November 12, 2014
#587
Joint Legislative Committee on Performance
Evaluation and Expenditure Review (PEER)
Report to
the Mississippi Legislature
Mississippi’s Progress Since 2010 in
Implementing Electronic Health Records
Since PEER’s 2010 report on procurement and implementation of electronic
health records systems, the University of Mississippi Medical Center has established its
electronic health records system as one component within its larger health care
information system, known as Epic. Epic officially went live June 1, 2012.
Although the Division of Medicaid initially implemented an electronic health
records system on June 4, 2010, neither the division’s original contracted provider nor a
second contracted provider could provide an electronic health records system that met
revised federal electronic health records and Medicaid user acceptance standards.
Consequently, the Division of Medicaid shifted to providing a clinical data repository.
Many of the federal regulations specific to an electronic health records system no longer
apply, but the division reports that it is in compliance with applicable federal and state
electronic health records requirements.
While the Mississippi Health Information Exchange system is mostly in place, the
Mississippi Health Information Network is still in its early stages of adding providers to
the system, with most early participation being from the Gulf Coast and the Delta. The
Mississippi Health Information Network has application modules in place as part of the
Mississippi Health Information Exchange to assist providers in meeting meaningful use
requirements as well as for meeting requirements of components of the Patient
Protection and Affordable Care Act. These include reporting requirements (e. g.,
immunization) as well as patient alerts, with the goal of assisting providers and insurers
in tracking patients and managing patient care more effectively.
PEER: The Mississippi Legislature’s Oversight Agency
The Mississippi Legislature created the Joint Legislative Committee on Performance
Evaluation and Expenditure Review (PEER Committee) by statute in 1973. A joint
committee, the PEER Committee is composed of seven members of the House of
Representatives appointed by the Speaker and seven members of the Senate appointed
by the Lieutenant Governor. Appointments are made for four-year terms, with one
Senator and one Representative appointed from each of the U. S. Congressional
Districts and three at-large members appointed from each house. Committee officers
are elected by the membership, with officers alternating annually between the two
houses. All Committee actions by statute require a majority vote of four
Representatives and four Senators voting in the affirmative.
Mississippi’s constitution gives the Legislature broad power to conduct examinations
and investigations. PEER is authorized by law to review any public entity, including
contractors supported in whole or in part by public funds, and to address any issues
that may require legislative action. PEER has statutory access to all state and local
records and has subpoena power to compel testimony or the production of documents.
PEER provides a variety of services to the Legislature, including program evaluations,
economy and efficiency reviews, financial audits, limited scope evaluations, fiscal
notes, special investigations, briefings to individual legislators, testimony, and other
governmental research and assistance. The Committee identifies inefficiency or
ineffectiveness or a failure to accomplish legislative objectives, and makes
recommendations for redefinition, redirection, redistribution and/or restructuring of
Mississippi government. As directed by and subject to the prior approval of the PEER
Committee, the Committee’s professional staff executes audit and evaluation projects
obtaining information and developing options for consideration by the Committee.
The PEER Committee releases reports to the Legislature, Governor, Lieutenant
Governor, and the agency examined.
The Committee assigns top priority to written requests from individual legislators and
legislative committees. The Committee also considers PEER staff proposals and written
requests from state officials and others.
PEER Committee
Post Office Box 1204
Jackson, MS 39215-1204
(Tel.) 601-359-1226
(Fax) 601-359-1420
(Website) http://www.peer.state.ms.us
The Mississippi Legislature
Joint Committee on Performance Evaluation and Expenditure Review
PEER Committee
SENATORS
NANCY ADAMS COLLINS
Chair
KELVIN E. BUTLER
VIDET CARMICHAEL
THOMAS GOLLOTT
GARY JACKSON
SAMPSON JACKSON II
PERRY LEE
TELEPHONE:
(601) 359-1226
FAX:
(601) 359-1420
Post Office Box 1204
Jackson, Mississippi 39215-1204
Max K. Arinder, Ph. D.
Executive Director
www.peer.state.ms.us
REPRESENTATIVES
BECKY CURRIE
Vice Chair
MARGARET ELLIS ROGERS
Secretary
RICHARD BENNETT
KIMBERLY L. CAMPBELL
STEVE HORNE
RAY ROGERS
PERCY W. WATSON
OFFICES:
Woolfolk Building, Suite 301-A
501 North West Street
Jackson, Mississippi 39201
November 12, 2014
Honorable Phil Bryant, Governor
Honorable Tate Reeves, Lieutenant Governor
Honorable Philip Gunn, Speaker of the House
Members of the Mississippi State Legislature
On November 12, 2014, the PEER Committee authorized release of the report entitled
Mississippi’s Progress Since 2010 in Implementing Electronic Health Records.
Senator Nancy Adams Collins, Chair
This report does not recommend increased funding or additional staff.
PEER Report #587
ii
PEER Report #587
iii
Table of Contents
Letter of Transmittal .................................................................................................................................i
Executive Summary ............................................................................................................................. vii
Introduction ................................................................................................................................1
Authority ................................................................................................................................1
Scope and Purpose............................................................................................................................1
Scope Limitation................................................................................................................................2
Method ................................................................................................................................3
Background: Electronic Health Records and Health Information Exchanges ................................4
What are the major components of electronic health
information technology? ...............................................................................................................4
What factors have influenced the development and implementation
of electronic health records and health information exchanges
in Mississippi? ................................................................................................................................5
What did PEER conclude in its 2010 report on Mississippi’s electronic
health records systems?................................................................................................................8
What progress has the University of Mississippi Medical Center made
since 2010 in implementing its electronic health care information system?.............................. 10
What progress has the University of Mississippi Medical Center made
in implementing electronic health records?........................................................................... 10
Does the University of Mississippi Medical Center’s Epic system
enable UMMC to comply with the EHR requirements of federal
and state law? ............................................................................................................................. 12
How did UMMC fund implementation of the Epic system? What
expenditures have been made to date toward implementing Epic?
What expenditures remain to be made and for what purposes?....................................... 14
What progress has the Division of Medicaid made since 2010 in implementing
electronic health records? ..................................................................................................................... 16
What progress has the Division of Medicaid made in implementing
electronic health records? ...................................................................................................... 16
What comprises the Division of Medicaid’s clinical data repository?
Does this system meet federal and state requirements for electronic
health records? ......................................................................................................................... 19
How did the Division of Medicaid fund implementation of its
electronic health records/clinical data repository system? What
expenditures have been made to date? What expenditures remain
to be made and for what purposes?..................................................................................... 21
PEER Report #587
iv
Table of Contents (continued)
What progress has the Mississippi Health Information Network made
since 2010 in implementing electronic health records?...................................................................22
What is the Mississippi Health Information Network and what
is the Mississippi Health Information Exchange?...............................................................22
What progress has the MS-HIN made in implementing a health
information exchange since the Legislature passed the Health
Information Technology Act in 2010?..................................................................................23
Does the Mississippi Health Information Exchange meet the
EHR requirements of federal and state law?.......................................................................27
How did MS-HIN fund implementation of the Mississippi Health
Information Exchange? What expenditures have been made to date
toward implementation? What expenditures remain to be made and
for what purposes?...................................................................................................................28
Conclusion .............................................................................................................................31
Appendix A: Glossary of Terms Related to Electronic Health Records .........................................33
Appendix B: Meaningful Use ..................................................................................................................36
Appendix C: Detailed Description of UMMC’s Epic ..........................................................................38
Appendix D: University of Mississippi Medical Center Timeline
of Implementing Electronic Health Records........................................................................................43
Appendix E: Electronic Health Records Incentive Program Incentive
Payments Received by the University of Mississippi Medical Center
through July 1, 2014 .............................................................................................................................44
Appendix F: UMMC Expenditures for Epic, by Category of Expenditure,
FY 2011 Actual-FY 2016 Budgeted........................................................................................................45
Appendix G: Mississippi Division of Medicaid Timeline of
Implementing Electronic Health Records ............................................................................................47
Appendix H: Mississippi Health Information Network Timeline
of Implementing Mississippi Health Information Exchange............................................................48
Agency Responses .............................................................................................................................49
PEER Report #587
v
List of Exhibits
1. UMMC’s Epic Health Care Information System ........................................................................ 12
2. Examples of Sources of Data for and Users of the
Mississippi Health Information Exchange................................................................................. 24
PEER Report #587
vi
PEER Report #587
vii
Mississippi’s Progress Since 2010 in
Implementing Electronic Health Records
Executive Summary
Introduction
H. B. 392, Regular Session 2014, amending MISS. CODE ANN. §
41-119-19 (1972), requires PEER to report by December 1, 2014,
on progress in implementing the electronic health records
system in the state of Mississippi.
For this report, PEER reviewed implementation of electronic
health records by the University of Mississippi Medical Center
(UMMC) and the Division of Medicaid (DOM). The University of
Mississippi Medical Center was selected because it is one of the
state’s largest health care providers and the Division of
Medicaid was selected because it is one of the largest providers
of health care coverage to persons in the state.
PEER sought to
determine what progress these two entities have made in
implementation since issuance of PEER Report #542, A Review
of Requests for Proposals Used by the Division of Medicaid and
University of Mississippi Medical Center to Procure Electronic
Health Records Systems in 2010.
PEER also reviewed the Mississippi Health Information Network
because it is tasked with developing the statewide health
information exchange that will encompass UMMC, DOM, and
other providers and entities throughout the state.
While H. B. 392 tasked PEER with evaluating the state of
Mississippi’s “progress in implementing the electronic health
records system,” PEER limited this review to evaluating the
progress of the previously named three entities in
implementing electronic health records (EHR).
Background: Electronic Health Records and Health Information Exchanges
Electronic health information technology is the use of
technology to collect, store, retrieve, and transfer by electronic
means a patient’s clinical, administrative, and financial health
information. For purposes of this report, the major
components that make up the electronic health information
technology structure are electronic medical records, electronic
health records, health information exchanges, and community
health records. (See the Glossary in Appendix A, page 33, of
the report for definitions of terms related to electronic health
records.)
PEER Report #587
viii
Factors that have influenced the development and
implementation of electronic health records and health
information exchanges in Mississippi are:
The federal Health Information Technology for Economic
and Clinical Health (HITECH) Act, passed in 2009, offers
financial incentives to health care providers to implement
electronic health records based on compliance with
prescribed standards.
Electronic health records also serve as a tool to help
achieve the goals established in the Patient Protection and
Affordable Care Act (PPACA) passed by Congress in 2010.
The Health Information Technology Act, passed by the
Legislature in 2010, established the Mississippi Health
Information Network to coordinate and facilitate building a
statewide capability to securely, electronically exchange
health information.
In its 2010 report, PEER concluded that UMMC and DOM had
complied with best practices to date for procurement of their
electronic health records systems. At that time, UMMC
estimated that its system would cost $70 million and DOM
projected that the cost of its system would be less than $10
million. At the time of that report, it was not yet possible to
know what portion of American Recovery and Reinvestment
Act funds that Mississippi providers would receive with which
to implement health information technology.
What progress has the University of Mississippi Medical Center made since 2010 in
implementing its electronic health care information system?
UMMC’s electronic health care information system, known as
Epic, replaced twenty existing legacy systems and officially
went live June 1, 2012. Epic is a comprehensive, unified
electronic health care information system, including electronic
health records, a centralized patient portal, a centralized
master patient index, research support, and improved
administrative and billing components, including tying billing
to the electronic health records.
UMMC reports that Epic complies with applicable EHR
requirements. Epic currently maintains required EHR
certification with the Office of the National Coordinator for
Health Information Technology. UMMC also reports that Epic
complies with all requirements of the Health Insurance
Portability and Accountability Act of 1996. Further, UMMC and
its providers remain on track for meeting the Electronic Health
Records Incentive Program requirements (e. g., “meaningful
use”), generating over $24 million in incentive payments to
date for progress in adopting and implementing electronic
health records.
PEER Report #587
ix
UMMC funds Epic through patient revenues. Through May 30,
2014, UMMC had spent approximately $97 million on training,
staffing, consultants, software licensing fees, Epic
implementation fees, and hardware costs to implement Epic.
UMMC expects to spend from $15 to $17 million per year in FY
2015 and FY 2016 to operate and maintain Epic.
What progress has the Division of Medicaid made since 2010 in implementing
electronic health records?
