Defense to re-engineer electronic health record system

After complaints that a $6 billion proprietary system is slow and unreliable, officials plan new architecture based on commercial software and open standards.

The Defense Department has laid the groundwork for a radical shift in the way it processes and stores soldiers' and veterans' electronic health records, planning to re-engineer a network it spent $6 billion and eight years developing in-house for one based on industry standards, commercial software and re-use of existing code that will serve Defense and the Veterans Affairs Department, top officials told Nextgov.

Comment on this article in The Forum.The Military Health System, which has been building an electronic health record system called the Armed Forces Health Longitudinal Technology Application, will work to create by the end of 2009 an enterprise architecture for the system, said Charles Campbell, the chief information officer at MHS. The agency will collaborate with a military and industry team to develop a new service oriented architecture for a record system designed to will serve 9.2 million active duty and retired military personnel and their families.

The system will manage outpatient records, a task currently handled by AHLTA, inpatient records, which is a function not available on AHLTA, and battlefield records, Campbell said. He added that the new architecture "is the framework, not new applications. We are not planning to get rid of AHLTA."

VA plans to work closely with Defense in development of the new architecture, particularly on the service oriented architecture, which will allow one department to re-use software components developed by the other, said Paul Tibbits, deputy CIO for enterprise development at VA.

The departments will design the architecture to be interoperable with the VA electronic health record system Tibbits said. Campbell said the VA would be part of the MHS development effort.

The House and Senate Armed Services committees, in the final version of the fiscal 2009 Defense Authorization Bill approved on Tuesday, said Defense and VA must adopt technology-neutral guidelines and standards to support the use of fully interoperable electronic health information systems. Rep. Ike Skelton, D-Mo., chairman of the House Armed Services Committee, anticipates the House and Senate will pass the final version of the bill and sent to President Bush before Congress adjourns for its fall break on Friday.

AHLTA has been a source of controversy. In July, Ward Casscells, assistant secretary of Defense for Health Affairs, said MHS needed to move away from AHLTA because military doctors were "fed up" with the system and it was "sometimes down and sometimes slow." He also said MHS planned to work with the VA toward a "converged evolution" of AHLTA and VISTA, which the department started developing in 1985.

Casscells had planned to brief Congress on the new Defense-VA plan for electronic health records by the end of July, but Tibbits said the new converged systems will not be announced until the second quarter of fiscal 2009.

Tibbits said the new architecture will assure data sharing between Defense and VA to create a single health record for patients and to integrate health care operations without requiring either department to abandon its system. Hospital staff will be free to use applications that are most suited to the mission of their departments.

Each department will continue to have operational responsibilities for the components of its own system, Tibbits said. "This is not a single computer system," he emphasized. "It is a single logical health record for each patient that is sufficiently robust for integrated healthcare delivery."

Casscells, speaking at a Government Executive breakfast on Aug. 13, estimated that it would cost $15 billion to evolve the Defense and VA systems. David Brailer, who served from 2004 to 2006 as the nation's first National Health Information Technology Coordinator in the Health and Human Services Department, agreed with the price tag, comparing it to Britain's National Health Service project to develop a health IT system to serve 50 million patients. That system, originally estimated to cost £10 billion in 2003, is now pegged at £20 billion (U.S. $37.1 billion).

Brailer, now chairman of Health Evolution Partners, a health care venture capital firm based in San Francisco, said developing and deploying a large-scale health information system requires significant customization, which drives up costs and extends schedules.

But Campbell said the new architecture could be developed for less than $1 billion. And by using a service oriented architecture, the departments will save time and cut costs because MHS can reuse code and applications developed for AHLTA, much the same way MHS has done with battlefield medical systems, said Col. Claude Hines, program manager for the Defense Health Information Management System.

Campbell said the use of standards-based systems, as well as commercial products, also will hold costs down because they will replace some AHLTA components that are old and therefore difficult and expensive to maintain. For example, Hines said some systems within MHS are so old they do not use the Health Level 7 electronic messaging standard mandated by the Office of the National Coordinator for Health Information Technology. Not being able to follow this standard requires more expensive customization, Hines said.

Those developing the architecture for the new Defense-VA electronic health records system must heed VA's software development culture, which is based on clinician involvement at every stage of the process, said Joseph Dal Molin, founder of e-cology Corp. in Toronto and who works on deployments of an open source version of VA's electronic health record software.

Brailer agreed that clinicians must participate in the development of the system, a lesson Britain learned in development of its national electronic health record system. He added that Defense and VA also must convince Congress to sign off on their grand plan and develop a budget and management structure that spans the two departments. He suggested the formation of a joint Military Veterans Health Information Technology Office to oversee the process.