Connecting Patients, Providers and Payers

1. Health Information Technology
Connecting Patients, Providers
and Payers
Health Care Information Exchange Strategy and
Roadmap

2. About me Patrick Mulrooney
14 years providing successful delivery of Enterprise Strategy Programs and
solutions that create and optimized IT & Business combined road-maps, while
ensuring that the appropriate technologies are being utilized to maximize,
Capitalize and support business strategies .
Successful delivery of 50 + projects in a management role.
Expertise:
 Global Solution Delivery
 IT Governance
 Enterprise Architecture
 Business Insight
 Information Management
 Business Value Analysis and Benefits Management
 Organizational Design
Group Affiliation:
 Microsoft in Health, Enterprise Architecture Consultants,
 Microsoft BI & Datawarehouse Professionals, IT Governance &
 Outsourcing, Data Architect USA, Solution Architecture Workshop of
Microsoft, Microsoft Amalga, Enterprise Management Architecture.
Home: Buffalo New York
Love Golf
Veteran: United States Air Force

3. Scope of Engagement
 Deliver Business Foundation & Road Map strategies
 Nationwide Health Information Network (NHIN)
 Health Information Exchange (HIE)
 Integrate Health Information Technology (Health IT)
 Incorporate Medicaid Information Technology Architecture
(MITA)
 Map Architecture Framework

Business Architecture

Information & Data Architecture

Technical Architecture
 Assemble Architecture Development Model (ADM),
Enterprise Continuum
 Architectural Assets (Building Blocks)
 Technical Designs
 Solutions
 Platforms
 Tools……

4. Stakeholders
 Senior leadership (CFO, COO, CEO,CIO,CTO)
 Medical Professionals and Health care
Providers;
 Clinic managers, Nursing staff, Billing and
administrative staff, Medical records staff….
 Patient advocates
 Government agencies, Federal & Local
 Health plan sponsors (employers / unions).
 Special Investigation (SIU)
 Corporate Sales & CRM executives.
 550,000 members/beneficiaries

5. My Role
“Multiple Hats”
 Ensuring that the business and IT strategies were in
position.
 Accomplish Needs analysis and roadmap
development. (IBM Blue Works)
 Architect Solutions that were in line with current
Business/IT environment.
 Align technology to business objectives.
 Business case development.
 Secure the active participation of key stakeholders.

6. My Role
“Multiple Hats” cont
 Drive common approaches and expose information
assets and processes across the enterprise. (Enterprise
Continuum)
 Link the business mission, strategy and processes
of an organization to its IT strategy .
 Show how the current and future needs of the
organization will be met in an efficient, sustainable,
agile, and adaptable manner.
 Allow both the Business and IT strategies to enable
and drive each other.
 Making sure that there is a vision...

7. Value of my Contribution
 Successful alignment of IT strategy and planning
with company's business goals.
 Optimization of information management
approaches.
 Integrated Long-term strategic responsibility for the
company's IT systems.
 Promotion of shared infrastructure and applications.
 Reduce costs and improve information flows.
 Ensured that projects did not duplicate functionality
or diverge from each other.

8. Value of my Contribution
cont.
 Mitigated the risks associated with information and
IT assets through appropriate standards and
security policies.
 Built staff development, knowledge and skills.
 Transferred understanding of evolving business
needs and technology capabilities.
 Direct involvement in the development of policies,
standards and guidelines that express the selection,
development, implementation and use of
Information Technology within the enterprise.

9. Business Foundation & Road Map
Mission Statement
Our Goal
Business Value
Business & IT Alignment
 Eight IT Priority Areas of Focus
Enterprise Road Map
Required Data Exchanges
Business Imperatives

10. To successfully institute a framework of business
processes and technologies that support and
improved program administration for the
enterprise and stakeholders.
 Thinking Globally
 Acting Dynamically
 Focus on the individual

11. Our Goal
Patient Centric Health
Information Exchange
Diagnostic Pharmacies
Labs
Hospitals
Behavioral Health Public
Provider & Health Physicians &
Patient Staff
11

12. Business Value & Benefits
• Develop capabilities for standards-based,
secure data exchange nationwide.
• Improve the coordination of care &
information among hospitals, laboratories,
physicians offices, pharmacies, and other
providers.
• Ensure appropriate information is available
at the time and place of care.
• Ensure that members health information is
secure and confidential.