The Division of Medicaid initially implemented an electronic
health records system on June 4, 2010, prior to the 2011
federal requirements for certified electronic health records.
Neither DOM’s original contracted provider nor a second
contracted provider could provide an electronic health records
system that met federal EHR and Medicaid acceptance
standards. Consequently, in 2014, after consultation with the
Centers for Medicare and Medicaid Services, DOM made the
decision to provide clinical data repositories instead of
supplying Medicaid providers with electronic health records
systems. A contract was subsequently assigned to
Mede/Analytics in 2014 to proceed with a clinical data
repository system.
The Division of Medicaid’s new clinical data repository system
includes a clinical data repository in which providers can
search patient records, a master patient index, and a secure
provider portal. The Division of Medicaid is partnering with
the Mississippi Health Information Network to capture
Medicaid-specific provider data at the hospital and clinical level
to add to the clinical data repository. Many of the federal
regulations specific to an EHR system no longer apply, aside
from Health Insurance Portability and Accountability Act and
other privacy and security requirements. DOM reports that it is
in compliance with remaining applicable federal and state EHR
requirements.
From FY 2009 to FY 2014, the Division of Medicaid spent $14.1
million to attempt to procure and implement a statewide
electronic health records system.
What progress has the Mississippi Health Information Network made since 2010 in
implementing electronic health records?
MISS. CODE ANN. § 41-119-7 (1972) tasked the Mississippi
Health Information Network with developing the Mississippi
Health Information Exchange, an electronic exchange of health
information in Mississippi that allows providers access to a
patient’s community health record.
PEER Report #587
x
While the exchange system is mostly in place, the MS-HIN is
still in the early stages of adding providers to the system, with
most early participation being from the Gulf Coast and the
Delta. The MS-HIN continues to build and develop the
exchange to expand opportunities to the remainder of the
state’s medical providers. MS-HIN has application modules in
place as part of the exchange to assist providers in meeting
meaningful use requirements as well as for meeting
components of the Patient Protection and Affordable Care Act.
MS-HIN has received approximately $12.8 million in federal,
state, and private funding and has expended approximately
$11.2 million to create and implement the Mississippi Health
Information Exchange. While one goal of MS-HIN is to be self-
sufficient, it has not yet reached a point where it has sufficient
revenues to cover operational and additional build-out costs
completely. Furthermore, MS-HIN expects additional
expenditures for providing patients with a searchable system
projected to commence in 2016, for which the specific costs
are unknown to date.
For More Information or Clarification, Contact:
PEER Committee
P.O. Box 1204
Jackson, MS 39215-1204
(601) 359-1226
http://www.peer.state.ms.us
Senator Nancy Collins, Chair
Tupelo, MS
Representative Becky Currie, Vice Chair
Brookhaven, MS
Representative Margaret Rogers, Secretary
New Albany, MS
PEER Report #587
1
Mississippi’s Progress Since 2010 in
Implementing Electronic Health Records
Introduction
Authority
In accordance with MISS. CODE ANN. Section 5-3-51 et seq.
(1972) and House Bill 392, Regular Session 2014, the PEER
Committee reviewed the progress of the University of
Mississippi Medical Center, the Division of Medicaid, and the
Mississippi Health Information Network in implementing health
information exchanges/electronic health records in
Mississippi.
1
Scope and Purpose
Within recent years, health care providers nationwide have
begun moving from manually maintained paper health records
to computerized health information systems. The
development of an information technology infrastructure for
patients’ health care records has the potential to improve the
safety, quality, and efficiency of health care.
Through the use of financial incentives and penalties
implemented under the Health Information Technology for
Economic and Clinical Health (HITECH) Act (as part of the 2009
federal American Recovery and Reinvestment Act [ARRA]),
health care providers have accelerated implementation of
health information technology. Even prior to ARRA, within
Mississippi, both the Division of Medicaid (DOM) and University
of Mississippi Medical Center (UMMC), as well as other public
and private health care providers, had been making strides in
implementing health information technologies.
H. B. 392, Regular Session 2014, amending MISS. CODE ANN. §
41-119-19 (1972), requires PEER to report by December 1, 2014,
1
According to the Strategic and Operational Plan issued in 2010 by the Mississippi Health Information
Infrastructure Task Force, an electronic health record is “an electronic record of health-related
information on an individual that conforms to nationally recognized interoperability standards that
can be created, managed, and consulted by authorized clinicians and staff across more than one health
care organization.”
PEER Report #587
2
on progress in implementing the electronic health records
system in the state of Mississippi.
For this report, PEER reviewed implementation of electronic
health records by the University of Mississippi Medical Center
and the Division of Medicaid. The University of Mississippi
Medical Center was selected because it is one of the state’s
largest health care providers and the Division of Medicaid was
selected because it is one of the largest providers of health care
coverage to persons in the state.
PEER sought to determine
what progress these two entities have made in implementation
since PEER’s 2010 report (#542, A Review of Requests for
Proposals Used by the Division of Medicaid and University of
Mississippi Medical Center to Procure Electronic Health Records
Systems [see page 8]).
PEER also reviewed the Mississippi Health Information
Network’s implementation of electronic health records because
it is tasked with developing the statewide health information
exchange that will encompass UMMC, DOM, and other
providers and entities throughout the state.
Appendix A, page 33, is a glossary of the acronyms and terms
related to electronic health records.
In this review, PEER sought to determine the following:
What progress has Mississippi made in implementing
electronic health records since 2010
2
?
Do the University of Mississippi Medical Center, the
Division of Medicaid, and the Mississippi Health
Information Network each have a fully functioning
electronic health records system that meets federal and
state requirements? If not, what are the missing elements?
What is the timeline for completion?
What were the sources of funds for expenditures to
implement electronic health records systems? What are
total expenditures to date for implementation? What
expenditures remain to be made and for what purposes?
Scope Limitation
While H. B. 392, Regular Session 2014, tasked PEER with
evaluating the state of Mississippi’s “progress in implementing
the electronic health records system,” PEER limited this review
to evaluating the progress of the previously named three
entities in implementing electronic health records.
2
On November 9, 2010, in response to the requirements of H. B. 941, 2010 Regular Session, the PEER
Committee issued Report #542, A Review of Requests for Proposals Used by the Division of Medicaid and
University of Mississippi Medical Center to Procure Electronic Health Records Systems
. This report
evaluates implementation progress since issuance of that report. See page 8 for a summary of Report
#542.
PEER Report #587
3
Method
In conducting this review, PEER:
reviewed MISS. CODE ANN. Title 41, Chapter 119 (1972) and
House Bill 941, Regular Session 2010, establishing
Mississippi’s “Health Information Technology Act,”
including the Mississippi Health Information Network;
reviewed relevant provisions of the American Recovery and
Reinvestment Act (including the HITECH Act), the Patient
Protection and Affordable Care Act, and the Health
Insurance Portability and Accountability Act of 1996
(HIPAA);
reviewed documentation relevant to progress made by the
University of Mississippi Medical Center, the Division of
Medicaid, and the Mississippi Health Information Network
in implementing electronic health records systems;
viewed demonstrations of the University of Mississippi
Medical Center’s Epic system and the Mississippi Health
Information Network health information exchange; and,
interviewed staff of the University of Mississippi Medical
Center, the Division of Medicaid, and the Mississippi Health
Information Network regarding implementation of
electronic health records systems.
PEER Report #587
4
Background: Electronic Health Records and Health
Information Exchanges
This chapter addresses the following questions:
What are the major components of electronic health
information technology?
What factors have influenced the development and
implementation of electronic health records and health
information exchanges in Mississippi?
What did PEER conclude in its 2010 report on Mississippi’s
electronic health records systems?
What are the major components of electronic health information technology?
Electronic health information technology is the use of technology to collect, store,
retrieve, and transfer by electronic means a patient’s clinical, administrative, and
financial health information. For purposes of this report, the major components that
make up the electronic health information technology structure are electronic medical
records, electronic health records, health information exchanges, and community health
records.
As noted in PEER Report #542, electronic health information
technology refers to the use of technology to collect, store,
retrieve, and transfer by electronic means a patient’s clinical
and financial health information. The ultimate goal of health
information technology is to bring together vital pieces of
patient data that are scattered among providers.
Databases of providers (such as clinics and hospitals) utilize
either electronic medical records or electronic health records.
By using electronic medical records (EMR), providers have a
digital version of a paper chart that contains all of their
patients’ medical histories from one practice. However, the
providers cannot easily share the information stored in
electronic medical records with providers outside their
practice.
In contrast, by using electronic health records (EHRs), providers
can share patient records that can be created and managed
across more than one health care organization. EHRs also offer
additional tools, including financial software to manage patient
billing and decisionmaking tools to manage patient care.
The electronic sharing of patient information (EMRs and EHRs)
between legally authorized health care providers (such as
medical providers, insurers) is known as a health information
exchange. This exchange can be either a limited scope process
(i. e., between two or more providers) or a broader and more
PEER Report #587
5
formal process (i. e., the Mississippi Health Information
Network, which is discussed on page 22). Using this shared
information, the health information exchange generates a
community health record, which is an aggregate of patient
information from multiple health care systems throughout the
community.
In summary, providers electronically send medical data that
feeds into a patient health record, which can then feed into a
community health record through a health information
exchange. The overall goal is to create a database that allows
medical providers access to a consolidated patient file from a
patient’s various providers and pharmacies.
What factors have influenced the development and implementation of electronic health
records and health information exchanges in Mississippi?
The federal Health Information Technology for Economic and Clinical Health (HITECH)
Act, passed in 2009, offers financial incentives to health care providers to implement
electronic health records based on compliance with prescribed standards. These
electronic health records also serve as a tool to help achieve the goals established in
the 2010 Patient Protection and Affordable Care Act (PPACA). Also, the Health
Information Technology Act, passed by the Mississippi Legislature in 2010, established
the Mississippi Health Information Network.
Factors such as advances in health information technology, the
need to control medical costs, and the desire to manage and
track patient data more effectively have encouraged providers
to seek opportunities and efficiencies in modernizing the
health information infrastructure. Continued development and
implementation have been brought about primarily by the
HITECH Act and the PPACA at the federal level and by
establishment of the Mississippi Health Information Network at
the state level.
The Health Information Technology for Economic and Clinical
Health (HITECH) Act of 2009
Upon passage of the HITECH Act, Congress implemented the Electronic Health
Records Incentive Program to authorize financial incentives for health care
providers to implement electronic health records.
In 2009, Congress passed the HITECH Act, which was funded
by the 2009 American Recovery and Reinvestment Act (ARRA).
One key provision of the HITECH Act was the Electronic Health
Records Incentive Program, commonly referred to as
“meaningful use.”
The HITECH Act states that as of January 1, 2014, all public
and private health care providers and other eligible
professionals must have adopted and demonstrated
“meaningful use” of electronic medical records in order to
maintain their existing Medicaid and Medicare reimbursement
PEER Report #587
6
levels. In addition, meaningful use provisions offer financial
incentives for health care providers to implement electronic
health records.
Meaningful use of electronic health records, as defined by
HealthIT.gov, consists of using digital medical and health
records to achieve the following:
improve quality, safety, efficiency, and reduce health
disparities;
engage patients and family;
improve care coordination; and,
maintain privacy and security of patient health information.
In order for eligible providers to receive meaningful use
incentive payments, they must meet certain thresholds
established by the Centers for Medicare and Medicaid Services
(CMS). These thresholds vary depending on whether they refer
to the Medicare program or to the Medicaid program. For a
brief description of meaningful use programs, see Appendix B
on page 36.
Patient Protection and Affordable Care Act (PPACA) of 2010
Electronic health records serve as a tool to help achieve many of the goals set
forth in the Patient Protection and Affordable Care Act of 2010, such as
supporting the development of accountable care organizations, curbing hospital
readmissions, and reducing paperwork and administrative costs.
While the PPACA does not specify requirements for the
development of electronic health records, as the HITECH Act
does, electronic health records do serve as a tool to help
achieve some of the PPACA’s goals. These goals include:
supporting the development of and communication among
accountable care organizations--The Patient Protection and
Affordable Care Act provides a cost-savings incentive to
accountable care organizations.
