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It’s been nearly three years since the Defense Department started the rollout of its new electronic health record. And after a somewhat rocky start in the Pacific Northwest, officials say they’ve done a lot to overcome the learning curve: The latest deployments in California and Idaho went much more smoothly.

Examiners from DoD’s office of Operational Test and Evaluation (DOT&E) and the Government Accountability Office faulted poor training and documentation, usability problems and patient safety concerns in the MHS Genesis rollout as recently as last June. GAO reported medical personnel were forced to develop their own training on at least some aspects of the system during the first wave of deployments in Washington State.

But speaking to reporters this week, Defense health IT officials said they learned from those early mistakes, and they were much less of a factor during the second wave at Travis Air Force Base, Mountain Home Air Force Base, Naval Air Station Lemoore and the Monterey Presidio.

Genesis has now been up and running at those facilities for four months, and Col. Kristen Beals, the commander of the David Grant Medical Center at Travis, said it’s been a relatively smooth ride, with many fewer problems than she expected.

“It was really kind of benign functionality issues, and I was very surprised and pleased to know that my folks were using the system in a deliberate fashion, and that they did not immediately come to me and say, ‘this system is dangerous, it’s not functioning,” she said. “We had read all the DOT&E and after action reports from the Pacific Northwest, so we were well prepared for the worst case scenario. And to be quite honest, it went far better, because the functionality had improved so much.”

Functionality issues down for most part

According to the Defense Health Agency, Genesis only has about one third the number of trouble tickets being worked on as it did at a similar point during the initial wave of deployments. Most of them had to do with relatively-mundane and simple problems like ensuring the right users had access to the right interfaces.

Bill Tinston, the program executive officer for Defense Healthcare Management Systems, said much of that comes down to better training than in the first go-round.

“In our initial deployments, we made the mistake that IT people often make, which is to train tools. This is not an effort that’s about tools, it’s about enabling — through an IT solution — a transformation in the Military Health System and the way that care is delivered,” he said. “So at Wave Travis, we trained people how to get their jobs done. We trained the workflows that people were going to be moving to and we put in place the peer expert concept, which extends that training through extra-trained people that can help providers as they begin to use the system. And we’ve also put in place a competency process where we evaluate that our training has been effective and we’ve imparted the information that people need to be effective at their jobs.”

Out of 300 findings DOT&E issued during its initial tests, Tinston said 90% have been resolved, including all of the most serious ones. Along the way, the look, feel and functionality of the electronic health record providers deal with on a day-to-day basis has evolved, he said.

That’s due in part to input from the Department of Veterans Affairs, which is in the process of adopting the same commercial EHR Genesis is based on, Cerner Millennium.

“We’re making a joint decisions at the lowest possible level amongst the clinical communities so that they can solve the problem together,” said Maj. Gen. Lee Payne, is DHA’s assistant director for combat support. “I’ll give you an example: we had a joint session for VA configurations. The VA brought forward 25 nursing workflows, and DoD accepted 20 or 21 of those because they had great documentation of evidence-based practice. VA, on the other hand, has accepted some of the lessons learned that we’ve experienced where it might not be intuitive as to why we’ve made the choice that we made. But as we began to explain to them, ‘Here’s what we experienced and here’s how we dealt with that,’ the VA acknowledged that perhaps our decision was the right one.”

Officials say the relatively smooth rollout in California and Idaho was also helped by the fact that DHA and the Defense Information Systems Agency installed more network capacity and other back-end IT infrastructure in advance of the Genesis go-live.

DoD also had conducted some pre-deployment upgrades before the first installations in Washington State, but they turned out to be inadequate. Officials say they did not see any similar capacity problems during the second wave.

But Tinston acknowledges DoD’s Genesis deployment process is still far from perfected, and DHA still has more work to do between now and 2023, when the system is expected to be fully-deployed worldwide.

“While we made tremendous strides from our prior efforts — we had the right people in the right places,  we had the right leadership at the military treatment facilities, we’re getting the job done — we still need to industrialize the process,” he said. “We need to make the deployment process such that we don’t have to swarm it with labor, people and management attention to be effective. A lot of that had to happen at Travis. We continue to strive to squeeze the labor, automate this process as much as possible, put the tools in the MTF commander’s hands so that they can be effective at managing their teams and the adoption at their facilities. That is the biggest lesson we took out of this.”

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