Health Information Exchange (HIE)
How this system supports the Medicaid Program
A Health Information Exchange allows medical information to be accessed and shared by patients and health care providers, leading to improved coordination of care and better community monitoring.
CMS-Required Outcomes
None. There are no CMS-Required outcomes for HIE.
As such, for an HIE system to be certified states will need to create or reuse State-Specific Outcomes which target state-specific problems and derive Medicaid program benefits.
State-Specific Outcomes - CMS Approved
States requesting enhanced FFP for systems that fulfill state-specific program needs, beyond minimum legal requirements and the baseline of the CMS-required outcomes, should propose State-Specific Outcomes which address the proposed enhancements.
When drafting state-specific outcomes statements, keep these tips in mind.
Examples for Health Information Exchanges
We are actively gathering and evaluating outcomes statements crafted by states for this business area.
Please send examples from your state that you’d like to share to MESCertificationRepo@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. |
| Alabama | Care Coordination |
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 provide Hospital utilization frequency, and key clinical summary measures for each Medicaid eligible recipient participating Alabama community care networks, thereby improving understanding and insight into Medicaid’s care plan performance and services by identifying frequency of Hospital encounters and Transitions of Care (TOC) clinical summaries to enable the Medicaid program administration and provider to measure and gauge care coordination and community network effectiveness. • Ability to provide a report to Medicaid detailing frequency and consistency on Hospital ADT and TOC data content, thereby improving data provenance review into Medicaid’s clinical data by identifying sources of exchange of ADT and transitions of care summaries to enable Medicaid to improve the quality and consistency of clinical information to gauge and measure the recipient outcomes. | A monthly extract of ADT’s data files submitted to Medicaid to be used to determine the frequency and effectiveness of the ACHN care coordination as a direct comparison of Hospital encounter avoidance and readmissions. |
| Alabama | Care Coordination |
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 provide Hospital utilization frequency, and key clinical summary measures for each Medicaid eligible recipient participating Alabama community care networks, thereby improving understanding and insight into Medicaid’s care plan performance and services by identifying frequency of Hospital encounters and Transitions of Care (TOC) clinical summaries to enable the Medicaid program administration and provider to measure and gauge care coordination and community network effectiveness. • Ability to provide a report to Medicaid detailing frequency and consistency on Hospital ADT and TOC data content, thereby improving data provenance review into Medicaid’s clinical data by identifying sources of exchange of ADT and transitions of care summaries to enable Medicaid to improve the quality and consistency of clinical information to gauge and measure the recipient outcomes. | A monthly extract of ADT & C-CDA data files submitted to Medicaid to be to identify gaps in medications and allergies/problems during transitions between Hospitals, community care networks, and post-acute care facilities. |
| 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. | To demonstrate that this functionality is operational, the following information will be provided to Medicaid: -Number of Alerts sent to each PCMH each Month |
| Arkansas | Event Notifications | To provide timely information to Medicaid Primary care physicians when an attributed member tests positive for COVID. The HIE will demonstrate the ability to flag Medicaid Members who has tested positive for COVID and provide the Medicaid Primary care physician with a daily notification. This timely access to this information can be utilized by Medicaid providers to improve disease management and coordination. | To demonstrate the functionality is operational, the following information will be provided to Medicaid: -Number of Medicaid beneficiaries that have tested positive for COVID 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. | To demonstrate the functionality is operational, the following information will be provided to Medicaid: -Monthly count of messages or encounters on Medicaid attributed members sent to each individual PASSE. |
| 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. | Ability to flag patients as participating with an MCO |
| 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. |
| District of Columbia | Provider Directory |
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: • A provider directory allows providers to look up other providers in the beneficiaries’ network to enable referral and improve transitions of care. | Number of times a provider launched the Provider Directory within ULP and searched for another provider. |
| District of Columbia | Provider Directory |
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: • A provider directory allows providers to look up other providers in the beneficiaries’ network to enable referral and improve transitions of care. | The number of providers listed in the directory that are searchable either by a structured search or a free text search. |
| 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 | Public Health | Improve Medicaid providers’ ability to effectively treat Medicaid beneficiaries by enhancing statewide public health reporting to support case management, patient care, and population health and reduce medical errors to make more efficient use of healthcare dollars. | The number of immunization records, eLRs, syndromic surveillance messages, eCRs, and advanced directives reported electronically via KHIE to public health registries. |
| 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. |
| Maryland | Event Notifications | Reduce Emergency Department and hospital readmissions by improving outreach and care coordination across care team members. | Ability to flag patients as participating with an MCO |
| Maryland | HIE Services | Improve insight into Medicaid services by identifying utilization of ED and hospital admissions and gaps in services to inform Medicaid’s program administration and providers on Medicaid population’s health. | Timely delivery of a report to Medicaid detailing beneficiary hospital utilization (ED, inpatient, readmission) and key prevention quality indicators (PQIs) |
| Maryland | PDMP | Medicaid providers are able to access the PDMP data via CRISP to improve care management for their patients | Number of times the PDMP is accessed by providers for a Medicaid patient |
| Maryland | PDMP | Medicaid providers are able to access the PDMP data via CRISP to improve care management for their patients | Users accessing PDMP within an EHR compared to the total users accessing PDMP |
| 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 |
| North Dakota | HIE Services | The use of NDHIN’s Direct Secure Messaging services (HISP, web portal) is beneficial to provider point-to-point communications and supports care referrals and use cases for sensitive patient information such as Substance Use Disorder/42 CFR Part II. | The number of Direct Secure Messages sent using NDHIN’s HISP or web portal service. |
| Oregon | Event Notifications | Reduce Emergency Department utilization and hospital readmissions resulting from improving care coordination across disparate care team members and improving outreach and engagement with Medicaid beneficiaries. | Ability for users of the Collective Platform to create a “5 in 12” cohort identifying Medicaid members who are high utilizers of ED services. |
| Oregon | Event Notifications | Reduce Emergency Department utilization and hospital readmissions resulting from improving care coordination across disparate care team members and improving outreach and engagement with Medicaid beneficiaries. | Ability to create a global flag identifying the Medicaid patients with mental illness who are accessing the ED for physical health reasons |
| 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. | The number of ADT notifications sent (# ADT notifications sent through Direct secure messaging) |
| 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) |
| Rhode Island | Event Notifications | Support the Medicaid program in improving health outcomes by providing clinicians in an emergency department (ED) hospital setting with a flag on a patient record in their EHR when that patient is at risk of an opioid overdose. Connecting beneficiaries to treatment for opioid use disorder after presenting at an ED is a critical opportunity that leads to numerous downstream improvements in care, and might result in a decrease in ED readmission. ED Smart Notifications also support clinical decision-making regarding ED and inpatient care. | Ability to provide an opioid flag in ED Smart Notifications (EDSN) (Opioid Flag in place) |
| 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. |