In 2010, the Defense Department’s primary health IT system was facing a crisis of confidence.
At a hearing whose very title characterized the system — AHLTA — as “intolerable,” the Pentagon’s top civilian health official told Congress he was creating a task force to study the problem. Two years later, this group — the “Way Ahead” office — issued a report that recommended that DoD:
Not attempt to fix AHLTA
Not attempt to build a new EHR
Not attempt to adopt the Department of Veterans Affairs’ VistA EHR System
Acquire a Commercial Off The Shelf (COTS) product to replace AHLTA
It took DoD two more years to issue the request for proposals for MHS Genesis, and in 2015, it awarded a contract to Leidos to implement the Cerner Millennium COTS product at a cost of approximately $4.7 billion (the next-highest bidder proposed their product at over twice that cost).
Since then, the Government Accountability Office has issued multiple reports voicing concern about cost, schedule and performance. Nonetheless, in 2017, the Department of Veterans Affairs moved to adopt the same Cerner product. It issued a $16.1 billion sole-source contract — the largest such non-military contract ever awarded.
Four years later, the new VA secretary has launched a 12-week strategic review of its electronic health record modernization program.
Many of the issues involved here are highly technical and very complex, but that is why I like analogies.
Suppose you had a perfectly good aircraft carrier. It was old and in need of modernization, to be sure, but it performed every single one of its roles very well and was by popular consensus the best aircraft carrier in the world.
In this analogy, one of the reasons for its superiority is that it was designed, built, and operated by the sailors who actually used it. And over the 20-plus years of its existence it has been constantly upgraded and improved based on the experience and recommendations of its crew. Best of all, this aircraft carrier was, by design, capable of maintenance, upgrade and modernization while continuing to serve as the best aircraft carrier in the world. In fact, there was a comprehensive plan in place to do just that and continue the useful life of this aircraft carrier well into the future at a reasonable cost (at least in terms of aircraft carriers).
But then a different organization with different needs — and who operated only an “intolerable” carrier model — decided to rent a generic boat that could only go so fast, hold only so many aircraft, was quite old itself, and came with multiple restrictions on its use. Added to that, the cost of the rental on this boat was drastically understated, the remodeling required was tragically underestimated, and the capability of this boat was over promised. After five years of missed milestones, dismal performance and shredded budgets, this boat was dead in the water. What to do?
Unfortunately, the answer to that question was proposed by folks who had absolutely no knowledge of or interest in aircraft carriers. They mandated that the owners of the best aircraft carrier in the world spend tens of billions of dollars to salvage the boat rental. Worse, they also mandated the world-class carrier’s retirement in favor of the rental boat.
Some of the carrier’s crew were told to be quiet or be fired, but the questions remain.
How will two very different organizations with different requirements and different cultures jointly manage and govern this boat rental? Who is in charge? Is this boat rental even capable of meeting the barest minimum requirements of these two organizations? What is the ultimate cost of this boat rental, and on and on and on?
Today the VA finds itself in a very difficult spot. Several billion dollars have already been spent, and many good people have spent years working diligently to try to make this contract work. There is a natural tendency at the VA to believe that “heroic management” can overcome any obstacle. But heroic management cannot overcome deeply flawed technical, cultural and business realities.
This strategic review must ask and answer several very difficult questions that should have been asked and answered years ago. It must employ objective outside experts without a “bought-in” mentality. It must demand that specific, meaningful requirements and metrics be produced, analyzed, and tested. They must model a joint VA-DoD end state environment and test the proposed Cerner solution’s ability to succeed in that environment.
The good news is that there are solutions available to meet the needs of both organizations. There is a “way ahead” that can salvage some of the work and expense already invested and result in a truly interoperable, scalable and secure system of systems that can meet both organizations’ needs.
Doing so would require a strategic pause in both programs while a comprehensive digital transformation strategy is developed. It would not take very long, as the VA has been working on a digital enterprise platform for several years.
DoD could adopt this approach and use the knowledge it has recently gained about its healthcare environment to develop its own healthcare digital enterprise platform. The key to success is the adoption of a Platform-to-Platform (P2P) architecture based on adherence to standardized programming interfaces and a service-oriented framework that will facilitate evolutionary improvements to both systems — a much better approach than the current rip-and-replace methodology.
Several benefits that have accrued based on the current programs could still be carried forward — such as the continuation of significant funding to get the job done and the cooperation and “jointness” between these two very different organizations.
There is an opportunity to turn a looming disaster into a crowning achievement if only the courage and leadership exists to stop, look, rethink and see the better way ahead
Edward Meagher recently retired after 24 years in government, 26 years in the private sector and four years in the U.S Air Force. He served for seven years as the deputy assistant secretary and deputy CIO at the Department of Veterans Affairs. Ed divides his time between his own executive consultancy, VETEGIC, LLC and extensive involvement with several veteran focused organizations including his own Service Member Support (SMS) Foundation.