Strategic Options for the Modernization ofthe Indian Health ServiceHealth Information TechnologyRoadmapExecutive SummaryOctober 20191

Indian Health Service HIT Modernization ProjectTable of Contents1.0 Purpose of Roadmap32.0 Roadmap Tool Development43.0 Goals of Roadmap: Moving IHS towards HIT Modernization54.0 Objectives, Activities, Milestones, and Stakeholders65.0 Next Steps106.0 Risks, Constraints, and Mitigations11References142

Indian Health Service HIT Modernization Project1.0Purpose of RoadmapThe IHS HIT Modernization Project Roadmap provides guidance to the Department of Health and HumanServices (HHS) and the Indian Health Service (IHS) in their efforts to modernize the IHS healthinformation technology (HIT) system. The Roadmap is an overarching plan to support improved clinicaland non-clinical operations across IHS, Tribal, and Urban (I/T/U) healthcare facilities through HIT. Itidentifies key improvement opportunities, related work initiatives for implementing such opportunities,and estimated timelines and performance indicators.The Roadmap is derived from a synthesis of best practices in HIT Modernization efforts as well asfindings and recommendations from the current Modernization Project work. The Roadmap is atechnology-agnostic strategic and decision-support tool, designed to guide the overarching modernizationstrategy, whether it be upgrade of the existing HIT system, selection of a commercial-off-the-shelf(COTS) product, or a hybrid of the two. The Roadmap is aligned with IHS’ goals and strategic plan.The Roadmap team made up of tribal, federal and private industry stakeholders recommends that the IHSincorporate a human-centered design approach when using the tool, as well as an iterative methodology tomaintaining and revising the Roadmap. The human-centered design approach, a cornerstone of theModernization Project, places people at the center of the process when fulfilling critical requirements.3

Indian Health Service HIT Modernization Project2.0Roadmap Tool DevelopmentThe Roadmap team efforts have produced an Enterprise Architecture Roadmap Tool that can guide theIHS towards HIT Modernization. This tool was constructed using the following steps:Figure 2.0-1 Steps to Roadmap Development4

Indian Health Service HIT Modernization Project3.0 Goals of Roadmap: Moving IHS towards HITModernizationThe Roadmap includes four key domains. These domains are defined as follows:Figure 3.0-1 Four Key Roadmap Domains5

Indian Health Service HIT Modernization Project4.0 Objectives, Activities, Milestones, andStakeholdersEach domain is comprised of multiple objectives, activities, and milestones that contribute toward thesuccess of each respective domain and of the entire HIT modernization effort.4.1Key Performance IndicatorsThe IHS organizational goals from the Strategic Plan FY 2019-20233 that were selected for inclusion inthis Roadmap are displayed in the graphic below. In conjunction with the IHS HIT Modernization projectframework, the Roadmap was created with a people, process, and technology paradigm.Figure 4.1-1 IHS Strategic Goals with a People, Process, and Technology Paradigm6

Indian Health Service HIT Modernization ProjectKey performance indicators (KPIs) are consistent with the IHS’ organizational goals and drive theRoadmap strategy. Each KPI is mapped to one or more organizational goal and is addressed in one ormore Roadmap domain.Table 4.1-1 KPI Crosswalk with Organizational Goals and Roadmap DomainsOrgGoalKey Performance Indicator (KPI)ModernizationPlanning andExecution2KPI-001: Improved health status for AI/AN people receivingcare from IHS 2KPI-002: All IHS facilities will achieve and maintainrecognition as Patient Centered Medical Homes 1KPI-003: Improved access to services for AI/AN peopleseeking care from IHS 1, 3KPI-004: Improved patient engagement through electronicaccess to health information 3KPI-005: Improved interoperability and sharing of patientinformation within the organization, across the I/T/U andwith private and government partners (e.g. VA) 2KPI-006: Improved quality of care provided by IHS, asdemonstrated by government and industry benchmarks 3KPI-007: Improved organizational maturity in use ofinformation technology systems in service of the IHS mission 3KPI-008: All sites successfully complete and regularly updatea Security Risk Analysis 3KPI-009: Improved ability for IHS to provide services in asustainable way through cost recovery 3KPI-010: Provider satisfaction with HIT usability. 7RPMSStabilization and Data ExchangeEarly Wins Infrastructure

Indian Health Service HIT Modernization Project4.2Work InitiativesThe Roadmap leverages IHS processes, supporting applications, and improvement opportunities togenerate work initiatives (WIs), which are specific actions required to achieve IHS HIT modernization. Ahigh-level program plan is displayed in Figure 4.2-1.Figure 4.2-1 High Level Program Plan and Timeline8

