From Parallel Universes? Dueling Accounts of VA/DoD EHR Integration

At a March 2010 post "VA / DoD EHR Interface Debacle: Will It Take the Luminosity Of A Dozen Supernovas To Shed Light On The Obvious About Healthcare IT?" I wrote about problems with ongoing efforts to integrate the Veteran Administration's EHR and the Dept. of Defense (active military) EHR.

Now there appears to be two dueling accounts of the task's progress:

Account One:

DOD, VA to Speed Integration of Health Records
By Jim Garamone
American Forces Press Service

WASHINGTON, Feb. 5, 2013 – The secretaries of Defense and Veterans Affairs announced their departments will speed implementation of the Integrated Electronic Health Record program, allowing service members and veterans better access and more importantly, better medical care.


This approach is affordable, achievable, and if we refocus our efforts we believe we can achieve the key goal of a seamless system for health records between VA and DOD on a greatly accelerated schedule,” said Defense Secretary Leon E. Panetta following a meeting with Secretary of Veterans Affairs Eric Shinseki at VA headquarters here.

The departments are able to step up the records program because of advances in information technology while working with existing platforms. The original goal was to have the system deployed by 2018. Now the expectation is by the end of next year.

The goal is to provide one set of electronic records from entry into the military through veteran status. The program is designed to allow service members or veterans to download information and present it to doctors or other health care providers without delays.

Previously, service members had to hand carry paper files from DOD facilities to Veterans Affairs. Once complete, the record program will provide DOD and VA clinicians with the complete medical records of more than 18 million service members, veterans and their beneficiaries.

“We’ve agreed to improve interoperability before the end of this year by standardizing health care data,” Shinseki said. The two departments will also accelerate the exchange of real-time data by September. The departments are upgrading the graphical user interface to display the new standardized VA and DOD healthcare data by the end of this year, Shinseki said.

... “By this summer, DOD and VA will field and begin conducting a pilot program on the common interface for doctors at seven joint rehab centers across the country and we’ll also expand its use at two other sites,” Panetta said. “All of these facilities will be interoperable by the end of July 2013, so fast time track, but we think we can get it done.”

“Rather than building a single, integrated system from scratch, we will focus our immediate efforts on integrating VA and DOD health data as quickly as possible by upgrading our existing systems,” Panetta said.

 

Account Two:

IMMEDIATE RELEASE: February 6, 2013 CONTACT: Curt Cashour (202) 225-3527

Senate and House Veterans’ Committee Leaders Fault VA and DoD on Integrated Health Record System

WASHINGTON, D.C. – The chairmen and ranking members of the Senate and House Committees on Veterans’ Affairs today faulted the Pentagon and Department of Veterans Affairs for backing off plans to create a single computer system to integrate electronic medical records for troops and veterans.

Senate Committee on Veterans’ Affairs Chairman Bernie Sanders (I-Vt.) said: “I am deeply disappointed by the VA and Defense Department decision to back away from a commitment to develop and implement a truly integrated, single, electronic health record. President Obama charged the departments with creating a seamless system of integration so that service members transitioning from active duty to civilian life don’t have to worry about whether their health records will be lost or their claims delayed. An integrated record would allow for a streamlined and timely claims process, faster decisions on benefits, less duplication in medical testing and more efficient, cost-effective treatment for both physical and mental health needs. Now more than ever we need greater cooperation between the departments to solve the serious challenges that continue to confront our service members and veterans. I will continue to work to achieve better coordination by the departments and to ensure that the needs of veterans are met.”

House Committee on Veterans’ Affairs Chairman Jeff Miller (R-Fla.) said: “The decision by DOD and VA to turn their backs on a truly integrated electronic health record system is deeply troubling. The need for a record system integrated across all DOD and VA components has been universally accepted for years, and until yesterday, both agencies have given us nothing but assurances they were working toward that goal.