13. Business Value & Benefits cont
• Offer members new capabilities for managing
and controlling their personal health records as
well as providing access to their health
information from Electronic Health Records
(EHR) and other sources.
• Reduce risks from medical errors.
• Supporting the delivery of appropriate, evidence
based medical care.
• Lower healthcare costs by reducing
inefficiencies, medical errors, and incomplete
patient information.

14. Enterprise Road Map
Required Data Exchanges
2013
 Lab results delivery
 ePrescribing
 Claims and eligibility checking
 Quality & immunization reporting
2014
 Registry reporting and reporting to public health
 Electronic ordering
 Health summaries for continuity of care
 Receive public health alerts
 Home monitoring
 Populate Personal Health Records (PHR)
2015
 Access comprehensive data from all available sources
 Experience of care reporting
 Medical device interoperability

15. Joint Business & IT Priority Areas
“Road Map”
1. Incorporate technologies that protect the privacy of health
information and promote security in a qualified electronic
health record.
 Including for the segmentation and protection from disclosure, of
specific and sensitive individual identifiable health information.
2. A nationwide health information technology infrastructure
that allows for the electronic use and accurate exchange of
health information.
3. The utilization of a certified electronic health record for
each person by 2014.
4. Technologies that, as a part of a qualified electronic health
record, allow for the accounting/auditing of disclosures
made by a covered entity.

16. Joint Business & IT Priority Areas (cont.)
5. The use of certified electronic health records to improve
the quality of health care.
6. Technology solutions that allow individually identifiable
health information, to be rendered unusable, unreadable,
to unauthorized individuals.
7. The use of electronic systems to ensure the
comprehensive collection of patient demographic data,
including at a minimum, race, ethnicity, primary language,
and gender information.
8. Technology solutions that address the needs of children,
elderly and other vulnerable populations.

17. Business Benefits

18. Change the Way We Think
 Beneficiary & Member centric focus
 Public & private collaborations
 Dynamic synergy with the
Department of Health

19. Change the Way We
interact With Technology
 Develop & Require Best Practices
 Expand Project Management Disciplines
 Engage Enterprise Solution Architectures
 Integrate Testing & Quality Assurance
 Faster “Time to Market”
 Create successful business-technology
roadmaps

20. Change the Way We Work
 Learning & Growth
 Organize Around Strategy
 Align to Create Synergy
 Promote Process Innovation
 Mission Based Motivation

21. Change the Way We Govern
 Business Based Priority Setting
 Govern Based on Facts
 Goal & Objective Based Decision Making
 Execution Based Upon Value

22. Change the Way We lead
 Strategic Accountability
 Performance Accountability
 Operational Excellence
 Strategic Flexibility

23. Give us Strategic Advantage
 E-prescribe, MTM, Part D
 Electronic Health Records
 Linking our Health Community
 Business Agility
 Member Empowerment
 Improved Health of Members &
Beneficiaries
MTM=Medication therapy management, Part D = Medicare Prescription Drug Benefit

24. Make us a Better Company

25. Nationwide Health Information
Network (NHIN)

26. Health Information Distribution

27. Goals NHIN seeks to achieve
• Developing capabilities for standards-based, secure data
exchange nationwide.
• Improving the coordination of care information among
hospitals, laboratories, physicians offices, pharmacies, and
other providers. (Amalga )
• Ensuring appropriate information is available at the time and
place of care.
• Giving consumers new capabilities for managing and
controlling their personal health records as well as providing
access to their health information from Electronic Health
Records (HER) and other sources. ( Health Vault )
• Reducing risks from medical errors and supporting the delivery
of appropriate, evidence-based medical care.
• Lowering healthcare costs by reducing inefficiencies, medical
errors, and incomplete patient information.
NHIN =Nationwide Health Information Network

28. Health Information Exchange
(HIE)

29. Health Information Exchange (HIE)
is designed to:
• Improve individual patient care.
• Provide early detection of infectious
disease outbreaks around the country.
• Improved tracking of chronic disease
management.
• Provide quality measurements.
 ( HEDIS )
HEDIS = Health Care Effectiveness Data for Information set

