A few years back, after the Veterans Affairs Department and DoD leaders announced they’d stop building a shared electronic health records system despite hundreds of millions of dollars in sunk costs, a seemingly exasperated Congress ordered the two departments to at least come up with a way to seamlessly share outpatient data between their existing systems and move on to modern health IT standards.
DoD leaders attested last week that they’ve now done that and much more, even though it was a year later than Congress wanted.
“We are certifying that we have not merely met this requirement, but have gone even further to integrate data from other DoD systems, including inpatient, theater and pharmacy into this process, thereby exceeding the NDAA’s requirements,” Frank Kendall, the undersecretary of Defense for acquisition, technology and logistics wrote in a letter to the Congressional committees that oversee DoD. “The additional data requirements were established by DoD and VA functional providers as important for continuity of care.”
For the last several years, DoD and VA clinicians have been using a hodgepodge of purpose-built tools that allowed them to view patient data in one another’s systems. As leaders in both departments are fond of pointing out, they’ve already been sharing more data than any two large health systems for several years. But within the next few months, the Joint Legacy Viewer, which is on its fourth software release in the past 22 months, will become the one-and-only application for reading data across departments.
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In a show-and-tell session on Thursday, DoD and VA officials walked reporters through how JLV can show a clinician any of the particular details a doctor might care about from any medical encounter an individual service member or veteran has had in either health system, going back, in many cases, to the early 1990s, when both departments first started using electronic records.
“Users in both departments are using the exact same viewer, and it lets our clinicians look at not just structured data like known allergies and lab results,” said Chris Miller, DoD’s program executive officer for defense health system management. “They’re also getting the unstructured clinical notes from each encounter — that’s where the provider writes down their thoughts and gives you context. Those things are really a goldmine and provide a lot of things that you wouldn’t normally get.”
But JLV, in and of itself, is not the secret sauce behind the level of interoperability DoD and VA officials say they now have. It just happens to be the Web-based tool they’ve settled on, for now, to access the trove of data in each other’s’ IT systems.
The real work over the past two years, they said, was in first agreeing on a common set of terminology and standards across 25 different data “domains” and then retrofitting their back-end IT systems so that all were speaking the same language.
“The interoperable data we now have is completely independent of JLV,” said David Waltman, the chief information strategist for the Veterans Health Administration. “And our follow-on application, the Enterprise Health Management Platform will use the same data streams we’re using now to power JLV. And because we now have those data streams available that follow national standards, we can build new features we couldn’t have ever built before. We can do things like automated decision support that looks at a much broader set of data, including a patient’s DoD record. That’s really important when you’re looking at what particular medication you’re going to prescribe or a particular intervention or protocol to follow.”
Waltman said EHMP, part of an ongoing upgrade to VA’s VistA electronic health record, will become the main tool medical staff uses for both inputting new data into the VA’s existing EHR and for reading both department’s historical patient data, replacing the read-only capabilities JLV delivers now.
As DoD gets ready to deploy a commercial-based system to replace its various legacy EHRs, Miller said the department is still working with its vendors, chiefly Leidos and Cerner, to determine how JLV fits in with the new system and to make certain that the interoperability standards are worked in to the new product, set to deploy to military medical facilities beginning at the end of next fiscal year.
Even though DoD is striving to do as little as necessary to add its own customizations to the commercial product, some will be needed, he said, because adopting a purely-commercial solution would be a step backward for interoperability, since DoD and VA are unique in their ability to look at a single, integrated and longitudinal view of health data over a patient’s life.
“The commercial model makes provisions for a Consolidated-Clinical Document Architecture (C-CDA) when a patient moves from one provider to another. It’s electronic, but it’s still basically a static box of information that’s moving with the patient from one place to another,” he said. “If we were to use that model in DoD and VA, it would be thousands of pages of documents for each patient, and it also wouldn’t capture all of the data that we’re exchanging now, like pre-and-post deployment information and a lot of the things that inform the rest of the picture we already have. We need able to see the patient’s entire integrated record in the same place.”
It’ll likely take some time to determine whether the integration picture is as rosy in real life as DoD and VA officials are currently portraying it. But if borne out by future events, it will be an interesting case study for future scholars of government. As far as I can tell, the recipe for getting two disparate bureaucracies to overcome their differences was the fact that fairly small cadres of smart, dedicated, lower-level people on each side worked together over a period of years to accomplish a very hard task. The key ingredient actually wasn’t “leadership from the top,” as we’re so often told.
Indeed, Robert Gates, the former DoD secretary who worked with Eric Shinseki, the former VA secretary, to bring the two departments together around health records says consistent cabinet-level direction didn’t seem to make any difference while they were in office.
“The problem was that we and our deputies would meet, we would agree to do things, and it would all fall apart the second he and I weren’t on top of it,” Gates said in testimony last month before the Senate Armed Services Committee. “I just had the feeling that [Shinseki] was sort of on the bridge of the ship with the big wheel in his hand, but all the cables below the wheel had been cut off to every other part of the organization … these bureaucracies were just at each other’s throats over whose computer program they were going to use, VA’s or DoD’s.”