THEGEORGEWASHINGTONUNIVERSITYISTM6204PROJECT2

DoDandVeteransAffairs
ElectronicHealthcare
RecordInitiative,iEHR

SaudAlhawwas
SarahAlMalik
NorahAlsalamah
MartinGavin
AlexSingleton

TheGeorgeWashingtonUniversity
SchoolofBusiness

Dedicatedtoourcountrysfinest.

TableofContents

Abstract
Objectives
Background
VAVistA
DoDAHLTASystem
FailureFactors
AHistoryofFailure
MattersSeriatim
ScopeCreep
InsufficientPlanning
AbsenceofPerformanceMetrics
VariationinStatePrivacyRules&Compliance
CostsAssociatedwithInteroperability
SuccessFactors
IPOCreated
BidirectionalHealthExchangeCreated
StandardizedCodingSystemCreatedwithInteroperable/DigitizedMedicalRecords
AlignmentwithHIPAA
VeteransAccesstoCareAct
OutsideHelp
Retrenchment
Assessment&Debrief
Scope
SuccessFactorsAssessment
FailureFactorsAssessment
Recommendations,RemarksandConclusion:ASuccessfulFailure?
Appendix
Bibliography

Abstract
Since1998,theDepartmentofDefense(DoD)andtheDepartmentofVeteransAffairs(VA)have
initiatedstrategicimplementationstowardscreatinganinteroperableexchangefromwhichtosharethe
electronichealthrecords(EHR)ofactiveservicemembersandtheirdependentsaswellasveteransand
theirdependents.Thisinitiativesincurredcostoverrunssustainedbybothdepartmentsexceeding
wellover$1.3billiondollars.(Dan,1)

Todate,bothDepartmentsinitiativesincludetheFederal
HealthInformationExchange(FHIE),whichenablesthe
onewaytransferofservicememberselectronichealth
informationfromDoDtoVAforallseparatedservice
memberstheBidirectionalHealthInformationExchange
(BHIE),whichallowshealthcareprovidersfromboth
Departmentsviewableaccesstorecordsofsharedpatientsthe
ClinicalDataREpository/VeteransAffairsHealthData
Repository(CHDR),whichenablestheDoDandVAto
exchangecomputableoutpatientpharmacyanddrugallergy
informationforsharedpatientsandtheLaboratoryData
SharingInterphase(LDSI),whichallowsDoDandVA
facilitiestosharelaboratoryinformation.(Jansen,Panangala,
StatusoftheIntegratedElectronicHealthRecord(iEHR),
2013)

Manyobstaclesimpededprogresstowardstheoverallgoalofinteroperableaccess
ofhealthrecords(iEHR).Theseobstaclesincluded,butwerenotlimitedto,alackof
planningonbehalfofbothDepartments,alackofknowledgeregardingthetechnical
specificationsthatwouldberequiredinordertoensurethatthedatawasaccuratelyand
timelyaswellassecure,alackofadherencetostandardizedmedicalterminology
regardingprocedures,tests,pharmaceuticals,imaging,andscopecreep,aswellasahost
ofprivateintereststhatplayedaroleintheultimatefailureoftheproject.

Effortstocomputerizeandstandardizemedicalrecordsstretchesbacktothe
ClintonAdministration.Astheprojectmeanderedonandpublicopinionregardingthe
treatmentofwoundedsoldiersandveteransconvergedintoapoliticalfirestorm,the
recommendationturnedintocongressionalmandatein2008whentheDoDandVA
werechargedbylawtojointlydevelopandimplementelectronichealthrecordsystemsto
allowforfullinteroperabilityofpersonalhealthcareinformationinordertosupportthe
deliveryofhealthcarebybothDepartments.(Jansen,Panangala,9)Thislaw,in
conjunctionwiththeClingerCohenActhelpedformtheInteragencyProgramOffice
(IPO),whichwastaskedwithcongressionaloversightofiEHR.Althoughprogress
advancedinteroperabilityofthetwolegacysystems(VistA,theVAssystemand
ALTHA,theDoDssystem)itwouldtakeyetanotheractofCongressin2014anda
threattorescindfundingfromtheDoDsbudgetlineitemsforthetwoagenciesto
concludedissolvingtheprogramaltogether.Finally,in2013,theIPOannouncedthatit
haddecided(sic)thattheVAshouldstickwithitshomegrown,opensourceVistAand
thePentagonshouldgoitsownwaywithacommercialsystem.(Mazmanian,2015)
TheNationalDefenseAuthorizationActof2014(NDAA2014)establishedadeadline
forprojectcompletionbyOctober1,2014.

Objectives
TheVAandtheDODsprimaryobjectiveincreatinganinteroperablehealthrecord
exchangewastoimprovethequalityofcareforactivedutysoldiers,veteransandtheir
dependants.Thecreationofanelectronicmedicalrecord(EMR)enablessoldierstopersonally
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accessvitalinformationregardingtheirmedicalhistories,whichinturnwouldenableaseamless
transitionfrompublictoprivatelife.Thisintegratedelectronichealthrecordwouldbecreated
duringthesoldiersfirstphysicaluponentranceintothearmedservicesandspantheirentire
lives.TheiEHRwouldallowqualifiedcaregiversfromtheDoD,theVA,andprivatepracticing
physicians,toimplementandupdatethedatareceivedintherecordtoensureaqualityofcare
thatonlytechnologycanprovide.
Thecriticalpathtosuccessisfraughtwithobstaclesbutattainable.Theprojecttypology
regardingtheiEHRiscomplex,highlytechnological,spansmanygeographicboundaries,andis
underthereviewofmultiplestakeholders.Inordertoachievetheproject,planningisparamount.
Inordertofulfillthedeliverablesforaprojectofthismagnitude,clearobjectivesandmetrics
mustbeestablished.Thepoliticallandscapeandenvironmentmustbeconsideredandaproper
riskanalysisassessmentmustbeallencompassing.
In2008,aVA/DoDteamdefinedfunctional,infrastructure,and
policyinteroperabilityrequirementsthatresultedinaVA/DoD
multiplegatewayconceptofoperations....achievingthe
developmentandimplementationofanenterprisearchitecture
infrastructuresolutionandestablishmentofaseriesof
strategicallyplannednetworkgateways...toprovidesecure
redundantconnectivity(and)facilitatetheseamlesstransferof
healthdata.(VA/DoD,34)