30. Patient Visit/Discharge Summary Exchange
4
Patient receives care and
3 details are noted in
hospital medical record
As a result of a referral,
admission, or emergency,
patient registers in hospital
HIE service checks 7
provider directory for
2 routing instructions
Consents and Standard format
provider routing discharge summary
preferences are sent or ER report is
to HIE service transmitted to HIE
network
6
Patient is discharged
from hospital
Patient visits PCP or specialist HIE service routes
and establishes trusted discharge summary to
relationship and consents for PCP, specialist or 5
release of data other interested and
1 trusted party (e.g.,
health insurance case
HIE = Health Information Exchange manager)
PCP = Primary Care Provider 8

31. 2
Provider refers patient to a Referrals
specialist, hospital or other
provider for consultation or
service
4
3 HIE service checks provider
directory for routing
HIE service submits instructions and sends referral
referral authorization request with pertinent patient
information / history, diagnosis
request to payer for
and service requested to
approval and referral # consulting provider; business
rules can be stored in HIE
service for elements of real-
time decision support
Patient visits PCP HIE service routes
1 or specialist and visit summary to PCP,
Patient visits consulting
establishes trusted specialist or other
Standard format provider, receives
relationship and interested and trusted
visit summary with services, and details are
consents for release party (e.g., health
consultation notes noted in patient chart ,
of data; consents insurance case
transmitted to HIE electronic medical
and provider routing manager)
network record or other result is
preferences are created (e.g., at lab)
sent to HIE service 7
6
HIE = Health Information Exchange
5
PCP = Primary Care Provider

32. Laboratory Results
2
Consents, lab
results, and provider
routing preferences
are sent to HIE
service
3
HIE service checks
provider directory for
routing instructions and
sends laboratory results
to patient’s preferred
provider
1 4
Patient undergoes tests
from his or her Authorized providers
physician, establishes can access patient’s
trusted relationship and laboratory results
consents for release of
laboratory data
HIE = Health Information Exchange
PCP = Primary Care Provider

33. Standardized Quality Data
2
Consents, provider
routing preferences
and applicable data
are sent to HIE
service
Standard format visit
1 summary or batch with data for
determining quality metrics is
Patient visits PCP,
sent to payer, government
specialist, hospital or
agency or other quality metrics
other provider and
3 organization based on patient
establishes trusted
consent and business HIE
relationship and
service.
consents for release of
data
HIE = Health Information Exchange
PCP = Primary Care Provider

34. Community Provider Directory
3
HIE service consolidates
organizational provider
information into a single
1 community provider 4
directory
Provider
Provider information Authorized HIE
organizations track
from each provider users can access
and maintains
organization is sent community provider
internal provider
to HIE service directory
directory
2
HIE = Health Information Exchange
PCP = Primary Care Provider

35. Health Information Technology
(Health IT)

36. Health Information Technology
(Health IT)
 Health Information Technology (Health IT) is the use of computer
applications to record, store, protect, retrieve, and transfer, clinical,
administrative, and financial information electronically within health
care settings.
 New Health Reform laws requires implementation of uniform
standards for electronic exchange of health information by 2013.
36

37. Health IT Strategic Goals
 Develop the infrastructure for Electronic Health
Records, including privacy, confidentiality, and data
standards.
 Provide incentives and create tools to facilitate the
adoption of Health IT and EHRs.
EHR = Electronic Health Records
EHR = Electronic Health Records
37

38. Benefits Associated with
Broad use of HIT
 Improve health care quality
 Prevent medical errors
 Reduce health care costs
 Increase administrative efficiencies
 Decrease paperwork
 Expand access to affordable care

39. Benefits: Better Engaged Patients
 Electronic Health Record systems can connect
patients to community resources and support.
 Provides information that permits them to
participate in shared decision-making with their
healthcare provider.
 Supports home monitoring of reported
symptoms related to chronic conditions with the
goal of preventing unnecessary hospitalization.
HIT = Health Information Technology
(Smith, Meyers, & Miller, 2001; Humphreys & Moos, 2001)
39