Indian Health Service HIT Modernization Project4.3StakeholdersEach Work Initiative will be assigned one or more suggested key individuals or groups to be responsible,accountable, consulted, or informed about the effort. The Roadmap displays each stakeholders proposedinvolvement and role in each Work Initiative. The HIT Modernization Program will need to engage withthese stakeholders as it moves toward modernization. The list below presents some of the proposedstakeholder roles that should ideally be engaged in this program.Table 4.3-1 Proposed Stakeholder RolesIHS LeadershipIHS Boards and Committees IHS Director IHS Clinical Governance BoardsIHS Chief Medical Officer (CMO) IHS Technical Governance BoardsIHS Chief Information Officer (CIO) Information Systems AdvisoryIHS Chief Technology Officer (CTO)Committee (ISAC)IHS Enterprise Architecture (EA)IHS Chief Information Security Officer(CISO) IHS Chief Health Informatics Officer(CHIO) IHS Chief Medical Informatics Officer(CMIO) IHS Privacy OfficerHHS Chief Information Officer (CIO)HHS Chief Technology Officer (CTO)HHS Chief Information Security Officer (CISO)HHS Customer Experience LeadHHS Chief Privacy Officer (CPO)Other federal partners including: Veterans Affairs (VA) Department of Defense (DoD) Office of the National Coordinator (ONC) Centers for Medicare & Medicaid Services (CMS) I/T/U Field Tribes / Urban ProgramsProject Management Office (PMO) and ModernizationTeamFederal Partners I/T/U Representation External Advisory BoardSteering CommitteePMO Exec DirectorPMO Program ManagerPMO Staff9

Indian Health Service HIT Modernization Project5.0Next StepsThe Roadmap will evolve to meet the HIT Modernization Program needs. The Roadmap is a launchingpoint for IHS HIT modernization. The Roadmap is to be referenced and updated on a regular basis asinformation is gained and funding is acquired.To facilitate growth and evolution of the Roadmap, ownership by the Department of Health and HumanServices (HHS) is required. HHS should initially adapt the model to IHS needs as appropriate. It shouldlater oversee the execution of Roadmap steps, ensuring a coordinated and comprehensive approach to HITmodernization.Broad-based clinical and technical leadership commitment is essential to implementation and success ofthis endeavor. Leadership must fully understand and commit to the Roadmap to ensure a successfulmodernization effort. Once leadership commitment is secured, communication to the I/T/U of theRoadmap’s next steps is crucial to generate buy-in and further coordinate the modernization effort.Transparency and responsiveness to I/T/U concerns are key for preparing for modernization of a healthenterprise as large as IHS. The modernization effort belongs to them as well as to IHS and HHS.The Roadmap outlines immediate steps that should be taken to set the modernization effort into motion.Table 5.0-1 Roadmap Next StepsDomainNext StepsModernization Planningand Execution RPMS Stabilization andEarly Wins Take steps to standardize and normalize RPMS databases across the country Complete 2015 Edition certification, resolving usability issues of affected RPMScomponents to the extent possibleData Exchange Improve Internal and External Interoperability, including connections to Health InformationExchanges serving appropriate states and federal agenciesInfrastructure Address identified critical infrastructure gaps, engaging federal and industry partnersReassess the organization of HIT governance processes within the agencyFill critical vacancies within IHS’s Office of Information TechnologyEstablish and charter the HIT Modernization Advisory Committee (HITMAC)Execute an acquisition for expert Program Management Office support10

Indian Health Service HIT Modernization Project6.0Risks, Constraints, and Mitigations6.1Risks and MitigationsSeveral key risks warrant consideration and mitigation when using the Roadmap:RisksProposed MitigationsOperating Model Integration: If the ImprovementOpportunities identified and related Work Initiatives are notintegrated into IHS’ operating model, then the modernizationprogram may fail due to an unclear vision or deficientexecution.The HIT Modernization team will brief Executive leadership and seniorstaff on key elements of the Roadmap, including identifiedimprovement opportunities, proposed work initiatives to remediatecited deficiencies, attendant risks, and interdependencies. Suchbriefings shall be iterative and interactive.Executive Sponsorship: If IHS’ executive leadership, seniorstaff, and domain and subject matter experts are not fullyengaged and involved in the review, adoption, and evolution ofthe Roadmap, then the modernization program may fail due to alack of executive sponsorship, buy-in and resistance to change.Executive leadership and senior staff will be engaged in the review andrefinement of key elements of the Roadmap, focusing on theidentification of improvement opportunities, proposed work initiativesto remediate cited deficiencies, attendant risks, and interdependencies.Such interactions shall be iterative, and last for a period spanning handoff of the Roadmap to ensure IHS’ buy-in, adoption, and ownership.Cost and Time Estimates: If the cost, projectinterdependencies, and inherent risks of IHS' HITmodernization program are underestimated or understated, thenthe scope, delivery time, and quality of deliverables will benegatively impacted.Conduct a comprehensive cost analysis, accounting for the full scope,schedule, and resource requirements of modernization. Verify andvalidate core requirements for infrastructure upgrades and datacleansing, normalization, standardization, migration, and postmigration validation.Requirements Management: If the requirements elicitationprocess for modernization is deficient or fails to capture, verify,and validate critical system requirements and theirinterdependencies, then the scope, cost, and schedule of themodernization program may be understated and the resultantquality of program outcomes severely impacted.As a critical work initiative of IHS' HIT modernization program'sroadmap, IHS must review and refine existing requirements elicitationpractices into a formal Requirements Management process.Service Maturity and Governance: If IHS is deficient in ITservice maturity or critical internal controls and governancepractices, processes, and SOPs to guide and enablemodernization, then the modernization program will beimpeded and unnecessarily protracted due to avoidable delaysand rework that will increase costs.As foundational work initiatives of IHS' HIT modernization program'sroadmap, IHS must enhance existing IT service delivery, internalcontrols, and governance practices into repeatable, verifiable processes.11

