Lindsey Ferris, DrPH, acts as a senior advisor at Maryland-based CRISP (Chesapeake Regional Information System for Our Patients), a regional health information exchange (HIE), and is an advisor to the Consortium for State and Regional Interoperability, a collection of the nation’s largest and most robust nonprofit healthcare data organizations. In addition to these roles, Dr. Ferris is a Senior Director at Audacious Inquiry, bringing years of experience working in electronic health record implementation, advising on public health initiatives, and supporting states and HIEs in securing funding for and implementing health IT projects.
Dr. Ferris recently co-authored an article in Healthcare IT News about Medicaid IT funding, so we decided to pick her brain on her experience working with state Medicaid programs and HIEs in the post-HITECH funding era.
Read our full Q&A for insights on how states have succeeded in securing Medicaid Enterprise System funding for health IT projects and how health data utilities can support public health and Medicaid goals.
Q: To start, can you tell us more about your role with Audacious Inquiry and the work you do at the Chesapeake Regional Information System for our Patients (CRISP) as a senior advisor?
Dr. Ferris: Since starting at Audacious nearly 10 years ago, I have primarily been contracted to CRISP full time. As CRISP has grown over the years, I’ve taken on different roles and responsibilities, starting as a project manager, then managing a team of project managers, to now serving as an advisor to CRISP and its HIE affiliates. I oversaw many of the Maryland grants, managed Medicaid funding for CRISP, and also helped with CRISP’s transition from the HITECH funding to the Medicaid Enterprise System (MES) funding that other experts at Audacious Inquiry helped create the roadmap for. Now I’ve taken that expertise and have applied it to all the different HIE affiliates of CRISP, so I’ve worked with Maryland, Washington D.C., West Virginia, Connecticut, and now Alaska.
Q: You also serve as an advisor to the Consortium for State and Regional Interoperability (CSRI). Could you explain what that organization does and how you are involved?
Dr. Ferris: CSRI is a way for multiple health information exchanges to come together and share ideas, identify priorities where there can be a collaboration, and leverage different areas of expertise across those organizations. CSRI offers subject matter experts in various areas through its members, which CRISP is a founding organization, whether in technology, standards, advocacy, or funding. I am one of the subject matter experts available to consult on MES funding as a service to other HIEs that need it.
Q: One of the topics you touch on in the HealthcareIT News article relates to the strain the COVID-19 pandemic has put on Medicaid programs, particularly its impact on staffing and financial resources. How have you been working with state partners to navigate these difficult times to ensure that health IT doesn’t get shortchanged?
Dr. Ferris: I can speak to this from my perspective of working with the State of Maryland since I was heavily entrenched in multiple technology efforts that CRISP deployed in partnership with the state throughout COVID. The impact on staff was substantial since the response efforts touched so many agencies and programs and required collaboration and data sharing in new ways. Many of the staff had to shift towards COVID response efforts and required constant, round-the-clock support.
I do think that the states that have been most successful were those that invested in healthcare IT prior to the pandemic and had infrastructure and sources of data in place that could be leveraged to support state mitigation strategies related to COVID.
For example, in Maryland, we were able to leverage existing infrastructure to communicate COVID testing and, eventually, immunization data to providers at the point of care and display statewide dashboards to key stakeholders. We were also able to quickly stand up new technology to assist with statewide reporting and analytics and drive-through COVID testing centers. From the early stages of COVID to now, state needs evolved quite a bit and the technology has evolved with it. The key ingredient for handling the evolution of needs throughout the pandemic has been the state-level leadership to prioritize healthcare IT to support response efforts, and a nimble technology partner like CRISP.
Q: Why is it important for Medicaid programs to work with health information exchanges? You talk about the tremendous value created by HIEs in the health IT ecosystem–what is the value proposition for investing in health IT when budgets are tight?
Dr. Ferris: Medicaid programs have invested a lot of money into health information exchanges over the years through HITECH, and Centers for Medicare & Medicaid Services (CMS) has explicitly prioritized reuse of technology as a condition of enhanced federal funding within and among states. With the end of HITECH funding, it makes sense to bring HIEs into the certified Medicaid Enterprise System (MES) ecosystem to leverage those technologies for the value they are already bringing. A big value of HIEs is that we have high connectivity in the provider space, and we are able to deliver information to providers in a way that Medicaid systems alone may not be structured to do currently, especially within the provider’s workflow.
