From Parallel Universes? Dueling Accounts of VA/DoD EHR Integration

At a March 2010 post "VA / DoD EHR Interface Debacle: Will It Take the Luminosity Of A Dozen Supernovas To Shed Light On The Obvious About Healthcare IT?" I wrote about problems with ongoing efforts to integrate the Veteran Administration's EHR and the Dept. of Defense (active military) EHR.

Now there appears to be two dueling accounts of the task's progress:

Account One:

DOD, VA to Speed Integration of Health Records
By Jim Garamone
American Forces Press Service

WASHINGTON, Feb. 5, 2013 – The secretaries of Defense and Veterans Affairs announced their departments will speed implementation of the Integrated Electronic Health Record program, allowing service members and veterans better access and more importantly, better medical care.


This approach is affordable, achievable, and if we refocus our efforts we believe we can achieve the key goal of a seamless system for health records between VA and DOD on a greatly accelerated schedule,” said Defense Secretary Leon E. Panetta following a meeting with Secretary of Veterans Affairs Eric Shinseki at VA headquarters here.

The departments are able to step up the records program because of advances in information technology while working with existing platforms. The original goal was to have the system deployed by 2018. Now the expectation is by the end of next year.

The goal is to provide one set of electronic records from entry into the military through veteran status. The program is designed to allow service members or veterans to download information and present it to doctors or other health care providers without delays.

Previously, service members had to hand carry paper files from DOD facilities to Veterans Affairs. Once complete, the record program will provide DOD and VA clinicians with the complete medical records of more than 18 million service members, veterans and their beneficiaries.

“We’ve agreed to improve interoperability before the end of this year by standardizing health care data,” Shinseki said. The two departments will also accelerate the exchange of real-time data by September. The departments are upgrading the graphical user interface to display the new standardized VA and DOD healthcare data by the end of this year, Shinseki said.

... “By this summer, DOD and VA will field and begin conducting a pilot program on the common interface for doctors at seven joint rehab centers across the country and we’ll also expand its use at two other sites,” Panetta said. “All of these facilities will be interoperable by the end of July 2013, so fast time track, but we think we can get it done.”

“Rather than building a single, integrated system from scratch, we will focus our immediate efforts on integrating VA and DOD health data as quickly as possible by upgrading our existing systems,” Panetta said.

 

Account Two:

IMMEDIATE RELEASE: February 6, 2013 CONTACT: Curt Cashour (202) 225-3527

Senate and House Veterans’ Committee Leaders Fault VA and DoD on Integrated Health Record System

WASHINGTON, D.C. – The chairmen and ranking members of the Senate and House Committees on Veterans’ Affairs today faulted the Pentagon and Department of Veterans Affairs for backing off plans to create a single computer system to integrate electronic medical records for troops and veterans.

Senate Committee on Veterans’ Affairs Chairman Bernie Sanders (I-Vt.) said: “I am deeply disappointed by the VA and Defense Department decision to back away from a commitment to develop and implement a truly integrated, single, electronic health record. President Obama charged the departments with creating a seamless system of integration so that service members transitioning from active duty to civilian life don’t have to worry about whether their health records will be lost or their claims delayed. An integrated record would allow for a streamlined and timely claims process, faster decisions on benefits, less duplication in medical testing and more efficient, cost-effective treatment for both physical and mental health needs. Now more than ever we need greater cooperation between the departments to solve the serious challenges that continue to confront our service members and veterans. I will continue to work to achieve better coordination by the departments and to ensure that the needs of veterans are met.”

House Committee on Veterans’ Affairs Chairman Jeff Miller (R-Fla.) said: “The decision by DOD and VA to turn their backs on a truly integrated electronic health record system is deeply troubling. The need for a record system integrated across all DOD and VA components has been universally accepted for years, and until yesterday, both agencies have given us nothing but assurances they were working toward that goal.

Previous attempts by DOD and VA to use disparate computer systems to produce universal electronic health records have failed, and unfortunately it appears they are repeating past mistakes.  [This seems the "focal point" of the apparent discrepancy, one system vs. two that are interfaced - ed.]  When DOD and VA take shortcuts, the veterans and service members under their care will be shortchanged.”

