May 03 2013

Military Health System loses control of its IT spending

Published by at 12:46 am under AHLTA,Heath IT,Underground Railroad,VistA

Here’s the latest event in the saga of VA/DoD health information sharing from Bob Brewin: Military Health System and TRICARE Lose Control Over IT Budget

One official said the move reflects frustration among senior Pentagon leaders with MHS efforts to procure new health IT systems, both independently and in partnership with the Veterans Affairs Department to develop the integrated electronic heath record. The departments have spent at least $1 billion over the past five years pursuing an integrated system.

This follows Chuck Hagel’s testimony to Congress that We Don’t Know What the Hell We Are Doing and former DoD Undersecretary for Health Affairs Ward Cascell’s that 2009 revelation that AHLTA is Intolerable.   I got private emails from DoD docs that were even more explicit:

AHLTA is far worse that you even alluded. It has virtually sucked the life out of our Providers and our MTFs. Yes, there may be some benefits but the pain is worse than the gain. I can’t believe that there will ever be a system that could successfully create a bi-directional interface with AHLTA. Any discussions that CHCS Ancillary functions will be replaced by the AHTLA as an architecture are just smoke screens for the embarrassment that AHLTA really is.

The worst part of AHLTA is when you actually have to read some of the documentation it generates…. there is rarely a coherent statement in a 3 page clinical note.

AHLTA is more than Intolerable…It’s the 3rd highest reason listed by the Army at the June 08 AUSA Conference Providers are leaving the military…

The first time I saw the AHLTA design, I thought that this was a reversal of all the successes the federal government had seen in health IT.  I remember thinking, “This is just one giant single-point-of-failure.”

30 years ago, we had two operational VA/DoD sharing sites.Tom Munnecke, Ingeborg Kuhn, George Boyden, Beth Teeple showing off the first VA/DoD Health IT interface Here is March AFB’s Beth  Teeple’s oral history of the March AFB/Loma Linda test.

Thanks in part to Chuck Hagel’s early support of VistA, Rep. Sonny Montgomery, chair of the House Veterans Affairs Committee, noted that while VA had deployed a Core VistA system in all 172 hospitals for $82m, DoD had only produced prototypes of 4 stand-alone modules – for $250m (prices in 1985 dollars).  DoD called this IOCs – Interim Operating Capabilities, but we called them “Incompatible Operating Capabilities.” Each was  completely independent of the others, using incompatible coding systems, hardware, user interfaces, and communications protocols.  “Integration” was intended to come later.

This was classic DoD “Humpty Dumpty” development.  Break the system into pieces, then hire systems integrators to put it all back together again.  This is a wonderful business opportunity for the beltway systems integrators, but after 30 years of broken systems, its time to reevaluate the whole approach.

VistA never broke into pieces, but was based on common metadata and a shared set of tools.  It was “integrated” by virtue of never having been “disintegrated.”  Over the years, I learned that when someone speaks of “integrating” a system, we have to ask, “what disintegrated it in the first place?”  Until those forces are addressed, there is little chance of success.

Here is an excerpt of a letter  Sonny Montgomery sent me in 1984 Sonny Montgomery sent me in 1984:

As you know, the Committee and I fully supported Chuck Hagel’s decentralized ADP plan when he announced it in March of 1982 during his tenure as the VA Deputy Administrator. After Chuck left the VA, the plan, which relied heavily on the resources of the Underground Railroad, was derailed and appeared to be approaching its demise.

In order to get it back on track, I wrote a strong letter to the Administrator, and solicited the help of Chairman Boland of the HUD-Independent Agencies Subcommittee of the Committee on Appropriations. Subsequently, the Congress provided the funds and the VA, with the outstanding assistance of the Underground Railroad, performed a near miracle in bringing the largest health care system in the western world into the present day ADP world!

The VA and DoD forked into two paths: DCHP became VistA, and has won many awards and distinctions.  DoD reluctantly accepted CHCS, but under its management, has spiraled down into the mess we see today.

Here is 1984 Oct 10 Congressional Record authorizing DHCP as competitor in CHCS, my 1985 overview of DHCP to TRIMIS Program Office, 

And here is a 1984 oct 4 montgomery letter to Sec Def Casper Weinberger re DoD use of VA software:

Mr. Secretary, I cannot understand the DOD reluctance to try the VA system, which will provide on a timely basis the mandatory system compatibility between the two agencies.

It’s amazing that we are having the same conversation 29 years later.  Not a whole lot has changed, except that we’ve spent billions of dollars and decades delivering “intolerable” health care to those who most deserve it.

I’m getting tired of rehashing 30 year old events, but it seems necessary.  DoD has been relentlessly trying to do the same thing – and failing.  It’s time we break out of the “More Expensive Failure” mode and move to an approach that works.

In my next post, I’ll present a proposal for some solutions.



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