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CHIC Full Proposal 1-7 - University of Utah - School of Medicine

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					Section 1: Quality System Assessment

1. Political & State Agency Leadership

      The Children’s Healthcare Improvement Collaboration (CHIC)∗ aims to offer a medical

home for every child enrolled in Medicaid/CHIP in Utah and Idaho, focusing on coordination of

care for those with chronic conditions and using health information technology (HIT) to improve

measurable quality and health outcomes. Utah’s Governor, Gary Herbert, and Idaho’s Governor,

Butch Otter, are committed to investing in children and the quality of healthcare they receive.

      Utah – Governor Herbert has made health system reform a priority, with a goal that all Utah

citizens have health insurance coverage. In the last few years, Utah’s political leadership has

contributed in many ways to health care reform, assuring access to affordable, quality health care

and optimizing use of the state’s public programs. During the 2008 legislative session, the Utah

Legislature passed several key bills involving the state’s health care environment, including

House Bill 133, which established a health systems reform legislative task force and provided

funding for the nation’s first transparent all payer database that allows Utah’s Department of

Health (UDOH) to match and track all Utahns’ healthcare expenses across different insurance

plans. The legislature also passed House Bill 236, allowing Utah’s CHIP to remain continuously

open, thereby ending closed enrollment periods. Other legislative reforms include: Senate Bill

132 – Healthcare Consumer’s Report (2005), House Bill 9 – Healthcare Cost and Quality Data

(2007), House Bill 47 – Standards for Electronic Exchange of Clinical Health Information

(2008), House Bill 128 – Electronic Prescribing Act (2009), and House Bill 165 Health Reform

Administration Simplification (2009). Find links at http://medicine.utah.edu/upiq/CHIPRA/.

      In May 2009, Governor Herbert appointed David Sundwall, MD, Executive Director of



∗
    for a list of recurring acronyms and the Bibliography, see the last pages of the Appendix;
    see http://medicine.utah.edu/upiq/CHIPRA/ for direct links to legislation and other resources
                                                  1
UDOH, to lead the Utah HIT Governance Consortium. As the state’s HIT Coordinator, he

ensures the coordination of efforts to develop a strategic statewide electronic health architecture.

   These legislative reforms, executive leadership, and regional cooperation have enabled Utah

to initiate and pilot a market-driven health information exchange (HIE), developed by the Utah

Health Information Network (UHIN) and named Clinical Health Information Exchange (cHIE).

The cHIE aims to enable access to all relevant clinical information by all providers in Utah.

UHIN is a broad-based coalition of Utah healthcare insurers and providers that, since 1993, has

operated a successful, self-funded administrative data exchange, handling ninety percent of all

insurers’ administrative claims, remittance, and eligibility data. Utah’s CHIP and Medicaid

Management Information System (MMIS) is connected with UHIN’s system to exchange claims

and eligibility data and is developing the exchange capacity to share clinical data with the cHIE.

   Idaho – Governor Otter and Idaho legislators have also committed to improving healthcare

outcomes and access to healthcare for children. Idaho Medicaid requires all children to enroll in

its primary care case management program (Healthy Connections) to assure access to healthcare

through a “medical home.” A report directed by the Idaho Legislature recommended that Idaho

expand the Healthy Connections Program to achieve significant savings while providing quality

care and a “medical home” to Medicaid and CHIP participants. In 2006, House Bill 776 resulted

in streamlining enrollment processing of Medicaid participants into Healthy Connections. All of

Idaho’s identified stakeholders see the value of medical homes as a means of improving care.

Idaho’s proposal to integrate Idaho Medicaid services and resource data into Utah’s Medical

Home Portal (see Category B) aligns with the legislature’s interest in the medical home.

   In 2006, Governor Otter signed House Bill 738 which reads, “It is the intent of the legislature

that the Department of Health and Welfare (IDHW) promote improved quality of care and

improved health outcomes through investment in health information technology and in patient


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safety and quality initiatives in the state of Idaho.” This legislation resulted in the creation of the

Health Quality Planning Commission (HQPC). The initial focus of the commission was to

achieve improved quality of care and improved health outcomes through investment in HIT.

After two years of research and work, the HQPC determined that the most effective way to

achieve its charge was to promote the establishment of a health data exchange.

    In August 2007, Governor Otter convened the Idaho Health Care Summit to evaluate Idaho’s

healthcare system and recommend ways to make healthcare more accessible. One month later, he

established the Governor’s Select Committee on Health Care to evaluate their recommendations,

which included advancing quality healthcare for children and addressing healthcare reform.

    In 2008, the Idaho Health Data Exchange (IHDE) was created as a non-profit corporation to

govern the development and implementation of a statewide HIE in Idaho. The IHDE is governed

by a Board of Directors that includes representation from both the public and private sectors,

including the health care delivery and financing systems, Idaho Employers Coalition, and

consumers. All partners have made a financial commitment to the data exchange. The IHDE is

planning to connect more than 1,500 Idaho physicians, 30 hospitals, and 10 ancillary service

providers across the state to share clinical data in real time over the next four years. Connecting

the IHDE and the cHIE would support existing patient flows from Idaho to regional referral

centers in Utah (e.g., Primary Children’s Medical Center and other Intermountain Healthcare

facilities), as well as improve the care of Utah patients cared for by Idaho clinicians and facilities

(e.g., Portneuf Medical Center in Pocatello and St. Luke’s Health System in Boise).

    After the IHDE was established, the Health Quality Planning Commission shifted focus to

identify areas where a statewide, organized effort to improve health outcomes would be

beneficial. A subcommittee was established with representation from a variety of health

organizations in the state, including Medicaid, to make recommendations to the HQPC. Three


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focus areas were agreed to: improving access to healthcare, improving immunization rates, and

decreasing obesity. Work is underway to gather information from all major stakeholders and to

make recommendations for a coordinated, statewide approach to improve health outcomes. This

work is being coordinated with the IHDE, as providers may report measures related to health

outcomes in these areas through the exchange. Developing a two-way interface between IHDE

and Idaho’s Immunization Reminder Information System (IRIS) will improve immunization

outcomes for Idaho children by providing healthcare professionals with easy access to

immunization records, as well as a more consistent reporting method. For direct links to Idaho

legislation and other documents, see http://medicine.utah.edu/upiq/CHIPRA/.

2. Stakeholder Support

   This proposal has the full support of Utah and Idaho’s Governors, Medicaid and CHIP

Administrations, and the leadership of the Idaho and Utah Health Data Exchanges. UHIN, IHDE,

and several divisions within the state of Utah’s Department of Health and Idaho’s Department of

Health and Welfare, will be substantially involved in implementing this proposal.

   The Utah Healthcare Delivery and Payment Reform Task Force was established by House

Bill 165 Health Reform Administration Simplification (2009) to develop strategies to reduce

growth in healthcare costs, improve healthcare outcomes, reduce waste in the healthcare system,

and improve satisfaction among patients, providers, payers, and purchasers. The Task Force

includes representatives from a cross-section of stakeholders, including insurers, employers,

provider organizations, public health, academics, and consumer and political advocacy groups.

HealthInsight (see next paragraph) serves as facilitator for the Task Force. “Section 2. Section

31A-22-614.6” of the bill provides for “Health care delivery and payment reform demonstration

projects” that are being developed by the Task Force’s Core Work Group, which is comprised of

a similar cross-section of interested parties. Two demonstrations of alternative approaches to


                                                4
compensating for care are moving forward – one paying for pregnancy as an episode of care and

the other paying for diabetes care through a combination of retainer, fee-for-service, and sharing

of savings. The Core Work Group recently added our proposed demonstration using “embedded”

Medical Home Coordinators (Category C) as a third potential demonstration, enabling inclusion

of an alternative payment approach as part of the demonstration and detailed analysis of cost and

process outcomes through the Utah All Payer Database (APD). If this proposal is funded, we will

work with the Core Work Group on payment strategies and the potential for additional funding

to expand the planned demonstration or enable earlier implementation of the later components.

   HealthInsight is a private, non-profit Quality Improvement Organization (QIO) and the

federally Chartered Value Exchange (CVE) for Utah. Through the CVE, more than two dozen

key healthcare stakeholders are convened to address healthcare reform, including transparency of

cost and quality, realigning incentives and promoting the adoption and use of HIT. HealthInsight

has led many initiatives to improve the quality of care delivered in Utah over the past 30 years.

HealthInsight has applied to be the HIT Regional Extension Center (REC) for the state of Utah

and expects to begin this work early in 2010.

   Qualis Health is the QIO for Idaho and has applied to be the HIT REC in Idaho and

Washington. Along with the MacColl Institute for Healthcare Innovation and the Commonwealth

Fund, Qualis is working with the Idaho Primary Care Association to develop a replicable and

sustainable implementation model for medical home transformation.

   Utah’s ARRA HIT funding opportunities are coordinated through the Utah HIT Governance

Consortium, led by David Sundwall, MD, who heads the Department of Health and is the state-

designated HIT Lead. This group leads the creation of the state HIE plan. All key healthcare

stakeholders participate, including Medicaid, UHIN, medical associations, universities, and

HealthInsight. The CHIC will work with the HIT Governance Consortium and the CVE to link


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related projects, leverage resources, and avoid duplication. HealthInsight has agreed that, if they

are the REC, practices participating in this project will receive priority assistance.

   Intermountain Healthcare (Intermountain) is a large, integrated healthcare system with one

hospital in Idaho and 22 in Utah, including Primary Children’s Medical Center (PCMC) in Salt

Lake City – the only tertiary care children’s facility in the two states. About one-third of children

admitted to PCMC are Medicaid/CHIP enrolled. Intermountain is nationally known for its

leadership in improving the quality and cost effectiveness of the care it provides.1 PCMC is the

primary teaching facility for the University of Utah (UofU) Department of Pediatrics and

pediatric programs in surgery, radiology, and other specialties. UofU faculty, based at PCMC,

comprise over 90% of Utah pediatric sub-specialists. Together, the UofU and PCMC are key to

providing quality sub-specialty care for Medicaid- and CHIP-insured children in Utah and Idaho.

   Intermountain’s Institute for Health Care Delivery Research, led by Brent James, MD, has

agreed to offer its Advanced Training Program in clinical quality improvement to clinicians and

medical home coordinators participating in the CHIC. Lucy Savitz, PhD, Senior Scientist with

the Institute and Director of the UofU Clinical and Translational Science Award (CTSA)

Community Engagement Core, will perform an independent evaluation of the CHIC.

   The Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ), established in 2003,

includes the UofU Department of Pediatrics, Utah Medicaid, the UDOH, the Utah Chapters of

the American Academy of Pediatrics and American Academy of Family Physicians,

HealthInsight, Intermountain Healthcare’s Primary Care Clinical Programs, Utah Voices for

Children, Molina Healthcare of Utah (which offers a CHIP program), University of Utah Health

Care (which offers a Medicaid managed care plan), and PCMC’s Pediatric Education Services.

UPIQ’s aim is to improve the health and healthcare of Utah’s children by supporting primary

care practices in implementing evidence-based and measurement-guided quality improvement


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strategies. UPIQ has involved 120 pediatric clinicians, from 60% of the state’s 97 pediatric

practices, 3 Medicine-Pediatrics physicians, and 47 family medicine clinicians in at least one

(some in as many as 5) of 14 quality improvement projects. These have focused on topics such as

asthma, ADHD, immunization delivery, screening for developmental and social-emotional

problems, oral health risks, and obesity, and implementation of Medical Home concepts related

to children and youth with special healthcare needs (CYSHCN). Results of UPIQ’s first project

were published2 and a second manuscript, presented at a national meeting, is under review.

   The Medical Home Portal (www.medicalhomeportal.org) is a collaborative effort among the

UofU Department of Pediatrics and Spencer S. Eccles Health Sciences Library, the UDOH, Utah

Family Voices (local chapter of a national organization for families with CYSHCN), and the

Utah chapter of the American Academy of Pediatrics. It is a web-based resource for medical

homes, families of CYSHCN, and other professionals which began in 2001 to support a Maternal

and Child Health Bureau-funded medical home project. The Portal provides information about

specific diagnoses, professional and community services for children and families, educational

services, use of technology by and for CYSHCN, screening and prevention, and implementation

of the medical home model in practice. For families, it provides information about partnering

with professionals, managing care and family issues, and advocacy. The Portal’s mission and

scope have expanded as its potential for supporting improvements in the care of CYSHCN has

been tapped for several subsequent projects. With National Library of Medicine (NLM) funding

(G08 LM007680 / G08 LM007680-03S1), the site’s infrastructure was rebuilt to improve every

aspect of the site and to enable integration of services data from other states/regions.

   The table below lists involved stakeholders, their level of support, and indicates those who

have agreed to serve on an advisory or governance committee. Letters of support that exceed the

capacity of the Appendix can be found at http://medicine.utah.edu/upiq/CHIPRA/.


                                                  7
 Stakeholder Name & Title      Stakeholder Type                  Level of Support
Gary Herbert, Utah Governor    Utah Chief          Letter of support required by the Grant and
                               Executive Official  oversight of the grant implementation
C.L. Butch Otter, Idaho        Idaho Chief         Letter of support required by the Grant and
Governor                       Executive Official  oversight of the grant implementation
Michael Hales, Director Utah   Utah State          Letter of support, oversight of grant
Medicaid Health Care           Medicaid Director   implementation, provide staff and other
Financing Division                                 resources, governance committee member
Leslie M. Clement,              Idaho State        Letter of support, oversight of grant
Administrator                   Medicaid Director implementation, provide staff and other
                                                   resources for implementation, evaluation
                                                   and governance
David Sundwall, MD              State Government Letter of support; grant implementation
Executive Director              Agency Partner     oversight, governance committee member,
Utah Department of Health                          chair of Utah HIT Governance Consortium
Senator Richard Compton,        Idaho Legislative Letter of support; recommendations for
Chair                           Commission         needed legislation. The Commission was
Idaho Health Quality Planning                      mandated by Legislation; Commission
Commission                                         members are appointed by the Governor
Representative Ronda Rudd       Vice Chair, Utah Letter of support and can make
Menlove                         House Health and recommendations to the legislature for any
Utah House of                   Human Services     legislative changes that may be neede
Representatives                 Committee
Edward B. Clark, MD, Chair, Academic Partner, Letter of support; grant governance
Dept. of Pediatrics, University Non-Profit Partner committee chairperson; Leader of the
of Utah; Chief Medical          Agency, Utah       Regional Pediatric Referral Medical Center
Officer, Primary Children’s     Child Health       for Utah and Idaho
Medical Center                  Provider
Jonathan Sugarman, MD,          Non-profit Partner Letter of support; Medicare Quality
MPH, President and CEO,         Agency; Idaho      Improvement Organization. As HIT
Qualis Health, Idaho Medicare Quality Improve- Regional Extension Center will help
Quality Improvement             ment Org.          providers adopt EHRs and IHDE
Organization
Mark Bennett, CEO               Non-Profit Partner Letter of support; as the HIT Regional
HealthInsight, Utah Medicare Agency; Utah          Extension Center, HealthInsight will help
Quality Improvement             Quality Improve- practices adopt EHRs & cHIE and put
Organization and Federally      ment Org.          them to meaningful use; grant governance
Chartered Value Exchange                           committee member
Marc Probst, CIO                Non-Profit Partner Letter of support; collaboration on HELP2,
Intermountain Healthcare        Agency             integration of the Portal; governance
                                                   committee member
Karen Crompton, Director        Consumer/Family Letter of support; provide staff to serve on
Voices for Utah Children        Advocate Group     grant advisory committee
Barbara Leavitt, Director       Utah               Letter of support; disseminate information
Partners for Infants &          Consumer/Family to parents of CYSHCN; provide and
Children (PIC)                  Advocate Group     review resources for the Medical Home
                                                   Portal; staff serve on advisory committee


                                               8
 Stakeholder Name & Title         Stakeholder Type                   Level of Support
Michelle Britton,                 State Government     Letter of support; share and maintain Idaho
Administrator                     Agency               services data for the Medical Home Portal;
Idaho Dept. of Health and         Idaho Division of    participate in implementation of the
Welfare                           Health & Welfare     Medical Home Portal in Idaho
Keely Cofrin Allen, PhD           State Government     Letter of support; advisory committee;
Utah Department of Health         Agency               direct and facilitate access to and analysis
Office of Healthcare Statistics                        of data from the Utah All Payer Database
Utah All Payer Database
Joe Mott, CEO                     Non-Profit Partner Letter of support; facilitating institutional
Primary Children’s Medical        Agency             support and cooperation
Center (PCMC)
Evelyn Mason, Executive           Idaho                Letter of support; disseminate information
Director Idaho Parents            Consumer/Family      to parents of CYSHCN; resources and
Unlimited, Inc.                   Advocate Group       information for the Medical Home Portal
Larraine Clayton, Chair           State Government     Letter of support; disseminate information
Early Childhood Coordinating      Agency - Idaho       to parents and providers of CYSHCN;
Council                           Governor’s           provide resource and referral information
                                  Coordinating         for the Medical Home Portal
                                  Council
LaDonna Larson, Director          Non-Profit           Letter of support; develop and implement
Idaho Health Data Exchange        Organization         IHDE–UHIN and IHDE–IRIS interfaces.
                                                       Idaho’s Governing Agency for the
                                                       Implementation of HIT
Janet L. Root, PhD, Executive     Non-Profit Agency    Letter of support; partner agency/
Director Utah Health                                   contractor to build interfaces for cHIE and
Information Network (UHIN)                             between Idaho and Utah’s HIEs
Creighton Hardin, MD              Idaho Child Health   Letter of support; advisory committee;
Pocatello Children’s Clinic,      Provider             Chapter will lead development of Idaho
President, Idaho Chapter of                            Improvement Partnership and
the American Academy of                                demonstration of Medical Home care
Pediatrics (AAP)                                       coordination implementation in Idaho
Karen Buchi, MD President         Utah Child Health    Letter of support; assist with ongoing
Utah Chapter, American            Provider             support for UPIQ and the Medical Home
Academy of Pediatrics                                  Portal
Dieuwke Spencer, Bureau           State Government     Letter of support; advisory committee;
Chief, Idaho’s Children’s         Agency               provide resource and referral information
Special Health Program                                 for the Medical Home Portal and assist its
                                                       implementation in Idaho
James F. Bale, MD, Vice-          Academic Partner     Letter of support; guide and direct
Chair for Education,                                   development and implementation of QI
Residency Program Director,                            curriculum for pediatric residents; national
UofU Dept. of Pediatrics                               dissemination
Jennifer Leiser, MD, President    Utah Health          Letter of support; ongoing support for
Utah Chapter, American            Provider – Family    UPIQ; liaison for family medicine
Academy of Family                 Medicine             collaborations
Physicians


                                                  9
 Stakeholder Name & Title        Stakeholder Type                Level of Support
Holly Williams, RN, MS           State Government Letter of support; advisory; assist in
Director - Bureau of CSHCN       Agency             development of MHC training; ongoing
Utah Department of Health                           support of medical homes throughout Utah
Denise Chuckovich, Executive     Idaho Child Health Letter of support; provide resources to the
Director Idaho Primary Care      Provider           Medical Home Portal; advisory committee.
Association                                         Have a Qualis grant for Medical Home.
Bette Vierra, Executive          Utah Community Letter of support; association of federally
Director, Association for Utah   Health Provider    qualified health centers that has a CHIP
Community Health                                    outreach grant
Gina Pola-Money, Director        Consumer/Family Letter of support; Medical Home Portal
Utah Family Voices; UDOH         Advocacy           advisor; coordinate Parent Partners in
Family Advocate                  Organization       medical home demonstration.

