Detailed Information on the
Indian Health Service Resource and Patient Management System Assessment

Comprehensive business-oriented analysis of requirements for third party billing, accounts receivable, and cost accounting. Alternatives analysis and acquisition or development of enhanced system integrated with RPMS. This activity will position IHS to respond to the President's Executive Order for price and quality. Requirements completed and an RFP is being issued for an alternatives analysis. In 2009 a decision will be made regarding acquisition versus development to meet the requirements. This activity will position IHS to respond to the President's Executive Order for price and quality.

Develop 2-3 new performance measures to replace eliminated measures.

IHS improved the RPMS Exhibit 300 score for the FY 2008 budget submission and received a score of 40, the first HHS investment to receive this high a score from OMB.

IHS maintained the earned value variance for two years. The RPMS investment did not exceed cost/schedule variance by +/- 10%.

Develop RPMS' capability to provide a valid cost accounting link to health outcomes by specific activity. The IHS will not obtain full cost accounting functionality through the implementation of the Unified Financial Management System (UFMS), though IHS had originally thought that UFMS would provide this functionality.

Measure: Develop comprehensive electronic health record (EHR) with clinical guidelines for select chronic diseases: Targets: FY 2003: Prototype EHR/Asthma; FY 2004: HIV/AIDS; FY 2005: Obesity; FY 2006: Cardiovascular; FY 2008: Comprehensive EHR

Explanation:The EHR provides accurate, timely, and comprehensive clinical and administrative information to health care providers and program managers, complete with reminders and decision support for a number of chronic diseases and conditions. The majority of targets for this long-term measure have been achieved and it will be retired in FY 2009.

Measure: Derive all clinical measures from RPMS and integrate with EHR (Clinical Measures/Areas).

Explanation:This measure is reflective of the information system's ability to capture and report services and support quality care. Clinical performance measures, and the accompanying reminders provided in the EHR and other RPMS applications, prompt clinicians to perform associated clinical activities, facilitate integrated care, reduce medical errors and contribute to improved health outcomes. As new performance measures are identified, the RPMS system will undergo corresponding development to support clinical reminders and documentation.

Measure: Develop and deploy automated behavioral health system

Explanation:This measure tracked the release and deployment of an updated graphical user interface to the RPMS Behavioral Health System application. The Behavioral Health System supports the integration of behavioral health and primary care and improved health outcomes. Although enhancements continue in response to end-user needs, the major functional requirements have been met and this measure will be retired.

Measure: Deploy Electronic Health Record.

Explanation:IHS is on target to deploy the EHR to all direct federal IHS sites by the end of FY 2008. The long term goal will have been met and therefore the measure will be eliminated.

Measure: Develop and deployment of patient safety measurement system. (New measure, added February 2007).

Explanation:This measure contributes to operational performance and productivity by encouraging participation in and contributions to an on-going self-assessment designed to raise awareness of patient safety and identify areas for improvement. In FY 2010 the measure will be eliminated because the response to the patient safety measurement system has been considerably greater than expected; full deployment will be achieved without the need to use the measure as a challenge. An additional measure will be identified that will reflect and encourage the efficient use of taxpayer resources in carrying out the activities of the RPMS program.

Is the program purpose clear?

Explanation: The program purpose is clear. The Resource and Patient Management System (RPMS) is a distributed electronic information system designed to enhance the ability of Indian Health Service (IHS), Tribal and Urban facilities to provide high quality health care to American Indian/Alaska Native (AI/AN) patients by providing accurate, timely and comprehensive clinical and administrative information to health care providers and program managers at the local, regional and national levels.

Evidence: 25 U.S.C. 1662, Automated Management Information System requires IHS to establish an automated management information system that would include ". . . a financial management system, . . . a patient care information system for each Area served by the Service, . . . a privacy component that protects the privacy of patient information held by, or on behalf of, the Service, and . . . a services-based cost accounting component that provides estimates of the costs associated with the provision of specific medical treatments or services in each area office of the Service. "

Does the program address a specific and existing problem, interest, or need?

Explanation: The multidisciplinary health care providers in IHS, Tribal and Urban facilities require accurate, timely and comprehensive information about the AI/AN patients they serve. Local, area and headquarters managers need access to this information for planning and management. Clinicians and administrators need this information for clinical and health systems research and analysis.

