VA says goodbye to VistA, hello to Cerner for new EHR–and possible impacts (updated)

The new sheriff just turned the town upside down. Veterans Affairs’ new Secretary, Dr. David J. Shulkin, as expected moved quickly on the VA’s EHR modernization before the July 1 deadline, and moved to the same vendor that the Department of Defense (DoD) chose in 2015 for the Military Health System, Cerner. VA will adapt MHS GENESIS, based on Cerner Millenium. The rationale is seamless interoperability both with DoD and with private sector community providers and vendors, which base their services on commercial EHRs. The goal is to have one record for a service member through his or her lifetime and to eliminate the transition gap after discharge or retirement. (Transition gaps are also repeated when reservists or National Guard are called up for active duty then returned to their former status.) Another priority for VA is preventing the high rate of suicide among vulnerable veterans.

Updates: VA confirmed that Epic and Leidos will keep the development of the online medical appointment scheduling program, awarded in 2015 and currently in pilot, to be completed in 18 months. The contract is worth $624 million over five years. Wisconsin State Journal  The House Appropriations subcommittee on Veterans Affairs likes the Cerner EHR change. The Senate Veterans Affairs Committee is meeting Wednesday to discuss the VA budget sans the EHR transition. The EHR numbers are expected to be sooner rather than later. POLITICO Morning eHealth 

Dr. Shulkin is well acquainted with the extreme need for a modernized, interoperable system serving the Veterans Health Administration (VHA), having been on the US Senate Hot Grill for some years as Undersecretary of Health for VA. The foundation for the move from homegrown VistA to Cerner was laid last year during the prior Administration through an August RFI for a COTS (commercial off the shelf) EHR [TTA 12 Aug 16] and in later hearings. “Software development is not a core competency of VA” and it has been obvious in system breakdowns like scheduling, maintaining cybersecurity and the complex interoperability between two different systems. To move to Cerner immediately without a competition, which took DoD over two years, Dr. Shulkin used his authority to sign a “Determination and Findings” (D&F) which provides for a public health exception to the bidding process. The value of the Cerner contract will not be determined for several months.

For those sentimental about VistA, he acknowledged the pioneering role of the EHR back in the 1970s, but that calls for modernization started in 2000 with seven ‘blue ribbon’ commissions and innumerable Congressional hearings since. He understated the cost in the failed efforts on interoperability with DoD’s own AHLTA system, VA’s own effort at a new architecture, and modernizing the outpatient system. This Editor tallied these three alone at $3 billion in GAO’s reckoning [‘Pondering the Squandering’, TTA 27 July 13]. 

It is still going to take years to implement–no quick fixes in something this massive, despite the urgency.

  • Both MHS and VA will be running two systems at once for years (more…)

VA’s moves spell the end of the homegrown EHR

The Veterans Health Administration (VHA) is formally reaching out to the private sector to explore switching from its current, pioneering EHR system, VistA (also referred to as CPRS, Computerized Patient Record System) to a commercial system. Their ‘feeler’ is an August 5 and 8 notice in FedBizOpps.gov titled 99–TAC-16-37877 * RFI – VHA supporting COTS EHR REQUEST FOR INFORMATION (RFI), Solicitation Number: VA11816N1486. This requests information on business support for transitioning to a commercial-off-the-shelf system (COTS–don’t governments love acronyms?–Ed.) and closes 26 August, which is not a lot of time even for an RFI.

VHA has been under extreme pressure from Congress to modernize its EHR, lately in July hearings before the Senate Appropriations Committee. EHR replacement is also in line with the Congressionally-mandated, now concluded Commission on Care’s recently published recommendations on a total, top-down reorganization of VHA, including a sweeping reorg of their HIT management. The VHA strategy appears to be that while they are walking down the road to replace VistA and have already spent to assess where they are with KLAS and other EHR consultancies (spending $160,000+ on surveys), they are essentially ‘kicking the can down the road’ to the next administration (POLITICO’s Morning eHealth, 14 July).

Current state is to continue to upgrade VistA through late 2018, though the closely related Department of Defense’s Military Health System is in the long process of cutting its homegrown AHLTA over to Cerner-Leidos as MHS Genesis, awarded last August, with a first trial in the Pacific Northwest later this year (HealthcareITNews, Ed. emphasis). Of course, it will take the VHA years to roll it out; there are close to 9 million veterans enrolled in the closed system that is the VHA.  FCW, Morning eHealth 10 August

Love EHRs or hate them, the sheer size of the VHA and its growing concession that VistA won’t do in caring for American veterans makes it clear that the future of EHRs is in private systems from major developers–a field which is winnowing out to The Few (take that, GE).  (more…)

EHRs: now safety, info exchange concerns (US, AU, CA)

What’s this? EHRs reducing, not increasing, safety? Reports from both the US and Australia seem to indicate another spanner (US: wrench) in the EHR works, aside from the laggardness in achieving the HITECH Act’s goals [TTA 27 Mar].

