Health Information Exchange (HIE)
How this system supports the Medicaid Program
Health Information Exchanges (HIEs) allows patients and health care providers to access and share medical information across hospitals/provider networks/health systems. Depending on the nature and extent of a given HIE’s capabilities, investments are expected to lead to improved individual- and population-level health outcomes through improved coordination of care and the use of data to inform health policy decision-making.
CMS-Required Outcomes
None. There are no CMS-Required outcomes for HIE.
For an HIE system to receive enhanced funding, states will need to identify outcomes and associated metrics that show clear benefits to their respective Medicaid programs (i.e., the HIE must be able to show how its reach extends beyond individual patients to advance the state’s overall Medicaid objectives).
State-Specific Outcomes - CMS Approved
The state is responsible for drafting State-specific outcomes and metrics. These should detail the benefit to Medicaid program.
When drafting state-specific outcomes statements, keep these tips in mind.
Examples for Health Information Exchanges
While each HIE is unique, common system capabilities are listed below. Some are technical, but a good outcome will focus less on the technology itself and more on the business functions and/or programmatic objectives that the technology enables/facilitates/advances.
- Event Notification Services - Event Notification Services keep providers informed of any current admissions, discharges, or transfers (ADTs) for their empaneled patients. Well-informed providers can better coordinate care, reducing duplication of services and minimizing any gaps, ultimately leading to better health outcomes and reduced costs to the Medicaid program.
- Care Coordination/Clinical Data Exchange - With Clinical Data Exchange, providers utilize a portal or in-workflow viewer to access clinical data (imaging, consult reports, etc.) originating from outside their own Electronic Health Records (EHRs). Continuity of Care Documents (CCD) are the most frequent type of clinical summary exchanged, although several states are also offering registries for patient advance care directives/Medical Orders for Life Sustaining Treatment (i.e., ensuring that patient desires are respected during critical moments).
- Direct Secure Messaging - Encrypted, secure messages (via the Direct protocol) are exchanged via the healthcare organization’s EHR and/or an HIE-operated portal.
- Public Health – Public Health Registries and Reporting - Through this capability, the HIE facilitates exchange of immunization records, electronic lab reports (eLRs), syndromic surveillance messages, electronic case reports (eCRs), Prescription Drug Monitoring Program (PDMP) records and other data of interest to public health agencies.
- Population Health Analytics/Support to Value-Based Care Initiatives - The state utilizes clinical and/or administrative data stored in the HIE to identify Medicaid members for potential individual-level interventions (high utilizers, missed vaccinations, etc.), as well as to identify opportunities for potential benefit improvements/demonstrations.
- Quality Reporting - Many HIEs make data available to support meeting state and federal requirements for reporting standardized clinical quality metrics.
- Emergency Response - Emergency response capabilities, such as Patient Unified Lookup System for Emergencies (PULSE), enable medical emergency responders to view clinical and medication histories of individuals who have been displaced (typically due to natural disasters) and must seek care outside their normal, routine settings.
Many states are leveraging their HIE infrastructures in support of other Medicaid program priorities that involve multi-provider coordination/collaboration, including closed-loop referral systems for health-related social needs and inpatient/sub-acute bed availability registries. States may have unique and novel uses of their HIE not represented above, and we welcome those outcome statements crafted by states to update this listing. Again, HIE investments (and thus their outcome statements) must demonstrate a benefit to the respective states’ Medicaid programs in addition to the individual members that are the subject of an ADT message, immunization report, etc.