Evidence: RPMS is an integrated system consisting of over 60 software applications that allow for data to be recorded, entered and accessed at each of the various service points. Examples of the patient-based clinical applications include the diabetes case management system, dental data system and immunization tracking system. Examples of the patient-based administrative applications are the patient registration system, third party billing system and medical staff credentials. Examples of the financial and administrative applications are the area data consolidation, area office billing tracking system and IHS contracts information system.

Is the program designed so that it is not redundant or duplicative of any Federal, state, local or private effort?

Explanation: RPMS is an automated management information system that addresses the unique needs of the diverse set of IHS, Tribal and Urban health care delivery facilities and programs and the AI/AN population. RPMS shares a common technical core with the Department of Veterans Affairs (VA) and includes design features that facilitate integration with private sector products.

Evidence: In its initial design phase, RPMS adopted VA's hospital-based information system, Decentralized Hospitalization Computer Program, as its foundation. Modifications were made in the core programming to meet IHS' unique needs. These unique features include: primary focus on outpatient care; inclusion of cultural information such as tribal affiliation and blood quantum; ability to bill third parties; local facility flexibility to implement components of RPMS software without implementing the entire system (e.g. a small outpatient facility would not need the Blood Bank or Admission/Discharge/Transfer software).

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: RPMS is not free of major flaws that would limit its effectiveness or efficiency. RPMS cannot provide a valid cost accounting link to health outcomes by specific activity and respective funding sources between its patient-based clinical and administrative applications and financial and administrative applications.

Evidence:  

Is the program effectively targeted, so program resources reach intended beneficiaries and/or otherwise address the program's purpose directly?

Explanation: RPMS is effectively targeted so that resources will reach the intended beneficiaries and address the program's purpose.

Evidence: The IHS Information Resources Management Plan and the IHS Enterprise Architecture show that RPMS is designed around a blend of national, regional and local site level responsibilities to ensure that national program resources are used to maintain economies of scale and uniformity of design when appropriate. Also, as mentioned above, sites have flexibility in which software packages to implement.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: RPMS has a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program.

Evidence: (1)Improve compliance with clinical practice guidelines for five chronic diseases (diabetes, asthma, cardiovascular disease, HIV/AIDS and obesity) through the development and deployment of an electronic health record (EHR) to all IHS, Tribal and Urban sites using RPMS by FY 2008; (2) Derive all national clinical performance measures electronically from RPMS-EHR by FY 2008; and (3) Improve treatment effectiveness in behavioral health services through development and deployment of enhanced automated behavioral health systems to all IHS, Tribal and Urban sites using RPMS by FY 2008.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program has ambitious targets and timeframes for its long-term measures.

Evidence: By FY 2008, RPMS will: (1) include a case management system for diabetes, asthma, cardovascular disease, HIV/AIDS and obesity and a comprehensive electronic health record; (2) include all 39 clinical GPRA indicators, an automated electronic reporting system and integration into EHR; (3) develop and deploy an integrated behavioral health system.

Does the program have a limited number of specific annual performance measures that demonstrate progress toward achieving the program's long-term measures?

Explanation: The program has a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals.

Evidence: (1) Develop a comprehensive electronic health record (EHR) with clinical guidelines for five chronic diseases; (2) Expand the automated extraction of GPRA clinical performance measures; and (3) Expand the number of IHS, Tribal and Urban programs that have implemented the use of the Mental Health/Social Services data reporting system.

Does the program have baselines and ambitious targets and timeframes for its annual measures?

Explanation: The program has baselines and ambitious targets for its annual measures.

Evidence: During FY 2003: (1) Develop and deploy asthma case management software, gather requirements for an HIV/AIDS case management application and preliminary requirements for a cardiovascular disease case management application, continue to enhance diabetes management including enhancement to diabetes case management system and gather requirements for obesity-based indicator; (2) 34 indicators in 12 Areas; complete the collection of baseline data for performance measures begun in FY 2002, implement electronically derived performance measures as their accuracy is proven to be sufficient and distribute semi-automated Laboratory Observation Identifier Nomenclature Codes (LOINC) mapping tool for IHS' clinical information system to all IHS, Tribal and Urban sites and achieve full local LOINC mapping at 23 sites; and (3) Assure at least 50 percent of the IHS, Tribal and Urban programs will report minimum agreed-to behavioral health-related data into the national data warehouse by increasing the number of programs utilizing the system by 5 percent over the FY 2002 rate.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, etc.) commit to and work toward the annual and/or long-term goals of the program?

