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Appendix 1 Environmental Scan

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					Appendix 1: Environmental Scan
PROVIDER PROFILE

Montana Primary Care physicians
According to the Kaiser Family Foundation, primary care physicians in the state fall into the
following categories:

Distribution of Nonfederal Primary                           % of Total    % of Total
Care Physicians by Field, 2008            # Physicians    Primary Care    Physicians
  Internal Medicine                                255             24%          9.6%    Montana
  Family Practice                                  503             47%        19.1%     Hospitals
  Pediatrics                                       119             11%          4.5%        61
  Obstetrics/Gynecology                            123             11%          4.7%          M
  General Practice                                  71              7%          2.7%
                                                                                              edi
  Total Primary Care                              1071        100.00%         40.6%
                                                                                              car
Total Nonfederal Physicians                       2636
                                                                                              e
       Acute Care Hospitals
           o 47 CAH
           o 14 PPS hospitals
           o PHS hospitals
      1 State Hospital at Warm Springs
      1 Veterans Administration (VA) Hospital at Fort Harrison

EHR TECHNOLOGY SUMMARY (in brief)

Primary Vendor presence by community:

           o   Billings – Cerner, Meditech, Centricity, eClinicalWorks
           o   Bozeman – Meditech, NextGen
           o   Great Falls – Meditech, Integreat IC-Chart
           o   Helena – Meditech, LSS MPM, Integreat IC-Chart
           o   Butte – Meditech, Centricity, eClinical Works
           o   Missoula – Meditech, NextGen, Mysis PM
           o   Kalispell – Meditech, ICA CareAlign, eClinicalWorks, Mysis PM
           o   Anaconda - Health Management Systems




ELECTRONIC BILLING AND CLAIMS

In excess of 95% of all claims in Montana are filed electronically.

Health-e-Web, Inc. (HeW) is a service-centric, all payer, Montana-based company committed
to reducing health care costs, by offering premier clearinghouse, consulting, and other services
that enable employers, health care providers and insurance carriers to operate more efficiently.

Since 1986, HeW has grown to a successful all payer clearinghouse, with connectivity to more
than 1,400 payers. HeW currently holds contracts with approximately 85% of the health care
providers throughout Montana, including most major hospitals and processes approximately 7
million claim transactions annually.


ELECTRONIC PRESCRIBING AND REFILL REQUESTS

The Montana e-prescribing landscape has significantly changed from three years ago when
virtually all of the e-prescribing activity was done by “e-faxing”. At present, many of the larger
health systems in Montana, like the Billings Clinic and the Western Montana Clinic inMissoula
are using the SureScripts application to truly e-prescribe. In addition, we have learned that many
of the smaller clinics and stand alone physician practics are also using the SureScripts method.
Pharmacies throughout Montana are also now able to receive these e-Rx’s via this mechanism. It
is difficult to say exactly what percent of rx’s in Montana are being sent via true epRx, but
looking at the facilities using it and their location, an estimate of electronic prescribing would
now be closer to 20% of the facilities. The numbers for e-faxing are significantly higher, with an
estimated 70% of practices with this ability. Extrapolating the potential use and ability of
Montana physicians to use, and surveys of chain and independent pharmacies we believe that no
more than10% of scripts are transmitted via true e-scribe, 60% thru an e-faxing mechanism, and
30% through either written or phone in methods. Mountain-Pacific is currently conducting a
survey of physician offices and will have more information on the percentage who are using e-
prescribing versus e-faxing (

The status of prescription fill status and/or medical fill history in the state.
We have systems in Montana that aggregate Rx and medical claims information for their clients,
but only for data gathering, actuarial and risk management purposes. An example of this
mechanism is the Montana Association of Health Care Purchasers. They aggregate health care
information for the Montana University System and the State of Montana Employee Benefit
Programs. This information is not available to physicians electronically by patient.

