The Defense Department is a few days away from certifying to Congress that the patient data in its existing electronic health record is interoperable with the Department of Veterans Affairs and with some private sector medical providers. But the assurance did little to assuage lawmakers who believe that the two departments should have found a way to use a single, shared health IT system.
The box DoD said it will check by the end of this week is in response one of several mandates in the 2014 Defense authorization bill in which Congress expressed its frustration with the two departments’ slow progress toward health record integration and threatened to withhold funding. The Pentagon said it will certify that the data in its systems now complies with the national standards set by the Office of the National Coordinator for Health Information Technology, which are being adopted by private health systems and which VA has been instructed to use as well.
DoD is about a year late in complying with the mandate to comply with ONC standards. But Chris Miller, the department’s program executive officer for health care management systems, said there’s a reasonable explanation for that: The 2014 NDAA only ordered DoD to make its outpatient data compliant with the ONC guidelines, and officials decided they needed more interoperability throughout their systems.
“When we meet with our users to understand what they want to be able to access in an integrated view as the NDAA required, they came back and said, ‘It’s much more than your outpatient data. It’s your inpatient data. It’s your data from the private sector. It’s the data from in-theater systems. And so, because of that, DoD took the last year to integrate much more than what the NDAA required because I felt that was the right thing to do,” Miller told a joint hearing of the House Oversight and Government Reform Committee and Veterans Affairs Committee. “And so I will defend the time we took because it is what our functional users really asked for.”
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VA is also late in complying with the interoperability mandate. Laverne Council, the department’s new CIO, said the department won’t issue its certification until 2016.
She said that’s partially because VA must ensure DoD and VA are on the same page when it comes to the real-world implementation of the standards, but also because the department’s new leadership wants to build a broader data strategy that extends beyond health records.
“Our veteran has more than just health data that we’re concerned about, it’s active duty and other sets of data that we’ll be bringing together,” she said. “One of the key factors of our new strategy is starting and establishing a strong data management capability to give us a holistic look at the veteran and be able to interchange and engage with that veteran in a very different way than we do today. We need to be able to look at not just the health, but broader so that we can change the veteran’s experience with everything by integrating data that’s important to their benefits, the health care and the end care that they receive.”
Council also suggested Tuesday that VA may be reassessing its overall approach to health record modernization. Since DoD and VA abandoned their plans to create a single, shared IT system in 2013, VA’s plan has been to gradually modernize its existing VistA system through a program called VistA Evolution.
But Council and David Shulkin, VA’s undersecretary for health have jointly ordered a new business case analysis for VistA to determine the next near-term steps.
“What I really want to understand with any large business system investment is what do we expect to be the outcome, what are we really trying to play for and what do we think it’s going to do for us?” she said. “We didn’t want to take it from the cuff. He and I will be looking at that case, and spending a concerted amount of time to really decide on those core next steps. What we’ve got to figure out is what opportunities we have to continue with VistA as a backbone and whether we should be moving with different levels of technology that we haven’t used before. And thinking about it differently architecturally and thinking about how the veteran should engage with it and how it should engage with the clinician.”
Most members of Congress were not particularly happy with the answers they got from DoD and VA on Tuesday. Though various pieces of legislation, they have been directing the two departments to harmonize their health records and ease service members’ transition from one medical system to another since at least 2008, when lawmakers first established an interagency program office to foster health record integration.
“It is still unclear whether VA and DoD will achieve interoperability between their electronic health records by the end of 2016, and it raises what I believe to be the heart of this decade-long effort and why the achievement of this goal always seems to be just out of reach: What, in practical terms, does interoperability mean to DoD, VA and private providers, and what measure are we going to use to hold them accountable?” asked Rep. Ann Kuster (D-N.H.) “As DoD pursues an overhaul of its EHR and VA continues with its incremental plan to modernize VistA, I’m concerned that these separate efforts, at the end of the day, might not fully match the capabilities we envision.”
For DoD’s part, officials believe the $4.3 billion contract they awarded this summer puts them on the right track toward full interoperability with both the commercial sector and VA, since compliance with national health IT standards was built into the contract requirements. But the system isn’t even scheduled for an initial deployment — in the Pacific Northwest — until late 2016.
In the meantime though, Miller said DoD and VA have been working on updates to their Joint Legacy Viewer, which lets clinicians from both departments see records in one another’s existing systems.
“We’ve delivered four releases in 22 months jointly, focused on improving interoperability, getting feedback back, incorporating it in,” he said. “That’s actually a little faster than Apple rolls out their iPhone every year. So we have demonstrated that we can make this move faster. I think the bigger thing is that we’ve all got to remember is that this is much bigger than IT. That’s the easy part of what we’re talking about today. What we don’t seem to ever want to tackle is the people stuff, the process stuff, all the things that make business systems really hard. ”
But the Government Accountability Office has concluded that pursuing separate IT paths only compounds the risk that the two departments will never reach meaningful interoperability between their health records.
“A single system does not guarantee interoperability,” Miller said. “You can go talk to any major national health care provider and they will tell you that they struggle when you’re talking about regions or working across large geographic areas. I hear what GAO says, and I would like to believe a single system between DoD and VA would be able to be there tomorrow. But we have to view this as an incremental progression.”
Miller said the work the two departments are doing right now in building a shared data viewer and converging around ONC’s standards may be a precursor to moving to a single IT system once there’s a defensible business case for doing so.
“I think what we tried to do back in 2010 was way ahead of the technology, it was way ahead of where our processes were, it was way ahead of where we are in data, and we fundamentally set ourselves up to fail,” he said. “It’s not because we didn’t have people that believed, it’s not because I couldn’t show you a pretty technology slide that shows you all the whiz-bang things that were going to happen, we failed for non-technical reasons. Those things are things that we have to understand and we have to deal with. That’s why we’re now focused on getting our collective houses in order, and I think you’ve seen more progress in the last two years than ever before.”