Nontechnical problems doomed joint VA/DOD health record, top official says

Lawmakers from both parties can be relied on to express indignation and exasperation when it comes to the inability of the departments of Defense and Veterans Affairs to share health data. The complaints have been coming for years and were again in evidence during an Oct. 27 hearing held jointly by subcommittees of the House Oversight and Government Reform Committee and the Committee on Veterans' Affairs.

The anger is understandable given the time and money expended. Since 1998, the two large and unwieldy bureaucracies have failed time and again to integrate health data in a way that allows VA practitioners to access and update military health records and gives DOD caregivers full access to VA records.

The DOD/VA Interagency Program Office, created in 2010, spent an estimated $564 million on planning for an integrated electronic health record (EHR) before deciding in 2013 that VA should stick with its homegrown, open-source VistA and the Pentagon should go its own way with a commercial system.

DOD picked Cerner as its EHR provider in July 2015 in a deal that includes Leidos and Accenture and could be worth about $9 billion over its 18-year lifetime. Meanwhile, the VA is in the midst of its VistA Evolution Program, which was launched to modernize VA's system after plans for a joint solution were scrapped. Congress funded the effort at $182 million in fiscal 2015; the overall life cycle costs are expected to be in the billions.

Lawmakers continue to be outraged and incredulous that the process of integrating the two departments' systems is proving so elusive and costly -- and making it difficult for retiring service members to move between the two systems, which in some cases could endanger their health and quality of care.

Christopher Miller, who as program executive officer for the Defense Healthcare Management Systems led the DOD EHR procurement and leads the joint VA/DOD program office, was browbeaten by lawmakers into offering that rarest of commodities at an oversight hearing: real talk.

"We've all got to remember, it's bigger than the IT," Miller said. "The IT has to be the easy part [of] what we're talking about here today."

The VA and DOD are not being stymied by the technical obstacles to creating an interoperable EHR, he added. Instead, the problem lies in the fact that a health record for a medical enterprise is the digital representation of thousands of work processes -- ways of giving care, accounting for resources, managing schedules and more.

"What we don't seem to ever want to tackle are the people stuff, the process stuff -- all the things that make business systems really hard," Miller said. "I hear what [the Government Accountability Office] says. I would like to believe that a single system between DOD and VA would be able to be there tomorrow. The reality is we've got a lot of hard things that make joint programs in DOD incredibly hard. Adding another level with the VA makes it even more hard."

Combining IT systems would require some level of integration in the funding, staffing and governance of the Veterans Health Administration, which is responsible for a population of 24 million, and the activities of the Defense Health Agency, which cares for a population of 9.5 million. And even if that effort was successful, it might not result in a fully interoperable system.

Furthermore, Miller said a single system would not prevent some of the interoperability problems the VA and DOD face now or that VA faces with the multiple instances of its VistA product.

"You can go talk to any major national health care provider," he said, "and they will tell you that they struggle when you're working across regions or working across large geographical areas."

Miller told legislators that the interoperability effort has nonetheless made considerable progress in the past two years, including four releases in the past 22 months. "That's actually a little faster than Apple rolls out their iPhone every year," he said.

Miller also said that although a joint DOD/VA health record is off the table for the time being, the agencies are making progress toward the goal of one day combining systems.

"I personally believe that what DOD and the VA are doing right now [is] getting both houses in order to position us [for] the future, when we're ready to have a discussion about moving to a single system, if there's actually a business case" for doing so, Miller said.