Please send examples to MES@cms.hhs.gov. Our team will collect and share the best examples.
| State | Medicaid Program Goal | Outcome Statement | Metric(s) |
|---|---|---|---|
| Alabama | Event Notifications |
Alabama Medicaid attests its providers and beneficiaries utilization of ALOHR Health IT infrastructure and investment in systems and services will improve health outcomes by:
• Ability to flag each Medicaid recipient participating both in the Alabama Coordinated Health Network (ACHN), thereby reducing Emergency Room and hospital readmissions by improving care coordination with more timely patient engagement by their community care team. | The total number of ADT alerts exchanged with each ACHN entities for the Medicaid recipients. |
| Arkansas | Event Notifications | Medicaid providers and Medicaid beneficiaries use the HIE to improve care coordination and reduce readmissions while working towards the goal of reducing unnecessary hospitalizations. The HIE will demonstrate its ability to notify PCMHS when their attributed member has an encounter at a hospital. These real-time notifications provide information to PCMHs about a patient’s medical services encounter, demographics, as well as the date and time of the event. The timely collection and distribution of these notifications to the PCMH facilitates the needed follow up care required to improve the overall quality as well as lower the cost of care delivered to patients. | Number of Alerts sent to each PCMH each Month |
| Arkansas | Event Notifications | To improve care coordination of PASSE members by providing real time data to the PASSE. The HIE will demonstrate the ability to send real time ADTs to Medicaid attributed PASSE members to the PASSE’s analytical tool. The real time flow of ADTs for intense care coordination improves patient’s outcomes and improves follow up after an acute encounter. Once the PASSE receives the ADT, the system generates automated tasks and transitions protocols established by Medicaid. | Monthly count of messages or encounters on Medicaid attributed members sent to each individual PASSE. |
| Colorado | Event Notifications | The state will use the HIE to send ADT notifications to RAEs, which will use those alerts to improve care coordination and targeted follow-up with Medicaid beneficiaries. | The number of notifications sent on behalf of the Medicaid population per RAE per month |
| Connecticut | Event Notifications |
CT Medicaid attests Medicaid providers and Medicaid beneficiaries use of the HIE care coordination technical investments will improve health outcomes including:
•The Empanelment and Encounter Alert Service triggers alerts and flags patients who present to the hospital, allowing for improved outreach and care coordination across care team members aimed at improved care as seen by reducing future Emergency Department visits and hospital readmissions. | Number and percent of unique Medicaid beneficiaries empaneled each month |
| District of Columbia | Event Notifications |
DHCF attests that Medicaid providers use of the HIE care coordination technical investments for Medicaid beneficiaries will improve health outcomes. Here is how:
• The notification system triggers alerts and flags patients, including Medicaid beneficiaries, who present to the hospital, allowing for improved outreach and care coordination across care team members aimed at reducing future Emergency Department visits and hospital readmissions. | Number of alerts sent to individual MCOs each month |
| District of Columbia | Care Coordination |
Department of Healthcare Finance (DHCF) attests that Medicaid providers use of the HIE care coordination technical investments for Medicaid beneficiaries will improve health outcomes. Here is how:
• Medicaid providers are able to view and share radiological images and results/results within the Image Exchange system to improve care management for their patients. | Number of times a provider launched the image exchange and searched for a core or emergent image for a Medicaid patient. |
| Florida | Care Coordination | County Health Department providers can securely and efficiently leverage health information exchange services to access clinical records for use in improving Medicaid patient care. | Florida |
| Florida | Public Health | The eCR system will reduce administrative burden on providers by allowing them to submit required case reporting electronically. Medicaid providers will spend less time compiling and managing generation and submission of reportable disease case reports. | Percent of cases reported (or counted) by FDOH that have an electronic case report |
| Kentucky | Care Coordination | Improve Medicaid providers’ access to clinical data through the ePartnerViewer and Platinum connection, to improve care coordination and overall health outcomes of Medicaid beneficiaries. | The number of ADTs, labs, radiology reports and transcribed notes submitted via HL7 into the HIE. |
