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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
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ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the
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M. Vest is president of the National Academy of Engineering.
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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
