Summary and Recommendations

The Centers for Medicare and Medicaid Services (CMS) is the agency in the Department of Health and Human Services responsible for providing health coverage for seniors and people with disabilities, for limited-income individuals and families, and for children—totaling almost 100 million beneficiaries. Collectively, these programs make CMS the largest purchaser of health care in the United States. CMS interacts with thousands of health care providers across the country, ranging from individual physicians to hospitals large and small, as well as with other providers such as ambulance services and rural health centers. The agency’s core mission was established more than four decades ago with a mandate to focus on the prompt payment of claims, which now total more than 1.2 billion annually. To fulfill that role, CMS processes more than 3 million eligibility inquiries and makes more than $1 billion in feefor-service payments daily.

Recent legislation has given CMS new and expanded responsibilities for driving national improvements in areas such as the greater efficiency of health care services, the elimination of health disparities, the support of health care quality, the adoption of health information technology, a drive toward value-based purchasing, and the collection and analysis of data to promote health and wellness. CMS also has responsibility for testing innovative care and payment models and for overseeing the newly established state-based insurance exchanges.

With CMS’s mission expanding from its original focus on prompt claims payment come new requirements for the agency’s information



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Summary and Recommendations T he Centers for Medicare and Medicaid Services (CMS) is the agency in the Department of Health and Human Services responsible for providing health coverage for seniors and people with disabilities, for limited-income individuals and families, and for children—totaling almost 100 million beneficiaries. Collectively, these programs make CMS the largest purchaser of health care in the United States. CMS inter- acts with thousands of health care providers across the country, ranging from individual physicians to hospitals large and small, as well as with other providers such as ambulance services and rural health centers. The agency’s core mission was established more than four decades ago with a mandate to focus on the prompt payment of claims, which now total more than 1.2 billion annually. To fulfill that role, CMS processes more than 3 million eligibility inquiries and makes more than $1 billion in fee- for-service payments daily. Recent legislation has given CMS new and expanded responsibilities for driving national improvements in areas such as the greater efficiency of health care services, the elimination of health disparities, the support of health care quality, the adoption of health information technology, a drive toward value-based purchasing, and the collection and analysis of data to promote health and wellness. CMS also has responsibility for test - ing innovative care and payment models and for overseeing the newly established state-based insurance exchanges. With CMS’s mission expanding from its original focus on prompt claims payment come new requirements for the agency’s information 1

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2 STRATEGIES AND PRIORITIES FOR INFORMATION TECHNOLOGY AT CMS technology (IT) systems. These new challenges arise even as CMS must cope with the growth of the “baby boom” Medicare population and continue to meet challenging day-to-day operational requirements and to make frequent adjustments to its business processes, software code, databases, and systems in response to changing statutory, regulatory, and policy requirements. Complicating matters further, the efforts to evolve its systems come in the midst of changes to the nation’s health care IT more broadly. CMS’s ongoing operational requirements are currently being met with a very large and complex set of hardware, software, and communications systems that vary considerably in age, capability, and sophistication. The ability of these systems to continue to keep up with the ongoing changes and new missions demanded of them is an understandable source of con - cern. CMS asked the National Research Council to review its plans for its IT capabilities in light of these challenges and to make recommendations to CMS on how its business processes, practices, and information systems can best be developed to meet today’s and tomorrow’s demands. The recommendations and conclusions offered by the Committee on Future Information Architectures, Processes, and Strategies for the Centers for Medicare and Medicad Services cluster around the follow - ing themes: (1) the need for a comprehensive strategic technology plan; (2) the application of an appropriate meta-methodology to guide an iter- ative, incremental, and phased transition of business and information systems; (3) the criticality of IT to high-level strategic planning and its implications for CMS’s internal organization and culture; and (4) the increasing importance of data and analytical efforts to stakeholders inside and outside CMS. The committee notes the significant benefits of modernizing and transforming CMS IT and the costs of not doing so. CMS has an oppor- tunity now to plan strategically for necessary advances and needs to move quickly. Given the complexity of CMS’s IT systems, there will be no simple solution. Although external contractors and advisory organiza- tions will play important roles, CMS needs to assert well-informed techni- cal and strategic leadership. The committee argues that the only way for CMS to succeed in these efforts is for the agency, with its stakeholders and Congress, to recognize resolutely that action must be taken, to begin the needed cultural and organizational transformations, and to develop the appropriate internal expertise to lead the initiative with a comprehensive, incremental, iterative, and integrated approach that effectively and strate- gically integrates business requirements and IT capabilities. CMS has an opportunity now to effect these needed transformations—the technology exists to do what must be done.

