US Defense Think Tank Calls for DoD to Adopt the Open Source VistA EHR and Avoid Closed and Proprietary EHRs.

Roger A. MaduroOne of the most prestigious U.S. defense think tanks, the Center for a New American Security (CNAS), issued a white paper Thursday calling on the Department of Defense (DoD) to replace their existing dysfunctional “vendor-lock” medical records system with an electronic health records system (EHR) that is "extensible, flexible and easy to safely modify and upgrade as technology improves and interoperability demands evolve." The white paper warns that a "closed and proprietary" commercial EHR - such as the ones offered by Epic, Cerner or Allscripts - will lead to "vendor-lock” and isolation of health data.

The authors of the paper are General H. Hugh Shelton, U.S. Army (ret.) former chairman of the Joint Chiefs of Staff, and currently the chairman of Red Hat Software; Stephen L. Ondra former senior advisor for health information in the White House Office of Science and Technology Policy, and today senior vice president and chief medical officer of Health Care Service Corporation; and, Peter L. Levin former chief technology officer at the U.S. Department of Veterans Affairs (VA), and today the co-founder and chief executive officer of Amida Technology Solutions.

In addition to their EHR recommendations, they also made a series of proposals for reforming the military health system, recommending that the upcoming TRICARE solicitation be consistent with the recently-released HHS/CMS guidelines regarding "fee for value" medical reimbursement model, and urged DoD to start using the Blue Button personal health records to help military personnel and their families have access to their medical records and facilitate medical records exchange with the VA.

General H. Hugh Shelton, U.S. Army (ret.)The paper is very timely as DoD’s effort to replace their current “vendor-lock” EHR systems was placed by the Government Accounting Office (GAO) on their “High Risk” list on Wednesday, due to skepticism of its success after 15 years of failed EHR-sharing between the DoD and the VA. The current DoD EHR solicitation is called the DoD Healthcare Management System Modernization (DHMSM), and a decision on the next EHR system is expected to be announced in July.

The open source option that the white paper references is a hybrid open source/commercial version of the VA’s VistA that has been put forward by a team led by PricewaterhouseCooper (PwC) and includes commercial VistA EHR vendors DSS, Inc. and Medsphere Systems Corporation, as well as MedicaSoft, and systems integrator General Dynamics Information Technology (GDIT). The open source team was recently joined by Google as we detail in this Open Health News article. The PwC/Google solution is called the Defense Operational Readiness Health System (DORHS).

The other EHR teams bidding on the DoD EHR procurement include:

• Epic and IBM Federal Services (and Apple although Apple is not officially listed).
• Cerner, Leidos/SAIC, and Accenture.
• Allscripts, CSC, and HP.

This article from E-Commerce Times has a good description of the teams as of last September.

Open Source vs.Vendor Lock-In...Let the Combat Begin...

The CNAS white paper begins with a stern warning that that:

As of this paper’s publishing, DoD is about to procure another major electronic (health records) system that may not be able to stay current with – or even lead – the state-of-the-art, or work well with parallel systems in the public or private sector. We are concerned that a process that chooses a single commercial “winner,” closed and proprietary, will inevitably lead to vendor lock and health data isolation.

Stephen L. OndraSheldon, Ondra and Levin propose an open source, innovation driven approach-the authors state:

Failing to choose wisely, with forethought about technological innovation could be tantamount to having bought a twenty-year contract for the then-“state of the art” BlackBerry service in 1999, or even 2009, just as wireless data services were changing the landscape. Installing a DoD- requirements-driven EHR platform based on current-need specifications risks missing opportunity in the rapidly changing and hard-to-predict EHR technology space, and at worst could lock the DoD into another dead end. Health information technology (IT) is one of the fastest growing and dynamically changing segments of the technological landscape. For the health of our uniformed service members, and to protect the promises made to retirees and veterans, DoD planners cannot allow or afford single-system lock-in to occur without allowing for flexible and market-responsive services.

Levin elaborated on the open source advantages in an interview with Politico where he said that “any proprietary system inherently restricts the number of people who can work on the platform,” adding that “those companies make their money by restricting access to the system, and by restricting access to the data in ‘their’ system.” Proprietary systems are fully capable of sharing data according to Levin, but “there’s no precedent for it,” Levin told Politico. “The VA [using VistA] is in the business of sharing data. I want to make sure the decision-makers at DoD are making a clear-eyed, unbiased choice.” Levin also pointed out that an “open-source solution is more secure and has a lower total cost of ownership, key to lowering DoD’s costs.”

A History of Bureaucratic Inertia at DoD

The publication of this paper is certainly going to stir up a debate on this huge $11 billion EHR procurement. The Center for New American Security, which describes itself as “An independent, nonpartisan and nonprofit organization that develops strong, pragmatic and principled national security and defense policies” has certainly put a stake on the ground and is making a call for a public debate. The paper, and the debate, should transcend the DoD EHR purchase. As the authors outline in the paper, at the heart of the problems of the current DoD EHRs are DoD’s bureaucracy and institutional inertia.

