DevOps: Advance software solutions and improve outcomes

This October, my colleagues and I attended the National Association of Health Data Organizations (NAHDO) annual meeting in Park City, Utah. NAHDO is a national non-profit membership and educational association dedicated to improving healthcare data collection and use. NAHDO is also a co-founder and member of the All-Payer Claims Database (APCD) Council, which provides leadership and technical assistance to states implementing APCDs. For more on the history of NAHDO, click here.

This year’s conference centered on balancing transparency, privacy, and quality in an age of enhanced reporting on public health information. As a follow-up to the annual meeting, I wanted to share with you some of the key takeaways:

1. Stakeholder engagement is key to achieving increased data transparency. As state agencies, hospitals, researchers, and other health data representatives embark on data transparency-related initiatives, representatives from Colorado, Maine, New Hampshire, and Washington made clear the importance of having the right stakeholders involved from the start. To NAHDO attendees these stakeholders include attorneys, providers, members, state agency representatives, legislators, payers, and others with the subject matter expertise and experience to integrate and publicly share health information data.
2. Collaboration maximizes cost transparency. Collecting cost-related information from providers, and making the information accessible to health data consumers, remains a difficult task for many organizations. Although several states have worked diligently with legislators to mandate that providers supply cost-related information to state health agencies, several other states have partnered with their member, provider, and insurance communities to form work groups that collaborate in the name of making healthcare more accessible and affordable.
3. If you build it, they may not come. Building treasure troves of information for health data consumers is only beneficial if the consumers know the information exists, and are interested in using it. To help spread the word about new web-based platforms and/or tools, organizations across the nation are leveraging creative marketing strategies via Google AdWords and Facebook. Colleagues from Colorado’s Shop for Care, Maine’s CompareMaine, New Hampshire’s HealthCost, New York’s FAIR Health, and Washington’s HealthCareCompare shared their successes and challenges in making the public aware of critical healthcare information. In support of this takeaway, Andrea Clark, BerryDunn’s Senior Analytics Manager, joined colleagues from the Center for Improving Value in Health Care, Washington State, and FAIR Health to speak about BerryDunn’s work helping clients develop enhanced public use healthcare data products. You can read more about that here.

Rally behind “The Year of Data Quality.” During the recent Medicaid Enterprise Systems Conference (MESC) in Portland, Oregon, Julie Boughn—Director of CMS’ Data and Systems Group—named 2018 “The Year of Data Quality.” NAHDO attendees, in support of this mission, highlighted that consistent nation-wide file layouts, coupled with consistent field definitions across databases, could go a long way in improving data quality in health IT solutions, such as APCDs.

In sum, the annual meeting was an excellent venue for hearing from data gurus, state health information officials, and those passionate about affecting change through health data solutions. As the conference in years past was attended mostly by APCD gurus, the stakeholder audience continues to broaden to include all those who have a hand in improving citizens’ health and well-being.

Read this if you are a state public health agency or a key interested party in state public health data systems design, development, and implementation.

In recent years, addressing disease risk through mitigation of Social Determinants of Health (SDOH) has become a shared goal between public health and the Centers for Medicare & Medicaid Services (CMS), bringing these agencies into the limelight for efforts to reduce healthcare costs, mitigate disease, and improve the health of the population. Efforts include leveraging Health Information Technology (HIT) and data sharing for electronic reporting of disease surveillance data, lab data, and health registry data. To do this, state agencies need to develop, enhance, or procure capable data systems and identify funding sources to support this work. With the number and size of data system enhancements needed and the fluctuations of public health funding, public health agencies need long-term, sustainable funding sources.

CMS policies and initiatives such as Electronic Health Record (EHR) Incentives, 21st Century Cures Act, Promoting Interoperability, and Medicaid Enterprise Systems (MES) are consistently, and sustainably funded through federal allocations to support HIT design, development, and implementation. When state Medicaid programs and public health agencies are able to identify shared goals and electronic reporting needs, joint efforts can tap into the same federal funding sources used by CMS to support the design, development, and implementation of public health data systems. State public health agencies who want or need to leverage this opportunity for federal funding will need to build or strengthen partnerships with their state Medicaid offices to learn more about applying for funding by submitting an updated Advance Planning Document (APD).