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3 SUMMARY AND RECOMMENDATIONS CMS’S INCREASINGLY DYNAMIC AND CHALLENGING OPERATIONAL CONTEXT The nature, scope, and scale of the changes with which CMS is grap - pling are significantly greater than past transitions it has successfully weathered (such as the successful implementation of Medicare Part D, which was itself a large challenge). The variety of new activities for which CMS is responsible, the new legislation to which it must be responsive, the pending proposals that it must monitor, and the changing shape of health care broadly are all part of a highly dynamic context in which the agency operates. Just during the course of this study, CMS was tasked with major new efforts such as ensuring the implementation of meaningful-use regu- lations and overseeing development of the health insurance exchanges called for in the Patient Protection and Affordable Care Act (PPACA). Such additional responsibilities reflect the fact that the needs and demands of CMS’s customers and stakeholders are changing. And CMS must manage the overall integration of its programs, processes, and sys - tems while fighting fraud, providing the required levels of security and privacy, and achieving new efficiencies. In addition to anticipated changes to CMS’s own programs, the broader health care, practice, and policy environments are undergoing significant change, including ongoing evo - lution of technology and changes in policy expectations regarding trans- parency, fraud resistance, timeliness, and the greater involvement of key stakeholders. Importantly for this study, virtually all of the new initiatives and activities CMS is being asked to cope with have significant implica - tions for its IT infrastructure and systems. IT is at the heart of virtually every CMS business interaction, process, and decision. Rising health care costs are a central challenge facing the nation, and CMS is expected to play a major role in addressing such costs and their impact on federal spending. As the country heightens its efforts to improve care quality and control the costs of care it will rely increas- ingly on CMS to be at the forefront. Indeed these expectations have been described in recent legislation. The study committee concurs with the views expressed by CMS in meetings and discussions that serious work is needed to prepare the agency’s business and information systems for the future and that investment in CMS’s IT is critical to controlling costs in the long term. RECOGNIZE THAT A COMPREHENSIVE STRATEGIC TECHNOLOGY PLAN IS CENTRAL TO CMS’S MISSION AND EFFECTIVENESS The committee agrees with views it heard from CMS and others over the course of the study that the status quo is not a realistic option. If the

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4 STRATEGIES AND PRIORITIES FOR INFORMATION TECHNOLOGY AT CMS programs CMS administers were to remain fundamentally static and the only issue were the growth in claims volume driven by an aging popu- lation, it is possible that CMS’s current systems could be evolved and adapted to satisfy the anticipated growth in transaction volume. How - ever, the programmatic requirements that CMS must meet now and in the rest of this decade present an extreme challenge to fulfillment through the structure of its existing systems. The necessary changes cannot be delayed given the agency’s legislative mandates. While the status quo is insufficient, simply urging major “systems modernization” is also not adequate. Industry experience has repeatedly reinforced the lesson that “big bang” approaches to systems moderniza - tion almost always fail. Such approaches are difficult to execute and, even when the end-state seems clear, their record of success is poor. More - over, such approaches often ignore the fact that new systems change the environment in which they operate, and hence the future requirements to which they are subject. At the same time, reactive, year-by-year and program-by-program approaches to upgrading CMS systems also will not work to meet the new and emerging demands on CMS. There should be no expectation on the part of CMS or its stakeholders, including Congress, of an “ultimate” or finished CMS IT system. Although this report focuses on information technology systems, IT systems and the organizations that support them do not exist entirely independently of other parts of the CMS enterprise. This interdependence has two implications: (1) developing a coherent and effective vision for IT is dependent on a vision for CMS as a whole, and (2) IT should be viewed throughout the agency and by stakeholders as a central vehicle for supporting the effective performance of CMS’s activities, businesses, and programs. To get to a vision for future IT at CMS, the agency itself should have a clear expression of how it intends to, or believes it will, function in the future. Such a vision will likely anticipate CMS program - matic extensions into quality, safety, equity, and value management and will need to account for an increasing frequency of legislative and regula - tory mandates that will change CMS programs and requirements. Thus, CMS itself needs a strategic plan that is broadly accepted; it will be an evolutionary document that will require periodic updating as mandates are refined, experience is amassed, and the health care delivery system as a whole changes. In concert with the agency’s strategic plan, a well- aligned strategic technology plan is also needed. A comprehensive strategic technology plan provides a vision to help guide an organization as it executes on programs and projects with a clear sense of strategic priorities, while minimizing the risk of wasting resources on applications and projects that are redundant. A strategic technology plan offers a strategy for the deployment of technology and

