Pentagon sticking to its guns in commercial approach to health record system

Within the next few months, the Pentagon will release a multibillion dollar solicitation to buy a new commercial IT system to manage its health records, and the officials managing the project say they will resist the Defense Department’s usual urge to customize the system so much that it no longer looks anything like a commercial product.

After DoD and the Department of Veterans Affairs abandoned their multiyear effort to build a single, shared electronic health record (EHR) system, DoD decided the next best way to solve the data sharing problem between the two departments was to buy a commercial health IT system that adhered to the common data standards around which the private healthcare world has already begun to coalesce.

Defense Secretary Chuck Hagel ordered that course change just over one year ago, and DoD has been busily issuing requests for information and draft requests for proposals ever since.

After circulating three draft versions, the Pentagon expects to publish a final RFP by the end of September and will likely issue a 10-year contract worth several billion dollars by the third quarter of next year.

Throughout that process, nothing has changed the Pentagon’s view that it needs to buy a commercial-off-the-shelf solution and demand very few government-specific modifications, said Chris Miller, the program executive officer for defense healthcare management systems.

“If you go and do research on the acquisition of major business systems or IT systems, where they usually get in trouble is when they try to take a commercial tool and change how it’s built,” Miller said. “We’re eyes-wide-open to that, and it’s also been a very clear message we’ve gotten back from the commercial sector. If you really want this to be successful and have agility, you’ve got to minimize those kinds of things.”

Speaking to reporters just after an industry day DoD hosted for 600 vendors who are pursuing the EHR procurement, Miller said the department has two main principles for its adoption of a commercial solution.

First, while it’s perfectly acceptable to make configuration changes within the parameters the developers designed, any requests to change the underlying software so that it suits the way military healthcare facilities do business right now should be very few and far between.

The second principle is closely related. DoD says it wants to use the new EHR system as a prod to standardize the way the military services conduct their business and clinical operations around the world, not the other way around.

“We are not going to tailor this for every single healthcare facility or even every military service,” Miller said. “We really want people to have to work through how they can use the tools before we customize the tools. If you want to be agile, you really have to minimize how much customization there is.”

The Pentagon estimates the new EHR system will cost $11 billion over its roughly 15-year lifecycle. Under the current acquisition strategy, the contract award it expects to make next year will last for up to 10 of those years.

Miller said the long performance period is justified because of the complexity of the tasks the winning team will have to perform, which will take several years to fully implement across the DoD healthcare system.

“We wanted to build a contract structure that incentivizes the contractor to really do the right things,” he said. “I want them to see that we have a commitment, and one way to do that is to make sure they don’t have to worry about competing for a new job every other year. You also have to consider the length of the deployment over more than 1,000 different locations. We would like to modernize our system quickly, but we recognize there are places that are going to take longer to get to. We want to make sure the contract covers the full deployment of the modernized system and also has a couple years of incentives, so that the industry partner can make the kinds of investments they need to in order to make this program successful.”

Success will mean that DoD delivers a health IT system that lets DoD healthcare facilities freely exchange patient data with VA and also moves the military’s own aging systems into the 21st century.

Miller said he expects somewhere between four and six teams of health IT software developers and systems integrators to compete for the contract, and did not foreclose the possibility of adopting some variant of VA’s VistA system.

When VA and DoD went their separate ways on the EHR project, VA decided its way ahead was a modernization of VistA with help from the open source software community, and it remains possible that one of DoD’s offers will involve a commercialized and modernized version of the software VA released to the public in 2011.

In any case, before DoD can make a serious run at integrating a modern health record system into its day-to-day operations, the department has a lot of in-house cleanup work to complete, officials said.

For years, it has layered on numerous and often uncoordinated data translation schemes so that military hospitals and VA can share at least some information with one another, and even though the ad-hoc web of workarounds is not something that either department would design if it were building a system from scratch, the information sharing capabilities that are already in place are not something the department is willing to jeopardize.

DoD says it will be working furiously over the next year to bring some rationality to that patchwork of IT so that it conforms with the same data standards it will demand from whichever vendor wins next year’s competition.

“Understanding our existing interfaces and information exchange processes is paramount to us achieving the real-time interoperability we’re looking for,” said Capt. John Windom, the program manager for the EHR modernization program. “Access to the legacy data is imperative.”

The challenge is sufficiently daunting that DoD created a new office whose main function is to untangle the military’s existing health IT systems and get them sufficiently modernized, so that they can interface with whichever system DoD winds up purchasing.

The Defense Medical Information Exchange (DMIX) is now in charge of most systems that move patient data from one military IT system to another and between DoD and VA.

Craig Schaefer, who inherited those systems when he became the first program manager for DMIX, said the picture is not pretty, but is gradually improving.

“Being in the IT field, I’ve gone to a lot of network operation centers where you could look at a screen and get a real-time view of all of the systems and see whether they’re up or down and how the traffic is flowing. We don’t have that,” he said. “At the beginning, I was getting emails that told me systems that were under my purview had been down for two weeks, but I had no ability to see that. That’s unsatisfactory, and we’re fixing that. Within the last three months, we’ve gone from Fred Flintstone-mobiles to VWs, and I’m hoping to get to a good Chevy by the end of the year.”

The DMIX office is also charged with combining many of DoD’s main existing healthcare data sources into a single, standards-compliant “spigot” by next year and reengineering the department’s data workarounds so that they can support the volume of traffic that will flow through them once the Pentagon opens the valve wide enough to share data between all of its existing facilities. After consulting with industry, the department came to the conclusion that it would be close to impossible for an outside vendor to implement a commercial EHR until it cleaned up its existing systems.

“There are instances in our systems right now where DoD clinicians request data from a DoD system that goes to a VA system that goes back to a DoD system, all in order to draw DoD data. Those things were all done by very well-intended folks in order to serve a mission at the time, but that’s not the environment we want you to come into,” Schaefer told vendors Wednesday. “For many of the capabilities we’re using, we’re using adaptors, and when we get to the full amount of data we want to exchange when we fully deploy, the capacity just simply isn’t there yet.”

Once DoD does award a contract, it will be in place for the next decade. But Miller said the government will remain in the driver’s seat when it comes to high-level decisions about how to evolve the EHR over that period and that the eventual RFP will insist that the new system be flexible and modular enough to keep pace with changes in the state of the art of health IT.

“We don’t want to pick Beta in a Beta-VHS war,” Miller said. “We want to make sure we’re riding a system that can evolve, because the commercial health IT market is robust and growing. Our strategy is to figure out how to leverage that, so we can make the lives of our clinicians better. We’re also trying to improve our service members and veterans’ access to their own health records. In the commercial space, Google, Apple, Fitbit and others are all doing things that make things a whole lot more personalized. We’re really trying to make sure our members get access to that information, and they can get access to their own health records.”

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