
On-going
On-going
Q2, Q3
Conduct HIT MITA assessment Issue MMIS Replacement Modular RFP
On-going
On-going
Q1, Q2, Q3, Q4
Implement Modular MMIS Replacement Systems Certification of PQRS Registry for PCMH
Q4
Q1, Q2, Q3, Q4
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Q1, Q2, Q3, Q4
Common Acronyms used in WDH HIT AHRQ ARRA CAH CCD CDC or CDCP CEHRT CHIPRA CHPL CIO CMS CQM DFS EHR EFT EH EHDI EMR EMS EP EPLS ETS FQHC HIE
Agency for Healthcare Research & Quality American Recovery & Reinvestment Act Critical Access Hospital Continuity of Care Document US Centers for Disease Control & Prevention Certified Electronic Health Record Technology Children's' Health Insurance Program Reauthorization Act Certified Health IT Product List Wyoming Office of the Chief Information Officer Center for Medicare & Medicaid Services Clinical Quality Measurement Wyoming Department of Family Services Electronic Health Record Electronic Fund Transfer Eligible Hospital Early Hearing Detection & Intervention Electronic Medical Record Emergency Medical Service Eligible Professional Excluded Parties List System Wyoming Department of Enterprise Technology Services (formerly IT) Federally Qualified Health Center Health Information Exchange
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HIEES HIS HISPC HIT HITECH I-APD IIS IT LEIE MFCU MIE MITA MMIS MOU NLR NPI OAH ONC ONC-ACB PBM PHI PHR P-PAD QIO REC RFP
Wyoming Medicaid Health Insurance Eligibility and Enrollment System US Indian Health Service Health Information Security & Privacy Collaboration Health Information Technology Health Information Technology for Economic and Clinical Health Act Implementation - Advanced Planning Document Immunization Information System Information Technology List of Excluded Individuals/Entities Medicaid Fraud Control Unit Medical Informatics Engineering Medicaid Information Technology Architecture Medicaid Management Information Systems Memorandum of Understanding National Level Registry National Provider Identifier Office of Administrative Hearings Office of the National Coordinator for Health Information Technology Office of the National Coordinator - Authorized Certification Body Pharmacy Benefits Management Personal Health Information Personal Health Record Planning - Advanced Planning Document Quality Improvement Organization Regional Extension Center - Wyoming-Montana Regional Extension Center (Mountain-Pacific Quality Health Foundation) Request for Proposal
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RHC RHIO SAO S-CHIP SDE SLR SMHP SNAP SOA TANF TIN VA WDH WHIN WOLFS WWAMI WyHIO WyIR WYPCA
Rural Health Clinic Regional Health Information Organization Wyoming State Auditor's Office State Children's Health Insurance Program State Designated Entity (e-Health Partnership) State Level Registry State Medicaid Health Information Technology Plan Supplemental Nutrition Assistance Program (Food Stamp Program) Service Orientated Architecture Temporary Assistance for Needy Families Taxpayer Identification Number (Social Security Number) US Department of Veterans Affairs Wyoming Department of Health Wyoming Health Information Network Wyoming Online Financial Systems Washington-Wyoming-Alaska-Montana-Idaho; University of Washington Medical Education Program Wyoming Health Information Organization Wyoming Immunization Registry Wyoming Primary Care Association
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Appendix A: State Flexibility Rule State Medicaid Health Information Technology Plan Update Addendum This addendum to the Wyoming State Medicaid Health Information Technology Plan (SMHP) addresses anticipated program, system, and audit changes related to the Certified Electronic Health Record Technology (CEHRT) Flexibility rule. The Centers for Medicare and Medicaid Services (CMS) published the CMS 2014 CEHRT Flexibility Final Rule (the Flexibility Rule) on August 29, 2014 that was effective October 1, 2014. The rule provisions allow providers to meet meaningful use (MU) requirements with electronic health records (EHRs) certified to the 2011 or the 2014 Edition criteria, or a combination of both Editions for the 2014 EHR Reporting Period. The rule requires providers to report using 2014 Edition CEHRT for the EHR Reporting Period in 2015, and extends Stage 2 through 2016. Wyoming does not have any participating Medicaid-only Eligible Hospitals (EH); therefore, this addendum shall only reference Eligible Professionals (EP) from this point forward.