Sen. Richard Burr (R-N.C), the ranking member of the Senate committee, said: “The fact that VA and DoD would reverse course on a plan they have been working towards for years that would create a coordinated electronic health record system between the two agencies is concerning and disappointing. I am concerned about what this means for our nation’s service members and veterans, particularly those who will be transitioning from active duty service to civilian life in the near future. We owe it to our nation’s defenders to do all we can to care for them and provide the most effective, efficient service we can, and coordination and communication between these two agencies is absolutely vital.”

Rep. Mike Michaud (D-Maine), ranking member of the House committee, said: “This is a huge setback and completely unacceptable. For years we have been told by both agencies that progress was made and that things were on track. I’m disappointed that our nation’s two largest government agencies – one of which is the world’s foremost developer of high-tech machines and cyber-systems – could not come together on something that would have been so beneficial to those that served. We have just witnessed hundreds of millions of dollars go down the drain.”

Additional Contacts:
Michael Briggs (Sanders) 202 224-5141
David Ward (Burr) 202 228-2971
Ed Gilman (Michaud) 202 225-6306

So, some are touting a marvelous effort ready for prime time in 2014, and others are speaking of hundreds of millions of dollars down the drain with nothing to show for it.

As Captain Kirk said to Mr. Spock in the award-winning Star Trek episode "The City on the Edge of Forever" about conflicting accounts of the early 1930's death of Edith Keeler, played by a pre-Dynasty Joan Collins, vs. Keeler's mid-to-late-1930's rise to national fame and her becoming the cause of World War Two being lost ... "They both can't be true." 

(Using the clock-mender's tools, Spock gets an image on his tricorder screen of a newspaper report. Edith Keeler, social worker from 21st Street Mission was killed today, it says. Kirk enters.)
KIRK: How are the stone knives and bearskins?
SPOCK: I may have found our focal point in time.
KIRK: You may also find you have a connection burning someplace.
SPOCK: Yes. I'm overloading those lines. I believe we'll have our answer on this screen.
KIRK: Good.
SPOCK: And, Captain, you may find this a bit distressing.
KIRK: Let's see what you have.
SPOCK: I've slowed down the recording we made from the time vortex.
KIRK: February 23rd, 1936. Six years from now. (reading below the headline FDR confers with slum area 'angel') The President and Edith Keeler conferred for some time today
(Then the whole thing goes up in flames.)
KIRK: How bad?
SPOCK: Bad enough.
KIRK: The President and Edith Keeler.
SPOCK: It would seem unlikely, Jim. A few moments ago, I read a 1930 newspaper article.
KIRK: We know her future. Within six years from now, she'll become very important. Nationally famous.
SPOCK: Or Captain, Edith Keeler will die - this year. I saw her obituary. Some sort of traffic accident.
KIRK: You must be mistaken. They both can't be true. 

Based on the points I raised in the aforementioned March 2010 post about current IT leadership and organizational structures (not to mention Beltway Bandit IT consultants), I am skeptical that either plan - monolithic vs. interfaced - has a snowball's chance of success.

Edith Keeler dies in either scenario. 

Let's just hope a war is not lost because of this cybernetic "how to do health IT poorly" feud.

-- SS

Feb. 7, 2013  Addendum:

I've received a comment that this post is a bit "geeky" but droll.

My response is a word often used by another highly popular SF character:  Indeed.

-- SS

If Our Honored Military Personnel's Medical Care Was Not Involved, This WSJ Letter Might Have Been Considered Oddly Funny

In the WSJ today, a letter to the editor was published extolling the major strides made by the U.S. military in voice recognition technology for electronic health records:

[Note: this is not to denigrate the military, and I am very thankful to all who serve and defend our country and freedoms. Health IT problems seem unfortunately universal - ed.]

Shared Information Can Give Better Medical Results
Wall Street Journal
JUly 26, 2010

There is no question that medical information, notes and all, belong to both the patient and the provider, helping each of them to manage a medical condition ("The Informed Patient: What the Doctor Is Really Thinking," Personal Journal, July 20).