AccordingtotheVA/DoDJointExecutiveCouncilFY2009AnnualReport,these
objectivesweretoincludethedevelopmentofaHealthServicesReferenceModelFramework.
(VA,DoD,28)TheVA/DoDHealthArchitectureInteragencyGroup(HAIG)alsocollaborated

toidentifyjointinformation,datarepresentation,security,andtechnicalstandardspublished
annuallyanddefinedacategoryofstandardsforVA/DoDinformationsharing.(VA,DoD,29)
Aninteragencyclinicalinformaticsboardwasestablishedto,amongotherobjectives,
demonstratethecapabilityforscanningmedicaldocumentsofservicemembersinDoDEHR
andforwardingthosedocumentselectronicallytoVA.(VA,DoD,31)Theseobjectiveswere
necessaryinordertopromoteinteroperability,(which)dependsontheuseofagreedupon
standardstoensurethatinformationcanbesharedandused.(GAO,14302,5)
OnMarch17,2011,theSecretaryofVeteransAffairsandtheSecretaryofDefense
reachedanagreementtoworkcooperativelyonthedevelopmentofacommonelectronichealth
recordandtosunsetcorrespondinglegacysystemsandtransitiontoanewiEHRby
2017.(Jansen,Panangala,12)Theobjectives,thoughbroadandsweeping,lackeddepthand
precision.Amongtheobjectiveswastoimproveinteroperabilityanddatasharingofmedical
historybetweendepartmentssupportelectronicmedicaldatacaptureandexchangebetweenthe
privateU.S.healthcaresystemandthefederal,state,andlocalgovernmentandreduceoverall
costsofhealthITinvestmentsandtomanageefficiencyofcostandscale.(Jansen,Panangala,
12)
In2012,anestimatedevelopedbytheIPOputthecostoftheintegratedsystemat29
billion(adjustedforinflation)fromfiscalyear2013throughfiscalyear2029.(GAO,16).
Platformintegrationswasabandonedduetocostconcernsandaninteroperablehealthrecord
exchangesystemwascommissionedinlieu.Duetotheshiftinscope,newobjectiveswere
established.Thesenewobjectivesincluded,butwerenotlimitedto,theVAmodernizingits

VistAhealthinformationsystemandDoDbuyingacommerciallyavailablesystemtoreplaceits
existingAHLTAhealthinformationsystem.(GAO,18)Alsoamongthenewobjectiveswereto
expandtheuseofGUIsandagreeingonhowtoidentifypatientsthatwereinthecareofboth
theVAandDoD.Itwasalsodeemednecessarytodevelopasecurenetworkinfrastructurefor
VAandDoDclinicianstoaccesspatientinformationandcorrelatingtheminastandardized
patientrecord.(GAO,18)Complexityisapparent,however,expenditurestotalingover$1
billionisunacceptablydelayedandincompleteduetoalackofproperplanning,establishinga
clearanddefinedscopeofwork,orprovidingabaselineonwhichtomeasureearnedvalueofthe
project.

Background
Fornearlytwodecades,bothVAandDODattemptedtoupgradetheirsystemstoachieve
interoperability,butencounteredmanyobstacles.TheNationalDefenceAuthorizationAct
(NDAA)for
FiscalYear2008
commissionsbothdepartmentstojointlydevelopandimplement
fullyinteroperableelectronichealthrecordsystemsorcapabilitiesin2009(Melvin,2015,p.4).
Thoughtheywereabletoaccomplishsixinteroperabilityobjectivesestablishedbytheir
InteragencyClinicalInformaticsBoard,theyfacedmanychallengesthatcontinuallyhindered
theirabilitytoaccomplishfullinteroperability(Melvin,2015,p.4).
InMarch2011,bothdepartmentssecretariesannouncedthattheywoulddevelopanew,
jointintegratedelectronichealthrecordsystem(referredtoasiEHR)(Melvin,2015,p.4).The
primarygoaloftheiEHRsystemwastoreplacethetwoseparatesystemswithonesingle
commonsystemusedbyeachdepartmentavoidinganyinteroperabilitychallengestheyhad
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encounteredinpreviousinitiatives.Althoughthiscouldhavesidesteppedinteroperability
challenges,thetripleconstraintofcost,scope,andtimewasinvariablyunavoidable,leadingto
theterminationofthe2011initiativeofdevelopingasinglecommonsystem(iEHR).
TheVAcommittedtomodernizetheirexistingVistAsystemandtheDoDdecidedto
purchaseanewsystemtoreplaceAHLTA,whilebothdepartmentsconsider
interiminteroperabilityfunctionalitiestoimproveefficiencywhileloweringcostshowever,both
departmentsdidnothaveaclearcutplanofexecution.Inresponse,theNationalDefense
AuthorizationActfor
FiscalYear2014
statesrequirementspertainingtotheimplementation,
design,andplanningforinteroperabilitybetweenVAsandDODselectronichealthrecord
systems(Melvin,2015,p.6).TheNDAAwasintendedtoguideaconcisetimelineforboth
departmentsindeliveringtheirsystems.

