The U.S. Department of Veterans Affairs (VA)’s new $16-billion-dollar Cerner electronic health record (EHR) system will use open application programming interface (APIs) and Fast Healthcare Interoperability Resources (FHIR) standards to enable interoperability with the private sector, according to a Cerner executive, which potentially positions the VA as a leading force to drive interoperability forward in the healthcare industry.
The ability of the VA’s healthcare system to seamlessly share patient data with the U.S. Department of Defense (DoD) as well as health systems and physicians in the private sector continues to be a top concern among Congressional leaders as the VA is now six months in to its implementation of a new Cerner EHR, and the topic dominated a House oversight subcommittee hearing on Wednesday.
Congressional leaders pointed out that interoperability between VA and DoD and between VA and community providers would be key to the success of the VA electronic health record (EHR) modernization effort. “If you can’t make that step work, then this won’t work,” Rep. Phil Roe, M.D., (R-Tenn.) chairman of the House Veterans Affairs committee, said.
During the hearing, members of the House Veterans Affairs' technology modernization subcommittee reviewed the electronic health record modernization (EHRM) program’s accomplishments, to date, and questioned VA and Cerner leaders about implementation planning, strategic alignment with the DoD’s MHS Genesis project, as DoD also is rolling out a new Cerner EHR, as well as interoperability efforts.
The VA signed its $10 billion contract with Cerner in May to replace VA’s 40-year-old legacy health information system—the Veterans Health Information Systems and Technology Architecture (VistA)—over the next 10 years with the new Cerner system, which is in the pilot phase at DoD. The VA project will begin with a set of test sites in the Pacific Northwest in March 2020.
In October, the U.S. Secretaries of the VA and DoD signaled their commitment to achieving interoperability between the two agencies by implementing a single, seamlessly integrated EHR, according to a joint statement both agencies issued. VA Secretary Robert Wilkie and Defense Secretary James N. Mattis signed a joint statement Sept. 26 pledging that their two departments will “align their plans, strategies and structures as they roll out a EHR system that will allow VA and DoD to share patient data seamlessly."
However, subcommittee chairman Jim Banks (R-Ind.) noted during the hearing, “Community provider interoperability has always been the elephant in the room. VA-DoD interoperability is very important, but VA is further behind in exchanging records with its community partners. There are helpful tools, such as health information exchanges (HIEs), but no out-of-the-box EHR system completely solves this problem.” Banks added, “Community interoperability is a very real problem, and for $16 billion, VA had better solve it.”
It is estimated that up to a third of VA patients receive care in the private sector.
"I’m not ready to sound the alarm, but I’ve heard very little on the subject [interoperability with DoD and community providers],” Banks said, noting that a review by industry experts indicated that VA and DoD need to be on the same instance of the Cerner EHR in order to achieve seamless interoperability. “That means both departments have to pull patient data from the same database. The two implementations have to be joined at the hip. It raises the stakes. It’s important to put this reality out in the open, and early.”
During her testimony, Laura Kroupa, M.D., acting chief medical officer with the VA’s Office of Electronic Health Record Modernization (OEHRM), noted that interoperability with community healthcare providers was a challenge that VA and Cerner leaders were working together to address. “Going on the Cerner platform will allow us to utilize national systems in place for interoperability. Our community care councils also look at all the different workflows for how patients get referred into and out of the VA to make sure that information is exchanged and put into the system, not just as a piece of paper or image, but actually the data itself,” she said. Kroupa said project leaders are working to utilize interoperability mechanisms that Cerner currently has as well as HIE initiatives already in place, such as Carequality and CommonWell, to ensure interoperability between VA and the private sector.
John Windom, who leads the VA’s EHR modernization project as the executive director of VA’s OEHRM program, said, “There are two issues—one is technology-based which is solved, the HIEs, CommonWell, Carequality, allow seamless exchange of information. But, there is also another piece, the information has to be put in, and so that information has to be made accessible by the people on those networks; we’ve got the technology piece solved.”