| Kentucky | Care Coordination | Improve Medicaid providers’ access to clinical data through the ePartnerViewer and Platinum connection, to improve care coordination and overall health outcomes of Medicaid beneficiaries. | The total number of CCDs contributed and queried through a Platinum (IHE) connection. |
| Kentucky | Care Coordination | Improve Medicaid providers’ access to clinical data through the ePartnerViewer and Platinum connection, to improve care coordination and overall health outcomes of Medicaid beneficiaries. | The total number of provisioned users accessing the ePartnerViewer. |
| Kentucky | Event Notifications | Increase the number of Event Notifications exchanged in order to deliver healthcare providers with the most current patient information. Thereby reducing duplication of services and gaps in care ensuring beneficiaries receive quality healthcare by well-informed providers. | The number of event notifications exchanged via each route. |
| Kentucky | HIE Services | Provide direct secure messaging to participants to enable information exchange where KHIE connections lapse. | The number of Direct Secure Messages exchanged via KHIE’s HISP and CareAlign Portal. |
| Mississippi | Care Coordination | Use the CDIP ecosystem to identify beneficiaries who are high utilizers of DOM services and assigned to care management |
Use the Clinical Data Interoperability Program's (CDIP) ecosystem to develop reports to identify beneficiaries enrolled in care management:
- # of Emergency Department visits The report will be reviewed monthly by DOM staff and used to inform CCO oversight and compliance engagement strategies. |
| Montana | Clinical Data Exchange | The activity will deliver a consolidated clinical data feed to Medicaid that will reduce data duplication and improve data consistency and eliminate the additional cost and infrastructure to build and maintain direct data interfaces from Montana Medicaid to multiple health systems and other Medicaid certified providers in the BSCC network. BSCC manages a network of data interfaces from clinical providers across the state of Montana. Data is ingested, normalized, matched to patients and integrated into a single longitudinal patient record and combined with clinical data from Medicaid claims as well as clinical claims data from other participating payor organizations. This combined patient record data set is then delivered to Medicaid on a scheduled basis as described above. | Number of updated patient Summary CCDs provided to Medicaid |
| Montana | Care Coordination | This activity will provide a tool/platform that will improve the Medicaid program and Medicaid providers ability to track, manage and report on quality metrics, risk profiling and population health. The platform will provide Medicaid a comprehensive suite of medical risk scores based on the claims and clinical data in the HIE. The Department will use these risk scores to complement its own population health data to create a comprehensive health profile of Medicaid members which will inform care program assignment, care coordinator clinical recommendations, and improve member outcomes. The increased access by Medicaid Provider users will give them real-time access at the point of care to the metrics that describe a Medicaid member’s health status and conditions which will support improved member outcomes. If users don’t have access to the metrics, they will make suboptimal healthcare decisions that could negatively impact Medicaid member overall health condition. Access to these metrics enables Medicaid to improve the quality and coordination as well as lower the cost of care delivered to patients. |
Number of patient records with associated updated risk scores
Number of patients with Risk scores provided to Medicaid |
| New Jersey | Clinical Data Exchange | Improve Medicaid providers’ access to clinical data through NJHIN to improve care coordination, overall health outcomes of Medicaid beneficiaries and allowing consumers to access their health information. | The number of CCDA documents shared with providers and facilities via the NJHIN. |
| New Jersey | Event Notifications | The state’s Medicaid providers will receive valuable alerts on their patients when they utilize any of these services allowing them to proactively engage the patients in follow-up care which supports the CMS ADT CoP Notification mandate. | The number of ADT messages contributed to NJHIN. |
| New Jersey | Event Notifications | The state’s Medicaid providers will receive valuable alerts on their patients when they utilize any of these services allowing them to proactively engage the patients in follow-up care which supports the CMS ADT CoP Notification mandate. | The number of ADT messages sent to providers and facilities via the NJHIN. |
