Organizational, Administrative, and Cultural Challenges
In the general case, organizational and cultural change—encompassing people and process dynamics—is a significant factor in the effectiveness of new technology as well as in its adoption by the relevant stakeholders. Technology management—the strategic planning, design, development, and deployment of IT solutions, including new technologies—is a critical factor in successful transformation efforts.1 Indeed, the number of failures (based on metrics such as cost, schedule, and function) of large-scale projects of the sort being discussed in this report exceeds the number of successes. Both technical implementations and business process challenges have contributed to many expensive failed efforts in industry. Successful efforts depend a great deal on understanding and addressing the requirements of all of the relevant stakeholders and depend critically on acceptance or adoption of the new processes. Depending on the significance of the changes, a cultural change in the supported enterprise is likely to be an integral part of a successful effort.
CMS will need to grapple with these challenges, and studying what has tended to be most successful in the past would be instructive. The need for information systems to accommodate changing business requirements is matched if not surpassed by the need for these systems to meet increasing technical requirements—not only those relating to the scope and scale of transactions and data volumes, but also those relating to performance, efficiency, and cost. Advances in all areas of IT over the four decades of the life of CMS have been profound, with improvements in architecture, capacity, performance, and cost-effectiveness. Most IT solutions that are critical to CMS, including databases, data warehouses, transaction processing, and distributed computing, have matured through several generations. To accommodate significant business change and to take advantage of modern IT solutions, it is common for all
decades-old systems to be considered for modernization. This modernization could involve re-architecting or re-implementing the existing information system and might involve migrating information system components—for example, databases, business rules, and other contents that must be incorporated in the modernized information system.
Reforming infrastructure in the face not only of demanding new requirements, but also of potentially significant changes to those requirements in the short term and medium term, will be difficult, and the process will be further complicated by the ever-changing policy environment in which CMS must operate. Moreover, cultural change to address new demands and requirements means a change in the way that the agency and its stakeholders operate and do business day to day. Such change will require an array of new skills and new ways of managing the development of needed functionality. In particular, architecting a sophisticated, complex, and constantly evolving system is a challenge when individual components of it are implemented and maintained by different entities (whether internal or on a contractual basis). A coordinated and direct management approach to ensure appropriate integration and adherence to well-articulated architectural requirements will likely be needed.
But CMS’s efforts are further complicated by federal budgeting—which does not easily allow for sustained long-term agency budgets or flexibility in resource allocation—the oversight context within which CMS must operate, and the complexity of the overall U.S. health care system. Resource constraints pose a significant challenge to successful transformation. The year-by-year, project-by-project approach to federal IT demanded by the budgeting process makes it difficult for CMS to prepare, plan, or implement a long-term, multiyear, multiprogram IT project. Moreover, past experience has been that funds for the development of new or refined systems are often obtained only by the removal of funds from other equally critical areas. However, the transformations and reengineering suggested above will likely require a substantial net investment made over an extended period of time. As noted previously, CMS has accommodated significant adjustments to its mission (and consequently its systems) over time, most recently the implementation of the Medicare Part D program for subsidizing the costs of prescription drugs. However, the scope and scale of upcoming changes associated with the recent legislative mandates described earlier seem, in the committee’s view, to present even greater challenges than any that CMS has thus far encountered.
Part of grappling with the kind of transformation described in this report involves developing ways to ascertain the needed skill sets and key gaps in those skill sets as well as devising and implementing a plan to address those gaps. High-level strategy setters, not the IT managers, should drive the development of business processes and definitions. However, the IT leadership at the agency must “sit at the executive table” as the high-level strategic directions of CMS, including the evolving business model, processes, and requirements, are addressed. Such participation by the IT leadership ensures that decisions made are cognizant of IT best practices in such areas as systems integration and standardization of processes and data, among others. In addition, in large-scale transformations, it is typically the program managers, architects, and transformation managers at the middle levels of the organization who have the most difficult job—that of transforming the technical results of the practitioners into the business results demanded by the executives and external stakeholders. Thus, building
organizational trust in this middle level—and nurturing and hiring champions of the needed transformation efforts within it—is as essential as ensuring clear leadership at the top.
The role and impact of modern information systems can be seen in terms of the ecosystems in which the systems exist. Along with user and process ecosystems that make up the operational ecosystem that is its reason for being, an information system exists in several other ecosystems, including those defined by its organizational, management, development, and operational contexts. As with a user or process ecosystem, the success of a modernized information system depends critically on understanding and addressing those contexts (which are ecosystems in themselves), each of which must participate in and support the modernization effort and adopt the resulting system. For example, the information system must align with organizational missions and goals; modernization requires management support and leadership to address significant challenges; and it requires the development and operational life cycles to have the means to support the transformation.