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5 SUMMARY AND RECOMMENDATIONS clearly defined responsibilities for the use and application of technol - ogy. The IT environment in CMS is too complex to rely on outmoded ways to keep the CMS business functioning and thriving. To balance the many crucial and changing demands to move the organization forward, strategic technology planning, coupled with a business-driven IT gover- nance process, will be needed. Instituting strategic technology planning integrated with CMS business planning can serve as a catalyst that effec - tively brings together the dynamics of cross-enterprise communication and summarizes key, relevant data to inform decision making. CMS’s Office of Information Services (OIS) has developed or is in the process of developing many components of a strategic technology plan as outlined here. The plan and meta-methodology described in this report are a generalization of that described by OIS itself in, for example, its enterprise and shared services plan, enterprise data environment, and OIS-wide architectural and life-cycle guidelines, among others. OIS has articulated the need to formalize and define services that can be shared across its various businesses. The documents seen by the committee also suggest a governance model that spans the business and IT organiza - tions, involving all stakeholders. The committee applauds this direction in CMS, and nothing said here should contradict the ideas expressed in those documents. The committee uses its own terminology in this report only for consistency and clarity. Recommendation: CMS should develop a comprehensive strate- gic technology plan that supports and extends the ability of CMS to achieve its envisioned mission. Particular emphasis should be focused on ensuring that CMS has the necessary data, information, and IT capabilities to effectively implement legislatively mandated, value-based payment programs. The plan should articulate an IT vision consistent with the evolving mission of CMS as mandated by Congress, and cognizant of a rapidly evolving health care system. The plan should be fundamentally informed by the various stakeholders in CMS IT and by a clear and comprehensive view of both the current state and projections of the future state. The plan should be broadly communicated both within CMS and to all of its stake - holders and serve as a roadmap for future IT initiatives. The CMS strategic technology plan should: • Be evolutionary and incremental. • Explicitly articulate CMS’s core technical competencies and con- sider what IT functions and activities might be carried out by the private sector or other public agencies.

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6 STRATEGIES AND PRIORITIES FOR INFORMATION TECHNOLOGY AT CMS • Identify as many shared services as possible and create a shared services model across all CMS business organizations. • Emphasize systems leveraged across programs to reduce unneces- sary redundancies; emphasize using existing proven technologies wher- ever possible; and prioritize standards-based solutions. • Include an enterprise architecture framework; explicit prioritiza- tion and a roadmap; an assessment of human capital requirements; and periodic planned review and iteration of the plan itself. A strategic technology plan for CMS is needed against which to plan, act, and make ongoing refinements based on experience. The rationale for the development of such a plan is multifaceted; the plan would: • Rationalize the process of making the difficult, and necessarily long-term, decisions about systems replacement, evolution, moderniza - tion, and transformation. • Contextualize the funding requests for IT and provide a mission- driven rationale for and prioritization of individual initiatives and fund - ing requests. • Drive toward coordination of efforts to garner increased efficiencies. • Ensure that the entire complex organization and its stakeholders understand the overall direction and intent of use of IT at CMS. • Identify long-term needs for resources, and align those resources effectively. • Mitigate execution risk; in large organizations, many projects fail because of failure to recognize the coming interdependencies. • Facilitate the alignment of the core and contracted parties. Not only is federal IT management—and IT management, in general—notoriously difficult, but federal budget constraints and fund - ing models also place additional pressure on agencies to maintain, and even increase, productivity in spite of limited financial resources. Agen - cies such as CMS are typically not allocated sufficient funds to modernize or upgrade existing systems in an enterprise-wide integrated fashion, and as a consequence must cope with the dual challenge of (1) program- by-program stove piping that makes it difficult to properly integrate programs or achieve the efficiencies (programmatic and operational) that would result and (2) inconsistent year-by-year funding that makes it dif - ficult to do long-term planning of the sort possible with capital budgets. A sustained funding approach is needed that recognizes the benefits of investment in enterprise-wide modernization and transformation over the long term.