What is the Medicaid Enterprise System (MES)?

The MES is a modernized, state-based Medicaid Management Information System (MMIS) that uses modules to support enterprise-level systems interoperability. The MES is designed to help states efficiently manage and deliver Medicaid-funded services to their eligible populations and streamline interoperability across healthcare providers and regulatory agencies, including public health agencies. The development and adoption of the MES is part of CMS’s Promoting Interoperability Program.

The Promoting Interoperability Program and the development of the MES modules are built upon past programs for healthcare provider EHR incentives. These programs funded certified EHR system enhancements to electronically report health and billing information to state and federal agencies. As part of Promoting Interoperability, the reporting requirements have been updated to include electronic health information exchange and exchanging data with public health agencies. For calendar year 2023, CMS-certified systems are required to report on four scored objectives and their measures:

• Electronic prescribing
• Health Information Exchange (HIE)
• Provider to Patient Exchange
• Public Health and Clinical Data Exchange

The Public Health and Clinical Data Exchange objective requires that eligible hospitals and CMS-qualified providers actively engage with a public health agency or clinical data registry to submit electronic public health data. Data submission requirements for the Public Health and Clinical Data Exchange Objective may include the following:

• Immunization registry reporting
• Syndromic surveillance reporting
• Specialized registry reporting for either public health registries or clinical registries
• Electronic reportable laboratory results reporting
• Electronic case reporting
• Funding public health systems development

With the addition of the Public Health and Clinical Data Exchange objective, healthcare providers and state agencies are eligible for federal funding to support HIT systems design, development, and implementation. While several public health infrastructure and data modernization funding opportunities are available, MES federal funding can be leveraged to cover the costs of system enhancement, thus freeing up other funding sources to support modernized data management and use. As an example, MES funding can support immunization registry development while public health infrastructure funding supports data visualization tools and integration.

To apply for federal funding, state public health agencies will need to partner closely with their state Medicaid offices to understand their current and past APD processes, submissions, and approvals. Collaboration between Medicaid offices and state public health agencies is critical for this process since the APD submission and approval process is managed by CMS regional offices. The public health field is plagued by siloed programs and data systems that challenge collaboration efforts. Cross-agency collaboration between public health and Medicaid can be an additional challenge, but not one that cannot be overcome.

If you have any questions, please contact BerryDunn’s Public Health or Medicaid consulting teams for Public Health and/or Medicaid Agencies. We’re here to help!

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification or modernization efforts.

Over the last two years, the Centers for Medicare and Medicaid Services (CMS) has undertaken an effort to streamline MES certification. During this time, we have been fortunate enough to be a trusted partner in several states working to evolve the certification process. Through this collaboration with CMS and state partners, we have been in front of recent certification trends. The content we are covering is based on our experience supporting states with efforts related to CMS certification. We do not speak for CMS, nor do we have the authority to do so.

How does the focus on outcomes impact the way states think about funding for their Medicaid Enterprise Systems (MESs)?

Outcomes are becoming an integral part of states’ MES modernization efforts. We can see this on display in recent preliminary CMS guidance. CMS has advised states to begin incorporating outcome statements and metrics into APDs, Requests for Proposals (RFPs), and supporting vendor contracts.

Outcomes and metrics allow states and federal partners to have more informed discussions about the business needs that states hope to achieve with their Medicaid IT systems. APDs will likely take on a renewed importance as states incorporate outcomes and metrics to demonstrate the benefits of their Medicaid IT systems.

What does this renewed importance mean for states as they prepare their APD submissions?

As we’ve seen with initial OBC pilots, enhanced operations funding depends upon the system’s ability to satisfy certification outcomes and Key Performance Indicators (KPIs). 

Notably, states should also prepare to incorporate outcomes into all APD submissions—including updates to previously approved active APDs that did not identify outcomes in the most recent submission. 
 
This will likely apply to all stages of a project’s lifecycle—from system planning and procurement through operations. Before seeking funding for new IT systems, states should be able to effectively explain how the project would lead to tangible benefits and outcomes for the Medicaid program.

How do outcome statements align with and complement what we are seeing with outcomes-based or streamlined modular certification efforts?

