Despite new EHR system, DoD faces big data interoperability challenges

By next summer, the Defense Department plans to buy an off-the-shelf electronic health record system which meets modern health IT standards. But the system won’t be a silver bullet for the challenges the department faces with regard to sharing health data within its own facilities or with the Department of Veterans Affairs.

The new system will ensure that any health data which makes its way into DoD databases makes use of robust mechanisms...

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By next summer, the Defense Department plans to buy an off-the-shelf electronic health record system which meets modern health IT standards. But the system won’t be a silver bullet for the challenges the department faces with regard to sharing health data within its own facilities or with the Department of Veterans Affairs.

The new system will ensure that any health data which makes its way into DoD databases makes use of robust mechanisms for interoperability based on standards set by the Office of the National Coordinator for Health IT, officials said. But the system, in and of itself, will have no effect on the interoperability of the patient data the department has been collecting for the past few decades.

In other words, even if everything goes according to plan, DoD is going to be dealing with a mixture of truly modern health IT, legacy data and paper records for the foreseeable future.

“Veterans who are now going to the VA were serving even before we had the legacy health IT systems we have now,” said Mary Ann Rockey, the deputy program executive officer for DoD’s modernization effort. “We have paper data, we have data in multiple legacy systems, and when we get the new EHR, that’s not going to change. We will have data in multiple systems.”

In the meantime, DoD is laying the groundwork for the more modern system by doing everything it can to make its existing data more interoperable with VA’s systems and modern standards. Rockey told a health IT forum organized by ACT-IAC that the department’s Defense Management Information Exchange (DMIX) office has identified 26 broad areas in which it’s mapping legacy data elements to match up with interoperability standards.

“By the end of this year, we’ll have millions of those data elements mapped to the standards so that we’ll be able to use that data more effectively,” she said. “There are a lot of use cases that are going to demand standardization in other areas as well, but 26 is a great start.”

For DoD and VA, the problem is not that the departments can’t share data with one another. They do on a vast scale — each department has access to a shared repository that includes the health records of 6.5 million patients and 1.5 million pieces of information moved electronically between the two departments every day.

The real issue is interoperability. It’s one thing to move raw information across a data pipeline – making it usable to the human beings who need to interact with it is another question.

“Most of the sharing we do is not standards-based,” Rockey said. “For example, a clinician in VA has access to VA lab results in VistA for the patient they’re seeing, but then they see that that patient also has data in DoD. They click on a remote data viewer, and it just brings up a long big blob of information and they have to sort through it and try to find what they’re looking for. That’s hard to do when you have a scheduled appointment window. The data might be there, but since we don’t make it easy for them to find it, they’ll just order another lab or do whatever they need to do.”

During the long saga of attempts to integrate DoD and VA’s records, the Pentagon has created a series of projects to make various types of data more interoperable between the two departments. The Pentagon only recently consolidated all of those efforts into the DMIX office. In addition to building data exchange tools to improve data flows between DoD and VA, the office is in charge of integrating medical information from DoD’s large network of private sector providers under its TRICARE program.

“And in the future, when we get the new health record, which will have robust data exchange, that mechanism is then going to point at our legacy data stores, and that will be the way that we get the predominant amount of our legacy information so that we can marry it all together with the new information in our new EHR,” Rockey said. “We have to be able to get to that legacy information for a lot of use cases, including benefits adjudication with VA and with the Social Security Administration as people apply for benefits, so we have to be able to bring all of that information together.”

If DoD and VA manage to translate their paper and legacy electronic data into an interoperable architecture, the implications would be enormously positive. Not only would it benefit individual patients, but it would also see through one of the promises long-made by health IT boosters: the idea that better data can lead to a better understanding of precisely which practices make for better long-term patient outcomes.

Even though the long trail of medical data the two departments hold for millions of patients is not yet interoperable, the fact that it exists at all represents a huge potential for improving clinical practices, said Dr. Joe Francis, the chief quality and performance officer for the Veterans Health Administration.

“The singular challenge in understanding patient outcomes and bringing value to health care is longitudinality,” Francis said. “Almost everything that we do today in health care quality and performance measurement is cross-sectional. I take a sample of my population today and next quarter and next year. What I really want to do is take one patient, and over the 20 years that we’re taking care of his blood pressure and diabetes, how is his outcome changing? And what health plan is going to institute a 20-year contract that ensures that one hospital or doctor or health system can be fairly compensated for improving one patient’s health? Right now, there’s only one place in the country that can do that, and it’s the combined DoD-VA health care system.”

Unlocking the power of that data storehouse is going to take a lot more work. Until recently, DoD had not even applied much pressure to its own health officials to standardize the way they record information in military health IT systems, and how that information should be communicated between the military services.

The newly-created Defense Health Agency represents some change on that front. Health IT is one of the shared services DHA created to consolidate some of the functions the military departments had been duplicating among themselves.

“When I came to DoD I was amazed that the services do almost nothing the same way,” said David Bowen, DHA’s chief information officer. “Their HR procedures are different, their finance procedures are different, their care procedures are different, so trying to bring all of this stuff together is really a challenge. But if we’re going to be effective, we’ve got to define what our data’s going to be and how it’s going to be collected. We’ve got to be able to ensure that that data is in fact comparable. Standards are a huge part of this. We have to analyze what we’ve got, decide what the standards are, and then rationalize all of the activities that are nonstandard into some sort of standard model.”

But the creation of DHA hasn’t solved all of DoD’s data exchange challenges either. The surgeons general of each military service are still legally in charge of many of the aspects of the health care services they provide, and they’re also bound by the IT policies of their own services.

“We operate in an environment where if I’ve got a system that gets an information assurance certification from the Army, the Navy doesn’t recognize that. We don’t even recognize our own certifications within DoD,” Bowen said. “Talk about stovepiping. We’ve got some more work to do.”

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