3
If the accountable care
organizations can provide high quality care and reduce
costs to the overall health care system, they can keep some
of the money that they have helped save. One possible way
to achieve improved integration is to utilize electronic
health records.
managing patient health care more effectively and curbing
hospital readmissions--Providers can potentially utilize
electronic health records to manage a patient’s continuum
of care more effectively by making more well-informed and
timely decisions. For example, a provider could use
electronic health records to target patients once they are
3
An accountable care organization (ACO) is a coordinated network of health care providers that share
financial and medical responsibility for providing care to patients with a goal of meeting specific
quality of care benchmarks and controlling costs. The PPACA authorized CMS to create an accountable
care organization program.
PEER Report #587
7
discharged from the hospital in order to schedule and track
follow-up appointments with the goal of reducing the
number of hospital readmissions.
generating more comprehensive data for understanding
health disparities--To help understand health disparities,
the PPACA requires any ongoing or new federal health
program to collect and report racial, ethnic, and language
data. By implementing electronic health records, hospitals
and providers will not only have a greater ability to
generate electronic medical information, but also more
readily searchable and transferrable patient information.
The U. S. Department of Health and Human Services can
then use this data to help identify and ultimately work
toward reducing health disparities.
reducing paperwork and administrative costs--The PPACA
standardizes billing and requires health plans to begin
adopting and implementing rules for the secure,
confidential, electronic exchange of health information.
Using electronic health records has the potential to reduce
paperwork and administrative burdens, which can reduce
costs.
Mississippi Health Information Technology Act of 2010
The Mississippi Health Information Technology Act of 2010 created the
Mississippi Health Information Network (MS-HIN) through MISS. CODE ANN. § 41-
119-5 et seq. (1972). The primary goal for MS-HIN is to serve as a centralized
coordinated health information exchange in Mississippi.
In 2010, the Mississippi Legislature enacted the Health
Information Technology Act (House Bill 941, 2010 Regular
Session) to create the Mississippi Health Information Network,
thus expanding its predecessor Mississippi Coastal Health
Information Exchange (MSCHIE) from a local coastal health
information exchange to a statewide health information
network. The Legislature created the Mississippi Health
Information Network to provide statewide capability to
exchange health information securely and electronically.
Examples of patient data that can be collected and shared
through MS-HIN are x-rays and lab reports. Such information
can then be used to create a consolidated, searchable,
electronic patient file for each Mississippian that can be
reviewed by physicians and specialty providers.
Building on the statewide health information exchange, another
goal is for the data collected through MS-HIN to be shared with
Healtheway, formerly known as the Nationwide Health
Information Network (NHIN). The Nationwide Health
Information Network exchange includes entities such as
Centers for Disease Control and Prevention, Centers for
Medicare and Medicaid Services, and the Department of
Veterans Affairs.
PEER Report #587
8
What did PEER conclude in its 2010 report on Mississippi’s electronic health records
systems?
In its 2010 report, PEER concluded that UMMC and DOM had complied with best
practices to date for procurement of their electronic health records systems. At that
time, UMMC estimated that its system would cost $70 million and DOM projected that
the cost of its system would be less than $10 million. At the time of that report, it was
not yet possible to know what portion of ARRA funds that Mississippi providers would
receive.
In its report entitled A Review of Requests for Proposals Used by
the Division of Medicaid and University of Mississippi Medical
Center to Procure Electronic Health Records Systems (Report
#542, November 9, 2010), the PEER Committee:
evaluated the requests for proposals for the
implementation and operations services for the Division of
Medicaid and the University of Mississippi Medical Center
electronic health records systems and e-prescribing system
for providers;
evaluated the proposed expenditures of the Division of
Medicaid and the University of Mississippi Medical Center
regarding electronic health information; and,
evaluated the use of American Recovery and Reinvestment
Act of 2009 funds for electronic health records system
implementation in Mississippi.
Because the Division of Medicaid’s and the University of
Mississippi Medical Center’s health information technologies
were in their early stages of implementation at the time of the
2010 review, PEER did not review the operations of such
technologies. However, PEER did determine that:
Both UMMC and the Division of Medicaid complied with RFP
components considered to be “best practices” based on
procurement requirements of the Department of
Information Technology Services, the Personal Service
Contract Review Board, and the American Bar Association.
UMMC initially estimated the lifecycle cost of its health care
information system to be $70 million. The Division of
Medicaid’s consultant projected the cost of its electronic
health records and e-prescribing system at less than $10
million.
ARRA provided more than $19 billion to states for Medicare
and Medicaid health information technology incentives over
five years, but at the time of that report, it was not yet
possible to know the portion of ARRA funds that
Mississippi providers would receive.
The full text of PEER Report #542 is available at
www.peer.state.ms.us.
The next three chapters address what progress UMMC, the
Division of Medicaid, and the Mississippi Health Information
PEER Report #587
9
Network have made toward implementing electronic health
records since issuance of Report #542. These chapters also
discuss the extent to which each respective entity complies
with the EHR requirements of federal or state law, the costs of
implementation, and what expenditures remain to be made and
for what purposes.
PEER Report #587
10
What progress has the University of Mississippi
Medical Center made since 2010 in implementing
its electronic health care information system?
UMMC’s electronic health care information system, known as Epic, replaced twenty
existing legacy systems and officially went live June 1, 2012. UMMC reports that Epic
complies with applicable requirements. Through May 30, 2014, UMMC had spent
approximately $97 million to implement Epic and it expects to spend from $15 to $17
million per year in FY 2015 and FY 2016 to operate and maintain Epic.
This chapter addresses the following questions:
What progress has the University of Mississippi Medical
Center made in implementing electronic health records?
Does UMMC’s Epic system enable UMMC to comply with the
EHR requirements of federal and state law?
How did UMMC fund the implementation of the Epic
system? What expenditures have been made to date toward
implementing Epic? What expenditures remain to be made
and for what purposes?
What progress has the University of Mississippi Medical Center made in implementing
electronic health records?
UMMC’s electronic health care information system, known as Epic, replaced
twenty existing legacy systems and officially went live June 1, 2012.
In 2009, the University of Mississippi Medical Center chose to
eliminate its existing systems and create a new consolidated
health care information system. On August 23, 2010, UMMC
entered into a contract to purchase the Epic electronic health
care information system from Epic Systems Corporation. Epic
is a comprehensive, unified electronic health care information
system, including electronic health records, a centralized
patient portal, a centralized master patient index, research
support, and improved administrative and billing components,
including tying billing to electronic health records.
The Epic system officially went live (i. e., became operational)
on June 1, 2012. The four major project areas that comprise
Epic’s health care information system are:
Enterprise-wide Patient Access and Revenue Cycle--includes
applications for collecting, tracking, and maintaining
patients’ registration information; managing patients’
hospital stays from preadmission to discharge for
centralized and/or decentralized admitting; and a Welcome
Kiosk that expedites patient flow via a self-service touch
screen that allows patients to check in for appointments,
PEER Report #587
11
answer questionnaires, sign forms electronically, and make
payments. In addition, Epic provides billing with provider-
or hospital-level reporting and online work queues for
billing edits, claim edits, denial management, and paperless
collections.
Inpatient Clinical Systems--includes the patient data
repository, clinical documentation, computerized physician
order entry, and medication management.
Ancillary Department Clinical Systems--includes
applications supporting lab, pharmacy, oncology, radiology,
operating room management and anesthesia management,
transplant support, and health care information
management, including chart tracking, release of
information, and deficiency tracking, coding, and
abstracting.
Ambulatory Electronic Health Record--includes the
electronic medical record component, the application for
directly interacting with other providers (i. e., Care
Everywhere and Care Elsewhere). It also includes the
MyChart Shared patient record, which provides patients
with controlled access to their electronic medical record
and self-service options such as scheduling, refill request,
and bill paying.
A few Epic applications still remain in the development
process. UMMC is also in the process of onboarding
4
its
electronic health records with MS-HIN, with an expected go live
date in fall 2014.
Exhibit 1, page 12, shows the interaction of the Epic
components with the patient portal MyChart, referring
providers, the Mississippi Health Information Exchange, and
the research and education component of UMMC and other
entities. Appendix C, page 38, includes additional description
of each of the Epic applications. Appendix D, page 43, presents
a timeline of UMMC’s implementation process.
4
Onboarding is the management of the early stages of incorporating a provider, such as UMMC or DOM,
into the MS-HIN health information exchange, including issues of connecting and interfacing systems.
PEER Report #587
12
Exhibit 1: UMMC’S Epic Health Care Information System
The four major components of Epic interact with the patient portal MyChart,
with referring providers, with the Mississippi Health Information Exchange,
and with the research and education component of UMMC and other entities.
SOURCE: PEER analysis of Epic Health Care Implementation Program Charter, University of Mississippi
Medical Center, February 1, 2011.
Does the University of Mississippi Medical Center’s Epic system enable UMMC to
comply with the EHR requirements of federal and state law?
Epic currently maintains required EHR certification with the Office of the
National Coordinator for Health Information Technology. UMMC also reports
that Epic complies with all requirements of the Health Insurance Portability and
Accountability Act of 1996. Further, UMMC and its providers remain on track for
meeting the Electronic Health Records Incentive Program requirements (e. g.,
“meaningful use”), generating over $24 million in incentive payments to date for
progress in adopting and implementing electronic health records.
Maintaining Federal EHR Certification
To qualify for the Electronic Health Record Incentive Program, Epic maintains
required EHR certification with the Office of the National Coordinator for
Health Information Technology.
In order to qualify for the Electronic Health Record Incentive
Program (i. e., “meaningful use;” see page 5), an electronic
Ambulatory Electronic
Health Record (EHR)
Ancillary Department
Clinical Systems (Lab,
Pharmacology, Oncology,
Radiology, and Operating
Room Health Information
Management)
Inpatient Clinical Systems
(Clinical Documentation,
Computerized Physician
Order Entry, and
Medication Management)
Enterprise Wide Patient
Access and Revenue Cycle
UMMC EPIC
Mississippi
Health
Information
Exchange
Patient
Portal
MyChart
Referring
Providers
Research &
Education
PEER Report #587
13
health records system must meet standards set by the Office of
the National Coordinator for Health Information Technology
(ONC) accrediting body and be certified. The ONC keeps a
Certified Health IT Product List on its website. As the Centers
for Medicare and Medicaid Services and the ONC change or
update these standards, electronic health records vendors are
required to be recertified or lose their certification and force
their customers to find another certified electronic health
record. UMMC’s Epic continues to maintain certification as an
electronic health record with the ONC accrediting body.
Compliance with HIPAA
UMMC reports that Epic complies with all requirements of the Health
Insurance Portability and Accountability Act of 1996.
The Health Insurance Portability and Accountability Act
(HIPAA) is a federal law that provides baseline privacy and
security standards for medical information. The U. S.
Department of Health and Human Services (HHS) is the federal
agency in charge of enforcing HIPAA.
HIPAA was passed in 1996 in order to set standards for
transmitting electronic health data and to allow people to
transfer and continue health insurance after they change or
lose a job. In 2003, the HHS issued the first national data
privacy and security rules under HIPAA. The most frequently
referred to of these rules is the Privacy Rule that gives
individuals rights with respect to protecting their health
information. In 2013, HHS’s Omnibus Rule made several
important changes to the HIPAA rules and it implemented
many provisions of the HITECH Act.
UMMC reports that Epic complies with all HIPAA requirements.
All staff accessing Epic have a secure login and can only access
the sections they have permission to access. For example, a
social worker may only access and modify patient files
pertaining to his or her role as a social worker, but cannot
access and/or modify patient files outside his or her job
function.
Implementing the Electronic Health Records Incentive Program
UMMC and its providers have attested to meeting the first year of the
Electronic Health Records Incentive Program (i. e., “meaningful use”)
requirements set by CMS, to date generating over $24 million in incentive
payments for progress in adopting and implementing electronic health
records and meeting meaningful use program requirements established by
CMS.
The University of Mississippi Medical Center qualifies for two
incentive programs under the Electronic Health Records
Incentive Program: (a) Eligible Hospitals, which applies to the
University of Mississippi Medical Center and includes all
hospital-based providers, and (b) Eligible Professionals, which
PEER Report #587
14
applies separately for each of the approximately 400 eligible
professionals at University Physicians.
