A few years ago, CIOs in health and human services (HHS) couldn't get department directors' attention. But now those department directors are calling on CIOs for answers and solutions. The governor wants assurances that the state and local public health infrastructures are connected and prepared to respond to bio-terrorism or avian flu threats. The finance secretary wants to know the total clients being served by multiple agencies, and whether the programs are verifying the state as the last resort for payment. Meanwhile, most of the CIO's IT resources are dedicated to decade-old operating and maintaining systems, and staff are on the verge of retirement.
Similar scenarios are occurring at HHS departments across the country. Social policies and legal pressures are forcing government to increase its coordination among previously disconnected systems. In turn, a more consumer-centered approach is evolving and enabling greater efficiencies, measurement, quality of care, access and safety. With respect to technology, this shifting terrain requires that CIOs maintain existing systems, develop new ones, and introduce commercial off-the-shelf (COTS) applications and Web services to add and extend existing functionality.
It all adds up to a changing HHS marketplace, in which the need for greater coordination requires better interoperability. At the center is the CIO, whose role is also changing -- HHS IT chiefs are becoming more closely aligned with agency heads as they adapt to changing business requirements.
A History of Disconnected Silos
HHS agencies comprise more than 40 percent of state spending. Federal agencies provide categorical entitlement or grant funding, which is generally matched by state funding, but many services are funded solely by states or local governments. Overall, government financing imposes complicated and often redundant administrative reporting requirements.
For example, state agencies use their employees and contract with community- based organizations to provide services. Counties receive state and federal financing, occasionally appropriate their funds, and provide services through county employees and contracts with community-based organizations.
Consumers are served by multiple agencies including health, behavioral health, child and family human services, and employment programs. Families and individual consumers are forced to navigate multiple eligibility processes in different office locations with redundant and disconnected case management approaches.
The lack of coordination results from numerous factors. Federal and state categorical funding requirements have effectively dictated separate infrastructures and organizations. Enabling legislation has created distinct agencies, with advocacy groups lobbying discrete legislative subcommittees for special attention, and information sharing is impeded by conflicting interpretations of privacy. Educational institutions and licensing organizations support professional development and career paths -- such as clinical social workers, psychologists or nurses -- which have different approaches and are represented disproportionately in different agencies. Also, employee unions resist changes in job responsibilities or work conditions without engaging in a bargaining process.
To some extent, IT has impeded rather than enabled coordination. In the 1980s, the federal government supported an automation model based on the transfer of legacy systems. The goal was that a statewide child welfare information system developed for one state could be transferred to another. The code would be given to the new jurisdiction.
Unfortunately problems have been abundant. Transfer systems were designed for particular states. Business processes vary dramatically across jurisdictions, however, limiting the systems' reuse. States were forced to retool these transfer systems to meet local needs. It could take five years to install a system that was built 10 years earlier. The result was an obsolete architecture that required continuous modifications -- agency heads became increasingly dependent on the few staff who understood how these systems worked, and could modify them and change the business rules over the long-life cycle.
From Legacy to Interoperability
The human services IT market is fluctuating. Hundreds of millions of dollars have been spent on child welfare systems, but only a few have achieved federal certification. Legacy welfare systems, such as temporary assistance for needy families (TANF), are in desperate need of replacement. There is pent-up demand to upgrade behavioral health systems, and the list goes on.
Many states are turning to enterprise frameworks to overcome their frustration with legacy transfer systems, and are extending common functions -- such as eligibility or case management -- across agencies. For instance, Virginia is looking to replace its TANF system with a framework that can extend from child care to other departments.
Time is of the essence -- states must offset the high cost of maintaining mainframe systems, but are impatient with the time it takes to implement an enterprise system. In these cases, a combination of approaches will occur. States will replace a legacy system in one agency, and utilize COTS applications to add functionality and take advantage of legacy investments in other agencies. Iowa, for instance, is seeking a framework approach to replace its child-care system that will interoperate with a modern and user-friendly front end to its state automated child welfare information system.
Similarly, counties and large community-based organizations are implementing a variety of solutions. The Community Services Act in Virginia encourages counties to integrate case management for at-risk youth across health, human services, juvenile justice and education systems. Blue Earth County, Minn., is looking to integrate case management with a common client view across programs. Ozaukee County, Wis., is implementing a similar approach across multiple government services. The Casey Family Foundation, a thought leader in child welfare, uses a best-of-breed case management approach in its human service projects across the country, including Indian reservations.
Over the next few years, government officials will increasingly focus their attention on how counties and states access legacy information. The problem is particularly acute where county workers and providers have to transmit program and client information to separate state legacy systems -- a frustrating situation for counties developing integrated approaches. With the development of more innovative COTS rules and middleware, counties will have the technical ability to integrate their data and translate it to separate state legacy systems.
This issue relates to the Administration for Children and Families, its policy on building a single system and who pays for it. It goes to the question of the value proposition of state legacy systems. Despite the fact that counties collect and submit client data, they do not necessarily have the ability to retain information. One new model used in Virginia, called the System Partnering In a Demographic Registry (SPIDER) will provide counties access to some integrated client information aggregated by the state.
The Changing Role of the CIO
HHS CIOs must define the value proposition of IT in the context of changing business requirements. Advances in technology can enhance the kind of coordination HHS agencies need in areas such as public health preparedness, performance management and cost control.
When CIOs utilize the Internet's power, workers can collaborate across agencies, share information and hold virtual meetings. By adopting Web services and a common language (XML), CIOs can provide their agencies with access to data stored in disconnected mainframe legacy systems.
