A House Veterans Affairs Committee hearing on the decision by the Defense and Veterans Affairs Departments to scale back plans for a joint integrated electronic-health records systems dredged up longstanding issues with the two departments’ EHR efforts.
The new strategy from VA and DoD promises quicker, cheaper results on data standardization at the expense of a single, core technological platform.
But, by and large, committee lawmakers were skeptical of the new approach. Committee Chairman Jeff Miller (R-Fla.) likened the shift in strategy to a “U-turn” and said it was akin to “moving the goalposts” after billions of dollars had been spent.
Lower-risk, lower-cost strategy?
In March 2011, VA and DoD first announced the project for a single, joint system with an expected completion date of 2017.
But over the past few year and a half, the iEHR project had struggled to keep up with milestones, according to Roger Baker, VA’s assistant secretary for information and technology and chief information officer. In September 2012, the original cost estimate from the Interagency Program Office of between $4 and $6 billion more than doubled.
The new strategy aims to provide the same end goal through a “lower-risk, lower-cost path than we were on,” Baker said.
Both Baker and Elizabeth McGrath, DoD’s deputy chief management office, told the committee the new focus is a recommitment to integrating the data — making sure EHR data is built on a common standard — as opposed to constructing a new platform.
A step backward?
But committee members were not all that receptive to the departments’ shift in focus.
“I’m concerned that this new approach is a step backwards towards the model that had been previously tried and failed,” Miller said. “Namely, maintaining two different systems between two different departments and wishfully thinking that the two systems will eventually talk to one another.”
Baker said both departments remain committed to the iEHR’s underlying goals: common data, common applications and a common user interface. For example, by the end of this year, DoD and VA will begin sharing a common graphical user interface in their respective clinical environments.
Among the most important elements in the VA-DoD agreement is a health-data dictionary, Baker said.
“The data produced by VA and the data produced by DoD will be represented exactly the same way in exactly the same database so that it’s accessible from any facility in the VA or DoD,” he said. “Adherence to that and focusing on achieving that will provide the largest benefit of all the things we’re working on — if you were to break those pieces down.”
Committee wants answers on lack of core technology
But even with the renewed focus on data standardization, the two departments now envision the data being operated from two separate core technological platforms (where once the strategy had envisioned a joint platform).
“Why in the world can’t we get to one core technology?” Miller asked McGrath.
McGrath said the idea for a single common platform first laid out in 2011 eventually proved unaffordable. In addition, it was difficult to balance risk and integration in building a new platform from scratch.
“The more things you need to connect together, the higher the risks, the higher the costs, the higher the integration,” McGrath said. “And, so we said, ‘Is there an opportunity to reduce risk — still with the business outcome that we want to achieve — maintain schedule, produce the integrated record at a lower cost?’ … So you build out from something, as opposed to the entire system brick by brick.”
VistA turf war?
Since the departments have abandoned the idea of developing a new joint system, committee members wanted to know why DoD couldn’t simply adopt VA’s core technology, the Veterans Health Information Systems and Technology Architecture (VistA).
“The VA is quite happy with and convinced that the VistA system is the place to start,” Baker said. “It’s a good system, and we own it. The DoD is not yet there, from their perspective.”
DoD will consider using VistA, McGrath said, but the department also wants to evaluate other commercial options as well.
While VistA works seamlessly with VA since it is a homegrown system, DoD will face issues in implementing it, said Jonathan Woodson, assistant secretary of defense for health affairs and the director of DoD’s TRICARE Management Activity.
“No matter how you slice this program, for the Department of Defense, this is a new acquisition,” Woodson said. “As good as VistA is, it’s not one system; it’s a number of different systems. So we would have to choose one of those 100-plus systems to transfer over.”
And Woodson questioned the level of support that VA would be able to provide DoD in implementing the system.
If DoD were to turn to a commercial off-the-shelf solution from the private sector, they would be provided with integration support, Woodson said. But there’s no comparable support structure for transferring VistA systems to DoD hospitals and clinics, he added.
Still, VA is helping DoD analyze how to move the system to DoD, Woodson said.
“The issue is that it clearly it is of a lower risk for the Department of Veterans Affairs because it’s already functioning in their system — it reflects their business processes … For the Department of Defense, it represents a new acquisition,” Woodson said.
Woodson said it’s also important to “skate to where the puck will be.”
In other words, he explained, DoD is convinced industry solutions are further along in the development of next-generation EHR solutions than what VistA currently provides. Switching too soon to VistA risks putting both departments behind the development curve, Woodson said.