The overall objectives of the Electronic Health Records
Incentive Program are:
to implement use of a certified electronic health record in a
meaningful manner;
to exchange health information electronically between
providers;
5
and,
to generate the ability to submit quality, descriptive, and
other measures automatically to government agencies.
UMMC and its providers
6
have attested to meeting the first year
of the Electronic Health Records Incentive Program (i. e.,
“meaningful use”) requirements set by CMS, generating over
$24 million in incentive payments to date for progress in
adopting and implementing electronic health records and
meeting meaningful use program requirements. For a
breakdown of incentive payments received by the University of
Mississippi Medical Center through July 1, 2014, see Appendix
E, page 44.
How did UMMC fund implementation of the Epic system? What expenditures have
been made to date toward implementing Epic? What expenditures remain to be made
and for what purposes?
UMMC funds Epic through revenues generated from serving patients. Through
May 30, 2014, UMMC had spent approximately $97 million on training, staffing,
consultants, software licensing fees, Epic implementation fees, and hardware
costs to implement Epic. UMMC expects to spend from $15 to $17 million per
year in FY 2015 and FY 2016 to operate and maintain Epic.
UMMC funds the cost of the Epic system with revenues
generated from serving patients. UMMC also receives ARRA
funds for participating in the Electronic Health Records
Incentive Program to achieve meaningful use of electronic
health information (see page 5). These revenues help offset a
portion of the costs for investing in health information
technology.
5
To support communication with other health care providers, UMMC uses the industry-recognized
Health Level Seven (HL7) language to standardize electronic communication between UMMC and other
eligible hospitals and eligible providers. MS-HIN also uses HL7. HL7 provides a unified communication
framework (and related standards) for the exchange, integration, sharing, and retrieval of electronic
health information.
6
UMMC’s 400 plus providers, as part of University Physicians, each attest to meeting specified
meaningful use requirements separately, as approved by CMS, and thus are in various stages of
completion of the requirements.
PEER Report #587
15
Through May 30, 2014, UMMC had spent approximately $97
million on staffing, consultants, software licensing fees, Epic
implementation fees, and hardware costs. UMMC expects to
spend approximately $17 million in FY 2015 and approximately
$15 million in FY 2016 to operate and maintain Epic, including
UMMC staffing and consultants and software license fees.
7
See
Appendix F on page 45 for a breakdown of UMMC’s Epic
expenditures by category (for FY 2011 actual to FY 2016
budgeted).
As noted in the 2010 PEER report, the University of Mississippi
Medical Center initially estimated in 2009 the five-year lifecycle
cost of its health care information system Epic to be
approximately $50 million. However, after receipt of proposals
and selection of a preferred vendor, UMMC, with approval of
the Department of Information Technology Services, revised
Epic’s five-year lifecycle cost in 2010 to be approximately $70
million. However, these costs did not include additional third-
party transactional costs.
7
These costs do not include projected one-time FY 2016 implementation and hardware costs to add
UMMC Grenada to UMMC’s Epic system.
PEER Report #587
16
What progress has the Division of Medicaid made
since 2010 in implementing electronic health
records?
Although the Division of Medicaid initially implemented an electronic health records
system on June 4, 2010, neither the division’s original contracted provider nor a second
contracted provider could provide an electronic health records system that met revised
federal EHR and Medicaid user acceptance standards. Consequently, the Division of
Medicaid shifted to providing a clinical data repository. Many of the federal regulations
specific to an EHR system no longer apply, but DOM reports that it is in compliance
with applicable federal and state EHR requirements. From FY 2009 to FY 2014, the
Division of Medicaid spent approximately $14.1 million to attempt to procure and
implement a statewide electronic health records system.
This chapter addresses the following questions:
What progress has the Division of Medicaid made in
implementing electronic health records?
What comprises the Division of Medicaid’s clinical data
repository system? Does this system meet federal and state
requirements for electronic health records?
How did the Division of Medicaid fund the implementation
of its electronic health records/clinical data repository
systems? What expenditures have been made to date? What
expenditures remain to be made and for what purposes?
What progress has the Division of Medicaid made in implementing electronic health
records?
The Division of Medicaid initially implemented an electronic health records
system on June 4, 2010, prior to the 2011 federal requirements for certified
electronic health records. Neither DOM’s original contracted provider nor a
second contracted provider could provide an electronic health records system
that met federal EHR and Medicaid acceptance standards. Consequently, in
2014, after consultation with the Centers for Medicare and Medicaid Services,
DOM made the decision to provide a clinical data repository instead of supplying
Medicaid providers with an electronic health records system. A contract was
subsequently assigned to Mede/Analytics in 2014 to proceed with a clinical data
repository system.
As noted in PEER Report #542, in 2010, the Division of
Medicaid initially issued a request for proposals to implement
an electronic health records system that could be utilized by all
Medicaid providers. In 2009, the Division of Medicaid
PEER Report #587
17
competitively selected Shared Health, Inc., as the vendor to
design, develop, and implement an e-health records and e-
prescribing system, executing a contract on July 1, 2009.
Changes in Contractors
The Division of Medicaid initially implemented an electronic health records
system on June 4, 2010, prior to the 2011 federal requirements for certified
electronic health records. Neither DOM’s original contracted provider nor a
second contracted provider could provide an electronic health records system
that met federal EHR and Medicaid user acceptance standards.
Partnering with Shared Health, the Division of Medicaid’s
Medicaid Electronic Health Record System and ePrescribing
system (MEHRS/eScript) went into production on June 4, 2010.
However, in 2011, the Office of the National Coordinator for
Health Information Technology began requiring that all
electronic health records systems be certified under federal
requirements. Shared Health was unable to provide a
transition from a non-certified to an ONC-certified electronic
health record system, as required by its contract with DOM. In
March 2012, Shared Health informed the Division of Medicaid
that it would not be a good business decision for Shared Health
to continue developing a certified EHR and thus it was exiting
the EHR market.
Because Shared Health was still under contract to provide
electronic health records services for the Division of Medicaid,
Shared Health, on behalf of the Division of Medicaid, sought a
replacement vendor in compliance with its original contract
terms. Shared Health used criteria from Medicaid’s original
request for proposals and statement of work to evaluate
proposals by two vendors: Orion Health, which partnered with
subcontractor Mede/Analytics, and eMD.
According to DOM staff, Shared Health vetted the technical
proposals and considered which would be the best option for
the state, including, for example, the ability to meet Medicaid
contract requirements. After vetting the two providers (Orion
and eMD), Shared Health concluded that eMD was not able to
meet the technical requirements of the Division of Medicaid,
but that Orion could fulfill these requirements. According to
DOM staff, the Division of Medicaid also reviewed the vetting
and the documents submitted by Orion based on Shared
Health’s recommendation. Ultimately, in August 2012, the
Division of Medicaid made the decision to select Orion (along
with its subcontractor Mede/Analytics) based on its responses
to meeting requirements defined in the contractual statement
of work.
By August 2013, Orion had put into production its version of
the new Medicaid system, but subsequent testing showed that
it did not meet the user acceptance test standards established
for the product by Medicaid. DOM’s staff noted that Orion’s
system was not popular with the Medicaid providers. Also, the
Division of Medicaid’s system was about to have to meet the
PEER Report #587
18
Centers for Medicare and Medicaid Services’ new requirements
for the 2014 certification of the product by ONC. Orion
subsequently chose to no longer continue providing services to
the Division of Medicaid prior to being terminated for failure to
meet contract terms.
Shift to a Clinical Data Repository
In 2014, CMS began encouraging state Medicaid agencies to move toward
providing a clinical data repository with clinical data (not just Medicaid
claims) instead of supplying Medicaid providers with an EHR system. DOM
determined it to be in the best interest of the state to utilize existing
investments in technology and move forward with provision of a clinical data
repository.
When DOM first began developing a statewide EHR system,
local provider implementation of EHRs was limited. After
Congress created the Electronic Health Records Incentive
Program to encourage development of electronic health records
at the provider level, providers began installing electronic
health records systems on their own in return for incentive
payments. Therefore, state Medicaid agencies no longer
needed to build statewide EHR systems.
In 2014, the Centers for Medicare and Medicaid Services (CMS)
began changing course regarding electronic health records and
published Medicaid Information Technology Architecture 3.0,
in which CMS encouraged state Medicaid agencies to move
toward providing clinical data repositories with clinical data
(not just Medicaid claims) instead of providing EHR systems for
Medicaid providers’ use.
Once the Division of Medicaid determined that Orion was
unable to fulfill the terms of the contract to implement a
certified electronic health records system, DOM reevaluated its
options. By making the shift to a statewide clinical data
repository, Mississippi’s Division of Medicaid could gain access
to a statewide, searchable Medicaid patient record and access
to more data to manage patients.
Orion’s subcontractor Mede/Analytics had successfully gone
live with a clinical data repository and enterprise master
patient index in December 2013. Rather than pursuing legal
recourse against Orion because it had chosen to no longer
provide services, DOM determined it to be in the best interest
of the state to utilize those existing investments in technology
and move forward with Mede/Analytics. Subsequently, after
consultation with the Centers for Medicare and Medicaid
Services, the Division of Medicaid required Orion to assign the
remaining portion of the EHR contract to Mede/Analytics for
implementation of a clinical data repository.
Appendix G, page 47, presents a timeline of the Division of
Medicaid’s implementation process.
PEER Report #587
19
What comprises the Division of Medicaid’s clinical data repository? Does this system
meet federal and state requirements for electronic health records?
The Division of Medicaid’s new clinical data repository system includes a clinical
data repository in which providers can search patient records, a master patient
index, and a secure provider portal. The division is partnering with the
Mississippi Health Information Network to capture Medicaid-specific provider
data at the hospital and clinical level to add to the clinical data repository. Many
of the federal regulations specific to an EHR system no longer apply, aside from
HIPAA and other privacy and security requirements. DOM reports that it is in
compliance with remaining applicable federal and state EHR requirements.
Components of the Clinical Data Repository System
The Division of Medicaid’s new clinical data repository system includes a
clinical data repository in which providers can search patient records, a
master patient index, and a secure provider portal. DOM is partnering with
the Mississippi Health Information Network to capture Medicaid-specific
provider data at the hospital and clinical level to add to the clinical data
repository.
By coordinating with CMS, the Division of Medicaid was able to
transition by incorporating existing Mede/Analytics
components and build a centralized state electronic Medicaid
patient file into which providers can log in and search instead
of building an electronic health records system. The Division of
Medicaid noted that it plans to further develop and improve
the Medicaid data imported into this system.
Components of the clinical data repository system are:
Clinical data repository--contains up to nine years of
historical data (e. g., diagnoses, procedures, medications)
for each Medicaid beneficiary. This data is view-only for
providers and is updated weekly from the Medicaid
Management Information System.
Master patient index--creates a single patient identifier and
ensures that patients are represented only once across all
systems. It also verifies whether the patient is a Medicaid
patient.
Medical and Medicaid management tools--offers tools to
allow the Division of Medicaid to identify critical patterns
and correlations where cost savings may exist, such as
identifying high-risk beneficiaries for care management and
measuring utilization across various service categories.
DOM staff stated that the goal of these components is to
pursue seamless data exchange with the Mississippi Health
Information Network (MS-HIN).
One long-term goal of the clinical data repository system is to
allow DOM to move toward an automated prior authorization
process and to meet some of the new service requirements
PEER Report #587
20
under the Medicaid Information Technology Architecture
(MITA) 3.0. Furthermore, the Division of Medicaid, MS-HIN, and
CMS are partnering to provide funding to MS-HIN in which CMS
and MS-HIN provide approximately $4 million over two years
(90/10 share) to expand MS-HIN services to forty-two additional
eligible hospitals in exchange for the necessary clinical data to
potentially automate the prior authorization process. In
exchange for this funding, MS-HIN will provide the Division of
Medicaid with:
laboratory reports;
radiology reports;
pathology reports;
admission, discharge, and transfer reports;
continuity of care documents; and,
consolidated-clinical document architecture (C-CDA)
8, 9
As of September 2014, the Implementation Advanced Planning
Document
10
had been completed and had been resubmitted to
the Centers for Medicare and Medicaid Services for approval.
Compliance with Federal and State Electronic Health Records
Requirements
Because the Division of Medicaid ceased offering an electronic health records
system in early 2014 by converting to a clinical data repository system, many
of the federal regulations specific to an EHR system no longer apply (aside
from HIPAA and other privacy and security requirements). DOM reports that it
is in compliance with remaining applicable federal and state EHR
requirements.