3. Status of Medicaid/CHIP Health Delivery Systems in Utah and Idaho

    Utah covers low-income children through Medicaid, CHIP, and an 1115 premium assistance

program titled Utah’s Premium Partnership (UPP). Benefits are provided statewide through

health plans or fee-for-service. Children approved for UPP receive a subsidy to help pay for their

family’s employer-sponsored health insurance. Children with family incomes up to 200% of the

Federal Poverty Level (FPL) can receive coverage through one of these medical programs Utah’s

Department of Workforce Services implements the application and eligibility process. As of

October 2009, there are 40,449 children enrolled in CHIP with either Molina Healthcare of Utah

or Utah’s Public Employee Health Plan. An additional 130,058 children are covered by Utah’s

Medicaid fee for service or a contracted Medicaid Health Plan. There are four Medicaid health

plans – Healthy U, affiliated with UofU, and Molina Healthcare of Utah are managed care plans;

Select Access is a Preferred Provider Network; and the HOME program, also with the UofU,

focuses on individuals with “dual diagnosis” (developmental disability and mental illness).

    Utah’s Quality Assessment and Performance Improvement Plan (QAPIP), in place since

2003, provides for oversight of contracted health plans’ quality data through on-site reviews and

required reports, and other internal and external data. This information is used to determine

compliance with state Medicaid and CHIP requirements and federal regulations pertaining to


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managed care entities, and to identify opportunities for improvement and areas of non-

compliance. In addition to tracking HEDIS and CAHPS requirements, quality improvement data

regarding emergent care, urgent care, and non-urgent care access standards are collected and

reported yearly. This ensures that enrollees have access to care in a timely manner based on the

level of care needed. Utah tracks all childhood HEDIS measures, and considers access to care

and immunization measures to be of highest importance. The state has implemented pay-for-

performance incentives to plans based on their HEDIS rates for immunization of two year olds.

   The healthcare delivery structure for children in Idaho is the same for Medicaid and CHIP.

Healthcare is provided through a fee-for-service delivery system with mandatory enrollment in

Healthy Connections, a primary care case management model of managed care. Primary care

providers are paid a $3.50 per member per month (PMPM) fee for coordination of specialty

services. As of October 2009, there were 24,864 children in CHIP and 118,733 children covered

by Idaho’s Medicaid program.

   Idaho’s progress towards a comprehensive program to improve the quality of health care of

children enrolled in Medicaid and/or CHIP involves implementing its Preventive Health

Assistance (PHA) program that rewards parents for keeping their children’s well child checks

and immunization appointments. A current study (not posted yet) suggests that there has been a

significant (10-20%) improvement in Well Child Check compliance rates in the CHIP population

because of the PHA program compared to the general Medicaid population. This program also

has components that involve behavioral health, weight management, and tobacco cessation. It

provides vouchers to pay for program management fees and tobacco cessation products.

Approximately 400 Idaho children have enrolled in the program since implementation in January

of 2007 with a goal of increasing enrollment by 10% each calendar year.

   Idaho also conducts an annual utilization review of their children’s mental health services


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with a designated Medicaid clinical team working with families and providers when services are

not meeting the needs of the child. The Division of Family and Community Services also

conducts quality assurance activities for several Medicaid funded developmental disabilities

programs including the Children’s Developmental Disability Agencies (DDAs) and Children’s

Service Coordination Agencies.

   The state of Idaho’s Disease Management Program pays its federally qualified health centers

incentives for completing diabetic management plans and hemoglobin A1Cs. Through the

Healthy Schools Program, 10 full-time nurses work in 15 school districts to provide health

screens, health education, and health counseling, and improve immunization compliance. In

2008/2009 notable outcomes of the program included: 204 children who were not current on

immunizations were referred for updates; 2,516 health education presentations were made to

students and staff; 14,932 health screens were conducted (927 potential problems referred to

health care providers); 3,551 students/families were provided individual health counseling.

   Individual case quality assurance in Idaho is completed through eligibility determination and

prior authorization. Prior authorization is required for Intensive Behavioral Intervention (IBI)

and Service Coordination. The Division also reviews individual treatment plans every 6 months

for all IBI participants to assure progress, rule compliance, and effective treatment strategies.

   Agency level quality assurance is conducted through training, technical assistance, and a

rigorous certification process. Staff review provider qualifications prior to processing provider

agreements to assure agencies and individual providers are qualified. Staff provides technical

assistance and training to service providers before and during delivery of services. Quality

assurance reviews – including assessments of consumer and family satisfaction and case review

and therapy observations – are conducted to maintain quality, assure adherence to rule

requirements, and encourage positive outcomes. Failure of providers to meet standards can result


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in corrective action, up to and including suspension and termination of provider agreements.

State Activities Related to the Various Grant Categories

4. Activities related to quality measures, HIT, and care delivery models

   Utah’s Data Warehouse supports the state’s quality strategies and includes data regarding

administration, enrollment, disenrollment, capitation, claims processing, and contract

management for all of the state’s CHIP and Medicaid members and is in the process of reviewing

the data specifications for UDOH’s All Payer Database (APD). Funding for the APD was

provided via House Bill 133 in 2008. UDOH’s Office of Health Care Statistics (OHCS) is

currently responsible for building and managing the APD, which is poised to become the first

APD in the country to analyze episodes of care (EOC) derived from statewide health insurance

claims. An EOC is defined as a complete course of care from initial diagnosis through treatment

and follow up and can be traced regardless of patients switching providers or health plans. UHIN

developed the secure electronic data exchange and test files are currently being submitted by all

payers throughout the state of Utah. Initial data submissions from these plans consist of

identified medical and pharmacy claims and enrollment data from 2007, 2008, and first quarter

2009. OHCS recognizes the sensitivity associated with collecting healthcare data of this

magnitude and has taken extraordinary steps to ensure that privacy is guaranteed. Requests for

data will pass through a designated data use committee with representation from payer,

professional, research, and consumer communities to ensure that consumer privacy is not

compromised. This committee will also ensure that no released data can be reverse-engineered to

determine patient identity between payers or providers. The children for whom this project

establishes a medical home in Utah will be monitored and evaluated using the APD to answer

questions about healthcare costs, access, and quality, as well as other critical public health issues.

As the development of this APD required Utah state legislative approval, it will not be used as a


                                                 13
resource for Idaho during the grant cycle, but we hope to demonstrate that this design will be the

best example of how an APD should be developed on a regional level, requiring precise

longitudinal linking of statewide healthcare data across all payers.

       The predominant care delivery model in Utah and Idaho is fee-for-service independent

practice at the primary care level and, in Idaho, at the pediatric sub-specialty level. Exceptions

include Intermountain Healthcare’s primary care clinics, where the Pediatric Care Continuum

Managers program has been extant for more than 10 years and the pediatric sub-specialty clinics

and programs located at PCMC and staffed by University of Utah faculty. We will be building

on both of these programs to develop a seamless system of coordination of care between primary

and sub-specialty care and across independent and Intermountain systems. We will also involve

the independent sub-specialists in Idaho as our demonstration expands in years 3-5.

5. Degree of Stakeholder Involvement in Evaluating Quality Measure, HIT, & Care Model Use

   Please refer to the stakeholder discussion and table above that provide details on stakeholder

involvement. An independent evaluation will be led by a Senior Scientist in the Intermountain

Institute for Health Care Delivery Research, who has over two decades experience in conducting

such studies (Section 3). The numerous stakeholders involved in UPIQ and HealthInsight will be

intimately involved in evaluation of quality measures selected for the medical home

demonstration and each QI project, in terms of appropriateness of measures for assessing

anticipated outcome, for consistency with evolving national measures, and for efficiency and

accuracy of measure acquisition and analysis. Particular attention will be given to evaluation of

measures and outcomes by our consumer and advocacy groups.

6. Relationship of Proposed CHIPRA Demonstration on Current Projects & Legislative Efforts

   Support for UPIQ projects has come from a variety of sources, including contracts with

UDOH, charitable foundations, portions of federal grants obtained by UDOH, and, for the first


                                                 14
five years, administrative matching through Medicaid. Current UDOH grant projects in which

UPIQ is participating are: Effective Follow-up in Newborn Screening: Utah Newborn Screening

Clinical Health Information Exchange (HRSA, U22MC16508, 09/01/2009 - 08/31/2012) and

Utah Autism Spectrum Disorder (ASD) Systems Development (HRSA, H6MMC11061, 9/1/08-

8/31/11). A collaborative effort between the UDOH and the UofU College of Pharmacy on a

Medicaid Transformation Grant (Appropriation No. 7570516), now in final data analysis,

involved training practices in the treatment of asthma in children. UPIQ’s roles in these are

project specific and, though complementary to the activities proposed for the CHIC, will not

overlap, nor would the funding be supplanted by CHIPRA Quality Demonstration funding.

   The Medical Home Portal’s development, begun in 2001, has been supported by the UDOH,

charitable donations, portions of federal grants supporting medical home implementation, and

from 3/1/2005 through 2/28/2009 by a National Library of Medicine grant and an ARRA

Administrative Supplement (G08 LM007680 / G08 LM007680-03S1). Current funding includes

portions of the two grants obtained by the UDOH and mentioned above under UPIQ. The

Portal’s role in those projects involves development of content and inclusion of resources

specific to those projects – disorders detected through newborn screening and ASDs. Those will

complement, but not be supplanted by, the proposed Objective B.6. and related activities.

   The demonstration outlined in Category C will enhance and complement implementation of

Utah House Bill 133, enabling addition of a comprehensive medical home demonstration to the

previously planned pregnancy and diabetes care demonstrations.




   (Note: see the last pages of the Appendix for a list of acronyms and the Bibliography, and

       http://medicine.utah.edu/upiq/CHIPRA/ for links to legislation and other resources)


                                                15
    Abstract – Children’s Healthcare Improvement Collaboration (CHIC)

Utah and Idaho propose a collaboration to develop a regional quality system, guided by the
Medical Home model, to enable and assure ongoing improvement in the healthcare of children
enrolled in Medicaid/CHIP programs. The project will focus attention on improving care and
outcomes for children and youth with special health care needs. Meaningful use and robust
integration of electronic health records, health information exchanges (HIE), and other health
information technology (HIT) and informatics tools will support implementation of the system.
These HIT resources will be integrated into existing and new quality improvement (QI) and care
coordination programs, leveraging regional and national expertise in chronic care, QI, HIT, and
informatics. Committed leadership within state governments, healthcare delivery systems,
academic institutions, healthcare provider and QI organizations, and child and family advocacy
organizations will assure success and sustainability. CHIC will be involved in a multi-payer
demonstration in Utah, enabling inclusion of all children in participating practices. The Utah All
Payer Database will support comprehensive evaluation of costs and process outcomes.
Category B – Promote the Use of HIT in Children’s Health Care Delivery
• Optimize adoption and meaningful use of EHRs and HIE linkages by primary and sub-
  specialty child health practices to improve continuity, care coordination, and collaboration
  among clinicians and other providers, and to support quality measurement and reporting
• Create a cross-state interface between Utah’s clinical health information exchange (cHIE) and
  the Idaho Health Data Exchange (IHDE)
• Develop interfaces with public health data sources (e.g., immunization registries)
• Expand and improve the content, infrastructure and sustainability of the Medical Home Portal
  (www.medicalhomeportal.org) to support clinicians and families with information and
  resources to enhance care and access to services; integrate Idaho’s 2-1-1 services database
• Develop a Pediatric Patient Summary tool that will collect clinical data through HIEs to assist
  clinicians in maintaining up-to-date patient information to guide clinical decision-making
Category C – Evaluate Provider-Based Models … Improve Children’s Healthcare Delivery
• Pilot a new administrative service, using Medical Home Coordinators “embedded” in primary
  and sub-specialty care practices, to support ongoing improvements in care, coordination of
  care, and support for children with chronic and complex conditions and their families
• Train and assist at least 24 primary and sub-specialty child health practices in implementing
  systems to support the Medical Home model, care coordination, and ongoing measurement-
  driven QI. CHIC will accomplish this through “learning collaboratives,” development of
  practice teams, and support from Practice Coaches and Parent Partners
Category E – Development of State/Regional Models for a National Quality System
• Develop an Improvement Partnership in Idaho involving multiple stakeholders, including
  Medicaid, commercial payers, public health, provider organizations, and Quality Improvement
  Organizations, to guide, assist, and support practice-based efforts to improve quality around
  common clinical problems, such as immunization delivery, developmental screening, etc.
• With the Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ) and the Idaho
  Improvement Partnership, develop an enduring, regional improvement network
• Train pediatric residents in QI and Medical Home to help perpetuate systems for improvement
The ultimate outcomes of the CHIC will be improved healthcare and health for children in Utah
and Idaho; robust integration of HIT and HIEs into child health practices; a regional quality
system; and valuable QI tools and resources that will be shared with other states and regions.
Budget: The total 5-yr. budget request is $15,000,000; Utah – $12,750,000, Idaho - $2,250,000


                                                 16
                                            16
Section 2: Grant Categories, Objectives, and National Evaluation Questions

            Children’s Healthcare Improvement Collaboration (CHIC)

   Through the proposed Children’s Healthcare Improvement Collaboration (CHIC), Utah and

Idaho Medicaid/CHIP agencies and collaborators will leverage, enhance, and integrate existing

and evolving programs in health information technology (HIT), health information exchange

(HIE), quality improvement (QI), and care coordination to develop a sustainable system for

improving healthcare and outcomes for children. We will create a new medical informatics tool,

establish a new QI organization, and develop a new model to support practice-based QI and care

coordination. The CHIC will produce a replicable system for regional QI and demonstrably

effective and efficient programs and resources for supporting Medical Homes in QI, continuity

and coordination of care, and clinical decision-making that will be shared with other states.

   This proposal addresses three categories offered in the CHIPRA Quality Demonstration

FOA: B) Promote the Use of HIT in Children’s Health Care Delivery, C) Evaluate Provider-

Based Models Which Improve the Delivery of Children’s Health Care, and E) Create a Model

Targeting Health Care Delivery, Coordination, Quality, or Access. Utah, as lead state, and Idaho

Medicaid/CHIP programs bring multiple partners with considerable expertise, experience, and

resources, including state executive and legislative officials, HIEs, QI organizations, professional

provider organizations, public health programs, health care delivery systems, health insurance

companies, an academic institution, child and family advocacy organizations, and a web-based

Medical Home information resource. The proposal integrates the three categories around the

meaningful use of HIT to support ongoing practice-based QI and implementation of the Medical

Home model, with a focus on children and youth with special health care needs (CYSHCN). The

Utah and Idaho Medicaid/CHIP programs will guide and coordinate the proposed project and

assure compliance with state policies and collaboration with state agencies and resources.