Agencies no longer have to wait to replace large systems to modernize functionality. Service-oriented architecture has spawned COTS offerings in numerous areas -- disease management, call centers, decision support, document management -- that can enrich existing Medicaid, child welfare, public health or human service systems. Advancements in security allow access to data to be defined by role. In sum, the public sector can coordinate how it serves common clients across multiple systems through increased interoperability, merging some functions while keeping organizations largely intact.
CIOs must keep archaic systems operating while planning for, budgeting and implementing new systems and applications. IT workers who have skills maintaining old systems may not be qualified with more modern approaches. As the legacy systems age, so do workers -- when they retire, the CIO is left with few resources that understand the old technology, including the history of modifications and rule changes. CIOs may have to provide incentives to keep these staff employed or to bring them back as contract employees.
At the same time, CIOs have an opportunity to provide greater satisfaction to front-line workers. A younger work force has grown up in an increasingly connected world, in which their home entertainment system can serve as their personal computer. An environment where essential client data is locked away in a legacy system -- in which the worker needs to go to the home office to retrieve or enter case information -- is inefficient. Case workers, first responders and health inspectors can spend more time in the field, using mobile devices to communicate with one another when client data in legacy systems is more accessible.
CIOs need to become trusted advisers to decision-makers responding to pressures to modify business practices. Most HHS agency heads underestimate the value of technology, partly because, in the past, IT has been associated with large investments in legacy systems that took years to build, cost more than expected and ate up increasing percentages of budgets for maintenance and operation. Today CIOs can help HHS executives sort through approaches to meet pressing demands.
CIOs must develop a roadmap with alternatives for current and future investments. Flexibility, sequencing and timing will become paramount. For instance, an agency chief may want to merge functions, such as provider management, or consider common case management approaches. Their choices will be affected by a combination of politics, policies and resource considerations.
CIOs are developing enterprise architectures (EA) to define a vision of how IT will address changing business requirements. The federal EA has served as a springboard for these developments. The National Association of State Chief Information Officers publishes its weekly Enterprise Architecture Newsbriefs, which tracks state government advancement. These approaches rationalize use of IT assets in an evolving technology field -- from mainframe systems to thin client and Web services.
CIOs will strategize about the order in which to upgrade health, welfare, child protection or behavioral health systems. For example, a mental health agency may not have the resources to rebuild an outdated system. If there is urgency to view common clients across programs, enhance case management functionality or pull data elements from various systems to track expenditures, the CIO can advise on the benefits of Web services and COTS applications.
CIOs should explore multiple approaches to finance EA, such as benefit-funded models, cost sharing and IT trusts. They need to understand federal and state financing requirements, and waiver options. A CIO may propose building enterprise functionality in agencies more heavily financed by federal agencies.
For instance, a 90 percent federal funding match supports Medicaid management information systems. In replacing this system, the CIO may adopt a framework approach, adding functionality that can be extended to other agencies. The CIO will need to work with finance directors and agency heads to demonstrate through a waiver request how their EA supports federal funding requirements.
As HHS spending grows, state executives will look to measure outcomes, derive efficiencies and simplify administration. Currently business processes hinder state agencies and technology systems that fail to collect or report complete client information, resulting in regulatory violations, penalties and reduced revenues. By linking common data elements across multiple systems serving the same clients, CIOs can assist executives in reducing fraud and abuse, ensuring the state is the payer of last resort, and that the state receives maximum reimbursements or matching funds.
CIOs must continually review what to buy vs. build in a changing environment. Decision-makers may outsource call centers or claims processing. A CIO outsourcing a major legacy system may carve out data warehousing and keep it in-house to extend it across multiple systems. CIOs are likely to establish program management offices that combine government and contract employees, coordinate interoperability and integrate approaches across multiple programs.
By understanding how business demands change, CIOs should seek solutions proven effective in one enterprise that can be applied to another. For instance, CIOs have already tapped into collaboration, messaging and alerting strategies between public health and justice systems. Also, the use of a common client index in human services has similar applicability as a record locator system in the electronic health records field. Increasingly, we will see eligibility and benefit determination approaches converged with commercial financial services markets.
Challenges and Opportunities
In a prior career, I served in executive roles in state government, and had extensive experience working with county and federal governments. Much of that experience dealt with integrating health, human services and justice system approaches to serving citizens. Organizational and individual resistance to change could always be anticipated. In many instances a crisis -- legal, political, budgetary -- served as the catalyst to better coordinate services.
In all successful instances, there was supported by data driven decision-making. Unfortunately getting the data was often a problem and a tedious exercise. Relevant information was often maintained only in hard copy and electronic records were locked away in disparate program and agency systems that didn't communicate with each other.
Today government officials face greater challenges, but the opportunities to provide better service are just as great. Social, legal and political forces spanning HHS are driving the development of more consumer-centered and -connected approaches. And IT is better equipped to meet changing business requirements.
In this environment, the CIO becomes an important and necessary adviser to agency decision-makers. The advent of Web services, service-oriented architecture and COTS applications enable disparate systems to communicate with added functionality. It is unlikely that most state executives will pursue radical departmental reorganization efforts.
It is, however, necessary that they seek ways to better coordinate approaches across programs. Attention will be focused on administrative simplification and performance measurement. Many common business functions will be merged across programs. Interoperability will facilitate new collaborative approaches. IT can accommodate these developments, and the CIO can provide a blueprint to help.