Regarding DOM’s compliance with federal and state EHR
requirements:
From July 1, 2013, to June 30, 2014, DOM reported
compliance with 45 C.F.R. Part 17 concerning standards for
testing and implementing an electronic health records
8
Together with the Continuity of Care Record standard, the Clinical Document Architecture forms the
basis for the Continuity of Care Document standard for patient document information exchange. Both
the CCR and CCD standards meet the United States government’s guidelines for the meaningful use of
EHR technology.
9
The Consolidated-Clinical Document Architecture implementation guide defines nine different types
of commonly used CDA documents, including: (a) Continuity of Care Document; (b) Consultation
Notes; (c) Discharge Summary; (d) Imaging Integration and DICOM Diagnostic Imaging Reports; (e)
History and Physical; (f) Operative Note; (g) Progress Note; (h) Procedure Note, and, (i) Unstructured
Documents.
10
An Implementation Advanced Planning Document (IAPD) is a recorded plan of action to request
federal financial participation in the costs of designing, developing, and implementing a system. The
Centers for Medicare and Medicaid Services approves and funds IAPD requests.
PEER Report #587
21
system, as well as “meaningful use requirements,” while
offering a certified EHR system to Medicaid providers.
From June 4, 2010, to June 30, 2014, DOM reported that it
was in compliance with HIPAA while offering a certified
EHR to Medicaid providers and that its clinical data
repository system’s provider portal was also in compliance
with HIPAA.
When DOM later shifted from an EHR system to a clinical data
repository in 2014, as noted on page 18, the federal and state
EHR requirements no longer applied.
Regarding DOM’s compliance with federal and state
requirements that are still applicable:
The Division of Medicaid reported that it is compliant with
42 C.F.R. Part 2 and MISS. CODE ANN. § 41-30-1 et seq.
(1972) regarding confidentiality for alcohol and drug abuse
prevention, treatment, and patient records. DOM has
implemented a sensitive data policy, which prohibits the
display/disclosure of alcohol abuse data in the former EHR
system and in the current provider portal.
The Division of Medicaid reported that it is compliant with
MISS. CODE ANN. § 41-21-97 (1972), which provides for the
confidentiality of hospital records and patient information
pertaining to mental health treatment.
How did the Division of Medicaid fund implementation of its electronic health
records/clinical data repository system? What expenditures have been made to date?
What expenditures remain to be made and for what purposes?
From FY 2009 to FY 2014, the Division of Medicaid spent $14.1 million to
attempt to procure and implement a statewide electronic health records system.
From FY 2009 to FY 2014, the Division of Medicaid spent $14.1
million to procure and implement a statewide electronic health
records system. Federal funding through grants accounted for
47% of total project funding and state funding through
matching grant support accounted for 7%. Shared Health
funded the remaining 46% through payments to Medicaid and
EHR contractors after Shared Health did not meet its contract
obligations in implementing an electronic health records
system.
Costs included payments to Shared Health, Orion, and
Mede/Analytics for designing and developing an electronic
health records system, payments to Fox Systems for planning,
including MITA planning and finding a provider (Shared
Health), and consulting and project management services.
PEER Report #587
22
What progress has the Mississippi Health
Information Network made since 2010 in
implementing electronic health records?
While the Mississippi Health Information Exchange system is mostly in place, the
Mississippi Health Information Network is still in its early stages of adding providers to
the system, with most early participation being from the Gulf Coast and the Delta. The
Mississippi Health Information Network has application modules in place as part of the
Mississippi Health Information Exchange to assist providers in meeting meaningful use
requirements as well as for meeting components of the Patient Protection and
Affordable Care Act. These include reporting requirements (e. g., immunization) as well
as patient alerts, with the goal of assisting providers and insurers in tracking patients
and managing patient care more effectively.
This chapter addresses the following questions:
What is the Mississippi Health Information Network and
what is the Mississippi Health Information Exchange?
What progress has the MS-HIN made in implementing a
health information exchange since the Legislature passed
the Health Information Technology Act in 2010?
Does the Mississippi Health Information Exchange meet the
EHR requirements of federal and state law?
How did MS-HIN fund implementation of the Mississippi
Health Information Exchange? What expenditures have been
made to date toward implementation? What expenditures
remain to be made and for what purposes?
What is the Mississippi Health Information Network and what is the Mississippi Health
Information Exchange?
MISS. CODE ANN. § 41-119-7 (1972) tasked the Mississippi Health Information
Network with developing the Mississippi Health Information Exchange, an
electronic exchange of health information in Mississippi that allows providers
access to a patient’s community health record.
As noted on page 7 in this report, the Mississippi Health
Information Infrastructure Task Force initially created the
Mississippi Coastal Health Information Exchange (MSCHIE) in
2007 as a pilot project for the state’s coastal counties that were
most affected by Hurricane Katrina.
In 2010, the Mississippi Legislature enacted the Health
Information Technology Act (House Bill 941, 2010 Regular
Session, now codified as MISS. CODE ANN. § 41-119-5 et seq.
[1972]) to create the Mississippi Health Information Network
PEER Report #587
23
(MS-HIN), thus expanding MSCHIE from a local coastal health
information exchange to a statewide network.
The Legislature created the Mississippi Health Information
Network to coordinate and facilitate building a statewide
capability to securely, electronically exchange health
information. The MS-HIN is a secure electronic exchange of
health information that allows providers quick, reliable access
to a patient’s community health record.
Exhibit 2, page 24, shows the sources of data for and users of
the Mississippi Health Information Exchange.
The intent of the MS-HIN is to retrieve patient data (e. g., lab
reports) from the provider level (e. g., hospitals) and create a
consolidated, searchable, electronic patient file for each
Mississippian that can be reviewed by physicians and specialty
providers. Public health agencies receive more searchable data
more quickly on patient health (e. g., for monitoring disease
outbreaks) or for research on public health (e. g., for review on
past sample cases of cancer) without having to search
individual patient records manually.
Appendix H, page 48, presents a timeline of MS-HIN’s
development.
What progress has the MS-HIN made in implementing a health information exchange
since the Legislature passed the Health Information Technology Act in 2010?
While the Mississippi Health Information Exchange system is mostly in place, the
MS-HIN is still in the early stages of adding providers to the system, with most
early participation being from the Gulf Coast and the Delta. The MS-HIN
continues to build and develop the Mississippi Health Information Exchange to
expand opportunities to the remainder of the state’s medical providers, focusing
primarily on hospitals and clinical providers, then expanding to ancillary
providers, including long-term care providers and pharmacies.
Since its initial expansion from a pilot project on the Gulf Coast
(see page 22), the Mississippi Health Information Network has
targeted expanding into hospitals and clinics. As of June 2014,
MS-HIN included:
at least 600,000 unique covered patients;
thirteen participating hospitals;
thirty-nine participating clinics/federally qualified health
centers; and,
PEER Report #587
24
Exhibit 2: Examples of Sources of Data for and Users of the Mississippi
Health Information Exchange
The Mississippi Health Information Network, utilizing the Mississippi Health
Information Exchange, electronically receives patient information from multiple health
care systems throughout the community, establishes a community health record for
each patient, and through the use of queries and push exchanges, aggregates and
transfers health information to health insurance companies, to public health agencies,
and to providers to monitor health.
SOURCE: PEER analysis.
twenty hospitals in active onboarding, including University
of Mississippi Medical Center (including University
Physicians), Rush Health Systems, and the North Mississippi
Medical Center system.
Also, as of June 2014, MS-HIN had:
1,001 total secure e-mail accounts, including 986 providers
(doctors or nurses at hospitals or clinics);
ninety-three hospitals with secure e-mail accounts;
Mississippi
Health
Information
Exchange
Long-Term
Care
Providers
Public Health
Agencies (Mississippi
Department of Health,
Healtheway)
Specialty
Care
Providers
Pharmacies
Lab Providers
(e. g., lab
tests, x-rays)
Hospitals
Insurance
Providers
Primary
Care
Providers
PEER Report #587
25
1,616 separate medical providers (e. g., doctors, nurses)
with secure access identification to log in and search
records on MS-HIN’s community health record; and,
165,106 community health record chart views by a doctor
or nurse in calendar year 2013.
The long-term goal of MS-HIN expansion is to onboard all
hospitals throughout Mississippi.
Services Provided by the Mississippi Health Information Exchange
Providers are able to search the web-based Mississippi Health Information
Exchange to view patient information aggregated from multiple health
providers throughout the state into a consolidated patient file.
The Mississippi Health Information Exchange service allows
providers to query available patient health information within a
network. With the click of a mouse, providers can access
information such as patient laboratory reports, past
procedures, diagnosis, and medications. The MS-HIN offers
health care providers a single point of access to a
comprehensive community health record. Providers use this
web-based clinical application to view patient information
aggregated from multiple systems throughout the community
in a secure electronic format.
The Mississippi Health Information Exchange offers the
following services:
community health records;
community medication history; and,
results distribution.
11
One example of how these services may be utilized is that the
community results distribution could be combined with the
community health record to provide an emergency department
staff with real-time patient information, test results, and
medical history, necessary for when a trauma, heart attack, or
stroke patient is transferred into one hospital from another
hospital.
Subscribing to the Mississippi Health Information Exchange
allows health care providers to share messages and health
information needed to provide patient care. Providers can
electronically send and receive patient information quickly and
securely. Additionally, the MS-HIN Direct Program enables
eligible professionals and eligible hospitals participating in
incentive payment programs to meet meaningful use
requirements.
Also, providers can electronically send, schedule, and track
patient referral information. Providers can see the status and
communicate about each referral for their practice; upon
11
Results distribution is the delivery of structured clinical results from one EHR to another.
PEER Report #587
26
making a referral, search the MS-HIN network by physician
name, practice name, or service; and specify how they want to
receive referrals by adding questions and instructions for the
referring office. An example of how direct messaging could be
used is that when a primary care clinic emails a referral request
to a specialist and attaches relevant patient history documents,
the specialist could then send back an email with a diagnosis
and/or recommendation for care.
MS-HIN also assists providers with public health reporting.
With the advent of meaningful use and its associated
requirements to exchange data (see page 5), health care
organizations are under pressure to implement standards-
based interoperability solutions in a relatively short time
frame. To support health care organizations in complying, the
State Department of Health and MS-HIN have created a set of
solutions that can help make provider data reporting to both
the State Department of Health and the Centers for Medicare
and Medicaid Services easier by leveraging MS-HIN interfaces
and the Office of National Coordinator for Health IT-approved
solutions. For example, MS-HIN forwards required data to the
State Department of Health to satisfy electronic lab reporting
requirements and MS-HIN supports program specific interfaces
such as the state’s immunization registry and state hospital
discharge reporting requirements.
Impact of MS-HIN on Patients
While MS-HIN does not directly serve patients, the Mississippi Health
Information Exchange offers the potential for improved benefits and services
for patients and their care.
As the Mississippi Health Information Exchange expands, it has
the potential to make a patient’s interactions with the health
care system more convenient, more reliable, and less time-
consuming. Examples of potential benefits and services for
patients and their care include:
rapid information sharing between providers;
reduced paperwork; and,
reduced duplication in medical tests by shared access to
prior results.
While the Mississippi Health Information Network offers the
potential for improved benefits and services for patients and
their care, implementation and use of its exchange may vary
from provider to provider as health information technology
continues to develop at both the provider level and at the state
and industry level.
PEER Report #587
27
Does the Mississippi Health Information Exchange meet the EHR requirements of
federal and state law?
The Mississippi Health Information Network’s Mississippi Health Information
Exchange serves as a tool that enables providers to meet the EHR requirements
of the Patient Protection and Affordable Care Act and the HITECH Act. MS-HIN
itself does not have to meet any Patient Protection and Affordable Care Act
standards or meaningful use requirements under the HITECH Act. However, the
Mississippi Health Information Exchange does have built-in privacy and security
features to ensure HIPAA compliance.
As noted previously in this report, an electronic health records
system must comply with multiple federal regulations in order
to be classified as a federally certified system. Since the MS-HIN
is building a statewide health information exchange with the
goal of creating a statewide network to connect providers’
electronic health records systems, it does not have to comply
specifically with some of these regulations as an entity.