The only mechanism we have found for electronic lookup of filling history the Medicaid
WebPortal that physicians can log in to and find their patients prescription drug history as well as
some medicla history. This is only for Medicaid recipients however and is also based on paid
claims. There is no history for prescriptions that have been written and NOT filled. Through
Mountain-Pacific’s Drug Utilization Review, Drug Prior Authorization, and Pharmacy Case
Management programs for Medicaid, we assess prescription drug histories and identify potential
drug therapy problems, helping physicians manage the care they provide for a Medicaid
recipient. This is accomplished through access to and analysis of the medicaid paid claims
databases as a contractor and is not related to the WebPortal


LABS
The vast majority of all labs are performed either in office/clinic based labs or provider’s
affiliated hospital.

The most widely used third-party laboratories in Montana are: Pathology Associates Medical
Laboratories (PAML), LabCorp and Quest Diagnostics. Mayo’s reference lab has a presence in
the northwest part of the state. These vendors offer a variety of connectivity options including
web-based results and EMR interfaces.

Products and services summary:

   1.   Remote printers or fax delivery
   2.   Requisition and label printers
   3.   Internet reporting and order entry
   4.   Electronic medical records interfaces
   5.   Laboratory information system interfaces
   6.   Mobility solutions for PDAs

ELECTRONIC PUBLIC HEALTH REPORTING

The Montana Department of Public Health and Human Services has a variety of methods used to
collect reportable information and voluntary submission of health information.

Immunization Department:

A handful of the largest providers can submit immunization information electronically into the
state-provided database. However, the majority are hand-entering the information into the state
system through the provided portal. The state generates reports out of the system and conducts
site visits to providers providing the data comparisons. The Immunization program is using a
custom developed in-house software package but hopes to update it to a new program that will
allow HL7 data exchange.

Public Health and Safety- Sexually Transmitted Diseases: The HIV program does not have any
electronic lab reporting. All reports are faxed to the department and the data is manually entered
into the system. The HIV program has contractors who conduct interventions to prevent the
spread of the disease. These contractors provide summary, de-identified information into the
HIV Surveillance Data System which is funded out of a CDC grant. This system is a national
database with summary data.

Cancer Registry:

The Registry collects information electronically through an SSL/FTP portal. The larger facilities
use software to abstract their information, enter it and send it. Faxed information comes in
directly to a secure fax server and is hand entered into the database. No one is sending
information in computer to computer.
Diabetes Program:

The Diabetes Program has 50+ providers using DQCMS (Diabetes Quality Control and
Management System), a registry tool for monitoring and care of patients with diabetes. The
registry tool does not electronically connect to the state. Rather the tool produces a quarterly
report which summarizes the data for the quarter for each provider. This summary is submitted
via fax, entered into a database and feedback is produced to each provider along with
comparative data from all sites combined.

The Community Health Centers have a software package called PECS (Patient Electronic Care
System) which can produce a summary report as well for tracking and improving the care for
patients.

Trauma Registry/Injury Surveillance Information System - With the growing interest in
injury control programs within the traffic safety, public health, and enforcement communities,
there are a number of local, state, and federal initiatives which drive
the development of Injury Surveillance Systems (ISS). These systems typically incorporate
prehospital (EMS), emergency department (ED), hospital admission/discharge, trauma registry,
and long term rehabilitation databases to track injury causes, magnitude, costs, and outcomes. A
Montana Patient Care Record Dataset was established February 2004 and contains
approximately 100 data elements. ITS data – Intelligent Transportation Systems (ITS),
Geographic Information Systems (GIS) and Global Positioning Satellite (GPS) data, and other
tools are being used to develop program evaluations to include statistical data analysis, Bayesian
evaluation, and use of normalizing factors.

Quality Reporting Capabilities

Hospitals

CMS provides an economic incentive for hospitals to report quality of care data called the
Annual Payment Update (APU) program. All of Montana’s PPS hospitals report quality data
quarterly to CMS to be eligible for the annual payment update. The larger facilities use vendors
to abstract and submit their data. Two of the smaller PPS facilities and all but two of the Critical
Access Hospitals also report quality of care data using a free tool from CMS called the CART
tool. The QIO provides technical assistance to the facilities using the CART tool under their
contracts with CMS. The quality of care data is available for public review on the CMS
Hospital Compare website.

Long Term Care Facilities

Long Term Care Facilities are required to complete the MDS (Minimum Data Set) an extensive
patient information form and submit the information electronically to a centralized database at
CMS. The information is used to generate reports for public review on the Nursing Home
Compare website.

