Rep. Phil Roe (R-Tenn.), chairman of the House Veterans Affairs Committee, returned from a recent visit to Fairchild Air Force Base, Wash., alarmed that the Department of Veterans Affairs might have made a bad decision last June to replace its legacy electronic health record system, VistA, with the same commercial off-the-shelf system that the military is adopting, starting with Pacific Northwest bases.
“I came back blowing the bugle,” said Roe, a physician, who saw staff at Fairchild's hospital frustrated at the MHS Genesis system in ways that recalled for Roe his experience years earlier shifting paper to electronic medical records.
In this case, however, Fairchild physicians were frustrated that only minimal patient data had transferred from the Defense Department's legacy system, AHLTA, into the Cerner Millennium architecture used in MHS Genesis.
If VA adopted the same system, Roe remembered fearing, physicians would have to spend two to three additional minutes on each patient just looking into VistA data that Roe had expected would be transferred into the new record system.
“If I don't have it all in front of me,” Roe said, “you've just added another hour to my day. You ask doctors today what's frustrating them. It's the damn electronic health system. It takes part of the joy out of medicine.”
Roe said he feared that a lot of the efficiency savings that VA expected to realize from modernizing electronic records would be lost by having to maintain the legacy system alongside the new system, perhaps for decades.
That's why Roe sounded retreat, he said. He's put away his horn, however.
VA Secretary David Shulkin, back in December, paused contract negotiations and plans to piggyback onto the deployment of MHS Genesis for reasons unrelated to physician frustrations Roe witnessed. In fact, Roe said, Shulkin soon reassured him that VA medical data won't face the same transfer challenges as military patient data stored on ALTHA. Shulkin told him, Roe said, that contracting officials expect to be able to transfer up to five years of VA medical records into the new system for every patient enrolled in VA health care.
“They should have everything pertinent in there,” Roe said. “They will keep the rest of that information stored for legal purposes or, I guess, if they had to deep dive when somebody left information out or a disability claim that still needed to be data mined. But for the most part, if I'm a [VA] doc sitting in front of my screen, getting ready to see my patient, I'll have everything I need on one system.”
Roe remains concerned that the Department of Defense will have to keep ALTHA accessible to medical staff for years longer than VA will need to use VistA, even though VA's patient base is at least twice as large.
What Roe discovered at Fairchild, however, has been well known for years among architects of government electronic health records. Since at least 2009 when the Obama administration announced plans for a virtual lifetime record system using worldwide standards, the Department of Veterans Affairs has taken more care than did DoD to collect and store medical data in a common format, compatible with popular electronic record systems in the private sector.
Defense officials knew they would face hurdles on data transfer when they signed the $4.3 billion 10-year Defense Healthcare Management System Modernization contract in July 2015, with Leidos Inc. tasked to deploy two popular commercial systems -- Cerner Millennium for medical records and Dentrix Enterprise for dental - to modernize military health records.
“DoD does not concede this will be a problem for us,” said Stacy Cummings, program executive officer for Defense Healthcare Management Systems. She acknowledged VA and DoD are modernizing different legacy models. DoD, in fact, has three legacy electronic medical record systems in AHLTA, Essentris and CHCS, each of which manages health data differently.
“As we transition to MHS GENESIS,” Cummings said, “we will sunset legacy tools locally -- at each medical facility -- and once we have fully transitioned we will sunset the legacy programs at the enterprise level.”
Health care providers at military facilities, meanwhile, will continue to view legacy health data through the Joint Legacy Viewer, a clinical application created years ago to allow “read only” access to medical records stored by DoD, VA and private sector partners who participate in the common data viewer.
MHS Genesis' rollout began in February 2017 at Fairchild and at Oak Harbor Naval Hospital in June. Madigan Army Medical Center on Joint Base Lewis-McChord and Naval Health Clinic Oak Harbor followed. Plans are to have the system fully deployed at these sites by 2019 and throughout the military by 2022.
Further expansion at these bases is in a planned pause, for eight weeks, while managers review more than a thousand user complaints and make necessary adjustments to enhance the system, DoD and contract officials explained.
Shulkin paused VA contract negotiations with the Leidos-Cerner team in December so the not-for-profit MITRE Corporation could study the draft contract and identify issues. Roe said MITRE made many recommendations. One would direct VA, not Cerner, to own the connection portal, or API gateway, between, community providers and insurance companies. Another would require VA to create an external panel to conduct annual interoperability assessments to judge how effective the new system is in accessing and transferring medical data.
Patrick Flanders, chief information officer for the military health system, said the requirement to keep medical records available through AHLTA, at least through full deployment of Genesis, is tied to it being “an old system” and with “poor” data.
Some of the frustration Roe heard from providers at Fairchild, Flanders said, are “part of just the growing pains” of using a new system installed at targeted sites for the purpose of achieving initial operational capability.
Adrian Atizado, deputy national legislative director with Disabled American Veterans, has been studying VA plans to piggyback on the DoD plan for modernizing records, using the same contractors and architecture, applying DoD lessons learned and using the same staff that brings MHS Genesis to life.
Atizado questioned whether the piggyback arrangement can be sustained for too long if, in every region of the country, VA can transition to the new health record system faster than DoD because of ease of medical data transfer.
If VA had followed DoD's lead into Washington state, for example, would VA have to delay its own progress modernizing records at VA facilities in state while DoD paused for weeks to fix user complaints at military hospitals, Atizado asked. “And if VA doesn't rollout behind them, but in front, what will that do to VA costs?”
Shulkin was expected to announce resumption of contract negotiations soon.
Roe applauded the secretary's caution on a contract estimated at $15 billion.
“You know this is the biggest electronic rollout that anybody's ever done. Biggest in the world,” Roe said. “And VA doesn't have the greatest track record of rolling big stuff out on time and under budget. I can tell you that.”
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