THE GEORGE WASHINGTON UNIVERSITY – ISTM 6204 – PROJECT 2

DoD and Veterans Affairs Electronic Healthcare Record Initiative, iEHR

Saud Alhawwas Sarah AlMalik

Norah Alsalamah Martin Gavin Alex Singleton

The George Washington University School of Business

Dedicated to our country’s finest.

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Table of Contents Abstract Objectives Background

VA VistA DoD AHLTA System

Failure Factors A History of Failure Matters Seriatim

Scope Creep Insufficient Planning Absence of Performance Metrics Variation in State­Privacy Rules & Compliance Costs Associated with Interoperability

Success Factors IPO Created Bidirectional Health Exchange Created Standardized Coding System Created with Interoperable/Digitized Medical Records Alignment with HIPAA Veterans Access to Care Act Outside Help Retrenchment

Assessment & Debrief Scope Success Factors Assessment Failure Factors Assessment

Recommendations, Remarks and Conclusion: A Successful Failure? Appendix Bibliography

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Abstract

Since 1998, the Department of Defense (DoD) and the Department of Veterans Affairs (VA) have

initiated strategic implementations towards creating an interoperable exchange from which to share the

electronic health records (EHR) of active service members and their dependents as well as veterans and

their dependents. This initiatives incurred cost­overruns sustained by both departments exceeding

well­over $1.3 billion dollars. (Dan, 1)

“To date, both Departments’ initiatives include the Federal Health Information Exchange (FHIE), which enables the one­way transfer of service members’ electronic health information from DoD to VA for all separated service members; the Bidirectional Health Information Exchange (BHIE), which allows healthcare providers from both Departments viewable access to records of shared patients; the Clinical Data REpository/Veterans Affairs Health Data Repository (CHDR), which enables the DoD and VA to exchange computable outpatient pharmacy and drug allergy information for shared patients ; and the Laboratory Data Sharing Interphase (LDSI), which allows DoD and VA facilities to share laboratory information.”(Jansen, Panangala, Status of the Integrated Electronic Health Record (iEHR), 2013)

Many obstacles impeded progress towards the overall goal of interoperable access

of health records (iEHR). These obstacles included, but were not limited to, a lack of

planning on behalf of both Departments, a lack of knowledge regarding the technical

specifications that would be required in order to ensure that the data was accurately and

timely as well as secure, a lack of adherence to standardized medical terminology

regarding procedures, tests, pharmaceuticals, imaging, and scope­creep, as well as a host

of private interests that played a role in the ultimate failure of the project.

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Efforts to computerize and standardize medical records stretches back to the

Clinton Administration. As the project meandered on and public opinion regarding the

treatment of wounded soldiers and veterans converged into a political firestorm, the

recommendation turned into congressional mandate in 2008 when the “DoD and VA

were charged by law to jointly develop and implement electronic health record systems to

allow for full interoperability of personal health care information in order to support the

delivery of health care by both Departments.”(Jansen, Panangala, 9) This law, in

conjunction with the Clinger­Cohen Act helped form the Interagency Program Office

(IPO), which was tasked with congressional oversight of iEHR. Although progress

advanced interoperability of the two legacy systems (VistA, the VA’s system and

ALTHA, the DoD’s system) it would take yet another act of Congress in 2014 and a

threat to rescind funding from the DoD’s budget line­items for the two agencies to

conclude dissolving the program altogether. Finally, in 2013, the IPO announced that it

had “decided (sic) that the VA should stick with its homegrown, open source VistA and

the Pentagon should go its own way with a commercial system.”(Mazmanian, 2015)

The National Defense Authorization Act of 2014 (NDAA­2014) established a deadline

for project completion by October 1, 2014.

Objectives

The VA and the DOD’s primary objective in creating an interoperable health record

exchange was to improve the quality of care for active­duty soldiers, veterans and their

dependants. The creation of an electronic medical record (EMR) enables soldiers to personally

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access vital information regarding their medical histories, which in turn would enable a seamless

transition from public to private life. This integrated electronic health record would be created

during the soldier’s first physical upon entrance into the armed services and span their entire

lives. The iEHR would allow qualified caregivers from the DoD, the VA, and private practicing

physicians, to implement and update the data received in the record to ensure a quality of care

that only technology can provide.

The critical path to success is fraught with obstacles but attainable. The project typology

regarding the iEHR is complex, highly technological, spans many geographic boundaries, and is

under the review of multiple stakeholders. In order to achieve the project, planning is paramount.

In order to fulfill the deliverables for a project of this magnitude, clear objectives and metrics

must be established. The political landscape and environment must be considered and a proper

risk analysis assessment must be all encompassing.