Travis Dalton, president of government services at Cerner, testified that Cerner would use open APIs and FHIR-based integration to enable interoperability between VA and healthcare providers in the private sector.
“We’ve committed to that contractually. It’s going to happen, it’s technically possible and feasible,” Dalton said, adding, “What will be powerful to the industry and commercial partners is if VA and DoD choose a common standard. That will move the industry forward because this isn’t always a technical issue, it’s a standard-based issue. The power of the DoD and VA to make that choice to move it forward will influence the commercial marketplaces. The tools exist, through HIE and Direct exchange; it’s a standards issue.”
Congress created the technology modernization comittee to provide more rigorous oversight of the project amid concerns about the project’s cost and alignment with the defense department’s electronic health record roll-out.
There have been ongoing questions about VA leadership, specifically with regard to the EHR modernization project, beginning with the ouster of the previous VA Secretary, David Shulkin, M.D., earlier this year, as well as other shake-ups, including the resignation of Genevieve Morris only two months after she was tapped to lead the VA’s EHR project.
An investigation by ProPublica, detailed in a report published Nov. 1, asserts that VA’s EHR contract with Cerner has been plagued by multiple roadblocks during the past year, including personnel issues and changing expectations. According to that report, Cerner rated its EHR project with the VA at alert level "yellow trending towards red.” To investigate the underlying factors that have contributed to the EHR project's problems, the publication reviewed internal documents and conducted interviews with current and former VA officials, congressional staff and outside experts.
In parallel, Rep. Banks has expressed concerns with the VA’s “apparent loss of focus” on innovation, specifically as it relates to open APIs. In a letter to acting VA Deputy Secretary James Byrne dated Oct. 10, Banks noted that two years ago the VA initiated an open-API gateway interoperability platform concept, called Lighthouse. Back in March, during the HIMSS Conference, the VA also announced an open API pledge, with the launch of a “beta” version of its Lighthouse Lab, which offers software developers access to tools for creating mobile and web applications to help veterans better manage their care, services and benefits. Banks wrote that these efforts seem to have “lost momentum.”
In the letter, Banks noted that the VA needs a flexible platform to translate data coming in from multiple EHRs and on which to build, and so its private sector partners can build, interfaces to and from medical practice billing systems, insurance companies, external applications, veterans’ devices and one day Medicare and Tricare’s systems. “The need to ‘future-proof’ the technology that VA is acquiring is very real. Moving forward with the open-API gateway and sustaining the open API pledge are important steps to do that,” Banks wrote.
Progress Made in the First 180 Days
During the hearing, Windom outlined the EHRM program’s accomplishments, to date, including the establishment of 18 workflow councils and current state assessments of the initial implementation sites. VA and Cerner project leaders also completed an analysis report to assess the DoD’s MHS Genesis system as EHRM’s baseline. The workflow councils are mostly comprised of clinicians in the field who provide input to enable configuration of national standardized clinical and operational workflows for the VA's Cerner EHR system, Windom said.
Dalton said the site visits of the initial implementation sites provided important insights into VA’s IT needs. “VA has a unique patient population, you’ve got an older, sicker population, with unique needs, such as behavioral health. Some areas that we uncovered that we need to focus on now include telehealth, behavioral health and reporting. These are big content areas,” he said, adding, “I expect the work that we do will help to lead us into the future in that area. We expect that as we work closely together to meet the needs of the agency that will help to makes us better commercially.”
Dalton said the VA Cerner are committed to applying commercial best practices, as well as any lessons learned from our DoD experience, to the VA’s EHRM program.
“We learned some hard lessons with the DoD experience,” he said. “Transformation is always difficult. We’re doing things a lot differently—we’re engaging with sites early and often. We’re also doing more workshops up front, so it’s more of an iterative process.” And, he added, “This is a provider-led process. We have the 18 councils that are assisting us with validation of the workflow.”