Explanation: All IHS partners commit to and work toward the annual and/or long-term goals of the program.

Evidence: IHS cannot mandate that Tribal or Urban sites use RPMS. However, 96 percent of Tribal sites (425 0f 445) and 56 percent of Urban sites (19 of 34) use RPMS to submit their performance information. For those Tribal and Urban sites that use a different information system, IHS has a data warehouse to receive and convert this information. To facilitate the commitment of Tribal and Urban partners to the annual and long-term goals of RPMS, IHS has the Information Systems Advisory Committee (ISAC) to identify strategies and long-term goals for RPMS and other IT-related components. The goals of the ISAC guide the development of the Annual Work Plan. The ISAC includes representatives from the National Indian Health Board, Tribal Self-Governance Advisory Committee Board, National Council of Urban Indian Health Board, Council of Chief Medical Officers, and National Council of Clinical Directors.

Are independent and quality evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: All IHS hospitals and ambulatory facilities are subjected to accreditation surveys by the joint Commission on Accreditation of Health Care Organizations (JCAHO) and the Association for Ambulatory Health Care (AAAHC) on a regular basis. 78 IHS facilities were surveyed in 2000. JCAHO surveyed 81 percent of these. One of the performance areas assessed by JCAHO is Management of Information.

Evidence: The JCAHO scores range from 1 to 5 (substantial, significant, partial, minimal, and noncompliance respectively). The Management of Information function includes five areas which are scored at each facility (Information Management Planning, Patient-Specific Data and Information, Aggregate Data and Information, Knowledge-Based Information and Comparative Data and Information). In 2000, only one IHS facility received a 3 (Patient-Specific Data and Information) in any of the five areas. All other scores were either 1 (substantial compliance) or 2 (significant); the former more prevalent than the latter. In addition, the Institute of Medicine, in its study "Leadership by Example", examining the federal government's quality enhancement processes, noted that "IHS has developed a performance evaluation system to meet the performance measurement requirements of JCAHO's ORYX initiative. . .".

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: RPMS and other information technology is funded within Hospitals and Clinics, the single largest activity funded in the IHS budget. Consequently, the performance indicators for RPMS are included in this section of the Congressional Justification. However, the funding level is presented in the aggregate for Hospitals and Clinics. In the Information Technology Infrastructure section of the Congressional Justification, the aggregate funding for Information Technology is presented and the indicators are presented. However, there is no budget linkage to the specific activities of RPMS.

Evidence: IHS FY 2004 Congressional Justification.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: IHS states that its resource needs are presented in a complete and transparent manner in its Capital Asset Plan and Business Case (Exhibit 300 for RPMS). However, this information has not been integrated into its budget justifications.

Evidence: Capital Asset Plan and Business Case, Exhibit 300 for RPMS.

Has the agency/program conducted a recent, meaningful, credible analysis of alternatives that includes trade-offs between cost, schedule, risk, and performance goals and used the results to guide the resulting activity?

Explanation: Alternatives analysis and risk management are an integral and ongoing part of RPMS development. Critical assessments are: Can the desired functionality be obtained within the current technology suite? Is there a commercial product available? If no to these questions, then assess: Can the the desired functionality be built in an integrated environment?

Evidence: One recent example of this process is the IHS Division of Oral Health's request to replace the current RPMS/DDS software with another product. Four alternatives were developed: (1) Do nothing; (2) Improve the current software using existing IHS resources; (3) Replace the current software by partnering with another government agency that is currently developing a dental software solution; and (4) replace the current RPMS/DDS software using the competitive bid process to procure a commercial system. IHS elected to submit a Request for Proposal to ascertain the cost of pursing the fourth alternative in order to conduct a more thorough analysis of the alternatives.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: The IHS Information Technology Support Center (ITSC) regularly collects timely and credible performance information and uses it to manage the program and improve performance.