In 2008, “ a VA/DoD team defined functional, infrastructure, and policy interoperability requirements that resulted in a VA/DoD multiple gateway concept of operations. ...achieving the development and implementation of an enterprise architecture infrastructure solution and establishment of a series of strategically planned network gateways...to provide secure redundant connectivity (and) facilitate the seamless transfer of health data.”(VA/DoD, 34)

According to the VA/DoD Joint Executive Council FY 2009 Annual Report, these

objectives were to include the “development of a Health Services Reference Model Framework.”

(VA, DoD, 28) The VA/DoD Health Architecture Interagency Group (HAIG) also “collaborated

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to identify joint information, data representation, security, and technical standards published

annually; and defined a category of standards for VA/DoD information sharing.” (VA,DoD, 29)

An interagency clinical informatics board was established to, among other objectives,

“demonstrate the capability for scanning medical documents of service members in DoD EHR

and forwarding those documents electronically to VA.”(VA,DoD, 31) These objectives were

necessary in order to promote interoperability, “(which) depends on the use of agreed­upon

standards to ensure that information can be shared and used.”(GAO, ­14­302,5)

On March 17, 2011, “the Secretary of Veterans Affairs and the Secretary of Defense

reached an agreement to work cooperatively on the development of a common electronic health

record and to sunset corresponding legacy systems and transition to a new iEHR by

2017.”(Jansen, Panangala, 12) The objectives, though broad and sweeping, lacked depth and

precision. Among the objectives was to “improve interoperability and data sharing of medical

history between departments; support electronic medical data capture and exchange between the

private U.S. health care system and the federal, state, and local government and reduce overall

costs of health IT investments and to manage efficiency of cost and scale.” (Jansen, Panangala,

12)

In 2012, an “estimate developed by the IPO put the cost of the integrated system at 29

billion(adjusted for inflation) from fiscal year 2013 through fiscal year 2029.” (GAO, 16).

Platform integrations was abandoned due to cost concerns and an interoperable health record

exchange system was commissioned in lieu. Due to the shift in scope, new objectives were

established. These new objectives included, but were not limited to, the VA “modernizing its

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VistA health information system and DoD buying a commercially available system to replace its

existing AHLTA health information system.” (GAO, 18) Also among the new objectives were to

expand the use of GUI’s and agreeing on how to identify patients that were in the care of both

the VA and DoD. It was also deemed necessary to “develop a secure network infrastructure for

VA and DoD clinicians to access patient information; and correlating them in a standardized

patient record.” (GAO, 18) Complexity is apparent, however, expenditures totaling over $1

billion is unacceptably delayed and incomplete due to a lack of proper planning, establishing a

clear and defined scope of work, or providing a baseline on which to measure earned value of the

project.

Background

For nearly two decades, both VA and DOD attempted to upgrade their systems to achieve

interoperability, but encountered many obstacles. The National Defence Authorization Act

(NDAA) for Fiscal Year 2008 commissions both departments to “jointly develop and implement

fully interoperable electronic health record systems or capabilities in 2009” (Melvin, 2015, p. 4).

Though they were able to accomplish “six interoperability objectives established by their

Interagency Clinical Informatics Board,” they faced many challenges that continually hindered

their ability to accomplish full interoperability (Melvin, 2015, p. 4).

In March 2011, both departments’ secretaries announced “that they would develop a new,

joint integrated electronic health record system (referred to as iEHR)” (Melvin, 2015, p. 4). The

primary goal of the iEHR system was to replace the two separate systems with one single

common system used by each department­ avoiding any interoperability challenges they had

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encountered in previous initiatives. Although this could have sidestepped interoperability

challenges, the triple constraint of cost, scope, and time was invariably unavoidable, leading to

the termination of the 2011 initiative of developing a single common system (iEHR).

The VA committed to modernize their existing VistA system and the DoD decided to

purchase a new system to replace AHLTA, while both departments consider

interim­interoperability functionalities to improve efficiency while lowering costs; however, both

departments did not have a clear­cut plan of execution. In response, the National Defense

Authorization Act for Fiscal Year 2014 states “requirements pertaining to the implementation,

design, and planning for interoperability between VA’s and DOD’s electronic health record

systems” (Melvin, 2015, p. 6). The NDAA was intended to guide a concise timeline for both

departments in delivering their systems.

