Welcome to session “ State of the Industry Overview- Tribal Health”

1. Welcome to session “State of the Industry Overview- Tribal Health” Presented by Mitchell Thornbrugh, Acting Chief Information Officer Indian Health Service - November 2018

2. INDIAN HEALTH SERVICE • Mission: • …to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level

3. Annual Patient Services: InpatientAdmissions: 39,305 Outpatientvisits: 13,742,0788 40 UrbanPrograms

4. IHS TOP CHALLENGES HEALTH INFORMATION TECHNOLOGY Electronic Health Record (EHR), IT Security, and Telehealth Infrastructure LIFE EXPECTANCY 73.7 years VS. 78.l (all races) for Al/AN populations LEVEL OF NEED FUNDED 55% according to the Federal Disparity Index which compares mainstream health insurance to IHS funding for medical services FACILITIES & EQUIPMENT Aging facilities and equipment in hospitals, clinics, and service units RECRUITMENT & RETENTION Challenges such as remote locations, leave parity, salary, and hiring freezes

5. IHS Workforce Total IHS employees: 15,369 76% of workforce is American Indian /Alaska Native Interested in supporting our mission? IHS.GOV USAJOBS.GOV *GS-2210 Series for Information Technology positions

6. HEALTHCARE data Under SIEGE • In 2017, a total of 477 data breaches were reported to the Department of Health and Human Services’ Office for Civil Rights • a rate of more than one per day. • Hacking/IT incidents and insider breaches accounted for 37% of last year’s breaches. • Healthcare is an industry where the threat from inside is greater than that from outside. • There was a major increase in malware/ransomware attacks in 2017 - more than twice the level seen in 2016.

7. HEALTHCARE DATA ATTACKS UP CLOSE

8. Why hackers target healthcare • The healthcare industry manages an enormous amount of sensitive, electronic data. • The average hospital generates nearly 700 terabytes of data annually. This reliance on technology opens the door to a wide range of attack vectors. • PHI/PII is valuable and information can be very difficult to track. Stolen data can be easily offloaded on the black market. Bad actors can steal records and seed medical care, obtain prescription drugs and expensive medical equipment, or defraud the government.

9. Valuable data • Member name • Date of birth • Social Security number • Member identification number • Email address • Mailing and/or physical address • Telephone number • Banking account number • Clinical information • Claims information

10. What is alwaysthe biggest vulnerability? People

11. RPMS EHR History • The Indian Health Service has long been a pioneer in using computer technology to capture clinical and public health data. • The IHS clinical information system is called the Resource and Patient Management System (RPMS). • RPMS development began nearly 30 years ago, and many facilities have access to decades of personal health information and epidemiological data on local populations. • The primary clinical component of RPMS, Patient Care Component (PCC), was launched in 1984. • The RPMS EHR graphical user interface represents the next phase of clinical software development for the IHS and was launched in 2004. • A brief history of RPMS - http://smh101.com/articles/Hx_RPMS_final.html

12. RPMS Pros Cons • Multiple SureScripts White Coat of Quality awards, two Davies awards, two ComputerWorld awards, and an HHSInovates Award. • Historically focused on Population Health and improving clinical outcomes • Designed by and for use in AI/AN healthcare delivery • Designed to meet specific functionality (i.e. PRC) • Increased functionality demands/requirements outpacing development capabilities • Source of software development limited to IHS/OIT • Limited sources of training and support • Heavy reliance on local system administration and configuration • Heavy reliance on contracted development • Decentralize data

13. EHR Deployments in IHS

14. Factors to consider • IHS is taking an advanced posture to plan for Health Information Technology Systems modernization. • RPMS and VISTA will continue to be supported in the near term only. • RPMS development is dependent upon the VISTA platform for core packages such as lab, radiology, and pharmacy. • There is the potential for significant cost savings and efficiencies by moving to a common Federal EHR platform. • IHS has unique mission for patient care, population health management, and referral management. A common federal platform may allow for the type of local flexibility many areas may desire. • IHS clinicians, administrators, tribes and tribal organizations and other stakeholders will be very involved in how the process moves forward and in the implementation of the system.

