As lead-contributor for a GWMSIST technical project-management study on the Department of Defense (DoD) and Department of Veterans Affairs (VA) Interoperable Electronic Health Record (iEHR), I examined the failure-factors delaying electronic-medical health care records exchanged between the two legacy-systems (see section below). In order to facilitate the aforementioned, DoD recently termed a joint-contract to Cerner and Leidos, industry-leaders in EMR, chartered to deliver a “secure” solution presumably protected by closed-source software, like .NET, incidentally proven penetrable by the recent Office of Personnel Management hack. Due to DoD involvement, my request to inquire further with Cerner was respectfully denied. As a proponent of open-source software, I recommend both companies to pivot or at least consider an approach currently in pursuit by Philips, in which health-care information may be exchanged and shared utilizing blockchain technology safeguarding anonymity in cryptocurrencies like Bitcoin. Although medical records are personal, life-saving data could be aggregated, thereby accelerating wellness for the greater-good with an “open-source health-care exchange of information,” conceivably akin to ARPANet, a precursory Internet championed by DARPA. Data analysis and archiving is easy, but procuring the data is the real challenge. Like the human-genome, medical data belongs to humanity, to the individual-not a corporation or government; however, any proprietary methodologies or remedies derived from the “open-source exchange” could be protected by U.S. patent laws. Life will not be contained; it always finds a way- and so will the money…
The report was published via Scribd, and also available in entirety at the bottom of the featured section below in addition to the team presentation via Google Slides.
- Failure Factors: Recall EHR/iEHR (Electronic Health Records/Interactive Electronic Health Records) facilitate streamlined-access to patient medical records through technological automation, historically documented on paper. Digital transcription of decentralized information is inherently difficult and only compounded by HIPAA (The Health Insurance Portability and Accountability Act of 1996). Through interoperability, information can be exchanged, from one health-care provider to another, “seamlessly integrated into the receiving provider’s EHR system, allowing the provider to use that health information to inform clinical care.” (Kohn, L. (2015)).
- A History of Failure: Since 1998, the DoD and VA have cooperatively undertaken initiatives tasked to electronically exchange personnel medical records, ultimately transforming healthcare into a system that can achieve goals of improved quality, efficiency and patient safety as viewed by stakeholders by sharing viewable data in legacy systems between both departments. (Melvin, V. (2015, October 27)) As scope-creep protracted development of a minimum-viable product (MVP) for nearly a decade, DoD/VA jointly-commissioned the Interagency Program Office (IPO) in 2008, which was mandated by the National Defense Authorization Act of 2008 requiring establishment of an interagency office staffed with a director from each agency for reporting until the initially proposed deadline of September 2009 (Timberlake, G). Due to incessant delays, the Secretaries of Defense and Veterans Affairs (Sec. Chuck Hagel & Gen. Sheshinski) announced a formal departure in February 2013, about two years after launching iEHR, which resulted from an assessment concluding cost-overruns out of budget (Melvin, V. (2015, August 13)). However, IPO was re-commissioned in December 2013 as the exclusive accountability agency overseeing interoperability, responsible for “establishing technical and clinical standards and processes to ensure integration of health data between the two departments and other public and private health care providers.” (Melvin, V. (2015, August 13)). A brief history was provided for context and sufficient for the scope of this analysis, but failure factors vis-a-vis 2014 National Defense Authorization (NDAA-2014) are only germane to this study.
- Matters Seriatim: The NDAA-2014 renewal enumerated compliance orders for national electronic medical data standards in February 2015. (Melvin, V. (2015, August 13)) Concordantly, IPO remains chartered to achieve interoperability between electronic medical health records systems between DoD and VA, as each pursued alternative solutions respectively known as DHMSM(privately requisitioned to Cerner and Leidos i/a/o $11 billion termed under 10-year contract) and the VistA 4 Roadmap pivoting the VA to “evolve” the existing Veterans Health Information Systems and Technology Architecture, (VistA)(a $4.3 billion contract likely to incur lifecycle cost over $9billion).((Melvin, V. (2015, August 13)) (Walker, M. B. (2015, August 18)). In spite of the aforementioned commencements, DoD’s DHMSM will not achieve operational capacity until the end of fiscal year 2022, meanwhile, the VistA Roadmap will not deploy until 2018-both dates obviously behind of the NDAA-2014 deadline (YE-2016). (Walker, M. B. (2015, August 18)) Ostensibly simple as an objective, DOD/VA system interoperability has proven difficult to effect due to several failure factors, examined herein:
- Scope Creep: Since inception, the interoperability initiative has been plagued by management weaknesses, specifically failure to define a plan, prolonged indecision, and continual scope-creep concerning the U/I|U/X (user-interface/user-experience)(Appendix::1.5.1)(Kohn, L. (2015)). It is fair to infer that execution was a failure-factor enabling scope-creep and freeze-cycles, indefinitely postponing the project to present-day. In 1998, EMR virtualization was narrowed to the scope information transfer, four years later as a part of the Federal Healthcare Exchange Initiative, only to be morphed again to incorporate private-sector health-care data in 2009 (Melvin, V. (2015, August 13)). Although some of the original initiatives presented in the NDAA-2008 were accomplished, clearly project execution is routinely problematic, especially due to insufficient planning.