VA VistA Veterans Health Information Systems and Technology Architecture (VistA) was

Introduced in 1996 by the CIO, intended to be an “automated environment that supports

day­to­day operations at local Department of Veterans Affairs (VA) health care facilities”

(“EHEALTH,” n.d.). The system was built on a client­server architecture, which enabled

access for both “workstations and personal computers with graphical user interface at

Veterans Health Administration (VHA), as well as software developed by local medical

facility staff” (“EHEALTH,” n.d.). VistA offers different applications to enable better

functionalities for its service members, families, and other beneficiaries. VistA was

developed in­house using the Agile process, where both the “VA clinicians and IT

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personnel” collaborated to produce the program. Applications embedded within the

system include “104 computer applications including 56 health providers applications, 19

management and financial applications, 8 registration, enrollment, and eligibility

applications, 5 health data applications, and 3 information and education applications”

(Melvin, 2014, p. 3). With the many applications within VistA, they are customized at all

128 VA sites, which in turn increases maintenance costs dramatically. However, in 2001,

the Veterans Health Administration decided to modernize the system they have at hand.

They set their goals to move away from a hospital­centric to a veteran­centric

environment with the addition of “enhanced functions based on computable data”

(Melvin, 2014, p. 4).

DoD AHLTA System The DoD’s Armed Forces Health Longitudinal Technology Application

(AHLTA) system is comprised of different commercial software products that were

implemented and customised to fit the needs of the DoD. In 1997 they had committed $2

billion to upgrade AHLTA through 2010 to acquire better services and functionalities,

specifically in performance (Melvin, 2014, p. 4). The system keeps track of 9 million

service members and their families. They planned on acquiring Way Ahead as the new

system to include real­time health records for service members and their families and

other beneficiaries. Additionally, it will provide comprehensive medical documentation,

capture and share medical data electronically in DoD (Lipowicz, 2010).

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Failure Factors

Recall EHR/iEHR (Electronic Health Records/Interactive Electronic Health Records)

facilitate streamlined­access to patient medical records through automation, historically

documented on paper. Digital transcription of decentralized information is inherently difficult

and only compounded by HIPAA (The Health Insurance Portability and Accountability Act of

1996). Through interoperability, information can be exchanged, from one health­care provider to

another, “seamlessly integrated into the receiving provider’s EHR system, allowing the provider

to use that health information to inform clinical care.” (Kohn, L. (2015)).

A History of Failure Since 1998, DoD and VA have cooperatively undertaken initiatives tasked to

electronically exchange personnel medical records, ultimately transforming healthcare

into a system that can achieve goals of improved quality, efficiency and patient safety as

viewed by stakeholders by sharing viewable data in legacy systems between both

departments. (Melvin, V. (2015, October 27)) As scope­creep protracted development of

a minimum­viable product (MVP) for nearly a decade, DoD/VA jointly­commissioned

the Interagency Program Office (IPO) in 2008, which was mandated by the National

Defense Authorization Act of 2008 requiring establishment of an interagency office

staffed with a director from each agency for reporting until the initially proposed deadline

of September 2009 (Timberlake, G). Due to incessant delays, the Secretaries of Defense

and Veterans Affairs (Sec. Chuck Hagel & Gen. Sheshinski) announced a formal

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departure in February 2013, about two years after launching iEHR, which resulted from

an assessment concluding cost­overruns out of budget (Melvin, V. (2015, August 13)).

However, IPO was re­commissioned in December 2013 as the exclusive accountability

agency overseeing interoperability, responsible for “establishing technical and clinical

standards and processes to ensure integration of health data between the two departments

and other public and private health care providers.” (Melvin, V. (2015, August 13)). A

brief history was provided for context and sufficient for the scope of this analysis, but

specific failure factors vis­a­vis 2014 National Defense Authorization (NDAA­2014) are

only germane to this study.

Matters Seriatim The NDAA­2014 renewal enumerated compliance orders for national electronic

medical data standards in February 2015. (Melvin, V. (2015, August 13)) Concordantly,

IPO remains chartered to achieve interoperability between electronic medical health

records systems between DoD and VA, as each pursued alternative solutions respectively

known as DHMSM(privately requisitioned to Cerner and Leidos i/a/o $11 billion termed

under 10­year contract) and the VistA 4 Roadmap pivoting the VA to “evolve” the

existing Veterans Health Information Systems and Technology Architecture, (VistA)(a

$4.3 billion contract likely to incur lifecycle cost over $9billion).((Melvin, V. (2015,

August 13)) (Walker, M. B. (2015, August 18)). In spite of the aforementioned

commencements, DoD’s DHMSM will not achieve operational capacity until the end of

fiscal year 2022, while the VistA Roadmap will not deploy until 2018­both dates

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obviously behind of the NDAA­2014 deadline (YE­2016). (Walker, M. B. (2015, August