                                                17
   Two programs based in the University of Utah (UofU) Department of Pediatrics (introduced

in Section 1) and founded as partnerships with the Utah Department of Health (UDOH) – the

Medical Home Portal (Portal, www.medicalhomeportal.org) and the Utah Pediatric Partnership

to Improve Healthcare Quality (UPIQ) – will provide leadership, structure, and resources for the

CHIC. Both grew from a 2001-4 medical home implementation project3 from which a key lesson

was that changing practice to improve care is very difficult. Through a 2003-4 national medical

home learning collaborative led by the National Initiative for Children’s Health Care Quality

(NICHQ), the Utah team learned how to apply QI approaches to effect the changes needed for a

practice to become a medical home for their CYSHCN. The development of UPIQ was spurred

by these experiences and a visit from the founders of the Vermont Child Health Improvement

Program (VCHIP), the first pediatric improvement partnership in the nation.

   Rationale for Category Integration – A goal of CHIC is to develop systems and resources,

both human and technologic, to optimize the care of the over 30% of children with one or more

chronic conditions.4 CYSHCN are a subset of this population whose conditions result in greater

need for care or services or impact on their daily lives5 – their national prevalence is 13.9%;6

Utah’s is 11.0%7 and Idaho’s 11.4%.8 CYSHCN utilize substantially more health care services

than other children.9 Analysis of recent data from a large Utah health insurer, Select Health,

found that the most expensive 11% of children, including only those with a chronic diagnosis,

were responsible for 63.2% of children’s healthcare costs and the top 1.1% were responsible for

33.4%. A further subset is comprised of children with very complex conditions (CVCC) whose

care involves multiple sub-specialists and who may be technology-dependent and medically

fragile. CVCC are receiving increasing attention, with over 30 clinical programs now focusing

on their care.10 One study estimated the prevalence of medically fragile children to be 0.22%.11

   The increased healthcare utilization by CYSHCN results in many opportunities for less than


                                                 18
optimal quality of service and care, described as underuse, misuse, or overuse of healthcare.12

This risk is enhanced by lack of familiarity with their conditions – except for asthma and ADHD,

most diagnoses of CYSHCN are uncommon or rare. However, their cumulative numbers are

substantial, representing 200-350 patients with 20-40 separate diagnoses, in a typical pediatric

primary care practice.13 Maintaining up-to-date knowledge of the evaluation and treatment of

these conditions and of local services and resources to help in their care is very challenging for

pediatricians, and even more difficult for family physicians who have fewer CYSCHN patients.

   Optimal care for CYSHCN, especially for CVCC, often requires the involvement of pediatric

subspecialists and expert providers of ancillary services. Coordination of care and collaboration

among these providers are essential to achieving the best outcomes and avoiding unnecessary

duplication of services and errors that result from poor care “hand-offs.” The medical home is

responsible for care coordination – usually the primary care practice, but, for some CYSHCN, it

may be a sub-specialty physician or complex care program. Physicians are rarely trained in care

coordination and are not compensated for the time and resources needed to provide this level of

care, and few clinicians have electronic systems that support care coordination and collaboration.

   Improving care and service is hard work, for which few clinicians have training, support, or

expertise – true for independent primary care practices as well as large care delivery systems.14,15

Implementing QI in practice requires time and resources that are not available to most primary or

sub-specialty care practices, particularly in areas, like the Intermountain West, where the ratio of

children to child health clinician is large and, thus, practices are busy. Child to pediatrician ratios

for Utah and Idaho are 2551:1 and 4580:1, respectively (national average is 1769:116). Similar

challenges exist for pediatric sub-specialists due to chronic shortages in their workforce.17,18

   Critical to enabling and sustaining QI in practice are effective HIT tools, information access,

practice-based systems and human resources, trusted leadership, and ongoing support, incentives,


                                                  19
and inspiration. Through the Objectives in the Categories below, the CHIC aims to integrate each

of these elements into a replicable, sustainable system for perpetually improving child health.

Category B – Promote the Use of HIT in Children’s Healthcare Delivery


Mission – Employ and improve existing HIT, hasten deployment of available HIT, and develop

new HIT to support implementation of the Medical Home model, ongoing practice-based QI, and

coordination of care for CYSHCN to improve health outcomes and reduce costs for children

enrolled in Medicaid/CHIP in Utah and Idaho. Enhance the Medical Home Portal to offer

decision support for clinicians and parents in caring for CYSHCN and provide information about

local professional and community services.

Vision – Enabled by sophisticated and interconnected electronic tools, clinicians caring for

children in Utah and Idaho effectively coordinate care and collaborate among themselves, with

parents, and with community services to achieve optimal health outcomes. They continually

measure and improve the care they provide. Medical homes are supported with condition-

specific, up-to-date information about patient management and important local services. By the

end of Year 5, this vision will be realized for at least 70% of the 24 (or more) practices

participating in Category C and will be enabled for all child health practices in Utah and Idaho.

   The Mission, Vision, and the Objectives below align with CMS’ Objectives by providing

ample opportunities to learn from successes and challenges in implementation of the HIT tools

used to support coordination of care (with a focus on CYSHCN), measure quality and use those

measurements to drive improvements, and to support the interventions described in Categories C

and E and measure their impact on quality and cost for CYSCHN.

 Objective 1. Optimize access to Intermountain Healthcare’s electronic health record (HELP2)

        to improve continuity and coordination of care for CYSHCN in Utah and Idaho.



                                                20
Strategy – Leverage an HIT resource, available to most primary care child health clinicians and

used by many pediatric sub-specialists caring for patients from Utah and Idaho, to improve

coordination and collaboration in the care of CYSHCN. This Strategy will immediately enable,

at no cost to clinicians, access to key clinical data and ability to communicate about patients.

Activities for Objective 1 (begin/end times – [Ygrant year.month-grant year.month])

A. Determine access to HELP2 and Message Log among primary care child health clinicians in

   Utah and Idaho who share care of CYSHCN with UofU/PCMC sub-specialists. [Y1.1-1.5]

B. Survey primary and sub-specialty clinicians to identify strengths and weaknesses of HELP2

   and Message Log in supporting care coordination and collaboration. [Y1.2-1.6]

C. With survey results and assistance of effective users, develop and deploy computer-based

   training for clinicians in using HELP2 and Message Log for care coordination. [Y1.6-1.12]

D. For those with HELP2 access but little use (expect ~150), provide information/training. For

   those without access, determine eligibility; among the eligible, determine interest; for those

   with interest (expect ~50), obtain access and provide information/training. [Y1.2-3.12]

Impact will be measured by changes in the number of child health clinicians using HELP2 and

Message Log; the relationship of use to completion of training or being a participating practice

(Category C); innovations in use of these tools generated by users; periodic satisfaction surveys.

Evidence of ability to implement and sustain the project

HELP2, developed by Intermountain Healthcare, is the electronic health record (EHR) used for

most in- and out-patient care delivered by UofU/PCMC sub-specialists and its Message Log is

used extensively for clinical communications among themselves and with some primary care

clinicians. The 2948 clinician users of HELP2 include 1718 physicians and 101 mid-level

providers who are not employed by Intermountain. Of the 182 pediatric sub-specialists using

HELP2, 74 use Message Log actively, as do 343 family physicians and 150 primary care


                                                 21
pediatricians. Intermountain will offer read-only and Message Log access to the remainder of the

270 primary care pediatricians in Utah and 140 in Idaho, and the roughly 40 Idaho pediatric sub-

specialists whose patients also receive care from UofU faculty or at an Intermountain facility.

Access to clinical information on HELP2 will allow immediate improvement in the continuity of

care across settings and Message Log will enable coordination and collaboration in patient care.

   Implementation barriers may be found in the administrative processes to enable access for

interested clinicians, but should be minimal. Successful use of HELP2 for care coordination will

present more substantial challenges for those using a different EHR – this will be addressed

through Objective 2 by increasing use of EHRs that will link to similar data through HIEs.

   Sustainability is assured because of its importance to Intermountain clinicians; enhanced

functionality is planned as Intermountain converts to a new EHR being jointly developed with

GE Healthcare – Enterprise Clinical Information System (ECIS) – over the next several years.

 Objective 2. Optimize adoption and meaningful use of EHRs and their linkage through HIEs

           among primary and sub-specialty child health practices in Utah and Idaho.

Strategy – Support, augment, and subsidize planned EHR- and HIE-related activities in Utah

and Idaho to enhance effectiveness of the Medical Home demonstration (Category C).

Activities for Objective 2 (begin/end times – [Ygrant year.month-grant year.month])

A. Assist HealthInsight and Qualis Health in identifying and motivating child health clinicians

   and practices in Utah and Idaho to adopt and meaningfully use EHRs and HIE.

    i. Promote EHR adoption and meaningful use through mail and email communications and

       at meetings of child health clinicians and practice managers. [Y1.4-4.4]

   ii. For practices participating in Category C, partially subsidize costs of HealthInsight or

       Qualis Health EHR-related technical assistance (up to $2,000 each). [Y1.12-4.4]

B. Support IHDE, UHIN, and their mutual HIE vendor, Axolotl, to implement robust


                                                22
   connections to enable cross-state sharing of clinical information. [Y2.1-3.12]

Impact will be measured by the number of participating practices that adopt and meaningful

use EHRs (aiming for 60%) and qualify for Medicaid EHR subsidy (expect 50%); and the

number of participating practices linked to HIEs (reported by UHIN and IHDE) (expect 75%).

Evidence of ability to implement and sustain the project

The vast majority of care received by children in Utah and Idaho is provided by clinicians in

small primary care or sub-specialty practices, in Intermountain primary care clinics, or in

UofU/PCMC sub-specialty clinics (Berwick’s “microsystems”19). About 61% of Utah primary

care practices, and a smaller proportion in Idaho, currently use an EHR, but none do so optimally

(as defined by “meaningful use”20). If funded as HIT RECs this year, HealthInsight and Qualis

Health will assist these practices to adopt and make meaningful use of EHRs and to qualify for

Medicaid subsidy of EHR-related costs over the next 4 years. The costs of their consultation and

assistance will be up to $2500 for primary care and $4,000-6,000 for sub-specialty practices.

These organizations have extensive experience – HealthInsight, for example, has already helped

over 200 practices transition to EHRs through their Doctors Office Quality – Information

Technology (DOQ-IT) project, funded by CMS, the Utah Medical Association, and the UDOH.

   Utah and Idaho are both using Axolotl Corporation to develop HIEs to link EHRs throughout

each state (cHIE and IHDE, respectively). The cHIE is being piloted in two rural communities

and both HIEs anticipate that federal stimulus funding will enable widespread implementation by

2011. Utah and Idaho intend to connect their HIEs so that patient data are available to clinicians

caring for patients from the other state. This is particularly important for children from Idaho

who receive sub-specialty care at UofU/PCMC, which included 1711 children enrolled in Idaho

Medicaid over the past two years. Funding from this grant will provide about one-third of the

connection costs, enabling implementation two years earlier than anticipated.


                                                23
   EHR implementation barriers are substantial, however, selection for participation in the

project will depend on practices’ intent and ability to adopt and meaningfully use an EHR.

Efforts under way with stimulus funding will improve broad penetration of EHR and HIE use.

   Sustainability of practice integration of EHRs is likely because of the incentives available

and increasing need for electronic functionalities; the HIE connection’s future is secure, given

both states’ commitment, the availability of stimulus funding, and the critical importance of

electronic connections to improve care and enable reporting of quality measures.

Objective 3. Optimize clinical access to public health-related patient data through HIEs in Utah

    and Idaho to support improving care for all children in those states (see also Category E).


Strategy – Support development of robust and, when possible, bi-directional integration of

clinical data between clinical practices and public health agencies in Utah and Idaho.

Activities for Objective 3 (begin/end times – [Ygrant year.month-grant year.month])

A. Develop and deploy electronic transfer of data between Idaho’s Immunization Reminder

   Information System (IRIS) and IHDE. [Y2.1-2.12]

B. Develop Utah public health’s capacity to query/pull new or additional vaccine records and

   newborn follow-up screening results through cHIE into public health managed clinical

   databases to assure the completeness of records in public health registries. [Y3.1-3.12]

Impact will be measured by completion of IRIS/IHDE integration and rate of utilization by

clinicians; completion of cHIE/CHARM interfaces and number of new records retrieved.

Evidence of ability to implement and sustain the project

Idaho is planning to replace the infrastructure of their IRIS over the next year, however there is

no funding to interface IRIS with IHDE. The IRIS data are essential to enable both primary care

and sub-specialty clinicians to assure timely and complete immunization of their patients.

   The Utah Statewide Immunization Information System (USIIS) is included in Utah’s Child

                                                24
Health Advanced Record Management system (CHARM), which will also include data from the

newborn screening and newborn hearing screening, birth defects registry, early intervention, and

vital records programs. An interface from CHARM to cHIE to distribute data from the newborn

screening programs is being developed with grant support (see Section 1) and funding is ready

for an out-going interface from USIIS data. The ability to query (“pull”) immunization records

and results of follow-up of newborn screening would enhance CHARM’s utility. These links

between practices and child-focused public health programs will move both states toward

integrated systems of care that will better meet the needs of children, families, and clinicians.

   Implementation barriers may result from technical and policy issues. Technical challenges

can be surmounted, since such interfaces have been built elsewhere. Data release policies are

needed to assure appropriate data privacy and access.

   Sustainability of the systems is likely because they will be integrated into existing and

expanding electronic systems that are part of broader state programs that will absorb the cost.

Objective 4. Implement systems to extract and report data relevant to pediatric quality measures

at clinician/practice levels to inform QI efforts and provide reports to public agencies and payers.


Strategy – Use and improve existing tools to enable practices to develop, report, and use

accurate and repeated measures of care and service.

Activities for Objective 4 (begin/end times – [Ygrant year.month-grant year.month])

A. Assist practices participating in Categories C and E to identify needed data from their EHR

   to support QI efforts and to report on national measures adopted by AHRQ. [Y2.1-5.12]

B. HealthInsight will reprogram and adapt an existing EHR/HIE software (EHR Measure

   Calculator) to extract data for selected measures from the EHRs of participating practices (up

   to 24 practices) and will work with those practices to implement its use. [Y2.1-5.12]

C. QI TeamSpace, a web-based quality data reporting tool, will be purchased and installed; up

                                                 25
   to 24 participating practices will be trained and supported in its use. [Y1.7-5.12]

D. Work with participating practices to run reports and to adapt and improve the extraction and

   reporting processes as needed. [Y2.1-5.12]

Impact will be measured by the number of EHRs and practices for which the extraction tool has

been adapted; the number of practices utilizing the Calculator and QI TeamSpace and number of

measures being reported; and the degree of improvement in those measures during the project.

Evidence of ability to implement and sustain the project

The substantial work required to achieve ongoing improvement in healthcare quality must be

guided by feedback on the outcomes of current care delivery and of each change in care. This is

true at all levels – microsystem (practices), organization, and policy/payment/accreditation.19

Integrating measurement, reporting, and use of quality measures requires coordinated efforts

among clinicians, vendors, HIEs, etc. The Agency for Healthcare Research and Quality (AHRQ)

is developing standard pediatric measures,20 but common data formats/reports will take time.

   HealthInsight’s EHR Measure Calculator connects directly to an EHR’s database to query

patient, lab, prescription, or other data needed to support an improvement strategy. The

Calculator compiles the data into performance rate reports (with no protected health information)

and emails them to the practice for analysis. The Center for Health Care Quality (CHCQ), based

at Cincinnati Children’s Hospital Medical Center, and Ursa Logic Corporation have developed

QI TeamSpace (www.qiteamspace.com), an open-source web application to import and track

data, report and compare performance, and guide QI projects. In Categories C and E, CHIC will

use these complementary tools to support practice strategies for QI and facilitate the reporting

needed to meet requirements for Maintenance of Certification in pediatrics (an incentive for

participation). Enabling practices to collect and analyze pediatric quality measures will allow

them to voluntarily report them to payment redesign initiatives or public transparency reports.


                                                26
   Implementation barriers may result from lack of clinician interest in looking at data or

sharing it with others. Extracting data from the repositories of Intermountain and the UofU will

require other approaches, but both systems have demonstrated interest in collaborating.

   Sustainability and spread of use of these inexpensive systems are likely because of their

utility in practice-based QI and will be enhanced by increasing payer and public requirements to

report quality data and the likely development of payment mechanisms based on these measures.

  Objective 5. Expand and improve the content, infrastructure, integrated access to, and long-

        range sustainability of the Medical Home Portal (www.medicalhomeportal.org).


Strategies – Build on an established, web-based knowledge and service information resource to

provide clinical decision and referral support and advance Medical Home implementation. Work

with CMS and other organizations to share the Medical Home Portal with interested states.

Activities for Objective 5 (begin/end times – [Ygrant year.month-grant year.month])

A. Employ a programmer to continue development of the Portal’s infrastructure, develop

   personalized features, add functionality for authors, and manage the site. [Y1.3-5.12]

B. Employ a Portal Manager to coordinate Portal activities, including developing, review, and

   updating of content, acquiring services data, and collaborations with other states. [Y1.3-5.12]

C. Continue, and expand as needed, employment of medical and lay writers to develop new and

   update existing professional and family content. [Y1.2-5.12]

D. Enable Portal access by links from “e-resources” in HELP2 and other EHRs [Y1.3-2.6];

   develop “infobutton” interfaces for HELP2 and other capable EHRs [Y2.1-4.2]; promote use

   via newsletters/presentations and with practices involved in Categories C and E. [Y1.5-5.12]

E. With CMS, American Academy of Pediatrics (AAP), and others, identify collaborators

   nationally; work with them to obtain and integrate local services data and to enhance the

   network of authors and reviewers to continually improve the Portal. [Y1.10-5.12]

                                               27
Impact will be measured by successful hiring into positions; amount of new/updated content;

number of EHRs through which the Portal is accessible; tracking visits by source, including e-

resources pages; number of states/211 programs with which the Portal is collaborating.