  • The Joint Commission, which is the chief US accreditation and certification body for healthcare organizations and programs, and thus to be taken very VERY seriously, released a Sentinel Event (Patient Safety Event) Alert yesterday. It warned of EHR-related adverse events affecting patient health, resulting from incorrect or miscommunicated information entered into EHRs. Interfaces built into the technology can contribute and studies have documented mixed results in the systems’ ability to detect and prevent errors. It identifies eight key factors,led by human-computer interface, workflow and communication and clinical content, that can lead to a sentinel event and three major remedy actions. While the JC does take pains to confirm the positive effects of well-designed and appropriately used EHRs, with strong clinical processes in place, it is the first ‘red flag’ this Editor can recall (more…)

Epic Systems getting into the app store business (US)

Epic Systems, the #1 company in the hospital and large practice EHR business, is launching its own app store, reportedly within a few weeks. This opens up interesting possibilities not only for mHealth app developers–who need application standards and guidelines soon–but also for Epic’s reputation as a closed system that shies away from interoperability with other EHRs like Cerner, Meditech and McKesson–a serious wrinkle with their Department of Defense EHR joint bid with IBM to replace AHLTA. The HIT Consultant article quotes a leading Epic customer consultant on that the first apps will be clinical, then crossing over into consumer; the latter seems an obvious move with PHRs (personal health records) as part of Meaningful Use requirements.

VA, DoD aren’t collaborating on EHR: GAO

Your ‘Dog Bites Man’ item for the weekend (no, it’s not in reverse!) is that the Government Accountability Office (GAO) has determined that Veterans Affairs (VA) and the Department of Defense (DoD) have not yet proved that their current two-system path, having rejected a single EHR, actually will be workable. In February 2013, both agencies abandoned a joint system after $1 billion in spend, and $4 billion in fixes/upgrades to their separate VistA and AHLTA systems. [TTA 15 Dec] By the two agencies going their separate ways, the GAO is mystified on what is going on with interoperability. The answer: not much. And as mentioned in our 15 December article, there was a 31 January deadline for an interoperability plan (or single system) to be implemented by 2016, mandated by the 2014 National Defense Authorization Act (NDAA). Obviously, this deadline has come and gone. FierceEMR article, GAO recommendation (full text PDF)

One way to overcome the interoperability problem and too much in the EHR? Get rid of those pesky backlogged patient records! The Daily Caller uncovered a VA whistleblower’s complaint to the VA’s Inspector General and their office of special counsel, plus Congress, that VA officials in Los Angeles intentionally canceled backlogged patient exam requests going back more than one year–and that the delay on exams went back 6-9 months. The deletions started in 2009. There is a wrongful dismissal (of said whistleblower) suit and other joy. Article, audio (02:21) Updates 3-4 March:  according to Under Secretary for Health Robert Petzel, the Daily Caller report was ‘scurrilous’. He stated that about 300 records were closed but not deleted after administrative review, generally for old imaging requests, and there was no effort to delete records to boost performance.  According to FierceHealthIT, the backlog is about 400,000. Also Military Times. According to EHR Intelligence, both DoD and the VA agree with the GAO recommendations; GAO will update its findings once the agencies have taken action. Also iHealthBeat.

EHR interoperability redux for VA, Department of Defense (US)

Back in late February, the US Department of Defense and Veterans Affairs announced that they would not achieve their goal of a single EHR by 2017, and would stick with their creaky AHLTA and VistA systems for the foreseeable future [TTA 3 April]–along with the general lack of interoperability–eyes rolled at the $1 billion down the drain, but seemingly not much else budged. (And this does not include the $4 billion spent on failed updates and fixes in both systems–TTA’s ‘Pondering the Squandering’, 27 July) To this Editor’s utter shock, the 2014 National Defense Authorization Act (NDAA), agreed to by the House and Senate this week, mandates a plan for either interoperability or a single system by 31 January–about 6 weeks from now–and to adopt it by 2016. Moreover, both systems must be interoperable with private providers based on national standards by 1 October 2014. A close reading of the NextGov article indicates that the bill adds levels of complexity and perhaps unworkability. Getthereitis, anyone?–or does this sound like Healthcare.gov, redux? FierceMobileHealthcare

And it takes a grad student to find a major info security flaw in VistA.  (more…)

