NHIN Direct: Renamed The Direct Project–Where is Direct Today? Nov 29 Webinar

NHIN 203: “NHIN Direct: Where We Are Today” from National eHealth Collaborative
Monday, November 29, 2010, 1:00 – 2:30pm ET
Led by Arien Malec,
Coordinator, The Direct Project
NHIN has been renamed (for now) the Nationwide Health Information Network (NW-HIN), and its counterpart program for provider to provider transfer of clinical information outside of NW-HIN has been renamed the Direct Project for now.

Per National eHealth Collaborative’s NHIN University, “Students will learn about the history of The Direct Project and how it fits within the framework of the Nationwide Health Information Network. The class will focus on current activities of The Direct Project and gain insight from its Coordinator, Arien Malec, on the success of the community-based, open approach to development and the future of the Project.”


  • “Understand the purpose and goals of The Direct Project, including its history and organizational structure
  • Gain insight into the collaborative process that is central to the mission of Direct
  • Learn about current activities of Direct and how they fit within the Nationwide Health Information Network and, eventually, the Standards and Interoperability Framework
  • Find out about the future of The Direct Project and how to get involved in the growing Direct community”

WEBINAR: https://nationalehealthevents.webex.com/nationalehealthevents/onstage/g.php?d=668619540&t=

AUDIOCONFERENCE: (866) 699-3239 or (408) 792-6300
(Please join the event with a computer system first and follow the audio instructions on the screen.)

ACCESS/EVENT CODE: 668 619 540

ATTENDEE ID: You will receive this number when you join the event first with a computer connection.

NHIN University Link to NHIN 203

CMS Organizes FAQs on EHR Incentive Payments

Electronic Health Record Incentive Payment FAQs, all 106 so far, reorganized in eleven categories.
plus three sets of ONC FAQs related to Certification
Accessed from CMS and ONC sites on 11/10/2010.

ALL Electronic Health Records (EHR) FAQs

FAQS from ONC site related to Certificiation

  • ONC Regulations FAQs Related to Certification
                                  PDF Version of ONC Regulations FAQs
  • Standards and Certification Criteria Final Rule: Frequently Asked Questions
  • Temporary Certification Program: Frequently Asked Questions
  • NHIN Governance: Learn to Speak NHIN on Nov 4 & Have Your Say Too!

    1. National eHealth Collaborative (NeHC) Presents
    NHIN 202:  NHIN Governance Authorities
    2. FACA Blog Seeks Governance Feedback Nov 3

    NHIN 202:
    Thur, Nov 4, 2010, 3:00pm to 4:00pm

    Excerpted/summarized from National eHealth Collaborative on 11/1/2010.
    You will learn about the initial recommendations of the Health IT Policy Committee’s Governance Workgroup and the process of turning them into rules. ONC and Advisory Committee/Workgroup leaders will serve as faculty and will respond to your feedback.


    • Mary Jo Deering, PhD – Senior Policy Advisor, Office of Policy and Planning, Office of the National Coordinator for Health IT (ONC)
    • John Lumpkin – Chair, Health IT Policy Committee Governance Workgroup; Senior VP and Director, Robert Wood Johnson Foundation
    • Michael Matthews – Chair, NHIN Exchange Coordinating Committee; Member, Health IT Policy Committee Governance Workgroup; CEO, MedVirginia


    • Aaron Seib – Interim CEO and NHIN Program Director, National eHealth Collaborative

    PHASE 1 Recommendations of Workgroup from FACA Blog Post 
    Or see FACA Blog post reposted below.
    WEBINAR: Click here

    AUDIOCONFERENCE: (866) 699-3239 or (408) 792-6300
    (Please join the event with a computer system first and follow the audio instructions on the screen.)

    ACCESS/EVENT CODE: 665 557 547

    ATTENDEE ID: You will receive this number when you join the event first with a computer connection.

    National eHealth Collaborative Relationship with NHIN
    “The Nationwide Health Information Network (NHIN) is a collection of standards, specifications and policies that enable the secure exchange of health information over the internet. Today, a group of federal and private entities known as the NHIN Exchange have implemented those standards, specifications and policies as one operational model for exchanging health information nationwide. As part of this model, those entities established a committee structure to administer and support their operational approach.

    “Through its cooperative agreement with ONC, NeHC is supporting that committee structure, and supports ONC’s efforts to disseminate information about the work of these committees to interested parties and the broader stakeholder community.”

    Federal Advisory Committee Blog Post:
    Feedback Requested by Nov 3
    Governance Workgroup Seeks Comments
    on Roles and Responsibilities for Governance

    Monday, October 25th, 2010 | Posted by: John Lumpkin on FACA Blog and reposted here by e-Healthcare Marketing. 

    The Governance Workgroup (Workgroup) is developing recommendations on governance mechanisms for the nationwide health information network.  The Workgroup identified overarching objectives, key principles and core functions for governance in its Preliminary Report and Recommendations on the Scope of Governance [PDF – 94 KB] presented to the HIT Policy Committee on October 20th.  The Workgroup is now preparing final recommendations on how governance functions should be implemented and by whom.  As a first step, the Workgroup would like to identify existing mechanisms that might be appropriate, with or without modifications, and with or without some added coordination; and whether new mechanisms are needed, and if so, which?  The Workgroup would like public input on these issues and has created a table listing the core functions and questions to frame the input.  The table is available at here [DOC – 81 KB]. A short version of the table is presented below, for your comments.  If you prefer, you can download and complete the table and email it to onc.request@hhs.gov. Please put “Governance Workgroup Recommendations” in the Subject Line.

    We would appreciate receiving comments as soon as possible and no later than November 3.

    Recommended Governance Functions include:

    (For more details, see the Recommendations report [PDF – 94 KB] presented to the HIT Policy Committee)

    I. Establish policies for privacy, security, interoperability and to promote adoption of the NW-HIN.

    a. Privacy and Security

    b.  Interoperability, Eligibility Criteria and Compliance Expectations

    c.  Address gaps; coordinate stakeholder input

    d. Coordinate with technical and validation bodies

    II. Establish technical requirements to assure policy and technical interoperability.

    a. Adopt requirements

    b. Coordinate with policy setting body

    c. Change and transition process

    d. Recognize or authorize shared technical services

    III. Establishing appropriate mechanisms to assure compliance, accountability and enforcement.

    a. Determine eligibility

    b. Evaluate compliance

    c. Assure accountability

    d. Enforce

    IV. Oversight of the governance mechanisms.

    a. Track issues

    b. Monitor ongoing compliance

    c. Assess risks and benefits to prevent harm

    d. Evaluate effectiveness

    e. Resolve disputes

    While all comments are welcome, we would specifically like input on these questions for each of the four recommended governance functions listed above:

    1. What existing entity or process could be leveraged NW-HIN governance? How does it function?
    2. What is the jurisdiction for its functions and under what authority does it operate?
    3. What level of formality is used (e.g. self-regulated, state regulated)?
    4. Can it scale to satisfy NW-HIN needs (w/ or w/out changes)?
    5. Does it satisfy NW-HIN governance objectives (w/ or w/out) changes?  If yes, provide rationale.
    6. Are additional mechanisms or processes necessary? Why?

    Thank you,
    John Lumpkin, MD, MPD, Chair, Governance Workgroup
    To comment directly, go to the FACA Blog post.

    Miscommunication Among Caregivers Tackled by Joint Commission Center for Transforming Healthcare

    Top U.S. Hospitals Identify Causes, Develop Targeted Solutions to Save Lives
    October 21, 2010 Press Release from Joint Commission excerpted below.

    (OAKBROOK TERRACE, IL – October 21, 2010) An estimated 80 percent of serious medical errors involve miscommunication between caregivers when responsibility for patients is transferred or handed-off. Recognizing this as a critical patient safety issue, a group of 10 leading U.S. hospitals and health care systems teamed up with the Joint Commission Center for Transforming Healthcare to use new methods to find the causes of and put a stop to these dangerous and potentially deadly breakdowns in patient care.

    Picture above clicks through to Joint Commission page with actual video.
    See storyboard Slide Set for “Improving Transitions of Care Hand-off Communications”

    Health care organizations have long struggled with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another. A hand-off process involves “senders,” the caregivers transmitting patient information and releasing the care of the patient to the next clinician, and “receivers,” the caregivers who accept the patient information and care of the patient.

    The Hand-off Communications Project began in August 2009. During the measure phase of the project, the participating hospitals found that, on average, more than 37 percent of the time hand-offs were defective and didn’t allow the receiver to safely care for the patient. Additionally, 21 percent of the time senders were dissatisfied with the quality of the hand-off. Using solutions targeted to the specific causes of an inadequate hand-off, participating organizations that fully implemented the solutions achieved an average 52 percent reduction in defective hand-offs.

