As DoD, VA begin multibillion dollar EHR rollouts, Congress asks who’s in charge

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It’s been a decade since Congress first created an interagency program office to push the departments of Defense and Veterans Affairs to integrate their electronic health records. Now, the IPO has a new mission on its plate: Ensuring the success of the commercial EHRs the two departments eventually decided to buy.

And lawmakers are asking whether the IPO itself is in need of an overhaul.

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Under current law, the IPO is required to serve as the single point of accountability for the two departments’ efforts to achieve interoperable health record systems. But officials testified Thursday that the office isn’t actually functioning that way, and has neither the budget nor the staff to do so.

Instead, DoD and VA say they are still in the process of figuring out a joint governance structure, even as key decisions are being made about how they’ll deploy their new EHRs, both of which are based on a Cerner software suite called Millenium. DoD has already installed its version, called MHS Genesis, at four Pacific Northwest hospitals and clinics. And VA signed a ten-year, $10 billion contract with Cerner to begin its own implementation in May.

Worried about waste

Rep. Mike Coffman (R-Colo.) is among many lawmakers who worry that the lack of a clear governance structure will lead to a repeat of the modernization stumbles the departments have suffered for more than a decade.

“You had two large federal entities, both considered to be co-equals with no one in charge, and people in the middle trying to negotiate with them unsuccessfully,” he said. “I’m not sure it’s going to be any different, and I worry that we’re going to waste another billion dollars on this. If either DoD or VA were in charge of this and not co-equals, I think this would be done by now.”

The billion dollar figure is based on an estimate from the Government Accountability Office, which found VA spent $1.1 billion between 2011 and 2016 on efforts to modernize its existing EHR. That was before the agency decided to purchase a commercial product.

Much of that spending went toward an earlier effort in which DoD and VA were attempting to work together to build a shared record system. That effort, on paper at least, was managed by the IPO.

But GAO says the office has never had the authority to take the lead on EHR modernization, even after having been rechartered and restructured at least twice in the past 10 years.

“I think it’s evident that they never had the clout to either mediate or resolve the issues between VA and DoD. The IPO was never set up to succeed, because neither of the departments were ever willing to relinquish control,” said Carol Harris, GAO’s director of IT acquisition management issues. “I think in terms of what you would see in leading organizations, what they have shown is that you have to have a single executive level entity that’s the point of accountability. It’s just one body, as opposed to multiple bodies, and it has to be at that executive level. Moving forward, certainly I would expect to see it, at a minimum, at the deputy secretary level.”

 A question of the IPO’s authority

DoD and VA have further reduced the IPO’s responsibilities in recent years. As a practical matter, it’s main tasks are to set joint health data standards for both departments to use. Harris says that’s a critical function, and Congress may want to consider simply removing the legal requirement that the IPO also have overall accountability for success of the EHR projects.

But Rep. Jim Banks (R-Ind.), the chairman of the newly-established House VA technology modernization subcommittee, said he favors an approach that would give the IPO more authority and responsibility, not less. He said that’s partly because the EHR implementation is expected to span the next decade, while individual politically-appointed leaders come and go.

“Unfortunately, we have seen far too much of that turnover in the early months of this program, and the IPO is of the few aspects of EHR modernization that is mandated by law. That means that it has a very important and permanent role to play in governance,” he said. “Most everyone here today agrees the IPO needs to do more. My hope is DoD and VA will hash out what that looks like. I am willing to give them additional time to do that, but I will not wait forever. The key decisions that will determine the EHR modernization’s future are being made over the next several months. I am skeptical of Congress imposing solutions, but we also have to keep the train safe on the tracks.”

New interoperability plan for EHRs coming soon

DoD and VA officials say they are working on a notional governance structure to make key decisions about how to configure their respective EHRs so that they’re fully interoperable. They expect to present that plan to Congress in the next few months.

It would involve at least three different decision making bodies: a “joint technical board,” a “joint functional board” and a “joint decision board.” The IPO would facilitate their meetings and record their decisions, but wouldn’t have much authority beyond that.

John Windom, VA’s program executive officer for electronic health record modernization said there’s a reason for multiple boards: The EHR projects are incredibly complex, and the departments want to resolve disagreements at the lowest level possible.

“There are a myriad of mission sets, and there’s no single body that is qualified in everything from the technical to the clinical areas,” he said. “Our job is to manage those and have elevation opportunities to resolve things that are unable to be resolved at the lowest level. That’s one thing I can’t impress upon the committee enough: governance has to be successful at the lowest possible level. Things can’t rise to the superior level on every matter.”

But Harris said GAO worries that the governance process the departments are contemplating is destined to dilute accountability for success or failure, a phenomenon we’ve seen before.

“Again, when you look at leading organizations, that single point of accountability should be at the executive level,” she said. “And one of the things that strikes me when you look at the [current] organizational chart, if you count the of boxes, there are at least 16 boxes, which shows that accountability has been so diffused so that when the wheels fall off the bus, you can’t point to a single entity who is responsible. And that’s a problem.”