VA-DoD: Winning the (ongoing) battle for interoperability

Department of Defense (DoD) and their efforts to modernize their electronic medical record (EMR). Both the DoD and the VA plan to standardize on Cerner’s EMR. The hope is that this will provide a more complete longitudinal health record and make the transition from DoD to VA more seamless for active duty, retired personnel and their dependents. It’s a laudable goal and we can all agree that those who serve our country deserve the best healthcare we can provide.

However, these efforts are running into significant problems:

• The DoD recently announced it would pause the rollout of their new EMR known as MHS Genesis. The pilot project began in February 2017 at Fairchild Air Force Base and concluded when Madigan Army Center, the fourth pilot site, went live in October 2017. Reports vary on why this pause is occurring but seem to center on workflow problems and results retrieval.
• After announcing in June 2017 that they had selected Cerner in a no-bid contract, the VA has now halted the contracting process due to concerns about interoperability. According to reports, the concerns are not around how well Cerner’s system would work within the VA’s network, but rather, if it would be fully interoperable with private-sector providers who play a key role in the military health system.
• Scott Blackburn, CIO of the VA, recently injected important realism into the discussion about how long it will take to complete the transition from VistA, the VA’s legacy EMR, to Cerner. According to Blackburn, “The Cerner implementation will take about a decade. If it’s starting in the northwest quadrant of the country and moving east, those on the Eastern Seaboard are going to be using VistA for about 10 years [more] or so…”

I wish I could say I’m surprised by these events but, I am not. I shared my concerns in this article back in August 2017. To be very clear, I am not criticizing the DoD, VA or Cerner. They are trying to do the right thing and provide an EMR that will better serve everyone. The challenges the VA and the DoD are encountering are endemic to healthcare and highlight a set of problems that are also affecting the civilian health system. At the heart of this challenge are two fundamental issues: an anemic definition of interoperability and the inevitable short comings of a “one platform” strategy.

Single platform strategies usually fall short

The “one platform to serve them all” approach is seductive. In theory, if all patients and providers are on the same EMR, interoperability will become a minor issue. I used to believe this, too. I was wrong for several reasons:

• Every implementation of an EMR is different and even same-brand EMRs do not seamlessly connect. Limits in scalability and/or health system mergers can result in multiple instances of a specific EMR and those different instances do not easily interoperate.
• It takes time to roll out a new EMR. It’s not like you can flip a switch and the legacy EMR is instantly replaced by the new one. Thus, Blackburn’s reminder that it will be at least 10 years before the legacy system is retired.
• It’s difficult to completely retire a legacy EMR. They have lots of important historic information that will be needed well into the future (if not forever). Some, but not all of that information will be imported into the new EMR. Ask a clinician what information they might need in the future and you will hear some version of, “I can’t predict. It could be almost anything at any time.” 10-year-old information can make a huge difference when trying to figure out if that change on a recent EKG or chest X-ray is new or long-standing. If you are admitted to the emergency department with chest pain, you want your doctors to have that information instantly available. It could literally be a matter of life or death and time is of the essence.
• The DoD cared for 9.3 million active military patients in 2016, while the VA cared for 9 million veterans in 2014. It’s a complex delivery system comprised of the DoD, VA and private facilities and providers. As a result, even when the DoD and VA complete their conversion, there still won’t be a common electronic medical record. This is a key reason the VA is currently focused so intently on interoperability between the military and civilian systems.
• For a variety of reasons, some providers do not want to switch from their own EMR to one offered by their local health system. Look at almost any healthcare market in the US and you will find at least one important group—like Cardiology, Oncology, Nephrology or OB-GYN—that are firmly committed to keeping their own EMR. This is further exacerbated in markets that have more than one large health system using different EMRs.
• On the civilian side, one platform solutions tend to focus on hospital and office based services. This leaves a huge gap when it comes to skilled nursing, rehabilitation, mental health, home care and the like. These services typically rely on their own specialty-specific EMR’s and, for good reasons, are reluctant to give them up.

In short, consolidation to a shared EMR platform has clear benefits, but it is not a panacea. Like any strategy, it has advantages and disadvantages. Some disadvantages can be solved over time, but some are likely to be with us for a very long time. This situation relates to, and gives us a great view into the other key problem: an anemic vision and approach to interoperability.

Robust interoperability is about much more than simple records portability.

The ability to move a patient record from one place to another is an important aspect of interoperability, but is only one feature. Robust interoperability enables a symphony of applications that connect, exchange and collaborate. This can mitigate many problems associated with the one platform strategy. Legacy systems can be tapped on-demand to retrieve important historic information in real-time. Military and civilian community-based providers and health systems can connect and share within and across their respective domains from the comfort of their own EMR.

Equally important, and as demonstrated in other industries, robust interoperability based on proven API technology encourages innovation by enabling market-driven _competition_to produce the best applications at the best price. Without this kind of interoperability, customers become highly dependent on their EMR vendor’s ability to innovate and are limited by that vendor’s talent, resources and priorities. This can stifle innovation and negatively impact usability, satisfaction, efficiency and clinical outcomes.

It’s time to soldier on

The VA and DoD deserve a lot of credit for taking on the difficult challenge of updating and integrating their EMR platforms. However, this will not, in and of itself, solve the interoperability problem. The civilian health system faces similar challenges which extend way beyond data exchange for simple records portability. Military and civilian health systems must be free to select the most innovative applications and seamlessly connect them with core EMR systems. Likewise, they need to connect different EMRs with each other.

Pursuit of a broad, robust, API-based approach to application integration and interoperability can mitigate the shortcomings of a single platform strategy and will be crucial to delivering on the promise of world-class care that civilians and our active military, veterans and their families rightfully deserve.