    The 10 hospitals and health systems that volunteered to address hand-off communications as a critical patient safety problem are:

    • Exempla Lutheran Medical Center, Wheat Ridge, Colorado
    • Fairview Health Services, Minneapolis, Minnesota
    • Intermountain Healthcare LDS Hospital, Salt Lake City, Utah
    • The Johns Hopkins Hospital, Baltimore, Maryland
    • Kaiser Permanente Sunnyside Medical Center, Clackamas, Oregon
    • Mayo Clinic Saint Marys Hospital, Rochester, Minnesota
    • New York-Presbyterian Hospital, New York
    • North Shore-LIJ Health System Steven and Alexandra Cohen Children’s Medical Center, New Hyde Park, New York
    • Partners HealthCare, Massachusetts General Hospital, Boston
    • Stanford Hospital & Clinics, Palo Alto, California

    Although The Joint Commission requires accredited organizations to use a standardized approach to hand-off communications, breakdowns in communication have been a leading contributing factor in sentinel events, which are unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. In addition to patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital.

    Recognizing that there is no quick fix, the Center and the participating hospitals set out to solve the problems through the application of Robust Process Improvement™ tools. RPI is a fact-based, systematic, and data-driven problem-solving methodology that allows project teams to discover specific risk points and contributing factors, and then develop and implement solutions targeted to those factors to increase overall patient safety and health care quality. Barriers to effective hand-offs experienced by receivers include incomplete information, lack of opportunity to discuss the hand-off, and no hand-off occurred. Senders identified too many delays, receiver not returning a call, or receiver being too busy to take a report as reasons for hand-off failures.

    “These 10 organizations are leading the way in finding specific solutions to the complex problem of hand-off communication failures,” says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. “A comprehensive approach that focuses on systems is the only way to ensure that the many caregivers upon whom patients rely are successfully communicating vital information during these transitions in care.”

    The targeted hand-off solutions from the Center, which are described using the acronym SHARE, address the specific causes of unsuccessful hand-offs. SHARE refers to: 

    • Standardize critical content, which includes providing details of the patient’s history to the receiver, emphasizing key information about the patient when speaking with the receiver, and synthesizing patient information from separate sources before passing it on to the receiver.
    • Hardwire within your system, which includes developing standardized forms, tools and methods, such as checklists, identifying new and existing technologies to assist in making the hand-off successful, and stating expectations about how to conduct a successful hand-off.
    • Allow opportunity to ask questions, which includes using critical thinking skills when discussing a patient’s case as well as sharing and receiving information as an interdisciplinary team (e.g., a pit crew). Receivers should expect to receive all key information about the patient from the sender, receivers should scrutinize and question the data, and the receivers and senders should exchange contact information in the event there are any additional questions.
    • Reinforce quality and measurement, which includes demonstrating leadership commitment to successful hand-offs such as holding staff accountable, monitoring compliance with use of standardized forms, and using data to determine a systematic approach for improvement.
    • Educate and coach, which includes organizations teaching staff what constitutes a successful hand-off, standardizing training on how to conduct a hand-off, providing real-time performance feedback to staff, and making successful hand-offs an organizational priority.

    In addition to hand-off communications, the Center is aiming to reduce surgical site infections (SSI) following colorectal surgery through a new project launched in August 2010 in collaboration with the American College of Surgeons. Participating organizations include the Mayo Clinic, OSF Saint Francis Medical Center, Cedars-Sinai Medical Center, North Shore-LIJ Health System, Cleveland Clinic, Stanford Hospital & Clinics and Northwestern Memorial Hospital. The solutions for this project are expected to be published in the fall of 2011.

    All Joint Commission-accredited health care organizations have access to the solutions through the Targeted Solutions Tool™ (TST), which provides a step-by-step process to measure performance, identify barriers to excellent performance, and implement the Center’s proven solutions that are customized to address an organization’s specific barriers. The first set of targeted solutions, created by eight of the country’s leading hospitals and health care systems working in collaboration with the Center, focuses on improving hand hygiene. Accredited organizations can access the TST and hand hygiene solutions on their secure Joint Commission Connect extranet. The targeted solutions for hand-off communications are currently being pilot tested to prove their effectiveness in demographically diverse hospitals and will be added to the TST in the second half of 2011.  A project to reduce the risk of wrong site surgery is also in process. Future projects are expected to focus on preventable hospitalizations, medication errors, and other aspects of infection control.

    Statements from the Center’s participating hospitals
    “The communication that is involved in patient transfers is a critical concern that can have a severe impact on care. Therefore, we are pleased to participate in The Joint Commission’s Hand-off Communications Project to find ways of improving this process. I am proud of our employees and their efforts.  It is rewarding to know that their work combined with similar activities at the other project participant sites will help improve patient-centered health care across the country.”
    Michael J. Dowling, president and CEO, North Shore-LIJ Health System

    “This work demonstrates a new and exciting way to deliver safer care. By collaborating with leading institutions around the country, we’re identifying proven strategies that improve communications during critical points of transfer for our patients.”
    Mark Eustis, president and CEO, Fairview Health Services
    “Patients’ safety is greatly enhanced when we have smooth and effective communication hand-offs as patients move across care settings. So, patients everywhere will benefit from what we and the other leading health care programs have learned in this collaborative effort with The Joint Commission. This initiative greatly increases the chances for good, safe continuity of care for everyone.”
    Susan Mullaney, administrator, Kaiser Permanente Sunnyside Medical Center

    “Partners HealthCare frequently collaborates with other institutions across the nation on patient quality and safety initiatives — but has never worked with such a comprehensive group at the same time. This collaboration has produced results beyond the capability of any single participant and validates The Joint Commission’s proposition that critical issues in health care can be addressed in a rigorous and thoughtful way. I know that our patients, and patients across the country, will reap benefits from this work.”
    Terrence O’Malley, M.D., medical director, Non-Acute Care Services, Partners HealthCare, Massachusetts General Hospital

    “We know that breakdowns in communication that can occur when patients are handed-off from one caregiver to another are a leading cause of patient harm and medical errors. Few areas within the spectrum of patient care give us such an enormous opportunity to improve patient outcomes and reduce mistakes as improving these communications. The Joint Commission’s initiative in this area is a welcome start.”
    Ronald R. Peterson, president, The Johns Hopkins Hospital and Health System, and executive vice president, Johns Hopkins Medicine

    “We believe that this has been an outstanding project and we are thrilled to have been a participant. Hand-off communication is critical to the patient care process. Being able to identify where there are breakdowns in the hand-off process and focus on where we can improve, as well as develop targeted solutions, will improve the quality of care our patients receive.” 
    Kevin Tabb, M.D., CMO, Stanford Hospital & Clinics

     ”Exempla Lutheran Medical Center is proud to participate in the Joint Commission Center for Transforming Healthcare’s critical initiative to improve the quality of hand-off communications. We know how important it is to communicate accurately and effectively when we transfer patients from one caregiver to another. But what is it that interferes with those communications? Working with the Center and the other participating hospitals, and with the use of Lean Six Sigma, we identified some of the critical barriers to effective communication to establish processes that can be replicated to consistently make patient transfers safer. We are committed to working with the Center and the other participating hospitals to help solve these complex patient safety issues and share best practices.”
    Grant Wicklund, president and CEO, Exempla Lutheran Medical Center

    The Center is grateful for the generous leadership and support of the American Hospital Association, BD, Ecolab, GE Healthcare, GlaxoSmithKline (GSK), Johnson & Johnson and Medline Industries, as well as the support of GOJO Industries, Inc. and The Federation of American Hospitals.

    ONC’s FACA Meeting Calendar for Sept 2010

    ONC logoSept 2010 FACA Meeting Calendar
    Emailed by ONC on Sept 10, 2010

    Please be sure the following Federal Advisory Committee (FACA) meetings are on your calendars!

    See the ONC Website, http://healthit.hhs.gov/FACAs, for information on how to participate via phone or web, or how to find the location of the public hearings (indicated with an asterisk *) which will be held at hotels in the Washington DC metro area.  

    HIT Policy Committee Meetings 
    Information Exchange Workgroup, Sept 13, 11 am to 2 pm/EDT

    HIT Policy Committee*, Sept 14, 10 am to 3 pm/EDT
    Crystal Gateway Marriott, Arlington, VA

    Meaningful Use WG*, Sept 22, 8:30 am to 4 pm/EDT
    Park Hyatt Washington, Washington, DC

    Enrollment WG, Sept 24, 11 am to 2 pm/EDT

    Privacy & Security Tiger Team, Sept 24, 3 pm to 5 pm/EDT

    Governance WG*, Sept 28, 9 am to 5 pm/EDT
    Washington Marriott Wardman Park Hotel, Washington, DC

    Quality Measures WG, Sept 29, 2 pm to 5 pm/EDT

    Information Exchange WG*, Sept 30, 9 am to 4 pm/EDT
    Location to be determined.