- Insufficient Planning: The interoperability initiative has been plagued by management weaknesses, specifically indecisiveness, complicated by the administrations of of DoD Sec. Chuck Hagel and Gen. Eric Sheshinski of the VA. Sharing of any kind, from intelligence to medical records, requires governance and trust- a concerted effort amongst entities(Kohn, L. (2015)). GAO testimonies substantiate the criticality of information introduced within the subject examination of failure-factors, specifically with “the need for governance and trust among entities, such as agreements to facilitate the share of information among all participants in an initiative. Kohn, L. (2015))” It should come to no surprise, yet again, that the “Potomac Two-Step” disrupts inter-agency cooperation and focus. “Alpha” project-managers (in the statistical construct, not in psychology) spend more time in the phase of planning than actual execution, which clearly hasn’t been observed at DoD or VA(Appendix::1.5.2)(Schwalbe, Kathy). Ideally, a comprehensive strategy outlines a critical-path governed by key-performance indicators (KPIs) to accomplish the primary objective, which in this case is not to be confused with integration, but rather information interoperability between the subject federal agencies. Although absent and only in recommendation as of this writing, a retrospective examination of metrics may be appropriate.
- Absence of Performance Metrics: It impossible to improve what can’t be measured. Acknowledging DOD and VA conduct toward achieving interoperability, Federal oversight review specifically attributes the current state of the interoperability project to absence of results-oriented metrics providing the departments and stakeholders with “objective, quantifiable, and measurable goals” (Melvin, V. (2015, August 13)).” Departmental plans lacked associated performance goals and measures that are a necessary basis to provide other departments and their stakeholders with a comprehensive picture to effectively manage their progress toward increased interoperability (Melvin, V. (2015, August 13)). Detrimental consequences ensued, precluding compliance with State-Privacy regulatory rules and approvals.
- Variation in State-Privacy Rules & Compliance: The push-pull dynamic between federal and state regulations yields a nebulous environment for both private and public organizations alike. HIPAA notwithstanding, EMR information exchange and transcription necessary for interoperability is continuously ensnared by variable legislation protecting individual patient privacy. Exchange-sensitivity is especially heightened for health-record information concerning mental-health and HIV infection (Kohn, L. (2015)). According to GAO stakeholder and initiative surveillance, personal health-care records containing sensitive information risks inadvertent aggregation with general health informational, thereby violating patient consent and privacy rules. (Kohn, L. (2015)) Furthermore, data-warehousing is increasingly convoluted by the absence of unique identifiers reconciling complete patient medical records. EHR systems utilize relationship mapping and modeling to incorporate demographic information (e.g. patient’s name and date of birth) to match additional information collected by different health-care providers. (Kohn, L. (2015)). Systemic uniformity would mitigate risk because as one stakeholder representative noted, “various agreements developed by different EHR initiatives could result in conflicting organizational policies. (Kohn, L. (2015))” Strategy requires stakeholder consensus- systemic incongruency invites errors in budget forecasting in turn limiting resources for interoperability.
- Costs Associated with Interoperability: Any retrenchment initiative is already mired in cost-overruns attributed to due-diligence, legal fees and technical redundancies(Appendix::.1.5.3)(Kohn, L. (2015)). Since 2009, federal government expenditures exceed well-over $30 billion dollars budgeted for campaigns within the HITECH act of the 2009 economic stimulus package funding 500,000 physicians and more than 5,000 hospitals caring for both Medicare and Medicaid recipients “to establish electronic health records systems through the meaningful use incentive program, which is carried out by the Centers for Medicare and Medicaid Services (Ahier, B. (n.d.)).” Interface-customization is another variable front-end cost that could be reduced by standardization. Ten of 18 EMR exchange focus-groups acknowledged “meaningful-use” or system-functionality offerings (e.g. messaging service within intranetworks) as frivolously diverting resources away from the primary interoperability objective (Ruoff, A. (2015, September 30)). Consistent implementation according to standards and targets defined by comprehensive stakeholder-mapping is the only way to reconcile and appropriate a budget delivering interoperability. This study concurs with the GAO general assessment directed to the IPO: “establish a time frame for identifying outcome- oriented metrics, define related goals as a basis for determining the extent to which the departments’ modernized electronic health records systems are achieving interoperability, and update IPO guidance accordingly” (Melvin, V. (2015, October 27)).