VAVistA
VeteransHealthInformationSystemsandTechnologyArchitecture(VistA)was
Introducedin1996bytheCIO,intendedtobeanautomatedenvironmentthatsupports
daytodayoperationsatlocalDepartmentofVeteransAffairs(VA)healthcarefacilities
(EHEALTH,n.d.).Thesystemwasbuiltonaclientserverarchitecture,whichenabled
accessforbothworkstationsandpersonalcomputerswithgraphicaluserinterfaceat
VeteransHealthAdministration(VHA),aswellassoftwaredevelopedbylocalmedical
facilitystaff(EHEALTH,n.d.).VistAoffersdifferentapplicationstoenablebetter
functionalitiesforitsservicemembers,families,andotherbeneficiaries.VistAwas
developedinhouseusingtheAgileprocess,whereboththeVAcliniciansandIT
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personnelcollaboratedtoproducetheprogram.Applicationsembeddedwithinthe
systeminclude104computerapplicationsincluding56healthprovidersapplications,19
managementandfinancialapplications,8registration,enrollment,andeligibility
applications,5healthdataapplications,and3informationandeducationapplications
(Melvin,2014,p.3).WiththemanyapplicationswithinVistA,theyarecustomizedatall
128VAsites,whichinturnincreasesmaintenancecostsdramatically.However,in2001,
theVeteransHealthAdministrationdecidedtomodernizethesystemtheyhaveathand.
Theysettheirgoalstomoveawayfromahospitalcentrictoaveterancentric
environmentwiththeadditionofenhancedfunctionsbasedoncomputabledata
(Melvin,2014,p.4).

DoDAHLTASystem
TheDoDsArmedForcesHealthLongitudinalTechnologyApplication
(AHLTA)systemiscomprisedofdifferentcommercialsoftwareproductsthatwere
implementedandcustomisedtofittheneedsoftheDoD.In1997theyhadcommitted$2
billiontoupgradeAHLTAthrough2010toacquirebetterservicesandfunctionalities,
specificallyinperformance(Melvin,2014,p.4).Thesystemkeepstrackof9million
servicemembersandtheirfamilies.TheyplannedonacquiringWayAheadasthenew
systemtoincluderealtimehealthrecordsforservicemembersandtheirfamiliesand
otherbeneficiaries.Additionally,itwillprovidecomprehensivemedicaldocumentation,
captureandsharemedicaldataelectronicallyinDoD(Lipowicz,2010).

FailureFactors
RecallEHR/iEHR(ElectronicHealthRecords/InteractiveElectronicHealthRecords)
facilitatestreamlinedaccesstopatientmedicalrecordsthroughautomation,historically
documentedonpaper.
Digitaltranscriptionofdecentralizedinformationisinherentlydifficult
andonlycompoundedbyHIPAA(TheHealthInsurancePortabilityandAccountabilityActof
1996)
.Throughinteroperability,informationcanbeexchanged,fromonehealthcareproviderto
another,seamlesslyintegratedintothereceivingprovidersEHRsystem,allowingtheprovider
tousethathealthinformationtoinformclinicalcare.(Kohn,L.(2015)).

AHistoryofFailure
Since1998,DoDandVAhavecooperativelyundertakeninitiativestaskedto
electronicallyexchangepersonnelmedicalrecords,ultimatelytransforminghealthcare
intoasystemthatcanachievegoalsofimprovedquality,efficiencyandpatientsafetyas
viewedbystakeholdersbysharingviewabledatainlegacysystemsbetweenboth
departments.(Melvin,V.(2015,October27))Asscopecreepprotracteddevelopmentof
aminimumviableproduct(MVP)fornearlyadecade,DoD/VAjointlycommissioned
theInteragencyProgramOffice(IPO)in2008,whichwasmandatedbytheNational
DefenseAuthorizationActof2008requiringestablishmentofaninteragencyoffice
staffedwithadirectorfromeachagencyforreportinguntiltheinitiallyproposeddeadline
ofSeptember2009(Timberlake,G).Duetoincessantdelays,theSecretariesofDefense
andVeteransAffairs(Sec.ChuckHagel&Gen.Sheshinski)announcedaformal

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departureinFebruary2013,abouttwoyearsafterlaunchingiEHR,whichresultedfrom
anassessmentconcludingcostoverrunsoutofbudget(Melvin,V.(2015,August13)).
However,IPOwasrecommissionedinDecember2013astheexclusiveaccountability
agencyoverseeinginteroperability,responsibleforestablishingtechnicalandclinical
standardsandprocessestoensureintegrationofhealthdatabetweenthetwodepartments
andotherpublicandprivatehealthcareproviders.(Melvin,V.(2015,August13)).A
briefhistorywasprovidedforcontextandsufficientforthescopeofthisanalysis,but
specificfailurefactorsvisavis2014NationalDefenseAuthorization(NDAA2014)are
onlygermanetothisstudy.