40. Benefits: Clinical Decision Support
Systems (CDS)
 Clinical Decision Support systems are seen as critical
components in creating EHR-based “learning systems”
 CDS continually incorporate clinical advances, applying
them to ever-growing and more detailed patient
databases
 CDS increase the providers abilities to predict (based on
patient data and demographics) which interventions will
offer the best outcome.
EHR = Electronic Health Records
Sources: Grantham, D. (November/December 2010) CDS systems seek “real life” data. Behavioral Healthcare. pp. 35-39;
Moore, J. (January/February 2011) CDS: more signal, less noise. Government Health IT, pp. 25-27
EHR =Electronic Health Records, Vitamin D deficiencies
40

41. Strategic Outcomes for Health IT Adoption
Strategic HIT Performance
HIT Strategic
Focus Areas Outcomes
Performance Metrics
Meaningful Use of
Reduced Unnecessary
EHR to reduce Cost/Utilization =
Cost Reduced PMPM &
Duplication, Errors
Containment
Strategic Planning Logic Map
and improve Lower % Admin Cost
Admin Efficiency
Meaningful Use of Improved Quality
Quality EHR to better Against HEDIS and
Improvement coordinate care and Other Benchmarks
Quality Performance
Meaningful use of Higher Provider
Administrative EHR to Reduce Satisfaction &
Efficiency Admin. Process Reduction in Admin.
Cycle Times Cost
Public Meaningful Use of Public Health
EHR to build
Health & Responsiveness
Population Reduction in
Research Health Mgmt. & Health Disparities
Research
01/05/13 Barrier USE
Meaningful PERFORMANCE Management
Barrier

42. Advantage: A Connected Health IT System
Hospital Care Diagnostics Specialist Referral
Coordination
Primary
Order
Care
Entry Lab
Medical
Result
Home
Reporting EHR/HIE Provider
Research &
E-Prescribing
Comparative
Remote Patient Medical Mgmt. & Effectiveness
Self Monitoring Administrative
EHR = Electronic Health Records Data
HIE= Health Information Exchange

43. Medicaid Information
Technology Architecture
(MITA)

44. Medicaid Information Technology
Architecture (MITA)
MITA represents a business-driven enterprise
transformation.
MITA is firmly grounded in enterprise
architecture principles.
MITA defines a business transformation over a
5-year and long-term (10 years and greater)
timeframe, and defines a technical architecture
and a transition strategy to enable the business
transformation.

45. MITA Objectives
 Promote reusable components through modularity.
 Adapt data and industry standards.
 Promote secure data exchange.
 Promote efficient data sharing.
 Beneficiary centric focus.
 Integration of clinical and administrative data to enable
better decision making.
 Breakdown artificial barriers between systems,
geography, and funding within the Title 19 program.
The Medicaid Title 19 program is designed to help persons who are age 65 years or older, or persons with disabilities between the
ages of 18 and 65, who are blind or who receive public assistance to pay medical expenses

46. MITA Goals
 Develop seamless integrated systems that effectively
communicate through interoperability and standards.
 Provide an environment that supports flexibility, adaptability,
and rapid response to changes in programs and technology.
 Establish a national framework of enabling technologies and
processes that support improved program administration for
the Medicaid enterprise.
 Dedicated to improving healthcare outcomes for Medicaid
beneficiaries.

47. Nation Wide Framework

48. “Partnerships”
Business and IT Alignment
MITA is intended to foster integrated business and IT
transformation across the Medicaid enterprise to improve the
administration of the Medicaid program.
It is a common business and technology vision for state
Medicaid organizations.
MITA is conceived in the context of:

 E-Gov Federal Enterprise Architecture
 Office of the National Coordinator for Health Information Technology
(ONCHIT).
 The Centers for Medicare and Medicaid Management (CMS)
 National Health Infrastructure Initiative (NHII).

49. Architecture Framework
(MITA)
 Business Architecture
 Information Architecture
 Technical Architecture

50. Business Architecture
Concept of Operations
The “Concept of Operations” is a methodology used to describe current
business operations and to envision a future transformation that
meets the needs of stakeholders.
 Definition of As-Is operations.
 Identification of current and future stakeholders.
 Identification of major business and data exchanges between stakeholders.
 Description of To-Be operations.
 Listing of key enablers required to meet the To-Be transformation.

