Office of Information Technology

Update for Combined Councils

Chuck Gepford, CIO (Acting)

Howard Hays, MD, MSPH

IHS National Combined Councils Conference

July 27, 2011

Topics

• Budget

• ISAC Priorities

• Director’s Priorities

• OIT efforts in support of Priorities

• Recognition

• Challenges

2

Budget

• Final OIT FY11 Enacted budget was lower than FY10

levels.

• Anticipated $4M increase included in the FY12

Presidential Budget for HIT security was not

enacted.

• FY11 Budget is fully encumbered

• FY12 Spend Plan currently under development

3

OIT Budget – Where Funds Go

4

Salaries & Benefits

(OIT, Awards)

21% Travel (Local &

TDY)

1%Training

1%

Contractual

Services

57%

Equipment

12%

Transfers

6%

Other (supplies,

utilities,printing,

transportation, etc)

2%

Area Information

Technology Assessments

• FY2011 – memo from IHS/CMO to AD, May 27, 2011

• Total of $4,024,000

• Security Certification & Accreditation

• Intersystems Cache/Ensemble upgrades, required to run RPMS

• FY2012 – OIT proposes to include (subject to approval by senior management):

• IBM maintenance contract and CAS Severn support ~ $950K

• Previously paid by OIT; directly benefits/supports sites

• Microsoft Enterprise Agreement for desktop licenses, about $2.7M

• Licenses previous IPAC'd from Areas via iSDP program, so no actual added cost to Areas

ISAC Priorities

for 2012-2013

• Practice Management

• Interoperability

• EHR

• Infrastructure & Architecture

• Clinical Decision Support

• Meaningful Use

• Workforce Development

• Telemedicine Coordination

• Tribal Shares Calculation

• Data Quality & Accuracy

• Master Person Index

• Administrative Management Tools

• Bandwidth

• Security & Regulatory Compliance

• Innovation

• Patient Communication

• Environmental Health

6

IHS Director’s

Priorities

1. To renew and strengthen our partnership with

tribes

2. To reform the IHS

3. To improve the quality of and access to care

4. To make all our work accountable, transparent, fair

and inclusive

7

8

IHS ISAC Priorities and IHS

Director’s Priorities MatrixPriority

Description

ISAC

Ranking

2012 -

2013

Supports

IHS

Director’s

Priority

Priority Description ISAC

Ranking

2012 -

2013

Supports

IHS

Director’s

Priority

Practice Management 1 1, 2 Tribal Shares

Calculation

9 1

Interoperability/HIE 2 1, 3 Data Quality/ Accuracy 10 1, 3

Electronic Health

Record

3 1, 3 IHS Master Patient

Index

11 2

Infrastructure/

Architecture

4 3 Administrative

Management Tools

12 2

Clinical Decision

Support

5 1, 3 Bandwidth 13 3

Meaningful Use 6 1, 2, 3 Security and

Regulatory Compliance

14 3

Workforce

Development

7 1, 3 Innovation of Technical

and Business Practices

15 4

Telemedicine

Coordination

8 1, 3 Patient Communication 16 1, 3

ISAC Priority 4 –

Infrastructure/Architecture

Medical Device Network Segmentation

• Problem – Medical Devices such as Lab and Radiology

equipment are computers, but they cannot accept antivirus

updates like regular desktop computers without

manufacturer intervention or risking how they function

• Risk – If these devices are connected to the IHS network

they can put the entire network at risk if infected

• Solution – “Network Segmentation” – all Medical Devices

must be placed on a “virtual” network separate from the

facility network

• Action – ensure facilities are complying with requirement

9

ISAC Priority 4 -

Infrastructure/Architecture

TIC - Trusted Internet Connection

• Problem – too many external internet connections into federal government networks, placing these networks at risk for intrusion.

• OMB Mandate – all federal agencies must implement “Trusted Internet Connections” (TIC)

• These connections will allow for all network traffic into and from the government to be closely monitored.