1.1.1 SMA Policy Changes The Flexibility Rule provides parameters defining acceptable reasons that providers were unable to fully implement 2014 edition CEHRT. Pursuant to these changes, a new screen on the Wyoming State Level Repository (WYSLR) will be developed for providers to complete during their attestation that includes the reasons for the inability to fully implement a 2014 CEHRT. The new screen will include check boxes as well as a free text box for providers to use to provide details for their attestation. The reasons below will be coded into the WYSLR and required for response if an EP utilizes the options provided in the Flexibility Rule. • •
My EHR vendor encountered issues (related to software development, certification, implementation, testing, or release of product) that resulted in the vendor not making the 2014 Edition available to us to begin implementation My EHR vendor encountered issues (related to software development, certification, implementation, testing, or release of product) that resulted in the vendor not making the 2014 Edition available to us in time to fully implement; we encountered the following issue(s): o An inability to train staff o An inability to test the updated system o An inability to put new workflows in place 101
•
I practice at multiple outpatient locations, and < or = 50% of my total outpatient encounters during the EHR reporting period occurred at locations where the 2014 Edition CEHRT which has been fully implemented. • I am unable to meet the Measure 2 for the Stage 2 Core Objective, Summary of Care, for provision of summary of care document (the intended recipients were impacted by 2014 Edition CEHRT delays and were unable to receive the electronic summary of care document The following reasons are not sufficient to warrant attestation under the CEHRT Flexibility Rule: financial issues, inability to meet one or more measures, staff turnover and changes, provider waited too long to engage a vendor, refusal to purchase the requisite software updates, or providers who fully implemented 2014 edition CEHRT and can report in 2014. The prepayment review process will require the EP to upload supporting documentation for verification of the ability to use the Flexibility options. Staff will work with EPs on an individual basis if additional documentation is needed to prove that their delay in implementation of 2014 edition CEHRT availability is attributable to issues related to software development, certification, implementation, testing, or release of the product by the EHR vendor.
1.1.2 Provider Registration and Attestation Wyoming EHR Incentive program staff and our vendor Health Tech Solutions, LLC are updating the WYSLR requirements for the CEHRT Flexibility Rule. The core code will be tested in December and the anticipated release to production is January 2015. Wyoming will not need to extend the existing attestation tail period which is currently set at 90 days and will provide enough time post production for providers to utilize the Flexibility Rule options. The process to validate the EHR certification is a web service connection in the WYSLR to the Office of the National Coordinator’s Certified Health IT Product List (CHPL). This ‘call out’ verifies that the certification number is valid. The process continues with manual verification by program staff using the search feature on the Medicaid HITECH website to verify that the CEHRT entered matches the product the provider has identified in their application documentation. The options for attestation available to the provider will be driven by the certification number they have entered as detailed in the charts below. EPs who are AIU will be required to have a 2014 CEHRT and are not considered for the Flexibility Rule changes. Options for EPs who are on Stage 1 MU 102
CEHRT Version
2011 2011/2014 Combination
Option to attest 2013 Stage 1 MU Yes Yes
2014 only No Options for EPs who are on Stage 2 MU CEHRT Version
2011 2011/2014 Combination 2014 only
Option to attest 2014 Stage 1 MU
Is a reason required?
No Yes
Yes Yes, Except for EPs attesting to Stage 1 2014 No
Yes
Option to attest 2013 Stage 1 MU Yes Yes
Option to attest 2014 Stage 1 MU No Yes
Option to attest 2014 Stage 2 MU No Yes
No
Yes
Yes
Is a reason required?
Yes Yes – Except for EPs attesting to Stage 2 2014 Yes – Except for EPs attesting to Stage 2 2014
1.1.3 Medicaid EHR Incentive Program Payment Administration Pre-payment validation of attestations will continue to ensure that providers meet the requirements prior to approving a payment. The Wyoming appeals process is sufficient to accommodate denials that occur as a result of not meeting requirements to attest under the requirements in the CEHRT Flexibility Rule.
1.1.4 Audit & Program Integrity The Wyoming EHR Incentive Staff is validating all EPs pre-payment for Flexibility Rule compliance; therefore, no changes are proposed to the post-pay audit strategy. 103
1.1.5 Outreach, Collaboration, Support Wyoming has been exploring outreach activities related to the release of the CEHRT Flexibility Rule. These efforts include updating the state website to include general information, materials, and links to national resources (such as links to specific pages on the Centers for Medicaid and Medicare Services website), as related to the CEHRT Flexibility Rule. Materials produced by Wyoming’s EHR Incentive outreach team include CEHRT Flexibility Rule Tip sheets, Frequently Asked Questions (FAQ) documents, and availability of Wyoming EHR staff for one on one discussion with providers.
1.1.6 State-Based Performance Measures WYSLR documents the CEHRT used for attestation. Information will be available that identifies EPs that have delayed implementing 2014 Edition CEHRT attributable to issues related to software development, certification, implementation, testing, or release of the product by the EHR vendor. This information will be available after all payments have been made for the 2014 program year. Wyoming will continue to participate in CMS HITECH All States Calls and Community of Practice (CoP) meetings to stay informed regarding CMS guidance.
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Appendix B: SLR Screen Shots SLR Provider details and Eligibility
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Meaningful Use Screens These screens will display for all providers attesting to Meaningful Use in the Wyoming Medicaid EHR Incentive Program across all program years and stages of Meaningful use.
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Meaningful Use Stage 1 Screens These Core and Menu Measure screens are only relevant for those providers attesting to Stage 1 the Wyoming Medicaid EHR Incentive Program.
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Meaningful Use Stage 2 Screens These Core and Menu Measure screens are only relevant for those providers attesting to Stage 2 the Wyoming Medicaid EHR Incentive Program.
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Clinical Quality Measures:
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These screens are consistent for all provider attesting for Stage 1 or Stage 2 in the Wyoming Medicaid EHR Incentive Program.
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