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Edward H. Shortliffe and Lynette I. Millett, Editors 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
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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 Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi - neering, 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: 978-0-309-22194-8 International Standard Book Number-10: 0-309-22194-3 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 2012 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 govern - ment 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 mem - bers, sharing with the National Academy of Sciences the responsibility for advis - ing 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 pro - viding 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, American College of Surgeons; 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, New Vantage 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 T. PEROT, Summit Health Institute for Research and Education, Inc. HELEN L. SMITS, Independent Consultant WALTER SUAREZ, Kaiser Permanente JOHN SWAINSON, Silver Lake Partners PETER SZOLOVITS, Massachusetts Institute of Technology Staff LYNETTE I. MILLETT, Senior Program Officer EMILY ANN MEYER, Program Officer ENITA A. WILLIAMS, Associate Program Officer ERIC WHITAKER, Senior Program Assistant v
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COMPUTER SCIENCE AND TELECOMMUNICATIONS BOARD ROBERT F. SPROULL, Oracle (ret.), Chair PRITHVIRAJ BANERJEE, Hewlett Packard Company STEVEN M. BELLOVIN, Columbia University JACK L. GOLDSMITH III, Harvard Law School SEYMOUR E. GOODMAN, Georgia Institute of Technology JON M. KLEINBERG, Cornell University ROBERT KRAUT, Carnegie Mellon University SUSAN LANDAU, Radcliffe Institute for Advanced Study PETER LEE, Microsoft Corporation DAVID LIDDLE, U.S. Venture Partners PRABHAKAR RAGHAVAN, Yahoo! Research DAVID E. SHAW, D.E. Shaw Research ALFRED Z. SPECTOR, Google, Inc. JOHN STANKOVIC, University of Virginia JOHN SWAINSON, Silver Lake Partners PETER SZOLOVITS, Massachusetts Institute of Technology PETER J. WEINBERGER, Google, Inc. ERNEST J. WILSON, University of Southern California KATHERINE YELICK, University of California, Berkeley Staff JON EISENBERG, Director RENEE HAWKINS, Financial and Administrative Manager HERBERT S. LIN, Chief Scientist LYNETTE I. MILLETT, Senior Program Officer EMILY ANN MEYER, Program Officer VIRGINIA BACON TALATI, Associate Program Officer ENITA A. WILLIAMS, Associate Program Officer SHENAE BRADLEY, Senior Program Assistant ERIC WHITAKER, Senior Program Assistant vi
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Preface T he Centers for Medicare and Medicaid Services (CMS) was origi- nally chartered in 1965 to provide prompt payment of provider claims for the purpose of ensuring that certain elderly and vulner- able groups would receive timely and effective medical treatment. Critical to the agency’s work is its information technology (IT) infrastructure. In the past 45 years, in response to numerous statutory, policy, and budget- ary measures, the scope and scale of the services CMS provides have significantly increased. This dynamic environment has led to new IT challenges for the organization. Key among IT issues is the need for CMS to position itself to ensure not only the continuity of its core operations, many of which are stressing the aging capabilities of systems that are currently in use, but also the capacity to rapidly and successfully manage new mission mandates that require changes to this core IT infrastructure, with an emphasis on data and system integration. Central to many of the changes underway at CMS is the 2010 Patient Protection and Affordable Care Act, which includes numerous mandates aimed at moving from fee-for-service payment to value-based payment. This is a paradigm shift for CMS and one for which it has only a few years in which to prepare. Although CMS’s mission is broader than payment, reforming payment is a component of meeting other national goals, such as the drive toward integrated health care delivery systems. Moreover, reforming payment is inevitably going to change the operations and cul - ture of CMS, because all of the newly proposed approaches require it to think more about impacts on quality and performance. CMS’s current IT vii
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viii PREFACE systems, which are predominantly claims-based, were not developed to satisfy the data and information needs of the new mandates and payment programs. With these looming realities in mind, CMS turned to the National Research Council to conduct a consensus study to strategize about how to modernize CMS’s business processes, practices, and information systems effectively to meet today’s and tomorrow’s demands, including how to build in the flexibility to deal effectively with changing requirements. The statement of task for the project is given in Appendix A. Composed of experts on large-scale enterprise computing, health care policy, health care quality, health care outcomes, large-scale data use and database operations, and health IT, as well as CMS itself, the Committee on Future Information Architectures, Processes, and Strategies for the Centers for Medicare and Medicaid Services was recruited for this effort. In the pro - cess of developing and recommending a CMS IT strategy and vision, the committee received input from a number of system experts, researchers, policy analysts, and others, both internal and external to CMS. Briefers to the committee are listed in Appendix B. Biosketches of the committee members are provided in Appendix C. The committee delivered an interim report containing its initial obser- vations on these issues, as well as its preliminary thoughts on the most promising paths going forward, on December 9, 2010.1 Its final report builds on the work of the committee’s first report, providing deeper dis - cussion of many topics tackled in the interim report as well as the commit- tee’s recommendations. This final report was developed based on input the committee received over the course of four in-person information- gathering meetings—including one at CMS’s headquarters in Baltimore in April 2011 and four additional information-gathering teleconferences. This input was supplemented by a site visit to CMS headquarters in January 2011 by a committee subgroup that focused on key technical issues. The committee also held several deliberative meetings and tele - conferences in order to weigh the information given to it and to come to consensus on the recommendations. As the committee delved into the details of the CMS environment from a technical perspective, it became clear that it would be unrealistic to provide a system-by-system assessment of what is currently in place, or even of the overall system architecture (which has evolved organically in response to legislative mandates over the years). CMS is a large organiza- tion, with myriad contractor and stakeholder relationships in addition to 1 NRC, 2010, Preliminary Observations on Information Technology Needs and Priorities for the Centers for Medicare and Medicaid Services: An Interim Report, Washington, D.C.: The National Academies Press.