Home Health Agencies
Home Health Agencies are required to complete and submit patient information and assessment
forms into a program called OASIS. The information from this system is used to generate
reports for public review on the Home Health Compare website

Physicians

Individual physician offices can voluntarily report quality of care information into a CMS
database called PQRI (Physician Quality Reporting Initiative). CMS provides payment
incentives to physicians who reach established goals for quality of care reporting. This program
is not used extensively at this time.

Other Quality Reporting Initiatives

There are several other quality reporting initiatives and capabilities throughout Montana. These
include the work of the Quality Improvement Organization, which studies and promotes quality
of care for specific topics such as hospital infections, nursing home pressure ulcers and restraints,
ambulatory mammograms and vaccinations. Blue Cross/Blue Shield has quality initiatives
associated with congestive heart disease and other diseases. Individual facilities participate in
other national quality initiatives such as heart disease projects, CDC registries for MRSA,
Premier Hospitals projects, etc. The state Department of Health also reports on quality of care
issues through the immunization program and the diabetes care monitoring program.

Clinical Summary Exchange for care coordination and patient engagement

Facilities in Montana use a variety of methods for communicating critical clinical information
regarding patients as they move from one setting to another. Currently facilities use a variety of
methods to share information but none are considered adequate to true care coordination. The
methods include: transfer sheets along with the discharge summary and/or a medication
reconciliation form; electronic record sharing for hospitals and nursing homes that are connected;
use of a standardized transfer form plus some clinical information; use of the latest MDS
(minimum data set); exchange of information via Meditech to outside physician offices that are
also connected to the system. The awareness of the need for a better care coordination solution
is high. It is expected that care coordination will be focused on under health care reform and it is
expected that the QIO contracts for the next cycle of work will be working on this topic with the
facilities.

BROADBAND

Montana Broadband Mapping –
The Montana State Department of Commerce has been awarded grant funding to map the
availability of broadband (high-speed internet) in Montana. Contacts for this project are Kelly
Casillas Legal Council, MT Dept of Commerce (406-841-2727) and Trudy Skari, Project
Coordinator. They will have preliminary mapping by Nov. 2009 and expect to have reportable
information in Spring 2010.

Access to Bandwidth
Bandwidth in urban/rural is better than rural/frontier areas but the challenge is obtaining
Sufficient bandwidth at a reasonable cost. The primary issues with broadband access are 1)
affordable access to fiber in areas where fiber currently exists 2) the availability of adequate
fiber, 3) piecing together multiple carriers, and 4) lots of gaps to be filled in. Some carriers are
very protective of their dark fiber and it is often not priced competitively. The pricing is higher in
rural areas.


FCC Broadband projects
The FCC awarded Montana two grants for HIT broadband. Montana Telehealth Alliance and
Health Information Exchange of Montana are the recipients.

Current ARRA Stimulus Broadband projects
Stimulus money is available for broadband projects. First round of grants awards are posted at
BroadbandUSA.gov. There were 2200 proposals across the country totaling $28 billion. There
is $4 billion to award. There are 13 initial Montana –based proposals and about 30 other
proposals that might address Montana needs.


Vision Net –
Incorporated in 1995, Vision Net, Inc. is a Montana company, wholly owned by nine established
telephone companies. On May 1, 2005 Vision Net, Inc. merged with Montana Advanced
Information Networks, Inc. (MAIN), to form a combined company uniquely positioned to
deliver a wide range of technical professional services.

Vision Net services includes: broadband network transport via SONET, ATM, MPLS, IP,
Ethernet, satellite and wireless; worldwide video conferencing; a range of Internet services;
customized wide area network management; a 24 x 7 call center delivering Internet and network
technical assistance support nationwide, and network and equipment monitoring services region
wide; access tandem switching; engineering design; and technical consulting.

Vision Net is a key provider for many Montana telehealth and telemedicine applications.


CURRENT REGIONAL HIES AND NETWORKS:

Health Information Exchange of Montana (HIEM)
HIEM –The Health Information Exchange of Montana, Inc. (HIEM) is a rural health consortium
of Northwest Montana healthcare organizations who have formally come together to address
their shared unique geographic and technological challenges in order to exchange basic medical
information and expand telehealth applications in northwest and north central Montana. It is a
non-profit organization comprised solely of 501(c)(3) healthcare organizations and supported by
dozens of affiliate partners within our service area, across our region and throughout Montana.