However, it serves as a tool that will help this network of
providers ensure compliance of electronic health records
systems with federal regulations.
How the Exchange Helps Providers Meet Requirements of the
HITECH Act and the Patient Protection and Affordable Care Act
The Mississippi Health Information Network’s Mississippi Health
Information Exchange is a tool that enables providers to meet the
requirements of the HITECH Act and the Patient Protection and
Affordable Care Act.
While MS-HIN, as an electronic health information network, is
not required to meet meaningful use requirements under the
HITECH Act, MS-HIN provides services that assist eligible
professionals and eligible hospitals in meeting meaningful use
requirements. These services include:
MS-HIN Direct Services--MS-HIN Direct, a peer-to-peer
messaging service for health care organizations, assists
providers in meeting meaningful use requirements for
eligible professionals and eligible hospitals and Patient
Protection and Affordable Care Act requirements by
enabling providers to send, receive, and share timely,
secure clinical documentation and other patient health
information with other providers. MS-HIN Direct capability
is a Stage 2 meaningful use requirement for all certified
electronic health records and can be utilized by eligible
hospitals and providers to fit their needs. MS-HIN Direct
may also be used to enhance provider workflow in
managing care coordination, referrals, and other key clinic
operations. The State Department of Health is using MS-
HIN Direct to satisfy program-specific reporting
requirements such as Hearing Screening and Stage 1
PEER Report #587
28
meaningful use attestation for lab results, immunizations,
and syndromic surveillance.
Summary of Care--MS-HIN assists providers in meeting
meaningful use requirements for eligible professionals and
eligible hospitals by providing an electronic transport
method for summary of care records (i. e., the continuity of
care documents) for transitions and referrals through MS-
HIN Direct.
Public Health Reporting--MS-HIN assists providers in
meeting meaningful use requirements for eligible
professionals and eligible hospitals by supporting
successful ongoing submission of laboratory results,
immunization, and syndromic surveillance data to the State
Department of Health.
Further, although MS-HIN itself does not have to meet any
specific PPACA standards, MS-HIN enables providers to meet
the requirements of the Patient Protection and Affordable Care
Act. For example, MS-HIN helps accountability care
organizations manage patient care by storing the patient’s
medical information all in one place, allowing the providers to
communicate and jointly manage the patient’s care more
effectively.
The Exchange’s Privacy and Security Features
The Mississippi Health Information Exchange has built-in privacy and security
features to ensure HIPAA compliance.
MS-HIN is built to enable role-based access so that only
authorized individuals can view patient information on a need-
to-know basis. Unlike paper record storage systems, the
Mississippi Health Information Exchange tracks who accesses
or changes information and maintains an audit log.
How did MS-HIN fund implementation of the Mississippi Health Information Exchange?
What expenditures have been made to date toward implementation? What
expenditures remain to be made and for what purposes?
MS-HIN has received approximately $12.8 million in federal, state, and private
funding and has expended approximately $11.2 million to create and implement
the Mississippi Health Information Exchange. While one goal of MS-HIN is to be
self-sufficient, it has not yet reached a point where it has sufficient revenues to
cover operational and additional build-out costs completely. Furthermore, MS-
HIN expects additional expenditures for providing patients with a searchable
system projected to commence in 2016, for which the specific costs are unknown
to date.
Since its establishment in 2010 (by House Bill 941, 2010
Regular Session), the MS-HIN has received approximately $12.8
million in grants and appropriations from the federal and state
PEER Report #587
29
government and not-for-profit foundations. Through June
2014, MS-HIN had expended approximately $11.2 million to
create, develop, and implement the Mississippi Health
Information Exchange and to collaborate with hospitals, clinical
providers to onboard them, and with insurance providers and
pharmacies to collaborate data collection and information
sharing. MS-HIN was not able to utilize approximately $1.3
million in HITECH grant funds under ARRA because of a lack of
matching funds, which subsequently lapsed in March 2014.
MS-HIN is in the beginning stages of self-generating revenue as
it develops the Mississippi Health Information Exchange and
thus is not yet capable of generating enough revenues to be
self-sufficient. Clinics and hospitals pay a combination of one-
time and/or annual fees based on a set fee schedule for clinical
services and hospital services based on the services they need.
MS-HIN has also established fee structures for ancillary
providers, including nursing homes, and pharmacies and
insurance providers pay a flat fee for data services. MS-HIN has
collected $330,155 in self-generated revenues as of the close of
FY 2014, but its financial sustainability model projects MS-HIN
needs from $2.5 million to $3 million in self-generated revenue
per year to operate. MS-HIN staff stated that its original 2011
goal of being self-sustaining by 2015 was ambitious, given the
developmental state of electronic medical/health records in
Mississippi.
In addition to ongoing operational costs, MS-HIN will incur
additional connection fee costs as it continues to build out the
hospital and clinical connections to the network. As discussed
on page 20, the Division of Medicaid and MS-HIN are in the
process of procuring another $4 million through an
Implementation Advanced Planning Document to assist the
Mississippi Health Information Network in building out the
network to an additional forty-two hospitals as well as paying
for Medicaid-specific data services. The Centers for Medicare
and Medicaid Services and MS-HIN will share the costs 90% to
10%. Additional funds will be needed to expand MS-HIN (and
subsequently Medicaid) to the remaining providers in future
years, but such costs and funding sources have not yet been
established. MS-HIN estimates these costs to be approximately
$5 million. As noted previously, Medicaid/CMS is projected to
cover forty-two hospitals at a cost of $4 million, plus the
services of providing Medicaid clinical data to Medicaid for
each MS-HIN provider. MS-HIN is also working with the
Mississippi Public Health Institute to obtain $900,000 in
funding from the BP Deepwater Horizon Settlement overseen
by the Louisiana Public Health Institute to fund a primary care
physician notification tool.
Regarding future costs, MS-HIN staff notes that additional costs
would be incurred with implementation of Phase Two, which is
projected to commence in 2016. This would add a patient
engagement solution to the existing MS-HIN, including
providing patients with a searchable patient portal. However,
MS-HIN has not further scoped or planned the security,
PEER Report #587
30
feasibility, and cost of such deployment to date. MSHIN is also
pursuing additional federal and/or grant funding to add
providers to the Mississippi Health Information Exchange in
Phase Two.
PEER Report #587
31
Conclusion
Since PEER’s 2010 report on procurement and implementation
of electronic health records systems, the University of
Mississippi Medical Center has established its electronic health
records system as one component within its larger health care
information system, known as Epic.
When Mississippi’s Division of Medicaid first began developing
a statewide EHR system, local provider implementation of EHRs
was limited. As Congress created the Electronic Health Records
Incentive Program to encourage the development of electronic
health records at the provider level, providers began installing
electronic health records on their own in return for incentive
payments based on requirements of “meaningful use.”
Although DOM originally was pursuing an electronic health
records system at the time of the 2010 PEER report, it has since
transitioned into a clinical data repository.
Finally, the Mississippi Health Information Network has evolved
from the original Mississippi Coastal Health Information
Exchange to a statewide network.
PEER Report #587
32
PEER Report #587
33
Appendix A: Glossary of Terms Related to Electronic
Health Records
ACOs (Accountable Care Organizations)--a coordinated network of health care providers that
shares financial and medical responsibility for providing care to patients with a goal of
meeting specific quality of care benchmarks and controlling costs. Under the Patient
Protection and Affordable Care Act, each ACO has to manage the health care needs of a
minimum of 5,000 Medicare beneficiaries for at least three years.
ARRA (American Recovery and Reinvestment Act)--an economic stimulus package enacted by
the 111
th
Congress in February 2009, commonly referred to as the “Stimulus” or “The
Recovery Act”
CAH (Critical Access Hospital)--a small facility that gives limited outpatient and inpatient
hospital services to people in rural areas
CCHIT (Certification Commission for Health Information Technology)--a private, not-for-profit
organization functioning as an ONC-Authorized Testing and Certification Body of electronic
health records
CEHRT (Certified Electronic Health Record Technology)--certified EHR technology gives
assurance to purchasers and other users that an EHR system or module offers the necessary
technological capability, functionality, and security to help meet meaningful use criteria
established by CMS and the Office of the National Coordinator for Health Information
Technology
CQM (Clinical Quality Measures)--tools that help measure and track the quality of health care
services provided by eligible professionals, eligible hospitals, and critical access hospitals
EHs (Eligible Hospitals)--under the Medicaid Incentive Program, includes acute care hospitals
(including Critical Access Hospitals and cancer hospitals) with at least 10% Medicaid patient
volume and children’s hospitals
EHR (Electronic Health Record)--an electronic record of health-related information of an
individual that conforms to nationally recognized interoperability standards that can be
created, managed, and consulted by authorized clinicians and staff across more than one
health care organization
Electronic Health Records Incentive Program (“meaningful use” requirements)--provides
financial incentives to health care providers to implement electronic health records in a
meaningful way, including meeting program requirements established by CMS
eMPI (Enterprise Master Patient Index)--a database that contains a unique identifier for every
patient in the enterprise who receives medical services, along with their demographic
information, in order to identify, match, merge, and create a consolidated patient record for
each individual patient in the database
EMR (Electronic Medical Record)--an electronic record of health-related information that can
be created, gathered, managed, and consulted by authorized clinicians and staff within one
health care organization
PEER Report #587
34
EP (Eligible Provider)--medical professional available for EHR incentive payments through the
Medicaid EHR Incentive Program: non-hospital based physicians (M.D. or D.O.), nurse
practitioners, certified nurse-midwives, dentists, and physician assistants who practice in a
federally qualified health center or rural health clinic that is led by a physician assistant
Epic--the health care information system purchased by the University of Mississippi Medical
Center from Epic Systems Corporation
ePrescribing--the ability to send an accurate, error-free and understandable prescription
electronically and directly to a pharmacy from the point-of-care
HIE (Health Information Exchange)--the electronic movement of health-related information
among organizations according to nationally recognized standards
HIN (Health Information Network)--a set of standards, services, legal agreements, and
governance that enables the Internet to be used for secure and meaningful exchange of
health information to improve health care
HIPAA (Health Insurance Portability and Accountability Act of 1996)--HIPAA is a federal law
that sets standards for electronic transmission of claims-related information and for
ensuring the security and privacy of all individually identifiable health information. HIPAA
applies to healthcare providers, health plans, and healthcare clearinghouses (collectively
called “covered entities”), as well as any of these covered entities’ business associates that
have access to medical records and transmit health information. HIPAA requires (1) certain
security standards for the protection of electronic protected health information, (2) certain
notification requirements if there is a breach of unsecured protected health information, and
(3) certain privacy standards regarding individually identifiable information.
HIT (Health Information Technology)--the application of information processing involving
both computer hardware and software that deals with the storage, retrieval, sharing and use
of health care information, data, and knowledge for communication and
decisionmaking11/24/14
HITECH (Health Information Technology for Economic and Clinical Health)--This was
legislation enacted under Title XIII of the American Recovery and Reinvestment Act of 2009.
The purpose of HITECH was to promote spending to expand adoption rates of HIT.
HL7 (Health Level Seven)--HL7 is one of several American National Standards Institute-
accredited standards-developing organizations operating in the health care arena. Health
Level Seven’s domain is clinical and administrative data.
IAPD (Implementation Advanced Planning Document)--a recorded plan of action to request
federal financial participation in the costs of designing, developing, and implementing a
system
Interoperability--Interoperability is the ability of different information technology systems
and software applications to communicate, exchange data, and use the information that has
been exchanged. This includes permitting data to be shared across clinicians, labs,
hospitals, pharmacies, and patients regardless of the application or application vendor.
Meaningful Use--Meaningful use is the use of certified electronic health records to improve
quality, safety, efficiency, reduce health disparities, engage patients and family, improve
care coordination, and maintain privacy and security of patient health information.
PEER Report #587
35
MEHRS/eScript (Medicaid Electronic Health Record System/eScript)--This system offers
providers an EHR that aids providers in meeting meaningful use criteria. Smart analytics and
predictive modeling enable improvement of care for Medicaid beneficiaries.