MattersSeriatim
TheNDAA2014renewalenumeratedcomplianceordersfornationalelectronic
medicaldatastandardsinFebruary2015.(Melvin,V.(2015,August13))Concordantly,
IPOremainscharteredtoachieveinteroperabilitybetweenelectronicmedicalhealth
recordssystemsbetweenDoDandVA,aseachpursuedalternativesolutionsrespectively
knownasDHMSM(privatelyrequisitionedtoCernerandLeidosi/a/o$11billiontermed
under10yearcontract)andtheVistA4RoadmappivotingtheVAtoevolvethe
existingVeteransHealthInformationSystemsandTechnologyArchitecture,(VistA)(a
$4.3billioncontractlikelytoincurlifecyclecostover$9billion).((Melvin,V.(2015,
August13))(Walker,M.B.(2015,August18)).Inspiteoftheaforementioned
commencements,DoDsDHMSMwillnotachieveoperationalcapacityuntiltheendof
fiscalyear2022,whiletheVistARoadmapwillnotdeployuntil2018bothdates
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obviouslybehindoftheNDAA2014deadline(YE2016).(Walker,M.B.(2015,August
18))Ostensiblysimpleasanobjective,DOD/VAsysteminteroperabilityhasproven
difficulttoeffectduetoseveralfailurefactors,examinedherein:
ScopeCreep
Sinceinception,theinteroperabilityinitiativehasbeenplaguedby
managementweaknesses,specificallyfailuretodefineaplan,prolonged
indecision,andcontinualscopecreepconcerningtheU/I|U/X
(userinterface/userexperience)(Appendix::1.5.1)(Kohn,L.(2015)).Itisfairto
inferthatexecutionwasafailurefactorenablingscopecreepandfreezecycles,
indefinitelypostponingtheprojecttopresentday.In1998,EMRvirtualization
wasnarrowedtothescopeinformationtransfer,fouryearslaterasapartofthe
FederalHealthcareExchangeInitiative,onlytobemorphedagaintoincorporate
privatesectorhealthcaredatain2009(Melvin,V.(2015,August13)).Although
someoftheoriginalinitiativespresentedintheNDAA2008wereaccomplished,
clearlyprojectexecutionisroutinelyproblematic,especiallyduetoinsufficient
planning.
InsufficientPlanning
Theinteroperabilityinitiativehasbeenplaguedbymanagement
weaknesses,specificallyindecisiveness,complicatedbytheadministrationsof
DoDSec.ChuckHagelandGen.EricSheshinskioftheVA.Sharingofanykind,
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fromintelligencetomedicalrecords,requiresgovernanceandtrustaconcerted
effortamongstentities(Kohn,L.(2015)).GAOtestimoniessubstantiatethe
criticalityofinformationintroducedwithinthesubjectexaminationof
failurefactors,specificallywiththeneedforgovernanceandtrustamong
entities,suchasagreementstofacilitatetheshareofinformationamongall
participantsinaninitiative.Kohn,L.(2015))Itshouldcometonosurprise,yet
again,thatthePotomacTwoStepdisruptsinteragencycooperationandfocus.
Alphaprojectmanagers(inthestatisticalconstruct,notinpsychology)spend
moretimeinthephaseofplanningthanactualexecution,whichclearlyhasnt
beenobservedatDoDorVA(Appendix::1.5.2)(Schwalbe,Kathy).Ideally,a
comprehensivestrategyoutlinesacriticalpathgovernedbykeyperformance
indicators(KPIs)toaccomplishtheprimaryobjective,whichinthiscaseisnotto
beconfusedwithintegration,butratherinformationinteroperabilitybetweenthe
subjectfederalagencies.Althoughabsentandonlyinrecommendationasofthis
writing,aretrospectiveexaminationofmetricsmaybeappropriate.
AbsenceofKeyPerformanceIndicators(KPIs)
Itisimpossibletoimprovewhatcannotbemeasured.Acknowledging
DODandVAconducttowardachievinginteroperability,Federaloversightreview
specificallyattributesthecurrentqualityoftheinteroperabilityprojecttoabsence
ofresultsorientedmetricsprovidingthedepartmentsandstakeholderswith

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objective,quantifiable,andmeasurablegoals(Melvin,V.(2015,August13)).
Departmentalplanslackedassociatedperformancegoalsandmeasuresthatarea
necessarybasistoprovideotherdepartmentsandtheirstakeholderswitha
comprehensivepicturetoeffectivelymanagetheirprogresstowardincreased
interoperability(Melvin,V.(2015,August13)).Detrimentalconsequences
ensued,precludingcompliancewithStatePrivacyregulatoryrulesandapprovals.
EarnedValuecalculations,CostandScheduleVarianceForecastingmaybe
opportuneconsiderationsforretrenchment.
VariationinStatePrivacyRules&Compliance
Thepushpulldynamicbetweenfederalandstateregulationsyieldsa
nebulousenvironmentforbothprivateandpublicorganizationsalike.HIPAA
notwithstanding,EMRinformationexchangeandtranscriptionnecessaryfor
interoperabilityiscontinuouslyensnaredbyvariablelegislationprotecting
individualpatientprivacy.Exchangesensitivityisespeciallyheightenedfor
healthrecordinformationconcerningmentalhealthandHIVinfection(Kohn,L.
(2015)).AccordingtoGAOstakeholderandinitiativesurveillance,personal
healthcarerecordscontainingsensitiveinformationrisksinadvertentaggregation
withgeneralhealthinformational,therebyviolatingpatientconsentandprivacy
rules.(Kohn,L.(2015))Furthermore,datawarehousingisincreasingly
convolutedbytheabsenceofuniqueidentifiersreconcilingcompletepatient

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medicalrecords.EHRsystemsutilizerelationshipmappingandmodelingto
incorporatedemographicinformation(e.g.patientsnameanddateofbirth)to
matchadditionalinformationcollectedbydifferenthealthcareproviders.(Kohn,
L.(2015)).Systemicuniformitywouldmitigateriskbecauseasonestakeholder
representativenoted,variousagreementsdevelopedbydifferentEHRinitiatives
couldresultinconflictingorganizationalpolicies.(Kohn,L.(2015))Strategy
requiresstakeholderconsensussystemicincongruencyinviteserrorsinbudget
forecastinginturnlimitingresourcesforeffectiveinteroperability.
CostsAssociatedwithInteroperability
Anyretrenchmentinitiativeisalreadymiredincostoverrunsattributedto
duediligence,legalfeesandtechnicalredundancies(Appendix::.1.5.3)(Kohn,L.
(2015)).Since2009,federalgovernmentexpendituresexceedwellover$30
billiondollarsbudgetedforcampaignswithintheHITECHactofthe2009
economicstimuluspackagefunding500,000physiciansandmorethan5,000
hospitalscaringforbothMedicareandMedicaidrecipientstoestablish
electronichealthrecordssystemsthroughthemeaningfuluseincentiveprogram,
whichiscarriedoutbytheCentersforMedicareandMedicaidServices(Ahier,
B.(n.d.)).Interfacecustomizationisanothervariablefrontendcostthatcouldbe
reducedbystandardization.Tenof18EMRexchangefocusgroups
acknowledgedmeaningfuluseorsystemfunctionalityofferings(e.g.

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messagingservicewithinintranetworks)asfrivolouslydivertingresourcesaway
fromtheprimaryinteroperabilityobjective(Ruoff,A.(2015,September30)).
Consistentimplementationaccordingtostandardsandtargetsdefinedbycomprehensive
stakeholdermappingistheonlywaytoreconcileandappropriateabudgetdelivering
interoperability.ThisstudyconcurswiththeGAOgeneralassessmentdirectedtotheIPO:
establishatimeframeforidentifyingoutcomeorientedmetrics,definerelatedgoalsasabasis
fordeterminingtheextenttowhichthedepartmentsmodernizedelectronichealthrecords
systemsareachievinginteroperability,andupdateIPOguidanceaccordingly"(Melvin,V.(2015,
October27)).