18)) Ostensibly simple as an objective, DOD/VA system interoperability has proven

difficult to effect due to several failure factors, examined herein:

Scope Creep

Since inception, the interoperability initiative has been plagued by

management weaknesses, specifically failure to define a plan, prolonged

indecision, and continual scope­creep concerning the U/I|U/X

(user­interface/user­experience)(Appendix::1.5.1)(Kohn, L. (2015)). It is fair to

infer that execution was a failure­factor enabling scope­creep and freeze­cycles,

indefinitely postponing the project to present­day. In 1998, EMR virtualization

was narrowed to the scope information transfer, four years later as a part of the

Federal Healthcare Exchange Initiative, only to be morphed again to incorporate

private­sector health­care data in 2009 (Melvin, V. (2015, August 13)). Although

some of the original initiatives presented in the NDAA­2008 were accomplished,

clearly project execution is routinely problematic, especially due to insufficient

planning.

Insufficient Planning

The interoperability initiative has been plagued by management

weaknesses, specifically indecisiveness, complicated by the administrations of

DoD Sec. Chuck Hagel and Gen. Eric Sheshinski of the VA. Sharing of any kind,

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from intelligence to medical records, requires governance and trust­ a concerted

effort amongst entities(Kohn, L. (2015)). GAO testimonies substantiate the

criticality of information introduced within the subject examination of

failure­factors, specifically with “the need for governance and trust among

entities, such as agreements to facilitate the share of information among all

participants in an initiative. Kohn, L. (2015))” It should come to no surprise, yet

again, that the “Potomac Two­Step” disrupts inter­agency cooperation and focus.

“Alpha” project­managers (in the statistical construct, not in psychology) spend

more time in the phase of planning than actual execution, which clearly hasn’t

been observed at DoD or VA(Appendix::1.5.2)(Schwalbe, Kathy). Ideally, a

comprehensive strategy outlines a critical­path governed by key­performance

indicators (KPIs) to accomplish the primary objective, which in this case is not to

be confused with integration, but rather information interoperability between the

subject federal agencies. Although absent and only in recommendation as of this

writing, a retrospective examination of metrics may be appropriate.

Absence of Key Performance Indicators (KPIs)

It is impossible to improve what cannot be measured. Acknowledging

DOD and VA conduct toward achieving interoperability, Federal oversight review

specifically attributes the current quality of the interoperability project to absence

of results­oriented metrics providing the departments and stakeholders with

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“objective, quantifiable, and measurable goals” (Melvin, V. (2015, August 13)).

Departmental plans lacked associated performance goals and measures that are a

necessary basis to provide other departments and their stakeholders with a

comprehensive picture to effectively manage their progress toward increased

interoperability (Melvin, V. (2015, August 13)). Detrimental consequences

ensued, precluding compliance with State­Privacy regulatory rules and approvals.

Earned Value calculations, Cost and Schedule Variance Forecasting may be

opportune considerations for retrenchment.

Variation in State­Privacy Rules & Compliance

The push­pull dynamic between federal and state regulations yields a

nebulous environment for both private and public organizations alike. HIPAA

notwithstanding, EMR information exchange and transcription necessary for

interoperability is continuously ensnared by variable legislation protecting

individual patient privacy. Exchange­sensitivity is especially heightened for

health­record information concerning mental­health and HIV infection (Kohn, L.

(2015)). According to GAO stakeholder and initiative surveillance, personal

health­care records containing sensitive information risks inadvertent aggregation

with general health informational, thereby violating patient consent and privacy

rules. (Kohn, L. (2015)) Furthermore, data­warehousing is increasingly

convoluted by the absence of unique identifiers reconciling complete patient

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medical records. EHR systems utilize relationship mapping and modeling to

incorporate demographic information (e.g. patient’s name and date of birth) to

match additional information collected by different health­care providers. (Kohn,

L. (2015)). Systemic uniformity would mitigate risk because as one stakeholder

representative noted, “various agreements developed by different EHR initiatives

could result in conflicting organizational policies. (Kohn, L. (2015))” Strategy

requires stakeholder consensus­ systemic incongruency invites errors in budget

forecasting in turn limiting resources for effective interoperability.

Costs Associated with Interoperability

Any retrenchment initiative is already mired in cost­overruns attributed to

due­diligence, legal fees and technical redundancies (Appendix::.1.5.3)(Kohn, L.

