Update on a mega-IT modernization effort

The Veterans Affairs-Defense Department electronic health record project is more than a patient wiki.

Because I had a flu-like few days of fever back in February, I was hoping an antibody test would come out positive. This led to my first-ever video doctor’s appointment. To arrange that I had to square my shoulders and take on something I’d dreaded and postponed: Figuring out how to get into my doctor’s practice group’s “patient portal.”

Eventually, success. I could tell the site, for security, used one of the third party data services like Experian. It asked security questions, the answers to which I had never recorded. That seemed like an improvement over answering questions generated by the application. In that case, if you have one punctuation mark wrong, you’ll be denied entry, which means you’ll have written down your answers somewhere only to lose the scrap of paper.

A few days later, I found I could log on successfully twice in a row, easing my dread of the portal. My doctor had sent me a note, negative on the antibody. So, no bonfire of the masks.

This little episode came to mind while I was interviewing Julie Stoner, the vice president for U.S. government services at Cerner. A techie with computer science and management information systems degrees, Stoner now finds herself with a foot on each of two logs: the Department of Veterans Affairs and Defense Department. Leidos is the prime contractor for the DoD implementation of a new electronic health record system. But both DoD and VA — and the Coast Guard, while we’re at it — are using Cerner EHR technology for the express purpose of having interoperable systems. This long-held dream is supposed to end the bureaucratic and potentially dangerous situation in which a service member’s health records must be manually transferred into VA’s completely incompatible VISTA system.

So the projects consist of more than installing the equivalent of a wiki page for each service member. To understand it, consider discarding the words “electronic health record.” An individual’s file is part of an EHR, but the system itself is the equivalent of what in manufacturing you’d call an ERM — enterprise resources management system.

“EHR as a whole have moved past just being a documentation system,” Stoner said. It pulls together the many strands of activity that add up to contemporary health care. This includes the internal workflows of multi-celled medical centers, clinical decision-making support, logistics, and data analysis for health trends.

Read more: Tom Temin Commentary

This means the ultimate “record” might look very different at DoD, VA and the Coast Guard. And, for that matter, to the radiology and pharmacy departments within a hospital. But the data elements should match, which is the real key to interoperability and consistency.

It also means everyone has to agree on data elements, units of measure, a myriad of other terminology. We’ll express everyone’s weight in pounds, not kilograms or stones, for instance. The point is to separate the data from the workflow logic, such that whatever view a practitioner (or patient) takes, the presentation will be accurate.

To take an extreme example, a female soldier injured in battle will enter a health care chain of events with highly specific workflows, corresponding to whatever happens in triage, surgery, recovery and rehab. Say, ten years later, she might be pregnant and having obstetrics services, with totally different workflows and procedures at a VA center. It’s the same patient. Each practitioner will see her data in the context of his or her work. It will be the same data.

Stoner said Cerner and the agencies can accommodate most of this wide variation with detailed configuration of the standard commercial product. Indeed, a recent Government Accountability Office look-see reminded VA program officials to make sure they include all of the possible system users in the configuration decision-making.

Stoner also said that the requirements of DoD, VA and the Coast Guard make for a bigger challenge than anything the company has seen commercially. In some instances, that means custom programming. My commentary: That should be the last resort.

Earlier EHR projects at DoD and Coast Guard have failed. Earlier efforts at joint EHRs with them and DoD have failed. This one is looking like it’ll work — not cheaply, and not quickly. Early implementation have been neither simple nor trouble free. When it come to software, expecting switched-on perfection is never reasonable. When VA begins to go live, expect that to be messy, with Cerner running here, the legacy VistA running there. But this has the strongest likelhood so far of getting over the line. Stoner said the VA timeline is ten years for the entire department.

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