SuccessFactors
InFebruary2013,theDepartmentsofVeteransAffairsandDefenseabandonedtheir
plansforanintegratedelectronichealthrecord(iEHR),citingproblemswiththecostsand
scheduling.DespitetheissueswithimplementingtheiEHR,therewereanumberofsuccesses
thatalludetoabrightfutureforthesystem.Thesystemresultedinanumberofchangesinthe
DepartmentsofVeteransAffairsandDefensethatallowedformoreeffectivemanagementofthe
healthrecordsofactiveservicemembers,veterans,andthedependentsofbothgroups.

IPOCreated
Oneofthemostimportantsuccessfactorsrelatedtothisprojectwasthecreation
oftheInteragencyProgramOffice(IPO).TheIPOwascreatedwiththeintentionof
optimizingcommunicationbetweentheDepartmentsofVeteransAffairsandDefense.

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BothoftheseDepartmentsarepartiallyresponsibleforthemedicalrecordsofsome
activeservicemembers,veterans,andthedependentsofbothgroups.Althougheach
departmentknewingeneralwhichrecordstheywereresponsiblefor,therewere
questionsoverwhereresponsibilityliesregardingpatientsthatweresharedbetweenthe
twoentities.Toavoidanyfutureconfusion,theIPOwassanctionedbylawsothatthey
couldaddresstheinabilityoftheDoDandtheVAtoestablishclearobjectivesand
measurablegoalsregardingtheimplementationoftheiEHR.TheIPOwasmeanttoact
asapointofaccountabilityforthedevelopmentofinteroperablehealthrecordsforboth
departments(

ElectronicHealthRecords,2014).Ratherthanhavingtheblamefallon
theDOD/VA,theIPOisanorganizationthatservesasapointofcontactbetweenthetwo
agenciesinregardstomajorITprojectsthatconcernbothdepartments.Inthecaseofthe
iEHR,itwasresponsiblefortakingovertheprojectandmakingsurethatbothsideswere
inalignmentwiththeprojectscope,budgetandscheduleandisthereforeitisaccountable
foranyissuesthatmayoccurintheseareasbetweenthetwoorganizations.

BidirectionalHealthExchangeCreated
BidirectionalHealthInformationExchange(BHIE)wasestablishedin2004and
wasaimedatallowingcliniciansfrombothdepartmentstogainaccesstopatientrecords.
BHIEisextremelyimportantforindividualswhoreceivecarefrombothdepartments,
whichcanhappenquitefrequently(VA/DoDJointExecutiveCouncilAnnualReport,
2009).Thebetterthetwodepartmentscancommunicaterecords,thebetteritisfor
everyoneinvolved.Byenablingthetimelyaccesstoaccuratemedicaldata,theVAand
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DODareabletocreatecostsavingsandbetterservethemedicalneedsofboththepatient
andtheircaregivers.Patientsaremorelikelytobetreatedeffectively,especiallypatients
withpreexistinghealthissues.Clinicianscanspendlesstimerepeatingtestsandmore
timetreatingpatientswhentheserecordsareeasilyaccessible.Havinganeffective
systemlikethisleadstoanincreasedamountofdatasharingbetweendepartmentsand
saveslivesduetotheincreaseinpatientinformationinashorterperiodoftime.(Devine,
2015).

StandardizedCodingSystemCreatedwithInteroperable/Digitized
MedicalRecords
InordertocreatetheBHIE,astandardizedcodingsystemhadtobeestablished.
SincetheVAandtheDODaredifferentdepartmentswithdifferentmanagement,thetwo
departmentspreviouslyhadcompletelydifferentwaysofcodingfordrugsandfor
procedures.Mostdrugsandprocedureshaddifferentcodesrepresentingtheminboth
departments,sowhenapatientgoesfromonedepartmenttoanothertheirrecordsare
unclear.Whenrecordsweretransferredbetweendepartments,thereceivingdepartment
wouldnotbeabletounderstandthecodingandeveniftherecordwasreceivedina
timelyfashionitwouldbeuseless.Becauseofthismanytesthadtoberepeated,anda
largeamountoftimewaswasted.In2001,threeyearsbeforeBHIEwasestablished,the
VeteransHealthAdministrationtooktheinitiativeofupdatingtheVistAsystemtheyhad
inplaceinordertomodernizethehealthinformationsoftware.Thesystemarchitecture
thatwasalreadyinplaceservedasaframeworktocreateasystemthatprovidedthesame
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benefitsandfunctionswithexpandedfunctionsbasedondatathatcanbecomputed.The
standardizationprocesswasoriginallybasedonsixphasesthatweremeanttobe
completedby2018,buttheplanseventuallyfellthrough.Still,thestandardizedcoding
systemthatwascreatedforthisprojectwillbeveryhelpfulforcoordinatingefforts
betweendepartments.
VeteransandactiveservicememberssinceWorldWarIwereabletohavetheir
recordsdigitized,sothatitiseasierforcliniciansintheDODandVAtoworktogether
andcreatethefullestpictureofanindividualshealthhistorytopreventfutureproblems.
CreatinginteroperableanddigitizedmedicalrecordsisessentialfortheDODandVAto
effectivelycommunicatemedicalrecordsforactiveservicemembers,veterans,andthe
dependentsofbothgroups.