• Impacts

• All IHS internet connections will be through TIC in DC, Albuquerque, or Atlanta

• No external connections to the IHS network unless it is connected through a TIC access point

• Clear demarcation between Federal and non-Federal networks

• Implementation estimated to be complete by late 201210

11

RockvilleAlbuquerque

SiSi

Data Center

LAN

SiSi

Data Center

LAN

FederalFederal

IHS

Wide Area Network

includes Federal and

Non-Federal Facilities

(approx 400)

InternetHHSNet

Federal

Federal

Non Federal

Non Federal Non Federal

Non Federal

Non Federal

Non Federal

Existing Circuits

IHS/Tribal Internet Connections – “As-Is”

12

SiSi

Data Center LAN

SiSi

Data Center LAN

Federal

Tribal

Federal

Tribal

Federal

Federal

IHS Federal

WAN

IHS

Non-Federal

WAN

Urban

HHSNet

Federal Federal

Tribal Tribal

Tribal

Internet

Albuquerque Rockville

IHS/Tribal Internet Connections – “To-Be”

E-Mail Upgrade – Microsoft Exchange Server 2010

• Improved Outlook Web Access (OWA) user

experience, on all popular browsers

• All IHS user mailboxes replicated from Rockville MD

to Albuquerque NM for Disaster Recovery

• High Availability, eliminating single points of failure

• Recycling Exchange 2007 hardware into the Exchange

2010 design to minimize expenditures.

• Project completion targeted for end 2011.

ISAC Priority 4 -

Infrastructure/Architecture

Biscom Secure E-Mail and Large File Transfer

• Allows IHS users and external users to exchange

emails and files back and forth securely.

• Recipient receives email message with a link to secure message.

• IHS users use AD logon, external users create an

account.

• FIPS 140-2 compliant storage and transfer.

• Pending NIST FIPS 140-2 certification.

• Target completion date – October 2011

ISAC Priority 4 -

Infrastructure/Architecture

ISAC Priority 14 – Security

and Regulatory Compliance

• The Security Authorization process formerly called Certification & Accreditation is transitioning to Continuous Monitoring.

• All Areas and Facilities must conduct security risk assessments at least annually

• OIT has provided a Risk Assessment Template

• Area ISSO have knowledge and responsibility for ensuring Area compliance

• Mandatory Patch Management must be implemented across IHS by October 1, 2011

• A CIO Memorandum on this subject will be forthcoming15

ISAC Priority 14 – Security

and Regulatory Compliance

Other Current Security & Infrastructure Initiatives

• Mobile Devices

• Considerable field interest in using mobile devices such

as iPad

• White paper developed and provided to HHS as input

on a final policy

• Agency-wide Cyber-Security Conference (July 2011)

• Development of 3 year Cyber-Security Plan

16

ISAC Priority 1 –

Practice Management

Principal Accomplishments in FY11 – RPMS PM

• Development to address HIPAA 5010 requirement

• Will be compliant by Jan 1, 2012

• Meaningful Use Reports

• New Referred Care Information System (RCIS)

component for EHR

• Includes ability to print Continuity of Care Document –

required for Meaningful Use:

• Patient Registration GUI v1.0 released 1/26/2011

• Scheduling GUI v 3.0 released 4/19/2011

17

Patient Registration –

Main View

Patient Registration –

Update Demographics

ISAC Priority 1 –

Practice Management

Current and Planned Development

• Continued development of HIPAA 5010 transaction sets

including pharmacy claims

• Accounts Receivable debt management enhancements

• Patient Registration GUI Version 2.0

• Scheduling GUI Version 4.0

• Development required for ICD-10 transition

• Additional TPB/AR and CHS enhancements, including

graphical interfaces

• Dependent on priorities and resource availability

20

Components of Health Information Exchange in IHS

Master Patient Index

• Identifies the same patient at different facilities

• Enables medical records to be shared within the IHS enterprise and externally.

• The Personal Health Record (PHR) will use MPI to provide patient information from multiple facilities

Health Information Exchange

• Gateway to the Nationwide Health Information Network, to exchange information externally

Continuity of Care Document (CCD or C32)

• First of multiple standard patient summary records that can be exchanged among I/T/U facilities and beyond

ISAC Priority 2 – Health Information

Exchange and Interoperability

HIE Project Status

Beta Phase

• Beta testing at Fort Defiance, Gallup and Zuni was completed at the end of March, 2011.

Implementation Phase

• Controlled National deployment of MPI and HIE has begun with Vangent as implementation contractor.

• The C32 has been released nationally to help meet Meaningful Use requirements.