Previous attempts by DOD and VA to use disparate computer systems to produce universal electronic health records have failed, and unfortunately it appears they are repeating past mistakes.  [This seems the "focal point" of the apparent discrepancy, one system vs. two that are interfaced - ed.]  When DOD and VA take shortcuts, the veterans and service members under their care will be shortchanged.”

Sen. Richard Burr (R-N.C), the ranking member of the Senate committee, said: “The fact that VA and DoD would reverse course on a plan they have been working towards for years that would create a coordinated electronic health record system between the two agencies is concerning and disappointing. I am concerned about what this means for our nation’s service members and veterans, particularly those who will be transitioning from active duty service to civilian life in the near future. We owe it to our nation’s defenders to do all we can to care for them and provide the most effective, efficient service we can, and coordination and communication between these two agencies is absolutely vital.”

Rep. Mike Michaud (D-Maine), ranking member of the House committee, said: “This is a huge setback and completely unacceptable. For years we have been told by both agencies that progress was made and that things were on track. I’m disappointed that our nation’s two largest government agencies – one of which is the world’s foremost developer of high-tech machines and cyber-systems – could not come together on something that would have been so beneficial to those that served. We have just witnessed hundreds of millions of dollars go down the drain.”

Additional Contacts:
Michael Briggs (Sanders) 202 224-5141
David Ward (Burr) 202 228-2971
Ed Gilman (Michaud) 202 225-6306

So, some are touting a marvelous effort ready for prime time in 2014, and others are speaking of hundreds of millions of dollars down the drain with nothing to show for it.

As Captain Kirk said to Mr. Spock in the award-winning Star Trek episode "The City on the Edge of Forever" about conflicting accounts of the early 1930's death of Edith Keeler, played by a pre-Dynasty Joan Collins, vs. Keeler's mid-to-late-1930's rise to national fame and her becoming the cause of World War Two being lost ... "They both can't be true." 

(Using the clock-mender's tools, Spock gets an image on his tricorder screen of a newspaper report. Edith Keeler, social worker from 21st Street Mission was killed today, it says. Kirk enters.)
KIRK: How are the stone knives and bearskins?
SPOCK: I may have found our focal point in time.
KIRK: You may also find you have a connection burning someplace.
SPOCK: Yes. I'm overloading those lines. I believe we'll have our answer on this screen.
KIRK: Good.
SPOCK: And, Captain, you may find this a bit distressing.
KIRK: Let's see what you have.
SPOCK: I've slowed down the recording we made from the time vortex.
KIRK: February 23rd, 1936. Six years from now. (reading below the headline FDR confers with slum area 'angel') The President and Edith Keeler conferred for some time today
(Then the whole thing goes up in flames.)
KIRK: How bad?
SPOCK: Bad enough.
KIRK: The President and Edith Keeler.
SPOCK: It would seem unlikely, Jim. A few moments ago, I read a 1930 newspaper article.
KIRK: We know her future. Within six years from now, she'll become very important. Nationally famous.
SPOCK: Or Captain, Edith Keeler will die - this year. I saw her obituary. Some sort of traffic accident.
KIRK: You must be mistaken. They both can't be true. 

Based on the points I raised in the aforementioned March 2010 post about current IT leadership and organizational structures (not to mention Beltway Bandit IT consultants), I am skeptical that either plan - monolithic vs. interfaced - has a snowball's chance of success.

Edith Keeler dies in either scenario. 

Let's just hope a war is not lost because of this cybernetic "how to do health IT poorly" feud.

-- SS

Feb. 7, 2013  Addendum:

I've received a comment that this post is a bit "geeky" but droll.

My response is a word often used by another highly popular SF character:  Indeed.

-- SS

Vladimir Putin and Common Sense on IT

Vladimir Putin may be known for showing off his pectorals riding horses bare chested, but he also seems to have a substantial amount of gray matter between the ears.

