Underinvestment Has Left Indian Health Service IT Systems in Need of Complete Overhaul, Study Finds

Jan. 30, 2020
Technical evaluation found that, as currently configured, the Resource and Patient Management System will be completely unsupportable in 10 years

In 2018, the Department of Health and Human Services (HHS) Office of the Chief Technology Officer launched an effort to modernize the health IT systems of the Indian Health Service. A year-long assessment of the current system, including surveys, found that 60.3 percent of users believe it needs either significant improvements or a complete overhaul, and 30.3 percent rated its overall quality poor or very poor.

HHS partnered with the Regenstrief Institute to conduct a year-long assessment of the Resource and Patient Management System (RPMS) and the opinions of people who rely on the system to deliver care to the tribal population. In a Jan. 27 Health Affairs blog, Theresa Cullen, M.D., and colleagues describe the challenges IHS faces in planning for a replacement of the RPMS.  “Initially developed specifically for the IHS, years of inattention and underfunding have left the RPMS unusable by current technological standards, making it difficult to provide continuous, consistent care to the already marginalized American Indians and Alaska Natives (AI/AN) community.”

A technical evaluation of the system found that as currently configured, the RPMS will be completely unsupportable in 10 years, the report said. A deeper analysis revealed that issues with the RPMS reflect larger systemic issues within the IHS. 

Cullen is very familiar with the health IT systems of the IHS. A family physician, she retired from the U.S. Public Health Service as Rear Admiral in 2012 after leading multiple software development and deployment initiatives within the IHS. Between 2012 and 2015, she worked as the chief medical information officer for the Veterans Health Administration.

The IHS modernization project was spurred in part by the VA’s May 2018 decision to replace its legacy EHR system, VistA, with a commercial product developed by Cerner, the same corporation chosen by the DoD. “This decision significantly impacts the IHS, whose own EHR has historically benefited from and been dependent upon VistA development for its core health IT applications,” the blog notes.

The blog points out the historical and ongoing disparities, both fiscal and health-related, between the veteran population and the AI/AN population. “While the VA has been appropriated $1.6 billion to fund its transition to the Cerner EHR, the IHS is poised to receive significantly less—a proposed appropriation $25 million for fiscal year 2020 to begin evaluating and updating its health system, despite providing care to a population equal to 27 percent of the VA. The $1.6 billion for the VA is an initial appropriation on what is believed to be a final cost of more than $10 billion.”

In fact, the Regenstrief authors noted, until FY 2020, there was no budget line item for IHS health IT at all. “Because of the extensive work needed to bring the RPMS up to minimum modern health IT standards, the proposed amount is inadequate to meet the United States’ responsibility for providing health care to tribal nations.”

A report entitled “Strategic Options for the Modernization of the Indian Health Service Health Information Technology Final Report” published in October 2019 made several key recommendations.

● Establish a roadmap that commits to a health information exchange that can provide a patient’s longitudinal record across facilities. To be successful, the enterprise model and the heterogeneity of the I/T/U system mandates evaluation of current models and the development of a comprehensive action plan to meet this goal.

● Establish governance for evaluation of HIT systems to have processes and policies that ensure that systems developed or purchased support interoperability including current and future data and messaging standards and open application program interfaces (APIs).

● Ensure that historical data is available and integrated into future solutions.

● Provide continuous evaluation and modification of processes to help ensure consistency in data quality, including data collection and data entry.

The following activities to achieve infrastructure modernization also were recommended:

● Address technological infrastructure concerns and work with consultant groups for modernization guidance.

● Select the fewest possible technology suites to minimize integration and maintenance challenges and maximize end-user satisfaction, focusing on three primary areas: patient safety, fundamental operational functions, and cybersecurity.

● Restructure the organization, guided by organizational change management (OCM) initiatives, to facilitate IHS HIT infrastructure modernization.

● If a commercially available off the shelf (COTS) solution is adopted, the IHS must sustain responsibility for VA-sourced applications or contract for continued maintenance of these applications with VistA-based companies until they are sunset.

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