Evidence: Performance collection tools include: weekly staff reporting, monthly project update meetings and reports, monthly contractor status reports, formal internal quality assurance procedures for software development, formal end-user testing procedures for RPMS software components and after-release bug reporting and enhancement requests, if applicable.

Are Federal managers and program partners (grantees, subgrantees, contractors, cost-sharing partners, etc.) held accountable for cost, schedule and performance results?

Explanation: Federal managers and program partners are held accountable for cost, schedule and performance results.

Evidence: IHS has implemented a Contract Administration Structure that identifies the responsible Federal managers and contracting partner. The Project Officer is responsible for the overall monitoring and performance of the contract and the relationship of the contractor. The Project Officer appoints Task Order Technical Monitors to provide technical assistance and keep the Project Officer apprised of all relevant matters regarding the contractor's technical performance. In 2002, IHS awarded its first performance-based contract. The contract was structured with performance measure standards (developed by the Project Officer and Contracting Officer) and a Quality Assurance Surveillance Plan that sets forth procedures and guidelines that IHS will use in evaluating the technical performance of the contractor. Federal managers and staff annual performance assessments include requirements that they meet objectives by the timelines required.

Are all funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: Funds for RPMS are obligated in a timely manner and spent for the intended purpose.

Evidence: Virtually all spending for RPMS is for staff or contracts. A schedule for obligations is established with the contractor that aligns with the program plan. Program spending is approved in the Administrative Resource Management System. The system requires the budget officer to sign off that adequate funding exists for the commitment. Additionally, management receives a monthly spending report from the budget officer and a quarterly report from finance. Invoices are reviewed by the Project Officer and Task Order Technical Monitors to validate the contracted work against the items on the purchase order. An automated receiving report is entered to authorize Treasury to issue payment.

Does the program have procedures (e.g., competitive sourcing/cost comparisons, IT improvements, approporaite incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: IHS has mechanisms to measure and achieve effectiveness and efficiencies in RPMS development and maintenance. As mentioned above, IHS implemented performance-based contracting principles established by the Department of Health and Human Services (HHS). IHS has also de-layered the contract management structure to empower Project Officers.

Evidence: IHS uses competitive bid process for establishing IT contracts. The responses are evaluated on their technical merits which may, in some cases, outweigh the cost of the lowest bidder.

Does the program collaborate and coordinate effectively with related programs?

Explanation: IHS collaborates and coordinates effectively with related programs within HHS, other Government agencies and non-governmental agencies that share similar goals and objectives.

Evidence: For example, since the mid-1980's IHS has maintained a mutually beneficial sharing agreement with Veterans Health Affairs. In addition, The Government Computer-based Patient Record project is a joint effort of the Departments of Defense and Veterans Affairs and the Indian Health Service. The objective of the project is to enable the electronic exchange of health records among the currently disparate information systems of the participants. Within HHS, IHS collaborates on information technology with the Agency for Health Care Research and Quality, the Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration. With respect to non-governmental agencies, IHS has participated in a cooperative effort with the Harvard University affiliated Joslin Diabetes Center in Boston to deploy Joslin's telemedicine modality. In the past year, IHS has sought and obtained data sharing agreements with State agencies for sharing Medicaid eligibility information.

Does the program use strong financial management practices?

Explanation: IHS estimates and budgets for RPMS through the information technology capital investment process. The contracts are monitored by IHS Project Officers and Technical Monitors. IHS follows contracting procedures to ensure that payments are made properly for the intended purpose and to minimize erroneous payments.

Evidence: IHS planning and budget documents for RPMS includes plans for staffing and contract expenditures. Project Officers and Technical Monitors scrutinize the contractor's performance through monthly reports, project reviews with contractor management, update meetings and progress demonstrations. The Director of the Information Resources Division and the Executive Officer of the Office of Management Support review monthly commitment registers of all funding obligations against the approved spending plan. An automated procurement system is used to track contract expenditures and deliverables.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: No management deficiencies were identified in this analysis.

Evidence:  

Is the program managed by maintaining clearly defined deliverables, capability/performance characteristics, and appropriate, credible cost and schedule goals?

