With the Department of Veterans Affairs (VA) formally signing on last month to adopt the same electronic health records system as the Department of Defense (DoD), the two agencies are putting a lot of chips on a solution to a problem that history suggests is pretty risky.
VA, after a delay resulting from leadership changes in the department, struck a 10-year, $10 million deal this month last month with Cerner for its electronic healthcare records (EHR) system, which will replace the current Veterans Information Systems and Technology Architecture (VistA). DoD already has begun limited implementations of Cerner’s EHR Genesis system under a 10-year, $4.3 billion contract that is being led by Leidos. Even the Coast Guard, which is part of the Department of Homeland Security, is getting on the Cerner train, announcing in April that it would piggyback on DoD’s project.
An interoperable EHR that could stay with service members and their families from enlistment through retirement and post-military life has been a goal of DoD and VA since 1998. But it has proved to be a Sisyphean task, with multiple projects and billions of dollars being invested and squandered. The Coast Guard has followed the same path, though on a smaller scale, abandoning its own EHR project in 2016 after 7 years and about $60 million. It’s been using a paper-based system since then.
Why are EHRs so hard? One factor is the sheer size of the systems DoD and VA are trying to implement.
DoD’s Military Health System (MHS) has nearly 10 million beneficiaries; VA’s health care system is just about as large. Those beneficiaries are treated by hundreds of thousands of doctors at hospitals and other facilities around the world, using a mix of software and operating systems, and devices ranging from older legacy hardware to new tools connected to the Internet of Things. A Government Accountability Office report on VA’s two most recent attempts at EHRs detailed some of the major challenges facing a project of this size.
Interoperability has been a serious challenge. Although DoD and VA have achieved limited interoperability between their systems, VA said last year that data exchange was far from seamless and that problems would persist as long as the departments remained on separate systems.
Adoption of EHRs themselves have proved to be a challenge in the private sector as well, with some doctors and hospitals resisting implementation, saying they’re more time-consuming to use, difficult to manage, and hard to implement. Ideally, an EHR would contain a patient’s entire medical history, including past doctor visits, treatments, lab tests, and prescriptions–many of which originated on paper–as well as data from current treatments, including medical tracking devices that exist solely in digital form. Mental health treatments, which involve different terminology, codes, and reporting requirements, can further complicate the process.
Some doctors also have complained that using EHRs also leaves them spending more time on data entry tasks with a computer than quality time with their patients. Dr. Lloyd Minor, dean of Stanford University Medical School, told PBS last year that current EHRs focus on billing and reporting but can interfere with direct doctor-patient care. “You’re thinking about the mechanics of the documentation, rather than the implications of the symptoms and findings,” Minor said. Something as fundamental as eye contact with the patient “is now being robbed from the medical encounter.”
DoD, VA, and the Coast Guard are hoping that this time, their efforts will lead to different results. They are hoping that this latest project will benefit from new technology, better interfaces and some hard lessons learned from trying to manage past efforts. DoD has already encountered some hiccups, putting a temporary hold on deployments early this year after a Director of Operational Test and Evaluation (DOT&E) assessment of initial implementations at four sites in the Pacific Northwest rated the system’s usability as “low” and found several cybersecurity vulnerabilities. DoD officials, however, said early problems were expected and that the hiatus was planned in order to address any problems. The department said it still expects to have MHS Genesis fully deployed by 2022. VA has said it wants its implementation to go more smoothly, in part because of the lessons learned from DoD.