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7 SUMMARY AND RECOMMENDATIONS Conclusion: To achieve the needed modernizations and transforma- tions that are basic to the realization of CMS’s vision and execution of its strategic technology plan, a sustained, predictable, and appro- priate investment is needed, including investments in enterprise information technology infrastructure and integration. Without such investment, CMS’s modernization and transformation efforts are unlikely to succeed. A forward-thinking strategic technology plan is essential to coping with ongoing changes in mandates and requirements both now and in the future. At the same time, there are also mandated near-term activities that cannot wait for a comprehensive plan and should be addressed now. It is important, however, not to completely decouple efforts to meet immedi- ate needs from long-term thinking. There are benefits that accrue from linking long-term planning to fast-track programs: for instance, reinforce- ment of the need for some pragmatics in longer-term planning efforts and clarification of the urgency of the longer-term planning efforts so that they do not drag on indefinitely. Shorter-term efforts may have to be thought of as prototypes of a sort, aimed at gathering the more precise knowledge needed to serve as the basis for more solidly conceived and implemented permanent solutions to be implemented in subsequent iterations. Recommendation: In parallel with developing a strategic technol - ogy plan, CMS should undertake fast-track efforts to satisfy imme- diate and near-term needs and mandates. These efforts should be well defined and constrained in scope and, to the extent possible, serve as a testing ground for longer-term strategic choices. EMBRACE A COMPREHENSIVE, INCREMENTAL, ITERATIVE, AND PHASED APPROACH A strategic technology plan lays a foundation and articulates a vision. But just as important is a comprehensive operational approach to mod - ernization and/or transformation of the information infrastructure and systems. For the purposes of this report the terms “modernization” and “transformation” refer to two ends of a spectrum of possible transitions for components of an information system. Modernization refers to mod- est or evolutionary transitions; transformation refers to significant or revolutionary transitions. The committee’s discussion of modernization and transformation is presented at an abstract (meta-) level that sets forth conceptual models for business roles and processes. The approach to modernization and transformation recommended in this report has two phases. The first phase focuses on the modernization

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8 STRATEGIES AND PRIORITIES FOR INFORMATION TECHNOLOGY AT CMS or transformation of the business aspects of CMS and the establishment of a plan for the business systems (the people, processes, services, and information required to operate and meet all the business requirements of a specific CMS business role), in the process defining the business require- ments. The second phase focuses on the modernization or transformation of CMS IT systems, is guided by the plan for the business systems, and creates a plan for the information systems (the systems required to build, develop, operate, and evolve one or perhaps multiple business systems). Both phases follow the same pattern: (1) understand the source sys- tems of interest and how they interrelate, (2) choose a starting point—a component to be transitioned, (3) understand the relevant target systems, (4) develop a mapping between the source and the target systems, and (5) implement the mapping and transition. At that point, choose the next component to transition and iterate through the cycle again—recognizing that the source systems of interest will have changed based on the results of the transition. Iteration, an incremental approach, and, perhaps most importantly, the strategic integration of business and IT are fundamental to the recommended meta-methodology. At the end of each roll-out, the incrementally updated target becomes the source for the inevitable subsequent efforts needed. This is true at both the business and the information system levels. That is, this process will repeat indefinitely in an iterative fashion as each transition task is accomplished. The source and target systems will be in a state of constant change that will have to be accounted for at each stage of the iteration. Each of the transition tasks should begin tactically, by looking at the most critical systems, and build to a more complete view. Representatives of the relevant business roles and functions, as well as those with relevant technical specializations, should be involved in the process. Recommendation: CMS should plan and execute the incremental, iterative, and phased modernizations and/or transformations of its business systems and their corresponding information systems, documenting and integrating business and information technol- ogy requirements within a comprehensive enterprise architecture framework. One element of CMS’s transformation will be to build on cur- rent work on data modeling to move toward a more consistent health information model that can guide all work and ensure more uniform conventions to support system integration and standardization. With such a model in place, the expensive task of creating customized, one- of-a-kind interfaces between disparate systems can be simplified and may be eliminated altogether. Data could be more integrated and more