Our country, including the healthcare IT sector, could probably learn something from him:

A Walled Wide Web for Nervous Autocrats
Wall Street Journal
Jan. 8, 2011

By EVGENY MOROZOV

At the end of 2010, the "open-source" software movement, whose activists tend to be fringe academics and ponytailed computer geeks, found an unusual ally: the Russian government. Vladimir Putin signed a 20-page executive order requiring all public institutions in Russia to replace proprietary software, developed by companies like Microsoft and Adobe, with free open-source alternatives by 2015.

The move will save billions of dollars in licensing fees, but Mr. Putin's motives are not strictly economic. In all likelihood, his real fear is that Russia's growing dependence on proprietary software, especially programs sold by foreign vendors, has immense implications for the country's national security. Free open-source software, by its nature, is unlikely to feature secret back doors that lead directly to Langley, Va.

It's also less likely to feature a backdoor to a hacker's basement, or a lot of bugs ("glitches") that some health IT vendors and customer organizations allow to accumulate into the thousands before lifting a finger.

This brings to mind the adage that "if you want something done right, do it yourself."

... For ordinary Internet users, there is one silver lining: The embrace of open-source technology by governments may result in more intuitive software applications, written by a more diverse set of developers.

[Read the whole article at the link above - ed.]

More intuitive IT applications could solve a lot of the current health IT problems, such as the mission hostile user experience of many closed-source products from major vendors.

Afrer major IT debacles including the £13 billion abyss of the National Programme for IT in the NHS (NPfIT), the UK also seems to be learning:

New approach urged for government IT
E-Health Insider

2 March 2011
Lyn Whitfield

A new report into government IT failures has warned that previous inquiries may have embedded problems by focusing on inappropriate ‘best practice’ instead of looking for alternative approaches.

The report, from the Institute for Government, says “existing ‘best practice’ project models do not deal with the fundamental issues at the heart of government IT.”

[As I've stated here, one has to consider the "worst practices" as well, the "thou shall not's." Typical Milquetoast, touchy-feely "best practices" models and their "sanitized accounts of successful projects" (cf. Greenhalgh et al.) avoid such inconvenient realities like the plague - ed.]

It also argues that: “By implementing these same, flawed project techniques in an increasingly rigid fashion, these traditional solutions can act to exacerbate the problems further.”

[This sounds familiar, typical of the inflexible, dogmatic business IT culture, descended from the punched-card programmable tabulator culture of the 1920's - see this link - ed.]

Instead, it calls for a new that focuses on using government’s huge buying power to get better deals for what it calls ‘platform' technologies – such as server capacity and PCs – while encouraging departments to adopt ‘agile’ methodologies to deliver systems to meet the particular challenges they face.

... Andrew Adonis, Director of the Institute for Government said: “The billions spent on cancelled IT projects, such as ID cards and National Programme for IT in the NHS, demonstrate precisely why we need a much more flexible approach to government IT.

... The report cites the national programme as one ‘symptom of failure’ in government IT; the tendency for projects to run late and for departments to struggle to keep suppliers on board or hold them to their original delivery requirements as a result.

Agile software development methodologies have traditionally been anathema to the culture of IS departments involved in mercantile, manufacturing and management varieties of business computing. As I've written many times, however, those methodologies are essential in healthcare IT, such as here and here. At the latter link I observed:

... In fact, in my observations IT personnel are the true Luddites [as opposed to clinicians who are often accused of that reactionary characteristic- ed.], clinging to inappropriate, rigid business-IT views on the healthcare IT development and implementation process (vs. more appropriate and modern agile methodologies), holding unshakable, stereotypical views about physicians, and remaining unreasonably obstinate on clinician complaints about "clunky" health IT user experiences.

Perhaps Mr. Putin and Mr. Adonis deserve a copy of the book "Medical Informatics 20/20: Quality And Electronic Health Records Through Collaboration, Open Solutions, And Innovation", Jan. 2007, by the VistA (open-source EMR) pioneers.

The "Open Solutions" part of that title says it all.

-- SS

VA / DoD EHR Interface Debacle: Will It Take the Luminosity Of A Dozen Supernovas To Shed Light On The Obvious About Healthcare IT?