Indian Health Service HIT Modernization Project6.2Known Constraints and MitigationsThe following known constraints and mitigations are presented for review:ConstraintsProposed MitigationsCritical and unique systemcapabilities currentlyimplemented in the Resource andPatient Management System(RPMS) persist to thereplacement HIT solution orecosystemIHS must provide HIT systems that are attractive to the I/T/U programs through support forintegrated, multidisciplinary care (behavioral health, dental, etc.) as well as population healthand individual patient care. Requirements and resultant capabilities and functionality relatedto traditional medicine, AI/AN population health, etc. must persist in the replacement HITsolution.Funding and staffing levelsNoted as a foregoing operational issue but not assessed in detail; as such, this report assumesthat funding to improve infrastructure, to recruit, train, and retain local and national supportstaff, and to address development and implementation costs for new or updated systems willbe available.Lack of organizational readinessfor changeThrough an enterprise-wide organizational change management initiative, IHS shall plan andexecute the required strategic and operational changes required for success of theModernization program.Site-specific infrastructureconstraints related to limitedbandwidth, poor cellular signal,degraded or inadequatetelephony and wide area network(WAN) infrastructure, etc.As a primary and critical initial step in IHS HIT Modernization program, IHS must conduct acomprehensive infrastructure analysis and subsequent infrastructure build-out to remediatecritical infrastructure deficiencies. Moreover, infrastructure constraints that are too costly tomitigate will proactively inform and influence the selection, architecture, design, andtopology of the new HIT solution in order to achieve cost-efficiencies and optimal systemquality.Interoperability requirementsThe replacement HIT solution or ecosystem must be intrinsically interoperable and mustsupport data sharing, both within and external to the I/T/U. The following recommendationswill assist in meeting interoperability goals: Conduct a gap analysis to identify and prioritize interoperability deficiencies inIHS' HIT ecosystem Define IHS' interoperability strategy and communicate it broadly to stakeholders Ensure interoperability needs are surfaced through the Requirements Management(RM) and Enterprise Architecture (EA) artifacts Partner with the Acquisition Planning and Procurement (AP&P) office to integrateinteroperability needs into acquisition planning Adhere to open standards in the design and implementation of interoperablesystems Ensure strict security and privacy of data and information shared acrossinteroperable systems to drive wide-scale adoption Utilize efficient, cost-effective infrastructure to achieve interoperability acrossdistributed and external systems Implement non-intrusive, value-added data governance practices12

Indian Health Service HIT Modernization ProjectRegulatory complianceThrough an improved requirements management process, value-oriented lightweightenterprise architecture (EA) practice, and outcome-driven governance, the replacement HITsolution or ecosystem will meet or exceed regulatory requirements, including the Office ofthe National Coordinator for Health Information Technology (ONC) and the Centers forMedicare & Medicaid (CMS) certification requirements and other regulatory constraints,such as Clinical Laboratory Improvement Amendments (CLIA).Security, confidentiality, patientprivacyThrough ongoing and augmented security practices, IHS shall identify, validate, andprioritize external and internal security vulnerabilities and threats through a security riskassessment (SRA). The results of this assessment will lead to improvements in data security,confidentiality, and privacy, thereby driving increased compliance and patient satisfaction.Support for legacysystems/subsystems/ componentsAny approach that retains legacy systems/subsystems/components must plan for ongoingoperations and maintenance (O&M) or replacement of VistA-derived packages. Moreover,there are associated cost and resource implications as well as related risks.13

Indian Health Service HIT Modernization ProjectReferences1. Info-Tech Research Group [Internet]. London (ON): Info-Tech Research Group (Health andHuman Services); 2009 Sep 12 [cited 2019 July 25]. Available from: Gartner Special Reports: providing actionable insights into major trends [Internet]. Stamford(CT): Gartner; 2019 [cited 2019 Aug 22]. Available eports.3. IHS Strategic Plan FY 2019-2023 [Internet]. Rockville (MD): Indian Health Services; 2019 [cited2019 July 9]. Available from: an-fy-2019-2023/.14

The Roadmap team efforts have produced an Enterprise Architecture Roadmap Tool that can guide the IHS towards HIT Modernization. This tool was constructed using the following steps: Figure 2.0-1 Steps to Roadmap DevelopmentFile Size: 923KB