Evidence of ability to implement and sustain the project

The Portal has been developed by the UofU Department of Pediatrics and Spencer S. Eccles

Health Sciences Library, the UDOH, and Family Voices of Utah. It is a web-based resource for

medical homes, families of CYSHCN, and other professionals. It provides information about

diagnoses of CYSHCN, the range of local community and educational services for children and

families, use of technology by and for CYSHCN, screening and prevention, implementation of

medical home, and it provides families with information about partnering with professionals,

managing care and family issues, and advocacy. The Portal’s development, begun in 2001, has

been supported by the UDOH, donations, portions of federal medical home implementation

grants, and from 2/2005–2/2009 by a NLM grant and ARRA-related supplemental funding.

   Past implementation barriers have included finding skilled programmers, willing expert

authors, and sufficient funding. With lessons learned and CHIPRA funding, we should be able to

surmount these and new challenges. Collaborations with other states will present some

challenges, requiring effective champions in those states and minimizing cost barriers for them.

   Sustainability after the CHIC will depend on demonstration of sufficient utility and value to

other states and/or federal funding agencies. Collaboration with 2-1-1 services and public health

departments will minimize the costs of maintaining accurate services data. Sharing the content

development and review tasks across several states and their academic institutions will also limit

costs that, along with infrastructure and administration costs, can be shared among multiple

states and federal entities, perhaps including CMS.




                                                28
   Objective 6. Develop and deploy for clinical use an electronic Pediatric Patient Summary

           (PPS), initially focused on children with very complex conditions (CVCC).


Strategy – Assure the ready availability of accurate and relevant clinical information about

complex patients to support continuity and high quality care.

Activities for Objective 6 (begin/end times – [Ygrant year.month-grant year.month])

A. Develop a set of requirements for an electronic PPS to effectively and efficiently

   communicate relevant information about children with chronic conditions, utilizing primary

   care and sub-specialty clinicians, health informaticists, and parents of CVCC. [Y1.1-1.7]

B. Design and develop a PPS and software to extract relevant information from EHRs available

   via cHIE; provide for verification, editing, and updating by clinicians; assure privacy/security

   of data at all stages; link from data (e.g. problem list) to content on the Portal. [Y1.3-3.5]

C. Design and develop electronic care plans, integrated into the PPS, linked to Medical Home

   Portal content, customizable by disease, editable by clinical users, and able to utilize coded

   data to interact with EMRs, HIEs, and evolving continuity of care documents. [Y2.3-3.3]

D. Pilot and improve the PPS in the Special Care Clinic with consented patients/parents and

   with their primary and sub-specialty care and other clinicians. [Y2.8-3.9]

E. Develop training materials [Y3.7-3.12]; expand implementation into practices participating

   in Category C for further improvement; provide training for practices. [Y3.10-5.12]

F. Open the PPS to all Utah/Idaho practices and interested projects nationally. [Y5.1-5.12]

Impact will be measured by completion of specified activities; satisfaction based on periodic

email surveys of clinicians and parents and feedback submitted from the PPS screens; and utility

tracking to identify common patterns and apparent user frustrations.

Evidence of ability to implement and sustain the project

Within provider networks, use of EHRs and HIEs can aid in chronic disease management.21-23

                                                 29
However, the available information is often copious and poorly integrated, making it difficult for

clinicians to access, process, and use effectively – particularly true for CVCC, a very vulnerable

population. A readily accessible summary of key information could substantially improve

continuity across clinicians and settings, improve clinical decision-making, and satisfy patients

who tire of repeating their histories and may inadvertently omit, or not be aware of, key data.

   Scott Narus, PhD and colleagues at UofU Department of Biomedical Informatics and at

Intermountain have developed disease-specific patient summaries, tailoring information from

EHRs and providing alerts and care recommendations.24 They have used this technology in

implementing a multi-disease chronic care model25 and explored architectural factors in HIE

implementation to aid clinical information sharing across chronic disease providers.26 They have

also shown how access to context-specific disease/treatment information at the point of care via

“infobuttons” can improve providers’ ability to answer clinical questions.27

   Dr. Narus and the UofU Informatics group, with clinical domain experts, will design,

develop, and implement a Pediatric Patient Summary (PPS) application. Personnel involved have

experience in domain modeling and ontology development, important to identifying relevant

disease-related information and mapping EHR data to chronic disease models and terminology.

They also have experience in automated clinical decision support systems, critical to generating

the tailored summaries, and developing web-based applications for clinicians and patients that

will support development of the graphical user interface applications for accessing the PPS.

   Past implementation barriers included finding consensus on data and recommendations and

storing the summary metadata to make them efficient to update and immediately available for

use. We anticipate similar challenges for the PPS and expect that acquiring data from a variety of

sources will add challenges. We will develop central models and terminology (metadata) to

describe the content and develop mapping logic to translate to data received from the various


                                                30
sources. We will implement this architecture using data from one data source and add additional

sources as each is validated. Barriers to clinical use are likely, since it will require a new step in

accessing patient data – participating clinicians will receive focused training.

   If the PPS proves to be of high utility and value to clinicians and patient care, sustainability

will derive from user demand for institutional maintenance, integration into ongoing translational

research (e.g., CTSA programs), and/or an “open source” approach to ongoing development.

   Category B Strategies align with CMS Objectives by offering opportunities to learn from

implementation of HIT/HIE tools to support clinical decision-making, continuity of care, and

collaboration, and to extract and report quality measures and, through integration with Categories

C & E, to learn about their impact on care, QI, costs, and expansion of consumer choice.

   Key stakeholders will be involved in each Objective, including clinicians, QI organizations,

public health, informaticists, and HIE leaders and staff, through a learning community

framework supported by facilitated, monthly information exchange calls. In addition, parents and

child advocates, educators, and medical librarians will participate in Objective 5.

   Implementation barriers and sustainability were addressed with each Objective.

   Answering the National Evaluation questions will be assisted by ongoing data collection

by project staff and periodic summaries and reports detailing development of the tools, their

implementation, and outcomes of their use. Both tools in Objective 4 will be used in reporting

for Categories C and E. For Objective 5, participating clinicians and staff will be required to

register on the Portal to allow tracking of its use by type of user (clinician, MHC, etc.) and

Google Analytics will enable tracking by geographic location. Use of the PPS will provide

feedback for improvements and for reporting to the National Evaluator.

Category C – Provider-based models which improve the delivery of children’s health care


Mission – Train, deploy, and support Medical Home Coordinators (MHCs), embedded in

                                                  31
primary and sub-specialty care child health practices in Utah and Idaho, to develop the

infrastructure and teamwork needed to implement the Medical Home model, effectively

coordinate patients’ care, and engage parents as partners in their children’s care.

Vision – Primary care and sub-specialty child health practices in Utah and Idaho function as

effective Medical Home teams, providing high quality, coordinated, and collaborative care, in

partnership with parents, and with particular attention to CYSHCN. By the end of Year 5, this

vision will be realized for at least 60% of the 24 participating practices and systems will be

available to support all interested practices in moving toward the vision.

  Objective 1. Develop the infrastructure to train, deploy, manage, and support Medical Home

          Coordinators (MHC) “embedded” in primary care and subspecialty practices.


Strategy – UPIQ will collaborate with Intermountain’s experienced Pediatric Continuum Care

Managers (PCCM) to develop an administrative program to serve non-Intermountain practices

and to train existing and new personnel to support practice-based QI efforts.

Activities for Objective 1 (begin/end times – [Ygrant year.month-grant year.month])

A. Develop a collaborative administrative structure between UPIQ and the PCCM program to

   provide shared leadership, training, supervision, and support for MHCs embedded in

   Intermountain and non-Intermountain child health practices. [Y1.2-1.12]

B. Develop curriculum to train MHCs in QI, HIPAA, use of HIT tools (EHRs, Medical Home

   Portal, data reports), care coordination, and accessing community resources. [Y1.4-1.12]

C. Hire and train two MHCs, by UPIQ, to work within participating primary care and sub-

   specialty MHPs; update/expand training of existing PCMC PCCMs to include QI. [Y1.9-2.3]

D. Hire and train a Practice Coach to guide and support participating practices in planning,

   implementing, measuring, and evaluating their QI efforts. [Y1.9-2.3]

E. Hire an experienced Parent Partner Coordinator (PP Coordinator) to work with participating

                                                 32
   practices and to help them identify, recruit, and support Parent Partners. [Y2.1-2.2]

F. Employ and train a “Concierge” to work with subspecialty practices and PCMC to coordinate

   scheduling of clinic and facility services for CYSHCN, particularly CVCC. [Y2.2-5.12]

G. Scale up hiring/training of MHCs and Practice Coaches to meet the needs of the expanding

   number of practices (MHCs ~1 per 3 practices, Coaches ~1/12-16 practices). [Y1.9-5.12]

Impact will be measured by successful development of a collaborative administrative structure;

completion of the initial curriculum (and iterative improvements); hiring/training of Practice

Coaches, MHCs, and PP Coordinator; tracking improvements in administrative approaches.

Objective 2. Implement and evaluate a demonstration of the Medical Home model of care using

 embedded MHCs, focusing on coordination of care for CYSHCN and on integrating ongoing,

      measurement-driven QI in practice – developing “Medical Home Practices” (MHP).


Strategy – Starting with practices trained in previous projects, recruit an expanding number of

primary care and sub-specialty child health practices into Learning Collaboratives to train and

support them in using embedded MHCs and practice-based QI to improve care and service.

Activities for Objective 2 (begin/end times – [Ygrant year.month-grant year.month])

A. Recruit and expand training of 6 (3 Intermountain / 3 non-Intermountain) Utah primary care

   practices and train 3 subspecialty practices in Medical Home, QI, and care coordination in

   Year 2; recruit and train 3 Utah and 3 Idaho primary care practices in Year 3; recruit and

   train 3 Utah and 3 Idaho primary care practices in Year 4; recruit and train 3 subspecialty

   practices in Year 5. In years 3-5, aim for diversity in practice distance from specialty care.

    i. Develop curriculum for training MHPs in Medical Home, QI, and care coordination.

       [Y1.7-1.12] Update and improve the curriculum for each additional cohort. [Y2.10-4.4]

   ii. Design implementation and evaluation of the demonstration; obtain Institutional Review

       Board approval from UofU, Intermountain, and UDOH. [Y1.6-1.12]

                                                33
   iii. Recruit initial practice teams – each with at least one clinician, a clinical staff member, an

       administrator, and a Parent Partner (parent of a CYSHCN). [Y1.8-2.1] Offer incentives

       (see Category E) – to include practice stipends to offset costs of lost productivity and

       travel (if distant) for the Learning Session (iii below) and for the Parent Partner. Recruit

       additional practices (outlined above), beginning 3-4 months prior to the start of each year.

   iv. Conduct a one-day Learning Session addressing Medical Home, QI, and development of

       initial aims and strategies. A second half-day Session will be offered each year to refresh

       and reinvigorate MHPs. Invite all MHPs to each Session, but full team attendance will

       not be required for those already trained during this project. [Y2.2, 3.2, 4.2, and 5.2]

   v. Conduct monthly web/phone conferences (for all MHP teams) to focus on specific topics

       of interest, provide team progress updates, answer questions, problem solve. [Y2.2-5.12]

   vi. Practice Coaches assist MHCs by phone/email and site visits to maintain momentum,

       problem solve, and help with access to needed resources. [Y2.2-5.12]

  vii. Through the Medical Home Portal, provide information to MHP teams about Medical

       Home implementation, the care and management of CYSHCN and specific conditions,

       relevant local services, and QI; gather feedback to improve the Portal. [Y2.2-5.12]

  viii. MHPs will help collect and report quality measures (those specific to MHP aims and

       selected standard AHRQ measures) to UPIQ monthly; UPIQ reports measures back to

       practices to guide improvement strategies and identify strong performers. [Y2.3-5.12]

B. Assign MHCs to MHPs and provide them with ongoing support, including information,

   training, facilitation, etc.; MHCs will help organize and become a valued member of the

   Medical Home team in each MHP and will provide care coordination for patients, in

   collaboration with other team members and directly, focusing on CYSHCN. [Y2.1-5.12]

C. In each MHP, engage parents of CYSHCN in substantive roles guiding QI efforts and in


                                                 34
   helping practices support CYSHCN and their families; may involve a single “Parent

   Partner,” a multi-parent Advisory Committee, or other model; PP Coordinator will help

   recruit, train, and support Parent Partners. [Y2.1-5.12]

Impact will be measured by successful completion of Activity A components; number of

MHPs recruited/employed; practice satisfaction with and perceived effectiveness of MHCs,

Practice Coaches, and PP Coordinators; achievement of QI goals; documented roles of MHCs in

team building, QI, and developing distributed care coordination roles among practice staff;

changes in practice policies related to Medical Home; changes in practice-specific and AHRQ

quality measures reported by practices; trends in patient costs and service utilization among

MHPs and compared to matched controls in other practices (analysis of data in the APD).

Quantitative analyses will be supported by qualitative study results as described in Section 3.

    Objective 3. Expand the proposed implementation of the Medical Home model and care

 coordination as a multi-payer demonstration; evaluate the impact on care, costs, and outcomes.


Strategy – Include and expand the MHC/QI implementation as a demonstration sponsored by

the Utah Health System Reform Task Force and developed by the Core Work Group (CWG).

Activities for Objective 3 (begin/end times – [Ygrant year.month-grant year.month])

A. Work with the CWG to develop models for alternative payment for Medical Home care,

   including care coordination, enhanced access (phone, email, etc.), etc. Possibilities include

   per member per month compensation, fee-for-service for billable services not currently

   compensated, enhanced payment for practices that meet certain criteria, pay-for-performance

   for quality measures, sharing savings based on a pre-determined budget, etc. [Y1.6-2.4]

B. Develop consensus for one or more models for a demonstration among MHPs; design project

   collaboratively with participating payers. [Y2.3-2.11]

C. Implement demonstration with funding from the payer group for needed expansion of the

                                                35
   existing project and practice compensation according to the chosen model. [Y2.12-5.12]

Impact will be measured by successful development of a multi-payer demonstration, the details

of the compensation strategies developed, and the outcomes as measured and analyzed through

designs based on the demonstration and through data from the All Payer Database.

   The Category C Strategies align with CMS objectives by building on existing programs to

create a new administrative model of practice-based QI and care coordination for CYSCHN in

primary and sub-specialty clinics across geographic settings – generating copious information on

challenges, solutions, and successes in planning and implementing the program and its impact.

   The stakeholders involved will include those on UPIQ’s Steering Committee, Intermountain

Healthcare/PCMC and the PCCM program, CWG members, UDOH Bureau of CSHCN, and

parent support organizations, e.g., Idaho Parents Unlimited and Utah Family Voices. The level of

involvement of participating practices, the PCCMs, Utah Family Voices, and UPIQ’s partners

will be intense throughout the project. Involvement of parent support organizations will likely be

focused and based on engagement of member parents with children in participating practices.

Evidence of ability to implement and sustain the project

   Despite the widely accepted importance of care coordination for CYSHCN, there is a paucity

of evidence about its optimal implementation or its impact on care or costs.28 Intermountain’s

PCCM program, initiated in 1998, pioneered the provision of care coordination services for

CYSHCN in Utah and has had considerable success as measured by clinician and parent

satisfaction. Each of the four PCCMs serves 2-3 pediatric clinics, collectively 51 clinicians. All

are RNs with many years of pediatric and care management experience. They coordinate

services, find resources, improve communication and access, act as advocates, and empower and

educate patients about diagnoses and treatments. In a recent year, PCCMs had 641 new referrals

and 5998 encounters (50% by phone) with 925 patients – an average of 6 per patient. The most


                                                36
commonly encountered diagnosis was ADHD; tracheostomy dependency was the eleventh most

common. The latter resulted in the most frequent encounters, at 8.72 encounters per child, and

ADHD had the least at 2.5. Over that year, 2372 encounters improved communication, 1602

reduced fragmentation, 753 increased patient knowledge/empowerment, and 138 increased

adherence to treatment. The program is partly funded by a $0.49 per member per month fee to

manage care for children with special health care needs for SelectAccess, Intermountain’s

Medicaid PPO. The PCCM Director is based at PCMC where she also manages the inpatient

discharge planners. PCMC is committed to continuing the program and supporting the CHIC in

training the PCCMs in QI and sharing leadership for the MHCs.

   Through previous medical home implementation and integrated services projects, UPIQ and

its predecessors have trained 20 practices across Utah in some components of the Medical Home

model, focusing on the care of CYSHCN. From 2001-4, 5 practices were trained in a MCHB-

funded collaboration between the UDOH and UofU Department of Pediatrics. Three additional

practices received training through a MCHB-sponsored national Medical Home Learning

Collaborative (2003-4) led by the National Initiative for Children’s Healthcare Quality (NICHQ).

