Healthcare leaders at the Defense Department, who are enjoying a clinical information technology system superior to most used in the private sector, are nonetheless pushing forward with an ambitious set of costly and sometimes troubled system upgrades.
At the same time, Defense leaders have joined their counterparts at the Veterans Affairs Department in a protracted campaign to reconnect their clinical IT systems. If successful, the departments will undo a 1987 programming fork that split development efforts on the genetically similar systems and rendered them virtually incapable of communicating with each other for more than a decade.
Clinical IT at the Defense Department has long been in the shadows of VA systems, but Defense has a system its healthcare leaders and users are proud of and rightly so, particularly in comparison to what passes for clinical IT in much of private-sector healthcare, which is like comparing the Enlightenment to the Dark Ages.
For example, doctors throughout the Military Health System, with its 70 hospitals among nearly 500 care sites, have been ordering laboratory tests and prescription medications on a computerized physician order-entry system for more than a decade. In the private sector, only about 4% of about 5,700 hospitals in the U.S. had fully operable CPOE systems as of February 2004, according to a 214-page market study released earlier this year by researcher KLAS Enterprises.
In the aftermath of Hurricane Katrina, when the healthcare facility at Keesler Air Force Base in Biloxi, Miss., went down, any provider across the Military Health System could pull up patient information on military personnel while the private sector scrambled to patch together an ad hoc network of prescription records for civilian Gulf Coast evacuees.
And Defense's Pharmacy Data Transaction System, a module connected to the department's main EMR system, permits military physicians to access the medication histories of their patients and triggers alerts for contraindicated drugs. It even includes prescriptions filled at private-sector pharmacies--something even the VA's IT system can't do.
From fiscal 1979 to 2005, Defense has spent $1.4 billion developing and deploying its Consolidated Health Care System, or CHCS I, according to testimony in May 2004 before a subcommittee of the House Veterans' Affairs Committee. In 1988, defense contractor SAIC was awarded a $1.01 billion, eight-year contract to modify the VA's MUMPS-based clinical IT system for Defense use. CHCS I was fully installed by about 1994 at all Defense healthcare sites.
The system documents the healthcare records of more than 9.2 million military personnel, their families and dependents. But it has its weaknesses, not the least of which is that because of CHCS I's reliance on regional databases, military medical personnel on the West Coast can't access the hospitalization records of a relocated patient whose records are in a computer on the East Coast.
Also, not all clinical data on military personnel is captured in CHCS I. The Army, Navy and Air Force each maintain their own databases for medical records of mobilized personnel. To address the problem, the military decided in 1997 to upgrade its disparate clinical IT systems, launching development of a successor system, CHCS II.
The new system would shift away from the MUMPS programming language and database of CHCS I to an underlying Oracle database management system and provide physicians, nurses and other clinicians with a common Windows-based user interface. Defense contractor Northrop Grumman Corp. is the prime contractor on CHCS II.
"We wanted to meet the requirement to move medical information on a patient anywhere in the world," says William Winkenwerder, assistant secretary of defense for health affairs since 2001. "We have people moving on regular intervals with changes of station and so forth. It (CHCS II) goes beyond that system in the U.S. for everyday healthcare to include, really, worldwide access to healthcare records, anywhere, any place and anytime, 24 hours a day, seven days a week."
`It's an evolution'
After more than four years of development and a year of testing, a phased rollout of CHCS II began in January 2004, starting with outpatient-care sites. The rollout was stopped five months later as the system became unstable, forcing Defense to place a 60-day moratorium on further installations.
"As it turned out, it was literally some hardware switching devices," says Army Col. Victor Eilenfield, program manager for CHCS II. "For the last year and a half, the system has run incredibly strongly."
Winkenwerder says the development problems were similar to those in the early days of Windows and the Internet. "Go back to the first days of Windows, things were slow and things got better. And Web sites got better and better. It's an evolution."
From fiscal 1997 to 2004, Defense reported spending about $600 million on software development and deployment of CHCS II, according to the latest in a series of Government Accountability Office reports on Defense and VA clinical IT systems.
Defense is on track to have CHCS II fully deployed at all outpatient-care sites by the end of 2006, says Carl Hendricks, chief information officer for the Military Health System. Before the system is turned on at a new care site, it is loaded with each location's inpatient and outpatient data for the previous 26 months, he says. Data including laboratory, pharmacy and radiology reports from more than 80% of Defense care sites have been uploaded already, and about half of the 140 care command groups throughout the system are trained or are training on the system.
Full inpatient and outpatient deployment of CHCS II is targeted for 2008. The long-term strategy calls for both Defense and the VA to interface with each other's databases and create a two-way exchange capability.
But the forking never should have occurred in the first place, according to Rick Marshall, a VA programmer from 1984 to 2003 and president of WorldVista, an association whose members, many of whom are veteran MUMPS programmers, are trying to promulgate an open-source version of the VA's clinical IT system in the U.S. private sector and in healthcare facilities around the world.
In the early 1980s, the Computer Assisted Software Staff--an arm of the VA's Department of Medicine and Surgery that supported quick, localized clinical computing efforts at individual hospitals--was engaged in a turf fight with the VA's centralized IT department, the Office of Data Management and Telecommunications.
Marshall says discussions between the Computer Assisted Software Staff and Defense over a joint clinical IT development scheme had matured to the brink of a deal, then collapsed as the Office of Data Management and Telecommunications waged war on the upstart Computer Assisted Software Staff, banning further development work by it, firing several programmers and forcibly removing computers from several hospitals. Eventually, the decentralized, homegrown software development philosophy of the Computer Assisted Software Staff prevailed at the VA, but by then a sea change had occurred at Defense, which settled into its current program of contracting out much of its IT work.
About a year
A mutual VA-Defense development effort was doomed. But despite the clash, Marshall says, the two agencies should have insisted on swapping code and working toward an integrated platform.
But Marshall agrees with congressional testimony given last year by Jonathan Javitt, former chairman of the health subcommittee of the President's Information Technology Advisory Panel, that making the two systems interoperable should only take about a year, if the conflicting strategies were harmonized.
"It's not an insurmountable technical problem, even today," Marshall says.
"If we sat down together, we could map out the differences between the two file managers. It is economics above all. They can end it any time they want to."