Integrated health record tests DoD’s agile acquisition aspirations

DoD and VA have both committed to moving from their legacy electronic health record systems to a joint, integrated system by 2017. But there are challenges: ...

The departments of Defense and Veterans Affairs both want to develop a single electronic medical record system that both agencies can use by 2017. But officials say getting there is going to require speedy development and agile acquisition mindset, a big change from the traditional DoD culture for developing big systems.

Complete record interoperability between the VA and Defense has been a holy grail of sorts for years. The current effort started with a handshake agreement between the two departments’ secretaries in early 2011.

A year later, Dr. Barclay Butler was appointed to direct the Interagency Program Office (IPO) that will coordinate DoD and VA’s activities. And he’s come to the conclusion that development of the Integrated Electronic Health Record (iEHR) just isn’t compatible with the traditional DoD acquisition system.

“In that waterfall approach, requirements are fixed. The difficulty we have is that the innovation cycle within health care IT is so short that these requirements corrode quite quickly,” Butler told AFCEA’s annual Warfighter Support IT day this week. “If we were to develop this system a year after the requirements were developed, the program manager would say ‘I developed the system that the requirements told me to develop.’ The tester would say ‘I tested the requirements, they all work.’ Then the actual clinician would say, ‘I don’t like this system. It doesn’t do what I need.”

So the DoD-VA arrangement has strived to put medical professionals in the driver’s seat, intimately involving them in designing and testing the new record system.

Dr. Barclay Butler, director, Interagency Program Office
“We’re working on 54 clinical capabilities, and they all came from the DoD and VA clinicians in the new interagency governance model deciding what they needed to best deliver care to our beneficiaries,” said Navy Capt. Michael Weiner, a military physician who’s serving as the program office’s director for clinical informatics. “It’s clinically driven, and God love them for putting up with the clinical community.”

Defense Secretary Leon Panetta and VA Secretary Eric Shinseki have taken a personal interest in the iEHR. Butler said that’s added a lot of momentum to their work, but it’s also set up some tough challenges.

For example, the secretaries want their two departments to produce some of the iEHR’s first core capabilities by the end of 2014, all-the-while keeping their legacy systems up and running. Within the next couple years, that will mean the team will be trying to establish around 30 distinct software capabilities all at the same time.

Butler said that’s one more reason the effort will require agile development, something he said VA’s IT community has already embraced through its Project Management Accountability System. The Pentagon has had less success with its Business Capability Lifecycle model, which tries to adapt DoD’s existing acquisition strictures to the rapid pace of IT change.

“Veterans Affairs is agile to the point where things are very project-focused, but they get a lot done,” he said. “On the DoD side, it’s still a waterfall approach and it’s an enterprise systems approach. Those culture [differences] are just a huge challenge for us.”

Officials say they’ve already made progress in the short time that the Interagency Program Office has been up and running in earnest. This year, they’ve established a baseline for the program and awarded a contract to design the iEHR’s Enterprise Service Bus, the architectural backbone that all the modular pieces of the health record system will plug into.

The first increment of the iEHR will begin to roll out to pilot sites in San Antonio, Portsmouth, Honolulu and Germany this fall, with initial capabilities including single sign-on and a new graphical user interface.

Next, industry will start to see a flurry of Requests for Information from the IPO as it starts to design more of the modular capabilities. There will be 14 of them in the next increment of development, including identity management and access control for clinicians as well as pharmacy and laboratory modules.

“Those RFIs are going to come out so that we can gather more information about the capability sets,” said Susan Perez, the iEHR program manager in the Interagency Program Office. “These pieces have to converge. Open standards are very important, having open [application programming interfaces], ensuring that products can be lifted and fit in with other products, those are important. We don’t want to sit and buy one big thing. We want to make things that work together, and quite frankly we want the best. We want the best lab product, we want the best barcoding product and we want them to work together to fit the needs of the clinical community.”

Perez said the existing legacy electronic health record systems — VA’s VistA and DoD’s AHLTA — will still play a major role in the two departments for years to come. The two systems won’t begin to be dismantled until 2015.

But by that time, pieces of the iEHR will have to be tested and ready to take over. Perez said the IPO team has repeatedly been told by observers that their timeline is too ambitious and the two agencies will never make it.

“But I know Dr. Butler and I share a couple perspectives in common. One of them is, ‘OK, tell me I can’t do it, and then come back and tell me in two years that you were wrong. Because I’m going to show you that we did.'”


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