UPIQ and the UDOH trained another 12 practices in the MCHB-funded Integrated Services for

CYSCHN project from 2005-8. UPIQ and UDOH are also involved in two current projects that

incorporate medical home principles – one focused on integrated services for children with

autism spectrum disorders (ASD) and the other on improving follow-up of newborn screening

(mentioned in Section 1). The former includes training “dental homes” for children with ASDs.

   Most of the trained practices have maintained some of the improvements made during the

projects and receive ongoing support from the UDOH Bureau of CSHCN and UPIQ through

occasional site visits, emails about news or resources, and email/phone advice and problem-

solving. The Bureau and UPIQ also provide newsletters about selected medical home topics (16


                                               37
in the past 7 years) and conference calls (49) that have been transcribed and archived on the

Portal. Intermountain practices with PCCMs have been the most successful at sustaining their

medical homes and Utah Valley Pediatrics, with 6 offices and 32 clinicians, recently employed a

care coordinator to work with one of their clinics. Many clinicians feel that an in-office care

coordinator is the most important resource to enable them to improve the care of CYSHCN.

   Intermountain’s Institute for Health Care Delivery Research will offer its Advanced Training

Program in QI to participating clinicians and MHCs. Technical assistance will also be provided

by the Center for Health Care Quality, Cincinnati Children’s Hospital Medical Center, which has

extensive experience in organizing large QI projects through the Improving Performance in

Practice (IPIP) program.29

   Sustainability of the CHIC infrastructure and changes implemented in participating MHCs

will depend on healthcare compensation reform. The “Patient-Centered Medical Home” has

garnered substantial attention since the concept was adopted by adult specialty organizations and

is receiving support from employers and insurers (www.pcpcc.net). The National Committee for

Quality Assurance (NCQA) has developed criteria for recognizing practices as medical homes

(http://www.ncqa.org/tabid/631/Default.aspx). Passage of health reform bills by both houses

offers some optimism that reforms will be forthcoming. Multiple approaches to compensation

could support the services that contribute to a comprehensive Medical Home.

   Implementation barriers to becoming a medical home (learned in previous projects) are

substantial, largely due to the lack of third-party payment for the enhanced services involved.

Coordinating care, accessing community services, and maintaining knowledge of uncommon

conditions, available resources, and practice tools are time consuming and uncompensated.

Changing practice requires time and resources, as well as QI techniques and teamwork. Success

of the intervention will be enhanced by starting with six practices with some previous training in


                                                 38
medical home. The embedded MHCs will help practices overcome some barriers by providing

knowledge, team building skills, and care coordination services. They will assist in monitoring

for and reporting barriers and will help in problem-solve and implement solutions. The HIT tools

described in Category B will help MHPs access information and provide feedback on the impact

of attempts at improvement. Spread within practices has been challenging – in most, only 1-3

(out of 4-8) clinicians have been fully involved. We expect the MHCs to help with this by

making participation both easier and more rewarding.

   Answering the National Evaluation questions will be assisted by the PCCM’s records of

past activities and UPIQ’s records of previous and current medical home projects. These include

job descriptions, training curricula, quality goals and interim measures/reports, and Learning

Session and process evaluations. Ongoing collection of updated information, practice data, and

quality measures, including the impact measures listed with each Objective, will be performed

by CHIC staff and facilitated by MHCs and Practice Coaches and by the HIT tools discussed in

Category B. The Utah All Payer Database (APD) will provide access to data about claims and

paid amounts for services provided in MHPs and will permit comparisons to matched practices/

patients (data to be de-identified before analysis). With the APD for analysis, 24 practices should

provide sufficient scale to answer several key questions about medical home implementation.

Category E – Development of state/regional models for a national quality system


Mission – Develop a new Improvement Partnership in Idaho; through it and UPIQ deploy the

leadership, supports, tools, and incentives needed to engage child health practices in ongoing

quality improvement, including measurement and evaluation. Initiate development of an

enduring improvement network among child health clinicians to support and sustain ongoing

improvements in care, service, and outcomes for children enrolled in Medicaid and CHIP.

Vision – Clinicians caring for children will continually improve care, based on measurement and

                                                39
evidence, enabled by HIT, inspired by colleagues in enduring improvement networks, supported

by rational compensation, and with leadership from state/regional improvement partnerships. By

the end of Year 5, at least 50% of participating practices will have documented substantial

improvement and will be collaborating with colleagues in planning for broader improvements.

        Objective 1. Establish regional leadership, support, and infrastructure for improvement

partnerships to foster, guide, facilitate, and measure ongoing quality improvement in the care of

  children, focused on optimizing access to high quality care and improving health outcomes.


Strategies – Expand and build on the experience and infrastructure of UPIQ to establish a state-

wide pediatric improvement partnership in Idaho. With regional collaboration, develop an

approach to improving care and service for children enrolled in Medicaid/CHIP that can serve as

a model for a national quality improvement framework.

Activities for Objective 1 (begin/end times – [Ygrant year.month-grant year.month])

A. Enhance the infrastructure of UPIQ, its partnerships, and support

   i. Employ an Executive Director with QI, health care administration and/or public health

          background and leadership, education, research, and/or statistical expertise. [Y1.4-5.12]

  ii.     Engage additional partners from among commercial insurance carriers, employers,

          hospitals, educators, consumer groups, parent organizations, and an associate pediatric

          residency program director from the UofU (see Objective 3 below). [Y1.10-5.12]

 iii.     With participation of the partners and interested parties in Idaho, update the UPIQ Needs

          Assessment and expand to include regional data, issues, and resources; involve the APD

          to access and analyze reliable population-based utilization data. [Y2.0-2.6 and Y4.0-4.6]

 iv.      Identify priority QI topics (e.g., immunization delivery, mental health screening, asthma

          care); develop and implement QI projects in Utah and Idaho (activities similar to those

          outlined in C.2.A.iii-viii) – Y1: 1 topic, Y2: 2 topics, Y3-5: 3 topics per year. [Y2.4-5.12]

                                                   40
  v.   Employ additional QI staff, including Practice Coaches, as needed to meet the needs of

       existing and new QI projects. [Y2.6-5.12]

  vi. Implement EHR Measure Calculator and QITeamSpace for extracting, measuring, and

       reporting standardized QI data for practices (see Category B, Activity 4). [Y2.8-5.12]

 vii. Enhance incentives for QI project participation, e.g., education credits for nurses and

       mid-level providers, help in seeking NCQA Patient-Centered Medical Home recognition,

       and working with payers to develop compensation models for quality. [Y3.1-5.12]

 viii. Work with UPIQ’s and the Idaho Improvement Partnership’s (see Activity B below)

       partners and others to develop and implement strategies for enhancing the value of

       practice-based QI efforts and for their long-term sustainability. [Y3.7-5.12]

B. Establish a Pediatric Improvement Partnership for Idaho – options include an independent

   Idaho Improvement Partnership (IIP) that could collaborate with UPIQ on regional efforts or

   a semi-independent IIP, with an infrastructure that is an extension of UPIQ. [Y1.10-3.6]

Impact will be measured by development of UPIQ infrastructure and establishment of IIP and

its infrastructure; annual completion of QI projects; number of participating practices/ clinicians;

and number of clinicians receiving MOC credit (see below) and practices recognized by NCQA.

   Objective 2 Initiate development of an “enduring improvement network” among practices

          participating as MHPs and in other improvement projects in Utah and Idaho.


Strategy – Build on the HIT resources, improvement partnerships, and lessons learned to work

with Utah and Idaho practices to initiate a culture of collaboration, innovation, and constructive

competition aimed at improving care, service, and outcomes for children and their families.

Work with partners and stakeholders to develop the community, institutional, and governmental

supports and compensation strategies needed to perpetuate and expand this culture.

Activities for Objective 2 (begin/end times – [Ygrant year.month-grant year.month])

                                                 41
A. With all interested participating practices, develop and prioritize QI goals and strategies for

   the network. Expect that 15-25 clinicians from 8-15 practices across Utah and Idaho will

   have sufficient interest to serve as “pioneers.” [Y3.9-4.4]

B. Work with key stakeholders interested in priority goals to develop network-based QI project,

   preferably as a demonstration involving innovative compensation strategies. [Y4.2-5.2]

C. Implement the network-based improvement project with guidance, coordination, and support

   from UPIQ, IIP, and a broad base of stakeholders. [Y5.0-5.12]

Impact will be measured by improvements related to priority goals and in clinician satisfaction;

measured outcomes appropriate to project aims; evidence of a sustainable network/culture.

   Objective 3. Develop and initiate a curriculum for pediatric residents focused on perpetual

                       quality improvement and the Medical Home model.


Strategy – Build for the future by inculcating pediatric trainees with didactic and experiential

exposure to the principles and practice of QI and the Medical Home model.

Activities for Objective 3 (begin/end times – [Ygrant year.month-grant year.month])

A. Informed by the activities in Categories C and E and curricula used elsewhere (e.g.,

   Intermountain ATP), develop a curriculum and program for training residents at the

   UofU/PCMC in QI and Medical Home. [Y3.1-4.4]

B. Involve residents in QI projects in inpatient and outpatient settings where they work; require

   active resident participation in at least one QI project during their 2nd or 3rd year. [Y4.5-5.12]

C. Share the curriculum and lessons learned with other training programs at pediatric academic

   meetings and through the Association of Pediatric Program Directors; seek collaborators for

   national implementation, evaluation, and ongoing improvement. [Y5.5 and beyond]

Impact will be measured by development and incremental improvement of the curriculum;

numbers of residents trained; their evaluations of the training; publication and/or presentation of

                                                 42
the curriculum in national journals/meetings; implementation in other residency programs.

   The Category E Strategies align with CMS Objectives by enhancing an existing QI

organization to build and evaluate a regional model for training clinicians and implementing QI

in diverse practices. The QI projects will provide substantial opportunities for learning about

collaboration amongst stakeholders and identifying and problem solving around implementation

challenges. The impact measures outlined for each Objective will inform the CMS regarding the

success (or failure) of implementation, specific approaches, and outcomes.

   The numerous stakeholders involved in UPIQ and engaged in developing the IIP will be

actively involved in setting priority targets for QI and outcome measures through the Steering

Committees. Ongoing stakeholder engagement will be sought through periodic reports on

progress and measures, requests for feedback, and expectations for input into planning. We

expect the level of engagement to vary among stakeholders and over time – we will target

specific stakeholders to enhance their engagement with projects of particular relevance to them.

Evidence of ability to implement and sustain the project

Since 2003, UPIQ (see also Section 1) has implemented 14 QI projects, involving over 170

primary care clinicians from across Utah. This has been accomplished with limited staff

(currently 1.5 FTE and 0.2 FTE for the Director) and mostly project-specific funding. The annual

budget has averaged ~$200,000, which has permitted only limited evaluation of the projects and

their outcomes.2 However, each project has demonstrated improvements in measures related to

practice-chosen improvement aims and satisfaction among participants is consistently high.

   UPIQ’s approach to supporting practices in QI has taken two primary forms – “learning

collaboratives” (LC) and “academic detailing,” with “peer mentoring” augmenting the latter.

UPIQ’s LCs bring clinicians, office managers, clinical staff, and, for some projects, parents from

6-14 practices together to learn about the evidence, expert guidelines, and local services relevant


                                                43
to the project’s topic. Participants are also trained in basic QI and develop initial strategies and

goals. Education materials are provided in a binder, with evidence and guidelines, practice tools

(screening instruments, data collection tools, etc.), and lists of local services and other resources.

Local service agency representatives are often invited to Learning Sessions or in-office meetings

to build trusting relationships. After the Learning Session, practices receive support for 6-9

months through site visits, phone/email, periodic conference calls, and monthly chart audits on

selected measures. In academic detailing projects, practices receive the didactic components in

their offices. The use of peer mentors in these projects (clinicians with particular expertise and

who receive additional training) adds to the effectiveness by bringing very practical approaches.

   Five of UPIQ’s projects have been approved by the UofU’s IRB; two were also approved by

Intermountain’s IRB. The first was published,2 another is under review, two are in progress, and

one is complete and in final data analysis. The latter is a collaboration with the UDOH and the

UofU College of Pharmacy on a Medicaid Transformation Grant (Appropriation No. 7570516)

in which UPIQ provided academic detailing related to the treatment of asthma in children.

   Despite its success in providing clinicians statewide with practice-level support for QI, UPIQ

lacks sustained funding. Moreover, none of our practices has established sustainable systems for

ongoing QI. A survey of past participants, published in a broad-based QI needs assessment30 for

Utah children (http://medicine.utah.edu/upiq/Publications/), identified numerous suggestions for

greater effectiveness, including longer assistance and follow-up and networking among practices.

Though not addressed directly in the survey, additional barriers often mentioned included lack of

resources to dedicate staff (or clinician) time to QI and lack of compensation incentives.

   The CHIC will provide an optimal environment for testing implementation of this QI system

by offering support for practice innovation, feedback on both project-specific and standard

AHRQ quality measures, the potential to experiment with compensation-based incentives, and


                                                  44
development of a network of clinicians and stakeholders. UPIQ’s needs assessment,30 which

evaluated children’s health and healthcare quality status using publicly available measures, will

be updated periodically and will guide priority development among the partnerships.

   With funding from the Commonwealth Fund, a number of states are developing

improvement partnerships and, led by the Vermont Child Health Improvement Program, a

National Improvement Partnership Network (NIPN) is being created. UPIQ is a member of this

emerging network and will use Technical Assistance from the network’s leaders, Judith Shaw,

RN, EdD and Paula Duncan, MD, in organizing potential partners and establishing the new IIP.

   Among the incentives for QI are a few “sticks,” such as the new need to demonstrate QI in

practice for Part 4 of the American Board of Pediatrics (ABP) Maintenance of Certification

program (MOC). UPIQ was the first state improvement partnership to obtain ABP certification

to provide MOC for a QI project and it offers credit for three of its current projects.

   An “enduring quality improvement network” to experiment with and disseminate innovations

in healthcare may be one of the most important elements of a sustainable quality system.29 Such

a network could marshal the creativity and energies of its participants and influence others,

including local/regional payers and government officials. The Utah and Idaho Chapters of the

AAP each enthusiastically support this proposal and will provide leadership in identifying

interested clinicians and offering opportunities at meetings and through newsletters and other

communications to inform and motivate their memberships. Family physicians have been

involved in several UPIQ projects and a representative of the Utah Academy of Family

Physicians sits on the UPIQ Steering Committee. We anticipate similarly reaching out to Idaho

family physicians. Peter Margolis, MD, PhD and Keith Mandel, MD, leaders of the Center for

Health Care Quality, Cincinnati Children’s Hospital Medical Center, will provide Technical

Assistance in implementing rigorous measurement and reporting, using QI TeamSpace (see


                                                 45
Category B), and will bring their experience with the national Improving Performance in

Practice program (www.ipipprogram.org) and others in managing large QI projects and working

with payers to develop demonstrations that involve compensation incentives.

   Sustainability will be greatly enhanced if reform of health care compensation focuses on

quality and outcomes, rather than procedures and volume. If national Medicaid/CHIP reform,

guided by successful state demonstrations (as in Category C), supports improvement

partnerships and practices, commercial payers will be likely to follow and the development of

sustainable regional and national quality systems for children’s health care could be assured.

   Implementation barriers have been encountered in several previous UPIQ projects,

including recruiting sufficient numbers of practices (difficulty varies with topic and timing

during the year and relative to other popular projects). A current project focusing on dental

homes for children with autism spectrum disorders is struggling to recruit dentists. Other barriers

have included obtaining repeated measures from practices, maintaining interest among practice

leaders and staff, especially during busy periods, and sustaining changes after the project ends.

Close monitoring of barriers by CHIC staff will continue and each will be addressed by CHIC

leadership and the Steering Committees of the Utah and Idaho improvement partnerships.

   Answering the National Evaluation questions will be aided past QI project records that

include: recruiting materials, curricula, and practice reports on QI aims. The needs assessment30

compiled data on health measures and quality for Utah children, surveys of participants and sub-

specialists, reviews of potential areas for QI, and summary recommendations. CHIC staff will

collect, maintain, and report details of implementation of each Objective and will collaborate

with the National Evaluator to assure timely and focused response to all questions – of particular

interest will be sustainability and impact on health outcomes. With 12 planned QI projects and

HIT tools to measure quality, we expect the scale to be adequate for a robust evaluation.


                                                46
Section 3: Draft Operational Plan and Process for Development of the Final Operational Plan


                                     1. Implementation Plan


The draft implementation table below describes selected project activities (up to 4 per Objective)

with estimated start and end dates. All tasks are assigned an owner or accountable party and their

qualifications are indicated. The Idaho and Utah Medicaid/CHIP programs will each employ a

project manager with proven project management and leadership skills and business analysts

with documented skills in analyzing business issues at all levels. These professionals will be

responsible for coordinating efforts between Utah and Idaho, establishing the final plan with

CMS, and holding all parties and persons responsible and accountable for their assigned tasks

and for cooperation with other team members. Utah will also employ a programmer (identified

as a research consultant in the Budget) who will assist with data collection and data and

information technology management, including installation and support for QI TeamSpace.