(2015)). Since 2009, federal government expenditures exceed well­over $30

billion dollars budgeted for campaigns within the HITECH act of the 2009

economic stimulus package funding 500,000 physicians and more than 5,000

hospitals caring for both Medicare and Medicaid recipients “to establish

electronic health records systems through the meaningful use incentive program,

which is carried out by the Centers for Medicare and Medicaid Services (Ahier,

B. (n.d.)).” Interface­customization is another variable front­end cost that could be

reduced by standardization. Ten of 18 EMR exchange focus­groups

acknowledged “meaningful­use” or system­functionality offerings (e.g.

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messaging service within intranetworks) as frivolously diverting resources away

from the primary interoperability objective (Ruoff, A. (2015, September 30)).

Consistent implementation according to standards and targets defined by comprehensive

stakeholder­mapping is the only way to reconcile and appropriate a budget delivering

interoperability. This study concurs with the GAO general assessment directed to the IPO:

“establish a time frame for identifying outcome­ oriented metrics, define related goals as a basis

for determining the extent to which the departments’ modernized electronic health records

systems are achieving interoperability, and update IPO guidance accordingly" (Melvin, V. (2015,

October 27)).

Success Factors

In February 2013, the Departments of Veterans Affairs and Defense abandoned their

plans for an integrated electronic health record (iEHR), citing problems with the costs and

scheduling. Despite the issues with implementing the iEHR, there were a number of successes

that allude to a bright future for the system. The system resulted in a number of changes in the

Departments of Veterans Affairs and Defense that allowed for more effective management of the

health records of active service members, veterans, and the dependents of both groups.

IPO Created One of the most important success factors related to this project was the creation

of the Interagency Program Office (IPO). The IPO was created with the intention of

optimizing communication between the Departments of Veterans Affairs and Defense.

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Both of these Departments are partially responsible for the medical records of some

active service members, veterans, and the dependents of both groups. Although each

department knew in general which records they were responsible for, there were

questions over where responsibility lies regarding patients that were shared between the

two entities. To avoid any future confusion, the IPO was sanctioned by law so that they

could address the inability of the DoD and the VA to establish clear objectives and

measurable goals regarding the implementation of the iEHR. The IPO was meant to act

as a point of accountability for the development of interoperable health records for both

departments (“Electronic Health Records,” 2014). Rather than having the blame fall on

the DOD/VA, the IPO is an organization that serves as a point of contact between the two

agencies in regards to major IT projects that concern both departments. In the case of the

iEHR, it was responsible for taking over the project and making sure that both sides were

in alignment with the project scope, budget and schedule and is therefore it is accountable

for any issues that may occur in these areas between the two organizations.

Bidirectional Health Exchange Created Bidirectional Health Information Exchange (BHIE) was established in 2004 and

was aimed at allowing clinicians from both departments to gain access to patient records.

BHIE is extremely important for individuals who receive care from both departments,

which can happen quite frequently (VA/DoD Joint Executive Council Annual Report,

2009). The better the two departments can communicate records, the better it is for

everyone involved. By enabling the timely access to accurate medical data, the VA and

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DOD are able to create cost savings and better serve the medical needs of both the patient

and their caregivers. Patients are more likely to be treated effectively, especially patients

with preexisting health issues. Clinicians can spend less time repeating tests and more

time treating patients when these records are easily accessible. Having an effective

system like this leads to an increased amount of data sharing between departments and

saves lives due to the increase in patient information in a shorter period of time. (Devine,

2015).

Standardized Coding System Created with Interoperable/Digitized Medical Records

In order to create the BHIE, a standardized coding system had to be established.

Since the VA and the DOD are different departments with different management, the two

departments previously had completely different ways of coding for drugs and for

procedures. Most drugs and procedures had different codes representing them in both

departments, so when a patient goes from one department to another their records are

unclear. When records were transferred between departments, the receiving department

would not be able to understand the coding and even if the record was received in a

timely fashion it would be useless. Because of this many test had to be repeated, and a

large amount of time was wasted. In 2001, three years before BHIE was established, the

Veterans Health Administration took the initiative of updating the VistA system they had

in place in order to modernize the health information software. The system architecture

that was already in place served as a framework to create a system that provided the same

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benefits and functions with expanded functions based on data that can be computed. The

standardization process was originally based on six phases that were meant to be

completed by 2018, but the plans eventually fell through. Still, the standardized coding

system that was created for this project will be very helpful for coordinating efforts

between departments.

Veterans and active service members since World War I were able to have their

records digitized, so that it is easier for clinicians in the DOD and VA to work together

and create the fullest picture of an individual’s health history to prevent future problems.

Creating interoperable and digitized medical records is essential for the DOD and VA to

effectively communicate medical records for active service members, veterans, and the

dependents of both groups.