• System configuration and training activities for the controlled release are under way at Billings and Oklahoma areas and beginning at Phoenix and Tucson.

ISAC Priority 2 – Health Information

Exchange and Interoperability

HIE Project Challenges

Area participation

• Site Manager and Medical Records staff availability with competing projects

Technical

• System configuration

• Minimum hardware and software requirements need to be met

Schedule Risks

• Early on in the project, not all implementation risks have been identified as yet

• Continuous Improvement Methodology

• Apply lessons learned as we move through the rollout implementation under configuration and training tasks

ISAC Priority 2 – Health Information

Exchange and Interoperability

ISAC Priority 3 –

EHR

• RPMS is certified as a Complete EHR for Stage 1 Meaningful Use, effective April 2011

• Both Ambulatory and Inpatient Settings

• Only government-operated system to seek certification

• The “Certified EHR” will be released as a KIDS application called BCER v1.0

• Certification is valid until the Stage 2 requirements go into effect – currently Oct 1 2012, but could be delayed

• Significant patches/changes to Certified EHR may require re-testing

24

ISAC Priority 3 –

EHR

• Many RPMS packages required modification for certification –timely testing & release was difficult

• All software require for Stage 1 MU has been released – the largest was EHR v1.1 p8 (includes eRx mods)

• Other related releases include:• Personal Health Record v1.0 – software has been released for

MU but PHR use will need to wait for MPI deployment

• Clinical Quality Measures in CRS v11, p3

• Patient Volume Reports for Hospitals and EP

• Formal release of RPMS Suite (BCER) v1.0 – in testing (provides report showing installation of certified software, but is not itself essential for MU)

• Substantial installation/configuration/training required

• Principal NEW requirement for Hospitals seeking Medicare in 2011 is setting up local C32 generation

25

ISAC Priority 3 –

EHR

Major RPMS Releases thus far in 2011

• Patient Registration GUI v1.0

• Scheduling GUI v3.0

• iCare v2.1 with CMET

• EHR v1.1 patch 6 – numerous enhancements

• EHR v 1.1 patch 7 – QuickNotes

• EHR v1.1 patch 8 – Certification enhancements

• Pharmacy patches – Multiple Drug File, Inventory Management

• Several 3PB and AR patches26

RPMS EHR –

Current Deployment (7/2011)

• Outpatient – 304

• Federal - 104

• Tribal - 188

• Urban - 12

• Inpatient – 29

• Federal - 22

• Tribal - 7

• Alaska Village Clinics – 38

27

CPOE Data

from RPMS EHR

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Average CPOE Federal

Sites:

Average CPOE Tribal

Sites Reporting:

Average CPOE Urban

Sites Reporting:

Average CPOE All I/T/U

Sites Reporting:

Meaningful Use Incentive Program

• Authorized by the HITECH portion of the Recovery Act of 2009

• CMS to offer financial incentives to Eligible Hospitals and Eligible Providers that demonstrate Meaningful Use of Certified Electronic Health Record technology

• Incentives intended to improve the business case for more widespread adoption of EHR

• Three-stage program through 2016 (Medicare) or 2021 (Medicaid)

• ONC to develop criteria for EHR Certification, consistent with CMS criteria for Meaningful Use

ISAC Priority 6 –

Meaningful Use

ISAC Priority 6 –

Meaningful Use

Meaningful Use Timeline

• Hospitals – Medicaid

• Adopt/Implement/Upgrade Certified EHR by 9/30/2011

• Hospitals – Medicare

• Implement Certified EHR by 7/3/2011 to show 90 days of Meaningful Use by 10/30/2011

• Complete Security Risk Assessment by 9/30/2011

• Register/attest with CMS by Nov 30, 2011

• Eligible Providers – Dates are 90 days later for both programs

• Action – Enroll Providers with NIHB Regional Extension Center (REC)

30

I/T Hospitals –

Meaningful Use

Area Total

Hospitals

Plan to Meet

Medicare (2011)

Plan to Meet

Medicaid (2011)

Aberdeen 7 0 7

Alaska 7 1 3

Albuquerque 4 4 4

Bemidji 2 2 0

Billings 3 0 3

California 0 0 0

Nashville 2 2 1

Navajo 6 4 5

Oklahoma 6 1 5

Phoenix 7 4 5

Portland 0 0 0

Tucson 1 0 1

Totals 45 18 34

ISAC Priority 6 –

Meaningful Use

• Non-RPMS should ensure that their EHR vendors have

certified for Meaningful Use – list of certified EHR products -

http://onc-chpl.force.com/ehrcert

• OIT is developing MU performance reports for determining

achievement of MU measures for eligible providers and

hospitals.

