Monday’s announcement by the Department of Veterans Affairs that it plans to follow the lead of the Department of Defense and acquire a commercial off-the-shelf electronic health record system from Cerner was met with approval from healthcare IT groups and stakeholders.

They contend that the VA’s decision to replace its decades-old legacy Veterans Health Information Systems and Technology Architecture (VistA) with Cerner’s Millennium EHR, the same platform that DoD is currently implementing, has a symmetry and logic to it.

“The Department of Veterans Affairs’ selection of Cerner to develop its electronic health records system is wonderful news for U.S. veterans and their families,” said David Kibbe, MD, president and CEO of DirectTrust.

“This is also a banner day for the DirectTrust community, as Cerner has been a champion of Direct as a national standard for ubiquitous, easy, secure, interoperable health records exchange,” added Kibbe. “The choice of Cerner as its EHR makes it that much more convenient and economical for Direct exchange and messaging to become a major source of interoperable health information exchange between the federal agencies, particularly the Defense Department and the VA medical facilities, and hospitals and medical clinics in the private sector using Direct exchange through their own EHRs.”

Also See: VA picks Cerner to replace legacy EHR system

The VA and DoD have a complicated EHR history. In 2013, the two federal agencies scrapped a joint effort to develop a single system called iEHR—integrated electronic health record system. Instead, they decided to pursue their own respective EHRs and to focus on integrating VA and DoD health data later.

However, so far their success in achieving interoperability has been mixed at best, according to VA Secretary David Shulkin, MD.

“To date, VA and DoD have not adopted the same EHR system—instead, VA and DoD have worked together for many years to advance EHR interoperability between their many separate applications—at the cost of several hundred millions of dollars—in an attempt to create a consistent and accurate view of individual medical record information,” Shulkin said in Monday’s press briefing announcing his decision to replace VistA with the Cerner records system.

“While we have established interoperability between VA and DoD for key aspects of the health record, seamless care is fundamentally constrained by ever-changing information sharing standards, separate chains of command, complex governance, separate implementation schedules that must be coordinated to accommodate those changes from separate program offices that have separate funding appropriations, and a host of related complexities requiring constant lifecycle maintenance,” added Shulkin.

The bottom line, he said, is VA and DoD still don’t have the ability to share information seamlessly and fall short in achieving truly interoperable EHRs. Consequently, Shulkin reached the conclusion that if the departments remained on two different systems they would continue to face significant interoperability challenges.

Russell Branzell, president and CEO of the College of Healthcare Information Management Executives, praised Shulkin for his decision to transition VA to a commercial EHR and adopt the same Cerner platform as DoD.

“Secretary Shulkin’s announcement underscores the importance of achieving nationwide interoperability, highlighting many of the challenges experienced by healthcare CIOs today,” said Branzell. “I was pleased to hear that Secretary Shulkin consulted healthcare leaders, including hospitals CIOs, as he arrived at his decision to join the Department of Defense in moving toward a single EHR system from enlistment through retirement.”

Branzell believes Shulkin’s decision will “impact health systems nationwide as many veterans receive care through the CHOICE program outside of the VA,” adding that CHIME looks forward to “working with the VA and DoD to ensure that all patients can benefit” from his decision.

While Cerner’s chief EHR competitor Epic Systems did not comment specifically on being passed over by the VA to replace VistA, a spokesperson for the vendor emphasized the company’s dominant position in the market and its ongoing support for veterans.

“As the largest electronic health record vendor in the United States, covering two-thirds of the nation’s patients, we are proud to serve our veterans both through the VA scheduling project and through our customers that care for millions of veterans across America,” said Epic’s spokesperson in a written statement. “These customers are the top health systems in America and we stand with them, committed and eager to ensure veterans get the very best medical care, regardless of where they receive it.”

In July 2015, a Leidos-Cerner team beat out an IBM-led team that included Epic for the coveted $4.3 billion contract to provide DoD with a commercial EHR system. Going into the bidding process, Epic was considered the odds-on favorite to win the military procurement. However, when it lost to Cerner, Epic’s chances of becoming the VA’s EHR vendor of choice as a VistA replacement were all but negated, given the need for interoperability with DoD’s Cerner system.

At the same time, Shulkin emphasized that the VA has unique needs, many of which are different from the DoD.

“For this reason, VA will not simply be adopting the identical EHR that DoD uses, but we intend to be on a similar Cerner platform,” he said. “VA must obtain interoperability with DoD but also with our academic affiliates and community partners, many of whom are on different IT platforms. Therefore, we are embarking on creating something that has not been done before—that is an integrated product that, while utilizing the DoD platform, will require a meaningful integration with other vendors to create a system that serves veterans in the best possible way.”

As a result, Shulkin said the modernization effort is going to require the “cooperation and involvement of many companies and thought leaders” that potentially will “serve as a model for the federal government and all of healthcare.”

“Smooth transition of care for patients, servicemen and servicewomen, veterans, or civilian patients, and ongoing coordinated care, are predicated on interoperability and a mature digital infrastructure to support the exchange of health information,” added Branzell.

For its part, Cerner’s spokesperson offered that the vendor looks forward to “sharing more information as we build the team of innovative and experienced partners that will join us to complete this vital work.”

From Shulkin’s perspective, the VA must get out of the “software business” and leverage commercial product offerings from “companies who know how to do this better than we do.”

“By shifting to a commercial EHR, the VA can free up resources to focus on innovation, building apps and modules that layer on top of the core EHR system,” observed John Halamka, MD, chief information officer at Boston’s Beth Israel Deaconess Medical Center.

Yet, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, contends that while the VA choosing the same EHR platform as DoD offers the potential for a frictionless transition of records as patients move from active duty to veterans’ care, it doesn’t guarantee it.

“For example, if they implement it as a single enterprise-type system across the agencies, they won’t need to worry about interoperability per se because they would be sharing the same record,” said Tripathi, who thinks the move to a commercial system will be easier to maintain and allow the VA to focus more of its resources on patient care. “However, if they implement it as two different EHR instances, it opens the prospect of customizations on each side that could make record sharing more difficult.”

Currently, a major challenge for the VA is that the agency maintains 130 unique VistA instances across the enterprise making modernization and standardization efforts extremely complicated, expensive and time consuming.

“In the end, the biggest question won’t be whether it’s the same vendor or a different vendor, it will be whether the DoD and VA truly think of themselves as integrated care delivery organizations focused on providing the most cost-effective care over the lifetimes of their common patients,” concludes Tripathi. “That will require that they invest time and resources up-front in aligning their care and administrative processes, and execute a common or very tightly coordinated EHR implementation approach that makes good on that alignment.”

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