Alignment with HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was

enacted in order to protect people who have lost their jobs from losing health insurance,

and required the establishment of national standards for electronic healthcare

transactions. Since iEHR was created after HIPAA was enacted, it was essential that any

changes to the health records systems in place comply with the HIPAA guidelines. The

guidelines were created to protect the security of those whose records would be placed

online, so that their private information does not fall into the wrong hands. iEHR was

able to create secure interfaces that aligns with HIPAA guidelines so that the medical

records of veterans, active servicemembers and their families remain secure.

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Veterans Access to Care Act The Veterans Access to Care Act is a bill that was proposed in June of 2014 that

allows veterans to receive healthcare from non­VA facilities during certain

circumstances. This bill was proposed as a response to the revelation that many veterans

have to wait extended periods of time in order to see a doctor with the current healthcare

plan, and that many veterans have died waiting to see doctors. This bill is fully related to

interactions between the DOD and VA and it is an essential piece of legislation in regards

to the health of veterans and their families. Planning for iEHR helped bring to light issues

that veterans face in terms of healthcare, which resulted in this bill being proposed.

Outside Help The final success of the plan for an iEHR was that planning the system resulted in

the DOD and VA asking for help to improve their system. Previous of the move toward

an iEHR system, the DOD and VA had a number of serious problems regarding how

medical records for veterans, active service members and their families were dealt with.

These people were by no means receiving the medical care that they needed or deserved,

so the DOD and VA decided to work together to integrate their systems for a more

successful system. After encountering a number of complications, the two departments

realized that it was impossible to develop this complicated system alone. The

departments have insisted help in order to repair their outdated system, so that veterans,

active servicemembers and their families can have better access to healthcare.

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Retrenchment There is no doubt that the scope of this project was massive. However, as noted in

in a GAO report dated February, 2014 that the claims of the Secretaries of Defense and

Veterans Affairs regarding an integrated electronic health being too costly were

unsubstantiated.

The Government Computer Based Patient Record was begun in 1998 and since

that time progressive enhancements have been accomplished towards the end goal of

delivering an integrated or at least interoperable electronic health record system.

Currently the DoD and VA are using the Bidirectional Health Information Exchange

established in 2004. This exchange “provides clinicians at both departments with

viewable access to records on shared patients.”(GAO, 3) Though the system is

antiquated, it is still providing a useful function and should thus be continued while a

strategic plan to implement the AHLTA and VistA platforms can be established.

Many reports and analysis have been conducted by the GAO, the Inspector

General’s Office, the Office of Budget and Management, and a bevy of other public and

private entities. Throughout the decades of reports and analysis one common theme is

prevalent and that is the project continually risked failure due to management failures

rather than technical failures. It is therefore in the interest of the stakeholders that a

proper Delphi Technique should be applied in order to gather information to reach a

consensus, this technique will help to reduce the level of bias and undue influence. It is

further advised that the IPO created as an interagency effort to implement the project be

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commissioned as a separate entity without budgetary or management constraints that it

must conform to in the interest of the DoD or VA. This entity should only be answerable

to the Congressional Committee on Veterans Affairs.

Furthermore, proper project management plans, matrixes, and constraints should

be established prior to further advancing the project. Once a consensus has been reached,

then and only then should a move be made to forward the objectives. Looking at a cost

performance index it is easy to understand that there is a clearly defined need to rethink

current strategies and consider the percent complete of the work that has already been

accomplished. If the current strategy is to go forward, a need to eliminate redundancies of

prior efforts should be included in the project scope statement.

In order to realign and generate a return on the previous investments, it should be

established that the VistA platform is the way to move forward. Due to its open source

nature:

“the VistA system is a proven product and can be readily adapted for use in acute care, ambulatory, and long term care settings. It has been used in public and private healthcare provider organizations across the United States and in a number of international settings… also, leading information technology companies such as HP, Perot Systems, and IBM, and rapid­growth firms such as Medsphere Corporation, DSS Inc. and Mele Associates are actively supporting implementations in the United States and around the globe.” (IOM, 225)

As the way of the future, open­source software (free) would add true value to this

project and realign the return on investment and earned value of previous efforts. Also, to

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alleviate data transfer security concerns it should be noted that the advent of blockchain

technology affords many implications beyond cryptocurrency, as “open­source

health­care.” Due to issues concerning security clearance, Cerner respectfully declined to

comment for this study (Singleton, Alexander J.). Nevertheless, contributing scholars

implore Cerner and Leidos to pivot their approach if pursuing closed­sourced solutions,

substantiated in the last section concluding this study (Recommendations, Remarks and

Opinions).

