Posted on 03/11/2018 5:31:58 AM PDT by SandRat
Rep. Phil Roe (R-Tenn.), chairman of the House Veterans Affairs Committee, returned from a recent visit to Fairchild Air Force Base, Washington, alarmed that the Department of Veterans Affairs might have made a bad decision last June. That’s when to replace its legacy electronic health record system, VistA, with the same commercial off-the-shelf system the military is adopting, starting with Pacific Northwest bases.
“I came back blowing the bugle,” said Roe, a physician, who saw staff at Fairchild’s hospital frustrated at the MHS Genesis system in ways that recalled for Roe his experience years earlier shifting paper to electronic medical records.
In this case, however, Fairchild physicians were frustrated that only minimal patient data had transferred from the Defense Department’s legacy system, ALHTA, into the Cerner Millennium architecture used in MHS Genesis.
If VA adopted the same system, Roe remembered fearing, physicians would have to spend two to three additional minutes on each patient just looking into VistA data that Roe had expected would be transferred into the new record system.
“If I don’t have it all in front of me,” Roe said, “you’ve just added another hour to my day. You ask doctors today what’s frustrating them. It’s the damn electronic health system. It takes part of the joy out of medicine.”
Roe said he feared that a lot of the efficiency savings that VA expected to realize from modernizing electronic records would be lost by having to maintain the legacy system alongside the new system, perhaps for decades.
That’s why Roe sounded retreat, he said. He’s put away his horn, however.
VA Secretary David Shulkin, back in December, paused contract negotiations and plans to piggyback onto the deployment of MHS Genesis for reasons unrelated to physician frustrations Roe witnessed.
In fact, Roe said, Shulkin soon reassured him that VA medical data won’t face the same transfer challenges as military patient data stored on ALTHA. Shulkin told him, Roe said, that contracting officials expect to be able to transfer up to five years of VA medical records into the new system for every patient enrolled in VA health care.
“They should have everything pertinent in there,” Roe said.
“They will keep the rest of that information stored for legal purposes or, I guess, if they had to deep dive when somebody left information out or a disability claim that still needed to be data mined. But for the most part, if I’m a (VA) doc sitting in front of my screen, getting ready to see my patient, I’ll have everything I need on one system.”
Roe remains concerned that the Department of Defense will have to keep ALTHA accessible to medical staff for years longer than VA will need to use VistA, even though VA’s patient base is at least twice as large.
What Roe discovered at Fairchild, however, has been well known for years among architects of government electronic health records. Since at least 2009 when the Obama administration announced plans for a virtual lifetime record system using worldwide standards, the Department of Veterans Affairs has taken more care than did DoD to collect and store medical data in a common format, compatible with popular electronic record systems in the private sector.
Defense officials knew they would face hurdles on data transfer when they signed the $4.3 billion 10-year Defense Healthcare Management System Modernization contract in July 2015, with Leidos Inc. tasked to deploy two popular commercial systems, Cerner Millennium for medical records and Dentrix Enterprise for dental, to modernize military health records.
“DoD does not concede this will be a problem for us,” said Stacy Cummings, program executive officer for Defense Healthcare Management Systems.
She acknowledged VA and DoD are modernizing different legacy models. DoD, in fact, has three legacy electronic medical record systems in AHLTA, Essentris and CHCS, each of which manages health data differently.
“As we transition to MHS GENESIS,” Cummings said, “we will sunset legacy tools locally, at each medical facility, and once we have fully transitioned we will sunset the legacy programs at the enterprise level.”
Health-care providers at military facilities, meanwhile, will continue to view legacy health data through the Joint Legacy Viewer, a clinical application created years ago to allow “read only” access to medical records stored by DoD, VA and private sector partners who participate in the common data viewer.
MHS Genesis’ rollout began in February 2017 at Fairchild and at Oak Harbor Naval Hospital in June. Madigan Army Medical Center on Joint Base Lewis-McChord and Naval Health Clinic Oak Harbor followed.
Plans are to have the system fully deployed at these sites by 2019 and throughout the military by 2022.
Further expansion at these bases is in a planned pause, for eight weeks, while managers review more than a thousand user complaints and make necessary adjustments to enhance the system, DoD and contract officials explained.
Shulkin paused VA contract negotiations with the Leidos-Cerner team in December so the not-for-profit MITRE Corporation could study the draft contract and identify issues. Roe said MITRE made many recommendations. One would direct VA, not Cerner, to own the connection portal, or API gateway, between community providers and insurance companies.
Another would require VA to create an external panel to conduct annual interoperability assessments to judge how effective the new system is in accessing and transferring medical data.
Patrick Flanders, chief information officer for the military health system, said the requirement to keep medical records available through AHLTA, at least through full deployment of Genesis, is tied to it being “an old system” with “poor” data.
Some of the frustration Roe heard from providers at Fairchild, Flanders said, are “part of just the growing pains” of using a new system installed at targeted sites for the purpose of achieving initial operational capability.
