The Wyoming Department of Health is using its no-cost electronic health record (EHR) program as a platform to build a sophisticated central database to manage the health of its Medicaid population effectively and use the information to effect policy changes.

Earlier this month, The Wyoming Department of Health announced that it is the first state to offer a free, fully certified EHR to Medicaid providers in the state. The web-based EHR, provided by Medical Informatics Engineering (Fort Wayne, Ind.), will help Wyoming providers demonstrate meaningful use and qualify for the American Recovery and Reinvestment Act/Health Information Technology for Clinical and Economic Health (ARRA/HITECH) Act incentives while also helping their practice, and the state, improve patient care.

For context, Wyoming is the ninth largest state in the U.S. in size, yet has the smallest population, which is 568,158, according to a July 2011 U.S. Census Bureau report. Before instituting this no-cost EHR program, there was limited EHR adoption, as small practices found no reasonable return on investment, says James Bush, M.D., and medical director of the Wyoming Department of Health.

“Initially, we had a limited EHR adoption rate in Wyoming, because many of our physicians come from small- to mid-sized practices and were unable to find a cost effective and efficient EHR solution that wouldn’t disrupt workflow,” says Bush. “Many of our physicians also believed that there was no point in having an EHR if it didn’t connect with a health information exchange (HIE), hospitals, labs, pharmacies and/or other physician specialists.”    

The no-cost EHR initiative began in early 2011 and was rolled out slowly to Medicaid physicians across the state, starting with a pilot of 10 medical practices. To date, the state has more than 36 providers, 16 practices, and more than 31,000 patients registered in the initiative. The EHR was chosen, Bush says, for its impressive reporting ability and its flexibility and customization for different sizes of practices and sub specialties.

HIE and Population Health
All EHR data for the Medicaid population flows automatically into the Department of Health’s HIE, which has been functioning for two years. More than 200 individual Wyoming Department of Health databases have been linked up to share information. “One of the things I rapidly realized was that like in any practice, we only have the one patient,” says Bush. “And all of our various departments of health programs—whether it be immunizations, CHIP [Children’s Health Insurance Plan] for Medicaid, chronic diseases—we were all touching that same patient, but we had disparate databases. So we had the need to consolidate our databases, and we realized we can make this a tool for our providers to get them on to electronic health records and the health information exchange without any additional cost to ourselves.”
 
An integral part of the HIE is a CCD (continuity of care document) viewer, with a future vision to have bidirectional interchange with Medicaid providers. “So when [providers] pull a CCD on any Medicaid client, they can see current meds, a med list, allergies, procedures, and diagnoses,” says Bush. “Even if the doc is still on paper, the MMIS [Medicaid Management Information Systems] claims data and the immunization data will still be there on the CCD viewer.”

The data within the HIE provides clinicians with ways to manage healthcare gaps and non-compliant patients. A recent ambulatory quality measures assessment showed there were 10,709 opportunities to improve diabetes care for Wyoming patients. For example, one high utilization area that providers could focus on was the 4,000 diabetes candidates who were missing some recommended laboratory test or preventative screening, says Bush. The report also identified 3,972 high-risk patients, which could be children, chronic obstructive pulmonary disease (COPD), patients, diabetics, etc., who didn’t get flu shots during the past year and the more than 2,000 patients who were non-compliant with their cardiology medications.  

“It really allows us to get very specific to [understand] why are we so far off on national indicators in some areas,” says Bush.

The next stage of Wyoming’s population health plan will be to use the Medicaid claims and clinical information collected through the HIE to find the areas for greatest improvement. This will allow the Department of Health to use this data to assess the under or over utilization of particular drug therapies; analyze the areas that are most outside national standards and perform outreach to physicians; and perform outreach on specific public health initiatives like Hepatitis C, colorectal cancer, and cervical cancer prevention. For instance, physicians will be given a relative ranking based of their patients who have received preventative screenings and which patients fall outside of the criteria. “If they are missing some of these public health issues, the doc will get a flag on that to remind him,” says Bush.

Bush says a good example of how Wyoming was able to drill down on its population to effect change was analyzing the usage of Synagis, a medication used to prevent respiratory syncytial virus infections for children who have required treatment for chronic lung disease or been born prematurely. In 2010, Synagis was one of the top three drugs administered in the state, with 967 prescriptions being written at a cost of $1.8 million. The next year new criteria were implemented based on updated American Academy of Pediatrics guidelines that set age and time recommendations for the medication. Over the next two years, Synagis dropped to 587 prescriptions at a cost of $1.6 million. “Kids who did not meet clinical criteria were getting the drug, so we were able to affect significant savings with no adverse problems,” says Bush, “and that was a pretty cool example of how you can identify a problem, affect a change in policy, and give at least as good of care at a significant savings.”

In addition to the no-cost EHR, the state added a personal health record (PHR) (NoMoreClipboard; Fort Wayne, Ind.) to the offering last month. This system is intended to encourage high cost and high risk Medicaid patients to manage and improve their healthcare plans. Bush says that his department is in the process of implementing an awareness campaign for the PHR.

The costs for the EHR and HIE are coming out of the Medicaid budget. The vendor contracts were secured before ARRA money was distributed, so favorable rates were received, says Bush. Bush concludes the cost savings for providing better care has more than paid for the initial technical investment his department has made.