HIEM systems integrated using ICA (Informatics Corp of America) CareAlign Aggregation
Platform - The six hospitals, 12+ clinics, 1 long term care facility, and 1 home health facility
comprising the area’s healthcare system include: Glacier Community Health Center,
HealthCenter Northwest, Kalispell Regional Medical Center, Lincoln County Community Health
Center, North Valley Hospital, Northern Rockies Medical Center, St. John’s Lutheran Hospital,
St. Luke Community Hospital, and other participating sites in the region. All have disparate
legacy healthcare information technology on various platforms and in different locations,
including the following:


                                                               Midas+ quality
Amicas PACS             HealthPort document imaging
                                                               alerts
ChartBuilder                                                   MIE WebChart
                        HealthWyse home health
EMR                                                            EMR
                        ImageNow document imaging
DR PACS                                                        PenRad mammo
eClinicalWorks                                                 Pyxis pharmacy
                        Keane long term care
EMR                                                            orders
                                                               SoftMed
FileMaker EMR           MedHost ED
                                                               transcription
                        Meditech Client Server
Fletcher- Flora
                        abstracting, admission, lab,           Tech-Time ADT
LabPak
                        pharmacy
                        Meditech MAGIC admission
GE Centricity                                                  Xcelera cath
                        planning, pharmacy, order entry
perinatal                                                      images
                        departmental ,lab
GE QS OB fetal          Microsoft Word clinical
monitoring              documents

ICA developed a phased implementation approach which first integrated existing healthcare
technology into vaulted data with patient matching capabilities, allowing the segregation of
source data by participant while also enabling a longitudinal healthcare record to be generated
for a patient at any of the facilities. This was accomplished by selecting critical feeding systems,
piloting the approach and then expanding the aggregation phase throughout the community.

HIEM has identified “exchange with the State’s health exchange, HeathShare Montana” as a
goal.

HIEM has received FCC funding for the expansion of fiber optic connectivity within the
northwest portion of the state and is currently contracting with vendors to enhance broadband
services in that region.


NorthCentral Montana HealthCare Alliance -

The Northcentral Montana Healthcare Alliance is a collaborative consortium of 14 healthcare
facilities. The mission statement of the NMHA reads:
   “To collaboratively develop strategies, synergies, relationships, products and services, that
will improve delivery, access and quality, while controlling the cost, of not-for-profit healthcare
in all Alliance member communities.”

The membership of the NMHA includes Montana’s largest tertiary hospital, a 49 bed rural
hospital, a freestanding nursing home, two Indian Health Service facilities, and ten Critical
Access Hospitals.The 11 counties served by the NMHA member hospitals encompasses 31,828
square miles - that’s an area larger than the combined size of Vermont, New Hampshire,
Connecticut, Delaware and Rhode Island




Members of the NMHA and their communities are:

Benefis Hospitals, Great Falls
Big Sandy Medical Center, Big Sandy
Blackfeet Community Hospital, Browning
Central Montana Medical Center, Lewistown
Fort Belknap Hospital, Fort Belknap
Liberty County Hospital, Chester
Marias Medical Center, Shelby
Missouri River Medical Center, Fort Benton
Mountainview Medical Center, White Sulphur Springs
Northern Montana Healthcare, Havre
Northern Rockies Medical Center, Cut Bank
Phillips County Hospital and Medical Center, Malta
Pondera Medical Center, Conrad
Teton Medical Center, Choteau
Wheatland Memorial Healthcare, Harlowton

Rocky Mountain Health Network (Billings) – provider membership; provides practice
management services, billing services, and group purchasing including IT purchasing

Monida Healthcare Network (Missoula) – provider membership; provides staffing services,
education services, and group purchasing including IT

Defacto HIEs

       Billings Clinic – an integrated delivery system; vendor Cerner
      Bozeman Deaconess and community – Meditech hospital / NextGen ambulatory care
       EHR. Bozeman is unique in that nearly all physician offices have agreed on the NextGen
       option hosted through Bozeman Deaconess, have agreed on transparency of data across
       providers, and have a patient op-out solution.
      Montana Frontier Healthcare Network - Critical access hospitals in Deer Lodge, Granite,
       Prairie and McCone counties using a centralized ambulatory care information system
       approach that allows population health, quality reporting and information exchange,
       vendor DocSite.