51. Business Architecture
Maturity Model
A maturity model can be viewed as a set of structured levels that
describe how well the behaviors, practices and processes of
an organization can reliably and sustainably produce required
outcomes.

52. Business Architecture
Business Process Model
Medicaid Business
Process
Model
Member Provider Contractor Operations
Management Management Management Management
Program Business
Program Care
Integrity Relationship
Management Management
Management Management
The Business Process Model is a repository of business
processes common to most Health Care programs. The
BPM consists of a hierarchy of business areas that lead to
individual business processes.

53. Business Architecture
Business Self Assessment
The Business Self Assessment is used to determine current business
capabilities and document their plans for transformation to
achieve a higher level of business prowess.

54. Business Architecture
Strategy & Governance
 Prioritize business capability needs.
 Formal plan for implementing capabilities.
 Establish technical standards.
 Solidify strategic approach.

55. Business Architecture
Process Innovation
 Best practices in requirements gathering, project management,
architecture and software development.
 Governance process & portfolio management.

56. Architecture Framework
(MITA)
 Business Architecture
 Information Architecture
 Technical Architecture

57. Information Architecture
The Information Architecture describes a logical architecture for the
Health Care enterprise. It provides a description of the
information strategy, architecture, and data that may be used to
define the needs that will enable the future business processes
of the enterprise.

58. Information Architecture
Rational for Building a Clinical &
Administrative information Architecture
 Facilitates Cost and Quality Transparency
 Essential for Continuity of Care Records
 Facilitates Population Health Management
 Improves Medical Management
 Improve Program Evaluation and Decision
Making

59. Information Architecture
Data Management Strategy
 Provide a structure that facilitates the development of data that can be effectively
shared across a State’s Medicaid enterprise boundaries to improve mission
performance.
 Provides a mechanism for the agency to better understand data and how it fits in the
total realm of Medicaid information.
 Addresses fundamental areas necessary to enable information sharing opportunities.
 Positions the Medicaid agency to operate in an environment of global information.

60. Information Architecture
Key Components to Data
Management Strategy
 Data Governance defines the governance processes for making
enterprise-wide decisions regarding MITA’s information holdings.
 Data Architecture establishes standard data-management
procedures for the MITA data models.
 Data-Sharing Architecture describes technology considerations for
Medicaid enterprises to participate in information-sharing
communities.

61. Information Architecture
Conceptual Data Model
The conceptual data model is used
primarily as a communication tool between
the business user and IT architect to
obtain agreement on the overall
description of entities and their
relationships in business terms. It also
represents the beginnings of an overall
logical structure of the data.

62. Information Architecture
Logical Data Model
 Derived from the conceptual data model, the logical data
model defines aspects of the business, broken down into
data classes and attributes associated with each business
process.
 The model identifies all of the data elements that are in
motion within the system or shared throughout the Medicaid
enterprise. It also shows relationships between aspects of
business.
 The logical data model is the foundation for creating a
physical data model.

63. Enterprise Level Data Repository and Decision Support Infrastructure
Methods/Analytics Decision
•Episodes of Care Support
External Data / Profiles •Performance Measures Reporting
Public Health •Disease Staging Applications
Evidence-Based
Medical Management
Medicine
Comparative
Fraud Detection
Data Sets Data Data
Data
Beneficiary Data Warehouse Architecture
Architecture Performance Analysis
Data Management And
And
Sources Process Data
Data
Claims/Encounter Cubes Eligibility Analysis
•Security Protection Cubes
Clinical Data Sets •Integration Cost and Quality
•Translation Analysis
Demographic Data •Standardization
Prescription Drug •Data Validation
Profile and Screens Chronic
Chronic
EHR Data
Illness
Illness
Eligibility Data Health Plan &
Sub-databases
Sub-databases Health Plan &
Registries
Registries Provider Decision
Provider Decision
Program Data
Support
Support
Information Architecture

64. Architecture Framework
(MITA)
 Business Architecture
 Information Architecture
 Technical Architecture

65. Technical Architecture
The MITA technical architecture includes
 Data Architecture
 Application Architecture
 Technology Architecture
Collectively, they define a set of technical services and standards
that can be used to plan and specify future systems.

