IOM: No more DoD-VA integrated medical centers until iEHR

Additional integrated health centers along the lines of the James A. Lovell Federal Health Care Center in North Chicago, Ill., shouldn't be undertaken by the departments of Defense and Veterans Affairs until they stand up an interoperable electronic health records system, says the Institute of Medicine.

In a report commissioned by the DoD that was released Oct. 16, institute researchers say lack of EHR interoperability at the health care center costs at least $700,000 annually. The money is spent on five registered pharmacists who conduct manual checks on prescriptions to ensure that doctors without complete access to each other's systems don't accidentally prescribe medicine with negative interactions.

The two departments have spent more than $100 million to develop interoperable information technology capabilities, but order portability between the VA system (known as VistA) and the DoD system (known as AHLTA) resisted efforts. The main stumbling block, report authors say, is that VistA and AHLTA required changes to their systems in order to have the same sequential prescription numbers. However, the departments had agreed that interoperability at the center would have to be achieved without changes to the systems, which "left a gap."

As a result of experiences such as those the center has afforded, the DoD and VA announced in March 2011 creation of a new, common health record system known as the iEHR (i stands for "integrated"), with high-need modules such as one for pharmacy set for completion first. The Government Accountability Office has recently cast doubt on program managers' ability to meet projected time frames, calling them "optimistic and uncertain."

The level of interoperability required for an integrated DoD-VA medical center is of the highest order possible, report authors say. It's not enough that data from both systems can be simultaneously read, as is currently the case at the Lovell center. Rather, each system must be able to compute structured data from the other, they say.

There have been attempts to transport data across systems, report authors note, but medical officials haven't considered one known as the Clinical Data Repository/Health Data Repository reliable enough to ensure patient safety, while another, the Bidirectional Health Information Exchange, has a reputation for being "too awkward and slow to use in patient encounters."

The report also chronicles difficulties the two departments had in working together, including creating a single-sign-on system. Report authors say their field tests of the single-sign-on system for VistA and AHLTA showed difficulties. Each department selected a different vendor to provide that capability, and DoD's firewall and server weren't always cooperative; the interagency program office has since decided to just utilize one of the two vendors' solutions, the report notes.

DoD officials also insisted for a period that individuals accessing AHLTA have a secret clearance, despite the fact that there's no classified information within it. The VA operates on a public trust model. DoD officials, report authors say, were reluctant to compromise, but eventually in October 2010 agreed to settle for an Access National Agency Check with Inquiries investigation of staff and interim access while the investigations were conducted.

For more:
- go to a webpage to download the report (reg. req.)

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