| New Mexico | Quality Measurement | Support Medicaid providers by facilitating earlier identification of patients with HCV at the point of care and the number that achieve Sustained Virologic Response (SRV) | The total number of Medicaid enrolled HCV patients identified based on positive lab results for Medicaid beneficiaries, and the number who achieved Sustained Virologic Response (SVR) each month. |
| New Mexico | Care Coordination | Support Medicaid providers by facilitating earlier identification of patients with documented histories of SUD and Substance Exposed Infants (SEI) | The monthly number of Emergency Department visits for a Medicaid enrollee that meet criteria for a visit related to SEI, SUD and/or opioid overdose. |
| New Mexico | Clinical Data Exchange | Expedite and increase Medicaid providers’ access to beneficiaries’ clinical records through the SYNCRONYS HIE to directly advance care coordination and improve care outcomes among the Medicaid population. | The total number of Medicaid patient Consolidated Clinical Document Architecture documents (CCDA) contributed, and patient records queried through SYNCRONYS during a given month. |
| New Mexico | Care Coordination | Expedite and increase Medicaid providers’ access to beneficiaries’ clinical records through the SYNCRONYS HIE to directly advance care coordination and improve care outcomes among the Medicaid population. | The number of Health Level Seven International (HL7) ADT (Admit, Discharge and Transfer) messages; Observation Results, Unsolicited (ORU) for labs, radiology and patient notes; and MDMs (Medical Document Management notes and other documents), submitted monthly |
| New York | Quality Measurement | SHIN-NY entities make clinical data available to support the development and implementation of NYS Medicaid’s value-based payment (VBP) program. | Total number of members each QE was able to match by quality measure. |
| New York | Quality Measurement | SHIN-NY entities make clinical data available to support the development and implementation of NYS Medicaid’s value-based payment (VBP) program. | Number of members with clinical data relevant to the quality measure(s) being evaluated. |
| North Dakota | Care Coordination | Improve Medicaid providers’ access to clinical data through the NDHIN Clinical Portal to improve care coordination and overall health outcomes of Medicaid beneficiaries. | The number of HL7 messages submitted to NDHIN, including ADT messages; Lab results; radiology images; radiology reports; and transcribed documents. |
| North Dakota | HIE Services | Improve Medicaid providers’ access to clinical data through the NDHIN Clinical Portal to improve care coordination and overall health outcomes of Medicaid beneficiaries. | The total number of user logins to the NDHIN Clinical Portal, either web-access or single sign-on. |
| North Dakota | Care Coordination | Improve Medicaid providers’ access to clinical data through the NDHIN Clinical Portal to improve care coordination and overall health outcomes of Medicaid beneficiaries. | The total number of unique patient records accessed by NDHIN users on a monthly basis. |
| North Dakota | Public Health | Improve electronic public health reporting data quality in North Dakota to support Medicaid providers’ ability to coordinate care as it relates to improving population health for the Medicaid beneficiaries. | The number of immunization records, syndromic surveillance messages, reportable conditions (ELR), and electronic case reports reported electronically via NDHIN to the ND Department of Health. |
| North Dakota | Public Health | Improve electronic public health reporting data quality in North Dakota to support Medicaid providers’ ability to coordinate care as it relates to improving population health for the Medicaid beneficiaries. | Provider utilization of NDHIN to access patients’ immunization health data |
| Rhode Island | HIE Services | Improve Medicaid1 providers’ access to clinical data and event notifications through HIE services to improve care coordination and transitions of care, and to positively impact health outcomes of Medicaid beneficiaries. Timely access to relevant information for patient care and treatment is one of the most important core functions of an HIE. By monitoring providers’ use of HIE services, EOHHS and Medicaid can better administer the Medicaid program, working with the Accountable Entities (AE) and Managed Care Organizations (MCO) to assure optimal benefit from the use of the State’s HIE and its services. | The percent of healthcare sites that log in to CurrentCare Viewer 11+ times per month (# of practice sites that log in to Viewer 11+ times per month / # of sites with access to Viewer) |
