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Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services

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

NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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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.

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Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

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

Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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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

Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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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

Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
×

Preface

The Centers for Medicare and Medicaid Services (CMS) was originally chartered in 1965 to provide prompt payment of provider claims for the purpose of ensuring that certain elderly and vulnerable 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 budgetary 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 culture of CMS, because all of the newly proposed approaches require it to think more about impacts on quality and performance. CMS’s current IT

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Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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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 process 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 observations 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 discussion of many topics tackled in the interim report as well as the committee’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 teleconferences 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 organization, with myriad contractor and stakeholder relationships in addition to

image

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.

Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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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 available for preparing the report.

We were fortunate to be able to weigh in on such a remarkably significant 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, coordinating 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

Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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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, 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.

Suggested Citation:"Front Matter." National Research Council. 2012. Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services. Washington, DC: The National Academies Press. doi: 10.17226/13281.
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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 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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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. 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. With CMS's mission expanding from its original focus on prompt claims payment come new requirements for the agency's information technology (IT) systems.

Strategies and Priorities for Information Technology at the Centers for Medicare and Medicaid Services reviews CMS 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 report's recommendations and conclusions offered cluster around the following themes: (1) the need for a comprehensive strategic technology plan; (2) the application of an appropriate metamethodology to guide an iterative, 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. Given the complexity of CMS's IT systems, there will be no simple solution.

Although external contractors and advisory organizations will play important roles, CMS needs to assert well-informed technical and strategic leadership. The report 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 strategically integrates business requirements and IT capabilities.

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