    HIT Standards Committee Meetings
    Implementation WG, Sept 15, 12 pm to 2 pm/EDT

    HIT Standards Committee*, Sept 21, 9 am to 3 pm/EDT
    Washington Marriott Wardman Park Hotel, Washington, DC  

    Vocabulary Task Force, Sept 23, 10 am to 11:30 am/EDT  

    Clinical Operations WG, Sept 23, 12 pm to 1:30 pm/EDT

    ONC Site Map Updated in Conjunction with New Health IT Unified Theme

    “Connecting America for Better Health” – ONC for HIT
    Web Site Map for Office of the National Coordinator for Health IT
    On August 27, 2010, the Office of National Coordinator (ONC) for Health IT announced a new “unified identity for Health IT”  which includes a “new theme and visual identity” for the ONC Web site and ONC and can be seen at the top of ONC Web pages.

    The site map below for  ONC’s Web site is pulled primarily from the left navigation bar on the ONC site with some additional links to key areas. [Please send any corrections or comments to e-Healthcare Marketing. This is an update to a previous site map posted on February 16, 2010 on e-Healthcare Marketing, including new workgroups.]

    While the visible structure of the Web site remains mainly the same, the home page and much of the underlying architecture appears to have been updated to simplify access to users, highlight new and important content, and simplify the addition of new information anticipated to come soon, such as announcements of the  Authorized Testing and Certification Bodies (ATCB) and Certified EHRs and EHR Modules.

    The new theme and identity ”really captures the spirit of these combined efforts to boost national adoption of electronic health records and ensure success. The insignia will also help people easily identify and connect with official HITECH information, resources, programs, and partners,” wrote Communucations Director Peter Garrett on the Health IT Buzz blog on August 27, 2010. Now to the site map.

    DERIVED SITE MAP FOR  http://healthit.hhs.gov

              Meaningful Use
              Certification Program
              Privacy and Security
              HITECH Programs
              On the Frontlines of Health Information Technology
                   NEJM Articles: Dr. Blumenthal
                                                 Dr. Benjamin
              Federal Advisory Committees

    Top Banner Links
              Get email updates from ONC
              Follow ONC on Twitter

    HITECH & FUNDING Opportunities
              Contract Opportunities
              Learn about HITECH
              HIT Extension Program — Regional Extension Centers Program
              Beacon Community Program

         State Health Information Exchange Cooperative Agreement Program
         Health Information Technology Extension Program
         Strategic Health IT Advanced Research Projects (SHARP) Program
         Community College Consortia to Educate HIT Professionals Program
         Curriculum Development Centers Program
         Program of Assistance for University-Based Training
         Competency Examination Program
         Beacon Community Program

                      (Meeting Calendar At-A-Glance)

    HIT Policy Committee Meetings
              Meeting Webcast & Participation
    Upcoming Meetings
    Past Meetings
    HIT Policy Committee Recommendations
    HIT Policy Committee Workgroups
              Meaningful Use
              Information Exchange
              Nationwide Health Information Network (NHIN)
              Strategic Planning
              Privacy & Security Policy
              Privacy & Security Tiger Team
              Quality Measures

    Health IT Standards Committee Meetings
              Meeting Webcast & Participation
    Upcoming Meetings
    Past Meetings
    HIT Standards Committee Recommendations
    HIT Standards Committee Workgroups
              Clinical Operations
              Clinical Quality
              Privacy & Security
              Vocabulary Task Force

               Meaningful Use
               Privacy and Security
               Standards and Certification
              State-Level Health Initiatives 
              Nationwide Health Information Network
              Federal Health Architecture
              Clinical Decision Support & the CDS Collaboratory
                     FACA Meeting Calendar
              Fact Sheets
              Federal Health IT Programs
              Technical Expert Workshops

             News Releases (2007 – Present)
             FACA Meeting Calendar
             Fact Sheets
             Federal Health IT Programs
             Technical Expert Workshops

              Coordinator’s Corner: Updates from Dr. Blumenthal
              Budget & Performance
              Contact ONC and Job Openings
    #                             #                     #

    For a review of the new look and feel of the ONC site, see an earlier post on e-Healthcare Marketing.

    State Medicaid Directors Letters on Health IT from CMS

    State Medicaid Directors Letters from CMS on Health IT Programs
    2010 and 2009 Letters
    This post includes both the latest letter from 2010 in PDF and html formats, that was issued this week; and a link to letter from about one year ago in 2009 in PDF format only .
    August 17, 2010 Letter: 
              Federal Funding for Medicaid HIT Activities 
              ARRA of 2009 Section 4201
              PDF Version  (Excerpted below in html)

    September 1, 2009 Letter: 
              Federal Funding for Medicaid HIT Activities 
              ARRA of 2009 Section 4201
              PDF Version

    August 17, 2010 CMS Letter to State Directors on Health IT:
    Centers for Medicare & Medicaid Services
    Baltimore, Maryland
    Center for Medicaid, CHIP and Survey & Certification  
    SMD# 10-016

    August 17, 2010
    Re: Federal Funding for Medicaid HIT Activities

    Dear State Medicaid Director:

    This letter provides guidance to State Medicaid agencies regarding implementation of section 4201 of the American Recovery and Reinvestment Act of 2009 (the Recovery Act), Pub. L. 111-5, and our recently published regulations at 42 CFR Part 495, Subpart D. Section 4201, as well as our final regulations, will allow the payment of incentives to eligible professionals (EPs) and eligible hospitals to promote the adoption and meaningful use of certified electronic health record (EHR) technology.

    The Recovery Act provides 100 percent Federal financial participation (FFP) to States for incentive payments to eligible Medicaid providers to adopt, implement, upgrade, and meaningfully use certified EHR technology, and 90 percent FFP for State administrative expenses related to the program.

    The Centers for Medicare & Medicaid Services (CMS) issued a State Medicaid Director (SMD) letter on September 1, 2009, that provided guidance to States on allowable expenses for activities supporting the administration of incentive payments to providers. CMS has now promulgated final regulations that also govern State administrative expenses related to administering the program. Both the SMD letter and our regulations at 42 CFR section 495.318 explain that, in order to qualify for the 90 percent FFP administrative match, a State must, at a minimum, demonstrate to the satisfaction of the Secretary compliance with three requirements:

    •           Administration of Medicaid incentive payments to Medicaid EPs and eligible hospitals;

    •           Oversight of the Medicaid EHR Incentive Program, including routine tracking of meaningful use attestations and reporting mechanisms; and

    •           Pursuit of initiatives that encourage the adoption of certified EHR technology for the promotion of health care quality and the electronic exchange of health information.

    Page 2 – State Medicaid Director

    This letter and the accompanying enclosures provide more detailed guidance from CMS on the expectations relating to the activities and potential uses of the 90/10 matching funds.

    I.          Administration of the Medicaid EHR Incentive Program

    Title IV, Division B of the Recovery Act established the Medicare and Medicaid EHR incentives programs, as one component of the Health Information Technology for Economic and Clinical Health (HITECH) Act. This initiative supports the goals of health reform by helping to improve

    Americans’ health, and increase safety and efficiency in health care through expanded use of EHRs. Accordingly, States’ administration of the Medicaid EHR Incentive Program, and their role in fostering adoption and meaningful use of certified EHR technology, are essential components of broader reforms. States can receive the enhanced FFP for approved design, development, and implementation of systems and processes that are necessary to effectively administer the Medicaid EHR Incentive Program. When developing their implementation timelines, States should consider the critical role the Medicaid EHR Incentive Program plays in the success of related HITECH programs. In order for States to benefit most from available Federal resources, including time-limited funding and technical assistance, timely initiation of their Medicaid EHR Incentive Programs (i.e., as soon as possible in 2011) is important.

    Enclosure A outlines CMS’ expectations and provides examples of potentially allowable activities and reasonable costs related to State administration of the program.

    II.        Oversight of the Medicaid EHR Incentive Program

    Under section 1903(t)(9)(B) of the Social Security Act and our recently published regulations at 42 CFR Part 495, Subpart D, States are required to conduct adequate oversight of the Medicaid EHR Incentive Program. Although the provider incentive payments are paid by the States, they are 100 percent reimbursable under Medicaid. States must ensure that the program meets all statutory and regulatory requirements and is implemented in a manner that minimizes the potential for fraud, waste and abuse. The 90 percent matching rate for FFP is available to States for approved processes, systems, and activities necessary to ensure that the incentive payments are being properly made to the appropriate providers, in the appropriate circumstances, and in an auditable and defensible manner. We emphasize that an effective and efficient oversight strategy is one that is timely, targeted, and balances risk with available auditing resources.