The paper states:

“The corroding effects of institutional inertia and resistance to change any aspect of DoD’s health- care procurement are acute and plainly visible. A prime example of obstruction is the tortured history of DoD’s electronic health record (EHR). The DoD fielded its “Armed Forces Health Longitudinal Technology Application” (AHLTA) EHR system in 2005 and has spent more than $4 billion on development and maintenance since that time, not including the funds required by its predecessor, called CHCS, or twice-abandoned plans for its upgrade. This system has been pilloried by DoD’s own doctors and nurses as inefficient and poorly designed. It is not integrated to – nor can it seamlessly share data with – other health record systems, including the VA’s EHR system, which serves an important and overlapping population alongside DoD, and for which the seamless transfer of health information would greatly assist in health care and service-related benefits delivery.”

That is an important point of the paper as what the Center for New American Security is presenting is not just a solution for DoD’s dysfunctional EHRs, but a comprehensive approach to solving the deeper problems of providing for medical care for active duty military personnel, their families, and veterans. That concept is encapsulated in the title of the paper which is “Reforming the Military Health System: The opportunity and dire need for change in how we care for military personnel and their families.”

Peter LevinAs noted in the paper, the cost of healthcare for military personnel has increased more than 300% since the beginning of the Global War on Terror (GWOT) in 2001. The enormous cost of healthcare expenditures are causing serious problems for DoD. The paper cites several analyses, including one by Major General (retired) Arnold Punaro, chairman of the Reserve Forces Policy Board. According to the CNAS paper, Punaro “calculated that ‘the total costs of pay for active duty and retirees, their health care costs, veterans and other related costs [is] $417 billion a year – that’s 63% of the combined DOD/VA budget.’ He goes on to say that we ‘can’t let DOD turn into a benefits company that occasionally kills a terrorist.’”

While the costs of caring for hundreds of thousands of American soldiers wounded in combat has played a major role in the total increase in health costs, the paper emphasizes that “the core problem is that TRICARE’s fee-for-service approach is subject to the same perverse incentive structures that have driven up healthcare costs in the United States by explicitly connecting payment to volume of care, not value of care.” The impact of the fee-for-service medical reimbursement approach has been augmented by base closures in the U.S. as it is now “estimated that more than 70% of all DOD care (by volume) occurs as contract service,” with private sector healthcare providers.

The paper points out:

TRICARE’s use of a fee-for-service reimbursement model for the purchase of healthcare services in the private sector creates incentives to increase the volume of services, rather than the discovery of service efficiencies that can reach a desired health outcome. Volume-over-value thinking has driven up costs far beyond that seen in other nations, without an associated improvement in outcome or quality. DoD still uses this model almost exclusively in its private sector contracts – and not just for healthcare – because of its outdated procurement practices. Reforming healthcare service delivery could be a template for other DoD acquisitions, and a model for the rest of the country.

The authors of the paper then make a convincing case in the paper for DoD to shift healthcare procurement procedures to the “fee-for-value” model. In addition, they discuss how DoD and VA could increase the efficiencies of the use of their medical facilities and personnel, providing better care for their people while saving tens of billions of dollars a year. They discuss these synergies at length. Here is an excerpt:

...we believe that a sober review of mission scenarios mapped to a substantial active duty medical force would likely find billion-dollar inefficiencies. Facilities and other resources should be continuously rationalized to ensure that key mission support functions are adequate resourced and that military providers have the peacetime opportunity, and practical experience, to best meet both garrison and deployment needs. In fact, DoD healthcare planning has been exploring how to use innovative models of public and public-private partnership to maintain and improve skills of military healthcare providers.

An example is the joint DoD/VA facility in North Chicago, the James A. Lovell Federal Healthcare Center, where DoD and VA physicians work together to care for beneficiaries of both systems. This arrangement provides the VA with key specialists that are often in short supply to meet their population needs. DoD specialists benefit from having VA populations that provide an opportunity to keep skills sharp. The same is true for primary care, where the VA providers benefit from the DoD population diversity and DoD beneficiaries have access to wider primary care provider access.

Concealed behind misapplied fixed-cost investments is that the dearth of patient care opportunities that negatively impacts on skill development DoD providers, especially in the surgical and other specialty areas that coincidentally, the VA needs most. Indeed, the recent scandals at the VA have all too painfully demonstrated the dire need for improved veteran access to both primary and specialty care. The tragedy is that too many DoD doctors, especially the specialists most needed at the VA, are often underutilized in the DoD system, while VA patients wait to be seen. Again, entrenched interests, bureaucracy and antiquated paradigms are often the primary obstacle and source of frustration to those trying to make common sense changes in the DoD health system.