Outcomes are making their way into funding and contracting vehicles and this really captures the scaling we discussed in our last conversation. States need to start thinking about reprocurement and modernization projects in terms of business goals, organizational development, and business process improvement and redesign. What will a state get out of the new technology that they do not get today? States need to focus more on the business needs and less on the technical requirements.

Interestingly, what we are starting to see is the idea that the certification outcomes are not going to be sufficient to warrant enhanced funding matches from CMS. Practically, this means states should begin thinking critically about want they want out of their Medicaid IT procurements as they look to charter those efforts.

We have even started to see CMS return funding and contracting vehicles to states with guidance that the outcomes aren’t really sufficiently conveying what tangible benefit the state hopes to achieve. Part of this challenge is understanding what an outcome actually is. States are used to describing those technical requirements, but those are really system outputs, not program outcomes.

What exactly is an outcome and what should states know when developing meaningful outcomes?

As states begin developing outcomes for their Medicaid IT projects, it will be important to distinguish between outcomes and outputs for the Medicaid program. If you think about programs, broadly speaking, they aim to achieve a desired outcome by taking inputs and resources, performing activities, and generating outputs.

As a practical example, we can think about the benefits associated with health and exercise programs. If a person wants to improve their overall health and wellbeing, they could enroll in a health and exercise program. By doing so, this person would likely need to acquire new resources, like healthy foods and exercise equipment. To put those resources to good use, this person would need to engage in physical exercise and other activities. These resources and activities will likely, over time, lead to improved outputs in that person’s heart rate, body weight, mood, sleeping patterns, etc.
 
In this example, the desired outcome is to improve the person’s overall health and wellbeing. This person could monitor their progress by measuring their heart rates over time, the amount of sleep they receive each night, or fluctuations in their body weight—among others. These outputs and metrics all support the desired outcome; however, none of the outputs alone improves this person’s health and wellbeing.

States should think of outcomes as the big-picture benefits they hope to achieve for the Medicaid program. Sample outcomes could include improved eligibility determination accuracy, increased data accessibility for beneficiaries, and timely management of fraud, waste, and abuse.
 
By contrast, outputs should be thought of as the immediate, direct result of the Medicaid program’s activities. One example of an output might be the amount of time required to enroll providers after their initial application. To develop meaningful outcomes for their Medicaid program, states will need to identify big-picture benefits, rather than immediate results. With this is mind, states can develop outcomes to demonstrate the value of their Medicaid IT systems and identify outputs that help achieve their desired outcomes.

What are some opportunities states have in developing outcomes for their MES modernizations?

The opportunities really begin with business process improvement. States can begin by taking a critical look at their current state business processes and understanding where their challenges are. Payment and enrollment error rates or program integrity-related challenges may be obvious starting points; however, drilling down further into the day-to-day can give an even more informed understanding of your business needs. Do your staff end users have manual and/or duplicative processes or even process workarounds (e.g., entering the same data multiple times, entering data into one system that already exists in another, using spreadsheets to track information because the MES can’t accommodate a new program, etc.)? Is there a high level of redundancy? Some of those types of questions start to get at the heart of meaningful improvement.

Additionally, states need to be aware of the people side of change. The shift toward an outcomes-based environment is likely going to place greater emphasis on organizational change management and development. In that way, states can look at how they prepare their workforce to optimize these new technologies.

The certification landscape is seemingly changing weekly as states wait eagerly for CMS’ next guidance issuances. Please continue to check back for in-depth analyses and OBC success stories. Additionally, if you are considering an OBC effort and have questions, please contact our Medicaid Consulting team. 

Read this if you or your government agency may be interested in project management or a project management office.

You may think that PMO stands for Project Management Office, Program Management Office, or Portfolio Management Office, and you would be correct. However, when establishing your PMO priorities, think:
1.    P – Planning and Processes
2.    M – Motivation
3.    O – Operations

Determining where your organization will focus your efforts is fundamental to the successful functioning of the PMO, whether the PMO is well established or just getting started. With multiple competing projects and initiatives, spending some time planning and developing your PMO priorities in the short term will save you time and effort moving forward. 

According to the Project Management Institute’s (PMI’s) research, they reported that "aligning projects and strategic objectives has the greatest potential to add value to an organization.” 

