Since its founding in 1955, the Indian Health Service (IHS) has provided a comprehensive health service delivery system to approximately 2.56 million American Indians and Alaska Natives who belong to 573 federally recognized tribes in 37 states. The agency’s mission and vision are to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives (AI/AN) to the highest level, while building healthy communities and quality health care systems through strong partnerships and culturally responsive practices. To aid its mission, the IHS has historically relied on its electronic health record (EHR) system, the Resource and Patient Management System (RPMS), for its clinical, financial, and administrative needs. 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 AI/AN community.
Between June 2017 and May 2018, both the Department of Defense (DoD) and Department of Veteran Affairs (VA) elected to move to commercial off-the-shelf solutions to increase interoperability and meet the increasing requirements for modernized health information technology (IT) systems. In May 2018, the VA made a decision to replace its legacy EHR system, VistA, with a commercial product that was 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.
This decision also highlights 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 of $25 million for fiscal year (FY) 2020 to begin evaluating and updating its health IT 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, 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 Unites States’ responsibility for providing health care to tribal nations.
The Evolution Of IHS Health IT
Developed specifically for the IHS in the mid-1980s and intentionally designed to leverage the VA’s VistA system, the RPMS currently includes more than 100 software applications. Historically, this health IT system has been capable of fulfilling the variety of operations needed within a health care enterprise, including direct clinical, administrative, public, and population health functions.
Tribal health organizations helped inform the development of the RPMS allowing them to take ownership of their health IT configurations and ensure that they could be agile enough to resolve needs as they arose. The RPMS is the only certified EHR that was developed by federal agencies and continues to meet the majority of the agency’s clinical health IT needs.
The RPMS also contains a breadth of historical health data (dating back to 1960 in some health care facilities), which is a unique and important feature of the system.
Access to and use of this lifetime of data continue to be critical in monitoring disease and developing long-term strategies for combating disturbing health trends in Indian country.
However, long-standing underfunding of health IT within the IHS, coupled with a series of mandates unsupported by recurring funding (for example, the Meaningful Use and ICD-10 transition) has hindered the ability of the IHS Office of Information Technology to keep pace with industrywide advances in health IT capabilities, as well as user needs.
HHS/IHS Health IT Modernization Project
In 2018, the Department of Health and Human Services (HHS) Office of the Chief Technology Officer, concerned about the impact of the VA’s decision to change health IT systems, launched the HHS/IHS HIT Modernization Project to evaluate the potential need for modernizing the RPMS. Over a span of 12 months, the agency partnered with the Regenstrief Institute to assess the RPMS and the opinions of people who rely on this system to deliver care to the tribal population.
Using human-centered design methods and principles, initial discoveries through surveys and site visits (engaging with more than 2,000 users) were unsurprising, given the limited funding and support to the RPMS over the past years:
- 60.3 percent of users believe the RPMS needs either significant improvements or a complete overhaul to meet the health care team needs;
- 30.3 percent rated the overall quality of the RPMS as poor or very poor;
- 16.1 percent are very dissatisfied with its ability to help them do their jobs better; and
- Approximately 14.0 percent of users interviewed during site visits feel they do not receive the training or support required to properly understand and operate the system.
A technical evaluation of the system found that as currently configured, the RPMS will be completely unsupportable in 10 years. A deeper analysis revealed that issues with the RPMS reflect larger systemic issues within the IHS.
Across the majority of departments (such as primary care, nursing, lab, dental, and IT), IHS lacks necessary clinical and technical staff to operate its facilities. Most facilities are located in remote, rural settings, resulting in difficulty recruiting and retaining staff. Many facilities lack resources that are considered essential, such as Wi-Fi internet connectivity. Critical staffing shortages make it difficult to support the IT infrastructure, let alone the RPMS system.
In addition, the customizable nature of the RPMS has created variations in interface and capabilities from facility to facility, making it difficult for IHS area offices to create and implement consistent and useful training and support. Many interviewees referred to the system as “piecemeal” and inconsistent.
Finally, there is little to no interoperability between most IHS facilities and no usable personal health record. Despite the fact that the IHS operates multiple facilities under one enterprise, very few of its facilities can send or share patient data with others. Many patients can only access their records by speaking or visiting directly with hospital staff. Much of the AI/AN population is fluid and transient, moving from one reservation or city to another in search of employment or family connections. Patients have no easy, convenient way of bringing their health data with them.
