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
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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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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
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
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
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
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.
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
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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.
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.
Contents
1 ESSENTIAL CONSIDERATIONS AND BACKGROUND
CMS’s Mission, Roles, and Stakeholders
The Current State of Information Technology at CMS
What This Report Does and Does Not Do
2 TOWARD A COMPREHENSIVE STRATEGIC TECHNOLOGY PLAN
Motivating Modernization and Transformation at CMS
The Value of Incremental Approaches
The Importance of an Overall Strategic Plan for CMS as a Whole
Development of a Comprehensive Strategic Technology Plan for CMS
Near-Term Issues—Addressing Them Quickly
3 A META-METHODOLOGY FOR THE MODERNIZATION AND TRANSFORMATION OF BUSINESS AND INFORMATION ECOSYSTEMS
4 ACHIEVING CULTURAL AND ORGANIZATIONAL TRANSFORMATION
Basic Elements of the Cultural and Organizational Transformation Needed at CMS
Current CMS Organization and Relationships to Information Technology Functions
Defining the Information Technology-Enhanced Enterprise at CMS
Strategy, Guiding Principles, and Roadmap for Cultural and Organizational Transformation at CMS
5 ANTICIPATING A DATA-CENTRIC FUTURE
Consumer Access to CMS Information
B Briefers to the Committee 129
C Biosketches of Committee Members and Staff
D Sources and Uses of Data Within the Centers for Medicare and Medicaid Services
E A Two-Phase Approach to Modernization and Transformation of Business and Information Ecosystems