- After years of watching two of the nation’s largest healthcare systems flounder in front of Congress as they attempt to explain their struggles to meet federal health data interoperability goals, healthcare industry observers could be forgiven for losing some of their interest in the extended saga of the Department of Veterans Affairs (VA) and the Department of Defense (DOD).
After all, most healthcare organizations are wrestling with their own health information exchange conundrums that take up their attention, and the recent announcement that the DOD has selected Cerner and Leidos to help modernize its EHR capabilities seems to indicate that the military health systems’ problems are close to coming to an end.
Not so, said lawmakers during a joint hearing of the Committee on Oversight and Government Reform’s Subcommittee on Information Technology and the House of Representatives Committee on Veterans Affairs’ Subcommittee on Oversight and Investigations this week as they heard testimony from VA and DOD infrastructure experts.
In fact, the departments are on track to watch yet another critical deadline sail past as they continue stalling, finger-pointing, and prevaricating over the best way to ensure that active service members, veterans, and their beneficiaries are receiving high quality care that conforms to current expectations of interoperability and informed clinical decision making.
The technical challenges pale in comparison to leadership failures and furtive turf wars between DOD and VA leaders, stated Congressman Will Hurd (R-TX) in his opening remarks.
“Let me start this hearing by simply trying to state my frustration,” he said. “Our soldiers, sailors, Airmen, and Marines who are making the transition from DOD to VA healthcare are literally told to print out hard copies of their medical records and then walk them to the VA. We have sent men to the moon and robots to Mars. I feel like we should be able to move one electronic file, no matter how big or how old, from one computer system to another.”
“I don’t mean to understate the enormity of the challenge of integrating the two largest federal bureaucracies,” he continued, “but it’s clear to me that our inability to integrate these two systems is a failure of leadership rather than technical feasibility. This is not an issue of data standardization. This is management 101.”
Multiple reports from the Government Accountability Office (GAO) going back to the beginning of the century have scolded the VA and DOD for their leadership and organizational failures. Poor oversight, insufficient metrics, foggy goals, and interdepartmental sniping have led to nearly two decades of repeated failures across half a dozen attempts to establish more robust interoperability.
In February of 2015, these compounding problems landed the VA and DOD on GAO’s list of “high risk” programs. At that point, the VA had not yet addressed more than 100 GAO recommendations to improve access to care and strengthen its oversight procedures.
The VA was also struggling to cope with a massive patient access scandal that claimed the heads of several top executives, including VA Secretary Eric Shinseki. Dozens of veterans are said to have died due to subversion of the VA’s electronic scheduling system, and nearly half of veterans who requested appointments failed to receive them due to overloaded calendars and insufficient staff availability.
While Congress was quick to approve more than $16 billion in funding to expand VA facilities, usher out a number of ineffective executives, and overhaul its cultural insistence on meeting untenable internal goals, an ongoing resistance to change, cooperation, and integration with the DOD continues to be a major roadblock, said Rep. Tammy Duckworth (D-IL) during the hearing.
Duckworth, a combat veteran who took a position in the VA after losing both her legs in Iraq, slammed the Department for propagating the red tape mentality that has kept the interoperability project meandering along without making much progress.
"Week after week, and then when [discussions] went on to months, it would be a new one-star or a new two-star [general] who would rotate in," she said. "And the new one would come in and say, ‘I need a new study because I wasn't here for the all of those weekly meetings,’ or ‘I need a new study because we need to figure out what's going on.’"
But the Committee’s witnesses, which included top officials for the VA and DOD, did not take these frustrated accusations lying down. Christopher Miller, Program Executive Officer for Defense Healthcare Management Systems, argued that the two departments have made “significant progress” since the end of 2013, and “share a significant amount of health data – more than any other two major health systems.”
“DOD and VA clinicians are currently able to use their existing software applications to view records of more than 7.4 million shared patients who have received care from both Departments,” he added. “This data is available today in near real time and the number of records viewable by both Departments continues to increase. Both Departments’ healthcare providers and VA claims adjudicators successfully access data through our current systems nearly a quarter of a million times per week.”
Miller added that the DOD’s modernization project will further accelerate progress as it harnesses interoperability capabilities provided by the Leidos Partnership for Defense Health. Implementing a Cerner-based commercial system will also save money, Miller pointed out, costing an estimated $11 billion instead of the $16 billion that the previous joint iEHR plan was supposed to cost.
That’s “an immediate savings of nearly $5 billion,” Miller said, although he did not address the fact that the joint iEHR proposal was supposed to create a single electronic record system across two departments, where the $11 billion DOD project will only cover the DOD’s own infrastructure improvements.
LaVerne Council, Assistant Secretary for IT and Chief Information Officer at the VA, also reaffirmed her Department’s commitment to achieving significant cultural and technical transformation, but noted that the sheer scale of the Department’s activities requires a careful and long-term approach.
“IT is an enabler of each of VA’s disparate lines of business, including the largest integrated healthcare system in the United States; a benefits processing organization equivalent to a medium-size insurance company; one of the largest integrated memorial and cemetery organization in the country; a court system; and many other components,” Council said.
“Our vision is to become a world-class organization that that provides a seamless, unified Veteran experience through the delivery of state-of-the-art technology. Our guiding principles are to be transparent, accountable, innovative, and team-oriented. We will establish a strong technical foundation that ensures alignment with VA’s mission, data visibility and accessibility, data interoperability, infrastructure interoperability, information security, and enterprise services.”
However, Valerie Melvin, Direction of Information Management and Technology Resources Issues at GAO, repeated the organization’s skepticism that two separate modernization projects would be effective at establishing the interoperability infrastructure required to meet Congressional goals.
In addition, the DOD and VA are likely to miss a December 2016 deadline to have a number of key activities online: the VA’s VistA modernization program is slated to run until 2018, while the DOD’s decade-long EHR contract does not even hope to get its new EHR up and running until 2022.
“A significant concern is that VA and DOD had not identified outcome-oriented goals and metrics that would more clearly define what they aim to achieve from their interoperability efforts and the value and benefits these efforts are intended to yield,” Melvin added.
For the healthcare industry at large, the lessons all boil down to this: poor planning at the outset of major EHR implementation and health data interoperability efforts can mean disaster for a large-scale or long-term project. A clear, well-defined, and properly communicated roadmap is required for success with any health IT initiative, especially if the project requires interdepartmental or cross-organizational collaboration.
Developing firm goals, usable metrics, and standardized oversight processes may help other organizations avoid the quagmire of murky responsibility and the black hole of endless financial investment experienced by the VA and DOD, whose “what not to do” example does not seem to be coming to an end any time soon.