DOD health record effort pivots to lessons learned

The Department of Defense is in the midst of a multiyear rollout of its $4.3 billion electronic health record system, with initial efforts focused on facilities in the Pacific Northwest.

To go by some recent accounts, the rollout has hit a wall, as program managers and contractors focus on an overwhelming volume of complaints and support requests.

That's not quite right, according to Stacy Cummings, the official leading the acquisition and implementation of the MHS Genesis System, which is based on the commercial Cerner Millennium electronic health record.

Cummings, the program executive officer for the Defense Healthcare Management Systems, told Defense System's sister publication FCW  that the schedule announced late last year called for a period of time to process feedback from users before making the request to proceed to the full deployment phase, anticipated in early 2019. They're still on schedule, Cummings said, and the effort is not paused.

The rollout, which began at Fairchild Air Force Base in Spokane, and continued to include two naval hospitals and an Army medical center, has generated about 17,000 support requests or "trouble tickets" as they're called. About 11,000 of those have been resolved.

Of the remaining trouble tickets, about 5,000 are Tier 3, which a DOD spokesperson described as, "deferred for action because they involve enterprise-level changes that require higher approval authorities to adjudicate."

The tier 3 issues will be evaluated by Defense Health Agency officials. Some tickets might result in changes to workflow and some might result in changes to training or technology.

In retrospect, Cummings said, there may have been some confusion arising from having issues as mundane as basic tech support funneled into the same ticketing system as requests for policy and procedure changes or new features.

"That's not really a trouble ticket -- that's great feedback," she said.

Many of these tier-3 tickets likely involve issues of practitioner workflow – how doctors, nurses technicians and others go about the business of collecting patient data, ordering tests and more. The workflow issue is a knotty one that exposes differences between the best-laid plans of officials charting the future of the military health system and how things are done on the ground in different facilities.

In advance of the initial rollout of MHS Genesis, military health officials gathered 1,000 perspective users from sites around the world to help develop a standard set of procedures and practices mapped to the new software.

"It was not developed in a vacuum," Cummings said.

Consistency, Cummings said, helps offer a common experience for patients, for the workforce and for the enterprise at large. However, it also means that users who file a ticket hoping for workflow changes aren't likely to get the result they want quickly.

"We empathize with users that put tickets in and hoped to see responses quicker," Cummings said. "We had to wait until we had enough information to make the right decision – and we can see how that would be frustrating."

Cummings also noted that the implementation at Fairchild Air Force Base got some validation from an outside source. The facility achieved a Stage 6 rating from the Healthcare Information and Management Systems Society on its Electronic Medical Record Adoption Model. Among other things, that means that the MHS Genesis system is able to process a significant percentage of orders electronically, so that lab orders, test results and other data are moving electronically across the system without the need for paper or manual uploads of digital images or other media.

Cummings said the system is able to integrate well with outside "interoperability partners," but faxes and paper and emailed images are needed to share data with some other commercial systems. Interestingly, Cummings said there is no special interoperability functionality with outside Cerner systems. The MHS Genesis system is tapping industrywide groups like eHealth Exchange and the Commonwell Alliance to support information exchange with outside health systems.

Even as Cummings and the Defense Healthcare Management Systems program office look toward full deployment, there's plenty of new ground still to cover, including initial deployments in more challenging environments.

"The IOC sites provided us with breadth of the type of garrison military facilities we see in DOD, from small clinics to large medical centers," Cummings said. "We haven't gone forward with the operational theater solution."

Cummings said the DOD will follow a similar deployment strategy as it moves into new phases, whether aboard ships and submarines or in forward medical stations. One big challenge that could test the limits of what commercial vendors have to offer will be austere environments with no network connectivity.

"Clearly we do things that are not done in a commercial environment," Cummings said. "To test and really engineer around that low- and no-communications environment, to be distributed and offline and continue to do your job – that's where a significant engineering aspect comes in."