• OIT is developing reports to calculate patient volumes for

both eligible providers and hospitals to determine eligibility

for the Medicaid EHR Incentive Program.

32

ISAC Priority 6 –

Meaningful Use

RPMS Releases for C/MU

• Personal Health Record

• C32 Summary of Care

• Local on-the-fly from EHR or RCIS

• External through HIE

• E-Prescribing

• Ability to document review of Problems, Medications, Allergies

• MU Performance Measures

• Core/Menu Set Objectives in PCC Mgmt Reports

• Clinical Quality Measures in CRS

33

E-Prescribing

in RPMS

• Providers using RPMS with internal pharmacy will

meet eRx requirement using RPMS EHR alone

• Providers at clinics without pharmacies will need to

use electronic prescribing functions to meet MU

• RPMS e-prescribing meets requirements for

Certification & Meaningful Use

• IHS is finalizing our data exchange agreement with

SureScripts (the eRx clearinghouse)

• OIT is sponsoring extensive web-based training for

sites seeking to implement eRx.

E-Prescribing

in RPMS

ISAC Priority 6 –

Meaningful Use

MU Stage 2

• Requirements for Stage 2 have not been published –proposed rule expected in Sept, final rule not until December.

• Current implementation date Oct 1, 2012 – BUT considerable pressure to delay Stage 2 for at least one year because of short timeframe and simultaneous mandate for ICD-10

• Stage 2 will require care/treatment planning functions, increased patient communication (PHR), increased interoperability, tougher performance measures, among other things

36

ISAC Priority 7 –

Workforce Development

OIT-Sponsored Training Events

• FY2010 – 426 Events with 6,128 Attendees

• includes WebEx events

• FY2011 (Oct – June) 346 Events with 5,847

Attendees

• includes WebEx events

37

HIT Workforce Development Project

• IHS is working with American Indian Higher Education Consortium (AIHEC), Tribal Colleges and Universities (TCU), and the National Indian Health Board National AI/AN Regional Extension Center (NIHB REC) to develop a workforce strategy.

• IHS is coordinating meetings, creating potential internships near TCUs, providing FOIA RPMSdatabase to TCUs for use in healthcare courses and IT courses.

• Both Navajo Technical College and Salish Kootenai Tribal College have expressed interest and are looking at hardware needs.

• InterSystems will install Ensemble and Cache at the colleges and will develop a training course specific to TCUs. The training course will be offered at no cost to TCU personnel.

38

ISAC Priority 7 –

Workforce Development

ISAC Priority 11 –

Master Patient Index (MPI)

• Enables matching of unique patients across electronic record systems

• Permits sharing of health information between facilities (within and outside of I/T/U)

• Allows Personal Health Record to display information from multiple facilities

• Interfaces to the Nationwide Health Information Network and the Personal Health Record have been developed through our Health Information Exchange (HIE) Interoperability project

• Nationwide deployment of the MPI, HIE, and C32 is underway

39

ISAC Priority 16 –

Patient Communication

• Patient Education

• Existing Patient Education Protocols

• New NLM button in EHR – condition-specific health education

• New/revised patient education and health literacy websites

• Self-Management Support

• Assistance to IPC Program on documenting SMS

• New EHR component to document patient goals

• Access to Health Information

• Patient Wellness Handout – version 2, customizable

• Personal Health Record 40

Personal Health

Record (PHR)• Provides patients with online access to personal health information,

from any facility at which they are registered (using MPI)

• Aligns with MU requirements to display patient medications, recent

lab results, allergies, and problem list entries

• Requires in person authentication to create an account

• Each facility will need a PHR “registrar”

PHR –

Meaningful Use 2011

PHR –

Meaningful Use 2015

Sample IHS PHR Screens

PHR Pilot 19May, 2010

May, 2010 PHR Pilot 25

IHS PHR Allergies View

IHS PHR Lab Results View

Other Current and Upcoming

Development in RPMS

Emergency Department

Dashboard

• New application acquired from Chickasaw

• Cache Server Pages application fully integrated with

RPMS EHR and ERS

• Display patients checked in, including status, CC, Dx,

VS, orders, waiting times, etc.