Assessment & Debrief

In their pursuit of a partner for the Defense Healthcare Management System

Modernization (DHMSM), the Department of Defense recently decided to award a group led by

Cerner and Leidos with the contract for its much anticipated EHR modernization. The selection

of the Cerner/Leidos led team came as a surprise to some, as most analysts had expected EHR

market leader Epic, and its partners including computer services giant IBM to walk away with

the contract (Noble). Ultimately, the decision to award the Cerner consortium the contract over

Epic came to down to a matter of strategic compatibility with the vision that the DoD has for its

iEHR. Whereas Epic has a history of closed or proprietary based software, the Department of

Defense was looking for a system that was more focused on the open based standards that Cerner

and Allscripts rely upon (Walker). Ironically, Leidos has been down this road before. Leidos

Holdings, Inc., the company formally known as SAIC, has a storied history with the DoD dating

back to 1988. In that time span, the company has designed, developed and implemented several

health care systems for the DoD, including the current Armed Forces Health Longitudinal

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Technology Application (AHLTA), which launched in 2005 costing the department $1.2 billion

(Gur­Arie).

At the time of the final solicitation of bids presented in 2014, the estimated cost of the

DHMSM project was projected to cost the Department of Defense $11 billion. Recent statements

released by DoD Under Secretary for Acquisition, Technology and Logistics, Frank Kendall,

suggests that the robust competition generated in the bidding process might reduce the actual

costs of the program below $9 billion. What details have been released indicate that the initial

contract awarded to the Cerner/Leidos led team spans 2 years and is valued at $4.3 billion. If the

initial results demonstrate its intended efficacy, options to renew can raise the total contract

period to 10 years.

Scope

The scope of the DHMSM contract is considered a massive undertaking, as the

Cerner led group will be responsible for the upgrading and servicing of health records

totaling more than 9.5 million individuals in the DoD system. Perhaps the most vital

aspect of the entire operation is the sunsetting of the department’s 50 existing systems.

DoD officials have estimated that the cost of operating and servicing the department’s

legacy systems equals close to 95 percent of the DoD’s total IT budget (Sullivan).

Officials have already indicated that the full implementation of the VA/DoD EHR will

take six to seven years to complete. Unfortunately, current estimates for the full

operational capability being completed towards the end of fiscal year 2022 represents a

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significant deviation from the NDAA’s original December 31, 2016 target for

interoperability (Hirsch).

While the Department of Defense would have appeared to of scored a victory on

the cost front, the project is not without its critics. Several officials have expressed

frustration with the fact the DoD has chosen vendors that are largely responsible for the

legacy systems that the department is now looking to replace. While the DoD has

determined that an interoperable infrastructure is the best path forward, opponents have

suggested that the program is flawed and antiquated in comparison to an

internet/cloud­based platform. Other critics have suggested that the DoD’s inefficient

bureaucratic culture will result in increased overhead and delays in the implementation of

a system wide rollout in a timely fashion. Perhaps most frustrating of all, is the agency’s

failure to provide performance metrics and goals for how they intend to define the

success of the iEHR program, or how they intend to incorporate those goals into the

development process. While the DoD has recently touted the merits of the contract

awarded to the Cerner/Leidos led team and the synergies it will create, GAO has argued

that the department’s failures also extends to its inability to accurately define the budget

and cost basis for the development process.

Success Factors Assessment

Ultimately, the success of the program will be determined by the ability of the

project team to focus on measures of efficiency. After years of delays, and a reported

$1.3 billion wasted in an unsuccessful attempt to create an integrated EHR system, the

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program is finally beginning to see signs of improvement. At the heart of the program’s

success is how the departments manage their people and the processes they perform. Both

departments are already hard at work training the people who will be responsible for the

successful deployment of the new iEHR. The Interagency Program Office (IPO) has seen

recent success in its attempts to manage and guide the project by introducing metrics

intended to monitor the interoperability’s efficacy, which is the program’s primary

indicator of success. In essence, the project’s gravitation towards an open based system is

the clearest indication yet that management has learned from its past failures and is

prepared to move the project forward towards its stated goal of interoperability.

One success factor that can be factored in the accomplishments in this

integration/interoperability program would be the creation of the Interagency Program

Office (IPO). The IPO houses both departments’ (VA and DoD) interests, where they

discuss all matters associated with iEHR. Having the IPO provided groundwork

guidance, roles and responsibilities for both departments. The IPO “have taken actions to

increase interoperability between their existing electronic health record systems”

(Melvin, 2015). In 2004, they managed to standardize specific health data, which created

the the Bidirectional Health Information Exchange. This gave the ability to view patients’

records by clinicians from both departments in an integrated manner (refer to: Appendix

A). Additionally, they helped foresee the “longer­term initiatives to modernize their

respective electronic health record systems” (Melvin, 2015). Finally, they relayed the

necessary approaching for achieving interoperability in the technical sense.

