More than two years ago, lawmakers, impatient with the Defense and Veterans Affairs departments’ faltering efforts to combine their electronic health records, ordered them to at least translate their existing systems into a data format that both departments could understand. The Defense Department certified that it had done so last October, and VA has now done the same.

VA signed off on the documentation attesting it has met the interoperability standards on Apr. 8, officials told the House Veterans Affairs Committee Thursday.

For the time being, both departments’ clinicians are using an application called the Joint Legacy Viewer to access patient data in one another’s data systems. As of this week, about 55,000 VA users have been trained to use JLV. That represents roughly a quarter of VA’s clinicians, and the department expects the number to grow to 120,000 by the end of this year.

Still, after two years of work, JLV remains a temporary workaround. The fact that VA clinicians can now see an electronic view of a patient’s entire health history during the time he or she was in the military is a giant step forward, but the viewer is separate from the AHTLA and VistA electronic health record systems in which DoD and VA medical staff, respectively, do most of their work on a patient’s record.

So VA’s next planned step is to take the behind-the-scenes integration work both departments have done to make JLV a reality and turn it into web-based interface that integrates seamlessly with the VistA EHR. That product, the Enterprise Health Management Platform (eHMP) is due for wide deployment across VA medical centers in 2017.

At the same time, several core elements of VA health IT are in a significant state of uncertainty.

VistA itself appears destined for an earlier-than-expected retirement, and the department is having serious second thoughts about a $624 million contract it’s already awarded to replace its system for scheduling medical appointments.

That contract — awarded last year to Epic Systems — would pay for the acquisition of a state-of-the-art Medical Appointment Scheduling System (MASS) system and for the necessary engineering work to plug it into VA’s existing IT systems. But in the immediate aftermath of the 2014 patient wait time scandal, VA had already started a quick-turnaround project to turn the cumbersome text-based interface that contributed to widespread scheduling problems into a modern, graphical one.

Dr. David Shulkin, VA’s undersecretary for health, said the department has put the MASS contract on a “strategic hold,” and it’s entirely possible that VA will abandon that contract and stick with its homegrown solution, called VistA Scheduling Enhancement (VSE), since deploying VSE across the department would cost only $6.4 million.

“We still have a contract for MASS and we can still execute it at any point, but we’ve decided to roll out VSE for now,” he said. “Since we have a system that’s already available, we’re going to continue to deploy it because it’s in the best interest of the veterans and taxpayers. We’ll have that done over the summer, and if VSE doesn’t meet our needs, we can go ahead with a pilot of the MASS system. But the pilot alone would cost $152 million.”

Considering the views of VA’s current leadership about the long-term future of VistA, an investment of that size seemed increasingly unlikely.

Previous VA IT leaders had mapped out a strategy to modernize the health record with help from the open source community through a project called VistA Evolution.

But LaVerne Council, the department’s assistant secretary for information technology, began a review of VistA almost immediately upon taking office last year and called the project’s long-term future into doubt soon thereafter.

Council said Thursday that her office had laid the framework for an eventual VistA replacement that would use a cloud-based, software-as-a-service approach.

“We decided that we needed a new strategy as it relates to health records and what a great veteran experience would look like, because it is time,” she said. “The EHR today is the heartbeat of our health system, but it does not have everything we need to manage care from our private providers, to deal with our female veterans’ needs and handle a lot of the things we need to do to manage our clinics.”

Council said her office had developed the outlines of a new “digital health platform” which would use cloud technology bring all of VA’s health IT systems under one roof. VistA, she said, had not managed to do that, since there are some 130 different flavors of the EHR that have grown up to serve different needs in different locales.

The digital health platform has not yet reached the stage at which a prototype can be shown to Congress, she said. But her office has presented the concepts to Shulkin, and VA hopes to make decisions on how to structure the future of its health record by this coming summer.

“[This structure] is incredibly responsive, it’s aligned with the world-class technology everyone sees and uses today in things like Google and Facebook,” she said. “It’s agile, and it leverages what’s called Fast Health Interoperability Resources. We can bring things in, we can use them, we can change them and we can respond. We think we’ve provided an innovative solution based on industry experts coming in and assessing it as that.”

Shulkin emphasized that no final decision has been made as to whether the department would abandon its previous VistA modernization strategy in favor of the framework Council is proposing, which Council said would be “agnostic” as to the particular health IT products the department might buy in the future.

Shulkin also sought to assure members of Congress that the $510 million the department has spent toward modernizing VistA since 2014 has not gone to waste. Regardless of what decisions VA makes for the long-term, the department plans to stick with its current EHR for at least the next several years, and is continuing to deploy the products it’s been working on.

“VistA evolution went into five sites on April 5, so you’re finally seeing results after all these years of development. It’s going to be a major advance,” he said. “I’m sure it could have been done more efficiently, but it wasn’t a waste. It’s here now. VA has always been a leader in electronic medical records. What we’re looking at now is whether we want to stick with this system for the next 20 years. We owe it to veterans and to Congress to make sure that’s the right answer.”

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