| Rhode Island | HIE Services | Improve Medicaid1 providers’ access to clinical data and event notifications through HIE services to improve care coordination and transitions of care, and to positively impact health outcomes of Medicaid beneficiaries. Timely access to relevant information for patient care and treatment is one of the most important core functions of an HIE. By monitoring providers’ use of HIE services, EOHHS and Medicaid can better administer the Medicaid program, working with the Accountable Entities (AE) and Managed Care Organizations (MCO) to assure optimal benefit from the use of the State’s HIE and its services. | Assessment of frequency of use of Care Management Dashboards (Ratio of log-ins to dashboard users in a 30-day period) |
| Rhode Island | Public Health | Reduce administrative and reporting burden for Medicaid providers, and create efficiencies and optimizations for the Medicaid program, by supporting connections for public health and quality reporting where appropriate. The HIE is uniquely positioned to facilitate connections by utilizing existing clinical interfaces with provider systems for additional state and federal reporting needs. | The percent of non- hospital lab reportable disease results sent to NEDSS through the HIE (# lab reportable disease results/transactions sent to NEDSS Through the HIE/ # lab reportable disease results from non-hospital laboratories) |
| Rhode Island | Quality Reporting | Reduce administrative and reporting burden for Medicaid providers, and create efficiencies and optimizations for the Medicaid program, by supporting connections for public health and quality reporting where appropriate. The HIE is uniquely positioned to facilitate connections by utilizing existing clinical interfaces with provider systems for additional state and federal reporting needs. | The number of lab results sent to the Quality Reporting System (QRS) (# lab results sent to QRS) |
| Wyoming | Event Notifications | The state will use the HIE to send ADT notifications, which will improve care coordination and targeted follow-up with Medicaid beneficiaries. In addition, the state will use the ADT data from the HIE to improve health outcomes by improving insight into Medicaid service usage by identifying utilization of Emergency Department (ED) and hospital admissions and gaps in services. This information will be used to inform Medicaid administration and providers about the Medicaid population’s health and improve the evaluation of Medicaid program performance and client’s health outcomes. | The number of notifications sent to the Medicaid HMUM vendor per month. |
| Wyoming | Event Notifications | The state will use the HIE to send ADT notifications, which will improve care coordination and targeted follow-up with Medicaid beneficiaries. In addition, the state will use the ADT data from the HIE to improve health outcomes by improving insight into Medicaid service usage by identifying utilization of Emergency Department (ED) and hospital admissions and gaps in services. This information will be used to inform Medicaid administration and providers about the Medicaid population’s health and improve the evaluation of Medicaid program performance and client’s health outcomes. | The number of CCDs pulled for Medicaid HMUM patients per month. |
| Wyoming | Care Coordination | The State will use the HIE’s referral function to improve care coordination and targeted follow-up with Medicaid beneficiaries. In addition, the state will use the ADT data from the HIE to improve health outcomes for Medicaid diabetes and prediabetes patients through closed loop referrals between PCPs and RDs as part of the CDC’s National Diabetes Prevention Program (DPP). | The number of referrals for DPP per month. |
| Wyoming | Care Coordination | The State will use the HIE’s referral function to improve care coordination and targeted follow-up with Medicaid beneficiaries. In addition, the state will use the ADT data from the HIE to improve health outcomes for Medicaid diabetes and prediabetes patients through closed loop referrals between PCPs and RDs as part of the CDC’s National Diabetes Prevention Program (DPP). | The number of summaries by RDs per month. |
| Wyoming | Care Coordination | The state will use the HIE’s ability to aggregate health data from multiple sources to improve care coordination by enabling Medicaid care team members to see all relevant health data for Medicaid Patients. It will improve outcomes by maintaining continuity as patients’ transition into and out of Medicaid eligibility. | Number of Medicaid patients with records in WYFI over time. |
| Wyoming | Event Notifications | The state will use the HIE’s ability to aggregate health data from multiple sources to improve care coordination by enabling Medicaid care team members to see all relevant health data for Medicaid Patients. It will improve outcomes by maintaining continuity as patients’ transition into and out of Medicaid eligibility. | Number of Medicaid Patient encounter records in WYFI over time. |