15. Information Systems Advisory Committee (ISAC) • Purpose: Established to guide the development of a co-owned and co-managed Indian health information infrastructure and information systems. • Goal: assure the creation of flexible and dynamic information systems that assist in the management and delivery of health care and contribute to the elevation of the health status of Indian people. • Charter: Located on IHS.GOV/ISAC • Note: Being revised to simplify membership nomination and expand tribal participation • Meetings • Last: - March 2018 • Next: Albuquerque – November 2018

16. IHS/HHS Health Information Technology Modernization Research Project

17. Tribal Partners Indian Health Service HHS ONC Emerging Sun, LLC Regenstrief Institute Pistis, LLC IHS/HHS Our Team

19. Impetus & Goals of the Research Project • Role of the HHS CTO • Motivation for this HIT Modernization Research • Goal: Evaluate current status and create options for HIT in Indian Health Service • Gather and curate information to help inform the decision-makers

20. Today’s Goals: HIT Modernization Research Project • Present Impetus, Goals and Proposed Strategic Approach to Tribal Stakeholders • Discussion with Tribes about initial ideas and guidance and how best to build on work already accomplished • Determine I/T/U engagement strategy • Guidance on best ways to engage • Selecting sites to visit during the next 5 months

21. Strategic Approach • Establish Work Plan • Creation of a Blue Ribbon Advisory Panel • Create and implement assessment framework and methodology to guide recommendations • Analysis and Secondary tiered recommendations for HIT solutions and roadmap • Proposed prioritized roadmap • Establish virtual community of practice for I/T/U HIT

22. I/T/U Representation to Advisory Panel Engagement Options: two representatives from DST; two from TSG; Urban; NIHB; alternates as needed Tribal Leader and Technical Expert Potential Break Out Sessions with National Meetings in 2019 Develop site that can be used for information sharing/exchange Others? IHS/HHS Continued engagement with the Tribes

23. Planning & Strategy Goal: Establish Work Plan • Develop project plan • Literature review to identify and curate best HIT practices for resource-constrained environments Proposed Engagement • Determine and facilitate stakeholders/advisors who will be included

24. Expert Advisory Panel Goal: Understanding of the role of the Advisory Panel • Provide expert guidance, insight, and response to the research goal • Ongoing engagement over the next year Proposed Engagement • I/T/U Representation

25. I/T/U Facility HIT Assessment Goal: Create and implement assessment framework and methodology to guide recommendations • Attention to clinical, administrative, patient, community, and technical infrastructures Proposed Engagement • Listening sessions • Participation in tribal meetings • Site visits • Data calls

26. HIT Analysis & Recommendations Goal: Analysis and Secondary tiered recommendations for HIT solutions and roadmap • Use information from Advisory committee and HIT assessments to guide recommendations Proposed Engagement • Inform assessment criteria • Ongoing engagement with tribes for input and review

27. HIT Initiatives & Future Roadmap Goal: Proposed prioritized roadmap • Develop and propose capability maturity model that can help guide meeting the roadmap • Propose critical steps in roadmap Proposed Engagement • Ongoing engagement with tribes for review, comment and edit • Potential next steps

28. I/T/U HIT Community of Practice Goal: Virtual community of practice for HIT • Establish functional HIT community of practice Proposed Engagement • Voluntary participation and engagement by I/T/U individuals, tribes, and organizations

29. National HIT Modernization Timeline

30. Governance EHR Governance is the process by which you standardize your clinical practices and set them up to work electronically. Without predictable clinical practices, you won’t be able to get predictable clinical outcomes, and your EHR implementation will be challenging. …it is more than change control

31. EHR Governance •Electronic Documentation – How/when to create it, sign/authenticate it, use it? •Medication Order Standards– How/when to order certain medications? Non-formulary medications? In code blue/emergency situations? Over the phone? •Standards for lab/radiology orders– How/when to order certain tests? •Training standards – How do you train new employees? Existing employees? Implementation? •Clinical Tool Development – How do you develop order sets? Policies? Protocols? Documentation?

