But how so? Read on…

Part 1 – The challenge

NIEM is an important cog in a government case management solution. At some point in a case’s lifecycle, you may need to share the case-related information with other agencies or individuals, perhaps to get assistance in completing the case or maybe to give more information to another agency for a similar case that they’re working on. Whatever the reason, this information must be easily passed from one system to the next without being ‘lost in translation’.

NIEM (National Information Exchange Model) is a framework for sharing enterprise-wide information across all levels of government. It has a core set of elements that are standard across all the agencies and has more specific ones for the various entities and stakeholders. Agencies can now speak a common language, allowing one agency to publish data from its case management system to the XML standard, which can then be picked up and parsed by another agency that requires this information.

Now all you need is a case management system that lets you export data into the NIEM standard and then a parser to put it back in.

Pretty neat and simple, n’est-ce pas?

Almost. (Let’s face it, if it really were that simple, I’d have nothing to write about and I’d just put up some comics to keep you entertained.)

There are a few problems to watch out for:

• Before importing or exporting, the system must check the data’s security classification. A document requiring a classification level of Top Secret cannot be sent to an agency (or individual) with only Confidential level access. Perhaps only certain parts of the document are deemed to be Top  Secret, in which case, the publishing tool should be able to extract only those parts that are at the required access level.

• Large amounts of data may need to be continuously exported to, or imported from, an external system. Every time an update is made to case data, it may be necessary to push this information out to other agencies. So it may be better to export/import only the changed data and update the existing data. This reduces the time and cost of transfer and would help to reduce duplicated data.

• Data may be imported that already exists in the case management system. Checks need to be in place to handle matching data during import. When duplicate data is found, is it better to replace the data or create a new version of the existing data?

Armedia Case Management comes with a tool specifically to import from and export to NIEM that tackles these problems. Stay tuned for Part Two… The Solution, which discusses how ACM implements the NIEM publishing process.

Until then, here’s a comic strip to keep you entertained (don’t we all just love Dilbert)…

The case management system may not and probably should not be the evidence management system; however it should integrate with the evidence management system.  At a minimum, the case agent(s) need to understand the chain of custody of evidence associated with their case.  It would be better if it provided richer features like allowing the case agent to request evidence for charge out, reporting on state of evidence within case, electronic representation of evidence (i.e. picture) or etc.  The evidence administrator ensures that the evidence can be found when it is needed for whatever reason. 

The case management system should provide records management services. If deigned correctly, this will be transparent to the case agent.  As you clearly stated in “The People of Case Management”, the system has to make it easy for officers to document their investigation.  The records management system will ensure that the case adheres to the organization’s retention and disposition policies.  The records administrator maintains the file plan with its associated policies and enforces them during the lifecycle of the case. 

The evidence and records administrator supports the case agent by ensuring that physical and electronic material is tracked and available during the lifecycle of the case.

First and most importantly we have the case agent.  Case management is directed by a case agent or a team of case workers.  The case agent is supported by the organization and works within a framework of regulation and legal boundaries; still, the case agent is personally responsible for closing the case.

Every other benefit the organization gains from case management is derived from the case agent’s work.  Any case management system has to provide first-class support for the case agent’s needs.  Any new case management system has to be substantially better than the old system… No matter how bad the old system may seem, the case agents will have made it a part of their lives, and they will understand how to use the current system.  The introduction of the new system will make their lives harder in the short term.  The long term advantages of the new system must be very significant to make the effort worthwhile.  This is true even for electronic systems replacing a paper system.  Software developers think any electronic system is so superior to paper that they often neglect the hard work, thorough planning, and business analysis that goes into a deep understanding of the case agents and their day-to-day needs.

Law enforcement systems have to make it easy for the officer to document their investigation.  Software defect tracking systems have to make it easy for testers to enter defects and software developers to record the fixes.  Mortgage systems have to make it easy for underwriters to decide what to do.  Insurance systems have to make it easy for the adjusters to do the right thing.

Case agents have supervisors.  Supervisors are responsible for their case agents.  They have to know what cases each case agent is working.  Is each agent paying attention to the right cases?  Are the right cases assigned to the right agents?  Are the agents complying to the web of regulation and law and policy that affect their work?  Are the agents maintaining their case files?  Can I make a good case for hiring more case agents?  Any case management system has to make it easy for a supervisor to answer all these questions.

A case may involve a number of tasks that have to be fulfilled.  The tasks have to be assigned to people, usually by the case agent; and the task assignees have to report on the task status.  The assignee may or may not have access to all the details and background of the case file.  The case management system should make it easy for the case agent to create and assign tasks; for the assignees to receive the task; for the assignees to report on the task status; and for the agent to accept these reports.