Adrian Atizado, deputy national legislative director with Disabled American Veterans, has been studying VA plans to piggyback on the DoD plan for modernizing records, using the same contractors and architecture, applying DoD lessons learned and using the same staff that brings MHS Genesis to life.
Atizado questioned whether the piggyback arrangement can be sustained for too long if, in every region of the country, VA can transition to the new health record system faster than DoD because of ease of medical data transfer.
If VA had followed DoD’s lead into Washington state, for example, would VA have to delay its own progress modernizing records at VA facilities in state while DoD paused for weeks to fix user complaints at military hospitals, Atizado asked.
“And if VA doesn’t roll out behind them, but in front, what will that do to VA costs?”
Shulkin was expected to announce resumption of contract negotiations soon.
Roe applauded the secretary’s caution on a contract estimated at $15 billion.
“This is the biggest electronic rollout that anybody’s ever done. Biggest in the world,” Roe said. “And VA doesn’t have the greatest track record of rolling big stuff out on time and under budget, I can tell you that.”
Tom Philpott has covered the U.S. military for more than 30 years. To comment, send e-mail to milupdate@aol.com or write to Military Update, P.O. Box 231111, Centreville, VA, 20120-1111.
That's an argument to never ever try to upgrade, because there is always some overlap in this kind of transfer. Not quite the same as "it's pointless to build another refinery because it won't be finished for ten years", but similar. Good to see in the next paragraph that he came around to reality.
I am looking forward to the day when I go to a new doctor for whatever reason (emergency, out of my usual area, opportunity) and having them type my name into their computer and seeing my last five years of medical information instead of having to fill out a five-page "new patient" form.
Opting for an off the shelf system instead of a custom build sounds like a small step in the right direction.
The old VA system was very good. They needed to just expand the old electronic VA medical records system into the military rather than force a new system on everyone.
Follow the $$$$$$ to corruption.
He's put this Marine through HE$$. He's now in a wheelchair.
When my Internist office made the computer switch they only put in the current internist, not the first one I was seeing and had to medically retire. They missed a few meds. When she quit they stuck me with a UNDER Educated APN. After 2 visits I fired her. They best hire a Internist who can handle Seniors or they will end up with a lot less patients. Methodist doesn't talk with Baptist, nor do they talk to the Cathiloc hospitals.
They need to go back further than 5 yrs unless that is how old you are. All my health records from the 70’s on are LOST. Some of those from the 90’s are now needed and can’t be found either. DUMBO was supposed to fix that.
“The old VA system was very good.”
I thought it was horrible.
I know this is a long post, but it is for the benefit of some who might not realize the scope of what they have to do in order to bring this new Cerner EMR system online.
This is a huge endeavor and needs doing, but the thought of this is daunting. I do these kinds of migrations for a living, and they are always painful.
Always. And while the systems I have helped migrate may have millions of patients, studies and histories, the VA one is far, FAR larger and the systems (new and old) are likely just as disparate.
Additionally, the problem is not confined to simply figuring out what data points are in the old system, matching where those same data points belong in the new system, finding a way to export from the old into the new, and voila, you’re done!
Sure, there are things like PATIENT NAME, DOB, SEX, etc. that are always going to be present in some form in two systems, but even in two relatively modern systems, SEX may be three values “M”, “F”, “U” in your current system, but the new system may store values of 1, 2, 2, 3,4, or 5, and you may have to translate those M, F, U values into the new systems value that says the same thing. I have even seen old systems that had people free texting things in, and you saw things like M, Male, Man, etc. Those all have to be translated.
In many cases, the new system has capabilities that need data points (because it is NEWER and ostensibly has more capability) and in some cases, there may be not data points in the old system, so there is no flag. If it is a mandatory field, you have to do an exercise to see if an proxy value can be developed from the old data, and if not you figure out the least intrusive value to put in there so the field is populated and then update it with new data going forward as patients are processed through.
And there are even other cases where the new system doesn’t have the capability of the older system. So you have to do a gap analysis, study the capability of the new system, and compare it on a point by point basis. Which involves doing intricate work flow analysis, with flow charts and such to make an accurate evaluation and comparison. We had one such system had such a long and intricate workflow the analysis went to 10 pages, with arrows leading off the edge saying “Got to page 6” and such, and we never finished it. We got to the point we decided we were going to have to keep that old mainframe system running for a variety of reasons, and that function was one of them.
I remember many years ago we were evaluating transitioning a very old mammography system from the DOS system it ran on to Windows. We did the exercise to getting all the fields available, and comparing them. We found out the Old system had far more fields than the new system, which we thought might be preferable, but it involved long conversations with the developers who who actually wrote the code, asking questions like “What does this value here do in YOUR program? Armed with that information, you talk to the software developers at the NEW product, and they are baffled. “We don’t do to that way, we use thee flags with three data points to do that same function in our system, and we can’t use that point...”
Bottom line: we ended up running the two systems in tandem for a long time, because there was no other alternative. In these types of things, sometimes there simply is no alternative, because the political or patient care ramifications rule them out.
And so on.
