FedHealthIT’s President, Susan Sharer, had the opportunity to sit down with the Centers for Medicare & Medicaid Services’ Director & Chief Information Officer, Rajiv Uppal and the Agency’s Chief Operating Officer, Jennifer Main, to discuss challenges, innovation, the culture of change at the Agency, and how industry can help.

Tell us About Some of the Challenges You See

Main says some of the biggest challenges are things that cross the organization. In her role as COO, she is trying to think about integrating functions, and joint projects, about outcomes that are owned by multiple parties and where those parties might work together to achieve better total outcomes.

She explains an initiative within the Agency focused on modernizing and investing in CMS that is really focused on four key ideas: People, which includes hiring, and retaining and has included a streamlined hiring process; process, looking at improving how we do the work; structure which looks at how CMS is organized around its many programs, the geographic diversity that can come into play and differences with stakeholders including patients, providers and payers; and capabilities with a focus on what it’s really important for us to be great at such as ways we are buying, our data analytics, cybersecurity and how we are writing and managing contracts.

“In the midst of this effort we have really embraced the principles laid out in Measure What Matters, thinking of objectives and key results.”

From this view, Uppal says challenges include understanding how to better focus on stakeholders, ensuring an understanding of what they need and how they might be better supported to do their jobs better. This has involved a lot of process improvements and re-engineering.

“There has been a significant effort in making employees aware of Human-Centered Design (HCD), in understanding what the right solution and the right technologies are to really enable success.”

He says there is also an emphasis on ensuring compliance, in enabling compliance to ensure teams are able to build better architecture and more secure systems, ensuring the infrastructure is there, but also the appropriate services, and the right skillsets so internal and vendor partners can make appropriate decisions.

The Circle of Organizational Change

Uppal says any change must be in conjunction with partners and specifically, partners who bring capability in areas including Agile and HCD. “Partners who have Agile coaches who can ensure our team and theirs understand the product vs project mindset are a good start. We also provide training to our employees and vendors to ensure everyone has the same understanding, that the team is working toward a common goal rather than in silos within separate ecosystems.”

There must also be thought and discussion around setting expectations on process and patterns of technology, design and architecture to enable compliance, allowing them to be free to focus on the underlying functional issues, the areas they have expertise.

Main says communication is key, as is the commitment to move from “talking the talk, to walking the walk.” She says it is easy to tell vendors what the expectations are and then fall into bad habits so there is a focus on finding examples of where there is proven success, such as the QPP Program which was built in a very Agile way.

“Medicare was created as a fee-for-service model. Thinking of the modernization of that payment system, where paying for quality of care is more complex, those same principles apply. Some of our biggest vendors are aware of what we are doing and those examples of success really carry a lot of weight and can influence how we might approach procurement differently.”

Uppal says while apprehension to change is normal, across the Agency, people want to adapt and are willing to make change. “Agile must start somewhere. It is a mindset, a journey, but one in which we have already made significant changes from where we were.”

Main points to CMS’ 16 Strategic Initiatives, 6 that are program specific (like Medicare and Medicaid) and 10 that are cross cutting. “The Administrator is committed to modernization with efforts like MyHealthEData really focused on transparency with the goal of helping patients make better decisions. It is really powerful for the whole operations team for this to be one of the key strategic initiatives of the Administrator.”


Noting that collaboration is one of the key tenants of Agile, Uppal says CMS is focused on collaborating actively with business partners. “As we move forward as an IT organization, meeting with stakeholders, understanding the issues, finding solutions to help move those issues forward, and ways we can better engage and enable our stakeholders and partners takes on a key role.”

Internally, an IT alliance of all senior leaders across the Agency’s groups and centers is focused on goals including setting common governance to be able to move forward with data, analytics and other key initiatives.

CMS has focused on structural changes that make us an organization that is constantly learning, and setting a path for people to move through stages of competency. “A significant piece of this is upskilling employees. We have a culture that promotes upskilling where managers work with employees to help map their career path. We would love for people to have a breadth of knowledge, so then the next step is to ensure competency in those areas with targeted training and projects that provide the opportunity for hands-on work so they can stay engaged and up to speed beyond that initial training.”