The organization may have a separate group of people charged with mining value from the organization’s collective wisdom, as encoded in the repository of case files.  This is where electronic case management systems start to shine over their paper counterparts – if they are done correctly.  Analysts need to run reports, ad-hoc queries, and searches over the entire set of case files.  They may suggest changes to organization policy, point out non-compliance with existing policy, and propose changes in priority.  A case management system has to support analysts, without obstructing the case agents.

Any electronic system has administrators… it goes without saying that a case management system has to be ”administratable”.  I say this because, all too often, it does go without saying, and applications are released with no operational procedures, no way to edit lookup tables or drop-down lists, no backup windows, no upgrade path – in short, no joy for the poor underappreciated sysadmin.

In an interesting way, the public is sometimes a stakeholder in case management systems.  Most organizations have to prepare structured reports on their performance from a year-to-year or quarter-to-quarter basis.  How many crimes solved; how many defects closed; how many mortgages issued; how many claims resolved?  The public affairs officer needs accurate data from the case management system, without compromising ongoing cases.

Any organization considering a change to their case management system first has to understand who uses the system, how they use it, and whether the proposed change will make each user’s life easier.

Who uses your case management system?  Did I miss any prominent roles?

Case management obviously helps customers manage cases. So let’s back up and define a case.

A case is an incident of interest to some organization.  Law enforcement organizations have crimes.  Software development projects have defect reports.  Mortgage companies have loan applications.  Insurance companies have claims.  Crimes, defect reports, loan applications, and claims are numbered, tracked, and managed by these organizations.  They are all cases.

So we know what a case is.  A case also has stuff associated with it.  A case has people assigned to it; a history of actions taken by these people; tasks to be performed; relevant documents; a status; and a resolution.

The case agent focuses on the case and all its associated stuff.  That’s how crimes get solved, mortgages loaned, claims processed, and defects fixed.  The organization also pays attention to the collection of cases.  Data mining helps the organization improve.  How many cases did we process?  How much time to close a case?  Do we need to pay more attention to this kind of case, and less attention to that other kind?

Case management is how the organization manages a case and its stuff.  Case management is how the case agent defines, tracks, documents, and closes cases.  Case management helps the organization reflect on past performance and optimize future performance.

Nothing I’ve said so far implies anything about electronic support for case management.  Banks, law enforcement, and hospitals have managed cases for hundreds (even thousands) of years with no computers!

An electronic case management system should make life easier for the case agent, and give the organization more tools and better information.  It sounds obvious!  But you’d be surprised at how optimal paper processes can get, after decades or centuries of tuning.  I’ve seen applications try to replace one pencil scrawl with a dozen clicks, wizards, dropdowns, confirmations, and error messages.  I can say from certain knowledge that if a system is clunky, awkward, and hard for case agents to use – they won’t use it!  All the reporting, searching, information sharing, data mining, and metrics that organizations typically want – all of it is predicated on the case agent being willing to use the system to its full extent.

As my colleague has clearly stated in his blog, My name is NIEM, NIEM is not a silver bullet.  There are many issues to resolve:

1. Security of information once export from system.
2. Sharing of information between civilian and intelligence agencies – What if it contains data about US citizen?  How do we share with our international partners?
3. What if one system does not support all data elements and during the import data is lost?  Agency could be making decisions based on limited information.
4. When does the imported data become stale?  What if the case is active and new information contradicts the export data that has been shared?
5. Given the limited budgets of local and state law enforcements, how do they participate in collaborating to combat crime?
6. How do we combat data overload once data is being shared throughout the community?

These issues/concerns must and will be addressed because the alternative is not acceptable.  Our enemy wins when we allow distractions to take our eyes off accomplishing this goal of information sharing amongst the community.  As I review current and future procurements, I am glad to see the FBI, DHS and others make this a core element of their system.

NIEM which stands for the, inevitably, not so sexy sounding National Information Exchange Model is a formal information exchange schema developed by the US government (specifically DOJ and DHS) to further information sharing across Federal, and in time, State and Local government agencies and their business constituents. NIEM builds on from the much more bulky Global Justice XML Data Model (GJXDM) model; an off-shoot of post 9/11 information sharing initiatives. The idea of NIEM (currently in version 2.1) is to provide a consistent, non-redundant, open standards based XML schema that has some well defined entities and activities for improved inter-agency communication and information sharing.

All good…but what’s new, eh? Well, I think what is new is the fact that NIEM seems to be much more than just another academic exercise. Since its infancy in 2005, there have been multiple live and pilot projects (particularly around criminal investigation related content) at many Federal and State agencies, a set of open source tools have been developed and continue to grow, and the government (including Fed CIO, Vivek Kundra) seem more than ever to be pushing the standard and making it a part of the overall US government strategy for information sharing–see data.gov.