(Note: Academic/military readers of this post, I would enjoy your comments. Email sms88 AT drexel DOT edu. Thank you -- SS.)

(Dec. 2010 note: I have observed a large number of "hits" on this post from multiple offices of the Mitre Corporation in the past several weeks. Dear Mitre, I ask that if you use my materials in your proposals or writings, that you please let me know. Thank you. My email address is in my profile under "Contributors." -- SS)

The VA and DoD have been working for a number of years on interfacing the VistA EHR system and the military's EHR, AHLTA (why anyone would want to interface to AHLTA in its present state is of concern to me, but...)

[Note: this is not to denigrate the military, and I am very thankful to all who serve and defend our country and freedoms. HIT problems seem unfortunately universal - ed.]

The interface attempt, likely done by the usual actors in the traditional "business IT" manner has resulted in the predictable:

Glitch prompts VA to shut e-health data exchange with Defense
NextGov.com
By Bob Brewin 03/04/2010

The Veterans Affairs Department closed off access to the Defense Department's huge electronic health record system on Monday because it found errors in some patients' medical data clinicians downloaded from the Defense network, according to a departmental patient safety alert, which Nextgov obtained.

Although no patient was injured, the errors shed light on how software glitches could affect the accuracy of electronic medical records and a planned national system that has been backed by the Bush and Obama administrations.

"Shed light on how software glitches could affect the accuracy of electronic medical records?"

As my early medical mentor, Hahnemann cardiothoracic surgery pioneer Victor P. Satinsky would have said about purveyors of such wisdom: they are Masters of the Obvious.

I ask:

Why do we keep needing to "shed light" on the blatantly obvious, in your face, computer science 101 reality about electronic information systems? The light was shed when the first stored-program computers were developed in the late 1940's.

Exactly how much light do we need to shed before IT personnel "get it" about the need for the most extreme diligence in IT-based medical records?

Perhaps the light of a dozen supernovas?

Is this the amount of light it will take before the IT world "gets it" about the need for the utmost engineering rigor in healthcare IT? (click image to play video).

------------------------------------

*** Nov. 2011 addendum: I now personally face the aftermath of the worst-case "perfect storm" caused by health IT that began in May 2010, just two months after I wrote this post -

Here is what EHR dysfunction caused to me, personally

------------------------------------


It's fortunate the error was found in a somewhat less than life-threatening manner:

VA first discovered the problem in late February, when one of its doctors accessed the Defense health records system, called AHLTA, to review the prescription information of a female patient. The data showed a Defense physician had prescribed her an erectile dysfunction drug. The VA doctor suspected the system displayed erroneous information [although females have been known to use these drugs- ed.] and a check with the Defense medical facility that supposedly prescribed the drug informed VA that the data was wrong and the VA query had returned information for another patient.

... When doctors queried the Defense system for patient information, they received no data, a portion of the data, incorrect information, or the complete, correct data for the patient, according to the alert.

[Where have I seen these types of patient data errors mentioned recently? Perhaps at my recent post "FDA on Health IT Adverse Consequences: 44 Reported Injuries And 6 Deaths In Two Years, Probably Just Tip of Iceberg" ? - ed.]

The glitch did not cause harm to any patient, but "the potential exists for decisions regarding patient care to be made using incorrect or incomplete data," said Jean Scott, director of the Veterans Health Administration's Information Technology Patient Safety Office, in the alert issued on Wednesday.

Indeed.

"The VA clinician may see the patient's data during one session, but another session may not display the data previously seen," the alert noted. "This problem occurs intermittently and has been reported when querying DoD laboratory, pharmacy and radiology reports."

I would add that "intermittent errors" are by definition unpredictable. This is the most dangerous type of IT malfunction of all.

Until those systems are reactivated, VA doctors will have to obtain a patients' health information from their paper medical files, faxes or PDF attachments that are e-mailed to the physicians, Scott said.