HIEs are not trying to replace core functions of the MES system itself. The health information exchange technology is a bolt-on to the existing MES infrastructure that provides additional value through the services, such as care coordination and population health, offered to its participants that support the priorities of Medicaid. There is a lot of value that HIEs can provide directly to the Medicaid program, providers, and beneficiaries.
Q: In the article, you also talk about the evolution of the MES funding requirements set by CMS. How is it different from getting funding through HITECH?
Dr. Ferris: It is actually quite different. Under HITECH, there was only 90/10 funding available, and there was no concept of splitting out new IT work versus what is operational already. Under the MES world, it’s necessary to split new work like design, development, and implementation or planning work at 90/10 funding from operational services at 75/25 funding. Then, if the state and the HIE want to receive 75/25 enhanced operational dollars as opposed to 50/50 operational dollars, which does not have any additional requirements, the services have to go through a certification process.
Historically, the MES world has followed more of a technical checklist-type format that you go through and check off that the technology meets all those requirements. The certification process is changing overall all for the MES funding and CMS is moving towards an outcomes-based certification (OBC) process, where they look at the outcomes that the Medicaid program is trying to achieve and the metrics that demonstrate meeting those outcomes. The new OBC process has been evolving very fast while all HIEs are trying to move from the HITECH to the MES funding.
Then the key difference between MES and HITECH is the cost allocation. Under HITECH, there was a carve-out for the cost allocation that let you factor in eligible hospitals and providers, which could result in a fairly high cost allocation. Under MES, CMS must work within the regulations that define cost allocation, which changes the cost allocation methodology for HIEs from how it was historically calculated and impacts the overall budget.
Q: And as a follow up, in what ways do a partnership between a state and an HIE factor into qualifying for MES funding?
Dr. Ferris: There needs to be a close partnership between the HIE and the state Medicaid program for HIE technology to qualify for MES funding. Technically, there should be a relationship from the HITECH world, but in some states, those in Medicaid that were responsible for overseeing the HITECH funding are not necessarily entrenched within the same world as the those overseeing MES funding. So depending on the Medicaid program, some relationships need to be built and a lot of knowledge sharing may need to happen.
That strong partnership is crucial for HIEs since Medicaid requests the funding. HIEs cannot go directly to CMS, and this concept of HIEs being in the MES world is brand new. Those in Medicaid currently receiving MES funding are likely working with programs and technology that are strictly for Medicaid, so they have not had to cost allocate at all, or in the depth that they have to for an HIE because the HIE technology often serves more than just Medicaid.
One of the things that the CSRI Medicaid funding subject matter experts focus on when working with a State/HIE partnership is strengthening those relationships. We make sure that those in the MES space are familiar with the HIE services, how HIE technology fit into the Medicaid landscape, and how HIE technology supports Medicaid priorities, so the benefit to the Medicaid program is clear.
It’s kind of like trying to translate two languages. The HIEs are used to talking about its services as technical use cases, but translating that into benefits to the Medicaid program takes work. CMS needs to have that Medicaid value very clearly defined before funding requests are submitted.
Q: Are there any “success story” examples of state Medicaid programs working with HIEs to get funding to health IT initiatives?
Dr. Ferris: We’ve been very successful working with Medicaid in Maryland, D.C., West Virginia, and Connecticut through my work with CRISP. There is knowledge sharing across the states and HIEs as each move through the process and all have been successful at getting funding.
Maryland has been the cutting-edge state in this space. CRISP Maryland first started getting MES funding in federal fiscal year 2020. We worked with Audacious Inquiry subject matter experts to create a framework of how to move from HITECH to MES, and started moving technology from HITECH over to MES that was operational to get that enhanced (75/25) funding in phases until all operational health information exchange technology eligible under MES was transitioned in full in FFY 2022. Thankfully, other states that are part of the CRISP HIE collaborative, which reuses shared technology across all HIE affiliates, have benefited from that.
Q: Part of that success for Maryland was starting early, but would you say there were some other factors that could serve as strategy for other states trying to get funding now, a couple of years later?
Dr. Ferris: The states that came later are have generally been following the same steps, such as meeting internally first on what technology should be certified, then engaging in regular discussions with the state and with CMS (via the state) for certain specific topics. The conversations may vary from HIE to HIE since it depends on the technology maturity level and degree of connectivity within the state. The State and HIE formalize a plan around what technology will be certified, as well as the proposed outcomes and metrics. Once all the required materials are gathered, the state can request a certification review date for the outcomes-based certification, which is constantly evolving.