In the U.S. Army in Europe, we are taking the concept a little further, from "what the doctor is really thinking" to "what the doctor is saying." For the last two years, we have been evaluating voice-recognition technology to improve the provider's experience with our electronic medical record. During the process, we came across a wonderful discovery: As doctors dictate medical notes into the record during patient visits, patients are paying much more attention to what doctors are saying, prompting them to ask important follow-up questions, add statements about something else that may be bothering them, or, most importantly, correcting the doctor when a dictation error is made. It's the type of patient-safety feedback loop that would otherwise be absent.

The more we allow our patients behind the curtain to see and hear how we work, the more we will see patients become true partners in their own health care.

Robert Walker, M.D.
Chief Medical
Information Officer
Europe Regional
Medical Command
Heidelberg, Germany

Here's the problem, as I outlined at my July 1, 2010 post "$4 Billion Military EMR "AHLTA" to be Put Out of Its Misery? Also, Does the VA Have $150 Million to Burn on IT That Was Never Used?":

I have heard from numerous reliable sources that the military's $4 billion+ EMR known as "Armed Forces Health Longitudinal Technology Application" (AHLTA) is to be declared a failure, and replaced.

I'd written about AHLTA's considerable problems at the post "If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?" at http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html .

From that post:

[AHLTA has been described as] difficult for physicians to use. Intolerable. Slow. Unreliable. Frequently crashes. Near mutiny. Morale. Affecting patient care, decreasing patient load. Can it get worse?

Yes ... When the Army's Surgeon General observes that clinicians "spend as much or more time working around the system as they do with the system", and that the superusers are not enthusiastic about the system, and a Congressional hearing is held entitled "where do we go from here?" (it's clear to this author that they have no clue), one should start to very critically question basic assumptions about health IT.

Read my June 2009 post on the AHLTA failure at http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html, and the May 2009 piece I referenced from "US Medicine - the Voice of Federal Medicine" entitled "Electronic Records System Unreliable, Difficult to Use, Service Officials Tell Congress" by Sandra Basu, in their entirety.

Extolling voice recognition advances in a failed $4+ billion EMR debacle due to severe unusability of most of the information system is akin to extolling the virtues of improving screen-door aesthetics on submarines being flooded by water entry. It could almost be considered funny, in a dark-humor sort of way - except the results are anything but humorous. "Dead serious" is a more apt term.

Finally, while "shared information can give better medical results", there seems to be little shared information about others' healthcare IT failures.

Organizations seem to be constantly re-learning that which others have learned years or decades in the past, repeating the same IT mistakes.

The cost of this self-education is not at all cheap.

(This failure to learn from others is one reason I write that health IT lacks the science and rigor of the field it ostensibly serves: medicine.)

-- SS

Jurassic Attitudes about Medical Informatics: in the U.S. Navy?

The message below to a listserv for Chief Medical Informatics Officers and related positions was recently forwarded to me by a colleague. I cannot believe what I am reading, as it reflects attitudes I'd thought were extinct by the late 1990's ("I don't see the value of clinical informatics").

The last time I'd heard such nakedly Jurassic views, and other anti-physician informatics attitudes as in this 1999 essay I penned, was from the C-level officers of the hospital where I was CMIO in that time frame, Christiana Care Health System in Delaware.

From: (Withheld)
Date: Sun, Jul 4, 2010 at 9:24 AM

Hi All,

I was recently told by one of our senior leaders that he saw no value to Clinical Informatics and followed that up by disbanding the Clinical Informatics Directorate at the BUMED (Headquarters of Navy Medicine) level.

I successfully countered that argument with a more senior leader, but I tried to find objective evidence of the value of Clinical Informatics without success. As an academic family physician who lives, eats and breathes evidence-based medicine, I try to make all my decisions and arguments for and against positions/programs based on the best available evidence. In this case, all I could use was potential value and logic.

My question is this: Does anyone out there (and I have already discussed this with [name redacted - ed.]) have any objective evidence that shows the value of clinical informatics to the Enterprise (which has multiple definitions, but suffice it to mean across an entire health care system.however large)? I have already talked with [name redacted - ed.] about including a survey of CEO's/COO's/CMO's/CIO's as to the value they see in clinical informatics, but that is some time in the future. I really need some data now. Anyone have anything? Any and all assistance is greatly appreciated.

In the face of the apparent spectacular failure of AHLTA ($4 Billion Military EMR "AHLTA" to be Put Out of Its Misery? Also, Does the VA Have $150 Million to Burn on IT That Was Never Used?), I certainly view such statements as extraordinary, and in a very negative sense.