• Update in real time from EHR

• Print labels and med reconciliation worksheets

• Emergency department log, workload reports &

waiting time statistics

ED Dashboard –

Check-In View

ED Dashboard –

Edit Screen

RPMS Group Encounter

Application

• Adapted from VA Group Notes and similar to

Group entry in Behavioral Health

• Ad hoc or standing groups

• Enter all visit data (including notes) for entire group

at once

• Add individual data (additional notes, measurements,

etc.) for specific members

Group Notes

in EHR

EHR Nursing

Flow Sheets

• Intended principally for Inpatient, but can be used in

ED, Day Surgery, Observation, etc.

• Entry of Vital Signs, Input/Output, other assessments.

• Customizable view, including graphing, that is

compressible or expandable across time.

• Overlapping graph capability – I/O, BP, diuretic

administration, etc.

Nursing Flow Sheet

EHR Component

Prenatal Care

Module

• Near Term Development

• “Pregnancy Issues and Problems” list

• ICD-9 coded pick list

• Multiple notations for each item (interventions, plan of care)

• Document whether item pertains to current pregnancy or all

pregnancies

• Select and use as POV for visit

• TIU object to pull list and associated notations into TIU note

• Future Development

• Enhancements to EHR Nursing Flow Sheets to include

Prenatal data

Prenatal

Flowsheet

Pharmacy GUI

Development

• Absence of GUI has been frustrating for many pharmacists

• Current activity to develop GUI for various workflows:

• Direct pharmacy order entry (from paper)

• Finishing provider-entered orders

• Pending order queue

• Refills (including Audiocare)

• Allergy entry, Allergy verification

• Pharmacy reports (multiple)

• Inpatient GUI functions will follow

Pharmacy

GUI

Pharmacy

GUI

ADT GUI

(New Admission)

Clinical Scheduling

GUI v4.0

EHR v2.0

(Browser Enabled)

Recognition

• In March, the IHS received an HHSinnovates award

for our use of EHRs for public health surveillance.

• In collaboration with the Centers for Disease

Control and Prevention (CDC) and the Food and

Drug Administration (FDA), the IHS created a new

public health reporting tool.

• The tool used de-identified information from EHRs

to provide near real-time surveillance of the H1N1

flu in American Indian/Alaska Native populations.

64

Recognition

• The IHS was named a Laureate in the 2011

Computerworld Honors Program.

• The Indian Health Service's Population Management

tool, iCare, joined 254 others from 23 countries as

Laureates in this year’s program.

• The Computerworld Honors Program was especially

competitive this year because the program received

more than 1,000 nominations.

65

Challenges

• Transition to ICD-10

• See separate presentation for details

• Stage 2 MU

• New RPMS Development required

• May be delayed to 2014, i.e. coincident with ICD-10

• Challenges to implementation and support in the field

• Implementation of 2-Factor authentication

• Cost of Sentillion solution for RPMS isestimated at $3M

6666

For More Information

on IT and HIT Initiatives

• Charles Gepford, Chief Information Officer and Director, Office of

Information Technology (Acting), charles.gepford@ihs.gov, 301-443-2537

• Timothy Defoggi, Deputy CIO (Acting) and Director, Division of

Information Security, OIT, timothy.defoggi@ihs.gov, 301-443-3832

• George Huggins, Director, Division of Program Management and Budget,

OIT, george.huggins@ihs.gov, 505-248-4104

• Mike Danielson, Chief Technical Officer and Director, Division of

Information Technology, OIT, mike.danielson@ihs.gov, 505-248-4191

• LCDR Mark Rives, MBA, MSCIS, Director (Acting), Division of

Information Technology Operations, OIT, mark.rives@ihs.gov, 301-443-2019

• Raymond Willie, Tribal Liaison (Acting), OIT, raymond.willie@ihs.gov, 505-

248-4411

• Howard Hays, MD, MSPH, RPMS Investment Manager, OIT,

howard.hays@ihs.gov, 505-401-8731 67

DISCUSSION