The Road to a More Efficient Single-Payer System

As discussed in the paper, a core element of improving medical care while efficiently utilizing existing facilities and personnel requires a seamless EHR. In a broader sense, the authors have articulated a clear path towards a “single-payer system.” This is a concept actively promoted by Physicians for a National Health Program (PNHP). The U.S. Government is already running multiple single-payer systems. The CNAS paper discusses two, DoD and VA. There is also the Indian Health Service (IHS) that already works closely with the VA. IHS has leveraged the VistA code to develop their own world-class EHR, RPMS, and by building on VistA they managed to do it on a shoe-string budget.

There are multiple other government agencies that run medical systems, from the Coast Guard to the Bureau of Prisons. And these agencies have unfortunately been procuring “lock-in” EHRs with uniformly poor results. The one bright spot is the Peace Corps which is currently implementing the open source OpenEMR electronic health record system at field offices in 77 countries. It is serving as a global EHR for Peace Corps volunteers that work in countries aound the world, and generally in remote locations. OpenEMR proved to be the ideal solution as it has been translated to 34 languages, it is currently already in use in 182 countries, and its open architecture allows for both a "cloud-EHR" version to be used at locations with high-speed internet connections, and a local version for places with intermitent internet service.

Dr. Jason Kelley a PNHP member and physician at the VA Medical Center in White River Junction, Vermont, told Open Health News that “the idea of having a unified healthcare record system, not just VA and DoD, but expanding to the rest of the healthcare system would be desirable.” Dr. Kelley repeated the CNAS paper warning that “closed source EHRs were not anticipated back when single payer was conceptualized 40 years ago and it has become another barrier to efficient single payer medical systems.” As a practicing VA physician, Dr. Kelley pointed out that “VA patients are in a care continuum.” He said that “they start as members of the military and then move over into the VA medical system,” concluding that “it is amazing that we still don’t have a shared medical record between the DoD and the VA.”

The Need for Rapid Innovation in Health IT

CNAS has, for the first time, raised the need for a clear strategy, and not just for DoD’s EHR procurement. It has much broader implications as it elicits a national debate on the proper role of Health IT. And as the paper warns:

Given the fast pace of technology changes, we hope that DoD will not repeat the mistaken multi-billion dollar decision that will hold it captive to the innovations of any single company or the services of a solitary vendor. Because of how enterprise systems are deployed, a poor selection at the first stage will inexorably lower performance and restrict enhancement choices for more than a decade. Alternatively, the DoD could choose a platform that is extensible, flexible and easy to safely modify and upgrade as technology improves and interoperability demands evolve.

The paper’s conclusion was reiterated by Dr. Seong Ki Mun, CEO of the Open Source EHR Alliance (OSEHRA), who told Open Health News that “the statement by Major General Punaro, that we ‘can’t let DOD turn into a benefits company that occasionally kills a terrorist’ is a sobering reminder we need to find a better solution urgently.”

“At OSEHRA, we agree with the report that DoD should avoid any decision that would ‘lock DoD into another dead end’ for its electronic health record system,” said Dr. Mun, adding that “we believe the open source methodology and business model will provide DoD with the best possible products and services for many years to come—at the lowest possible cost.”

According to Dr. Mun, “the open source option is the only way for the military health information system to remain nimble and constantly updated in a high-tempo environment.” Open source is powerful, said Dr. Mun, “because the code provides collaborative transparency and is supported by a large, vibrant open community of users and developers.” Dr. Mun pointed to the OSEHRA community which “contains multiple corporations that do an excellent job using open source best practices to build and support open source product solutions.”

Several of the members of the PwC/Google Team are corporate members of OSEHRA (PwC, DSS, Inc., Medsphere, and MedicaSoft), and a major component of the open source proposal for the DoD EHR will include the ability of DoD to draw upon the rapid innovation that is taking place within the OSEHRA community.

Is there a chance that DoD will pick the Open Source Option?

The paper raises the issue of the current bias in DoD’s bureaucracy for picking expensive proprietary solutions. The PwC/Google Team may have the best option for DoD, but they are facing formidable “lock-in” vendors that have spent billions of dollars marketing their expensive and archaic EHRs (as documented in this RAND Corporation report).

As an open source solution, VistA has never been able to do any kind of PR and marketing promotion. Nevertheless, as we will document in our upcoming special report, VistA: The EHR of Record, VistA has been implemented at more than 3,000 facilities around the world, and entire countries, such as the Kingdom of Jordan, are implementing it throughout their whole country.

But with a July deadline, major national institutions need to become involved in the discussion. Organizations that serve military personnel and veterans, should be playing a key role in the discussion of the procurement of an EHR system that is so integral to the health and well being of America’s military personnel, veterans, and their families. Large and well established open source organizations like the Linux Foundation and Open Source for America should be backing OSEHRA and the open source bid for DoD’s EHR. The release of this paper will hopefully finally spark this long-delayed discussion.