It has become my opinion that Jurassic attitudes about medical informatics are virtually unremediable; they suggest an underlying technical and mental deficit in those who proffer such opinions that is not correctible by evidence and logic. (I can predict with a good degree of certainty that this "senior leader" had a role in AHLTA's demise.)

I suggest a different approach: surely patients received suboptimal care (and perhaps suffered injury) under AHLTA. The freebie newspapers serving the soldiers such as I have seen in my visits to Fort Dix, where my mother has commissary/PX privileges as a result of my father's service-connected injuries and disability, might find such a story "interesting."

In the meantime, I am doing a John Galt regarding persons espousing the "I don't see the value of informatics" view. I'm frankly tired that such people remain in the healthcare workforce. While I could provide a lot of material supporting the value of informatics (actually, its essential nature) that I and others have written over the years, I choose to no longer do so.

The military person proffering this view is apparently a "senior leader"; it's their responsibility and indeed obligation to make the Navy better. Let them lead.

And let the pieces fall where they may.

-- SS

$4 Billion Military EMR "AHLTA" to be Put Out of Its Misery? Also, Does the VA Have $150 Million to Burn on IT That Was Never Used?

I have heard from numerous reliable sources that the military's $4 billion+ EMR known as "Armed Forces Health Longitudinal Technology Application" (AHLTA) is to be declared a failure, and replaced.

I'd written about AHLTA's considerable problems at the post "If The Military Can't Get Electronic Health Records Right, Why Would We Think Conflicted EHR Companies And IT-Backwater Hospitals Can?" at http://hcrenewal.blogspot.com/2009/06/if-military-cant-get-electronic-health.html .

From that post:

[AHLTA has been described as] difficult for physicians to use. Intolerable. Slow. Unreliable. Frequently crashes. Near mutiny. Morale. Affecting patient care, decreasing patient load. Can it get worse?

Yes ... When the Army's Surgeon General observes that clinicians "spend as much or more time working around the system as they do with the system", and that the superusers are not enthusiastic about the system, and a Congressional hearing is held entitled "where do we go from here?" (it's clear to this author that they have no clue), one should start to very critically question basic assumptions about health IT.

One wonders if anyone responsible for AHLTA ever read my now decade-old site on health IT dysfunction, now at this link at Drexel University, or its many hyperlinks to additional resources.

Meanwhile, the VA is having its own problems as noted on the HISTalk blog:

[HISTalk News 6/30/10] Back in March, I dug out a juicy nugget from an internal VA report: it was scrapping a $150 million patient scheduling system without ever bringing it live. The GAO weighs in with its official report (warning: PDF), pegging the cost at $127 million and saying “VA has not implemented any of the planned system’s capabilities and is essentially starting over.” The contractor that developed the system with “a large number of defects” walks away with $65 million. GAO finds much to criticize about the VA’s involvement: lack of competitive bidding, sloppy specs, unreliable status reports, and lack of action by project oversight groups when the project started tanking.

The linked PDF report from the U.S. Government Accountability Office (GAO), entitled "INFORMATION TECHNOLOGY - Management Improvements Are Essential to VA’s Second Effort to Replace Its Outpatient Scheduling System", reveals errors that cause me to question whether the project leadership ever passed their introductory undergraduate IT courses (assuming they had any).

From that report:

VA’s efforts to successfully complete the Scheduling Replacement Project were hindered by weaknesses in several key project management disciplines and a lack of effective oversight that, if not addressed, could undermine the department’s second effort to replace its scheduling system:

• VA did not adequately plan its acquisition of the scheduling application and did not obtain the benefits of competition.
• VA did not ensure requirements were complete and sufficiently detailed to guide development of the scheduling system.
• VA performed system tests concurrently, increasing the risk that the system would not perform as intended, and did not always follow its own guidance, leading to software passing through the testing process with unaddressed critical defects.
• VA’s project progress and status reports were not reliable, and included data that provided inconsistent views of project performance.
• VA did not effectively identify, mitigate, and communicate project risks due to, among other things, staff members’ reluctance to raise issues to the department’s leadership.
• VA’s various oversight boards had responsibility for overseeing the Scheduling Replacement Project; however, they did not take corrective actions despite the department becoming aware of significant issues.
  

