Who's accountable for the $20B defense health IT overhaul?

Between them, the Pentagon and the Department of Veterans Affairs have more than $20 billion committed to the shared implementation of an interoperable electronic health record system based on Cerner software to provide servicemembers with a single EHR that follows them from the date of their induction through active duty and VA care.

The Defense Department's version of the Cerner system, MHS Genesis, is live at several military facilities in the Pacific Northwest, and more deployments are coming. VA is a few years behind -- officials agreed to adopt the same system as DOD in 2017, and they are set to begin fielding the Cerner platform in 2020.

Right now, responsibilities for the two efforts are stovepiped -- with no single person or entity having decision-making authority when it comes to disputes over data, governance, workflows, architecture, cybersecurity or other potential points of contention.

Some in Congress, particularly on the VA oversight committees in the House and Senate, have pressed for the establishment of a single point of accountability over the two projects. Top VA officials in hearings in February and March indicated that the agencies were very close to an announcement, but DOD and VA are still negotiating a management structure and the selection of its top leaders.

Acting Defense Secretary Patrick Shanahan hasn't talked with his counterpart at the VA since taking over the top job at the Pentagon about their shared EHR modernization project.

"I haven't talked to Secretary [Robert] Wilkie this year, given these responsibilities," Shanahan told a House Appropriations subcommittee on May 1. "I'll accept responsibility of the fact we have to go deliver on these systems."

A committee called the Joint Electronic Health Record Modernization Working Group is doing the due diligence on the selection of a leader and deputy "with concurrence from both VA and DOD," a VA spokesperson told FCW. "The lead will act as a neutral arbiter, ensuring timely decision-making regarding the requisite architecture and operations to support the core technology of VA and DOD’s EHRM efforts."

Lawmakers worry that the schedule to pick a leader is slipping.

"Secretary Wilkie and former Secretary [James] Mattis pledged to create a joint electronic health records management structure seven months ago," Rep. Phil Roe (R-Tenn.), ranking member on the House Veterans Affairs Committee, told FCW in an emailed statement. "Not only has the date come and gone for that structure to begin working, but the Department of Defense has yet to properly discuss it with Congress. I worry that if this continues, this critical modernization project will suffer severe setbacks."

One sticking point is who will lead the joint effort. Right now, DOD is more than two years ahead of VA in terms of implementation. It also has more experience than VA in leading expensive, high-volume software integrations. But some on Capitol Hill are concerned that if DOD takes over the project, VA will suffer.

"DOD can steamroll the VA if they want," Sen. Jon Tester (D-Mt.) said in February.

Part of the problem is that if VA loses clout, the VA authorizing committees may lose visibility into the project.

"The fact that the Congress has expressed issues about who should lead the management structure has put the VA under a lot of pressure to not accept DOD leadership," a source close to the negotiations told FCW. "This dynamic may be holding up DOD and VA coming to an arrangement."

The two agencies have been able to negotiate a number of sticky issues without recourse to a single, accountable executive. For example, the CIOs at both agencies worked out an arrangement -- currently being implemented by Cerner -- to have the system accept both DOD's CAC and VA's PIV cards as credentials.

But lawmakers are still pushing for coherent management structure.

"DOD and VA desperately need a single point of accountability if they are going to implement a single common electronic health record," said Rep. Jim Banks (R-Ind.), the ranking member on the IT modernization subcommittee of the House Veterans Affairs Committee. "But the EHR is only part of the picture. Regardless of which department winds up leading the new office, it needs to coordinate all aspects of interoperability to make sure medical records truly follow the patient."