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MITA Case Studies: Which came first – the enterprise or the architecture?
Presented to: MMIS Conference 2005: Big Sky, MTAugust 14 - 18, 2005
Mary Tavegia – IME Project Director, State of Iowa DHSErin Harris – IME MITA Coordinator, Software Engineering Services
MITA Case Study - Iowa Medicaid Enterprise 2
The Iowa Medicaid Enterprise Iowa Facts and Figures IME Vision
Similar to MITA Goals Implementing the Vision
RFPs, Contracts, and Performance Measures DDI – Building the IME
The Enterprise is Live! Initial Results What’s Next
“MITA-sizing” the IME
MITA Case Study - Iowa Medicaid Enterprise 3
Medicaid in Iowa
Iowa Population – 2.9 million Currently 10% of population Medicaid eligible Medicaid impacts one out of every three Iowans
Dramatic Medicaid Cost Increases Average Monthly Eligibility (> 39% in 5 years) Average Monthly Total Payments (> 69% in 5 years)
Results-based Accountability in Iowa Performance measurement Cost-effective healthcare
MITA Case Study - Iowa Medicaid Enterprise 4
MMIS in Iowa Last procurement in 1995
Fiscal agent customized MMIS Pharmacy Point of Sale (POS) Decision Support System (DSS) Medically Needy Managed Care Operated on Contractor hardware in Pennsylvania
and Georgia Professional Services and operational support by
Fiscal Agent Interfaces with state-operated Medicaid eligibility
systems (Title XIX, ISIS) Ability to adapt to change constrained
MITA Case Study - Iowa Medicaid Enterprise 5
Iowa Medicaid Enterprise (IME)
The Vision Improve service to Iowa Medicaid members, providers, and
partners Shift control from Contractor to the State
Increase accountability throughout Medicaid operations Enhance decision making ability
Implement “Best practices” in key Medicaid business functions State management with “Best of Breed” Contractors Improve health outcomes for members
Enhanced primary care case management Initiate disease management program Collect and analyze cost and outcome information
Collaboration rather than competition Increase flexibility and adaptability Leverage state IT infrastructure
MITA Case Study - Iowa Medicaid Enterprise 6
IME Similar to MITA Goals RFP for IME released in 2003 MITA Framework 1.0 published in January 2004
MITA Goals1. Integration and interoperability2. Flexibility to respond rapidly to
change3. Enterprise view to align technology
and business needs4. Data that supports analysis and
decision making5. Performance measurement for
accountability and planning6. Coordination with partners to improve
overall health
IME Strategy• Co-location state, contractors• Integrate contractor systems • Modular business units• Begin technology migration• Collaborative business model• Workflow integration• Collect clinical data• Improve DSS capabilities• Performance-based contracts• Enhanced monitoring and
reporting of trends, costs• Enhanced case and disease
management• PDL, pharmacy/clinical
coordination
MITA Case Study - Iowa Medicaid Enterprise 7
Implementing the IME Vision Single RFP, multiple components
Systems Professional Services
Contract with “Best of Breed” service providers 8 Systems and Professional Services Contractors Operational support from the State
Department’s Division of Data Management (DDM) Network Support Data Warehouse Other Medicaid State Systems
Department of Administrative Services Iowa Technology Enterprise (ITE) Printing and Mailing Services
Separate Responses MMIS administration, Workflow, Imaging Pharmacy POS Medical Services Pharmacy Medical Services Member Services Provider Services SURS Provider Cost Audits and Rate Setting Revenue Collection
MITA Case Study - Iowa Medicaid Enterprise 8
DDI – Building the IME One-year timeframe
IV&V and PMO contract services Early transfer MMIS to state hardware Build and transfer Medicaid Data Warehouse
Shared Data and Tools Co-location Common data sources for all IME staff
MMIS Medicaid Data Warehouse Workflow Process Management System
Integrate on- and off-site contractor systems with MMIS
Performance based contracts and Report Cards
MITA Case Study - Iowa Medicaid Enterprise 9
The Enterprise is Live!