What? That old-fashioned, unreliable 5,000 year old artifact upon which the foundations of modern medicine were built, and favored by Luddites?

The errors occurred in the Bidirectional Health Information Exchange, a project started in 2004 that allows clinicians in VA and Defense to view health information in patient files. Older code in the system became stressed at peak periods when clinicians were making the most number of queries, said Roger Baker, chief information officer at VA. At these times, the system did not clear out a memory cache, resulting in memory leaks "so that information from one patient is presented as it is from another," he explained.

Good software and information architecture engineering practices call exactly for testing under stress. Failure to clear caches, memory leaks, etc. are fundamental flaws that should never be permitted to see the light of day in clinical settings. That is what acceptance testing is designed to do. That's what mission critical software undergoes in other sectors. That is what drug and device clinical trials are designed to do.

At this link, for example, is NASA's Certification Processes for Safety-Critical and Mission- Critical Aerospace Software from 2003 (PDF). From that document:

... Since safety-critical aerospace software is prevalent and important to human life, what is the rationale behind certification of such software? In other words, how do engineers know when a new software product works properly and is safe to fly? In the United States, software must undergo a certification process described in various standards by various regulatory bodies including NASA and the Requirements and Technical Concepts for Aviation (RTCA) which is enforced by the Federal Aviation Administration (FAA).

There are no analogous requirements or enforcement in the healthcare IT sector. None.

In fact, the VA, of all places, should have been exceptionally wary of these types of malfunctions and exercised the highest levels of engineering rigor.

Why?

See "IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans Medical Centers" at this link. From that posting, reflecting a March 4, 2009 JAMA article by the same title by Bridget M. Kuehn (JAMA 2009;301(9):919-920):

... After a software update of the electronic medical records system at VA hospitals in August [2008], health care workers at these facilities began to report that as they moved from the records of one patient to those of a second patient, they would sometimes see the first patient's information displayed under the second patient's name. [If not for the diligence of the users then, that type of error could have led to dead patients -ed.]

This records-scrambling problem was reported at 41 of the 153 VA medical centers, said Gail Graham, deputy chief officer of Health Information Management at Veterans Health Administration Headquarters in Washington, DC. Graham explained that the jumbling of records was an uncommon occurrence that only occurred after a particular sequence of events.

... Health care workers at the VA medical centers were notified about this potential problem in October, and on December 20, the centers received a software "patch" to fix the problem.

Nine VA medical centers reported another type of problem related to their electronic records system: physician orders to stop medication were missed, causing some patients to receive intravenous medications longer than necessary. The problem occurred because after the software upgrade, physician orders to discontinue such medications, which had previously appeared at the top of the screen, were not displayed.

In 3 cases, patients received infusions of drugs such as heparin for up to 11 hours after their physician had ordered the drug to be discontinued. Graham said the affected patients were not notified because they had not been harmed by the oversights. This software problem was corrected on December 8.

As I noted in that post: "... if this type of error occurs once too often, your patient's dead."

Back to the current VA / DoD interface "glitch":

... The VA has fixed the [current] bug and plans to bring the BHIE back online on March 9. Baker emphasized the bug's effect on the medical records of patients that VA and Defense clinicians share was sporadic and occurred in one out of 100 queries. The glitch caused errors only in the records that VA clinicians accessed. Defense doctors still have access to records Veterans Affairs stores.

"Only" 1 out of 100? ... that's only 10,000 errors per million EHR queries. Not too bad at all ... how many soldiers are in a military division?

Baker said the department's response to the glitch showed VA's overall health system worked "because there is always a doctor in the loop" who checks the accuracy of a patient's health data in combination with a well established patient safety organization that quickly alerts clinicians to any errors.