    Enclosure B provides additional information about CMS’ initial expectations for States’ auditing and oversight of their Medicaid EHR Incentive Program.

    III.       Pursuing Initiatives to Encourage the Adoption of Certified EHR Technology and Health Information Exchange

    CMS expects that State Medicaid agencies will have a role in the promotion of EHR adoption and health information exchange. HITECH provided several funding sources, including various grant programs through the Office of the National Coordinator for HIT (ONC) for States to achieve improved health care outcomes through health information technology (HIT). Medicaid plays an important role as both a payer and a collaborator with these other HIT initiatives to produce the desired impact on the health care system. Where possible, CMS encourages State Medicaid agencies to collaborate on HIT initiatives with Federal programs and other partners in

    Page 3 – State Medicaid Director

    the States, such as public health departments, county governments, and local governments. Costs will be distributed equitably across all payers following fair share and cost allocation principles, per section 495.358.

    Enclosure C outlines the CMS guiding principles for the availability of the 90 percent FFP administrative matching funds for basic administration and oversight of the Medicaid EHR Incentive Program, as well as efforts to promote its success among eligible Medicaid providers.

    IV.       State Medicaid Health Information Technology Plan (SMHP) and HIT Implementation Advance Planning Document (HIT IAPD)

    The SMHP (the product of the initial HITECH planning funds awarded to States) should outline the State’s current (“As-Is”) and future (“To-Be”) HIT landscape and plan for the administration and oversight of its Medicaid EHR Incentive Program in compliance with our regulations. As States establish the broad vision for their Medicaid EHR Incentive Programs in the SMHP, however, not all activities will necessarily be eligible for FFP under HITECH. States must use the HIT Implementation Advance Planning Document (IAPD) to request FFP and receive approval before implementing proposed State Medicaid HIT plan activities and services or acquire equipment. There may be activities that are more appropriately reimbursed as Medicaid Management Information Systems (MMIS) or general program administration expenditures, or may not be eligible for any CMS funding at all.

    Enclosure D outlines the CMS process for reviewing the SMHP and associated funding request documents (HITECH and MMIS).

    CMS expects that States will take an incremental approach to the initial implementation of their Medicaid EHR Incentive Programs. For example States may begin by focusing on provider outreach and registration, then on provider attestation and verification of eligibility, next on provider payments, and finally on capturing meaningful use data. Toward that end, we have identified elements of an SMHP that are considered critical for the initial submission and those that may be deferred for future updates. States must outline their timeline, noting critical benchmarks and dependencies. An updated template for the SMHP for States to use as a guide is available on the CMS Web site for download at: http://www.cms.gov/EHRIncentivePrograms/91_Information_for_States.asp#TopOfPage .

    CMS will seek ONC input as we review SMHPs to ensure a coordinated approach for the State EHR Incentive Program and health information exchange (HIE) efforts. While the SMHP focuses on the Medicaid strategy for moving toward meaningful use of certified EHR technology, it should be consistent with and complementary to the overall State HIT strategy developed under section 3013 of the Public Health Service Act (PHS). CMS and ONC will work together in the review of both strategies to prevent duplicative efforts of statewide HIT/HIE activities, provider outreach activities, and Medicaid HIT activities.

    We encourage States to use the resources, tools, Frequently Asked Questions, and information available at the Federal level, particularly through the CMS EHR Incentive Program Web site: http://www.cms.gov/EHRIncentivePrograms/  and the ONC Web site: http://www.healthit.gov. We look forward to collaborating with State Medicaid agencies and learning from your experiences as we provide technical assistance, policy guidance, and Federal resources to ensure successful development and implementation of Medicaid EHR Incentive Programs. CMS believes that health information technology can be a transformative tool, improving the quality,

    Page 4 – State Medicaid Director

    efficacy, timeliness, and safety of patient care. With the States, as our partners, we can leverage the momentum provided by the Recovery Act’s EHR incentive programs to ensure that the innovations enabled by technology can support the framework of health care reform.

    For further information or clarification on this State Medicaid Director letter, please contact Mr. Rick Friedman at CMS…

    A) Administering the Medicaid EHR Incentive Program
    B) Oversight of the Medicaid EHR Incentive Program
    C) Guiding Principles for the Use of the 90 Percent FFP for EHR Promotion
    D) SMHP/IAPD Review Process

    CMS Regional Administrators

    CMS Associate Regional Administrators
    Division of Medicaid and Children’s Health Operations

    Ann C. Kohler
    NASMD Executive Director
    American Public Human Services Association

    Joy Wilson
    Director, Health Committee
    National Conference of State Legislatures

    Matt Salo
    Director of Health Legislation
    National Governors Association

    Debra Miller
    Director for Health Policy
    Council of State Governments

    Christine Evans, M.P.H.
    Director, Government Relations
    Association of State and Territorial Health Officials

    Cindy Mann Director

    Page 5 – State Medicaid Director

    Alan R. Weil, J.D., M.P.P.
    Executive Director
    National Academy for State Health Policy

    David Blumenthal, M.D.
    National Coordinator
    Office of the National Coordinator for HIT

    Page 6 – State Medicaid Director

    Enclosure A
    Administering the Medicaid EHR Incentive Program

    Under the Recovery Act, States have the option to participate in the Medicaid EHR incentive program. States may receive 90 percent FFP for reasonable administrative expenditures incurred in planning and implementing the program.

    States will undertake a number of activities relative to the administration of the Medicaid EHR Incentive program. As indicated in the CMS Electronic Health Record Incentive Program Final Rule at § 495.332, States will be expected to describe in detail in the State Medicaid HIT Plan (SMHP) a number of activities that CMS considers vital to the effective administration of the EHR Incentive Program. In order for States to claim the 90 percent FFP match, they must submit both a State Medicaid HIT Plan and an HIT Implementation Advance Planning Document (HIT IAPD). We recognize that not all States will administer the program using the same systems and processes; therefore we will assess each State’s SMHP to determine which activities would most appropriately be funded with the HITECH enhanced match and which might be better applicable to MMIS or regular program administration funding, or which may not be eligible for any CMS funding at all. In order to be eligible for the HITECH 90 percent FFP, activities must be directly related to the success of the Medicaid EHR Incentive Program, as described further in Enclosure C. In addition, please see Enclosure D for additional details about submitting SMHPs with HIT IAPD’s for both HITECH and MMIS funding.

    States may potentially receive 90 percent FFP for the following program administration activities (not an exhaustive list), subject to CMS prior approval. (Note, as required by § 495.358, all costs are subject to cost allocation rules in 45 CFR Part 95.):

    • System and resource costs associated with the National Level Repository (NLR)
    • Interface System and resource costs associated with State interfaces of a Health Information Exchange (HIE)–(e.g., laboratories, immunization registries, public health databases, other HIEs, etc.)
    • Creation or enhancement of a Data Warehouse/Repository (should be cost allocated)
    • Development of a Master Patient Index (should be cost allocated)
    • Communications/Materials Development about the EHR Incentive Program and/or EHR Adoption/meaningful use
    • Provider Outreach Activities (workshops, webinars, meetings, presentations, etc).
    • Provider Help-Line/Dedicated E-mail Address/Call Center (hardware, software, staffing)
    • Web site for Provider Enrollment/FAQs
    • Hosting Conferences/Convening Stakeholder Meetings
    • Business Process Modeling
    • System and resource costs associated with the collection and verification of meaningful use data from providers’ EHRs
    • System and resource costs to develop, capture, and audit provider attestations
    • Evaluation of the EHR Incentive Program (Independent Verification (IV) & Validations (V) and program’s impact on costs/quality outcomes)
    • Data Analysis, Oversight/Auditing and Reporting on EHR Adoption and Meaningful Use
    • Environmental Scans/Gap Analyses SMHP updates/reporting; IAPD updates
    • Developing Data Sharing & Business Associate Agreements (legal support, staff)

    Page 7 – State Medicaid Director

    • Ongoing costs for Quality Assurance activities
    • Multi-State Collaborative for Health IT annual dues
    • Staff/contractual costs related to the development of State-Specific meaningful use and patient volume criteria
    • Medicaid Staff Training/Prof. Development (consultants, registration fees, etc.)

    CMS strongly encourages States to collaborate with other State-level and local partners in the design, development, and even procurement of systems needed to administer their EHR Incentive Programs. Doing so would make more effective use of both CMS’ and States’ share of the cost and would shorten the timeline for actually dispersing incentive payments to eligible providers. CMS is available to provide technical assistance to States interested in exploring collaborative approaches, and will disseminate information on approved and successful models.

    CMS also strongly encourages States to consider the activities they plan to undertake to administer their EHR Incentive Program and to identify any that may overlap with other Federally-funded activities, such as provider outreach, development of a Master Patient Index, external inquiry management, etc. Where possible, these activities should be accomplished collaboratively, in which case costs are allocated across partners.