MES (Medicaid Enterprise System--the current Medicaid system for tracking and managing
financial billing and automation of Medicaid claims
MSCHIE (Mississippi Coastal Health Information Exchange)--the predecessor health
information exchange to MS-HIN
MITA (Medicaid Information Technology Architecture)--an initiative to promote
improvements in the Medicaid enterprise and systems that support it through collaboration
between CMS and the states. It is also a framework that provides a blueprint consisting of
models, guidelines, and principles to be used by states as they implement enterprise
solutions.
MMIS (Medicaid Management Information System)--The Medicaid Management Information
System is an integrated group of procedures and computer processing operations
(subsystems) developed to meet principal objectives.
NHIN (Nationwide Health Information Network)--NHIN is the federal government’s program
to implement a national interoperable system for sharing electronic medical records. NHIN
includes the set of standards, specifications, and policies that enable the secure exchange of
health information over the Internet.
ONC (Office of the National Coordinator for Healthcare Information Technology)--a staff
division within the U. S. Department of Health and Human Services primarily focused on
implementing an interoperable, private, and secure nationwide health information system
and supporting the widespread meaningful use of technology.
Portal--a website that offers a range of resources, such as email, chat boards, search
engines, and content
Provider--a provider is an individual or group of individuals that directly (primary care
physicians, psychiatrist, nurses, surgeons, etc.) or indirectly (laboratories, radiology clinics,
etc.) provide health care to patients
Shared Health, Inc.--a vendor providing DOM with MEHRS/eScript products
SOURCES: Division of Medicaid’s State Medicaid Health Information Technology Plan; ONC Glossary of
Terms on www.healthit.gov; www.cms.gov; and, www.medicaid.gov.
PEER Report #587
36
Appendix B: Meaningful Use
As part of the 2009 HITECH Act, the Electronic Health Care Record Incentive Program
(commonly referred to as “meaningful use”) provides incentive payments to health care
providers as they adopt, implement, upgrade, or demonstrate meaningful use of
certified EHR technology.
As part of the 2009 HITECH Act, the Electronic Health Care
Record Incentive Program--commonly referred to as
“meaningful use”--provides incentive payments to eligible
professionals, eligible hospitals, and critical access hospitals as
they adopt, implement, upgrade, or demonstrate meaningful
use of certified EHR technology.
The Medicare EHR Incentive Program is run by the federal
Centers for Medicare and Medicaid Services. The maximum
incentive amount is $44,000, with payments made over five
consecutive years. Providers must demonstrate meaningful
use every year to receive incentive payments. However, unlike
Medicaid, there is a penalty provision commencing in 2015 and
later for failing to implement; Medicare-eligible professionals
who do not successfully demonstrate meaningful use will have
a negative payment adjustment made to their Medicare
reimbursement. The payment reduction starts at one percent
and increases each year that a Medicare-eligible professional
does not demonstrate meaningful use, up to a maximum of
five percent.
In contrast, the Medicaid EHR Incentive Program is an incentive-
only program run by the state Medicaid agency (e. g., the
Mississippi Division of Medicaid). The maximum incentive
amount is $63,750, with payments made over six years (unlike
Medicare, payments do not have to be consecutive). In the first
year, providers can receive an incentive payment for adopting,
implementing, or upgrading EHR technology. Providers then
must demonstrate meaningful use in the remaining years to
receive further incentive payments.
Eligible hospitals may enroll and receive incentives for both the
Medicare EHR and Medicaid EHR programs, but will only receive
a penalty for non-compliance with the Medicare EHR program.
In contrast, eligible providers may only enroll in either the
Medicare or Medicaid program, but will receive a penalty,
based on the Medicare penalty, for failing to attest to
whichever program they enroll in (if they see Medicaid
patients).
To receive an EHR incentive payment, providers have to show
that they are “meaningfully using” their EHRs by meeting
thresholds for a number of objectives. CMS has established
the objectives for “meaningful use” that eligible professionals,
eligible hospitals, and critical access hospitals must meet in
order to receive an incentive payment.
PEER Report #587
37
The Electronic Health Record Incentive Programs have three
stages with increasing requirements for participation. Stage 1
and Stage 2 each last two years. A provider must successfully
meet the criteria of each stage for two consecutive years to
advance to the next stage. In addition, all providers
participating in the meaningful use program must also annually
report progress on the clinical quality measures, which
represent the Department of Health and Human Services’
National Quality Strategy priorities for health care quality
improvement. The criteria for Stage 3 have not yet been
determined by CMS.
SOURCE: Centers for Medicare and Medicaid Services (www.cms.gov);
University of Mississippi Medical Center; PEER Report #542.
PEER Report #587
38
Appendix C: Detailed Description of UMMC’s Epic
Enterprise-Wide Patient Access and Revenue Cycle (PARC)
Consolidated Patient Access
Welcome Patient Kiosk: Expedites patient flow via a self-service touch screen kiosk by
enabling patients to check in for appointments, answer questionnaires, sign forms
electronically, make payments, etc.
Cadence Enterprise Scheduling System: Searches for appropriate availabilities for joint,
recurring, and sequential appointments. Tracks and manages clinician and resource
scheduling via flexible templates.
Includes Referral Tracking to manage incoming, internal, and outgoing referrals.
Includes Advanced Rules-Based Scheduling, which provides automatic scheduling
based on definable procedures, associated resources, and rules.
Prelude Enterprise Registration System: Collects, tracks, and maintains registration
information, interactive reporting, and searching.
Admission/Discharge/Transfer System: Manages hospitals stays from preadmission to
discharge for centralized and/or decentralized admitting, including workflows for
authorizations, bed management, and environmental services.
Call Management/Customer Relationship Management: Centralizes customer services for
the organization. Provides flexible workflows for managing a variety of customer-related
communications. Records customer contacts, creates messaging pools, reviews
correspondence history, provides extensive reporting, etc.
Nurse Triage: Provides the patient information, practice management tools, and clinical
protocols nurses need to help sick patients over the phone. Walks nurse through the
triage process step by step using online protocols.
Consolidated Revenue Cycle
Resolute Professional Billing and Patient Accounting: Physician billing with provider-level
reporting and tracking of accounts receivable. Provides online work queues for charge and
claim edits, denial management, and paperless collections. Produces electronic claims
including the ANSI 837 v4010 Professional and Institutional formats. Includes an
electronic remittance loader for automatic payment posting of various formats including
HIPAA ANSI 835 v4010. Includes additional specialty modules for tracking dental billing;
residency documentation; anesthesia billing; and, state billing requirements.
PEER Report #587
39
Resolute Hospital Billing and Patient Accounting: Facility billing for inpatients, outpatients,
emergency department visits, and recurring visits. Provides online work queues for billing
edits, claim edits, denial management, and paperless collections. Calculates expected
reimbursement to monitor payment accuracy from payors and net down Accounts
Receivable. Produces electronic claims including the ANSI 837 v4010 Professional and
Institutional formats. Includes an electronic remittance loader for automatic payment
posting of various formats including HIPAA ANSI 835 v4010. Includes additional specialty
modules for abstracting and coding and state billing requirements.
EpicCare Inpatient Clinical System
Epicenter Enterprise Data Repository: Captures and organizes patient data from
applications and interfaces across the continuum of care. Includes Chart Review, Results
Review, In Basket, decision-support alerts, Notes, and accordion reports (data available
depends on modules selected).
Electronic Medical Record (EMR): Includes chart entries such as Patient History,
Demographics, Allergy Management, Problem List, Inpatient Notes, Flowsheet
documentation including Intake and Output Entry, and Patient Education; Intra-team
Communication; Patient Lists and Report Features.
Computerized Physician Order Entry: Order entry and decision support for pharmacy,
radiology, lab, and other orders.
Core Clinical Documentation: Includes Interdisciplinary Notes, Documentation Flowsheets,
and Intake and Output Review.
Extended Clinical Documentation: Includes Worklists, Discharge Instruction Writer,
Interdisciplinary Patient Education Record, and Data Capture for device integration.
Medication Administration Record: Includes the electronic Medication Administration
Record and reports, medication scheduling, integration with ordering and pharmacy
functionality, variance documentation, and workstation-based barcode medication
administration.
Interdisciplinary Care Plan
: Facilitates collaborative care model with multiple disciplines.
It allows care team to construct plan of care, evaluate document progress, alert clinicians
for unmet expected goals/outcomes and can be carried across multiple encounters.
Clinical Pathways: Allows customers to build templates of standard sequenced care (e. g.
orders, assessments, interventions, and teaching for admission day) for a given condition.
It also provides at-a-glance review tools with traffic light indicators for patient progress
trafficking.
ICU: Fine-tuned, configurable workflows for treatment decisions and review of high-
density information; enhanced IV and data management tools to increase staff efficiency;
and, configurable patient dashboard for critical care. However, it does not include real-
time telemetry or machine interfaces.
PEER Report #587
40
Willow Inpatient Pharmacy System: Inpatient Pharmacy System provides order entry and
verification for both simple and complex orders; interfaces with automated dispensing
systems such as Pyxis and Omnicell; supports multiple hospitals, pharmacies, formularies,
and charge calculation formulas. It also provides complete access to patient charts as well
as tools for monitoring and managing patients.
MobileMeds: Provides a vehicle for Five Rights/Positive ID in the hospital using a PDA or
mobile device. Includes Patient Lists, Rosters, Inpatient Nursing Medical Administration
Record, Inpatient Nursing Vitals, and Intake and Output Entry.
ASAP Emergency Department Information System: Includes electronic tracking board
views, patient status tools, and events logging, physician documentation and ordering,
nursing documentation, medication administration and reconciliation, and support for
quick patient arrivals. ASAP also includes full integration with the EpicCare Inpatient and
EpicCare Ambulatory patient chart and clinical decision support.
Ancillary Department Clinical Systems
(Lab, Pharmacy, Oncology, Radiology, and Operating Room
Health Information Management)
OpTime Operating Room Management System: Includes scheduling and staff availability,
case logs, inventory balances, and procedure requirements for multiple numbers of
operating rooms, sites, and locations. Manages schedules in conjunction with Cadence
Enterprise Scheduling System.
Perioperative Charting: Includes charting tools, nursing notes, flowsheet
capabilities, and detailed medication administration recording.
Anesthesia: Documents preoperative assessments, collects real-time data from
anesthesia monitors, and records intraoperative medication administrations and
assessments.
Beacon Oncology Information System (Pediatric and Adult): Includes protocol and
treatment plan management, protocol-based chemotherapy ordering and administration,
protocol-based decision support and treatment scheduling, and functionality for cancer
staging documentation.
Stork Obstetrics Information System: Provides an integrated, concise view of the patient’s
obstetric record, focusing on the continuum of care from the initial prenatal visit to the
delivery room, through specialized documentation and review tools for all aspects of the
obstetric experience, including ultrasound procedures, labor documentation, and delivery
reporting.
Kaleidoscope Ophthalmology Information System: Provides an infrastructure for capturing
numeric data from ophthalmology devices. Future functionality will include improved
integration with phoropters and other numeric devices, exam form configuration options,
and workflow tools for scheduling and resulting images and procedures.
Phoenix Transplant Information System: Provides a comprehensive view of the patient’s
transplant chart, focusing on the continuum of care from the initial evaluation to post-
operative follow-ups. Additionally, transplant-specific documentation tools allow tracking
of data for clinical operations and research and registry reporting. Support for patient
PEER Report #587
41
surveillance, waitlist management, UNOS waitlist reconciliation, and UNOS registry is
included. Current focus is on solid organ transplants.
EpicCare Home Health: Checks out the patient record onto a laptop so it can be used
remotely in the home, then synchronizes it back up with the repository after the visit. It
includes Home Health Billing. However, it does not support hospice requirements.
Willow Ambulatory Pharmacy System: Pharmacy order entry; interaction checking and
alerts; real-time claim adjudication through a third party; local or central fill of
prescriptions; order review; status tracking; inventory; interfaces to robotics/pill counters;
and, reporting and management tools.
Radiant Radiology Information System: Provides workflow support for complex radiology
departments. Combines technologists’ work lists, reading work lists, and support for
seamless embedded PACS integration alongside Epic’s tools for rules-based scheduling,
clinical documentation, results communication, mammography, and film tracking.
Natively supports Digital Imaging and Communications in Medicine.
