Two years after cancelling an electronic health record (EHR) modernization project with Epic, at a cost of about $60 million, the U.S. Coast Guard continues to use a paper-based process to maintain health records and Congressional leaders want answers to what went wrong and when the department will implement a new EHR system.
During a U.S. House of Representatives’ Transportation subcommittee hearing today, Congressional leaders expressed frustration over the U.S. Coast Guard’s failure to implement a new EHR system, and urged the agency to implement the same EHR system currently being rolled out by the Department of Defense (DoD).
During the hearing today, of the subcommittee on Coast Guard and Maritime Transportation, lawmakers heard from Coast Guard leaders and a representative from the U.S. Government Accountability Office (GAO) regarding the Coast Guard’s decision to cancel an EHR contract two years ago, which has led to Coast Guard clinical staff continuing to use paper records. Lawmakers on the subcommittee also wanted an update on the Coast Guard’s current efforts to health IT modernization efforts.
In September 2010, the Coast Guard awarded a five-year, $14 million contract to acquire a commercial off-the-shelf EHR system to manage the healthcare data of approximately 56,000 active Coast Guard members. The contract was awarded to Verona, Wis.-based Epic Systems.
A GAO report titled “Timely Acquisition of New System is Critical to Overcoming Challenges with Paper Process” tracks the Coast Guard ‘s struggles to replace its aging EHR system with a suite of modernized systems and credits the project’s failure to its growing scope, mismanagement and lack of executive oversight.
According to the report, while working to implement the new EHR system, Coast Guard officials determined that other healthcare-related IT systems were outdated and needed modernization. The project was then expanded and became the Integrated Health Information System (IHiS) project. The project consisted of various contracts with 25 vendors and was estimated to cost approximately $65 million to implement. In October 2015, the Coast Guard decided to terminate the IHiS project. At the same time, the Coast Guard also decommissioned its two legacy EHR systems and directed its clinics to revert to maintaining health records using a predominately paper-based process.
According to GAO, $59.9 million was spent on the project over nearly seven years and there is no equipment or software that can be reused for future efforts. The Coast Guard issued a request for information (RFI) on modernizing its EHR system in April 2017. However, two years after canceling IHiS and moving toward a predominately manual process, the agency has not yet made a final determination on this.
During the subcommittee hearing, Rear Admiral Erica Schwartz, director of health, safety and work-life, United States Coast Guard, testified that what began as a project to develop a simple EHR increased in scope and expanded into a much larger concept. “While well-intentioned, the project lacked appropriate oversight and governance which resulted in significant mission creep, untimely delays and increased cost. Upon realizing that it could not be completed in a reasonable time and at a reasonable cost, the Coast Guard made decision to cancel IHiS. We are incorporating lessons learned as we move forward with a new EHR.” she said.
With regard to governance, Schwartz said one key problem was that the CIO was not involved on the executive governance board.
Continuing, she said, “Since our outdated EHR had significant IT security concerns, we continue with just paper health records. As a physician, I know, first-hand, the risk of managing a medical program based on paper records—the of challenge of scheduling appointments, reading hand-written notes, decreased productivity—we cannot continue without an EHR, long-term. Our clinics and sick bays are managing, but this is not a permanent solution. We must have an EHR that is interoperable with the Department of Defense, and allows members to transition to the VA (the U.S. Department of Veterans Affairs).”
Rear Admiral Michael Haycock, the Coast Guard’s assistant commandant for acquisition and chief acquisition officer, testified that the department has applied lessons learned and taken steps to improve governance, oversight and project management with the development of a formal acquisition program.
David Powner, director of information technology management issues at the GAO, testified about the GAO’s review of the Coast Guard’s EHR modernization efforts. He noted that since decommissioning its legacy EHR system, the Coast Guard is attempting to use some DoD applications and workarounds to supplement the paper process. “Using paper is inefficient and dangerous. Coast Guard clinical staff reported major issues to us, problems with incomplete records, tracking medications and challenges with scheduling appointments.”
Based on its report GAO had a number of recommendations for the Coast Guard as it moves forward, Powner said:
- Managers and executives with the right IT background should be involved in the acquisition, and this should include the CIO.
- Executive governance needs to be active and frequent, and governance needs to be driven by the CIO and the leaders present at the hearing.
- Project management disciplines need to be carried out, including implementing the appropriate cybersecurity measures and involving the user community extensively since business process change will be significant to effectively deploy commercial products in this area.
- Strongly consider the EHR solution that DoD and VA pursuing.
Regarding this last recommendation, lawmakers on the subcommittee adamantly urged Coast Guard leaders to “piggyback” on the DoD’s MHS Genesis project and voiced frustration that the department wasn’t already moving in that direction. DoD contracted with Cerner to roll out a massive new EHR platform, MHS Genesis, across its vast system. The VA has signaled that it wants to work with Cerner to roll out the same platform across its system, although the VA has now halted the contracting process. As noted in this Healthcare Informatics article from Dave Levin, M.D., both of those projects have hit some snags.
“Why not use the solution that DoD is using, now? Why waste time and money looking at other solutions?” Rep. Duncan Hunter (R-CA) asked, also voicing frustration that the Coast Guard has nothing to show for the money it spent. “There’s no code, no software, no machinery. There’s $60M, and you literally got nothing out of it.”
Powner with the GAO said, “If you have nothing, then that’s even more reason to go with what the VA and DoD is doing, and piggyback on what's already there. They are already ahead of the game, and there are lessons learned on the business processes. It makes sense to go that route, especially given the fact that we have nothing.”
Powner added, “This is a robust area, as far as commercial products. I don’t why you’d look at anything further than commercial. Let’s piggy back on DoD and VA. Let’s make it simple; we’re making it too complicated.”
Haycock said the Coast Guard conducted an alternatives analysis, looking at various COTS solutions, and that the DoD/VA solution was the preferred alternative. “We are working through the details to make that happen.” He said a major decision would be made at the end of February.