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9 SUMMARY AND RECOMMENDATIONS shareable internally, and when necessary, externally. In addition, the time to create and the cost to build new systems, integrate legacy sys - tems, or extract data from any system could be improved. Having a more comprehensive health information model for health care data in the organization would also help ensure that any future systems being developed will follow well-articulated semantic and syntactic interoper- able guidelines and standards, which themselves may be modified and adjusted over time as needed. The development of such a model will take time and will require frequent iteration and continuing evolution. Recommendation: CMS should develop, implement, and maintain— revising and updating on an ongoing basis—an enterprise-wide health information model as the agency’s authoritative information model representing the structure and content of all shared infor- mation that is created, collected, maintained, used, and exchanged across the organization and with external partners. EMPHASIZE ACHIEVING CULTURAL AND ORGANIZATIONAL TRANSFORMATION The organizational environment and cultural acceptance of major changes in the roles, use, and architectural assumptions of IT systems and processes bear significantly on the success and effectiveness of mod - ernization and transformation efforts. If the need for modernization or outright transformation is inadequately understood, especially by CMS organizational leaders or the users and stakeholders who will be most affected, even the best-intended and well-designed projects may fail. Thus the kinds of changes in IT outlined above have to occur in the context of both internal adaptations in the CMS organization and a cul- tural adaptation that embraces the notion that CMS’s business functions are intrinsically tied to IT. IT is not simply a support service and mecha - nism for implementing programs but rather an integral component of the strategic directions of the agency. CMS has special challenges in this regard, because its agenda and priorities are often defined by external forces such as new legislation. But much of how CMS does what it does is determined internally, based on organizational structures, planning and decision-making conventions, internal availability of staff and resources, and relationships. In the committee’s view, there are related cultural and organizational transitions needed at CMS that would have positive repercussions for nearly all of CMS’s activities:

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10 STRATEGIES AND PRIORITIES FOR INFORMATION TECHNOLOGY AT CMS • A cultural shift from viewing IT as simply an operational necessity to embracing IT as a critical strategic element; • A cultural shift away from viewing IT leadership as overseeing a support group, complementing but not an integral part of the leadership mainstream, and toward viewing IT leadership as playing a key role in planning, designing solutions, and advising CMS business leaders regard- ing suitable approaches to their own responsibilities; • An organizational shift from a mission centered on transaction processing to a mission centered on data, information, and information management; • An organizational shift from a focus on paying claims to a focus on driving a combination of payment with improvements in quality, safety, and equity of health care and outcomes for individuals and populations; and • An organizational shift from relying on heroics from IT staff to ensuring a sustained investment in and commitment to infrastructure, resources, and staff. The committee believes that in order to meet emerging and future needs, CMS should undergo an organizational and cultural transforma - tion, actively integrating IT as a strategic partner in its business and deepening its internal IT core competency critical to CMS in several areas. Recommendation: CMS should integrate high-level IT leadership into CMS’s general strategic planning to ensure participation of IT and harmonization between the strategic technology plan and CMS’s overall strategy at the highest levels of the agency. IT strategic planning requires engagement and ownership at the high- est levels of the CMS organization and cannot be effectively driven by CMS’s IT organizations alone. As indicated by information the commit - tee gathered, CMS recognizes the importance of this engagement and is taking steps in this direction. Historically IT has been viewed, both in industry and government, as a tactical resource. Experience and the literature have both shown, however, that it is not possible to make stra - tegic decisions without considering the impact on IT and the impact and potential of IT. Given the strategic and operational importance of IT in CMS, the highest levels of the organization should be involved in the governance of the transition. High-level governance efforts should ensure that the systems modernization and transformation efforts achieve CMS’s goals. In addition governance should provide direction with respect to major changes to core processes, resolve policy issues raised by the implementa-