(Note: start and end dates follow the convention [Ygrant year.month – grant year.month])

             Category B               Responsible Party                    Qualifications
Objective 1: Optimize Access to HELP2
                                                           Regional Director,
1. Determine HELP 2access
                                    Joe Hales, PhD & staff Information Systems,
              [Y1.1-1.5]
                                                           Intermountain (RDIF)
2. Survey clinicians                                       RDIF; extensive clinician
                                    Dr. Hales; UPIQ staff
                [Y1.2-1.6]                                 contact
3. Develop training module          Mitch Perkins,         Clinical Information Systems
               [Y1.6-1.12]          CPHIMS                 Lead, PCMC
4. Provide training, access                                RDIF; 6 yrs training
                                    Dr. Hales; UPIQ staff
               [Y1.2-3.12]                                 experience
Objective 2: Optimize Adoption Meaningful Use
1. Assist practice recruiting       Chuck Norlin, MD;      Medical Director; UPIQ
                [Y1.4-4.4]          UPIQ staff             experience with clinicians
2. Support adoption/use of the cHIE
                                    HealthInsight & Qualis Extensive experience; HIT
and IDHE in participating practices
                                    Health staff           Regional Extension Centers
               [Y1.12-4.4]



                                                47
           Category B (cont.)             Responsible Party             Qualifications
Objective 2: Optimize Adoption Meaningful Use (cont.)
3. Connect IDHE to the cHIE            UHIN, IHDE, Axolotl
                                                                State HIEs and vendor
                [Y2.1-3.12]            staff
Objective 3: Interfaces with Public Health Data Resources
1. IRIS / IHDE interface developed and
launched                               IRIS and IHDE staff      Responsible for applications
                [Y2.1-2.12]
2. Develop/implement tools to “pull”
cHIE immunization/newborn data         UHIN, CHARM staff Responsible for applications
                [Y3.1-3.12]
Objective 4: Systems to Extract and Report Quality Measures
                                       Dr. Norlin and UPIQ      Experience working with
1. QI data needs assessment
                                       staff, HealthInsight     practices on QI design and
                 [Y1.3-4.2]
                                       staff                    implementation
2. EHR Measure Calculator adapted
                                       HealthInsight staff      Developed application
                [Y1.11-4.2]
                                       UDOH programmer;
3. QITeamSpace installed                                        Skilled programmer; QI
                                       Dr. Norlin; TA from
                [Y1.7-1.12]                                     experience; tool developers
                                       CHCQ
4. Extraction/reporting tools          HealthInsight, Dr.
                                                                Experience with tools, QI,
implemented                            Norlin, UPIQ staff and
                                                                and programming skills
                [Y2.1-5.12]            UDOH staff
Objective 5: Expand and Improve Medical Home Portal
1. Hire necessary staff                Dr. Norlin, Portal       Developed and directs the
                 [Y1.3-1.8]            Director and Idaho       Portal
2. Enable Portal access via HELP2 E- Dr. Norlin; with Joe
                                                                Portal Director; extensive
Resources                              Hales, PhD;
                                                                experience with HELP2
                 [Y1.3-2.6]            Intermountain IT staff
3. Promote Portal use/access and
                                       UPIQ staff, Idaho staff, Strong connections with
distribute training materials
                                       provider organizations clinicians and community
                [Y1.5-5.12]
4. Develop additional collaborations                            Portal Director; connections
                                       Dr. Norlin; AAP staff;
with other interested states                                    with AAP Chapters; grant
                                       CMS staff as interested
               [Y1.10-5.12]                                     program administrators
Objective 6: Develop Pediatric Patient Summary (PPS)
1. PPS designed and developed          Scott Narus, PhD;        Informatics faculty; Pediatric
                 [Y1.3-3.5]            Bryan Stone, MD; staff faculty, CYSHCN research
2. Design/develop care plans and                                Informatics and Pediatric
                                       Scott Narus, PhD;
training materials for PPS                                      faculty, see Section 2 for
                                       Bryan Stone, MD; staff
                 [Y2.3-3.3]                                     more detail
3. Pilot PPS with selected practices   Drs. Narus, Stone, and Experience and working with
                 [Y2.8-3.9]            Norlin and UPIQ staff practices in implementation


                                             48
           Category B (cont.)            Responsible Party             Qualifications
Objective 6: Develop Pediatric Patient Summary (PPS) (cont.)
4. Open PPS to all practices           Drs. Narus and Norlin, As above, working with
               [Y5.1-5.12]             UPIQ                    practices
               Category C                Responsible Party             Qualifications
Objective 1: Medical Home Coordinators (MHC)
1. Develop infrastructure and                                  CHIC Medical Director;
                                       Dr. Norlin; Evy Smyth,
curriculum for MHC’s                                           Director, PCMC’s PCCM
                                       RN, CCM; UPIQ Staff
               [Y1.2-1.12]                                     program manager
                                                               17 yrs Division Chief, and
2. Hire and train initial staff        Dr. Norlin; with Evy
                                                               program development;
                [Y1.9-2.3]             Smyth’s assistance
                                                               directs PCCMs
3. Conduct data collection and cost                            Documented skills in data
                                       Idaho and Utah Project
benefit analysis                                               collection and benefit
                                       Staff
                [ongoing]                                      analysis
Objective 2: Implement Medical Home Demonstration
                                       Dr. Norlin; UPIQ staff; Academic/program
1. Recruit and train initial practices
                                       Evy Smyth; Idaho        development; 14 past QI
[Y1.8-2.1]; add and train practices
                                       Improvement             projects; directs PCCM
annually [Y2.8-4.2]
                                       Partnership             program; new IP
2. Assign and support MHCs             Dr. Norlin, Evy Smyth,
                                                               As above
               [Y2.1-5.12]             RN; UPIQ staff
                                                               Director, Utah Family Voices
3. Engage and involve parents
                                       Gina Pola-Money         / UDOH Family Advocate,
               [Y2.1-5.12]
                                                               past Medical Home projects
Objective 3: Expand Multi-Payer Demonstration Project
1. Develop conceptual models for                               CHIC Director; VP at
                                       Dr. Norlin; Christy
compensation strategies and gain                               HealthInsight; mandated by
                                       North; Core Work
acceptance from commercial payers                              Legislative Health Reform
                                       Group
                [Y1.6-2.1]                                     Task Force
2. Design and implement project as an Dr. Norlin; Christy
expansion of CHIC                      North; Core Work        As above
              [Y2.12-5.12]             Group
               Category E                Responsible Party             Qualifications
Objective 1: Establish Regional Improvement Partnership
                                       Dr. Norlin; UPIQ        UPIQ Director; extensive
1. Enhance UPIQ infrastructure
                                       Steering Committee      experience / community
               [Y1.4-5.12]
                                       and Staff               support
2. Develop/deliver 1-3 QI projects/yr. UPIQ; Improvement       14 past QI projects; new
               [Y2.4-5.12]             Partnership in Idaho    organization / UPIQ help
3. Establish Idaho Improvement         UPIQ; Creighton         President, Idaho AAP; have
Partnership [Y1.10-3.6]                Hardin, MD; NIPN        developed 15 other state IPs



                                            49
           Category E (cont.)           Responsible Party         Qualifications
Objective 2: Initiate Enduring Improvement Network
1. Develop priorities and identify   UPIQ & Idaho
“pioneers” and stakeholders who will Improvement           Past experience and new
provide resources and support        Partnership (IIP)     roles
               [Y3.9-4.4]            leaders/staff
Objective 2: Initiate Enduring Improvement Network (continued)
2. Implement network improvement
                                     UPIQ & IIP            UPIQ experience and recent
project
                                     leaders/staff         Idaho experience
              [Y5.2-5.12]
3. Foster/support national network                         Extensive UPIQ and national
                                     UPIQ and IIP; NIPN
              [Y5.0-5.12]                                  experience
Objective 3: Develop QI curriculum for pediatric residents
                                     Dr. Norlin; Wendy     Faculty & UPIQ experience;
1. Develop QI curriculum
                                     Hobson, MD; UPIQ      Assoc. Program Director and
               [Y3.1-4.4]
                                     staff                 Director Continuity Clinics
2. Implement training in various     Dr. Norlin; Wendy
settings                             Hobson, MD; UPIQ      As above
              [Y4.5-5.12]            staff
3. Share curriculum/experience       Dr. Norlin; Wendy
                                                           As above
           [Y5.5 and beyond]         Hobson, MD



                                      2. Management Plan


Project Leadership will comprise the Directors of the Medicaid Divisions for Idaho and Utah

(Division Directors), the Medical Director (Chuck Norlin, MD), and the Project Managers (PM)

for Utah and Idaho. The Advisory Committee will include representatives of all stakeholders

listed in the Stakeholder table (see Section 1) and others identified during the course of the

project. The representatives may change over time or for specific meetings to assure appropriate

expertise or perspective. Contact will be maintained by Project Leadership with leaders in each

stakeholder organization to assure ongoing engagement of their representatives. The Governance

Committee will be comprised of:

 • (Chair) Edward B. Clark, MD; Chair, UofU Department of Pediatrics; Chief Medical

    Officer, PCMC; Chair, Pediatric Guidance Council, Intermountain Healthcare


                                                 50
 • David N. Sundwall, MD; Executive Director, Utah Department of Health; Chair, Utah HIT

    Governance Consortium; Member, Utah Governor’s Cabinet

 • Michael Hales; Director, Health Care Financing, Utah Department of Health

 • Marc Bennett, MA; President and Chief Executive Officer, HealthInsight

 • Marc Probst; Vice President and Chief Information Officer, Intermountain Healthcare

If the Final Operational Plan (or subsequent plans) for Idaho incorporates a multi-payer

demonstration or broader-based policy/compensation strategies, Idaho leaders will be added.

   The Division Directors will provide oversight and direction for the entire project and will

review, approve, and facilitate key project elements. The Medical Director, working closely with

the PMs, will lead and direct implementation of Categories C and E and the integration of

Category B Objectives with the entire project. The PMs will manage all aspects of the project in

accordance with the approved project plan, serve as liaison to the Advisory Committee and the

Governance Committee, supervise consultants and vendors, direct and lead the team members

toward project objectives, manage the budget, and handle all problem resolution.

   The Advisory Committee will review quarterly summaries of project activities, provide

guidance and recommendations to Project Leadership, and its members will provide counsel as

needed on project activities related to their expertise and influence. The Governance Committee

will periodically review critical measures of project progress related to long-range strategies (as

determined in Final Operational Plan development) and aims beyond the project. They will guide

Project Leadership and marshal needed resources and support to optimize the likelihood of

project success and sustainability of the programs and approaches that are proven effective.

   Project team members will include all leaders and staff involved in each Objective, including

analysts, programmers, UPIQ and Portal staff, MHCs, Practice Coaches, etc. Responsibilities of

team members will include: understand the needs and business processes of their respective


                                                 51
areas, communicate project status and progress to the PM’s and other stakeholders, review and

approve project deliverables, create work products, provide knowledge and recommendations,

help identify and minimize project barriers, and assure quality of work to meet project goals and

objectives. The final operational plan and the following communication plan will guide

management and monitoring for the project.

Communication

The communication aims are to inform key stakeholders about the process, objectives, desired

outcomes, and progress of the Utah and Idaho CHIC project. We will establish formal and

informal methods for stakeholders to provide input on project elements. Expectations will be

defined for how information is to be shared, who is responsible for initiation and follow-through,

timelines for formal communications, and timeliness of response. All communication materials

will be reviewed and result in accurate and usable information. A project SharePoint site,

accessible via the web, will be established to enable access to project documents by all team

members. A Go-To-Meeting license will be maintained throughout the project to enable sharing

documents during web/phone conferences and sufficient travel between states is planned to

enable effective team building and directly shared experience. Monthly project updates will be

sent to all team members, the Advisory and Governance Boards, and key stakeholders. Talking

points will outline important information to share with key stakeholders as needed. Media events

yet to be defined will be used as needed throughout the project. A Frequently Asked Questions

document will be developed to further inform interested parties about the project. A

comprehensive summary of the project purpose, objectives, scope, and approach will be

available on the SharePoint site. Project updates will also be provided at weekly targeting

meetings and other stakeholder meetings as requested. A written update will be sent to targeted

stakeholders once a month. All deliverables will be shared with appropriate team members along


                                                52
with a comment form. Team members will be asked to provide feedback on the deliverables. A

contact list will be updated regularly, identifying stakeholders and team members along with

contact information. Minutes will be taken at all governance, advisory, workgroup, and

committee meetings and posted on the SharePoint site.

                                          3. Monitoring


Risk assessment of the multi-faceted implementation will be a key and ongoing activity in

monitoring of this project. Assessments will be conducted on a monthly basis. The PMs will

analyze anticipated Implementation Barriers vis-à-vis the project performance, deliverables,

environments, and stakeholder input from a critical perspective to find any weaknesses or

sources of risk. As risks are identified, mitigation strategies and interim steps will be developed

to address those risks. A risk assessment document will be created to document the mitigation

strategies/interim steps and submitted to the Governance Committee and the Grant Officer. If the

mitigation strategies and interim steps are not deemed effective, the Medicaid program will take

other remedy action. Utah Medicaid Program will also institutionalize the capacity of measuring

the impact of HIT/HIE and meaningful use developed from this project.

                                        4. Data Collection

Both states will conduct a cost-benefit analysis of the Medical Home portion of the project that

will include collection and review of data. The Idaho plan will be developed prior to launching

that work with the stakeholders in southeast Idaho. Both states will guarantee that all data needed

for the National Evaluation is available and data to determine the effectiveness and impact of the

demonstration projects will be developed and collected throughout the grant period. We will also

document our data collection source, process, and methods of measuring the project impact. The

documents will be made publicly available and shared with all interested parties. Utah Medicaid

has a data sharing agreement with the Office of Health Care Statistics that manages population-

                                                 53
based healthcare data including All Payer Database (APD) and the Office of Vital Records that

manages the birth and death certificate records. The CHIC Project will be able to use these data

to measure potential project impact on Medicaid children as needed.

                                5. Independent Evaluation Plan


The independent evaluation will be led by Lucy Savitz, PhD, MBA (see Section 1). Our

participatory evaluation will engage a learning community to support accelerated adoption of

measures and care models with embedded user/parent champions. Our evaluation will be guided

by a pre-post design, collecting baseline and time series data at quarterly intervals. Usability and

perceived value of EHR modifications and quality measure information will be evaluated using a

mixed methods, replicated case study design where we will conduct key informant interviews

with a purposive sample of target users (1 office manager and 1 physician champion at baseline

and the office manager, 2 physicians, and care manager at year 4 per selected practice) and a

survey of physician users 6-months post EHR enhancement. Patient/family and clinician

satisfaction data will be collected at annual intervals. Trend data and pre-/post-assessment of

selected process and outcomes measures will inform short-term gains in quality, access, and cost

savings attributable to these program enhancements. We will closely monitor activities around

measure specification required by CHIPRA Public Law 111-3 that are being carried out in

collaboration by CMS and AHRQ with a panel of national experts (and we note our evaluation

lead has been invited to serve as an expert at the February, 2010 AHRQ meeting on this topic).

Our evaluation design will incorporate these measures as they become available.

                            6. Final Operational Plan Development


The Program Managers from Utah and Idaho and the Medical Director will have lead

responsibility for development of the Final Operational Plan. All stakeholders identified in

Section 1 have agreed to support the project and each will provide input and will have

                                                 54
opportunity to critique each draft iteration during its development. Upon notice of award, a

committee of stakeholders will be established to focus on the Operational Plan. That group will

have a kickoff meeting via web conference, lead by the PMs. Roles and responsibilities will be

defined, components of the Plan will be assigned to subgroups comprised of those with relevant

interest/expertise; time frames for development stages will be determined, and a future meeting

schedule set. The PMs will maintain communication with all committee participants and assist

with any barriers or obstacles to success in individual tasks. As additional stakeholders are

identified, the PMs and/or the Medical Director will work with organizational leadership to

recruit an interested representative. The PMs, Medical Director, and Division Directors will

maintain contact with stakeholder leaders to provide feedback on engagement and effectiveness

of their representatives.

   Opportunities for broader public input will be explored. Options will include presentations at

meetings, such as hospital grand rounds, advocacy group meetings, Parent-Teacher Association

meetings, and stakeholder board meetings. Articles and requests for input may be included in

newsletters for provider organizations, advocacy groups, etc.

    Regular workgroup updates will be provided to all workgroup members, resulting in the

final operational plan. Stakeholders will be consulted at the beginning of the planning session

and frequency of communication will be defined in roles and responsibilities documents and in

the communication plan. All deliverables leading up to the final Operation Plan will be sent to all

work group members electronically for review and comment. The author of each deliverable will

be expected to incorporate comments into the document where appropriate. Final documents will

then be made available to all project members via a project team SharePoint site. Additional

external stakeholders will be identified and encouraged to provide input during the project.

External stakeholders may include parents, providers, advocacy groups, etc.


                                                55
   The PMs will have skills in operational planning. Ample expertise in developing and

implementing operational plans and in guiding organizational change is available from among

actively involved organizations. These include: UDOH, Idaho’s Department of Health and

Welfare, HealthInsight, UofU, Intermountain (including their Institute for Health Care Delivery

Research), and UPIQ. We do not anticipate needing outside consultation in planning and

implementing this project.