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Back in 1997, “the President called for the two agencies to start developing a

‘comprehensive, life­long medical record for each service member’” (Calvaresi­Barr &

Steck, 2001, p.4). Both departments worked toward this objective and have successfully

backed all patient records from paper­based information to computer­based data. Thus,

pushing forward to enabling both departments to view, retrieve and update patient

records accordingly.

The Veterans Access to Care Act implements a program that provides veterans

the ability to seek non­VA health care providers or private physicians. This act allows the

veterans to receive higher quality medical care as well as faster treatment. The act

required the VA department to make contracts and assess appropriate hospitals for

veterans’ treatments (Veterans Access, Choice and Accountability Act).

Failure Factors Assessment

Since inception, the departments’ of Defense and Veteran Affairs efforts to

implement a seamless, fully interoperable EHR system has witnessed a great deal of

adversity. After a complete shift in strategy resulting in the delay of the project’s rollout

till 2022(at the earliest), management is left pondering where, and when, things went

wrong. Ironically, management is primarily to blame for the project’s failure up to this

point.

The program’s history of failure has been well documented. The setbacks have

been frequent and range from cost overruns to the lack of well­defined performance

metrics. The project’s original 2014 deadline is now an item of the past as management’s

27

indecisiveness has led to scope creep and numerous freeze cycles, largely the result of

insufficient planning. The lack of trust and effective collaboration between leadership at

both departments has led to the media labeling the partnership as the “Potomac

Two­Step”, due to the apparent inability to find common ground on the program’s

direction and scope. Although the program has recently shown signs of moving forward

with its new strategy of integrating each department’s EHR systems, management has

still failed to label key performance indicators by which to measures its success. The lack

of key performance indicators to quantify such metrics as the project’s progress towards

achieving increased interoperability has been a major detriment to the program’s success,

and one of the primary reasons behind cost overruns and time delays. Ultimately, the

program’s success depends not only on the topics already discussed, but also on the

capability of management to maneuver effectively through the political and regulatory

landscape. Success requires leadership to work with state and federal regulators to

guarantee that the new system conforms to all patient privacy laws. Failure to do so could

result in further costs in addition to the billions of dollars already spent to get the program

up and running.

Recommendations & Remarks: A Successful Failure?

As proponents of open­source software, this study advises DoD, VA, Cerner and Leidos

to pivot, or at least consider an approach currently in pursuit by Philips, in which health­care

information may be exchanged and shared utilizing blockchain technology guarding

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cryptocurrencies like Bitcoin, guaranteeing anonymity (Rizzo, P.). Data analysis is easy, but

procuring the data is the real challenge. Conceivably, a federal exchange may cultivate an

environment for collaborative innovation, akin to DARPA’s precursory development of the

internet (Asnaani, J.). In early October of this year, the Office of the National Coordinator for

Health IT (ONC) released a proposal entitled, “Connecting Health and Care for the Nation: A

Shared Nationwide Interoperability Roadmap,” advancing three themes (Asnaani, J.):

Giving consumers the ability to access and share their health data.

Ceasing all intentional or inadvertent information blocking

Adopting federally­recognized national interoperability standards.

In the era of the iPhone, the taxpayer still waits in the doctor’s office­ within the last

year alone, one in three patients experienced the following: submit a new chart because

existing records weren’t retrieved; required to bring an x­ray, MRI or equivalent result; wait for

results longer than beyond reasonable expectations (HealthIT.gov). Although medical records

are personal, life­saving data could be aggregated, thereby accelerating wellness for the

greater­good with an “open­source healthcare exchange of information.” Like the

human­genome, medical data belongs to humanity, to the individual­not a corporation or

government; however, any proprietary methodologies or remedies derived from the

"open­source exchange" could be protected by U.S. patent laws affording plenty of

opportunities for capitalization while improving the quality of care for all. Life will not be

contained; it always finds a way­ and so will the money…

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Appendix

September GAO

Schwalbe, Kathy (2013­01­01). Information Technology Project Management (Page G.8). Cengage Textbook. Kindle Edition. ss. 84

30

Estimated Annual Information Collection Burden | http://www.gpo.gov/fdsys/pkg/FR­2015­03­30/pdf/2015­06685.pdf

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