66. Technical Architecture
Technical Principles (MITA )
 MITA is a business driven, implementation neutral, platform
independent and is adaptable, extendible and scalable.
 The technical architecture is based on current and proven
open technology. Security, privacy, interoperability and
reliance on quality data are built-in.
 Technical principles shape MITA’s definition and the State’s
implementation of the Medicaid Enterprise Architecture.

67. Technical Architecture
Technical Principles cont.
 Guiding principles support flexibility, adaptability rapid
response and will promote an enterprise view. The result
should be less duplication while providing timely, accurate and
usable data.
 The technical architecture must support performance
measurement and effective communication.
 Provide for the adoption of data and technical industry
standards and the promotion of reusable components
(modularity).

68. Technical Architecture
Technical Architecture Defined
 Business Driven Design of IT processes.
 The adoption and use of common industry and IT standards and best
practices.
 Identification of business specific processes, data and technical
solutions.
 Built in security and delivery of data.
 Scalability, interoperability and extendibility of IT components.
 Performance metrics common to the various Business/ IT operations.

69. Programmatic Approaches
Enterprise Continuum
Technical Designs
Solutions
Platforms
Business Intelligence
Tools
Architectural Assets

70. Basic Health Information Exchange with Data
Repository
Health Plan Adm.. Sys
Clinical
HIE Data Repository
Record and Results Delivery
Clinician Data Repository
Provider EHR
Interfaces
Master Patient Index
Laboratories
Basic Patient Health
Summary
Pharmacies
Web Portal Server
Web Browser
HIE Utility Applications

71. Health Information Exchange Platform
Architecture
Collaborative Knowledge Management
Value
Security and Consent Policy
Added Web Services Application
Web
Services
Data Analysis Applications
Health Data Integration and Translation Layer
Platform
Services Health Data Management Layer
Health Data Publication Layer
Data
Sources
Radiology Rx History Administrative EHR Clinical Lab

72. HIT Infrastructure Platform Design

73. Architecture Overview
Local Gateway Participant Local Gateway Participant
Published Published
Patient Data Patient Data
EMRs and Other Interface Interface EMRs and Other
Enterprise Systems Engine Engine Enterprise Systems
or Portal Local Provider Local Provider or Portal
Directory Directory
HIE Application HIE Application
Server / Gateway Server / Gateway
Standard Messages,
e-mail or fax
encapsulation
Secondary Local E-Mail Web Server Fax Server Fax Server Web Server E-Mail Secondary Local
System Server Server System
•Local gateway users control integration, etc. Summary / Results Summary / Results
•Can leverage infrastructure for internal integration Viewer Viewer
•Interfaces can be direct or use interface engine or similar tools Internet /
Network
E-mail, fax or CCD Standard Messages, HTTP
HTTP encapsulation encapsulation
Network Subscriber Hosted Portal
Summary /
Published Patient Data
Results Viewer Web Server E-Mail
Fax Server
External Community Provider Directory
Networks HIE Application
Printer Server / Gateway
•Hosted by service provider (MA-SHARE)
•No infrastructure support requirement – just Internet connection, fax or e- •Provides document / data storage, HTTP viewing for subscribers, and
mail common provider index for dissemination to local gateway participants

74. Mapping Data Partners and Data Utilities

75. Enterprise Platform
Architecture Examination

76. Business Platform Review

77. Business Intelligence Stack

78. Business Intelligence Tool Set

79. Clinical Decision Support Systems (CDS)
Amalga frees the data locked in disparate systems
across the health enterprise to fuel discovery,
change, and innovation.
Amalga empowers users to drive improvements in
near-real time, as well as accelerate continuous
improvement over time.
Amalga links data from different departments so
that it can be shared more easily, which helps the
caregiver see the “whole patient,” not just
snapshots.

80. Clinical Decision Support Systems (CDS)

81. Microsoft HealthVault is a web-
based platform from Microsoft
that stores and maintains
health and fitness information.

83. Cloud Approach Research

84. To successfully institute a framework of business
processes and technologies that support and
improved program administration for the
enterprise and stakeholders.
 Thinking Globally
 Acting Dynamically
 Focus on the individual

85. Thank You
Q&A