Initial Results Preferred Drug List 1-15-05 Pharmacy Point Of Sale 6-25-05 MMIS, Workflow & Contractor systems 6-30-05 Began Paying claims with Payment Cycle 7-11-05 Phasing in Medicaid Reform: IowaCare Phase 1
Next Steps Medicaid Reform: Next phases IowaCare Better integration, expand SOA capabilities Monitor performance and fine tune collaboration Continue MITA-sizing and enterprise architecture
development
MITA Case Study - Iowa Medicaid Enterprise 10
Enterprise Architecture: MITA-sizing the IME
MITA activities for the IME Opportunities for Enterprise Architecture (EA)
MITA Tools for the IME EA Business Process Model Capabilities and the Traceability Matrix
EA and IME Strategic Planning MITA self-assessment Business–focused IT planning
MITA Case Study - Iowa Medicaid Enterprise 11
MITA for the IME
MITA Activities in Parallel to DDI at the IME Track and assess MITA framework
Contribute to MITA definition Apply MITA principles to the IME
Current DDI recommendations Problematic in timeframe
MITA continuing to evolve Plans and contracts for the IME already underway
Assess MITA impact for future planning Validate/pilot MITA and enterprise architecture
Business process modeling Collect architectural elements, artifacts
MITA Case Study - Iowa Medicaid Enterprise 12
IME’s Opportunities for Enterprise Architecture
Redesign of business operations Document business processes
Workflow Operational procedures Cross-functional integration
Planning for quality by measuring performance Extract and document business rules from transferred
MMIS Technical environment adapted to business needs
Configured for operational efficiency Flexible, adaptable modularity
MITA Case Study - Iowa Medicaid Enterprise 13
MITA LifecycleCollaboration
Phase 4 – Transition Plan Executionand Iterative Updates
MITA Capability
Matrix
Combined Target
Capabilities
State (CIO) Enterprise
Architecture
State Medicaid EA
MITA Medicaid EA Guidelines
Self Assessment
State/ Medicaid Strategic Planning
MedicaidEA
Development Process
NASCIO Enterprise Architecture Tool Kit
Phase 3 - Transition PlanDevelopment
Phase 1- Self Assessment
Phase 2 - State Medicaid
EA Development
(Recommended)
MITA ArchitectureFramework
State Transition Plan
Transition PlanDevelopment
Legend
State ProcessSub-step
MITAProcessStep or
Sub-step
MITA Product
State MedicaidProduct
State (CIO)
Product
MITA Case Study - Iowa Medicaid Enterprise 14
IT View: Enterprise Information Architecture
Where is the Business?
Richard Watson, Lawrence Livermore National Laboratorycsdl2.computer.org/comp/proceedings/hicss/2000/0493/07/04937059.pdf
MITA Case Study - Iowa Medicaid Enterprise 15
Business-centric Focus
Multiple dimensions of MITA EABusiness Process
CapabilityData
ApplicationTechnical
TimeMITA Maturity
Business Drivers
MITA Case Study - Iowa Medicaid Enterprise 16
EA Modeling Questions What? – the process
Verb + Object (Process Claims) How? – the capability/competency
Qualities: Timeliness Accuracy Efficiency Quality Cost-effectiveness Value
Who? – stakeholders, actors, customers What information? – the data With what? – the application(s) With who, when, where? – the technical infrastructure
MITA Case Study - Iowa Medicaid Enterprise 17
IME Business Process Model
Functional framework in IME RFP Business units Requirements capabilities
IME operational procedures manuals Decompose and recombine chronological events Develop outline of business processes (table) Create graphical representation (model) Review/Assess/Modify – visual aid to refine model
Functional hierarchy, redundancy, trigger events
MITA Case Study - Iowa Medicaid Enterprise 18
IME BPM Models
MITA Case Study - Iowa Medicaid Enterprise 19
MITA - IME BPM Crosswalk
Revealed Gaps in IME BPM Differences in granularity of BPMs
Multiple IME BPs map to a MITA BP BPs that cross IME business areas Highlights areas for BP and/or system integration
Provides roadmap for self-assessment Keeps IME BPM relevant to IME business model
No “forcing the framework” onto the enterprise
MITA Case Study - Iowa Medicaid Enterprise 20
Crosswalk SampleMITA Business
Model v21b IME Business
Model
Business Area Intermed 1 Intermed 2 Business Process Business Process Intermed 2 Intermed 1 Business Area
Member Management
Eligibility Determination
Determine EligibilityDetermine Medicaid
Eligibility DHS Eligibility Administration
Enrollment
Enroll Member
Enrollment Brokerfor ManagedHealth Care Member Services
Enroll Member for Waiver, Mental Health
DHS Eligibility Administration
Enroll Selected Members and Providers for EPCCM
Enhanced Primary Care Case Management (EPCCM) Medical Services
Enroll Selected Members and Providers for DiseaseManagement Program
Disease Management Medical Services
Lock-in Enrollment Lock-in Medical Services
MITA Case Study - Iowa Medicaid Enterprise 21
Initial Traceability Matrix ExampleIME Business
Area/Key Process"As is" Current
Capability"To be" IME Capability
"As is" -> "To be“ Gap Description
Stakeholders Business Value Goal Alignment
Medical Services
Medical Support
Claim Review Review claims foradministrative andJudicial appeals.Request additional information from providers as needed.
Provide well-qualifiedMedical Director(MD/OD) and professional staff or consultants formedical review functions.
Dispersed clinical review services with Limited staffing.Increasing Program focus on health outcomes.
Medical DirectorMed Srv Unit MgrMed Srv Ops MgrClaim Rev SuprvsrPolicy RepElig RepAtty Gen, Rep
Partner w/local medical communityto ensure fair review using established standards of care.