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11 SUMMARY AND RECOMMENDATIONS tion, address problems encountered during the transition, and approve, if necessary, the commitment of additional resources. IT governance should be developed to oversee the full set of CMS IT strategies, policies, and operations. The governing body that serves this function should be led by a senior business leader at the agency, and members of the body should be drawn from the senior leadership team.1 The governance function should include business integration, alignment of business and IT, col - laboration, strategic coordination, and planning—rather than focusing solely on operational and technology considerations. This function should have primary responsibility for developing CMS’s strategic technology plan, implementing the proposed meta-methodology, and managing the change process. In particular, governance mechanisms should be established for shared services, enterprise architecture framework, and the health infor- mation model. The transformation and modernization efforts are critically important to the agency; thus IT governance bodies should be structured so that senior leaders, including the CMS administrator, are well aware of the needs and efforts underway, are willing and able to integrate the planning into their business thinking, and are well informed so as to take advantage of opportunities that such planning provides. Adjusting the role of the Office of Information Services to better reflect the criticality of IT to agency strategy will be important. From an organizational and cultural perspective, an important part of the solu- tion will be clear, continuing, and effective communication, not only at an operational level but also at a strategic level, between IT leadership, senior leadership, and the other CMS units. A first step is membership of IT leaders on the relevant internal committees—including those that oversee and set directions for the CMS organization at the highest levels. The agency’s chief information officer has to be an active part of the top management team for the agency—included not just on the organizational chart but also at the table when major operational and strategic decisions are made and contributing fully to the broad management of CMS. Both planning meetings about long-term strategic goals and day-to- day planning meetings regarding business requirements and the appro- priateness and feasibility of IT solutions should involve and expect the contributions of IT leadership. As with the development of CMS’s stra- tegic technology plan as a whole, these processes must be iterative as 1 CMS currently has several IT governance bodies, e.g., the Executive Steering Committee, Information Technology Investment Review Board, and Configuration Control Board. These bodies are important. However, they focus largely on technical, tactical, and operational issues, as opposed to more strategic or policy-related issues at the intersection of business needs and IT.

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12 STRATEGIES AND PRIORITIES FOR INFORMATION TECHNOLOGY AT CMS experience is gained and as new requirements arise. In the absence of IT leadership, major strategic decisions can be made without recognizing the IT opportunities or challenges that are involved, resulting in either missed opportunities or poorly informed plans that project unrealistic expecta - tions onto the IT staff or infrastructure. CMS would benefit from the counsel of leaders from organizations in the public and private sectors that have effected significant IT-enabled organizational transformations. Inevitably, CMS will encounter issues and challenges for which the advice and insights of others who have tackled similarly scaled transitions would be very useful. Given the complexity of CMS’s environment and mission, it is important that those insights be as well informed as possible about the agency’s efforts and activities as well as its broad stakeholder communities. Developing such knowledge will require time and engagement on the part of the advisors in order to develop a deep understanding of CMS. An advisory panel of such leaders should be formed and structured in a way that enables them to obtain a clear understanding of CMS and its challenges and that fosters the frank exchange of ideas on an ongoing basis. As for other federal agencies, the context is complex within which cultural (attitudes, experiences, beliefs, and values of an organization) and organizational (structures and processes) transformation will occur at CMS. The agency will have to address the core components of business transformation—people (including external stakeholders and Congress), processes, and technology—all while operating under intense public scru- tiny, coping with federal funding idiosyncrasies, and adjusting to frequent leadership transitions. Recommendation: CMS should rapidly and coherently continue to improve its overall information technology and business process governance structures and to better integrate them as follows: • The Office of Information Services should be fully involved from the start in discussions with CMS business units regarding new requirements, programs, and processes. • OIS should assume and be given more direct oversight and coordinating responsibility over the agency’s enterprise IT resources, including coordination and communication of business requirements. • CMS should institute ongoing access to and dialogue with individuals and institutions from public and private sector organi - zations that have experience in designing and implementing large- scale IT-enabled modernizations and transformations.

