Can CBP Stand Up an Electronic Health Records System in 90 Days?

A Customs and Border Protection officer checks the documents of migrants who are on their way to apply for asylum in the United States as they depart Nuevo Laredo, Mexico, in September.

A Customs and Border Protection officer checks the documents of migrants who are on their way to apply for asylum in the United States as they depart Nuevo Laredo, Mexico, in September. Fernando Llano/AP

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Lawmakers eager to see Customs and Border Protection digitize its health care system are pushing a bill that would give the agency three months to go from paper to electronic records.

Legislation currently before the Senate would force Customs and Border Protection to expedite deployment of an electronic health records system in 90 days, a timeline one former official with experience in the area says is “incredibly optimistic” in the best of circumstances.

U.S. Border Patrol apprehended more than 977,000 people attempting to cross the southwest border illegally over the last year, an 88% increase over fiscal 2018 and the relatively stable numbers going back several years.

As those people are taken into custody, they are evaluated by medical personnel who document health issues and other medical conditions, according to the agency.

“CBP shares appropriate medical information with U.S. Immigration and Customs Enforcement and the Department of Health and Human Services prior to the transfer of migrants/detainees,” a CBP spokesperson told Nextgov. “In locations with medical contract support providing care onsite, that information includes documentation of an exit health interview and any appropriate medical treatment information. In other locations or circumstances, including in the case of referrals to local health systems, CBP shares appropriate discharge and care information with the aforementioned agencies.”

But that process is entirely paper-based, the spokesperson confirmed. The agency is currently working on an EHR system but did not respond to questions about whether the system was being built in-house or bought from a commercial vendor or whether officials had done any market research.

“CBP is currently developing an electronic health record system to facilitate the collection, retention, review and exchange of medical data in a manner that is compatible with agency operations and operational systems as well as consistent with extant privacy regulations and agency policies,” the spokesperson said. “Additional information about that system will be available as planning and implementation progress.”

That development process would be kicked into high gear under a proposed bill currently before the Senate.

In September, the House passed legislation introduced by Rep. Lauren Underwood, D-Ill., that would give CBP 90 days to establish an electronic health records system that would work across the agency’s components, including Border Patrol. The bill also requires the chief information officer to give a report to Congress within four months of deploying the system.

The bill is now in the Senate, where it was referred to the Judiciary Committee on Oct. 15.

But deploying an EHR system at scale is no easy task, as the departments of Defense and Veterans Affairs—and Veterans Affairs and Veterans Affairs—can attest.

Former VA Chief Health Information Officer for the Office of EHR Modernization Genevieve Morris, who also served as principal deputy national coordinator for the Office of the National Coordinator for Health IT at HHS, said 90 says is extremely optimistic, even if CBP were to cut corners.

“If you want literally no feedback or engagement from anyone who is going to use the system, then you could probably get it done in 90 days,” she told Nextgov. “But your adoption and usability issues—which will likely affect safety—are going to be really big issues. And you might also have a lot of people quit.”

In her role at VA, Morris led the department’s effort to transition from its own in-house EHR system, VistA, to a commercial solution from Cerner that is also being rolled out at the same time as the Defense Department’s new system, MHS GENESIS. She ultimately left the agency a little more than a month after being appointed, citing disagreements with VA leadership over the direction of the program.

Morris is currently the owner and operator of health IT consulting firm Integral Health Strategies and a Republican candidate for Congress in Maryland’s second district.

Before CBP can decide on an EHR solution, the agency will have to begin the hard work of mapping its physicians’ workflows to determine exactly what kind of information will need to be collected. While CBP generally tries to ensure all of its facilities have the same capabilities, the agency’s medical priorities will be different from that of other health care organizations.

“For example, it’s probably not as important to capture my old ankle injury coming into the country … versus capturing what immunizations I’ve had done,” Morris suggested. “There’s certain pieces of information because CBP is a special environment that are going to be very different in importance level than what you’d find at a traditional practice.”

That first step—determining what information the organization collects, what is most important and how the agency wants to display that in a digital environment—can take 30 days for the average small practice with one or two offices, Morris said.

“That process takes significantly longer if you’re dealing with multiple specialties, multiple locations, etc. It can take 90 days just to do that analysis,” she said.

CBP is definitely not a small operation—and it’s getting bigger.

The agency currently employs more than 250 contracted medical personnel—doctors, nurses, physician assistants, technicians and the like—along the southern border, a CBP official told Nextgov. That number is up from about 20 contractors one year ago, they said.

In some high-traffic areas like Rio Grande Valley and El Paso, CBP now staffs medical personnel on site 24/7. And while agency guidelines call for holding migrants no more than 72 hours, the large numbers of people being detained have led to longer holding times and overcrowded facilities.

Deploying an EHR system to help with this process “is a direct ask from medical officers at the Department of Homeland Security who have identified it as a high-priority barrier to providing care,” Underwood said during a September floor speech.

Once installed, the system will also have to be interoperable with ICE, as well as systems used by HHS, per the legislative intent.

“Immigration and Customs Enforcement has an EHR. The Office of Refugee Resettlement has an EHR. But Customs and Border Protection, which includes the U.S. Border Patrol, doesn’t,” Underwood said. “When I was at the border I saw busy, overworked Border Patrol officials having to keep health records on paper. I also saw how these records don’t always follow migrants between facilities and transfers of custody.”

That is easier when using the same commercial software, Morris said, but challenges remain.

“The interoperability piece is really hard no matter what system you use,” she said.

And, beyond federal systems, the agency will also have to connect the EHR with private sector health care organizations, as CBP often refers migrants with serious medical needs to local hospitals and treatment facilities.

“If the legislation says they have to be integrated systems, they could be thinking of something similar to what the VA and DOD did, where DOD had already selected their system and then VA” opted to use the same system, Morris suggested. If CBP choses the commercial route, it might consider buying a version of the EHR system used by ICE developed by eClinicalWorks.

“CBP might be thinking something very similar: If ICE is already using eCW and because it’s a very similar type of treatment environment, part of the 90 days is not actually selection process,” Morris said.

Even so, determining how an EHR system would need to be customized for CBP’s needs will take time, Morris said, especially if the agency plans to do it right.

“If you don’t want any input from the clinicians or the people using the system, you can do things faster,” Morris said, though she strongly urged against that tack. “But if you want to actually do workgroups and engage them, like what the VA did … that takes months to do.”

Even with that engagement and lots of training, it will still take users time to adjust to using the new system. In general, even when staff have been heavily engaged and well-trained, organizations still see a 20-40% reduction in the number of patients seen per day after a new EHR system is implemented, Morris said.

Those numbers will normalize over time, she said, but there will be a slowdown during the initial rollout no matter how well CBP prepares. If the agency does not sufficiently map workflows and provide enough training to users, the rate at which staff can see patients could slow as much as 60% or more.

“You could do that faster,” Morris said of the whole process. However, “you’re probably going to have a massive patient safety issue when none of [the staff] want to use the system and/or blow off their training and don’t want to do it well because they’re angry that you didn’t engage them.”

In her floor speech, Underwood said 90 days is “an aggressive but achievable timeline that reflects the urgency of the humanitarian situation at our southern border.” Her office did not respond to multiple requests for comment.

For Morris, all totaled, 90 days does not seem like a reasonable target, even with an optimistic outlook.

“With how many locations they have and the fact that they now have 250 staff, a 90-day implementation widow is probably not very realistic,” she said. “90 days is incredibly optimistic for implementation.”