Additionally, cost-allocation methodology has been a big topic of conversation. CMS is very open to any cost-allocation methodology being proposed, but certain things need to be in place that are consistent with regulations.
Q: Shifting gears a bit, could you talk about health data utilities (HDUs) and what role health information exchanges are playing in this clinical data resource?
Dr. Ferris: Conceptually, health data utilities are nonprofit organizations that work independently of the state to collaborate with the larger healthcare community and provide information that allows states to gain insights they can act on. HDUs are serving as a way to combine data, enhance that data, and deliver information back to clinical users that may be important about their patients, all in support of public health efforts. Established health information exchanges are very well positioned to serve as a statewide HDU given their existing governance structure, degree of connectivity, technology, and partnership with various key stakeholders.
The HDU concept really accelerated as a result of COVID. CRISP was able to supply crucial data states needed in their COVID response efforts because we were could master, prioritize, and normalize it from multiple data sources. This afforded states with more robust, complete information to act on the pandemic and direct interventions.
Q: And how will HDUs support the effective operation of Medicaid?
Dr. Ferris: You can gain better insights into your Medicaid population through the mechanism of an health information exchange as a health data utility. Because we are getting data from so many different sources, we can supply information back for population health-level insights. We can also provide that information to the clinical users and care teams that are treating Medicaid beneficiaries to improve care in the long run.
Q: What are some examples of ways HIEs and Medicaid programs can partner together to address public health issues like COVID-19?
Dr. Ferris: One of the key benefits of using an HIE is the connections to public health programs, clinical users, and Medicaid data. HIEs can supply information on Medicaid beneficiaries from its many data connections back to the Medicaid program to act on. For example, during the pandemic, we sent notifications directly to Medicaid to let them know which Medicaid beneficiaries tested positive for COVID-19. This allowed providers performing intensive case management to take necessary precautions when entering the beneficiary’s home when positive with COVID-19.The other aspect to this is providing information to healthcare providers about Medicaid beneficiaries related to the pandemic. CRISP displayed COVID-19 lab results at the point of care and sent proactive notifications when a patient tested positive. When vaccines were available, CRISP was able to combine the vaccination data with other key indicators, such as chronic conditions and age, for the managed care organization (MCO) and other provider panels into a dashboard view. The dashboard allows the organization to systematically get their active patients vaccinated using information that might be important in prioritizing outreach, such as chronic conditions, age, or other key factors.
There is a lot of opportunity to combine public health data with the Medicaid data and either supply information directly to the Medicaid program to impact services and initiatives or to Medicaid providers so they can better manage their Medicaid population amidst a pandemic.
Q: To close out, could you offer some communication tips or strategies for state Medicaid programs and HIEs, considering their common funding and public health goals?
Dr. Ferris: There is always a need for HIEs to communicate with the Medicaid program about what the health information exchange does for a baseline understanding of services and value. It’s more effective if the HIE can tie those services directly to Medicaid initiatives, priorities, and programs. It can take time to establish a common understanding of services, technical capabilities, and how HIE technology fits into the MES ecosystem. So, I just always recommend that baseline communication is happening.
If Medicaid is trying to pursue funding for HIE technology, there need to be regular touchpoints and a clear timeline of when things need to be submitted to CMS. Make sure there’s a clear understanding of what services will be funded and how, work towards creating all necessary materials for CMS, allow time for Medicaid’s review of all materials, and eventually submit to CMS. States should ensure there are key touchpoints along the way with CMS so the state officer is not surprised with anything submitted and rework and/or delays are avoided.
I also recommend communication at multiple levels within Medicaid. You should be working with those managing Medicaid submissions as well as Medicaid directors, to make sure they understand that health information changes the utility to the Medicaid program and what value it brings.
Lindsey Ferris, DrPH, MPH, serves as Senior Director at Audacious Inquiry, as well as Program Director HIE Projects at CRISP – Maryland’s State-Designated Health Information Exchange. Dr. Ferris has been recognized for her transformational leadership in advancing the use of health information exchange to support public health initiatives and for her dedication in mentoring women in the industry.
Diana Bauza is a content writer based in Philadelphia. She writes about products and services in the health and technology industries, with the goal of empowering consumers with quality information to help them make decisions that best serve their needs