   We look forward to CMS’ input and Technical Assistance as we develop the Final

Operational Plan. As indicated in the time frames above and in Section 2, some Objectives and

their related Activities need not await the full development of the Plan and, with CMS approval,

we anticipate moving forward on those during the 9-month planning phase. These include:

Category B, Objectives 1, 5, and 6; Category C, parts of Objective 1; and Category E, parts of

Objective 1.




                                               56
Section 4. BUDGET PRESENTATION AND NARRATIVE

Wu Xu, PhD, Director, Office of Public Health Informatics, Center for Health Data, UDOH, will

serve as consultant in areas of statewide health information exchange, meaningful use measures,

partnership building and project sustainability. 5% FTE each year spread over all 3 Categories.

CATEGORY B – Promote the use of HIT in children’s healthcare delivery

Objectives: 1) Optimize HELP2, 2) EHR Adoption/Meaningful Use, 3) Public Health Data

Access, 4) Quality Measure Reports, 5) Medical Home Portal, 7) Pediatric Patient Summary.

    Line Item         Year 1     Year 2          Year 3         Year 4        Year 5    TOTAL
Personnel               $98,307    $98,307        $98,307        $98,307       $98,307   $491,535
Fringe Benefits         $46,204    $46,204        $46,204        $46,204       $46,204   $231,020
Contractual TOTAL    $1,071,501 $1,328,124       $623,027       $578,834      $592,589 $4,194,075
    Univ. of Utah     $792,638 $866,586          $421,354       $381,908      $420,291 $2,882,777
    Intermountain       $44,612    $40,586        $41,803        $43,057       $44,349   $214,407
            UHIN      $162,476     $36,666        $14,666        $14,666       $14,666   $243,140
    Health Insight      $10,000    $60,000        $54,000        $48,000       $20,000   $192,000
  Idaho Medicaid        $61,775 $201,953          $51,870        $51,869       $53,949   $421,416
            IHDE             $0 $122,333          $39,334        $39,334       $39,334   $240,335
Indirect Charges        $16,474    $16,474        $16,474        $16,474       $16,474    $82,370
Travel                     $500                      $500                                  $1,000
         TOTAL       $1,232,986 $1,489,109       $784,512        $739,819     $753,574 $5,000,000

Personnel – Three FTEs are requested for Project oversight and data support. They will be

housed in UDOH Division of Health Care Financing (Medicaid and CHIP).

Project Manager (PM) – 100% FTE is requested, with 33.3 % FTE applied to each Category for

each year. The PM will be responsible for all aspects of the project, coordinating and monitoring

all Objectives, including working closely with Idaho colleagues and project participants.

Health Program Analyst – 100% FTE is requested, with 33.3 % FTE is applied to each Category

for each year. The Analyst will work with project staff, contractors, and participating practices to

collect and analyze all data, including data needed to support the National Evaluator.

Research Consultant – 100% FTE is requested. The research consultant will participate in

Category B objectives for all years of project and will be responsible for data and statistical


                                                 57
analysis, working with and managing data from the All Payer Database, and managing

installation and support for QI TeamSpace and analyses of data reported through that tool.

Fringe Benefits – A 47% fringe benefit rate has been applied to the total Utah personnel costs.

Contractual Costs

University of Utah – will have a lead role in several project components. Their costs include

Chuck Norlin, MD who will serve as Medical Director for the entire project, contributing 35% of

his time the first year and 50% or more in years 2-5. He will provide direction for all clinical

components and have advisory responsibilities for all others. The University will develop the

Pediatric Patient Summary, led by Scott Narus, PhD and involving Bryan Stone, MD. Cost for

enhancement and support of the Medical Home Portal are also included.

Intermountain Healthcare– will optimize access to its EHR to enable care coordination and

collaboration. Lucy Savitz, PhD, MBA, a health services researcher with extensive experience

evaluating healthcare interventions, and her staff will perform an independent evaluation of the

project. Dr. Savitz is nationally recognized for her work in QI and led a project for the Alliance

for Pediatric Quality (www.kidsquality.org) to identify improvement priorities, targeted QI

initiatives, and associated measures in support of a coordinated, national initiative.

UHIN – will work with Utah on an interface with CHARM and with IHDE on a UT-ID interface.

Costs are for working with their vendor, Axolotl Corp., to develop and support the interface.

HealthInsight – Will work with Utah practices to adopt and make meaningful use of EHRs/HIEs

as the HREC and the grant will subsidize practice costs; they will also implement their EHR

Calculator and assist practices in its use to extract and report pediatric quality measures.

Idaho Medicaid– will provide project direction and coordination for Idaho activities, including

the Idaho Project Co-Manager, a data collection specialist, data management specialist, and, in

addition to personnel time for cross-state project coordination, travel and related expenses.


                                                 58
IHDE– will enhance access to clinical data. Costs are for working with their vendor, Axolotl, to

develop and support the UT-ID interface and the interface with their immunization registry.

Indirect Charges –Indirect charges of 11.4% on Utah Medicaid personnel and benefits only,

Intermountain 10% on all direct charges, UHIN 10% and Health Insight 52% on all direct

charges, and Idaho indirect charges of $1,358 per year cover transaction costs for all categories.

Univ. of Utah is applying 32.7% on all direct charges but recognizes some question about the

allowable rate, based on the Q&A from 1/6/10, and will work with CMS once this is clarified.

Travel – Per FOA, one person must attend CMS-sponsored conference in Wash. DC in Years 1

and 3. $500 has been applied to each Category budget for a total estimated expense of $1,500.

CATEGORY C – Provider-Based Models

Objectives: 1) Infrastructure Development, 2) Medical Home Implementation, 3) Improvement

Network, 4) Multi-Payer Demonstration.

       Line Item       Year 1   Year 2             Year 3         Year 4     Year 5   TOTAL
Personnel             $52,658  $52,658            $52,658        $52,658    $52,658  $263,290
Fringe Benefits       $24,749  $24,749            $24,749        $24,749    $24,749  $123,745
Contractual TOTAL    $254,120 $635,987         $1,034,703     $1,318,642 $1,324,393 $4,567,845
    Univ. of Utah    $220,786 $582,299          $754,889      $1,007,627 $1,040,417 $3,606,018
  Idaho Medicaid    $ 33,334 $ 33,333             $79,814      $111,015     $83,976  $341,472
         Idaho IP           0  $20,355          $200,000       $200,000 $200,000     $620,355
Indirect Charges       $8,824   $8,824             $8,824         $8,824     $8,824    $44,120
Travel                   $500                        $500                               $1,000
         TOTAL       $340,851 $722,218         $1,121,434     $1,404,873 $1,410,624 $5,000,000

Personnel

Project Manager – 100% FTE with 33.3 % FTE applied to each Category budget for each year.

Health Program Analyst – 100% FTE with 33.3 % applied to each Category each budget year.

Fringe Benefits – A 47% fringe benefit rate has been applied to the Utah personnel costs.

Contractual Costs

University of Utah – Will develop infrastructure for and implement a demonstration using

Medical Home Coordinators in 24 primary and sub-specialty care practices in Utah and Idaho.

                                                59
Costs include Medical Director (see Category B), UPIQ, employment of Medical Home

Coordinators, Practice Coaches, and a Concierge.

Idaho Medicaid – Will provide direction & coordination for Idaho components/practices. Costs

include administrative roles and Idaho-based Medical Home Coordinators and Practice Coaches.

Idaho Improvement Partnership– Will work with Utah to implement the demonstration in Idaho.

Their costs are included in those of Idaho Medicaid above.

Indirect Charges –Indirects of 11.4% on Utah Medicaid personnel and benefits only, Univ. of

Utah 32.7% on all direct charges, and Idaho indirect charges of $1,358 per year for all categories.

Travel – Per FOA, one person must attend CMS-sponsored conference in Wash. DC in Years 1

and 3. $500 has been applied to each Category budget for a total estimated expense of $1,500.

CATEGORY E – National Quality Models

Objective: 1) Improvement Partnerships, 2) Improvement Network, 3) Resident QI curriculum

       Line Item      Year 1        Year 2        Year 3         Year 4        Year 5   TOTAL
       Personnel     $52,658       $52,658       $52,658        $52,658       $52,658 $263,290
  Fringe Benefits    $24,749       $24,749       $24,749        $24,749       $24,749 $123,745
Contractual TOTAL   $458,823      $743,435    $1,007,516     $1,200,485    $1,155,246 $4,565,505
    Univ. of Utah   $425,489      $710,102     $820,931      $1,013,900     $968,661 $3,939,083
  Idaho Medicaid     $33,334       $33,333       $33,334        $33,333       $33,333 $166,667
         Idaho IP         $0            $0     $153,251       $153,252      $153,252 $459,755
 Indirect Charges     $8,824        $8,824        $8,824         $8,824        $8,824    $44,120
           Travel       $500                        $500                                  $1,000
      Other Costs       $468          $468          $468          $468           $468     $2,340
         TOTAL      $546,022      $830,134    $1,094,715     $1,287,184    $1,241,945 $5,000,000

Personnel

Project Manager – 100% FTE with 33.3 % FTE applied to each Category budget for each year.

Health Program Analyst – 100% FTE with 33.3 % applied to each Category each budget year.

Fringe Benefits – A 47% fringe benefit rate has been applied to the total personnel costs.

Contractual Costs

University of Utah – will assist development of an Idaho improvement partnership, provide QI


                                                60
learning collaboratives, initiate an improvement network, and develop a QI curriculum for

residents. Costs include the Medical Director (see Category B), the activities of UPIQ, and

development and implementation of the QI curriculum.

Idaho Medicaid – will provide project direction & coordination for Idaho components/practices.

Costs include administrative roles for the Idaho Improvement Partnership and Practice Coaches.

Idaho Improvement Partnership – will work with Univ. of Utah to develop an improvement

partnership in Idaho, provide QI learning collaboratives, and initiate an improvement network.

Costs are included in the Idaho Medicaid figures above.

Indirect Charges –Indirects of 11.4% on Utah Medicaid personnel and benefits only, Univ. of

Utah 32.7% on all direct charges, and Idaho indirect charges of $1,358 per year for all categories.

Travel – As in the others, $500 has been applied to this Category for a total expense of $1,500.

PRELIMINARY BUDGET TOTALS FOR ALL CATEGORIES

Line Item    Year 1     Year 2     Year 3     Year 4     Year 5     TOTAL
 Personnel    $203,623   $203,623   $203,623   $203,623   $203,623 $1,018,115
 Benefits       $95,702    $95,702    $95,702    $95,702    $95,702   $478,510
 Contractual $1,784,444 $2,707,546 $2,665,246 $3,097,961 $3,072,228 $13,327,425
 Indirect       $34,122    $34,122    $34,122    $34,122    $34,122   $170,610
 Travel          $1,500         $0     $1,500         $0         $0      $3,000
Other Costs        $468       $468       $468       $468       $468      $2,340
    TOTAL $2,119,859 $3,041,461 $3,000,661 $3,431,876 $3,406,143 $15,000,000

CONTRACTUAL COSTS – BY ENTITY/AGENCY

Line Item        Year 1    Year 2    Year 3     Year 4     Year 5     TOTAL
 Univ. of Utah $1,438,913 $2,158,987 $1,997,174 $2,403,435 $2,429,369 $10,427,878
Intermountain      $44,612   $40,586    $41,803    $43,057    $44,349   $214,407
         UHIN     $162,476   $36,666    $14,666    $14,666    $14,666   $243,140
  Health Insight   $10,000   $60,000    $54,000    $48,000    $20,000   $192,000
Idaho Medicaid    $128,443  $268,619  $165,018   $196,217   $171,258    $929,555
          IHDE          $0  $122,333    $39,334    $39,334    $39,334   $240,335
      Idaho IP          $0   $20,355  $353,251   $353,252   $353,252 $1,080,110
      TOTAL $1,784,444 $2,707,546 $2,665,246 $3,097,961 $3,072,228 $13,327,425




                                                61
                              Appendices – Table of Contents
Pg.
   Attachment 1 – Notice of Intent to Apply (was not submitted, therefore no attachment)
   Attachment 2 – Prohibited Use of Grant Funds (per last Q&A, not included)
   Attachment 3 – Resumes
63. Charlene Frail-McGeever
64. Tammy Ray
65. Chuck Norlin, MD
66. Scott Narus, PhD
   Letters of support
67. Utah Governor Gary Herbert
68. Idaho Governor Butch Otter & Leslie Clement, Administrator, IDHW, Division of Medicaid
69. Michael Hales, Director, Division of Health Care Financing, UDOH &
       David Sundwall, MD, Executive Director, UDOH
70. Senator Richard Compton, Chairman, Idaho Health Quality Planning Commission &
       Representative Ronda Rudd Menlove, Utah Legislature
71. Jonathan Sugarman, MD, MPH, President and CEO, Qualis Health &
       Marc Bennett, President and CEO, HealthInsight
72. Edward B. Clark, MD, Chair, UofU Dept. of Pediatrics, Chief Medical Officer, PCMC &
       Marc Probst, Vice President and Chief Information Officer, Intermountain Healthcare
73. Creighton Hardin, MD, President, Idaho Chapter of the American Academy of Pediatrics &
       Karen Buchi, MD, President, Utah Chapter, American Academy of Pediatrics
74. LaDonna Larson, Executive Director, Idaho Health Data Exchange &
       Jan Root, PhD, Executive Director Utah Health Information Network
75. Karen Crompton, Executive Director, Voices for Utah Children &
       Barbara Leavitt, Director, Partners for Infants & Children
76. Larraine Clayton, M.Ed., Exec. Director, Idaho Early Childhood Coordination Council &
       Evelyn Mason, Executive Director, Idaho Parents Unlimited
77. Keely Cofrin Allen, PhD, Office of Healthcare Statistics, All Payer Database, UDOH &
       Brent Wallace, MD, Vice President and Chief Medical Officer, Intermountain Healthcare
78. Bibliography
80. List of Recurring Acronyms and Abbreviations
Letters from additional stakeholders (listed in Section 1) and the supporters listed below,
along with other supporting materials are posted at http://medicine.utah.edu/upiq/CHIPRA/
 Brent Wallace, MD, Vice President and Chief Medical Officer, Intermountain Healthcare –
    confirming contractual agreement for Lucy Savitz, PhD, MBA, and Mitch Perkins
 Lorna Koci, Services Director, Utah Food Bank/2-1-1
 Peter Margolis, MD, Co-Director, Center for Health Care Quality
 Paula Duncan, MD, National Improvement Partnership Network
 Paul Miles, MD, Senior VP, Maint. of Certification and Quality, American Board of Pediatrics
 Fan Tait, MD, Associate Executive Director, American Academy of Pediatrics


                                              62
                            Charlene Frail-McGeever, MBA
               Role on Project: Utah Project Manager | Effort: 100% in Years 1-5
Summary
Charlene Frail-McGeever is a healthcare program specialist for Utah Department of Health
Division of Medicaid & Health Financing Bureau of Access. She has over fifteen years of
experience in consumer healthcare in a combination of operations, administrative & strategic
leadership roles. For the past year, she has been responsible for increasing member enrollment
& community awareness Utah’s Medicaid & CHIP plans & managing all external
communications with federal & non-federal supporters to coordinate strategic community
outreach planning, development & implementation for the uninsured statewide. Before to
joining the Department of Health, she helped healthcare entities analyze workflow, choose, &
implement electronic credentialing systems. She has also audited third-party administrators to
determine health plan membership eligibility & managed a call center that administered
CAHPS/HEDIS surveys.

Education
1996 Master of Business Administration, Human Resources Wilkes University, Wilkes-Barre PA
1992 Bachelor of Science, Economics                          Wilkes University, Wilkes-Barre PA

Relevant Experience
2009-Present State of Utah Department of Health, Division of Medicaid & Health Financing
Health Program Specialist
2002-2008 CHG Healthcare, Manager for a NCQA certified credentials verification organization
& a JCAHO certified health care staffing agency. Integrated credentialing services & software
via the development & implementation of policies & procedures for various staffing &
permanent placement subsidiaries & clients.
2001-2002 ADP, Benefits Implementation Specialist provided technical assistance to third party
administrators, configuring databases to determine health plan member eligibility, produce
enrollment rosters & process premium payments to carriers.
1998-2001 PEGUS Research, Project Manager for a NCQA certified health care research
organization, conducting CAHPS/HEDIS surveys for health plans nationwide. Provided project
support for Phase IV clinical trials focusing on OTC switch of prescription medications &
medical devices. Developed study-related materials & contributed to study design, site selection,
monitoring, quality assurance & data management.
1996-1998 University of Utah Hospitals & Clinics, Credentialing Coordinator developed a
physician database in preparation for accreditation surveys by JCAHO & NCQA contracted
insurance providers. Participated in the development & tracking of clinical privilege criteria &
competencies for over 800 physicians
1995-1996 Pennsylvania Department of Health, Maternal & Family Health Services, presented
community education programs for the agency’s breast & cervical cancer screening program,
while developing innovative marketing concepts to enroll women in the program.