    Budgeting for the 90 Percent FFP

    States will be responsible for estimating the expenditures for the Medicaid EHR Incentive Program on the State’s quarterly budget estimate reports via Form CMS-37. These reports are used as the basis for Medicaid quarterly grant awards that would be advanced to the State for the Medicaid EHR incentive program. These forms are submitted electronically to CMS via the Medicaid and State CHIP Budget and Expenditure System (MBES/CBES). On Form CMS-37, States should include any projections of administration related expenditures for the implementation costs. On Form CMS-64, a State submits on a quarterly basis actual expenses incurred, which is used to reconcile the Medicaid funding advanced to States for the quarter made on the basis of the Form CMS-37. (Refer to Enclosure D and its section on State Reporting of Estimates, Expenditures, and Timing of the Grant Award Letter.)

    To assist States in properly reporting expenditures using the MBES/CBES, the CMS-37 and CMS-64 reports will include a new category for reporting the 90 percent FFP match for State administrative expenses associated with the Medicaid EHR Incentive Program. The new category will be called “Health Information Technology Administration.” This reporting category is located on the 64.10 base page lines 24A and 24B for Administration. Implementation expenditures are included on lines 24C and 24D.

    CMS will monitor State agency compliance through systems performance reviews, focused reviews, and audits of the processes documented in the SMHP, and other planning documents. CMS may review States’ EHR Incentive Programs using a variety of audit/review tools, including, but not limited to, financial audits, State Program Integrity Reviews, and payment data analysis. CMS is allowed to suspend payments if the State fails to provide access to information, per our final regulations, § 495.330.

    Page 8 – State Medicaid Director

    In order to track progress made towards the nationwide implementation of the Medicaid EHR Incentive Programs, CMS requests that States indicate to us through their State Medicaid HIT Plans, the target date by which they plan to launch their program. For consistency’s sake, we will consider a State’s Medicaid EHR Incentive Program ready to launch when a State has met all of the following criteria:

    The State has an approved SMHP and an approved IAPD. The State has initiated outreach and communications about the Medicaid EHR Incentive Program, including posting information on its Web site. The State has an effective and tested interface to accept provider registration information from the CMS NLR (i.e., has successfully tested with the NLR). The State is now capable, or will be capable within 3 months, of accepting provider attestations. The State is now capable, or will be capable within 5 months, of making provider incentive payments. The State has sufficient controls in place to ensure that the right incentive payments are made to the right providers before initiating provider incentive payments.

    Prior to the release of the 100 percent FFP provider incentive funding, CMS will require that States provide a brief written update regarding the launch criteria above.

    Page 9 – State Medicaid Director

    Enclosure B
    Oversight of the Medicaid EHR Incentive Program

    Under Section 1903(t)(9)(B) of the Social Security Act, States are required to conduct adequate oversight of the Medicaid incentive program. Our regulations, including §§ 495.318(b), 495.332, 495.366, and 495.368, also require States to conduct oversight to monitor, among other things, provider eligibility, payments, fraud, waste, and abuse.

    In addition, CMS is developing a joint Medicare/Medicaid audit strategy. In the interim, this enclosure provides initial CMS expectations regarding State responsibilities for oversight and audit in the early stage of EHR incentive program implementation. CMS will expand and build upon these requirements after the joint strategy is finalized and States begin implementing their programs.

    CMS expects States to implement a risk-based auditing approach to prevent making improper Medicaid EHR Incentive payments and to monitor the program for potential fraud, waste, and abuse. For 2011, CMS expects that, at a minimum, States will focus their auditing resources on the following specific items:

    Provider eligibility: for example, an identified means to verify that providers are credentialed, not-sanctioned, not hospital-based, practicing predominately, and are one of the types of eligible professionals or institutions under the EHR incentive program. Patient volume: for example, an identified means to audit or verify the attestation data, including use of proxy data (such as claims) where appropriate to identify risk. Adopt, implement, or upgrade (AIU): for example, have an identified means to audit or verify that providers have actually adopted, implemented, or upgraded certified EHR technology. (Note: CMS does not anticipate that States will audit meaningful use in 2011 as all eligible Medicaid providers can receive an EHR incentive payment for AIU in their first participation year.) Certified EHR technology: for example, States should collect the certified EHR technology code (see below) as part of provider attestation for AIU, and should verify that the code is on the Office of the National Coordinator (ONC) list of certified EHR technology prior to issuing an incentive payment to that provider.

    Prior to January 2011, ONC will make available through a public Web service (URL is still to- be-determined), a list of all certified EHR technology, including the name of the vendor and product, the product’s unique certification code, and the meaningful use criteria for which the product was certified. After January 2011, the ONC Web service is expected to have additional functionality related to combinations of certified EHR modules. For combinations of separate certified EHR technology that collectively could achieve meaningful use (e.g., modules), the ONC Web service would allow providers to enter the codes from the different certified modules and request a unique certification code that represents that specific combination. The Web service would then store and reflect for other providers that particular combination of certified EHR technology and the unique code associated with it. States should utilize the ONC Web service to automate the pre-payment verification of providers’ attestations regarding use of certified EHR technology. States should plan to test this process prior to accepting provider attestations. CMS will provide further details as soon as they become available.

    Page 10 – State Medicaid Director

    Using either their attestation system or other means, States must notify providers that it is the provider’s responsibility to ensure that its certified EHR technology code is listed on the ONC Web service before attesting to the State. Otherwise, the State’s verification system might produce a false negative result (e.g., the EHR technology was certified but there was a delay before it was added to the ONC Web service).

    States may receive enhanced matching funds for the following audit/oversight activities, subject to CMS prior approval:

    Auditing contractor(s)/Auditing In-House Activities Systems costs for interfaces to verify provider identity/eligibility (e.g., provider enrollment, license verification, sanctions, patient volume) System and Resource Costs associated with Provider Appeals for EHR Incentive Payments Staff and resources for data analysis and reporting requirements for the CMS EHR Incentive Program Privacy/Security Controls

    We strongly recommend that States consider the data sources and partners (such as Regional Extension Centers and HIEs, etc.) that are available to support their auditing and oversight responsibilities- including using them as tools for conducting risk assessments for fraud, waste and abuse. For example, where appropriate, States should utilize reliable third-party data sources rather than conduct resource-intense individual on-site reviews. As noted above, we will be issuing further guidance related to oversight and auditing of meaningful use in the Medicare and Medicaid EHR Incentive Programs. At that time, CMS will share with States its auditing plans for the Medicare EHR Incentive Program. We will look for opportunities where appropriate to leverage Federal efforts on behalf of the States, including, but not limited to our auditing strategy for hospitals that are eligible for both Medicare and Medicaid EHR incentive payments. Further details regarding potential State and CMS collaboration on the auditing of meaningful use for hospitals that are eligible for both incentive payments is forthcoming. States should recognize that it is their sole responsibility to audit hospitals that are Medicaid-only (e.g., children’s and cancer hospitals).

    The primary means for CMS and States to avoid duplicate payments to eligible professionals is through joint use of the National Level Repository (NLR). States must interface with the NLR not just to receive provider registration data and to ensure that there are no duplicative payments prior to issuing provider incentives, but also to notify the NLR when they have made an incentive payment. CMS expects that States will notify the NLR that an incentive payment has been made within 5 business days. Similarly, if a State has determined that the provider is ineligible for a payment, CMS expects that the State will notify the NLR within 5 business days. Finally, in accordance with our regulations, § 495.332, the State must make a payment within 45 days of completing all eligibility verification checks. In the case of providers registering at the end of a calendar year, a payment for that year must be made no later than 60 days into the next calendar year for EPs, or fiscal year, for hospitals. The full requirements document and interface control document developed for States’ interface with the NLR was made available to States through the CMS regional offices, with the July 13, 2010, release of the CMS final rule.

    Page 11 – State Medicaid Director

    CMS will monitor State agency compliance with audit and oversight requirements through systems performance reviews, focused reviews, and audits of the processes documented in the SMHP, and other planning documents. CMS may review States’ EHR Incentive Programs using a variety of audit/review tools, including, but not limited to, financial audits, State Program Integrity Reviews, and payment data analysis. CMS is allowed to suspend payments if the State fails to provide access to information, per our final regulations, § 495.330.

    In accordance with the CMS final rule, Medicaid agencies must implement a provider appeals process.     See § 495.370 of our final regulations for details regarding provider appeals, as well as the SMHP template, which is located on the CMS Web site at: http://www.cms.gov/EHRIncentivePrograms/91_Information_for_States.asp#TopOfPage. Enclosure E also discusses information regarding provider appeals in the context of the SMHP contents.