New isn’t always better. Well, if that is the case, why not stick with what you have and improve it? That is usually an option to evaluate, but many 10-30 year old systems have reached certain structural/database limits, cannot be protected from malware, cannot have the software upgraded any further...basically, you just reach the end of the road.
And then you have to do data migrations themselves, all don in a dynamic environment where patients are having things done every single day, and those migrations cover labs, radiology, patient notes, audit trails, pathology, appointments, cancels, which all need their own complicated migrations done.
And this doesn’t even take into account how putting in this new system interacts with other systems. You may have had a nice integration where when you opened the medical record of a patient and looked at an X-ray result in your medical record, that It automatically opened the images for viewing too. You have to maintain the same function, if you can’t outright improve it, which is what people expect.
I am fully on board with clinicians and patients who don’t like the modern concept of Electronic Medical Records (EMR). It turns high powered clinicians and doctors into data entry people, and often makes patients wait longer. But they do have their clinical upsides if done correctly, and in today’s litigious environment, being able to force people to capture a data point with a forced question has value, as does the IT aspect of being able to easily patch it to keep it protected from current threats.
It is a huge job, and I is going to cost the taxpayers a lot of money. But if we have to do it to improve care to our veterans...we have to do it.
The scope of it does make me a bit queasy, though.
See my post above, tired&retired. Sometimes, especially with older systems, they must be replaced.
Some systems are very good, but they cannot be protected from malware or other electronic attack, they cannot be re-written to take into account concepts of healthcare that weren’t even around when the program was originally written, and so on.
Sometimes it cannot be done, and you have to make the change before you find out you are in hot water up to your neck and HAVE to make an emergency switch to a new system.
And THAT is NEVER good for anyone, patients, staff, IT, the taxpayers. EVERYONE is hurt there.
I agree. I live miles from the VAMC I go to for all my care. Miles translates into almost 90 miles. When I need to talk to someone after hours I call a regional VA number, speak with a nurse and, after reading my record, transfers me to an appropriate facility. It has proved to be faultess.
My PCP was and is able to acces my records since 2006 and pick out the pertinent information. Of course, I think she is the smartest woman the VA has ever hired. And, actually she may be.
Never have I had a problem of inaccessible medical information while at the VA.
Actually, I don’t “get” it why it has to be changed? I think someone decided to make some money.
And what will the programs like Myhealthevet.gov or the Million Vet programs do with their data? I have no idea about all the programs dependent on data will do in the VA system?
I smell a disaster, denial, and monstrous amounts of money to fix it.
“Never have I had a problem of inaccessible medical information while at the VA.”
Not just within your VA. You could be on vacation and go to any VA Hospital anywhere and they have your medical records.
It also saves you from having a lot of duplicate tests. Your Internist can order a blood test and all the other MD’s can use the same results rather than retesting.
“And THAT is NEVER good for anyone, patients, staff, IT, the taxpayers. EVERYONE is hurt there.”
The old system was is a very secure system. It’s much better than the other government offices like the GO.
“I thought it was horrible.”
I’m curious in what way it was horrible for you.
My experience is that the medical records system is good, but not all the people using it are.
Now the VA can lose your records more efficiently.
Our hospital system is migrating to it this May
I’m not looking forward to it
It isn’t just security.
The problem is, that with changing regulations and capabilities in medicine, systems have to be able to adapt, and I have seen a lot of systems that have figurative “hardening of the arteries”, that is, they become so crusty with layers of adaptations over time, that they simply reach a kind of block obsolescence and upgrading becomes more and more difficult over time.
I have had to say goodbye to systems that were perfectly fine in my eyes, but were completely unsatisfactory in the overall scheme of things.
And you never want to reach the state where you have to upgrade at the point of a gun (figuratively speaking)
I agree. The addition of bureaucratic rules has burdened the VA medical record system immensely.
They started using the medical records system to create treatment statistics and then began altering the records to improve the statistics.
The VA has also started data mining their medical records system to predict individuals most likely to commit suicide for closer monitoring.
My local VA just updated their operating system last year.
They were running WindowsXP long after they stopped offering updates.
I am all for the concept of data mining, since I believe that in the world of a single EMR, they can find relationships between all kinds of diseases and various medication states and such. I believe hospitals in the public domain are trustworthy, because the government has show a zeal to prosecute and fine, so hospitals are extremely careful with patient data, and even then, when they make an honest mistake, the government pounces and levies extraordinarily harsh penalties.
However, I am 100% distrustful with the government, since they have shown they have zero trustworthiness with personal data, and to make it worse, there is zero accountability. Look at what happened with the IRS letting loose data on millions of citizens, and not a single person was disciplined or fired. Shameful. I don’t trust the government with any of my personal info even though I am forced by law to give it to them. And that is distrust for simple guarding of the data as any private entity would be required to due to accountability and business viability concerns.
When it comes to the misuse of my information by the government, I am doubly wary.
If I were a veteran dependent on the VA for care, I would always be concerned that anything I said would immediately end up in the hands of a government entity outside of the VA, and not in a good way.
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