Developing A Strategic Roadmap: Policy Recommendations
The way health care is delivered within the IHS has changed with time, but its mission has not. The IHS service delivery model embraces community-oriented primary and coordinated care, implicitly supporting the movement toward value-based medical delivery. The IHS actively supports patient-centered medical homes, critical steps in the journey to a more effective delivery care model that employs health IT to inform and evaluate optimal, value-based care in rural communities. Support for these models has relied upon the IHS health IT infrastructure that supports comprehensive clinical as well as public and population health.
The Indian Health Service has historically been and continues to be a leader in health information technology. Modernizing the health IT infrastructure and solutions, while designing and implementing creative methods to secure appropriate health IT staffing and increased support for remote employees, is needed to continue to address health disparities.
To produce a modern, engaging, and responsive system, the IHS must embrace a human-centered design approach for both health care delivery and health IT management and ensure the involvement of AI/AN partners and patients. Decisions about appropriate health IT solutions should be made based upon federal health IT requirements as well as those unique to AI/AN communities.
The agency must seek to understand and mitigate the complexities of the policies and barriers affecting funding, including unique operational challenges, complicated reporting requirements imposed by multiple funders, tribal policies on data ownership, and increasing compliance and accreditation standards. Any viable health IT solution for the IHS will integrate modern IT governance with the ability to monitor common performance standards with technical solutions that support streamlined, intuitive data capture and reporting; the solutions also must be respectful of both tribal self-determination and tribal data sovereignty.
There have been recurrent concerns from the Office of Inspector General and the Government Accounting Office about IHS health IT acquisitions and management structures that the IHS must address. The IHS Office of Environmental Health and Engineering acquisition office provides a high-functioning acquisition model for the IHS Office of Information Technology to emulate. The IHS also should reach out to the VA and DoD to engage and share opportunities as these agencies move forward with their own health IT modernization initiatives. Lessons learned from these organizations can result in immediate benefit to planning and implementation of a new IHS EHR as well as long-term benefit to other rural and resource-constrained health care systems.
In addition, the IHS must provide full support and an aggressive timeline for the implementation and evaluation of data exchange and interoperability between IHS facilities and with community-based providers. This will require an interoperability solution within the current IHS health IT data system and must be prioritized for the near future. Analytics and business intelligence capabilities must be expanded, with a focus placed on IHS security and compliance. Furthermore, telemedicine must be expanded, along with other community-based solutions that support coordinated and comprehensive primary care models. The development and funding of a program similar to the VA National Center for Collaborative Healthcare Innovation could encourage field-based innovation and evaluation. The IHS must also embrace transparency in its work and invite and extend opportunities for ongoing analysis, evaluation, and engagement with tribal, federal, and academic partners to collaboratively identify, evaluate, and actualize opportunities. Finally, modern health IT could maximize financial revenue for AI/AN people and tribes through improved integration of modern billing solutions with the EHR solution. While this is the impetus behind most EHR modernization, the need to improve clinical outcomes is of primary importance within the Indian Health Service.
The US government has an obligation to meet the clinical needs of AI/AN communities. Supporting the health IT needs within the IHS through appropriate funding and oversight of a health IT modernization program will be critical to achieving success. The VA and DoD have received substantial increases in funding to move their historical health IT systems into the future, while the IHS has not. This presents an opportunity for Congress to solidify its voiced support for tribes while creating an opportunity to innovate around health IT solutions for rural and resource-constrained communities. Budget estimates developed by the national Tribal Budget Formulation Workgroup suggest $3 billion is needed for health information technology solutions over a 10-year period, to care for a patient population equal to 27 percent of the number of patients cared for by the VA.
Health care for tribes is a guaranteed, nation-to-nation responsibility between the United States and tribal nations. The administration must take immediate steps to address unfulfilled trust and treaty obligations with tribal nations by implementing a strategy to end unacceptable health disparities and urgent life-safety issues facing the AI/AN population. An adequately sourced health IT program is an essential component to ensuring high-quality and safe care. To fulfill its obligations to this marginalized community, the administration must remember this is a start, not a finish.
Detailed information on this strategic roadmap and other project findings is available in a November 15, 2019, Dear Tribal Leader Letter and reports recently published by the IHS. The authors thank Brian J. Miller, MD, and Jean Garcia for additional editorial input.