Preliminary Observations on Information Technology Needs and Priorities at the Centers for Medicare and Medicaid Services

An Interim Report

Committee on Future Information Architectures, Processes, and Strategies for the Centers for Medicare and Medicaid Services

Computer Science and Telecommunications Board

Division on Engineering and Physical Sciences

NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Preliminary Observations on Information Technology Needs and Priorities at the Centers for Medicare and Medicaid Services An Interim Report Committee on Future Information Architectures, Processes, and Strategies for the Centers for Medicare and Medicaid Services Computer Science and Telecommunications Board Division on Engineering and Physical Sciences THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Department of Health and Human Services under sponsor award number HHSP23337011T. Any opinions expressed in this material are those of the authors and do not necessarily reflect the views of the agencies and organizations that provided support for the project. International Standard Book Number-13: 978-0-309-17693-4 International Standard Book Number-10: 0-309-17693-x Copies of this report are available from The National Academies Press 500 Fifth Street, N.W., Lockbox 285 Washington, DC 20055 800/624-6242 202/334-3313 (in the Washington metropolitan area) http://www.nap.edu Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON FUTURE INFORMATION ARCHITECTURES, PROCESSES, AND STRATEGIES FOR THE CENTERS FOR MEDICARE AND MEDICAID SERVICES EDWARD H. SHORTLIFFE, American Medical Informatics Association, Chair MICHAEL L. BRODIE, Verizon Communications DON E. DETMER, University of Virginia School of Medicine JOHN R. DYER, Jarrett Associates, Inc. JOHN GLASER, Siemens Healthcare LAURA M. HAAS, IBM Almaden Research Center BLAISE HELTAI, NewVantage Partners, LLC GEORGE HRIPCSAK, Columbia University YEONA JANG, McGill University RALPH W. MULLER, University of Pennsylvania Health System LEON J. OSTERWEIL, University of Massachusetts Amherst RUTH PEROT, Summit Health Institute for Research and Education, Inc. HELEN L. SMITS, Independent Consultant, Old Saybrook, Connecticut WALTER SUAREZ, Kaiser Permanente JOHN A. SWAINSON, Silver Lake PETER SZOLOVITS, Massachusetts Institute of Technology Staff LYNETTE I. MILLETT, Senior Program Officer EMILY ANN MEYER, Program Officer ERIC WHITAKER, Senior Program Assistant v

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COMPUTER SCIENCE AND TELECOMMUNICATIONS BOARD ROBERT F. SPROULL, Oracle, Chair PRITHVIRAJ BANERJEE, Hewlett Packard Company STEVEN M. BELLOVIN, Columbia University SEYMOUR E. GOODMAN, Georgia Institute of Technology JOHN E. KELLY III, IBM JON M. KLEINBERG, Cornell University ROBERT E. KRAUT, Carnegie Mellon University SUSAN LANDAU, Radcliffe Institute for Advanced Studies DAVID E. LIDDLE, U.S. Venture Partners WILLIAM H. PRESS, University of Texas, Austin PRABHAKAR RAGHAVAN, Yahoo! Research DAVID E. SHAW, Columbia University ALFRED Z. SPECTOR, Google, Inc. JOHN A. SWAINSON, Silver Lake PETER SZOLOVITS, Massachusetts Institute of Technology PETER J. WEINBERGER, Google, Inc. ERNEST J. WILSON III, University of Southern California Staff JON EISENBERG, Director RENEE HAWKINS, Financial and Administrative Manager HERBERT S. LIN, Chief Scientist, CSTB LYNETTE I. MILLETT, Senior Program Officer EMILY ANN MEYER, Program Officer ENITA A. WILLIAMS, Associate Program Officer VIRGINIA BACON TALATI, Associate Program Officer SHENAE BRADLEY, Senior Program Assistant ERIC WHITAKER, Senior Program Assistant vi

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Preface Increasingly, the core mission of the Centers for Medicare and Medicaid Services (CMS), an agency of the Department of Health and Human Services, is expanding from one of focusing on prompt claims payment to one of becoming more broadly involved in improving health care quality and efficiency. The requirements for the information technology (IT) systems of CMS are changing as its mission changes, and the efforts to evolve its systems from those designed to support the agency’s historical mission come in the midst of a push to modernize the nation’s health care IT more broadly. These new challenges arise even as CMS must meet challenging day-to-day operational requirements and make frequent adjustments to its business processes, code, databases, and systems in response to changing statutory, regulatory, and policy requirements. In light of these and other emerging challenges, CMS asked the National Research Council (NRC) to conduct a study that would lay out a forward-looking vision for the Centers for Medicare and Medicaid Services, taking account of CMS's mission, business processes, and information technology requirements. The statement of task for the project is presented in Appendix A. The study is being conducted by the NRC Committee on Future Information Architectures, Processes, and Strategies for the Centers for Medicare and Medicaid Services. The committee’s 16 members possess a broad range of expertise and backgrounds, including specific knowledge of CMS itself, large-scale enterprise computing, health care policy, health care quality, health care outcomes, large-scale data use and database operations, and health IT. Biosketches of the committee members are given in Appendix B. The study is being conducted in two phases. The first, which resulted in this interim report, draws on a series of teleconferences, briefings, and an information-gathering workshop held in Washington, D.C., on September 27-28, 2010. The second phase, drawing on that workshop and on additional briefings, site visits, and committee deliberations, will result in a final report with recommendations, to be issued at the end of the project in 2011. It is challenging for an external committee to learn about the complex environment and challenges that characterize an agency with the breadth of responsibilities and scope of CMS. The committee has benefited from the written materials provided by CMS staff and from their presentations and engagement both on telephone conference calls and at the workshop. The committee is accordingly grateful to the CMS staff who have contributed their time and insights to the study, and also thanks all of those individuals who participated in the September workshop and contributed their insights and experiences to the discussion. The committee thanks the reviewers of this report for their constructive feedback. And finally, the committee appreciates the work of the NRC staff members who have contributed to the process to date. vii

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Lynette Millett and Emily Ann Meyer, in particular, have demonstrated an intellectual engagement, a commitment to the task, and an ability to capture and integrate the wide-ranging discussions of a heterogeneous committee. We are indebted to them for their contributions to documenting the committee’s deliberations and to the writing of this report. Edward H. Shortliffe, Chair Committee on Future Information Architectures, Processes, and Strategies for the Centers for Medicare and Medicaid Services viii

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Acknowledgment of Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s (NRC’s) Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Michael Carey, University of California at Irvine, Christine Cassel, American Board of Internal Medicine, Renato A. DiPentima, Independent Consultant, Fort Lauderdale, Florida, Stephen Holden, SRA Touchstone Consulting Group, Ashish K. Jha, Harvard School of Public Health, Joseph Newhouse, Harvard University, Harry Reynolds, IBM Global Healthcare and Life Sciences, and Walker Royce, IBM Software Group. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was coordinated by Susan Graham, University of California at Berkeley Appointed by the NRC, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. ix

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Contents 1 CONTEXT 1 2 EMERGING REQUIREMENTS DRIVING MULTILAYERED TRANSFORMATION 4 3 CHALLENGES IN TRANSFORMING ENTERPRISE TECHNOLOGY AND 9 DATA MANAGEMENT 4 ORGANIZATIONAL, ADMINISTRATIVE, AND CULTURAL CHALLENGES 12 5 CONCLUDING OBSERVATIONS 15 APPENDIXES A Statement of Task 19 B Biosketches of Committee Members and Staff 20 xi

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