Strategic Options for the Modernization of the Indian Health Service Health Information System LEGACY ASSESSMENT FINAL REPORT 14-May-2019 1 Indian Health Service HIT Modernization Project Revision History Revision Date Author(s) Description of Change(s) 1.0 03-May-2019 Legacy Assessment team Initial Version 2.0 14-May-2019 Legacy Assessment team Revised to incorporate suggestions and feedback from key stakeholders. 3.0 12/04/2019 HHS OCTO Clearance Rewrites 2 Indian Health Service HIT Modernization Project Table of Contents 1.0 Executive Summary .......................................................................................................................... 6 Summary of Findings .............................................................................................................................. 10 2.0 Introduction to IHS and the Resource and Patient Management System ....................................... 13 2.1 The RPMS Modernization Question ........................................................................................... 13 2.2 Background ................................................................................................................................. 15 3.0 RPMS as a Legacy System ............................................................................................................. 23 3.1. Organizational Technical Maturity ............................................................................................. 23 3.2 Administration and Governance of RPMS ................................................................................. 23 3.3 RPMS Current Implementation Overview .................................................................................. 25 3.4 Technology -- RPMS Overview ................................................................................................. 28 4.0 Assessment of RPMS ...................................................................................................................... 50 4.1 RPMS User Experience and User Evaluation ............................................................................. 51 4.2 Organization ................................................................................................................................ 66 4.3 Technical -- Current Architecture ............................................................................................... 78 4.4 Telemedicine ............................................................................................................................... 93 4.5 Public and Population Health ...................................................................................................... 95 4.6 Personal Health Record ............................................................................................................... 95 3 Indian Health Service HIT Modernization Project 4.7 Infrastructure and Maintenance .................................................................................................. 96 4.8 Security and Compliance .......................................................................................................... 108 4.9 Regulatory Compliance............................................................................................................ 109 5.0 Opportunities ................................................................................................................................. 110 5.1 A Human-Centered Process for the Next Generation of Health IT .......................................... 110 5.2 Modular Design ........................................................................................................................ 111 5.3 One Approach to Modernize RPMS ......................................................................................... 112 6.0 Required Steps for IHS Modernization ......................................................................................... 115 6.1 Recommendations from User Research .................................................................................... 115 6.2 Recommendations from Technical Review .............................................................................. 119 6.3 Summary Statement .................................................................................................................. 127 Bibliography ............................................................................................................................................. 129 Appendix A -- Historical View of RPMS Architecture ............................................................................ 131 Appendix B -- Additional History of RPMS ............................................................................................ 132 Appendix C -- Core RPMS Technology and Applications ....................................................................... 134 Appendix D -- The VueCentric Framework ............................................................................................. 154 Appendix E -- RPMS and VistA -- Dependencies and Key Differences .................................................. 165 Appendix F -- External Interfaces and Central Services ........................................................................... 167 Appendix G -- Sample RPMS Infrastructure Bandwidth Findings .......................................................... 169 4 Indian Health Service HIT Modernization Project Appendix H -- Analysis of Telemedicine ................................................................................................. 172 Appendix I -- Examples of MUMPS System Modernization in Healthcare ............................................. 174 Appendix J -- RPMS Outside of Indian Country ...................................................................................... 176 Appendix K -- Glossary of Acronyms ...................................................................................................... 178 5 Indian Health Service HIT Modernization Project 1.0 Executive Summary On May 17, 2018, the Department of Veterans Affairs (VA) announced a decision to replace the legacy VistA electronic health record (EHR) with a commercial off-the-shelf (COTS) solution over the next ten years. The migration to a COTS solution and retirement of VistA has implications on the long-term viability of the Indian Health Service (IHS) Health IT system, the Resource and Patient Management System (RPMS), which relies upon core modules from VistA EHR. This fact, combined with the independent and well-recognized need for RPMS modernization based on feedback from the RPMS user base, IHS Programs and Offices, has led to the modernization research collaboration between the Department of Health and Human Services (HHS) Office of the Chief Technology Officer (OCTO) and the IHS, of which the Legacy Assessment is a component. This executive summary presents the findings of the in-depth RPMS assessment, including an evaluation of the people, processes and technology that are part of the current RPMS ecosystem, designed to answer whether RPMS can be modernized. The Legacy Assessment team took a human-centered design (HCD) approach to assess whether RPMS can be modernized. This assessment leveraged code reviews, technical evaluation, interviews, observations, literature review, and feedback from stakeholders to assess the findings and recommendations. This document is designed to answer two questions: 1. Can RPMS be modernized given its current state, functional scope, and known risks and constraints? 2. If RPMS can be modernized, what are the options to achieving such modernization while protecting the confidentiality, integrity, and availability of the longitudinal patient healthcare data stored in the system? The terms modernization, optimization, and stabilization are defined below as used in the context of this legacy analysis. 6 Indian Health Service HIT Modernization Project Modernization is the continued process of updating, converting, or replacing a legacy technology system to improve business processes and maximize user agility. Optimization is the process of modifying a legacy system to enable it to work more efficiently, use fewer resources, and provide the needed functionality. In this study, additional desired functionalities include but are not limited to interoperability, patient access to a personal health record, and improved usability and reporting. The stabilization of a legacy system ensures that the current configuration will remain reliable and functioning for approximately the next 3-5 years. The definition of IHS Modernization developed by the Legacy Assessment team is: An organizational endeavor which brings a health IT system to a new state that is continuously evolving. It is people-and process-centric; it is adaptive, progressive, and aims to rethink and redefine the problem to evolve a system and its capabilities to deliver value to its users and stakeholders. It is resilient, and able to withstand forces from within and without. It is synergistic with the clinical vision for the healthcare system. The findings of the Legacy Assessment are stated below. Please also refer to Section 5 - Opportunities, Section 6 - Required Steps, and in particular Section 6.3 - Summary Statement for more detail. The IHS RPMS HIT system can be modernized — modernization will enable the system to provide critical information technology support for health care services to American Indian and Alaska Native