The human side of developing integrated electronic health records

Don Wright/AP

Human processes, not technology, will be the biggest challenge in building the Defense-VA system.

As the Defense and Veterans Affairs departments work to develop an integrated electronichealth record the concept is simple—streamline the military health care system for active-duty service members, veterans and retirees—but getting there is not. The two departments will not deploy the system until 2017, eight years after President Obama kicked off the project in April 2009.

The interagency program office managing the iEHR wasn’t set up until October 2011, and its director wasn’t appointed until April 2012. That gives VA and the Pentagon five years to develop what Defense Secretary Leon Panetta dubbed the world’s largest electronic health record system, which would serve 9.7 million active-duty and retired military personnel and their families, and 7.8 million veterans.

The project is vital to the health care of roughly 6 percent of the U.S. population and requires a slow and deliberate approach to make sure “we get it right,” VA Secretary Eric Shinseki said in May.

“We’ll go as fast as we can without accepting . . . risk that’s not tolerable,” Shinseki said at the Capt. James A. Lovell Federal Health Care Center, a jointly operated Defense-VA hospital in North Chicago that serves as a showcase for pilot iEHR projects. “If we can go faster, we will. But quality and safety are the standards we measure ourselves by.” 

For Navy Lt. Cmdr. Donna Poulin, chief information systems officer at the North Chicago hospital, getting it right means focusing on business processes and the clinical staffers who use them, more than the information technology. At a tri-service medical IT symposium earlier this year, she said the “distinction between a business solution and a technical solution is always a challenge. IT is often seen as the problem solver, where business processes should be the driver of the technical solution.”

Dr. David Brailer, who was the first national coordinator for health information technology from 2004 to 2006, agrees. Development and deployment of the hardware and software needed for the iEHR pales in comparison to the “massive change management” processes that address the “human side” of the iEHR, he says.  

Brailer, now chairman of Health Evolution Partners, a San Francisco-based health care equity fund, says iEHR developers should expect to spend two to three times more on process changes than they will on hardware and software. 

VA Chief Information Officer Roger Baker pegged development costs for the iEHR at $4 billion, the amount Kaiser Permanente spent on an electronic medical record deployed in 2003 to serve 8.6 million patients—the closest project in scale. Brailer warns that when fully de-ployed, the iEHR initially will decrease clinician productivity, and he predicts it will take doctors up to a year to master the new system.

In a recent report to Congress, iEHR Interagency Program Office Director Barclay Butler said it’s a challenge to “effectively coordinate joint documents, policies and decisions through both departments for senior leadership approval in a timely manner,” which results in long lead times.

Defense and VA have fundamentally different views on how to develop the iEHR. Dr. Jonathan Woodson, the assistant secretary of Defense for health affairs, told Congress in April that the Pentagon wants to draw on best-of-breed commercial software to build the system. VA, on the other hand, backs an open software development approach based on upgrades to its existing Veterans Health Information Systems and Technology Architecture electronic health record system, known as VistA.

VA remains committed to developing a system “open in architecture and nonproprietary in design,” Shinseki said in May. 

Tom Munnecke, who helped develop VistA and worked on the Defense electronic health record when he was chief scientist at the Science Applications International Corp., believes the best-of-breed approach espoused by the Pentagon is bound to fail. It is analogous to the assumption that the best way to build a superior car is “to use the engine of a Ferrari and the leather seats from a Rolls-Royce,” says Munnecke, now an independent consultant.

Brailer acknowledges the catchall approach has its challenges, but he argues an amalgamation of commercial software is far better than open-source software, which he notes has never gained traction in health care IT, with the exception of VistA.

It appears Congress will have the final say on the structure of the iEHR. The House Defense and VA appropriations bills restrict any funding on the iEHR until both departments submit a fiscal 2013 execution and spending plan and a long-term roadmap for the project, including annual and total spending during the next five years.