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In a ceremony in Tacoma, Washington last week, defense officials marked a milestone in their rollout of a new $4.3 billion electronic health record. It’s now live at the four medical facilities the Defense Department picked for its initial deployment. But there’s still a lot left to do before DoD begins the process of deploying MHS Genesis to the 205,000 military health personnel who will eventually use it around the rest of the globe.

At the first four “go-live” sites, Genesis has now supplanted three different aging health IT systems. By the time it’s deployed worldwide in 2022, officials say it will have made DoD patient care “seamless” in that it will be interoperable with both private-sector medical providers and the Veterans Affairs Department, and will give clinicians real-time access to the entirety of a patient’s medical history, plus decision-support tools that are far beyond the grasp of the current systems, some of which date to the 1980s.

“We are in the midst of a transformation in health care,” said Vice Adm. Forrest Faison, the Navy’s surgeon general. “Today, because of the miraculous inventions that have surrounded us over the past 20 or 30 years, the volume of medical knowledge in the world is doubling every two years. We are rapidly approaching the point where we can’t make good on the promise of delivering the best health care our nation can offer without driving these clinical practice guidelines to the point of care, and that’s what Genesis is allowing us to do.”

But there are still a lot of steps in between last week’s ceremony and the worldwide rollout, including at the four facilities where Genesis has already been installed: Fairchild Air Force Base, Bremerton Naval Hospital, Oak Harbor Naval Health Clinic and Madigan Army Medical Center.

Next, the Pentagon’s independent Office of Operational Test and Evaluation will conduct its own assessments of how well the commercial-off-the-shelf software meets DoD’s stated requirements and how it’s performing. All the while, DoD will be harvesting lessons from the first four IOC sites, delivering more training to users, and deciding which business processes the military health system needs to change to get the most out of the new system.

“We’ve also learned that we definitely need to look at our IT infrastructure development and our ability to make sure that we have the right kind of platform for MHS Genesis in our MTFs,” said Vice Adm. Raquel Bono, the director of the Defense Health Agency. “We also need to look at our adoption of clinical and business workloads — I think that’s a large part of our transformation — and be able to address any of the challenges that come up in the trouble tickets from our users. Those are the main areas that we’ve identified.”

The trouble tickets users are already submitting don’t just have to do with technical glitches.
DoD is also using them to help figure out which of the workflows that developed around its legacy systems no longer make sense in the context of a modern health record, and how to adapt them to the “team-based” approach to health care delivery that Genesis is based on.

“For example, we need to make sure our clinical teams understand the transitions of care between seeing a patient in the emergency department when they’re admitted to the intensive care unit and that everyone understands their roles in the team, from the front desk clerk to the people doing vital signs to the people discharging a patient from the clinic,” said Dr. Paul Cordts, DHA’s chief strategic planner and the military health system’s “functional champion.”

“We understand that there are risks associated with deploying a brand-new electronic health record, and we’ve been studying that,” he said. “We have very good mechanisms in my mind to identify these potential risks. The staff have been extremely aware of these risks and just absolutely excellent in documenting them and providing that information to us. “

Defense officials expect to make a formal decision to fully deploy Genesis sometime in 2018. Once that milestone is reached, they expect installations at hospitals and clinics to move at a faster pace than they did at the initial deployment sites over the past year.

Once the system is broadly deployed, officials see one of its main benefits as interoperability, particularly with the Department of Veterans Affairs.

VA officials said last week that they are in the final stages of talks with Cerner, the health IT firm on whose software Genesis is based, to sign a 10-year contract for a system of their own that closely resembles DoD’s.

Stacey Cummings, the program executive officer for defense health management systems, said VA will also conduct its first deployments in the Pacific Northwest, and from there, follow a deployment schedule that matches DoD’s.

“And the great thing about that is the opportunity to partner up in the deployment of training and follow-up training to make sure the infrastructure is optimized for the region as we bring on this body of new users,” Cummings said. “We’re also going to take advantage of the investments DoD has already made in a common data center so that DoD and VA data will reside in a single platform. When a service member transitions, the data won’t have to move, it won’t have to be interoperable. The veteran truly becomes the center, and it’s the provider that comes in.”

But DoD is also trying to use the technology rollout to make its health system more interoperable with itself.

It comes at a time when the Defense Health Agency is under congressional orders to prepare to take over the management of military treatment facilities from the Army, Navy and Air Force, and Bono says DHA wants to use it as an opportunity to drive out some of the unnecessary variability in how MTFs are operated and managed.

Officials said that convergence around a common set of business processes is already starting to happen in the Pacific Northwest, where the initial deployment sites include two Navy hospitals, an Air Force clinic and a large Army medical center.

“The rollout was deliberate,” said Capt. Jeff Bitterman, the commander of Naval Hospital Bremerton. “We started at a small clinic, then went to a naval health clinic that also does ambulatory surgery and labor and delivery, then to a community hospital, and now to a medical center. We’ve rolled out the workflows incrementally, and as we refine them, they’re not being reinvented at every site. So I think we have achieved that goal to a large extent.”

One aspect of the goal has been to make those business process changes without demanding expensive and time-consuming changes to the software itself. So far, officials say they’ve imposed enough discipline to accomplish that, and are using the EHR in essentially the same way its commercial designers intended.

Adapting clinical practices around the software — rather than the other way around — has been challenging, said Col. Michaelle Guerrero, the commander of the 92nd Medical Group at Fairchild Air Force Base.

“The biggest change has been just a mindset. We’ve gone from a rotary phone to an iPhone X, and our comfort zone is the rotary phone,” she said. “It’s a work in progress as we continue to improve the system and move forward, but it takes a different way of thinking. The new system is very powerful and very customizable, like an iPhone, but again, it’s out of our comfort zone.”

But the tradeoff is a massive leap ahead in capability, said Capt. Christine Sears, the commander of Oak Harbor Naval Health Clinic.

“For example, just having a seamless health record from the outpatient to the inpatient is incredible,” she said. “That’s not something we had in the former system. The ability to see someone in the outpatient arena and have all that same data available in the inpatient arena as they move back and forth is truly life-changing for us.”

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