    Page 12 – State Medicaid Director

    Enclosure C
    Guiding Principles for Use of the CMS 90 Percent Administrative Matching Funds for the Medicaid EHR Incentive Program

    State Medicaid agencies can receive enhanced matching funds at a 90-percent rate for their administration and oversight of the Medicaid EHR incentive program. CMS also expects that States will request the enhanced matching funds for reasonable administrative expenses related to their efforts to promote the adoption of certified EHR technology and health information exchange (HIE).

    We recognize that not all States will implement their programs in the same manner, and each State may face unique barriers to adoption and meaningful use. The principles below provide an overarching framework by which CMS will consider State requests for 90 percent FFP. Each proposal will be examined by CMS (with input from ONC) to ensure funds provide direct support to the success of the Medicaid EHR incentive program, are coordinated with other State HIT-related activities, do not duplicate other funding sources, and are implemented in the most efficient and effective manner. In addition, we strongly encourage States to collaborate with other States and local partners in the design, development, and procurement of any new systems.

    CMS will consider approval for 90 percent FFP for EHR/HIE promotion initiatives that will meet all of the following criteria:

    • Serve as a direct accelerant to the success of the State’s Medicaid EHR Incentive Program and facilitate the adoption and meaningful use of certified EHR technology. Expenses that do not directly correlate to the EHR Incentive Program will not be approved. Examples that may correlate include:
                        – Expenditures related to provider needs assessments, provider outreach about adoption and meaningful use of certified EHR technology, staff training, identification and development of tools to connect to health information exchanges, record locater services, secure messaging gateways, provider directories, development of privacy and governance policies and procedures, master patient indexes, interfaces for data (e.g., laboratory) that is important to Medicaid providers to be fully successful in an HIE environment, and procuring technical assistance for Medicaid providers to achieve meaningful use.
    • Are consistent with the ONC long-term vision for health information exchange, and are supportive of the activities prioritized by ONC cooperative agreement funding, namely secure messaging, the electronic reporting of structured laboratory data and enabling e- prescribing.
    • Are not duplicating meaningful use technical assistance efforts conducted by the ONC- funded Regional Extension Centers, Workforce Grantees, Beacon Grantees or other Federally-funded projects whose target population is the same, as well as ONC cooperative agreement grant funding for the development of HIE.

    Page 13 – State Medicaid Director

    • Will, to the extent possible, be normalized and integrated into the Medicaid business enterprise. Examples include:          
                      -Expenditures related to technical bridges between Medicaid and health information exchanges or all-payer clinical/claims data warehouses or technologies to authenticate providers and beneficiaries (e.g., master provider or patient indices).
    • Cannot otherwise be funded by the MMIS matching funds. MMIS will be examined as a more appropriate funding source before HITECH because HITECH funds should be targeted toward scenarios that contribute to the transformation of the MMIS into a clinical- and claims-based engine that supports Medicaid’s broader health care reform goals. Examples of expenditures that relate to the Medicaid EHR Incentive Program but that might more appropriately be funded through the enhanced MMIS match include:
                     -  Expenditures related to the design, development, and testing of a standard continuity of care record (CCR) or continuity of care document (CCD) based upon Medicaid claims; or building a portal between the MMIS and a clinical data repository or an immunization registry.
    • Are designed to be well-defined, developmental, and time-limited projects, with specific goals that would enable eligible Medicaid providers who qualify for the Medicaid EHR Incentive Program to achieve meaningful use of certified EHR technology.
                     – Providers’ transactional and on-going expenses derived from participation in health information exchange would not be eligible for the 90 percent HITECH Medicaid administrative match. Instead, CMS believes such costs are more appropriately addressed through State reimbursement to providers. CMS will entertain State plan amendments that speak to payment policies designed to incentivize providers to report data, such as the medical home per-member/per- month model.
    • Are not intended to be permanent initiatives but will lead within a reasonably short timeframe to sustainable outcomes.
                      - Sustainability refers to the responsibility for on-going costs for operations and maintenance of systems initially developed or enhanced using HITECH funding. After a defined milestone, funding sources other than HITECH must be used.
                     – Personnel costs for those who work directly on the Medicaid EHR Incentive Program are permissible expenditures for the enhanced match over the short term; however, States must plan to absorb or bear those costs in the future.
    • Are developed in accordance with Medicaid Information Technology Architecture (MITA) principles, as required by §495.332.
    • Are distributed equitably across all payers following the fair share principle. CMS recognizes that Medicaid is often one of the largest insurers in a State and, as such, stands to benefit from efficiencies associated with health information exchange and meaningful use of EHRs. However, Medicaid’s contribution to health information technology should be weighted and allocated based on contributions by other payers, and not be the sole or primary source of start-up or operational funding.

    Page 14 – State Medicaid Director

    • Are cost-allocated per Office of Management and Budget (OMB) Circular A-87. CMS will work with States on an individual basis to determine the most appropriate cost allocation methodology.
                     -  HITECH cost allocation formulas should be based on the direct benefit to the Medicaid EHR incentive program, taking into account State projections of eligible Medicaid provider participation in the incentive program.
                     -  Cost allocation must account for other available Federal funding sources, the division of resources and activities across relevant payers, and the relative benefit to the State Medicaid program, among other factors.
                     -  Cost allocations should involve the timely and ensured financial participation of all parties so that Medicaid funds are neither the sole contributor at the onset nor the primary source of funding. Other payers who stand to benefit must contribute their share from the beginning. The absence of other payers is not sufficient cause for Medicaid to be the primary payer.

    Page 15 – State Medicaid Director

    Enclosure D
    State Medicaid HIT Plan and Implementation Advance Planning Process

    This Enclosure provides guidance on the following topics regarding the State’s Medicaid HIT Plan (SMHP) and the State’s HIT Implementation Advance Planning Document (HIT IAPD):

    • HIT IAPD Preparation and On-Going Planning Activities
    • Budget Preparation Tips
    • State Submission and CMS Review and Approval Process for the SMHP and the HIT IAPD
    • State Reporting of Estimates, Expenditures, and Timing of the Grant Award Letter
    • Retroactive Requests for Planning Activities Funded at 90/10 Federal Financial Participation (FFP)

    HIT IAPD Preparation and On-Going Planning Activities

    Since the publication of the State Medicaid Director’s Letter on September 1, 2009, nearly every State and Territorial Medicaid agency has been approved to conduct HIT planning activities through the HIT Planning Advance Planning Document process (HIT PAPD), with the remaining agencies expected to submit funding requests in the coming months. A required deliverable of the HIT PAPD is the completion of a State Medicaid HIT Plan (SMHP), which must include the elements contained at §495.332 of the Medicare and Medicaid Programs’ EHR Incentive Program Final Rule. Once approved, the SMHP and the results of the planning activities must be included in the States’ HIT Implementation Advance Planning Document (HIT IAPD). The HIT IAPD is a plan of action that requests FFP and approval to acquire and implement the proposed State Medicaid HIT Plan activities, services or equipment. The end result of implementation will be the ability for the State Medicaid agency to successfully operate its EHR Incentive Program. States will then be able to make provider incentive payments with 100 percent FFP for State expenditures.

    To the extent possible, the HIT IAPD must include the list of the HIT IAPD required elements that are contained in the Final Rule at: §495.338. In addition, the State should consider incorporating the optional SMHP elements included in the revised SMHP template located on the CMS Web site at: http://www.cms.gov/EHRIncentivePrograms/91_Information_for_States.asp#TopOfPage . It is possible that some planning activities may be on-going. In these instances, the State should continue to describe on-going planning activities using the As-Needed HIT Advance Planning Document Update (HIT APDU) process to request funding approval for project continuation, scope, and schedule changes, for incremental funding authority and project continuation when approval is being granted by phases.

    Page 16 – State Medicaid Director

    Budget Preparation Tips

    We believe the provisions of the HITECH Act provide the necessary assistance and technical support to providers, enable coordination and alignment within and among States, establish connectivity to the public health community in case of emergencies, and ensure that the workforce is properly trained and equipped to be meaningful users of certified EHR technology. It is therefore important that the HIT IAPD include information about any grants, State or local funds, or other funding sources that are available to the State and that will contribute to the costs of activities for which the State is requesting HITECH matching funds. This information is not meant to duplicate what is in the SMHP but rather to provide CMS with adequate information to determine if the proposed cost allocation and/or division of labor and responsibilities among the various State partners are appropriate to existing rules and regulations and CMS expectations. For example, if a State wishes to build System X, it should indicate all other sources of funding that will contribute to System X, including other Federal HIT grant funding.