The "system worked" because luck prevailed that fallible, busy human clinicians were not deceived by erroneous information provided by a computer? I fall back on first principles of IT:

A computer can free professionals from tedious, repetitive work which does not require judgment. It can provide facts and figures with lightning speed, giving domain experts more time to exercise their judgment thoughtfully

The system is not working when computers add to the tedium, and having to expend precious cognitive capacity in ferreting out computer errors is certainly in that category. This excuse reminds me of a recent quote from our Homeland Security secretary about how the "system worked" when an airplane nearly was blown out of the sky.

These failure excuses, possibly written by a public relations 'spin doctor' in an effort at damage control, remind me of a humorous sign I bought in a novelty store once, for placing on the wall: "Our policy is to always blame the computer."

Perhaps clinicians need to stand up for this motto: No more alpha and beta software rollouts in healthcare.

Robert Charette, a risk management consultant and president of the ITABHI Corp. in Fredericksburg, Va., which consults with Defense, said VA was lucky it discovered an error as obvious as prescribing an erectile dysfunction drug for a female patient. He wondered if VA would have detected the error if it were for drugs with similar names, adding that despite the low error rate, "it's the one out of 100 that can bite you."

It's also the one out of fifty thousand that can bite you, for instance as Merck recently discovered.

Baker said the complexity of medical records systems like BHIE would make regulating such networks [by agencies such as FDA - ed.] a daunting task.

I thought we were just at the point of transforming health with one thunderous click of a mouse after another per our prior HHS secretary at the 2005 HIMSS summit. Perhaps not...

Dave deBronkart, a patient advocate in Nashua, N.H., who spoke at last week's Health IT Policy Committee meeting, said in an interview with Nextgov that the glitch paralleled the problems he encountered last year when he tried to transfer information from his hospital medical record to Google Health, an online electronic health record database the search giant launched in 2008.

I wrote about that at "Should Google Seek the Resignations of Those Responsible for This Healthcare IT Debacle?" here.

If the United States wants to develop a national health electronic record system, it needs to make sure heath information exchanges work correctly, said deBronkart, who added VA should be commended for reacting quickly to the software problem and issuing the patient safety alert.

I believe this is not possible under the current leadership, organizational and regulatory structures found in the healthcare IT sector. As I've written before, healthcare cannot be 'reformed' or even improved by IT, until IT and its culture are themselves reformed.

For more on these issues, see my site below.

-- SS

For more on HIT challenges see "Contemporary Issues in Medical Informatics: Common Examples of Healthcare Information Technology Difficulties" - http://www.ischool.drexel.edu/faculty/ssilverstein/cases/

HHS to promote low-cost electronic health record software packages including the VA's VistA

If I were a proprietary health IT vendor, the following bolded passage in the new Healthcare Bill (PDF here) would make me a bit nervous:

SEC. 1102. ENCOURAGING MEANINGFUL USE OF ELECTRONIC HEALTH RECORDS.

(a) STUDY.—The Secretary of Health and Human Services shall conduct a study of methods that can be employed by qualified health benefits plans offered through an exchange to encourage increased meaningful use of electronic health records by health care providers, including—

(1) payment systems established by qualified health benefit plans that provide higher rates of reimbursement for health care providers that engage in meaningful use of electronic health records; and
(2) promotion of low-cost electronic health record software packages that are available for use by health care providers, including software packages that are available to health care providers through the Veterans Administration.

The VA system, VistA/CPRS ("computerized patient record system"), was developed with taxpayer money and is freely available. A free working demo is downloadable here (Windows only).

This represents a needed "public option" for healthcare IT, the estimates of cost of adoption of proprietary systems now at somewhere between $20 and $50 billion dollars, give or take. (I believe the actual figure to be far higher due to IT sector dyscompetence in HIT as I wrote at my post "Fuzzy Math Indeed.") To put that figure in context, $50 billion is enough to build approximately five hundred shiny new 100-bed hospitals, or one hundred 500-bed hospitals, at ~$1 million per bed.

Entrepreneurial companies have sprung up to adopt it for the private healthcare sector such as WorldVista. They probably won't be charging the multimillion dollar rates that the private HIT sector does, and the quality will likely be higher.

-- SS