Main says collaboration also means bringing leadership together to share knowledge and understanding, for joint objectives that create awareness for what else is going on within the organization for greater opportunity. “This is empowering, interesting and engaging.”

“We have some amazing leaders who bring a wealth of knowledge from the CMS perspective, Rajiv is a great example of someone we recruited who brings new perspective, new questions. The leadership team at CMS is a really great mix of people with longstanding experience and a diversity of backgrounds and experience which provides us all the opportunity to learn and grow.”

What’s Next?

Uppal says IT is working with the procurement side to adopt best practices. “Through a category management approach, we are looking at categories of IT procurement to see where we can build success. That is one example of leadership coming together.”

Having achieved this with one category, he says the next challenge will be scaling the pilot to encompass all of the other categories possible. “This is another example of Agile, trying something in a small pocket and then looking to scale, taking into account that some areas are further along.”

He says part of the effort must be around education, outreach and allaying concerns around the potential disruption that may be caused by change

Main says that CMS has already achieved success as a civilian leader in cloud, taking advantage of the cost savings, benefit for disaster recovery and readiness. “Moving forward, we’ll continue to look at artificial intelligence, machine learning and robotic process automation. We have a handful of small-scale RPA initiatives that we’re trying to understand how to create enterprise support for.”


Uppal says moving forward, one of the goals is building better cyber defense. Part of that involves actively searching for where they might be gaps in our cyber posture. “No matter how good you are, there will be things that are missed so breaking our own stuff, or trying to, must be part of our strategy.”

Main notes that one of the challenges in the Federal space is a culture of being risk averse. “There are a lot of areas where you can encourage risk, name it and ensure there is mitigation in place. We’re trying to create a culture that says, things won’t always be perfect and people will make mistakes, and that’s ok. It’s easier said than done but it’s a critical thing.”

Focused listening sessions are built around encouraging staff to share issues, to help them understand that if they see issues, they have the power to bring that forward without worry of the old ‘shooting the messenger’ reflex. In any organization, things will not always run as expected. The challenge with this kind of change management is to have things happen a few times and the response is to work together to solve the problem without any blame or recriminations.

How Industry Can Help

As the Agency focused on HCD, Uppal says there is an interest in engaging with partners with the same principles, those that are pushing the limits in areas like Agile, HCD and product management that can help CMS be better in those areas.

“We are upping our game internally,” says Main. “We expect industry to do the same. We need to be able to ensure if a vendor comes forward claiming a skillset, that they excel in that area and it is something we are paying more attention to. We want to be able to close the gap between the language of some of these innovations and ensuring we are able to reap the benefits of them.”

About Jennifer Main

Jenni Main started her career at the Centers for Medicare & Medicaid Services (CMS) in 2016 as CMS’s Chief Financial Officer and the Director of the Office of Financial Management. In 2018, Jenni transitioned into her current role as CMS’s Chief Operating Officer overseeing the operational and administrative activities for CMS, including information technology, acquisition and grants, financial management, facilities, and human resources. Prior to joining CMS, Jenni spent the majority of her over 20 year career in the area of financial management, both in the private sector and federal service. She has held the title of Chief Financial Officer in five different organizations over the span of her career, leading her various teams in finding solutions to complex financial challenges. 

About Rajiv Uppal

Rajiv Uppal is the Director of the Office of Information Technology and the Chief Information Officer for the Centers for Medicare & Medicaid Services (CMS). In this capacity, Rajiv provides leadership across the enterprise in all areas of information technology, including security and privacy, enterprise architecture, and IT investment planning. Rajiv is a visionary technology executive with 25+ years of experience in enterprise software, leading development from concept to launch of software applications, managing large, complex IT programs, steering IT strategic planning and applying best practices in IT management. Prior to joining CMS, Rajiv served as part of the US Digital Service team at the Department of Homeland Security, working on transformation initiatives such as the Trusted Traveler and Single Window projects. Over the course of his career, Rajiv has fostered highly effective leadership teams and developed relationships with major investors including venture capital firms, government entities and Fortune 500 companies, and has created multiple technology platforms acquired by industry leaders such as IBM.



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