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13 SUMMARY AND RECOMMENDATIONS Enhance Crucial Skill Sets—Technology, Informatics, and Innovation CMS’s development of its strategic technology plan and implementa - tion of the committee’s recommended meta-methodology will require the introduction of new skill sets into CMS and the strengthening of existing skills—in particular in the areas of technology and management of tech - nology change, and informatics. There are also opportunities to enhance the role of CMS’s new Innovation Center. CMS’s IT organization should be augmented and changed in some key areas. In the committee’s view, the CMS IT staff’s current commit- ment to the CMS mission, to getting the job done, and to the welfare of the public is notable. The group has shown unusual resourcefulness and inventiveness in successfully executing a number of difficult projects under significant time pressures, overcoming the challenges of outdated software and enormous complexity, and largely recognizing the need for positive organizational and cultural changes such as those outlined in this report. Moreover CMS’s staff continues to manage well a massive IT operation. To enable an effective response to the near and intermediate demands of payment reform and other responsibilities placed on CMS, these existing competencies should be strengthened. The evolving CMS mission hinges on public trust, and maintaining patient privacy and data security is one component of that trust. CMS must provide secure IT services to maintain patient and provider privacy. Creating a truly secure system can be especially challenging in an IT environment fashioned by disparate subcontractors, especially when the competing goals of access, openness, and transparency are implemented. The recruitment, retention, and training of IT professionals within CMS must reflect not only technical skill requirements but also organi - zational, management, and planning capabilities. The ability to manage subcontractors is critical, but so also is the ability to manage and respond to internal CMS organizational and cultural issues. Although soliciting and receiving advice about technology from contractors can be useful, the ultimate decisions about which technologies should be explored, evalu - ated, and deployed must reside with CMS and should be based on the judgments of people whose principal obligations are to CMS and the suc - cess of its missions and who can draw on deep insights and expertise in IT. Key decisions need to be made by the agency itself, and those decisions must be rooted in a strong grasp both of CMS issues and considerations, and also be informed by a strong grasp of technology. At its most funda - mental, in addition to enhancing and expanding the capabilities and role of IT at CMS, management of large-scale change will require the focused attention of the CMS leadership and the involvement of all CMS staff and its contractors.

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14 STRATEGIES AND PRIORITIES FOR INFORMATION TECHNOLOGY AT CMS CMS’s customer and stakeholder base will continue to change, espe- cially with a PPACA-mandated emphasis on clinical care quality and safety as well as health promotion and increased efficiencies and cost sav- ings. The demand for CMS-managed data to support research and other external analytical purposes continues to grow and may change in both character and volume. In particular, the field of biomedical informatics (the scientific discipline) and its application in clinical and public health settings (health informatics) are highly relevant to the current and future needs of CMS and its IT planning, design, and implementations. As a component of the organizational transformation needed to meet emerging demands, CMS should enhance its capacity in the informatics field, with clear roles in IT design and strategic planning. Informatics experts bring both technical knowledge of computing and communica - tions and a health professional orientation—many are also trained in one of the health professions, and all have substantial exposure to the processes, workflow, sources of error, and culture of health care as well as an understanding of the subtleties of real-world applications and their implications for quality of care and patient safety. Informatics organiza - tions generally exist separately from the related IT organization and typi- cally provide internal support in the form of analytical capabilities, taking into account the broad mandates and functions of an organization and tying them together both tactically and strategically, and they can help to bridge the technical and business functions of an enterprise. The creation of the CMS Innovation Center, mandated by Congress under the PPACA, has provided an excellent opportunity for the agency to propose, test, and evaluate new concepts that may influence the direc - tions of the organization for years to come. Although the emphasis thus far has been on new payment models that could enhance quality while reducing costs, the center’s authorization includes investigation of new models of service delivery. Given the close relationship between IT infra - structure and the CMS enterprise information architecture, the committee believes that the Innovation Center could also be investigating innovative IT to support CMS’s mission. This prospect becomes particularly intrigu - ing and attractive in light of the new PPACA mandates to move into areas related to quality, equity, safety, and maintaining the public’s health. For example, CMS still has to decide how best to respond to the new man- dates for gathering clinical indicators, and the Innovation Center could play a key role in exploring those options. Recommendation: CMS should enhance and strengthen the agen- cy’s capabilities as follows:

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15 SUMMARY AND RECOMMENDATIONS • Enhance or extend the skills of CMS staff in data management, architecture management, technology infrastructure management, technology investigation and evaluation, and security. • Build a dedicated capacity in informatics, placing such experts in strategic and planning roles that complement those provided by the IT organization. • Explicitly broaden the activities of CMS’s Innovation Center beyond exploration of payment models to include the exploration and evaluation of creative information technology and informatics opportunities that will support the mission of the agency. ANTICIPATE A DATA-CENTRIC FUTURE CMS’s role in the U.S. health care mosaic will be pivotal as the nation shifts to improved approaches for organization, payment, consumer engagement, understanding of bioscience foundations of health, and data management for health care. This transition will take place over many years, but some key shifts are already underway. At every stage, the capacity to improve decision making throughout the entire system will depend on having not only access to timely data but also the capacity to transform the raw data first into information and ultimately into intel- ligence to support future planning and action. CMS is in the process of transforming itself from being focused primarily on retrospective payment for health services for segments of the population to a focus on clinical data, information, and informa - tion management while still fulfilling its traditional mandates. Several trends in health care illustrate this broad need for a more data-centric approach, including the diffusion of electronic health records (EHRs), changes in practitioner relationships, efforts toward comparative effec- tiveness, monitoring for improvement of quality and reduction of dis- parities, and increased consumer access to and demand for health and medical information. In the aggregate, these trends regarding data will interact in ways to produce both additional work and new requirements for CMS. While the ultimate result of this convergence is not completely known, the drive to achieve great value for health care for both individuals and populations is not at all likely to abate, especially in light of the demographic pres- sures and size of the financial investment the nation is making in health care services. Data are essential to and underpin nearly all of the efforts CMS is undertaking—and are an essential driver for the development of a CMS strategic technology plan, motivate the recommended meta-methodology, and are a key impetus for the organizational changes discussed above.

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16 STRATEGIES AND PRIORITIES FOR INFORMATION TECHNOLOGY AT CMS The discussions above are all driven, at least in part, by CMS’s new and changing relationship to data and information: the data and infor- mation collected by CMS are now used extensively within the agency for analytic purposes, such as various quality efforts, policy analysis, combating fraud, informing consumers, managing payments, and, more recently, understanding racial and ethnic disparities and contributing to their reduction. In addition, outside researchers, many of whom are investigating quality-related research questions, currently make extensive use of the data sets generated by CMS, although there are concerns about access related to timeliness and expense. Many of the modernization and trans- formation steps discussed throughout this report will make data integra - tion easier (for example, integrating the reports from Medicare Managed Care with those from fee for service), leading toward earlier release of data. Much earlier release of survey data will support the best use of this important information. However, approaches to gathering this data and sorting out how to make it available and to whom cannot be envisaged adequately until all stakeholders have been engaged and are contributing to the discussion on an ongoing basis. Doing that incremental and ongo - ing engagement is part of the committee’s recommended approach and is essential to devising future mechanisms for data management. Recommendation: CMS’s strategic technology plan should support CMS’s own needs for data and also take into account use of CMS data by other authorized users for research and analytic purposes. With it CMS should: • Clearly articulate the process by which claims-based and clinical data furnished by providers that receive meaningful-use incentives will be made available to authorized users for analytic purposes. • Collaborate with the health services research, equity-focused, and quality communities to define claims-based, clinical, survey, and other data sets that can be made available in a more timely fashion. CONCLUSION The urgency of the challenges faced by the nation regarding the cost and quality of health care, and the central role that CMS plays in meeting these challenges, spotlight the need for a 21st-century information infra - structure at the agency. The committee’s recommendations are offered not

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17 SUMMARY AND RECOMMENDATIONS only to CMS, but also to Congress, and CMS’s stakeholders. Indeed, every American has a stake in the success of CMS’s efforts. CMS must cope with frequently changing demands, continue to operate its core functions at scale, and modernize and transform its systems and culture to handle new demands, all while facing a constrained and uncertain funding envi- ronment. Sustained funding and appropriate integrated governance will enable the agency to meet the demands that the nation is placing on it. Critically embedding IT in strategic conversations and planning at the agency is also essential. CMS should develop a comprehensive strategic technology plan that is well aligned with the agency’s overall strategy and that embraces a comprehensive flexible, incremental, iterative, and phased approach to business process and system transformation, in the service of its important national mission.

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