    Grant/Funding Source:    

    Share of the Cost Allocation    

    Timing of the Funding Contribution (e.g., current, FY11, TBD)    

    Lead Agency    

    Contact Information    

    State HIE Cooperative Agreement Program    


    State Office of E-Health    

    NamePhone numberE-mail  

    ONC Regional Extension Center Cooperative Agreement Program    


    State University of XYZ    

    NamePhone numberE-mail  

    Follow this link for a full description of each grant, listed in the bullets below:




    State Health Information Exchange Cooperative Agreement Program Health Information Technology Extension Program Strategic Health IT Advanced Research Projects (SHARP) Program Beacon Community Program

    Community College Consortia to Educate Health Information Technology Professionals Program Curriculum Development Centers Program Program of Assistance for University-Based Training

    Competency Examination for Individuals Completing Non-Degree Training Program

    The HIT IAPD proposed budget should follow the requirements at § 495.338 in the Final Rule and include the source of all funds which will be utilized by the State Medicaid agency for the

    Page 17 – State Medicaid Director

    specific activities outlined in the IAPD. This includes the following grants to the Medicaid agency:

    CHIPRA Quality Demonstration Grant, if HIT related Medicaid Transformation Grant Primary Care Stabilization Grant

    Enhancements to the State’s MMIS, such as building an interface to a source of HIT data, or shared reporting between the multiple projects, which will be cost allocated between the different projects, should be described in a separate MMIS APD. The separate MMIS APD may be included in the submission of the State’s HIT IAPD and, as an example, may be titled Part 1 – HIT, Part 2 – MMIS. Recovery funds must be tracked separately. That is the reason for separating the two documents. Funding requests for the MMIS APD should follow MMIS-specific guidance about the matching levels and permitted expenditures.

    State Submission and CMS Review and Approval Process for the SMHP and the HIT IAPD

    The State may simultaneously submit to CMS for approval both the SMHP and the HIT IAPD; or the State may choose to submit the SMHP first, receive CMS approval, and then submit the HIT IAPD to CMS. Either way, implementation activities cannot begin until the SMHP and the HIT IAPD have both been approved by CMS. As with the HIT Planning Advance Planning Document (PAPD), prior approval is required for States requesting FFP before conducting implementation activities. Exceptions will be made for States that have previously conducted planning activities and are requesting retroactive approval for 90 percent FFP for activities that occurred on or after February 18, 2009. Instructions for submitting these requests are described below under the heading, “Retroactive Approval of FFP with an Effective Date of February 18, 2009.”

    CMS will determine which activities will be eligible for a 90 percent FFP match for State expenses for administration of the incentive payments and for promoting EHR adoption implementation activities. States should contact their CMS regional office representatives regarding funding questions. Enclosures A, B, and C contain examples of partial lists of implementation expenditures/activities that may be considered eligible for 90 percent FFP for administrative expenses to implement the activities contained in the State’s SMHP and HIT IAPD.

    CMS will be using a joint Central Office/Regional Office review approach. In addition, CMS will share the States’ SMHPs with the Office of the National Coordinator for HIT (ONC) to ensure a coordinated approach for the State EHR Incentive Program and HIE efforts. While the SMHP focuses on the Medicaid strategy for moving toward meaningful use of certified EHR technology, it should be consistent with and complementary to the overall State HIT strategy developed under section 3013 of the Public Health Service Act (PHS). CMS and ONC will work together in the review of both strategies to prevent duplicative efforts of statewide HIT/HIE activities, provider outreach activities, and Medicaid HIT activities.

    Page 18 – State Medicaid Director

    State Reporting of Estimates, Expenditures and Timing of the Grant Award Letter

    For the purposes of this guidance, CMS is using the term “grant award” when approving Federal funding for allowable Medicaid expenditures. This should not be confused with competitive grant awards (e.g., Transformation Grants, CHIPRA grants, etc.) made by CMS or other Federal agencies, such as ONC, for HITECH activities. Once CMS has officially approved the SMHP and HIT IAPD, a CMS HIT approval letter will be issued notifying the State of the approved funding to conduct implementation activities. Only then may a State request to receive the grant award on a quarterly basis. On the Forms CMS-37.9 and CMS-37.10, the new line items listed below have been added to reflect provisions under section 4201 of the Recovery Act:

    Line 24A – HIT: Planning: Cost of In-house Activities Planning Activities for administrative expenses to oversee incentive payments made to providers: Cost of In- house Activities

    Line 24B – HIT: Planning: Cost of Private Contractors Planning Activities for administrative expenses to oversee incentive payments made to providers: Cost of Private Sector Contractors

    Line 24C – HIT: Implementation and Operation: Cost of In-house Activities Implementation Activities for administrative expenses to oversee incentive payments made to providers: Cost of In-house Activities

    Line 24D – HIT: Implementation and Operation: Cost of Private Contractors Implementation Activities for administrative expenses to oversee incentive payments made to providers: Cost of Private Sector Contractors

    In addition, the CMS 64.10 report includes expenditure reporting for the following line items:

    Line 24A – HIT Planning: Cost of In-house Activities Line 24B – HIT Planning: Cost of Private Contractors Line 24C – HIT Implementation and Operation: Cost of In-house Activities Line 24D – HIT Implementation and Operation: Cost of Private Contractors

    For both the CMS 37.9, 37.10 and 64.10 reports, estimates and expenditures only pertain to HITECH and not to MMIS reporting for the line items listed above. In that regard, do not include any projections or expenditures of provider incentive payment for this provision for either FY 2010 or FY 2011 on the CMS-37.9, CMS-37.10, or 64.10 reports. When State staff are preparing the budget for the HIT IAPD, it is critical that both program and financial staff communicate with each other to ensure consistent State reporting to CMS’ Financial Management Group in order to eliminate discrepancies in both the APD estimates and the information being reported by the State fiscal staff pertaining to Form CMS-37.9 and Form CMS-37.10.

    On the quarterly CMS-37 budget submission, a State may request to receive its HIT IAPD CMS grant award by including an estimated HIT IAPD expenditure in the CMS-37.10 Form. This estimated expenditure will result in a grant award to cover those expenses specified for that quarter. Therefore, it is imperative to accurately estimate the HIT IAPD expenditures by quarter.

    Page 19 – State Medicaid Director

    CMS will finalize the HIT IAPD grant award against the 64 HIT IAPD expenditures. The HIT IAPD grant award will be issued separately with a specified Payment Management System subaccount code.

    If a State has not received its HIT IAPD approval letter, the State may still include a footnote in the Form CMS-37.12 of anticipated HIT IAPD expenditures, broken out by quarter.

    Retroactive Approval of 90/10 FFP with an Effective Date of February 18, 2009

    For administrative activities performed by a State, prior to having an approved HIT PAPD, which are in support of administrative expenditures for planning activities for incentive payments to providers, a State may request consideration of retrospective FFP by including a request in a HIT advance planning document or implementation advance planning document update.  In considering such a request, the agency takes into consideration overall Federal interests which may include any of the following:

    (a) The acquisition must not be before February 18, 2009.

    (b) The acquisition must be reasonable, useful, and necessary.

    (c) The acquisition must be attributable to payments for reasonable administrative expenses per our regulations in §495.362.

    The activities must be related to planning, and can be requested in the HIT APD that is active at the time of the request. As an example, if the HIT PAPD has ended and the State is preparing the HIT IAPD, then this request can be included in a separate section titled: “Request for Retroactive HIT Planning Funding” and must follow the criteria above. It can also be included in an Update or in the Annual APD report due 60 days from the approved APD anniversary date.

    Patient Care Summary Exchange: State HIE Conference Call

    ONC’s State HIE Technical Assistance Webinar:
    Patient Care Summary Exchange and Meaningful Use
    August 6, 2010
    Excerpted from the State HIE Leadership Forum/Presentations and Webinars Page on August 11, 2010
    Slide Set PDF

    The audio (and appears to have been presented in teleconference audio format only) starts out talking about “meaningful use” since  the focus is on the exchange of  Patient Care Summaries and Stage 1 of Meaningful Use. It  includes a discussion about the Continuity of Care Record (CCR) and the newer Continuity of Care Document (CCD); NHIN direct and NHIN Exchange; and several case studies presented by the people involved (NEHEN in Massachussetts; MedVirginia in Virginia, NHIN, and Social Security Administration; KHIE in Kentucky; and Rhode Island HIE and NHIN Direct).

    Excerpts selected from slides:
    Care Summaries & Stage 1 Meaningful Use
    Based on the Meaningful Use Final Rule, “eligible professional, eligible hospital or CAH who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals.”

