The Department of Defense is planning to award a contract this year for replacement of its current healthcare records system with a “state-of-the-market” successor. At a projected acquisition cost of $11 billion, the Defense Healthcare Management Systems Modernization Program would be the biggest investment in an electronic health record (EHR) system ever made. The stated goal of the program is to fashion a digital records system that is comprehensive in scope, easily accessed from any location, and fully interoperable with healthcare information systems utilized by the Department of Veterans Affairs and private-sector providers.
These are worthy goals, mirroring the Obama Administration’s efforts to migrate the storage and sharing of civilian healthcare records from paper-based data systems to digital media. However, the acquisition strategy being pursued by the Department of Defense is doomed to failure, and will ultimately harm warfighters rather that help them. The reason why is that the department is proposing to purchase off-the-shelf enterprise software systems that are already viewed as outdated and unwieldy in the healthcare field. Furthermore, the department’s solicitation to industry assumes a relationship of ten years duration, which would lock the military healthcare system into a way of doing business detrimental to military personnel and their dependents.
None of this is readily apparent from the public documents the program office has released, which propose to “leverage commercial industry through open competition to ensure best value” in pursuit of an “open modular architecture” offering unprecedented “interoperability through health information exchange functionality.” Such terminology has become commonplace in an era of acquisition reform, but a review of the solicitation to industry reveals that the EHR system sought will reproduce on vast scale the same dysfunction already exhibited by enterprise EHR systems in the private sector. This point paper explains why acquiring a “state-of-the-market” health record system would be a profound disservice to warfighters and taxpayers alike.
- Healthcare lags other parts of the economy in information sharing. Medical experts have long anticipated that the computerization of health records would enable major gains in the precision, completeness and timeliness of care. The Obama Administration has sought to speed the transition to digital health records with subsidies and sanctions aimed at incentivizing early adoption. However, at a time when other sectors of the economy have moved to exploit the agility of the internet, social media and cloud computing, healthcare has remained mired in pre-internet technology that severely impedes the sharing of life-saving information. The most important impediment is widespread installation of proprietary enterprise software systems that either lack the ability to share data beyond their boundaries or impose hefty fees for the right to do so. These systems are incapable of delivering the benefits of open, internet-based solutions.
- The current “state of the market” in healthcare cannot meet military needs. Healthcare involves greater risks than most activities, and military healthcare amplifies those risks. Warfighters are routinely exposed to life-threatening environments, and many suffer injuries that stay with them for the rest of their lives. At a minimum, a health record system designed to meet their needs must be quickly accessible from remote locations and easily interpreted by caregivers charged with saving young lives. The balkanized information systems currently found in private-sector healthcare cannot provide such functionality, even though they were adopted pursuant to rules mandating “meaningful use.” Test results, medical histories, drug data and a host of other vital information is not stored in standardized format, cannot be communicated quickly, and often is jealously guarded by the vendors who levy fees for transmission.
- Achieving comprehensive interoperability requires internet-style solutions. Interoperability across heterogeneous networks is generally considered the most important feature of any modern EHR system. The internet and devices derived from its principles were designed with precisely this goal in mind, and yet a recent article in the Wall Street Journal observed that the “tech transition from client server to web, from desktops to mobile, and from locally-hosted to cloud has happened at an astounding clip everywhere but health care.” Using the terminology of the telecommunications industry, healthcare continues clinging to circuit-switched technology in a world that has moved on to packet switching, meaning ubiquitous, internet-based connectivity. All of the maladies afflicting information sharing in the healthcare field could be ameliorated if users would embrace the low cost and fast transmission standards of an internet-based economy.
- Defense department plans would delay the inevitable transition. By proposing to buy into the increasingly discredited enterprise-software approach to managing and moving health records, the Defense Healthcare Management Systems Modernization Program would in effect subsidize an archaic, sub-optimal way of doing business, wasting money and probably lives too in the process. The solicitation to industry as currently written actually precludes using an internet-based solution by requiring “best-of-suite” software — meaning a traditional enterprise-type system. With even the intelligence community now utilizing cloud computing and other internet-era innovations, there is no conceivable reason why the military healthcare system should be buying into solutions conceived in the pre-internet period. If the defense department remains on its current path, it will end up spending continuously on upgrades needed to keep its health records abreast of changes happening elsewhere. This cost is not reflected in current program plans.
- The acquisition strategy for defense EHR modernization needs to be rethought. A survey of public opinion released in March of 2015 found that three in four Americans believe their medical records should be easily sharable among physicians, hospitals and other care providers. Unfortunately, that is not what they have today, and it is not what the nation’s warfighters will have for the next ten years if the Department of Defense fails to adjust its acquisition approach for modernizing health records. The program office is certainly correct in citing the need to maximize interoperability with the VA and private-sector providers while avoiding vendor lock and excessive costs, but that is not where its solicitation leads. The program needs to be rethought in light of lessons learned from the private sector, rather than implementing a model of change that cannot possibly stay current with where the rest of the information economy is headed.
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