The impact of the scheduling project on the HealtheVet initiative cannot yet be determined because VA has not developed a comprehensive plan for HealtheVet that, among other things, documents the dependencies among the projects that comprise the initiative.

My question is:

By what miracle of God will the military's AHLTA's and the VA's scheduling system "replacements" be any better than what now exists? Through reliance on commercial EMR vendors and management consultant "experts", perhaps?

If so, I wish the military and VA the best of luck. They will need it.

The problems with computing in complex settings such as medicine are pervasive, far beyond the military. It is increasingly clear that the leadership of the healthcare IT ecosystem (and probably even the broader IT ecosystem) consists of recycled incompetents, never held accountable for project failures, even massive ones, instead moving on to wreak mayhem elsewhere. This has certainly been my own experience in both the hospital and pharma sectors.

Competent experts who actually try to do meaningful work (a.k.a. "rock the boat" or "non-team players" in the parlance of the incompetent and/or the power seekers) have become hopelessly marginalized - or unemployed. See the post "Edwin Lee on the Tiger We Are Now Riding" by Roy Poses. Our economy and even society is falling apart as a result of these leadership problems; Lee's post "Lightweight oil executives produce worthless disaster plans" as linked above is pathognomonic of these failures. Writes Lee:

... This week the executives of the other major oil companies (besides BP) presented their oil spill contingency plans to Congress. Several things were immediately evident: the plans were all grossly inadequate and carelessly done, they were all developed by the same outside consulting firm and they were essentially carbon copies of BP’s nearly useless plans. In other words, they were empty “cover your ass” documents rather than serious contingency plans. Some people may find this surprising. From my experience, it’s what we can and should expect from the vast majority of large, public institutions because of a universal and deeply flawed process for selecting their leaders.

... Those who are chosen to lead fit a mold: mediocre, short term thinkers with similar work experiences, outlooks, temperaments and personal incentives. Disaster response, creative thinking and fundamental changes are outside their limited range of interests or competencies.

Here is the major problem in a nutshell: no real accountability where it matters.

What follows from this is a first principle:

Recycled incompetents will never produce good information systems.

Major health IT commercial vendor CEO's have been reported as making statements that health IT usability -- one of AHLTA's major deficiencies - "will be part of certification over her dead body" (as described in my post at http://hcrenewal.blogspot.com/2010/05/did-epic-ceo-judy-faulkner-of-epic.html).

Why don't we recycle physicians with track records of killing patients? Better yet, make them Chairs of clinical departments?

The answer is obvious, but the IT culture seems immune to such considerations.

The UK's National Programme for IT in the NHS (NPfIT) is AHLTA on a national scale:

The UK Public Accounts Committee report on disastrous problems in their £12.7 billion national EMR program is here.

Gateway reviews of the UK National Programme for IT from the Office of Government Commerce (OGC) are here (released under the UK’s Freedom of Information Act), and a summary of 16 key points is here.

My prediction is this:

I do not believe health IT has advanced enough beyond the experimental stage for clinically efficacious, safe, cost effective mass dissemination.

Further, I do not believe that the human capital necessary to make such dissemination happen in a clinically efficacious, safe, cost effective manner exists in the IT industry.

Talent management in that industry -- based on cheap, just-in-time, "programming language/platform du jour", "smart people cannot or should not learn but should be declared obsolete", and Bart Simpson-style attitudes about ability and expertise -- does not allow the needed human capital to exist. A remarkable and revealing example comes from an article about health IT leadership a number of years ago in the journal “Healthcare Informatics”:

I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of hard knocks." In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman.

The "management improvements" sought by the VA may simply not be possible, until the IT field undergoes something comparable to the "Flexner report" that the medical professions and their educational programs underwent a century ago.

And perhaps until health IT leadership personnel begin to lose their homes and fortunes in court to harmed patient plaintiffs, to the point where the leadership start begging competent, marginalized professionals who actually know what they're doing to save their sorry asses.

-- SS

7/6 addendum:

For more on the topic of dinosaur-era attitudes about Medical Informatics that lead to such debacles, see my July 5, 2010 post "Jurassic Attitudes about Medical Informatics: in the U.S. Navy?"