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ix PREFACE its own internal organization and culture, and it would not be feasible for an external study committee to attempt a comprehensive review of every issue that was touched on during the information-gathering component of its work. Even answers to questions such as the total IT budget for CMS and how it is allocated, and estimates of cost and personnel for ongoing and prospective activities, were difficult to ascertain, given the complex ways in which IT dollars are spread among the operating offices and centers, including the Office of Information Services. What was clear were the historic tendency to provide IT funding on a program-by-program basis, confirmed at essentially every meeting with CMS staff, and the proportionately small budgetary elements available for infrastructure and modernization. The committee’s findings and recommendations reflect its decision about the scoping of the study effort, emphasizing the larger notions that were clear and proposing approaches that would help CMS to work out a detailed planning and implementation approach that would be beyond the ability of the committee to specify fully in the time avail - able for preparing the report. We were fortunate to be able to weigh in on such a remarkably sig- nificant topic at a critical time in the evolution of CMS and in U.S. health care. The U.S. health care landscape is undergoing major changes that will affect nearly every person in some way, and CMS is at the epicenter of that shift. However, this fluid dynamic meant that the committee had to be agile as well, as the “way things are” in one month often changed into the “way things used to be” the following month. I commend the members’ ability to comprehend quickly not only the new information that was presented to them, but also its significance, and I appreciate their considerable efforts to ensure that the report would remain relevant in spite of the dynamic environment in which it was developed. I also wish to thank the CMS staff. Not only were they responsive to the committee’s requests for information, but they were also truly hospitable in hosting both the subcommittee’s January 2011 site visit and the entire committee’s visit in April 2011. My thanks are also extended to the other experts who took the time to brief the committee; each of them thoroughly and thoughtfully responded to the questions asked and provided insights that allowed us to make the report richer. Finally, I thank the remarkable CSTB staff—Lynette Millett, Emily Ann Meyer, Enita Williams, Eric Whitaker, and Jon Eisenberg—for their efforts in steering the committee’s work, striving to master the domain, coordinat- ing the meetings and speakers, and editing and revising report material. Edward H. Shortliffe, Chair Committee on Future Information Architectures, Processes, and Strategies for the Centers for Medicare and Medicaid Services
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Acknowledgment of Reviewers T his 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, evi - dence, 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, Irvine, Janet Corrigan, The National Quality Forum, John Halamka, Beth Israel Deaconess Medical Center, Carl Kesselman, University of Southern California, Stephen Parente, University of Minnesota, Frank A. Perry, Science Applications International Corporation, Kevin Schulman, Duke University School of Medicine, Michael Shabot, Memorial Hermann Hospital, Michael Stonebraker, Massachusetts Institute of Technology, Kevin Sullivan, University of Virginia, and Gail Wilensky, Project HOPE. xi
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xii ACKNOWLEDGMENTS Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the con- clusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was monitored by Charles E. Phelps, University of Rochester, and coordinated by Susan L. Graham, University of California, Berkeley. Appointed by the NRC, they were 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.
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Contents SUMMARY AND RECOMMENDATIONS 1 1 ESSENTIAL CONSIDERATIONS AND BACKGROUND 19 CMS’s Mission, Roles, and Stakeholders, 19 Emerging Requirements for CMS, 28 The Current State of Information Technology at CMS, 38 What This Report Does and Does Not Do, 41 2 TOWARD A COMPREHENSIVE STRATEGIC TECHNOLOGY 45 PLAN Motivating Modernization and Transformation at CMS, 46 The Value of Incremental Approaches, 52 The Importance of an Overall Strategic Plan for CMS as a Whole, 54 Development of a Comprehensive Strategic Technology Plan for CMS, 56 Near-Term Issues—Addressing Them Quickly, 62 3 A META-METHODOLOGY FOR THE MODERNIZATION 65 AND TRANSFORMATION OF BUSINESS AND INFORMATION ECOSYSTEMS Model and Terminology, 67 Overview of the Meta-Methodology, 70 Preparing for Inevitable Transformations, 74 xiii
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xiv CONTENTS 4 ACHIEVING CULTURAL AND ORGANIZATIONAL 77 TRANSFORMATION Basic Elements of the Cultural and Organizational Transformation Needed at CMS, 78 Current CMS Organization and Relationships to Information Technology Functions, 81 Defining the Information Technology-Enhanced Enterprise at CMS, 90 Strategy, Guiding Principles, and Roadmap for Cultural and Organizational Transformation at CMS, 96 5 ANTICIPATING A DATA-CENTRIC FUTURE 107 Improving Quality, 109 Consumer Access to CMS Information, 114 Policy Analysis, 114 Reducing Health Disparities, 116 Fighting Fraud, 118 Data Governance, 121 Conclusion, 123 APPENDIXES A Statement of Task 127 B Briefers to the Committee 129 C Biosketches of Committee Members and Staff 132 D Sources and Uses of Data Within the Centers for Medicare and 146 Medicaid Services E A Two-Phase Approach to Modernization and Transformation 154 of Business and Information Ecosystems F Glossary 172 G Acronyms 175