AlignmentwithHIPAA
TheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)was
enactedinordertoprotectpeoplewhohavelosttheirjobsfromlosinghealthinsurance,
andrequiredtheestablishmentofnationalstandardsforelectronichealthcare
transactions.SinceiEHRwascreatedafterHIPAAwasenacted,itwasessentialthatany
changestothehealthrecordssystemsinplacecomplywiththeHIPAAguidelines.The
guidelineswerecreatedtoprotectthesecurityofthosewhoserecordswouldbeplaced
online,sothattheirprivateinformationdoesnotfallintothewronghands.iEHRwas
abletocreatesecureinterfacesthatalignswithHIPAAguidelinessothatthemedical
recordsofveterans,activeservicemembersandtheirfamiliesremainsecure.
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VeteransAccesstoCareAct
TheVeteransAccesstoCareActisabillthatwasproposedinJuneof2014that
allowsveteranstoreceivehealthcarefromnonVAfacilitiesduringcertain
circumstances.Thisbillwasproposedasaresponsetotherevelationthatmanyveterans
havetowaitextendedperiodsoftimeinordertoseeadoctorwiththecurrenthealthcare
plan,andthatmanyveteranshavediedwaitingtoseedoctors.Thisbillisfullyrelatedto
interactionsbetweentheDODandVAanditisanessentialpieceoflegislationinregards
tothehealthofveteransandtheirfamilies.PlanningforiEHRhelpedbringtolightissues
thatveteransfaceintermsofhealthcare,whichresultedinthisbillbeingproposed.

OutsideHelp
ThefinalsuccessoftheplanforaniEHRwasthatplanningthesystemresultedin
theDODandVAaskingforhelptoimprovetheirsystem.Previousofthemovetoward
aniEHRsystem,theDODandVAhadanumberofseriousproblemsregardinghow
medicalrecordsforveterans,activeservicemembersandtheirfamiliesweredealtwith.
Thesepeoplewerebynomeansreceivingthemedicalcarethattheyneededordeserved,
sotheDODandVAdecidedtoworktogethertointegratetheirsystemsforamore
successfulsystem.Afterencounteringanumberofcomplications,thetwodepartments
realizedthatitwasimpossibletodevelopthiscomplicatedsystemalone.The
departmentshaveinsistedhelpinordertorepairtheiroutdatedsystem,sothatveterans,
activeservicemembersandtheirfamiliescanhavebetteraccesstohealthcare.

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Retrenchment
Thereisnodoubtthatthescopeofthisprojectwasmassive.However,asnotedin
inaGAOreportdatedFebruary,2014thattheclaimsoftheSecretariesofDefenseand
VeteransAffairsregardinganintegratedelectronichealthbeingtoocostlywere
unsubstantiated.
TheGovernmentComputerBasedPatientRecordwasbegunin1998andsince
thattimeprogressiveenhancementshavebeenaccomplishedtowardstheendgoalof
deliveringanintegratedoratleastinteroperableelectronichealthrecordsystem.
CurrentlytheDoDandVAareusingtheBidirectionalHealthInformationExchange
establishedin2004.Thisexchangeprovidescliniciansatbothdepartmentswith
viewableaccesstorecordsonsharedpatients.(GAO,3)Thoughthesystemis
antiquated,itisstillprovidingausefulfunctionandshouldthusbecontinuedwhilea
strategicplantoimplementtheAHLTAandVistAplatformscanbeestablished.
ManyreportsandanalysishavebeenconductedbytheGAO,theInspector
GeneralsOffice,theOfficeofBudgetandManagement,andabevyofotherpublicand
privateentities.Throughoutthedecadesofreportsandanalysisonecommonthemeis
prevalentandthatistheprojectcontinuallyriskedfailureduetomanagementfailures
ratherthantechnicalfailures.Itisthereforeintheinterestofthestakeholdersthata
properDelphiTechniqueshouldbeappliedinordertogatherinformationtoreacha
consensus,thistechniquewillhelptoreducethelevelofbiasandundueinfluence.Itis
furtheradvisedthattheIPOcreatedasaninteragencyefforttoimplementtheprojectbe
21

commissionedasaseparateentitywithoutbudgetaryormanagementconstraintsthatit
mustconformtointheinterestoftheDoDorVA.Thisentityshouldonlybeanswerable
totheCongressionalCommitteeonVeteransAffairs.
Furthermore,properprojectmanagementplans,matrixes,andconstraintsshould
beestablishedpriortofurtheradvancingtheproject.Onceaconsensushasbeenreached,
thenandonlythenshouldamovebemadetoforwardtheobjectives.Lookingatacost
performanceindexitiseasytounderstandthatthereisaclearlydefinedneedtorethink
currentstrategiesandconsiderthepercentcompleteoftheworkthathasalreadybeen
accomplished.Ifthecurrentstrategyistogoforward,aneedtoeliminateredundanciesof
prioreffortsshouldbeincludedintheprojectscopestatement.
Inordertorealignandgenerateareturnonthepreviousinvestments,itshouldbe
establishedthattheVistAplatformisthewaytomoveforward.Duetoitsopensource
nature:
theVistAsystemisaprovenproductandcanbereadilyadapted
foruseinacutecare,ambulatory,andlongtermcaresettings.It
hasbeenusedinpublicandprivatehealthcareprovider
organizationsacrosstheUnitedStatesandinanumberof
internationalsettingsalso,leadinginformationtechnology
companiessuchasHP,PerotSystems,andIBM,andrapidgrowth
firmssuchasMedsphereCorporation,DSSInc.andMele
AssociatesareactivelysupportingimplementationsintheUnited
Statesandaroundtheglobe.(IOM,225)

Asthewayofthefuture,opensourcesoftware(free)wouldaddtruevaluetothis
projectandrealignthereturnoninvestmentandearnedvalueofpreviousefforts.Also,to

22

alleviatedatatransfersecurityconcernsitshouldbenotedthattheadventofblockchain
technologyaffordsmanyimplicationsbeyondcryptocurrency,asopensource
healthcare.Duetoissuesconcerningsecurityclearance,Cernerrespectfullydeclinedto
commentforthisstudy(Singleton,AlexanderJ.).Nevertheless,contributingscholars
imploreCernerandLeidostopivottheirapproachifpursuingclosedsourcedsolutions,
substantiatedinthelastsectionconcludingthisstudy(Recommendations,Remarksand
Opinions).

