Will the Defense Department buy a commercial electronic health-record system and consummate one of the largest healthcare information technology deals in U.S. history?
Or will the sprawling, 56-hospital, 361-clinic Military Health System line up with the Veterans Affairs Department and use a modified version of the VA's venerable VistA EHR, an open-source system that has a strong track record in VA facilities?
The answer is that no one, not even Defense Secretary Chuck Hagel, can say for sure which way Defense will go. EHR vendors, meanwhile, are salivating over the prospect of selling a new EHR system to the Defense Department, which could cost an estimated $6 billion or more.
Hagel and the Defense Department are likely under intense lobbying pressure to buy a commercial system, according to sources contacted for this story, even though the VA adopted plans to improve VistA using an open-source system development model, which VA officials deem to be a cheaper, faster way to improve their health IT system.
The lobbying is likely coming from developers, consultants, systems integrators and implementers, members of Congress and members of the military who are looking to leverage the contract for employment opportunities both during their military service and afterwards.
In February, the Defense and VA cabinet secretaries and the VA scrapped as too expensive a 5-year-old effort to develop a new, single, joint EHR for the two health services.
Last week, Hagel issued a memorandum, and one of his undersecretaries, Frank Kendall held a news conference on Defense's proposed new path.
Hagel said he was convinced that “a competitive process is the optimal way to ensure we select the best value solutions for DoD.” But Hagel also said that “a VistA-based solution will likely be part of one or more competitive offerings that DoD receives.”
Kendall, at his news conference May 22, said after doing market research, “we had about 20 responses from industry” by firms interested in bidding on the system. Three proposals were VistA-based approaches.
Kendall did not put his recommendation to Hagel in writing and declined to be interviewed for this story. That leaves pretty much a blank slate on which an EHR developer—proprietary or open source—can project their hopes and dreams.
“My read is that DoD has established a level playing field for a VistA-based open-source approach, other open-source approaches and nonopen-source approaches,” said Seong Mun, president of the Open Source Electronic Health Record Agent, a not-for-profit corporation created by the VA in 2011 to oversee its open-source project to upgrade VistA.
Although OSEHRA itself won't bid on an implementation of its open-source version of the VistA software, Mun said, some of its member companies could. He added that OSEHRA members put together a very credible assessment for Defense in response to its request for information.
Mun said he was “not disappointed” that Defense did not accept the VistA overture outright. “Even if one prefers one thing over the other, it still has to go through open bidding,” he said.
Tom Munnecke, a pioneering health IT programmer at the VA who helped develop both the VA and Defense EHR systems and currently works as a consultant, said the newly announced Defense approach using competitive bidding sounds “almost identical” to what it used back in the 1980s. One tell whether the new procurement program will go down the same path as the old one will come when the bid specifications for the new military EHR are written.
Former VA programmer Rick Marshall, executive director of the VistA Expertise Network, a not-for-profit collaborative of IT consultants and programmers, said Hagel is probably under tremendous pressure to open the process to competitive bidding. But whether VistA will be part of that mix remains to be seen.
“Even if I intended to go with VistA, I'd probably do what he is doing,” Marshall said. And yet, based on the memo, Hagel may have no intention of choosing anything other than an off-the-shelf, commercial EHR, according to Marshall. “It is the perfect Washington, D.C., maneuver, saying whatever people want to hear.”
Marshall said the best possible approach is to begin with that portion of VA-cloned software code that the Military Health System still uses to develop a new system. The VA, Defense and the Indian Health Service, which also uses a VistA-derived EHR in its healthcare network, would install those packages to unify their three systems.
“I think the DoD would go for it,” Marshall said. “They would have all their data and they would be getting decades of progress (from the VistA code that's more advanced), and even the VA would be getting some progress. And, because they're on the same code base, then they can decide what they want to spend on upgrades.”
Dr. Nancy Anthracite is president and chief medical officer of WorldVistA, a not-for-profit organization created in 2002 to promote the use of VistA outside the VA. She attributes much of the Defense Department's recent attention to VistA to comedian Jon Stewart, who broadcast a scathing critique of the inability of the two cabinet departments to work together on a common EHR.
“It made Congress sit up and pay attention,” she said. “There is no doubt in my mind that DoD should be using VistA.”
During his news conference, Kendall hedged when asked how much a new military EHR might cost. “We're going to have to assess that, OK?”
The VA's healthcare division, the Veterans Health Administration, is more than twice the size of the Military Health System. According to the VHA, it operates 151 hospitals and 827 clinics. Its former CIO, Roger Baker, said $16 billion was a reasonable estimate of the cost to replace VistA with a commercial off-the-shelf system at the VA alone. By that gauge, a commercial system for the Military Health System would cost more than $6 billion.
Another major consideration for the Defense Department and Kendall, who will retain a leadership role in the military's EHR procurement process, is the Obama administration's stated preference for open standards and open-source software.
Asked whether going with a proprietary EHR system might impede the president's push for open standards, Kendall said that is a concern. “One of the other things we have to consider is the degree to which we're locked into a specific vendor because of proprietary content and his products,” Kendall said. “As we go out and we ask people to bid to us, that's one of the things we're going to assess. We do not want to be locked into a specific vendor for the long-distance future.”
Follow Joseph Conn on Twitter: @MHJConn
Send us a letter
Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.
