"VA’s adoption of the same EHR system as DoD will ultimately result in all patient data residing in one common system and enable seamless care between the departments without the manual and electronic exchange and reconciliation of data between two separate systems."
-David J. Shulkin, MD
U.S. Secretary of Veterans Affairs
When the U.S. Department of Veterans Affairs (VA) announced it was going to migrate to Cerner’s electronic medical record (EMR), the same system being adopted by the Department of Defense (DoD), many assumed that this will result in seamless exchange of data that will improve care while reducing cost and hassle. Perhaps, but notice that Secretary Shulkin was careful to insert the word “ultimately” into the statement above. This is an acknowledgement that simply deploying the same EMR won’t fix the problems. In my opinion, if the VA and DoD don’t simultaneously pursue robust interoperability, “ultimately” could easily become “never.” This is true for civilian health systems as well.
Active duty military, veterans and their families represent a large, diverse and sometimes highly complex patient population. The numbers are impressive. On the DoD side, there were 9.3 million active military patients in 2016, while the VA cared for 9 million veterans in 2014. This complex delivery system is comprised of the DoD, VA and importantly, private facilities and providers. With no common EMR and very limited interoperability between the military and civilian systems, sharing information and coordinating care can be a nightmare for patients and providers alike. And, undoubtedly, care is less efficient and more expensive than necessary.
There’s no question that an EMR strategy of “one platform to serve them all” is seductive, particularly when facing the kinds of challenges the DoD and VA deal with. Proponents of this view maintain that if all patients and providers are on the same EMR, interoperability will become a minor issue.
I used to believe this as well, but time and experience have taught me otherwise. There are clearly shortcomings to the single-platform approach and robust interoperability will be essential for success.
Using the same brand of EMR is not the same as being on the same EMR
Let’s start with the reasonable, but incorrect assumption that two installations of the same EMR can easily share data. Many people assume that EMRs of the same brand can share information as easily as we pass around documents or spreadsheets created by the same application. After all, it’s the same EMR program, right? Nope.
The hard truth is that every implementation of an EMR is different and even same-brand EMRs do not seamlessly connect. Visit a large health system and you will discover that, due to limits in scalability or as a result of mergers, they must deploy or maintain multiple instances of their EMR and that those different instances do not easily interoperate. This is not unique to Cerner and I want to be very clear I don’t mean to single them out. The same is true, to a substantial degree, for all EMR platforms. The current plan is for DoD and VA to be on the same instance which is good.
Of course, they will still have an enormous problem being interoperable with civilian health systems. You see, the problem is even worse when trying to share across different EMRs, which is precisely what the DoD and VA will need to do for their many patients who also receive care from non-military providers (and those patients who will still be on a DoD or VA legacy system during the transition).
Robust interoperability is about much more than simple records portability
Obviously, moving patient records from one place to another is an important aspect of interoperability. But, it is not enough. True interoperability enables a symphony of applications that connect, exchange and collaborate. It encourages innovation by enabling market-driven competition to produce the best applications at the best price. Without this kind of interoperability, customers become highly dependent on their EMR vendor’s ability to innovate and are limited by that vendor’s talent, resources and priorities. This can stifle innovation and negatively impact usability, satisfaction, efficiency and clinical outcomes.
Consider just two examples that will be critical to the DoD and VA: telehealth and Injured Warrior applications. The case for telehealth in the military pretty much makes itself. Suffice it to say that, given the combination of global operations, complex medical needs and limited staff, telehealth will be an essential ingredient. And, not just any telehealth system will do. This one will need to be “military grade.” Are we satisfied that current EMR vendors have the best possible technologies for this mission?
Or, consider the emerging class of “Wounded Warrior” applications. The combination of advances in battlefield medicine, asymmetric warfare (like I.E.D.s) and extended, multiple tours of duty, have resulted in many more soldiers surviving far more complex injuries than in the past. Wounded Warrior applications are designed to improve the diagnosis and treatment of the unique physical and psychological injuries sustained on the modern battlefield. They represent a great hope for better care, but also a great challenge when it comes to interoperability. Like most digital health solutions, they are of limited use unless tightly integrated into clinical workflow, which often requires robust interoperability with the EMR.
EMR vendors typically lack the knowledge and resources to develop these kinds of specific applications. So, it’s great that the private sector is working on this and that the VA is pursuing innovation and holding events like VA Innovation Demo Day at the VA Center for Innovation (VACI). But, VA and DoD must also deploy Application Programming Interfaces (APIs) that provide robust interoperability for these applications. That’s the way to unleash the true value of their EMR investment and empower a whole new generation of solutions. Of course, these same concerns apply to civilian health systems as well. They also need to innovate and be free to choose the technology that aligns best with their strategies.
In summary, while the VA’s decision to migrate to the same EMR platform as the DoD is a sound one, it will not, in and of itself, solve the interoperability problem. This problem is similar to that faced by civilian health systems and extends far beyond data exchange for simple records portability. Military and civilian health systems must also be free to select the most innovative applications and seamlessly connect them with core EMR systems. Simultaneous pursuit of a broad, robust, API-based approach to application integration will be crucial to achieving the vision and delivering the world-class care that our active military, veterans and their families deserve.
Given their sacrifice for us, it is the least we can do.
Dr. Dave Levin has been a physician executive and entrepreneur for more than 30 years. He is a former Chief Medical Information Officer for the Cleveland Clinic and serves in a variety of leadership and advisory roles for healthcare IT companies, health systems and investors. You can follow him @DaveLevinMD or email DaveLevinMD@gmail.com.