    –Core requirement is to perform at least one test of EHR’s capacity ot electronically exchange information.
    –To fulfill menu set requirement, EHR must enable a user to electronically transmit a patient summary record to other providers and organizations including
            –at a minmum, diagnostic test results, problem list, medication list, and a medication allergy list
           –uses HL7 CCD or ASTM CCR

    Stage 1 Meaningful Use Objectives that might require sharing of a CCD/CCR:
    –Provide patients with an electronic copy of their health information upon request
    –Provide a clinical summary for each visit
    –Exchange clinical information electronically with other providers and patient authorized entities
    –Provide summary care record for each transition of care and referral
    –Provide patients with an electronic copy of their discharge instructions and procedures
    –Other MU requirements could use clinical documents (e.g. lab results, public health reporting)

    Initial Set of Standards
    –Requires clinical summaries for patients for each office visit in “human readable” format  and on electronic media
    –Clinical summary can (be) either HITSP C32-compliant CCD or ASTM CCR
    –Why 2 standards?
                — CCD growing in popularity
                — CCR still in use, especially among early adopters
                — In some circumstances the CCR is easier, faster, and requires fewer resources to implement than the CCD
                 — Electronic exchange not required in Stage 1, so why make anyone migrate now from one format to the other?

    NHIN Specifications
    –Both NHIN Exchaneg and NHIN Direct offers means to transport clinical summaries
    –Both mechanisms support Stage 1 Meaningful Use
    –Both rely on standards for effective communication
    –NHIN Exchange offers the means for transporting care summaries; relies on more spohisticated technology, most suitable when participants do not necesssarily know each other personally
    –NHIN Direct offers specifications that enable transport of care summaries; relies on simpler technology, most suitable when participants know each other personally and have a data exchange relationship
    –Many states are interested in supporting both models for different workflows.

    State HIE Strategies
    –Can take several forms, just like statewide HIE can take several forms
    –Requires some elements of policy, some elements of infrastructure
    –Use data from environmental scan to understand current situation, capabilities, pilots, including other relevant states
    –Work with RECs to develop consistent message and appropriate capabilities; rely on their services
    –Insist on common terminology and coding
    –Keep EHR system vendors’ feet to the fire in implementing capabilities “in the field”
    –Recognize that manysites are still using HL7 v2 messages
    –Provide HIE services to support care summaries
             –Full services like RLS, MPI, directory, IHE XCA
             –Enabling service for NHIN Direct like provider directory
    –Consider the impact of the availability of many clinical documents when exchange is successful

    Data Aggregation and Data Content issues to be considered are highlighted.

    Final Rules–Analysis Roundup Starting w/AHIMA, Halamka, HIMSS

    Latest analysis and some catch-up from last week

    Journal of AHIMA
    Kevin Heubusch posted a chart on July 19, 2010 “Tracking Changes in the Menaingful Use Rule,” showing Stage 1 Objectives for Eligible Professionals, Eligible Hospitals and Critical Access Hospitals (CAH), Stage 1 Measures, and Changes from proposed rule.

    John Halamka’s Life as a Healthcare CIO
    John Halamka  posted “A Meaningful Use and Standards Rule FAQ” on July 19, 2010, providing his personal interpretation of answers to five questions he’s received since the final rules have been announced.

    Health Information Management Systems Society (HIMSS) provides several updates on its “Members Only” resource page, “Meaningful Use, Certification Criteria and Standards, and HHS Certification Process,’ between July 13 and July 19, 2010. The latest update, ”Medicare & Medicaid EHR Incentive Programs – What’s Different Between the NPRM and the Final Rule?” reviews the major differences in a five-page document. 

    Kate Ackerman, iHealthBeat Senior Editor, wrote “Long-Awaited Final Rule on ‘Meaningful Use’ Strikes Compromise” on July 15, 2010 with brief analysis and reactions from experts.

    O’Reilly Radar
    Brian Ahier posted “Analysis: A defining moment for ‘meaningful use’: How new rules will affect patients, providers, and electronic health records” on July 15, 2010.

    Chilmark Research
    John Moore provided his viewpoint in “Meaningful Use Perspectve & Resources,” posted on July 15, 2010.

    Final Rules for EHRs: Incentives, Certification, Standards –Preliminary Roundup

    Guide to Initial Stories on Final Rules for Incentives, Certification, Standards

    Stakeholders still assessing final meaningful use rule
    July 14, 2010 | Diana Manos, Senior Editor
    “Initial response seemed to be cautiously optimistic, but the American Hospital Association expressed concerns.”

    HIMSS’s Government HealthIT
    Lower bar to meaningful use assures more EHR participation
    By Mary Mosquera   Wednesday, July 14, 2010
    “If initial reactions are anything to go by, the Centers for Medicare and Medicaid Services hit a home run with its final rule for meaningful use of electronic health records, simultaneously lowering the requirements bar and increasing the likelihood of more healthcare providers participating in the CMS’ incentive program and adopting EHRs.”

    CMS abandons absolutes, adds flexibility to meaningful use
    By Mary Mosquera             Tuesday, July 13, 2010
    “In its final meaningful rule published today, the Center for Medicare and Medicaid Services has abandoned its original all-or-nothing approach to offering incentives for electronic health record adoption and opted for flexibility.”

    Public comments reshaped CMS final rule
    By Mary Mosquera    Tuesday, July 13, 2010
    “The Centers for Medicare and Medicaid Services received some 2,000 comments after it published its proposed meaningful use rule in January, and they were key both to changes in the scope of the final rule published today and to the speed with which it was adopted.”


    Meaningful-use regulations released
    By Andis Robeznieks
          Posted: July 13, 2010
    “ ‘After reviewing the comments, we agree that requiring that (eligible professionals), eligible hospitals, and (critical access hospitals) satisfy all of the objectives and their associated measures in order to be considered a meaningful EHR user would impose too great a burden and would result in an unacceptably low number of EPs, eligible hospitals, and CAHs being able to qualify as meaningful EHR users in the first two years of the program,’the rule states.”

    AMDIS members take on ‘meaningful use’
    By Joseph Conn / HITS staff writer Posted: July 15, 2010
    “The recent release of the new rules on meaningful use of electronic health-record systems dominated the discussion during the opening day of the Association of Medical Directors of Information Systems’ annual Physician Computer Connection Symposium in Ojai, Calif., on Wednesday.”

    John Halamka’s Life as  Healthcare CIO blog
    A Do it Yourself Presentation on the Standards Rule
    July 14, 2010
    “Just as I did with the Meaningful Use Rule, I’ve prepared a presentation that you can use for your Board and stakeholders to review the Standards Final Rule.”

    A Do it Yourself Presentation on the Meaningful Use Final Rule
    July 14, 2010
    “Just as I did in January with the Meaningful Use NPRM, I’ve prepared a presentation that you can use for your Board and stakeholders to review the requirements the final Meaningful Use Rule. Feel free to use it without attribution to me.”

    An Analysis of the Final Standards Rule
    July 13, 2010
    “At 10am today, the final Standards Rule was released as described on my previous blog. Here are additional details for stakeholders who want a technical analysis.”

    Meaningful Use and the Standards are Finalized
    July 13, 2010
    “Today at 10am, CMS and ONC released the final rules that will guide electronic health record rollouts for the next 5 years…Here’s my analysis of the key changes in the Final Rule.”

    New York Times
    Standards Issued for Electronic Health Records
    By ROBERT PEAR     Published: July 13, 2010
    “The rules significantly scale back proposed requirements that the health care industry had denounced as unrealistic.”

    The Wall Street Journal’s Health Blog
    ‘Meaningful Use’ Regs for Electronic Medical Records Finally Drop!
    By Katherine Hobson  July 13, 2010
    “The final regulations — all 864 pages of them – on what will constitute “meaningful use” of electronic medical records are now here. And the changes they include make it easier for hospitals and doctors to qualify next year for the first round of incentive payments for adopting EMRs.”
     (Probably requires paid subscription.)

    Final Rules on ‘Meaningful Use,’ EHR Standards Released Today
    story roundup. “Blumenthal said the final meaningful use rule offers health care providers more flexibility than the proposed regulations released in January.”

    AMDIS: Health execs initially pleased with meaningful use rules
    By Mary Stevens, July 14, 2010
    “OJAI, Calif.—A first look at the 864-page final rule for Meaningful Use and EHR Certification shows that policymakers “listened and responded” to some physicians’ concerns, said speakers Pat Wise, RN, vice president of healthcare information systems at HIMSS, and Michael Zaroukian, MD, PhD, CMIO and associate professor of medicine at Michigan State University, during a presentation at the annual AMDIS Physician-Computer Connection Symposium Wednesday.”

    CMS, ONC release meaningful use final rules
    By CMIO Editorial Staff       July 13, 2010
    “In the final regulation is divided into two groups: a set of core objectives that constitute a starting point for meaningful use of EHRs and a separate menu of additional important activities from which providers will choose several to implement in the first two years, Blumenthal explained.”

    e-Healthcare Marketing posts
    See previous post on e-Healthcare Marketing for Final Rules PDFs, Press Release, Fact Sheets, and additional info.
    See Dr. Blumenthal’s blog post on same subject as above, republished on e-Healthcare Marketing.
    See Letter #17 from Dr. Blumenthal.