32. Governance Challenges

33. Technology– its everywhereIt has an impact on every role in healthcare today!

34. IHS Barriers to Digital Services • Low bandwidth and/or high latency networks in Rural areas • Poor infrastructure reliability at some locations (e.g. power, network, etc.) • Not every shared or cloud service meets the requirements for every stakeholder • Capital funding challenges

36. 2015 FCC Study • 17 percent of all Americans (55 million people) lack access to 25 Mbps/3 Mbps service. • 53 percent of rural Americans (22 million people) lack access to 25 Mbps/3 Mbps. • By contrast, only 8 percent of urban Americans lack access to 25 Mbps/3 Mbps broadband. • Rural America continues to be underserved at all speeds: 20 percent lack access even to service at 4 Mbps/1 Mbps, down only 1 percent from 2011, and 31 percent lack access to 10 Mbps/1 Mbps, down only 4 percent from 2011. • 63 percent of Americans living on Tribal lands (2.5 million people) lack access to 25 Mbps/3 Mbps broadband • 85 percent living in rural areas of Tribal lands (1.7 million people) lack access.

37. Network Modernization Bandwidth needs grow over time, but the majority of IHS facilities cannot increase network bandwidth without significant upgrades • Modern wired broadband uses Ethernet Circuits over fiber cable. • Many rural parts of the U.S. still use Time Division Multiplex (TDM) over copper cable. Limited upgrade options • Migrating to Ethernet is very expensive (>$1M per location in many cases)– Mostly because of the special construction costs to lay underground fiber. • Monthly bandwidth costs after Ethernet upgrades are generally lower at most IHS facilities, but significantly higher for approximately ~10% of IHS facilities surveyed. 58% 200 of All IHS Circuits are T1 (1.5Mb) Tribal and Federal locations only have a T1 connection to the IHS network

38. The Rural Health Care Program • Rural Health Care (RHC) Program • The FCC provides fiscal support and reduced rates to rural health care providers (HCPs) for telecommunications services and Internet access charges related to the use of telemedicine and telehealth. • Healthcare Connect Fund (HCF) Program: Receive a flat 65% discount on broadband expenses and network equipment • Telecommunications (Telecom) Program: Subsidy/discount based on the urban-rural price difference on telecom expenses • RHC funds save IHS and Tribal health care providers over $25 million per year. $25M 68% IHS/Tribal Health Care Provider Annual Cost Savings from the RHC Program of Americans living in rural areas of Tribal lands lack access to broadband internet

39. Case: Upgrading Bandwidth in San Felipe • San Felipe requires an upgrade from T1 (1.5mbps) to Ethernet (45mbps) to support clinical operations. • $1.8M project cost • Work still in progress: Over 18 months to upgrade a 20-mile long network circuit from Bernalillo to San Felipe • 6 Months - To collect/approve quotes and negotiate with pricing/contract issues with a local telco for special construction. • 6 Months - For IHS to award the contract, facilitate the site survey, and perform some site preparation work. • 6+ Months - For telecom vendors to do the work and provision the circuit.

40. Case: High Latency Barrier for Sharing IHS Services • Kayenta (Navajo Area) has a 200Mbps Ethernet connection to the IHS network. • This connection has a high latency to the IHS Datacenter in Albuquerque • Many services such as video conferencing and centralized EHRs require low latency network connections to operate. Network Packets travel 2500 miles to get from Kayenta to the IHS Data Center in Albuquerque (250 miles away)

41. Emerging Topics in Health Care and Health IT • Population Health • Care Coordination & Interoperable Health IT Systems • Value-Based Care • Patient-Centered Care • Healthcare Data Analytics

42. Questions?

43. Thank you for attending! For more info contact Mitchell.Thornbrugh@ihs.gov