#1 Improve service – H (3)#3 Best Practices - H (3)
Total Goal Alignment = 6
Pre-procedure/Pre-admission Review
Process paper or fax PAs and requests for exception to policy.
Accept electronicPAs. Provide medical consultingservices to DHS regarding policy changes, and to providers regarding policy for PAs and billing. Track all communications with providers regarding policy electronically.
Limited legacy system EDI capabilities.Dispersed clinicalreview services with limited staffing. No automated CRM or Documentmanagement systems.
Medical DirectorMed Srv Unit MgrMed Srv Ops MgrPA SupervisorsPolicy RepProvider Srv RepMember Srv Rep
Improved response time and accuracy of prior authoriza-tions improves provider and patient relations,and increases accuracy of billing.
#1 Improve service – H (3)#2 State control - L (1)#3 Best Practices - H (3)#4 Flexibility/Adapt - M (2)#5 Leverage state IT–L (1)
Total Goal Alignment = 10
Retrospective Inpatient and Outpatient Review
Perform medical review of 10% of all claims. Initiate revenue adjustments as needed.
Dispersed clinical review services with limited staffing.Increasing programfocus on claims quality.
Medical DirectorMed Srv Unit MgrMed Srv Ops MgrPolicy RepRetro Review
Sprvsr
Improved payment accuracy and monitoring of utilization.
#1 Improve service – L (1)#2 State control - M (2)#3 Best Practices - H (3)
Total Goal Alignment = 6
Capabilities/Goals/Business Value
MITA Case Study - Iowa Medicaid Enterprise 22
Traceability Matrix – EA Example
IME BusinessArea/Key Processl de
"To be" IME Capability
Related IME
Requirements Documents
Related IME
Design Documents
Technical Solutions Notes
Data ArchitectureNotes
Medical Services
Medical Support
Claim Review Provide well-qualifiedMedical Director(MD/OD) and professional staff or consultants formedical review functions.
> Requirements Confirmation Workbook – FINAL
> SRS061.000 Medical Support
> MQUIDS DSD 3-3-05 MQUIDS
> VB.NET using Visual Studio 2003
> 2-tier environment
> Crystal reports
> ADO.NET object model
> SQL Server 2000
> MMIS Claims History
Pre-procedure/Pre-admission Review
Accept electronicPAs. Provide medical consultingservices to DHS regarding policy changes, and to providers regarding policy for PAs and billing. Track all communications with providers regarding policy electronically.
> Requirements Confirmation Workbook – FINAL
> SRS061.000 Medical Support
> MQUIDS DSD 3-3-05
> WDS915.2_Prior Authorization
> WDS913_Workview
> WDS907.2_Medical Services
MQUIDS
> VB.NET using Visual Studio 2003
> 2-tier environment
> Crystal reports
> ADO.NET object model
OnBase Tech Env.
ELVIS Tech Env
MMIS Tech Env
> SQL Server 2000
> MMIS Prior Auth Master
Retrospective Inpatient and Outpatient Review
Perform medical review of 10% of all claims. Initiate revenue adjustments as needed.
> Requirements Confirmation Workbook – FINAL
> SRS061.000 Medical Support
> MQUIDS DSD 3-3-05 MQUIDS
> VB.NET using Visual Studio 2003
> 2-tier environment
> SQL Server 2000
> Crystal reports
> ADO.NET object model
> SQL Server 2000
> MMIS Claims History
EA Dimensions
MITA Case Study - Iowa Medicaid Enterprise 23
More EA/MITA Details in Extended Traceability Matrix
IME BusinessArea/Key Process
"To be" IME Capability
Timeliness Accuracy Efficiency Quality Cost-Effective-
ness
Value Performance Measures
Medical Services
Medical Support
Claim Review Provide well-qualifiedMedical Director (MD/OD) and professional staff or consultants for medicalreview functions.
Extend details captured in matrix for each EA dimension: Capability/competency definition (MMM qualities, performance
measures, etc.) Application architecture (COTS, legacy systems, subsystems, etc.) Data architecture (files, locations, formats, . . ., metadata repository) Technical architecture (hardware, telecomm, operating systems,
integration, services, etc.) EA details collected in matrices provide information to perform MITA
self-assessment
MITA Maturity Model (MMM) Qualities/Performance Measures
MITA Case Study - Iowa Medicaid Enterprise 24
EA and IME Strategic Planning MITA self-assessment
BPM extended traceability matrix + crosswalk self-assessment
Business–focused IT planning Traceability matrix collects EA artifacts Provides process change roadmap
Gaps, goals, stakeholders, data, applications, technical infrastructure
Scope and impact of change Incremental
Iterative process Granularity Focus: business process, functional area, business area,
enterprise
MITA Case Study - Iowa Medicaid Enterprise 25
Questions
Mary Tavegia, mtavegi@dhs.state.ia.us, (515) 725-1110Erin Harris, eharris@sesc-us.com, (615) 293-2993
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