Taking a new route

Cardiologist Dr. Lewis Coulson, a Veterans Health Administration physician for the past 42 years, works with one of the best electronic health information systems in the world—the VA's VistA.

But when a recently discharged veteran walks into his office at Jesse Brown VA Medical Center in Chicago and he calls up the health record, he gets only a care summary from his or her days in the military.

The summary contains important items such as the patient's medications, past diagnoses and appointments, but not rich and sometimes equally important detail.

It's nowhere near the comprehensive record available to older veterans through VistA, or the specialized summary available through the VA's computerized patient record system (CPRS), VistA's main user interface, which includes cardiac catheterization data, digitized X-ray and other imaging and detailed physician notes. “It's more of a general summary,” Coulson said of the version seen at the VA from the military. “I can see they've been seen by a heart doctor” but “it's not as good as CPRS, or if I could see the whole thing directly.”

Last week, Defense Secretary Leon Panetta and VA Secretary Eric Shinseki announced they were scrapping a five-year effort to build a new common electronic health record system—a plan once touted as the best solution to the decades-old interoperability problem plaguing medical record transfers between the military and the VA. Now, they said, the VA and DOD will pursue further improvements in the interoperability of their current EHR systems.

By December, healthcare data used by the VA and the Military Health System should be standardized and data will be exchanged in real time, Shinseki vowed. Also, of a Web-based interface called Janus, developed in 2003 by the VA and DOD, would be upgraded and its use expanded. Janus allows clinicians in either system to peer into each other's EHRs.

Success in building a unified system wouldn't come a moment too soon for veterans' advocates such as Adrian Atizado, the assistant national legislative director for the Disabled American Veterans. His group has been frustrated by years of failed efforts to achieve integration between the two systems.

“The severely injured service members, who have to hop between the VA and the DOD, they have to be impacted the most,” he said. “The meaningful sharing of health information has a direct impact on the cost of healthcare, the quality of healthcare and the patient's health outcome.

“It has to be computable to be meaningful to a clinician,” Atizado said. “If I'm a physician and I have 20 minutes to see a patient, I don't have time to read 20 PDFs. You cannot view DOD's health data in the VA's world. Not being able to compare MRIs, or spectrometers or X-rays, VA providers have to accommodate for that lack of meaningful information, which puts more burden on the actual provider.”

The military and VA brass admitting defeat in their efforts to build a one common EHR system is only the first step in achieving the interoperability goals sought by VA physicians, veterans and their advocates. While Panetta and Shinseki outlined an aggressive timetable last week, the two agencies have a history of missing deadlines.

The initial disconnect between IT systems of the VA and DOD dates to 1988. That's when software developer SAIC won a bidding competition to build the military its own EHR, basing the new system on free software code from the VA, which had been working on its own EHR since at least 1977. About $1 billion later, recalls programmer Tom Munnecke, who worked on both systems, the military deployed its Composite Health Care System, a “turnkey operation, hardware, software, maintenance and training at 750 sites all over the world.” The big flaw, though, was that the military's new EHR could not communicate with its VA forerunner.

Efforts to connect the systems began in 1998 with only partial successes. By April 2009, full interoperability was still so distant that the White House announced that the two departments had taken only a “first step” toward creating what President Barack Obama called a “joint virtual lifetime electronic record” that would enable “a streamlined transition of healthcare records between DOD and the VA.”

That hasn't happened yet, not completely. Last week, Panetta admitted the “frustrating” interoperability struggle had gone on for years without success.

“We can and must do better,” he said. “It's been inefficient for service members to have to hand-deliver records from one system to another when they get out of the military. Our service members often have extensive records. The last thing they need is to worry about their doctors having all the information that they need in order to provide them the care that they deserve.”

How much patient care has been affected by the decades of only partial interoperability between the two systems is anybody's guess, Atizado said. “It would really take a researcher to determine that,” he said.

Veterans are generally very happy with the care they get in VA, he said, because clinicians find ways to work around the information bottlenecks with the military.

Coulson, the Chicago VA doctor who is also a medical informaticist, agreed. The electronic patient summaries the VA receives from the military are a vast improvement over a decade ago, when discharged veterans might enter his office with paper records.

He is hopeful this latest surge by the brass will finally achieve the long-delayed goal of full interoperability. “Going from military life to civilian life and making it seamless ought to be the goal,” he said. “I think, the more information we have the better.”