Assessment&Debrief
IntheirpursuitofapartnerfortheDefenseHealthcareManagementSystem
Modernization(DHMSM),theDepartmentofDefenserecentlydecidedtoawardagroupledby
CernerandLeidoswiththecontractforitsmuchanticipatedEHRmodernization.Theselection
oftheCerner/Leidosledteamcameasasurprisetosome,asmostanalystshadexpectedEHR
marketleaderEpic,anditspartnersincludingcomputerservicesgiantIBMtowalkawaywith
thecontract(Noble).Ultimately,thedecisiontoawardtheCernerconsortiumthecontractover
EpiccametodowntoamatterofstrategiccompatibilitywiththevisionthattheDoDhasforits
iEHR.WhereasEpichasahistoryofclosedorproprietarybasedsoftware,theDepartmentof
DefensewaslookingforasystemthatwasmorefocusedontheopenbasedstandardsthatCerner
andAllscriptsrelyupon(Walker).Ironically,Leidoshasbeendownthisroadbefore.Leidos
Holdings,Inc.,thecompanyformallyknownasSAIC,hasastoriedhistorywiththeDoDdating
backto1988.Inthattimespan,thecompanyhasdesigned,developedandimplementedseveral
healthcaresystemsfortheDoD,includingthecurrentArmedForcesHealthLongitudinal
23

TechnologyApplication(AHLTA),whichlaunchedin2005costingthedepartment$1.2billion
(GurArie).
Atthetimeofthefinalsolicitationofbidspresentedin2014,theestimatedcostofthe
DHMSMprojectwasprojectedtocosttheDepartmentofDefense$11billion.Recentstatements
releasedbyDoDUnderSecretaryforAcquisition,TechnologyandLogistics,FrankKendall,
suggeststhattherobustcompetitiongeneratedinthebiddingprocessmightreducetheactual
costsoftheprogrambelow$9billion.Whatdetailshavebeenreleasedindicatethattheinitial
contractawardedtotheCerner/Leidosledteamspans2yearsandisvaluedat$4.3billion.Ifthe
initialresultsdemonstrateitsintendedefficacy,optionstorenewcanraisethetotalcontract
periodto10years.
Scope
ThescopeoftheDHMSMcontractisconsideredamassiveundertaking,asthe
Cernerledgroupwillberesponsiblefortheupgradingandservicingofhealthrecords
totalingmorethan9.5millionindividualsintheDoDsystem.Perhapsthemostvital
aspectoftheentireoperationisthesunsettingofthedepartments50existingsystems.
DoDofficialshaveestimatedthatthecostofoperatingandservicingthedepartments
legacysystemsequalscloseto95percentoftheDoDstotalITbudget(Sullivan).
OfficialshavealreadyindicatedthatthefullimplementationoftheVA/DoDEHRwill
takesixtosevenyearstocomplete.Unfortunately,currentestimatesforthefull
operationalcapabilitybeingcompletedtowardstheendoffiscalyear2022representsa

24

significantdeviationfromtheNDAAsoriginalDecember31,2016targetfor
interoperability(Hirsch).
WhiletheDepartmentofDefensewouldhaveappearedtoofscoredavictoryon
thecostfront,theprojectisnotwithoutitscritics.Severalofficialshaveexpressed
frustrationwiththefacttheDoDhaschosenvendorsthatarelargelyresponsibleforthe
legacysystemsthatthedepartmentisnowlookingtoreplace.WhiletheDoDhas
determinedthataninteroperableinfrastructureisthebestpathforward,opponentshave
suggestedthattheprogramisflawedandantiquatedincomparisontoan
internet/cloudbasedplatform.OthercriticshavesuggestedthattheDoDsinefficient
bureaucraticculturewillresultinincreasedoverheadanddelaysintheimplementationof
asystemwiderolloutinatimelyfashion.Perhapsmostfrustratingofall,istheagencys
failuretoprovideperformancemetricsandgoalsforhowtheyintendtodefinethe
successoftheiEHRprogram,orhowtheyintendtoincorporatethosegoalsintothe
developmentprocess.WhiletheDoDhasrecentlytoutedthemeritsofthecontract
awardedtotheCerner/Leidosledteamandthesynergiesitwillcreate,GAOhasargued
thatthedepartmentsfailuresalsoextendstoitsinabilitytoaccuratelydefinethebudget
andcostbasisforthedevelopmentprocess.
SuccessFactorsAssessment
Ultimately,thesuccessoftheprogramwillbedeterminedbytheabilityofthe
projectteamtofocusonmeasuresofefficiency.Afteryearsofdelays,andareported
$1.3billionwastedinanunsuccessfulattempttocreateanintegratedEHRsystem,the
25

programisfinallybeginningtoseesignsofimprovement.Attheheartoftheprograms
successishowthedepartmentsmanagetheirpeopleandtheprocessestheyperform.Both
departmentsarealreadyhardatworktrainingthepeoplewhowillberesponsibleforthe
successfuldeploymentofthenewiEHR.TheInteragencyProgramOffice(IPO)hasseen
recentsuccessinitsattemptstomanageandguidetheprojectbyintroducingmetrics
intendedtomonitortheinteroperabilitysefficacy,whichistheprogramsprimary
indicatorofsuccess.Inessence,theprojectsgravitationtowardsanopenbasedsystemis
theclearestindicationyetthatmanagementhaslearnedfromitspastfailuresandis
preparedtomovetheprojectforwardtowardsitsstatedgoalofinteroperability.
Onesuccessfactorthatcanbefactoredintheaccomplishmentsinthis
integration/interoperabilityprogramwouldbethecreationoftheInteragencyProgram
Office(IPO).TheIPOhousesbothdepartments(VAandDoD)interests,wherethey
discussallmattersassociatedwithiEHR.HavingtheIPOprovidedgroundwork
guidance,rolesandresponsibilitiesforbothdepartments.TheIPOhavetakenactionsto
increaseinteroperabilitybetweentheirexistingelectronichealthrecordsystems
(Melvin,2015).In2004,theymanagedtostandardizespecifichealthdata,whichcreated
thetheBidirectionalHealthInformationExchange.Thisgavetheabilitytoviewpatients
recordsbycliniciansfrombothdepartmentsinanintegratedmanner(referto:Appendix
A).Additionally,theyhelpedforeseethelongerterminitiativestomodernizetheir
respectiveelectronichealthrecordsystems(Melvin,2015).Finally,theyrelayedthe
necessaryapproachingforachievinginteroperabilityinthetechnicalsense.