The “value” here must be determined by each organization, but through establishing your PMO priorities early, you promote a culture of project management in order to gain greater experience in project management practices and personnel. This allows for more efficient processes, more focused and flexible project managers, greater scope, schedule, and budgetary control, and ultimately more successful projects implemented.

Planning and processes

The first step in establishing the priorities for your PMO requires planning and evaluating existing processes. Identifying all projects for the upcoming year is an excellent place to start. For each project or initiative, you will want to pull together information that will assist you in the prioritization process. This may include items such as type of project, expected outcomes, aligned strategic objective(s), targeted length of the project, targeted start date, funding sources, types of approvals needed, resource capacity, and risk versus reward analysis. Each organization can make the determination of what kind of information is necessary in this step to make prioritization more streamlined and specific to their current structure and processes.

As new team members enter and exit project work, there is a risk that knowledge transfer of the PMO processes get lost, or deviations in processes begin to occur. PMI notes “high-performing organizations succeed through a strategic focus on people, processes, and outcomes” and 74% of these high-performing organizations are supported by a PMO. Taking the opportunity for continuous process improvement―to review and share the PMO processes and templates with the organization on a reoccurring basis―helps to ensure consistency across programs within the organization. With consistency comes efficiency, allowing your project teams to focus on the work at hand, and not recreate processes. Consistency and efficiency will help streamline administrative activities, improve resource estimates, and increase the likelihood that projects will come in on time and on budget.

Motivation 

The second step in establishing PMO priorities is motivation. Having a working knowledge of your organization will help in this step―knowing what excites or drives them to succeed. Motivating factors may vary for different organizations. For example, if you’re a government entity, the deciding factor in priority may be a legislative mandate. Early identification of your organization’s motivating factors allows you to expedite the prioritization efforts and increase planning time for high-priority projects, including aligning resources sooner. Here are a few ideas to consider when thinking about finding what motivates people in your organization:

• Durations/meeting timeframes
• Legislation/mandates
• Strategic plans and goals
• Recognition
• Policy
• Outcomes/potential impacts
• Level of risk
• Return on Investment (ROI)

Operations

The third step in establishing PMO priorities is operations. By outlining operational aspects of the projects before establishing your PMO priorities, you can see the big picture and organizational strategy. Per PMI, organizations which “align their PMO to strategy report 38% more projects meet the original goals and business intent, while 33% fewer projects are deemed as failures.” This allows you to understand dependencies between projects, identify possible duplication or gaps, and plan for resources earlier. Below are a few examples to consider with this step:

• High-level strategy (will the work be delivered in phases or at the end of the project)
• Approximate Full-Time Equivalents (FTEs) required
• Skill level needed for the resources
• Organizational charts and reporting relationships
• Approximate cost for the project/initiative

Now that you are aware of the three steps―planning and processes, motivation, and operations, you are ready to begin establishing your PMO priorities. Evaluating all three steps helps ensure you’ve considered everything before prioritizing the work, although some items may clearly have more weight than others. There is no magic formula for establishing PMO priorities, and given the same projects, different organizations would have different priorities. One organization may define and identify project work as high, medium, or low, while another PMO may number projects, with number one being the first project to start. Either way is right. 

The important take-away is for your PMO to develop a consistent methodology as you are establishing priorities now and in the future. 

Does your organization need help establishing your PMO processes, prioritizing, or developing strategic plans? Contact our Medicaid Consulting team for more information on how we can help.

Resources cited

Project Management Institute. PMI’s Pulse of the Profession: The High Cost of Low Performance. PMI.org. Accessed July 8, 2020. https://www.pmi.org/-/media/pmi/documents/public/pdf/learning/thought-leadership/pulse/pulse-of-the-profession-2014.pdf?v=eb9b1ac0-8cad-457f-81ec-b09dbb969a38 
Project Management Institute. PMI’s Pulse of the Profession – 9th Global Project Management Survey: Success Rates Rise – Transforming the High Cost of Low Performance. PMI.org. Accessed July 8, 2020. https://www.pmi.org/-/media/pmi/documents/public/pdf/learning/thought-leadership/pulse/pulse-of-the-profession-2017.pdf