Explanation: The program is managed by maintaining clearly defined deliverables, capability/performance characteristics, and appropriate, credible cost and schedule goals.

Evidence: IHS uses competitive bid process for establishing information technology contracts. In 2002, IHS awarded its first performance-based contract to a company providing programming services for the RPMS clinical application, Patient Care Component. The contract was structured with performance measure standards with incentives based on the tasks identified in the Statement of Work, and a Quality Assurance Surveillance Plan for measuring contractor performance and identifying contractor performance incentives.

Has the program demonstrated adequate progress in achieving its long-term outcome performance goals?

Explanation: The program has demonstrated adequate progress in achieving two of its three long-term performance goals.

Evidence: The program has demonstrated adequate progress in its long-term performance goals to derive all clinical indicators from RPMS and integrate with EHR and to develop and deploy an automated behavioral health system to all IHS, Tribal and Urban facilities using RPMS. The long-term performance goal to develop a comprehensive electronic health record with clinical guidelines for five chronic diseases is a relatively new measure. The diabetes case management system was developed in 1998, however, there has been no activity on the long-term performance goal since then. The majority of targets for this performance goal are scheduled to be achieved between 2003-2008.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The program has demonstrated adequate progress in achieving two of its three annual performance goals.

Evidence: The program has demonstrated adequate progress in its annual performance goals to expand the automated extraction of GPRA clinical performance measures and to expand the use of the behavioral health data reporting system. The annual performance goal to develop a comprehensive electronic health record with clinical guidelines for five chronic diseases is a relatively new measure. The diabetes case management system was developed in 1998, however, there has been no activity on this performance measure since then. The majority of targets for this performance goal are scheduled to be achieved between 2003-2008.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program performance goals each year?

Explanation: The program has demonstrated improved efficiencies or cost effectiveness in achieving program goals each year. The number of modules/packages released has increased with nominal increases in the information technology budget. The increase in the number of modules/packages released can partly be attributed to improved requirements gathering. Additionally IHS has begun to develop products that can be reused between projects. For example, the Human Factors Interface works for the Behavioral Health Graphical User Interface being applied to the Electronic Health Record project with minimum rework.

Evidence: In 2000 IHS released 62 applications at a cost of $6.63 million; in 2001, IHS released 71 applications at a cost of $5.27 million; in 2002, IHS released 72 applications at a cost of $4.05 million.

Does the performance of this program compare favorably to other programs, including government, private, etc., that have similar purpose and goals?

Explanation: RPMS compares favorably to other programs within the federal sector. RPMS includes the same functionality as the Departments of Defense and Veterans Affairs health information systems with additional functionalities such as a life long medical record and population health query ability on demand. RPMS is also able to meet the majority of the minimum functional requirements, and some of the optional functional requirements for clinical practice management information systems used in community and migrant health centers.

Evidence: The Bureau of Primary Health Care Clinical Practice Management Information Systems Functional Requirements provides guidance on minimum and optional requirements for nine categories: Patient Scheduling; Patient Registration; Medical/Dental Data; Patient Follow-Up Monitoring/Tracking; Billing; Accounts Receivable; Management Support; Systems Management; and Managed Care. There are a number of commercial health information software packages, however none provide the functionality at the resource level expended on RPMS.

Do independent and quality evaluations of this program indicate that the program is effective and achieving results?

Explanation: As mentioned above, RPMS is evaluated on a regular basis through JCAHO facility reviews. IHS facilities consistently score high on its Management of Information reviews.

Evidence: In addition to the JCAHO reviews, IHS is currently pursuing an agreement with AHRQ to facilitate evaluation of RPMS and, specifically, the EHR project. The agreement with AHRQ will also include evaluation of future clinical IT projects.

Were program goals achieved within budgeted costs and established schedules?

Explanation: The program goals were achieved within budgeted costs and established schedules.

Evidence: The program has gained efficiencies in the production of RPMS applications due to improved requirements gathering and multiple use. The program has demonstrated progress in achieving two of its three performance goals while achieving economic efficiencies and increased production of applications. As mentioned above, there is no demonstrated performance on one of the measures because the majority of targets are schedule to be performed between 2003 and 2008.