By Sandra Basu

Trainer Felicia Dailey, left, teaches Madigan Army Medical Center staff member Johnny Crespo how to use MHS GENESIS, the DoD’s new electronic health record. Madigan began using MHS GENESIS this fall. Photo by Suzanne Ovel.

WASHINGTON—After announcing VA’s decision earlier this year to replace VistA with the same electronic health record (EHR) that DoD is using, VA Secretary David Shulkin, MD, made a trip to Capitol Hill last month to implore lawmakers to “quickly” approve funding needed to begin the project.

“We want to work with Congress to find a common solution to funding this EHR modernization plan in FY 2018,” Shulkin said.

Absent an appropriations bill by the end of the year, the agency would like permission to allow the agency to reprogram funds from its internal accounts. That would allow VA to award the new Cerner contract and put in place infrastructure to support the new system, among other things, Shulkin explained.

The VA secretary made his comments at a hearing last month held by the House Committee on Appropriations Military Construction, Veterans Affairs, and Related Agencies Subcommittee, where he discussed plans for the new EHR.

“Adopting the same EHR as DoD will vastly improve VA services and significantly enhance the coordination of care for veterans, not only at VA facilities but also at the Department of Defense and with community providers,” Shulkin explained.

VA officials explained that funding is needed quickly so the agency can piggyback its EHR deployment and implementation on DoD’s implementation, which has already started in the Pacific Northwest. If VA deploys in that region there will be “substantial efficiencies,” said VA Electronic Health Records Modernization Program Executive John Windom.

“By us deploying into the same geographical area, we’ll be able to leverage the resources that are already in that area,” he explained

Missing the opportunity to align efforts with DoD would add “at least 5% to the total project,” Shulkin said.

“We are in somewhat of a time crunch in that, in order for us to achieve the efficiencies … we do need to align closely with the DoD implementation, so we are trying to do the best thing for taxpayers here,” he said.

VA anticipates that it can begin to deploy the new EHR at its first site within 18 months of signing a contract and can complete the deployment within 10 years.

Sharp Deadlines

“The right thing to do in this situation is to act with urgency, to be aggressive and to establish sharp deadlines,” Shulkin emphasized.

At the same time, he pointed out that, as the new system is being implemented, VA will have to run a dual system of VistA and the new EHR for the “foreseeable” future until the new EHR is fully operational.

“We can’t afford to put veteran’s health at risk,” Shulkin said.

Windom told lawmakers that complete interoperability is expected between the DoD and VA systems, since they are on the same Cerner platform.

“I expect it to be 100%—and I am a veteran—so I am banking on it,” he said.

Lawmakers wondered aloud whether VA can actually meet its EHR deadlines.

“Is there any concern your timeline is too aggressive,” Rep. Debbie Wasserman-Shultz (D-FL) asked.

Shulkin explained that the project is different from prior EHR efforts, citing the use of commercial software instead of trying to develop proprietary EHR software. In addition, he said, the governance of the project will be out of the VA secretary’s office, and VA is using lessons learned from DoD’s implementation.

“We are committed to working with the private sector and DoD in ways that VA before just hasn’t been willing to do,” he explained, adding that the longer it takes “to implement this, the more costly it is and the greater we think the risk is to veterans, so we are trying to do this as aggressively as we possibly can.”

During the hearing, lawmakers reminded Shulkin of DoD and VA’s lack of success in addressing the EHR issue during the hearing.

“VA secretaries have come and gone promising that their records were achieving interoperability or that they were developing the same record as DoD or that they had decided to have two different systems that would talk to each other,” pointed out said subcommittee Chairman Rep. Charlie Dent (R-PA). “Now the pendulum has swung back to creating one record to be used by both departments—the position this committee has argued for from the start. The number of years and dollars that have been wasted reaching this point is extremely troubling.”

Shulkin said that he thought “skepticism is appropriate” given the history, acknowledging, “I don’t know any other way to interpret history than to say that this has taken way too long and that there have been many false starts along the way.”

Still, he assured lawmakers that he has “never seen better cooperation between DoD and VA,” on the issue.

Dent also asked Shulkin whether he thought the plan could stay on track with changes in political leadership or budgetary shortfalls over the years.

Shulkin said that, “while anything could happen,” he did not think the plan was “likely to be derailed.”

“I do not believe that this will be subject to political back and forths. We are going to set this up in a way that when we start this there is a full commitment,” he said.

Merger Controversy

VA was gearing up to move forward with its EHR plans as controversy was brewing on Capitol Hill regarding the future of the healthcare system.

House Committee on Veterans’ Affairs Ranking Member Rep. Tim Walz (D-MN) and Ranking Member of the House Committee on Appropriations Rep. Debbie Wasserman-Shultz (D-FL) sent a letter to Shulkin, President Donald Trump and DoD Secretary James Mattis concerning “secret meetings” they heard about “involving the participation of White House, Department of Veterans Affairs and Department of Defense officials regarding the merger of the VA Choice Program and Department of Defense TRICARE private health care program.”

“We are concerned this proposal is being developed without the input of Congress, Veterans Service Organizations and veterans who use the VA health care system, without the consultation of health care experts, and outside of public purview,” they wrote. At least some of the concern grew out of the close collaboration on EHR development between the VA and DoD.

Vice Ranking Member of the House Committee on Veterans’ Affairs Rep. Mark Takano (D-CA) said the Trump administration should “allow Congress to work with veterans on a solution.”

“The clear and consistent message we have received from veterans and health care experts is that a strong and sustainable VA is critical to providing quality care to those who serve. Any proposal that dismantles the VA health system or shifts the cost of care to veterans has no future in Congress,” he wrote. 

Advocacy groups have long been concerned with any efforts that could potentially take the agency down the road of privatization.