Systems sharing data, still behaving badly

A straight-shooting article in Healthcare Technology Online provides a overview of the EHR and Health Information Exchange (HIE) mess in the US. Essentially our major EHR systems (Cerner, McKesson, athenahealth, Greenway, Epic) don’t interchange data well, if at all–and the 600-odd practice EHRs were built on siloed designs, existing software and used proprietary formats, often in a rush to take advantage of Federal subsidy programs in Stage 1 Meaningful Use–as HTO’s EIC Ken Congdon stated, “electronic filing cabinets”–and heavily outsourced. Well, it’s now ‘uh-oh’ time as a key part of Stage 2 MU is interoperability. Basically we now have a set of what this Editor would term ‘paste ons’ and ‘add-ins’ to facilitate data exchange between systems that speak different languages (Editor’s emphasis):

direct protocol (a standards-based method for allowing participants to send authenticated and secure messages via the National Health Information Network), as well as those developed by HL7 (Health Level Seven), a nonprofit global health IT standards organization, provide EHR users with the building blocks for exchanging data. Blue Button, an application developed by the VA that allows patients to download their own health records, is also being adopted and manipulated by EHR vendors and independent developers as a way for providers to exchange data between systems. Moreover, regional and state-run HIEs offer healthcare providers in several parts of the country a network they can join (and technology infrastructure they can leverage) to share health data with other HIE members.

Some systems work well–EHR and pharmacy systems seem to. However, EHR to EHR interfaces are up to the provider and are expensive. Sharing/translation does not mean that all information makes it over without getting ‘bruised’ or having to be reentered manually.  HIEs, acting as a focal point for data exchange, are also generally non-profit; the exchange platforms cost millions to develop and further millions to maintain–and buy-in is low, as the article states. Fixing The EHR Interoperability Mess (free registration may be required)

(Updated 8/7 pm for Editor Donna’s POV) This is what happens when you rush adoption and development processes that should take years in order to gain quick subsidy money, and non-healthcare entities (that is you, the US Government) encouraged this, distorting the process. The private and public waste of scarce healthcare funds is appalling, and the disruption to the healthcare system is unforgivable–especially in practices where doctors and managers in many cases have been sold a bill of goods, and they are revolting by changing EHRs, going back to paper or retiring. And the Government should look to itself first. Look no further than to the multiple failures of two branches of the US government, Veterans Affairs and Department of Defense, which have the responsibility for current and veteran members of our Armed Services. They have failed spectacularly in serving Those Who Have Served not only the integration of their two EHRs but also in updating their basic architecture [TTA 27 July ‘Pondering the Squandering’… and 3 Apr ‘Behind the Magic 8 Ball’ both review the sad details.] The belief that HIEs with limited funding will solve the interoperability problem is Magic Thinking. At least one move in this direction makes sense: the CommonWell Alliance of six EHR heavy hitters to work on ‘data liquidity’ [TTA 5 Mar announced at HIMSS], but this may be another ‘uh-oh’ and face saving.

With basic, necessary health and patient information stuck in systems and getting lost in translation, how can anyone rationally expect that personal data from telehealth devices will be integrated anytime soon, in any meaningful way? Does this mean that parallel, separate systems and platforms will continue to develop–and yet another wave of integration?  

Pondering the squandering of taxpayer money on IT projects (US)

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2013/02/gimlet-eye.jpg” thumb_width=”150″ /]The Gimlet Eye has been in Observation Mode this week. But this handful of Dust-In-Eye necessitates a Benny Goodman-style Ray on another US governmental ‘fail’. When it comes to IT, the government admits…

Agencies Have Spent Billions on Failed and Poorly Performing Investments

Exhibit #1: FierceHealthIT summarizes five big ones out of a 51-page Government Accountability Office (GAO) report focusing on the inefficiency of agency IT initiatives–just in healthcare.

  1. Veterans Affairs (VA) VistA EHR system transitioning to a new architecture: terminated October 2010 at a cost of $1.9 billion
  2. VA-Department of Defense (DOD) iEHR integration: as previously written about, it collapsed under its own weight for another $1 billion [TTA 8 March]
  3. DoD-VA’s Federal Health Care Center (FHCC). Opened in 2010 as a joint facility under a single authority line, but somehow none of the IT capabilities were up and running when the doors opened. ‘Jake, it’s ChiTown.’ Only $122 million.

  4. DoD’s own EHR, AHLTA (no VistA–that’s VA’s) still doesn’t work right; speed, usability and availability all problematic. A mere $2 billion over 13 years.
  5. VA’s outpatient system is 25 years old. Modernization failed after $127 million over 9 years before the plug was pulled in September 2009

You’ll need Iron Eyes to slog through the detail, but it is a remarkable and damning document. PDF (link)

but…there’s more. Excruciating, hair-hurting, and would be amusing if not so painfully, and expensively, inept. Malware Removal Gone Wild at Commerce(more…)