The extremely long path toward health record interoperability between the departments of Defense and Veterans Affairs is strewn with millions of wasted dollars and years spent on since-aborted projects, like the idea that both departments should converge around a shared IT system, or that they should at least agree to buy technology pieces which fit together in a “modular” health IT schema.
But those earlier efforts — mostly led by mid-level officials who have failed to gain serious attention from the departments’ secretaries — have been superseded over the past two years as Congress has lost its patience and as top officials from both departments have inserted themselves into the problem.
Senior leaders from both departments have been increasingly vocal in recent weeks about the work they have been doing over the past two years to achieve interoperability in the absence of a common electronic health record, vowing in various public fora that they can meet Congress’ goal of health data interoperability without actually using the same software.
“It’s a big misconception that the new health care system we’re buying is about interoperability,” Frank Kendall, the undersecretary of Defense for acquisition, logistics and technology said last week as he announced the Pentagon’s long-awaited decision to spend $9 billion on a new commercial electronic health record from Leidos, Cerner and Accenture. “We are about to certify to the Congress that we are already interoperable.”
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The departments feel confident in that assertion, in part, because of their progress on the Joint Legacy Viewer (JLV). The Janus system, as it’s sometimes called, pulls a given patient’s medical records from already disparate DoD and VA systems into one interface so that a clinician in either department can see detailed histories from all of that patient’s past medical encounters on one screen.
Sloan Gibson, the deputy VA secretary said Friday that JLV has now been deployed to 13,000 users — a massive uptick from the 2,500 clinicians the system served when it was first installed in all of VA’s hospitals at the beginning of last October.
“And we’re about to see a quantum leap in the number of those users very soon as DoD dramatically expands the capacity for that system,” Gibson told a health IT conference organized by AFCEA’s DC chapter. “It’s a great tool: You query, it goes out and gets the data and it brings it back.”
The Defense Department, which generally requires much less VA health data to perform its missions than vice-versa, said JLV has only been deployed to about 1,200 of its users so far, but recent infrastructure upgrades should allow for the addition of another 9,000 in September. VA is planning another major expansion at about the same time.
But Gibson said the JLV tool was mostly designed as a proof-of-concept. He said the next stage in DoD-VA interoperability, a viewer the departments are calling the Enterprise Health Management Platform (eHMP) and that will eventually replace JLV, will begin to be rolled out in March.
Crucially, that tool will begin to incorporate records from private medical care providers, who already make up more than 60 percent of DoD’s patient encounters via its TRICARE system and account for an ever-increasing proportion of VA care as veterans are allowed to seek care in their local communities as part of the recent Choice Act.
“eHMP actually allows clinicians to pull information from all VA centers all across the country, from all DoD records and from any private sector care records that are resident anywhere on our systems,” Gibson said. “We can cache that information so a care team can look at their appointment schedule for the coming day, look at all the data for all of the patients they’re going to be seeing, and then as they see a patient they’re able to bring up a screen they can tailor that provides the summary snapshot of all the dimensions of care, all their past instances of care, the pace of care, all of the medications, when they’ve been seen, where they’ve been seen and what they’ve been seen for.”
Gibson said VA officials demonstrated the new system for White House officials last week to show off the value his department thinks its clinicians will glean from the new clinical interface.
In that show-and-tell, VA clinicians looked at the case of an elderly veteran who needed surgery to repair a broken bone. In any such event, the medical team would want to evaluate the patient’s past health history to help judge whether the operation itself would seriously endanger the patient’s life. For example, doctors might like to know whether the veteran has any history of coronary artery disease.
“The clinician just typed in the lowercase letters: ‘cad.’ With that general search, what we saw almost instantly was every single instance of any care or episode associated with coronary artery disease anywhere in that veteran’s record, whether it was through VA care, DoD care or from a private provider. It popped right up.” Gibson said. “How would we have to do that today? The clinician would have to go through each system and manually search for that information in all of VA’s systems, and then repeat the process on the DoD system. This is an incredibly powerful tool, and we’re going to field it very soon. This is not vaporware.”
VA is the biggest consumer of data in both the JLV and the eHMP programs, but Defense officials have had to make significant changes as well in order to provide that data, including buildouts of IT infrastructure and reformatting or translating its legacy AHLTA data into interoperable formats that meet the standards set by the National Coordinator for Health IT (ONC).
Both departments are fond of pointing out that they share millions of patient data fields with one other each day and have done so for years.
But they also feel confident that they are now complying with Congress’ longstanding wish that the data be useful to providers in both systems on a day-to-day basis, even while maintaining separate EHR systems.
“We are 100 percent committed to be interoperable, and we’ve now defined what that means,” said David Bowen, the chief information officer for the Defense Health Agency. “We have managed our information so that where we’re speaking different languages we can move our data back and forth with common standards. In some instances, those standards are already well-defined and well-known to the industry. In others, DoD and VA are working with ONC or the White House to determine what the standards should be and then implement them. Then, hopefully, they’ll be used around the nation in the sharing of health care data between other health care systems. We’re sharing lots of data already, but with the new EHR, that sharing is probably going to be better, faster and more complete.”
Bowen was reluctant to delve into many details of the new EHR purchase since the award is still only a few days old and the losing vendors have yet to be debriefed.
But he said the department expects to glean several significant benefits from the new system, many of which have little to do with interoperability or with other elements of the federal government.
For one, DoD thinks the new system will make the data it holds about its patients more interoperable with the devices they already have or could potentially use in their own homes — whether they be commercially-available FitBits or telehealth devices provided by military caregivers — letting patients participate much more in their own health decisions.
“As the market explodes with potentially-connected devices, we have an obligation to bring the patient along with us,” Bowen said. “The benefits from these technological advances are multiplied when we prioritize patient engagement and health literacy. The Military Health System is trying to move from a focus on the provision of health care treatment to the maintenance of health. We want our patients to be smart consumers, we want them to ask the right questions when they visit their provider, and we want them to know how our system is performing against our peers. The trend is toward greater public awareness of what we’re doing with the information we have and incorporating much greater feedback from the patient.”
But Bowen and other DoD officials say the EHR procurement — assuming it survives possible vendor protests — is only the start of what the department will need to do to actually implement an upgraded and unified health IT system throughout what is arguably the most complex medical care system in the world.
He said DoD will be working with its new vendor team over the next nine to 12 months to decide what tweaks need to be made to the commercial Cerner product to fit DoD’s needs, but also to make sure DoD can accurately articulate with one voice what the department’s needs actually are.
“As we’ve gone around and talked to people who have done EHR implementations, the one uniform comment we always get is that you’ve got to standardize your clinical processes. For some of these large institutions, that’s a big culture change. For DoD, it’s going to be a monstrous culture change,” he said. “Right now, we do everything differently between the Army, Navy and the Air Force. To get all of our clinicians together and agree to standardize more than 700 clinical processes is going to be a significant thing.”