So, how does this apply to content management? Well, as with 21CFR11, 5015 2&4, SOX and most your other garden variety compliance oriented standards, there is an opportunity. An opportunity to become compliant (read: running afoul of the government is not a good thing if you want to work with them). And, an opportunity to be productive (read: information transparency and efficient content sharing can lead to some bottom line savings and possibly…and this is where you need to put your salesforce.com hat on…new revenue development channels).

As far as ECM goes, it seems to me that minimally NIEM would have an obvious play along the lines of Case Management (particularly for investigative records) and, in a larger context, Records Management. Empirically though it’s not there yet. Case Management is still quite immature as an offering. Though there are, of course, many solutions out there, most are heavily bespoke or still based on legacy structured data and structured data management systems. In a world of exploding DOC, PPT, PDF, MP3, FLV, et al content sources the days of pure structured content solutions are numbered. As for Records Management, despite hype to the contrary, it seems we are still very much focused on eDiscovery related records management–hail Email Archival!! I think there is change afoot though, with greater investment than ever–at least by the government–in Case Management, Records Management and information sharing initiatives.

NIEM, of course, is not nor will ever be a silver bullet. Ultimately, it’s a suggested structure for content storage and exchange. However, as with the neighbor’s grass, you could always bemoan the greener pastures…only to realize in time that with a little spade work your own grass aint half bad. NIEM can be that spade…

It’s simple.  The new Content I/O Suite.  Armedia’s Content I/O Suite allows users to collect information from all of those billions of sources, migrate it to the centralized repository in the company, and then, if needed, deliver that information to the different web portals that may need to view the information later.  In fact, it can even send the information to multiple repositories all from the same interface.  So what if Human Resources uses Documentum, and Accounting uses Laserfiche, and some departments have their own collaborative eRoom set up, but you just merged with another company who uses SharePoint and FileNet.  What if one user could capture the information coming in from the website, or through email, or through regular snail mail, and deliver it into the appropriate system, without that one user ever having to be trained in each of those systems?  Sounds too good to be true, doesn’t it?  Check it out at http://armedia.com/products/suite/.

-Kristin Evans

So why hasn’t there been more progress on this front?  Technology really has little to do with it, technology is actually the easier part of the total effort.  There are several answers and they can vary slightly but it really boils down to the same reasons so many enterprise content management initiatives fail - because there is a lack of analysis, requirements definition, and careful strategic planning up front.  Plus, once systems are deployed, there isn’t sufficient governance and it quickly becomes a support and maintenance headache so the benefits and your ROI disappear.  Something as complex as electronic health records can also be hampered by key stakeholders from different areas failing to agree on a core set of requirements and policies in order to move forward.  If there isn’t a commitment among these interested parties to work together towards a common set of goals and objectives producing a successful solution will be extremely difficult.  This has certainly happened in the past but hopefully with the current momentum this obstacle can be overcome.

One of the key things for organizations planning this type undertaking is to understand and accept that it is not a one time thing.  These aren’t single projects they are programs.  Many projects have failed because the scope becomes way too ambitious and requirements are never properly defined.  With something as complex as electronic health records getting to a refined, specific set of requirements that can be implemented is challenging at best.  Which is why these programs should be broken up into a series of smaller, more tangible projects with scope that can be properly defined and is obtainable during a reasonable period of time.  Taking on more, smaller projects allows you to set more realistic goals, minimize risk, and learn from each iteration so you deploy a more reliable system that meets expectations and yields positive results.  I can’t stress the importance of properly defining requirements down to a specific level, if the requirements are ambiguous and cannot be broken out into use cases you will not wind up with a sound design and the solution will more than likely fail to meet expectations.  I am going to leave this point here since I am starting to cross over into software development methodology and process areas and I have whole separate article planned for that subject.  It may take more than one if I really get on my soapbox!

There certainly have been some good examples, if you haven’t read about it check out the Delaware Health Information Network.  The DIHN (pronounced The Din) as it is lovingly called has been an ongoing program and has been pretty successful.  Will it be a model for other states and possibly more?  I can’t say for sure but having a new VP from the great state of Delaware certainly can’t hurt!

So what can be done to help ensure that an electronic health records system is successful?  For starters realize what I mentioned above, it isn’t a single project, it is a program made up of multiple projects driven towards a common goal.  Of course stakeholder support and resources are a given as with any program but having stakeholders involved that know the different parts of the industry (i.e. Physicians, research, clinical, etc.) and are committed to the common goals is vital.  As with any type of record, health records have compliance regulations that have to be met, the most notable of course is HIPAA.  This is a risky area for electronic health records systems, one that has stumped efforts in the past.  How do you ensure patient privacy when these records become digital, especially with so many potential access points?  This is a big reason key stakeholder input is critical and why there is a great need for governance of the solution once it is deployed.  Roles and permission levels can be established but it is the subject matter experts that need to define them in order to help ensure accuracy.