12
Beaker Laboratory Information System: Includes General Lab and Microbiology and
supports interfaces with automated laboratory instrumentation. Also included are
Reference Lab and Lab Billing modules to support reference laboratory workflows. Does
not include Flow Cytometry, Molecular Pathology, Genetics, or Blood Bank.
Beaker Anatomic Pathology: Includes case entry, synoptic reporting, quality analysis
correlations, rules for screening, and work lists for histologists, pathologists, and
cytologists.
Ambulatory Electronic Health Record (EHR) and eHealth
EpicCare Ambulatory Electronic Medical Record (EMR):
Ambulatory Visits, Hospital Outpatient Visits (Emergency Department visits if used
in the Emergency Department and EpicCare inpatient is not licensed)
Care Everywhere - Care Epic: Used to share information among organizations that use
EpicCare.
Care Everywhere - Care Elsewhere: Used to share information between Epic and non-Epic
providers.
Haiku: Allows providers to view their schedule and patient information, including past
visits and results, on their mobile phone.
EpicCare Link: Allows affiliates who refer patients to follow the progress of their patients,
review their results, request appointments, place procedure orders, and communicate via
In Basket. Also improves the referral process to affiliates to whom you refer and allows
affiliate clinic managers the ability to manage user and provider records.
12
DICOM is an application layer network protocol for the transmission of medical images, waveforms
and accompanying information.
PEER Report #587
42
MyChart Shared Patient Record: Provides patients with controlled access to their
electronic medical record and important self-service options such as scheduling, refill
request, bill paying, etc. Patients can also maintain their own personal health record.
Features depend on applications licensed.
Lucy: Included with MyChart. Allow patients to upload the information provided
through MyChart and add their personal comments and clarifications. Patients can
elect to share both this uploaded information and their personal health record with
any health care organization.
MyChart in Hospital: Allows patients (and proxies) to keep friends and family informed
while they are admitted, includes interactive tools for patient education and tracking of
milestones toward recovery/discharge, and includes the ability of family and friends to
order gifts and flowers for the patient.
OutReach: Integrate with Beaker to facilitate reference lab services for providers outside
an organization, allowing them to place orders, view results, and manage specimens
online.
SOURCE: Epic Health Care Implementation Program Charter. University of Mississippi Medical Center.
February 1, 2011. Version 1.04
UMMC's Epic
system officially
became
operational
UMMC entered into a
contract to purchase
the Epic electronic
healthcare information
system
UMMC chose to
eliminate over 20
existing legacy systems
and create a new
consolidated healthcare
information system
Appendix D: University of Mississippi Medical Center Timeline of Implementing Electronic Health Records
Start
UMMC and its providers
successfully attested to
their first full year of
meeting meaningful use
requirements
UMMC qualified for its
first Electronic Health
Records Incentive
Program payments for
adopting and
implementing Epic
June
2012
August
2010
2013
January
2014
2009
Under the HITECH Act, all
public and private healthcare
providers must have adopted
and demonstrated meaningful
use of electronic medical
records in order to maintain
existing Medicaid and Medicare
reimbursement levels
45 Code of Federal
Regulations Part 170
required the Office of
the National Coordinator
for Health IT to certify all
electronic health records
systems
Congress passed the
American Recovery
and Reinvestment Act,
including the HITECH
Act and the Electronic
Health Records
Incentive Program
2011
SOURCE: PEER Analysis of University of Mississippi Medical Center documents and applicable federal and state law
PEER Report #587
43
PEER Report #587
44
Appendix E: Electronic Health Records Incentive
Program Incentive Payments Received by the
University of Mississippi Medical Center through
July 1, 2014
Financial Unit EHR Incentive
Program Funding
Category
Revenue by EHR
Incentive Program
Funding Category
Revenue by
Financial Unit
Medicaid Adopt,
Implement, or
Upgrade (2012)
$4,102,409
Medicaid Stage 1
Year 1 (2013)
$3,281,927
University of
Mississippi Medical
Center (eligible
hospital portion)
Medicare Stage 1
Year 1(2013)
$1,387,489
$8,771,825
Medicaid Adopt,
Implement, or
Upgrade (2012)
$772,000
Medicaid Stage 1
Year 1 (2013)
$617,600
UMMC - Holmes
County
Medicare Stage 1,
Year 1 (2013)
($555,645 pending)
$1,389,600
+
$555,645 pending
Medicaid Adopt,
Implement, or
Upgrade (2011)
$9,456,250
University
Physicians
Medicaid Stage 1,
Year 1 (2013)
$4,173,500
$13,629,750
Medicaid Adopt,
Implement, or
Upgrade (2012)
$212,500
School of Nursing
Providers
Medicaid Stage 1,
Year 1
Included in
University
Physicians Amount
$212,500
Combined Total Received: $24,003,675
Additional Pending:
$555,645
SOURCE: Health System Financial Incentive Programs, Quality Administration, University of Mississippi
Medical Center. Data through July 1, 2014.
Appendix F: UMMC Expenditures for Epic, by Category of Expenditure, FY 2011 Actual-FY 2016 Budgeted
*Thesecostsdonotincludeprojectedone�meFY2016implementa�onandhardwarecoststoaddUMMCGrenadatoUMMC’sEpicsystem.
FY 2011
Actual
FY 2012
Actual
FY 2013
Actual
FY 2014 (As of
05/30/14)
FY 2015
Budgeted
FY 2016
Budgeted* Total Cost
EPIC Payroll
4,055,986$ 9,712,748$ 8,676,036$ 8,676,036$ 8,676,036$ 8,676,036$ 48,472,878$
Staff Augmentation
-$ 4,222,231$ 4,318,178$ 475,169$ 1,000,000$ 1,000,000$ 11,015,578$
Software License Fees
(includes 11 months of
perpetual license fees post
2015)
3,051,970$ 4,365,611$ 4,705,161$ 4,017,787$ 4,611,744$ 2,797,074$ 23,549,347$
Epic Implementation Fees
1,957,490$ 5,095,253$ 3,423,286$ 174,644$ 150,000$ 150,000$ 10,950,673$
UMMC Epic
Training/Travel Costs
533,169$ 586,675$ 199,054$ 171,065$ 175,000$ 175,000$ 1,839,963$
UMMC buildout expenses
related to Epic
2,050,132$ 15,609$ -$ -$ -$ -$ 2,065,741$
Misc Expenses related to
implementation
-$ 552,761$ 79,324$ 579$ -$ -$ 632,664$
Hardware costs
6,218,816$ 10,024,634$ 1,989,157$ 617,118$ 500,000$ 500,000$ 19,849,725$
Third Party Software non
Epic billed
33,750$ 726,125$ 131,760$ 147,856$ 350,642$ 350,642$ 1,740,775$
Interface fees for third
party to Epic
-$ 1,095,430$ 103,655$ 104,975$ 5,495$ 5,495$ 1,315,050$
Siemens Conversion fees
33,750$ 274,659$ 74,676$ -$ -$ -$ 383,085$
Epic training renovations
-$ 507,976$ 27,968$ -$ -$ -$ 535,944$
Epic Maintenance
(includes Epic hardware
maintenance)
57,006$ 364,380$ 1,236,463$ 740,523$ 1,200,000$ 1,200,000$ 4,798,372$
Third party maintenance
related to Epic
-$ 178,115$ 1,480,524$ 126,473$ 355,776$ 355,776$ 2,496,664$
Epic transaction Items
(MyChart access,
CareEverywhere, Haiku,
etc.)
-$ -$ 21,550$ 48,680$ 103,314$ 103,314$ 276,858$
Epic Project Total
17,992,069$ 37,722,207$ 26,466,792$ 15,300,905$ 17,128,007$ 15,313,337$ 129,923,317$
PEER Report #587
45
Appendix F: UMMC Expenditures for Epic, by Category of Expenditure, FY 2011 Actual-FY 2016 Budgeted
*Thesecostsdonotincludeprojectedone�meFY2016implementa�onandhardwarecoststoaddUMMCGrenadatoUMMC’sEpicsystem.
NOTES:
1)
2)
3)
4)
5)
6)
NOTE: FY 2015 and FY 2016 projected amounts are as of June 30, 2014.
SOURCE: PEER analysis of expenditure information from UMMC.
Epic Payroll--UMMC's project team's expenses to implement Epic
Staff Augmentation--consultant fees related to training UMMC staff in and implementing Epic
Epic Implementation Fees--fees to implement Epic at UMMC
Siemens Conversion Fees--Siemens's fees to move UMMC patient data from Siemens Signature
and Siemens Invision to Epic
Epic Training Renovations--costs incurred to renovate classroom space to train approximately
4,000 UMMC employees to use Epic
Third-Party Maintenance Related to Epic--Maintenance costs for third-party applications
related to Epic that are already in use by UMMC (e. g., the fetal monitoring system Obix and
the document management system 3M Chart Link).
46
PEER Report #587
DOM agreed to Shared Health's selection of Orion and its
subcontractor Mede/Analytics to replace Shared Health
Shared Health informed DOM it was no longer pursuing development of a certified EHR
in line with the new 2011 requirements and was exiting the EHR industry
DOM entered into a
contract with Shared
Health to design,
develop, and implement
an e-health records and
e-prescribing system
Appendix G: Mississippi Division of Medicaid Timeline of Implementing Electronic Health Records
Start
Medicaid required Orion to assign the
remaining portion of the contract to Mede/
Analytics to provide a Clinical Data Repository
and Enterprise Master Patient Index
Orion chose to no longer continue
providing services to Medicaid
DOM and Shared
Health implemented
an electronic health
record system prior
to the 2011 federal
requirements
Mede/Analytics fully implemented the Clinical Data
Repository and Enterprise Master Patient Index
45 Code of Federal Regulations Part
170 required the Office of the
National Coordinator for Health IT
to certify all electronic health
records systems
Congress passed the American
Recovery and Reinvestment Act,
including the HITECH Act and the
Electronic Health Records Incentive
Program
CMS encourages state Medicaid agencies
to move toward providing clinical data
repositories instead of supplying providers
with electronic health record technology
Revisions to Electronic Health Record Certification
Criteria increased certification criteria for EHRs,
including technical capabilities and related
standards and implementation specifications
2011
June
2010
2012
August
2014
March
2014
December
2013
Late
2013
August
2012
December
2012
2009
SOURCE: PEER Analysis of Mississippi Division of Medicaid documents and applicable federal and state law
PEER Report #587
47
The Mississippi Health
Infrastructure Task
Force created the
Mississippi Coastal
Health Information
Exchange as a pilot
project
The Legislature enacted the
Health Information
Technology Act (H.B. 941,
2010 Regular Session)
creating the Mississippi
Health Information Network
Buildout of MS-HIN's Provider Network, including
eligible hospitals, ancillary providers, etc.
Appendix H: Mississippi Health Information Network Timeline of Implementing Mississippi Health Information Exchange
Start
Partner with Medicaid to buildout
eligible hospital network and
provide clinical data to Medicaid in
exchange for $4 million plus from
Medicaid
UMMC joins
MS-HIN to
add and
share data
Pending feasibility,
commence buildout of
patient engagement
solution, including
providing patients a
searchable patient
portal
2009
March
2014
2007
2010
Fall
2014
Congress passed the
American Recovery and
Reinvestment Act,
including the HITECH Act
and the Electronic Health
Records Incentive
Program
MS-HIN had to spend
all ARRA funds received
toward implementing
healthcare information
technology by March
2014 or ARRA funding
would expire
2016 &
Beyond
MS-HIN's statewide health
information exchange went
live after transfer of
MSCHIE's healthcare
information exchange to
MS-HIN
2014
SOURCE: PEER Analysis of Mississippi Health Information Network documents and applicable federal and state law
48
PEER Report #587
PEER Report #587
52
PEER Committee Staff
Max Arinder, Executive Director
James Barber, Deputy Director
Ted Booth, General Counsel
Administration
Evaluation Performance Budgeting
Tracy Bobo Kim Cummins Brian Dickerson
Larry Landrum Matthew Dry David Pray
Rosana Slawson Lonnie Edgar Linda Triplett
Gale Taylor Barbara Hamilton
Matthew Holmes
Barton Norfleet
Angela Norwood
Corrections Audit
Jennifer Sebren
Lou Davis MeriClare Steelman
Jenell Ward
Reapportionment
Ava Welborn
Ben Collins Sarah Williamson
Julie Winkeljohn
Ray Wright