      Other communities are developing projects around a primary vendor


TELEMEDICINE / TELEHEALTH

Montana Healthcare Telecommunication Alliance (MHTA): MHTA is a national model
recognized for collaboration and innovation. Stakeholders in healthcare organizations across
Montana work together to promote advancements in telecommunications through video-
teleconferencing and telemedicine. MHTA is a network of networks:
     Eastern Montana Telemedicine Network
     METNET – State of Montana
     Partners in Health Telemedicine Network
     Realizing Education and Community Health, REACH-Montana, a service of Benefis
       Healthcare, Great Falls
     St. Patrick Hospital
     FORTH (Fiber Optic Rural TeleHealth)
     Montana Advanced Telecommunications Alliance


REACH Montana Telehealth Network -
Promoting telehealth for northcentral Montanans through the activities of the REACH-Montana
Telehealth Network. This Great Falls-based IP televideo network serves the communities of
White Sulphur Springs, Choteau, Conrad, Cut Bank, Shelby, Chester, Fort Benton, Big Sandy,
Rocky Boy, Havre and Chinook.

Inter-network connections via private communications lines link RMTN with telehealth
networks in Billings, hospitals in Kalispell, Butte, and Missoula, and connections to the capitol
city of Helena via METNET (the State of Montana’s Tele-video arm), and MHA, an Association
of Montana Health Care Providers.

Montana Frontier Healthcare Network - Operates a web-based telemedicine network
currently comprising critical access hospitals in Deer Lodge, Granite, Prairie and McCone
counties and a consulting hospital in Missoula county.

COMMERCIAL HEALTH PLANS AND COVERAGE
The primary plans in Montana include Blue/Cross, New West, and Allegiance.

Blue Cross Blue Shield of Montana (BCBS), the state’s largest carrier, serves 240,000 members
across the state. BCBS has been working with providers in a pay-for-performance effort focused
around the Medical Home model.

The second largest carrier, New West, has tentative plans to participate in a pay-for-performance
program.

In 2003, the University of Montana’s Bureau of Business and Economic Research conducted an
in-depth survey of more than 5,000 Montanans on the topic of health insurance. Little more than
half of all Montanans had employer-offered health insurance. Individual health insurance
policies accounted for nine percent of the state’s population. Medicaid and the Children’s Health
Insurance Program (CHIP) accounted for six percent, a rate that was lowered somewhat by
counting persons who were dual-enrolled in Medicare and Medicaid as being Medicare-insured.
Medicare covered 15 percent of Montana’s population. The remaining 19 percent of the
population is uninsured. 1

Collaborative opportunities

The following lists the potential relevant collaborative opportunities that exist in Montana:

HealthShare MT is the only state level HIE in Montana.
The regional/local HIEs and Telehealth networks noted above.
Montana Primary Care Association (Community Health Centers)
MHA – An Association of Health Care Providers (hospital and other providers)
       Montana Performance Improvement Network (critical access hospitals)
Montana Medical Association
Montana Health Care Association (nursing homes)
Montana Department of Health and Human Services
Montana Medicaid Division
Mountain-Pacific Quality Health Foundation (QIO)
Blue Cross-Blue Shield, New West and Allegiance Insurance Companies
Veterans Administration
Montana Office of Rural Health/Area Health Education Center
Center for Translational Research - Montana State University//University of Washington
Indian Health Service
Montana Health Information Management Association
Montana State University, WWAMI Medical School, Nursing Extension, Engineering
University of Montana, Engineering, Health Informatics, Nursing, Pharmacy, Law
Community Colleges: Network administration.
AARP
Trauma Registry/Montana Department of Transportation/ State Highway Traffic Safety Office
Consumer organizations interested in HIE issues.

1
    Steve Seninger, “Lack of Health Insurance Plagues Montanans,” Montana Business Quarterly, Winter 2003

				
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