Once a system is deployed the Governance Committee should be the authoritative body that provides change management guidance and helps ensure the common goals of the solution are being met, including compliance.  As with any good program a road-map should be drawn so the team knows where they are and where they need to go.  The road-map should define key milestones for the program and basically layout the projects to be undertaken along with their high-level scope.  Earlier milestones will probably be more specific and it is OK if future milestones are more nebulous, this should be a living artifact that is revisited, and potentially revised, after each individual initiative at least.  The goal is to lay a solid foundation and build upon it with additional functionality while also factoring in changes in regulation and in the environment.

Although not as important as the aforementioned functional and human factors in ensuring success,  technology certainly has an important role to say the least.  Using content management platforms effectively with intelligent classification, metadata standards, and search applications to manage, relate, and access these records will be vital.  Usability is usually an after thought which is why new system adoption and sustainability can be difficult so it’s role in an initiative like this will be huge.  If the system is difficult to use and frustrating for the end user they simply won’t adopt.  You can build the best solution with all the functionality one could ever need but if nobody uses it the effort will still be an utter failure.  Using proven usability techniques and best practices will help facilitate positive results.  With any major industry shift towards technology, especially with as big as this movement is likely to be, the establishment of certain architectural standards will go a long way to help prevent data from being siloed and to make sure the information can be shared and can cross systems.  There has been success on this front as well that can be used as examples, the Global Justice XML Data Model is certainly one.  Another standard which is in a related area is Regulated Product Submission which is a standard that would allow regulated organizations such as those in the Medical Device, Pharmaceutical, and Veterinary Medicine industries for example to submit regulatory information to the applicable agencies using a single standard message format.

The potential benefits to electronic health records systems are there but what is debatable is whether or not it is realistic to think we can get there.  Eventhough there is strong support there are also those that feel that it is too grand a goal and that the benefit is simply not there.  I was just reading an editorial in the newspaper today where the authors basically said that the money for electronic health records technology would be better spent somewhere else, in fact these authors cited statistics that indicated that this type of technology may actually detrimental to health care.  Sorry, I just can’t buy that.  I just don’t believe we have been doing this long enough and effectively enough to gather accurate data on the subject.  Are there other areas of the health care industry that need funding, of course, this isn’t a silver bullet and to think so could possibly set unrealistic expectations and doom the effort before it ever really got going.

I for one believe that we should, can, and will get there.  Make no mistake, it will be a long complicated journey but one that is long overdue and it looks like it will have a great deal of Federal funding and support which will definitely help.  We really can’t afford not to take this step.  Many experts agree the current state of medical records contributes to rising health care costs.  Furthermore, there is a great deal of knowledge that is sitting there but isn’t being utilized simply because it can’t be found and linked together in context.  I mean, when you go into your Doctor’s office or into a lab to have a test performed do they pull up all your information digitally in a unified context?  No, I am sure they don’t, they walk back to those rolling file bins and pull your folder with hard copies of all your health records, once they find it that is, and only for what you have had done with that Doctor or by that clinic.  Now, think about it again, what if your Doctor is able to have all your records including x-rays, lab results, etc. from anywhere at her finger tips and can be referenced easily?  Or what if you move or are out of town and need to visit a Doctor or hospital and they can have all your records pulled up within seconds?   Once it starts to be put in perspective it becomes a very compelling argument.

What I think has the potential to be a tremendous benefit and improvement in overall health care but isn’t being talked about too much are the eDiscovery possibilities that begin to open up.  Think about it, if this information is digital, well attributed, and classified (content management professionals reading this are chuckling at this notion of ECM Zen but stay with me) this starts to not just be a system that manages discrete electronic health records it starts to become a knowledge warehouse.  For example, with all all of your health records stored this way your Doctors can cross reference past lab results and your history to make a better, more accurate diagnosis.  Intelligence can be built in to flag items if certain tolerances have been met and send alerts.  Reporting across geographical areas can be generated to identify potential outbreaks and if you have ever had the flu you certainly want Doctors and organizations like the CDC to have all the information they can at their disposal.  I genuinely believe that this will not only improve our economy and our health care system but that it will lead to more cures and better health in general.  Health records hold a great deal of valuable information and but they suffer from the same plight that a great deal of other content does, not that it doesn’t exist but that it can’t be found.