                                               63
                              Tammy W. Ray M.Ed., Ed.S.
 Role on Project: Oversight of Idaho Project Co-Manager (to be hired as a full-time contractor)
Summary
Tammy Ray is a Research and Development Analyst for the Idaho Division of Medicaid. She
has over 15 years experience in Project and Program Management, along with Federal grants
management. For the past two and a half years, she has been responsible for program and
project management for the Division, which has included research and development leading to
the formation of the Idaho Health Data Exchange. She is also the project lead on the Idaho
Children’s Health Insurance Awareness Project, which has been responsible for increasing
member enrollment and community awareness for Idaho Medicaid Children’s Health Insurance
Programs. Tammy has extensive experience with developing and managing budgets at the State
and local levels. She also has broad education and experience in writing performance matrices to
determine effective and efficient program models as well as developing other evaluation tools to
comply with Federal and State requirements. Before joining the Division of Medicaid, she
worked for the Idaho Department of Education in Federal Programs. While there, she managed
the Even Start and Learn and Serve grants for Idaho. Tammy also serves on the Board of
Trustees for the College of Western Idaho and has been focused on curriculum development for
Health Information Technology training.

Education
2007   University of Idaho          Ed.S     Adult and Organizational Learning
2000   University of Idaho          M.Ed. Adult Education
1999   Eastern Oregon University    B.S.     Psychology

Other Relevant Experience
2007-Present   Idaho Department of Health and Welfare, Division of Medicaid
2000- 2007     Idaho Department of Education
1999- 2002     University of Idaho, College of Engineering

Selected Publications
“Climbing the Ladder to Evaluation Success: A Tool to Measure the Impact of Parent Education
on Parenting Practice”

Selected Presentations
Treasure Valley Community College Women’s Conference “Returning to School: Barriers,
Benefits, and Balance”
“New Paradigms in River and Estuary Management” NATO Conference
National Even Start Conference - “Climbing the Ladder to Evaluation Success: A Tool to
Measure the Impact of Parent Education on Parenting Practice”
National Learn and Serve Conference - Performance Measurement and Assessment



                                              64
                                    Chuck Norlin, MD
        Role on Project: Medical Director | Effort: 35% in Year 1, 50-55% in Years 2-5
Chuck Norlin, M.D. is Professor of Pediatrics and Adjunct Professor of Biomedical Informatics
at the University of Utah School of Medicine. Before joining the faculty in 1990, he practiced
general pediatrics in Salt Lake City for 10 years. He has been Chief of the Division of General
Pediatrics since 1993. He practices and teaches general pediatrics and is the generalist for the
Pediatric Cardiac Transplant Team at Primary Children’s Medical Center. Since 2001, Dr.
Norlin has directed the Medical Home Portal (www.medicalhomeportal.org) aimed at supporting
primary care clinicians and families in caring and advocating for children with special health
care needs. He also serves as Director of the Utah Pediatric Partnership to Improve Healthcare
Quality (UPIQ), established in 2003 to improve the health and healthcare of Utah’s children by
helping primary care clinicians implement evidence-based and measurement-guided quality
improvement strategies. Dr. Norlin has served as Co-Director of three medical home-integrated
services projects funded by the MCHB.
Education and Training
1967-71   Bachelor of Arts, Chemistry                          Emory University, Atlanta, GA
1971-76   Doctor of Medicine                             New York Medical College, NY, NY
1976-77   Rotating Internship                        Highland General Hospital, Oakland, CA
1977-80   Pediatric Internship/Residency    St. Christopher’s Hospital for Children, Phila., PA
Other Relevant Experience
2000 - 2006      Medical Director, Pediatric Clinic, University of Utah Health Sciences Center
2001 - 2004      Co-Director, Utah Collaborative Medical Home Project
2002 - 2008      President (Elect & Past), Utah Chapter, American Academy of Pediatrics (AAP)
2005 - 2008      Co-Director, Utah Medical Home – Integrated Services Project
2008 - present   Co-Director, Utah Autism Spectrum Disorders Systems Development Project
2009 - present   Consultant, AAP Chapter Quality Network Asthma Program
Relevant Recent Presentations
Norlin C. “Quality Improvement, the Medical Home, and MOC – bringing it all together.”
Oregon Pediatric Society meeting. Eugene, OR. April 25, 2009.
Norlin C, Kerr LM, Rocha RA. “Using Clinical Questions to Structure the Content of a Web-
based Information Resource for Primary Care Physicians.” American Medical Informatics
Association Symposium. San Francisco, CA. November 16, 2009
Relevant Recent Publications
Young PC, Glade GB, Stoddard GJ, Norlin C. Evaluation of a Learning Collaborative to
Improve Delivery of Preventive Services by Pediatric Practices. Pediatrics. 2006;117:1469-76.
Norlin C, Romeo A, Rocha R. Developing a Web Site to Support the Implementation of
Medical Home. AMIA Annu Symp Proc. 2007:563-567.
Del Fiol G, Haug PJ, Cimino JJ, Narus SP, Norlin C, Mitchell JA. Effectiveness of topic-
specific infobuttons: a randomized controlled trial. J Am Med Inform Assoc. 2008;15(6):752-9
Norlin C, editor. Improving the Quality of Healthcare for Utah’s Children: 2008 and Beyond –
Needs, Challenges, and Goals. Utah Pediatric Partnership to Improve Healthcare Quality, Salt
Lake City, Utah. 2008. (available at www.upiq.org, see Publications)

                                              65
                                   Scott P. Narus, PhD
     Role on Project: Informatics Co-Investigator | Effort: 5% in Year 1, 3-5% in Years 2-3
Scott P. Narus, PhD is Assistant Professor of Biomedical Informatics at the University of Utah
School of Medicine. He was previously a senior medical informaticist at Intermountain
Healthcare where he was the director of clinical applications development. He currently directs
the development of the informatics research infrastructure for the University’s Center for
Clinical and Translational Science. He has participated in statewide health information
exchange efforts and consults with the Utah Department of Health on public health informatics
needs. He has extensive experience in health information technology, including electronic
medical records, clinical decision support, personal health records, and automated information
linkage and exchange. He is a board member of the Utah Health Research Network and a
member of the University of Utah Telehealth Steering Committee. He is also the PI for a
statewide master person index project funded by the NIH.
Education and Training
1981-85 B.S., Electrical/Computer Engineering       University of Notre Dame, South Bend, IN
1990-91 M.S., Electrical/Computer Engineering              University of Arizona, Tucson, AZ
1992-95 Ph.D., Medical Informatics                     University of Utah, Salt Lake City, UT
Other Relevant Experience
1985-1989    Space Shuttle Computer Systems Engineer; Radar Systems Engineer and Project
             Director, Vandenberg Air Force Base, CA
1990-1991    Teaching Assistant, Electrical and Computer Engineering Dept, Univ of Arizona,
             Tucson, AZ
1992-1994    Bioengineering Researcher, Anesthesiology Bioengineering Lab, Univ of Utah
             Health Sciences Center, Salt Lake City, UT
1994-2006    Senior Medical Informaticist, Intermountain Healthcare, Salt Lake City, UT
2000-2006    Adjunct Assistant Professor, University of Utah, Salt Lake City, UT
2006–present Assistant Professor, University of Utah, Salt Lake City, UT
Relevant Recent Publications
Clayton PD, Narus SP, Huff SM, et al. (2003). Building a comprehensive clinical information
system from components. The approach at Intermountain Health Care. Methods Inf Med,
42(1),1-7.
Wilcox AB, Jones SS, Dorr DA, Cannon W, Burns L, Radican K, Christensen K, Brunker C,
Larsen A, Narus SP, Thornton SN, Clayton PD. (2005). Use and impact of a computer-
generated patient summary worksheet for primary care. AMIA Annu Symp Proc, 824-8.
Wilcox A, Kuperman G, Dorr DA, Hripcsak G, Narus SP, et al. (2006). Architectural strategies
and issues with health information exchange. AMIA Annu Symp Proc, 814-8.
Dorr DA, Wilcox A, Burns L, Brunker CP, Narus SP, Clayton PD. (2006 Feb). Implementing a
multidisease chronic care model in primary care using people and technology. Dis Manag, 9(1),
1-15.
Del Fiol G, Haug PJ, Cimino JJ, Narus SP, Norlin C, Mitchell JA. (2008 Nov-Dec).
Effectiveness of topic- specific infobuttons: a randomized controlled trial. J Am Med Inform
Assoc, 15(6), 752-9.
Tripp JS, Narus SP, Magill MK, Huff SM. (2008 Nov-Dec). Evaluating the accuracy of existing
EMR data as predictors of follow-up providers. J Am Med Inform Assoc, 15(6), 787-90.

                                               66
67
                                       C.L. “B UTCH ” O TTER
                                                 GOVERNOR



                                                          January 7, 2009



David Greenberg
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850

Dear Mr. Greenberg:

Idaho and Utah are working collaboratively on a Children’s Health Insurance Program Reauthorization Act
(CHIPRA) quality demonstration grant. I am pleased to write this letter of support for the proposal, which
will improve the coordination and quality of healthcare for children with special health needs.

This multi-state collaboration, with Utah as the lead, is a logical partnership since over 1,700 Idaho
Medicaid and Children’s Health Insurance Program (CHIP) children annually utilize healthcare from the
University of Utah and/or Intermountain Healthcare Primary Children’s Medical Center in Salt Lake City.
Connecting the Idaho Health Data Exchange with the Utah Health Information Network will allow timely
and accurate sharing of health information for many Idahoans who receive medical care in Utah.

Additionally, Idaho will be able to continue to expand efforts promoting the meaningful use of Health
Information Technology (HIT) by creating networks to share clinical data. The bi-directional interface
between the Idaho Health Data Exchange and Idaho’s immunization registry will further assure that
accurate information on immunizations is available at the point of care.

This letter also affirms my support of the project to integrate Idaho Medicaid services and resource data
into the Medical Home Portal along with piloting a replica of Utah’s “Medical Home Coordinators” model.

I am designating the Idaho Department of Health and Welfare as the State’s lead agency for the CHIPRA
quality demonstration grant. As such, the Department will have the authority to oversee and coordinate the
activities outlined in the multi-state application. The Department will work with other state agencies, child
health providers, private foundations, academic institutions, and children’s advocacy.

Thank you for your consideration of this application allowing Idaho to work towards the establishment of
widespread use of networked electronic health information to promote improved patient outcomes.

                                              As Always – Idaho, “Esto Perpetua”




                                              C.L. “Butch” Otter
CLO:/ss                                       Governor of Idaho




                          STATE CAPITOL     B O I S E , I D A H O 83720   (208) 334-2100




                                                                                                                68
69
70
                                                                              10700 Meridian Ave N • Suite 100
                                                                              PO Box 33400
                                                                              Seattle, WA 98133
                                                                              Toll Free: 1.800.949.7536
                                                                              Office: 206.364.9700
                                                                              Fax: 206.368.2419
                                                                              www.qualishealth.org




December 10, 2009


Leslie M. Clement
Administrator, Division of Medicaid
3232 Elder St.
Boise, Idaho 83705

Dear Ms. Clement:

Qualis Health strongly supports the Utah/Idaho application for the Children’s Health
Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant. The
purpose of the grant is to support Idaho’s current efforts to improve access to health
information at the point of care through health information technology, as well as empower
individuals to make informed choices about the future of their health through the creation
of a Medical Home Portal. These objectives complement the goals of the Health
Information Technology Regional Extension Centers (REC), which are to provide
technical assistance to primary care providers in successfully selecting, implementing, and
meaningfully using Electronic Health Record (EHR) systems.

Qualis Health has applied to become the lead organization for the REC program in Idaho
and Washington. If funded, the REC will offer direct technical assistance, broad education,
and information on best practices to support and accelerate the adoption of EHRs among
healthcare providers. Additionally, Qualis Health, The Commonwealth Fund, and the
MacColl Institute for Healthcare Innovation have launched an initiative to help primary
care safety net clinics become high-performing patient-centered medical homes. The goal
of the Safety Net Medical Home Initiative is to develop a replicable and sustainable
implementation model for medical home transformation. The Idaho Primary Care
Association (IPCA) serves as one of five regional coordinating centers for this initiative.

The Utah/Idaho CHIPRA grant proposal clearly aligns with Qualis Health’s efforts on the
REC program and Safety Net Medical Home Initiative. We hope to continue working
together to enhance the quality and value of health care throughout Idaho.


Sincerely,




Jonathan Sugarman, MD, MPH
President and CEO




                                                                                                                 71
72
                                        Utah Chapter

     Utah Chapter
     3029 Holderhill Lane
     Salt Lake City, UT 84118
                                        December 21, 2009
     Phone: (801) 968-3411
     Fax: (801) 968-2616
     E-mail: office@aaputah.org
     www.aaputah.org                    Michael Hales, Director
                                        Medicaid and Health Financing
                                        State of Utah Department of Health

     President                          Dear Mr. Hales:
     Karen Buchi, MD, FAAP

     President-Elect
                                        The Utah Chapter of the American Academy of Pediatrics strongly supports the Children’s
     Claudia Fruin, MD, FAAP            Healthcare Improvement Collaboration (CHIC) proposed by Utah Medicaid and CHIP
                                        programs, the Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ), and other
     Immediate Past President
     Jeffrey Schmidt, MD, FAAP          partners. Our Chapter has a long history of involvement with UPIQ and has benefited from
                                        the quality of the programs it provides.
     Secretary-Treasurer
     Robert Terashima, MD, FAAP
                                        CHIC integration of health information technology will strengthen primary care physicians’
     Representatives-at-Large
     Marsena Conner, MD, FAAP
                                        ability to readily access and retrieve clinical data on children enrolled in Medicaid and CHIP.
     Peter Silas, MD, FAAP              This project is specifically designed to help physicians provide safer, more timely, efficient,
                                        effective, and equitable patient-centered care. Physicians will reduce their own time, stress
     Executive Director
     Cathy Oyler                        and expense associated with duplicate tests and missing patient information. Unique to this
                                        project is the emphasis on physicians improving care, service and outcomes for children
                                        guided by the medical home model and using quality measures from electronic health records.

                                        Utah Chapter members are keenly aware of the valuable resources and tools provided through
     AAP Headquarters                   the Medical Home Portal website. An expansion of these resources to better guide clinical
     141 Northwest Point Blvd
     Elk Grove Village, IL 60007-1098
                                        decisions related to children with special health care needs will be most welcome. Chapter
     Phone: 847/434-4000                members are also excited about the prospect of working with Medical Home Coordinators
     Fax: 847/434-8000                  embedded in primary care practices to support ongoing improvement in care, care
     E-mail: kidsdocs@aap.org
     www.aap.org                        coordination and support for children with chronic, complex conditions and their families.
                                        Chapter members recognize the value in earning credit toward Maintenance of Certification
                                        through locally tailored quality improvement projects and look forward to active participation
                                        in this initiative.

                                        The Utah Chapter looks forward to working with UPIQ and is committed to contributing to the
                                        success of the Children’s Healthcare Improvement Collaboration. Please do not hesitate to
                                        contact me if more information is needed.

                                        Sincerely,



                                        Karen Buchi, MD, FAAP
                                        President

                                        /co




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                                               79
                         Recurring Acronyms and Abbreviations

AAP – American Academy of Pediatrics
AHRQ - Agency for Healthcare Research and Quality
APD – All Payer Database (Utah)
CHARM – Child Health Advanced Record Management system (Utah)
CHCQ – Center for Health Care Quality
CHIC – Children’s Healthcare Improvement Collaboration (name of the proposed project)
cHIE – Clinical Health Information Exchange (Utah)
CHIP – Children’s Health Insurance Program
CHIPRA – Children’s Health Insurance Program Reauthorization Act
CPHIMS – Certified Professional in Healthcare Information and Management Systems
CTSA – Clinical and Translational Science Award
CVCC – Children with Very Complex Conditions
CVE – Chartered Value Exchange
CWG – Core Work Group (of the Utah Health System Reform Task Force)
CYSHCN – Children and Youth with Special Health Care Needs
ECIS – Enterprise Clinical Information System (in development by Intermountain and GE)
HELP2 – Intermountain’s electronic health record
HIE – Health Information Exchange
HIT – Health Information Technology
IHDE – Idaho Health Data Exchange
IDHW – Idaho Department of Health and Welfare
Intermountain – Intermountain Healthcare
IP – Improvement Partnership
IIP – Idaho Improvement Partnership
IPIP – Improving Performance In Practice (national project involving the CHCQ)
IRIS – Immunization Reminder Information System (Idaho)
LC – Learning Collaborative
MHC – Medical Home Coordinator
MHP – Medical Home Practice
MOC – Maintenance of Certification (American Board of Pediatrics program)
NCQA – National Committee on Quality Assurance
NICHQ – National Initiative for Children’s Health Care Quality
NIPN – National Improvement Partnership Network
NLM – National Library of Medicine
PCCM – Pediatric Continuum of Care Manager
Portal – Medical Home Portal (www.medicalhomeportal.org)
PP Coordinator – Parent Partner Coordinator
PPS – Pediatric Patient Summary
QI – Quality Improvement
QIO – Quality Improvement Organization
REC – Regional Extension Center
UDOH – Utah Department of Health
UHIN – Utah Health Information Network
UofU – University of Utah
UPIQ – Utah Pediatric Partnership to Improve Healthcare Quality
USIIS – Utah Statewide Immunization Information System

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posted:3/29/2013
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