26

Backin1997,thePresidentcalledforthetwoagenciestostartdevelopinga
comprehensive,lifelongmedicalrecordforeachservicemember(CalvaresiBarr&
Steck,2001,p.4).Bothdepartmentsworkedtowardthisobjectiveandhavesuccessfully
backedallpatientrecordsfrompaperbasedinformationtocomputerbaseddata.Thus,
pushingforwardtoenablingbothdepartmentstoview,retrieveandupdatepatient
recordsaccordingly.
TheVeteransAccesstoCareActimplementsaprogramthatprovidesveterans
theabilitytoseeknonVAhealthcareprovidersorprivatephysicians.Thisactallowsthe
veteranstoreceivehigherqualitymedicalcareaswellasfastertreatment.Theact
requiredtheVAdepartmenttomakecontractsandassessappropriatehospitalsfor
veteranstreatments(VeteransAccess,ChoiceandAccountabilityAct).
FailureFactorsAssessment
Sinceinception,thedepartmentsofDefenseandVeteranAffairseffortsto
implementaseamless,fullyinteroperableEHRsystemhaswitnessedagreatdealof
adversity.Afteracompleteshiftinstrategyresultinginthedelayoftheprojectsrollout
till2022(attheearliest),managementisleftponderingwhere,andwhen,thingswent
wrong.Ironically,managementisprimarilytoblamefortheprojectsfailureuptothis
point.
Theprogramshistoryoffailurehasbeenwelldocumented.Thesetbackshave
beenfrequentandrangefromcostoverrunstothelackofwelldefinedperformance
metrics.Theprojectsoriginal2014deadlineisnowanitemofthepastasmanagements
27

indecisivenesshasledtoscopecreepandnumerousfreezecycles,largelytheresultof
insufficientplanning.Thelackoftrustandeffectivecollaborationbetweenleadershipat
bothdepartmentshasledtothemedialabelingthepartnershipasthePotomac
TwoStep,duetotheapparentinabilitytofindcommongroundontheprograms
directionandscope.Althoughtheprogramhasrecentlyshownsignsofmovingforward
withitsnewstrategyofintegratingeachdepartmentsEHRsystems,managementhas
stillfailedtolabelkeyperformanceindicatorsbywhichtomeasuresitssuccess.Thelack
ofkeyperformanceindicatorstoquantifysuchmetricsastheprojectsprogresstowards
achievingincreasedinteroperabilityhasbeenamajordetrimenttotheprogramssuccess,
andoneoftheprimaryreasonsbehindcostoverrunsandtimedelays.Ultimately,the
programssuccessdependsnotonlyonthetopicsalreadydiscussed,butalsoonthe
capabilityofmanagementtomaneuvereffectivelythroughthepoliticalandregulatory
landscape.Successrequiresleadershiptoworkwithstateandfederalregulatorsto
guaranteethatthenewsystemconformstoallpatientprivacylaws.Failuretodosocould
resultinfurthercostsinadditiontothebillionsofdollarsalreadyspenttogettheprogram
upandrunning.

Recommendations&Remarks:ASuccessfulFailure?
Asproponentsofopensourcesoftware,thisstudyadvisesDoD,VA,CernerandLeidos
topivot,oratleastconsideranapproachcurrentlyinpursuitbyPhilips,inwhichhealthcare
informationmaybeexchangedandsharedutilizingblockchaintechnologyguarding

28

cryptocurrencieslikeBitcoin,guaranteeinganonymity(
Rizzo,P.
).Dataanalysisiseasy,but
procuringthedataistherealchallenge.Conceivably,afederalexchangemaycultivatean
environmentforcollaborativeinnovation,akintoDARPAsprecursorydevelopmentofthe
internet(
Asnaani,J.)
.InearlyOctoberofthisyear,theOfficeoftheNationalCoordinatorfor
HealthIT(ONC)releasedaproposalentitled,
ConnectingHealthandCarefortheNation:A
SharedNationwideInteroperabilityRoadmap,
advancingthreethemes(
Asnaani,J.)
:

Givingconsumerstheabilitytoaccessandsharetheirhealthdata.

Ceasingallintentionalorinadvertentinformationblocking

Adoptingfederallyrecognizednationalinteroperabilitystandards.
IntheeraoftheiPhone,thetaxpayerstillwaitsinthedoctorsofficewithinthelast

yearalone,oneinthreepatientsexperiencedthefollowing:submitanewchartbecause
existingrecordswerentretrievedrequiredtobringanxray,MRIorequivalentresultwaitfor
resultslongerthanbeyondreasonableexpectations(
HealthIT.gov)
.Althoughmedicalrecords
arepersonal,lifesavingdatacouldbeaggregated,therebyacceleratingwellnessforthe
greatergoodwithanopensourcehealthcareexchangeofinformation.Likethe
humangenome,medicaldatabelongstohumanity,totheindividualnotacorporationor
government
however
,anyproprietarymethodologiesorremediesderivedfromthe
"opensourceexchange"couldbeprotectedbyU.S.patentlawsaffordingplentyof
opportunitiesforcapitalizationwhileimprovingthequalityofcareforall.
Lifewillnotbe
containeditalwaysfindsawayandsowillthemoney

29

Appendix

SeptemberGAO

Schwalbe,Kathy(20130101).InformationTechnologyProjectManagement
(PageG.8).CengageTextbook.KindleEdition.ss.84

30

EstimatedAnnualInformationCollectionBurden|
http://www.gpo.gov/fdsys/pkg/FR20150330/pdf/201506685.pdf

31

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