Electronic Health Record Status and Modernization

An interview with John H. Windom, Executive Director of the VA Office of Electronic Health Record Modernization

By J.R. Wilson

ELECTRONIC HEALTH RECORDS (EHRs) are one of those technologies that came out of the shadows in the 21st century to become virtually ubiquitous in U.S. health care. Nowhere has their adoption been more extensive than in the Department of Defense (DOD) and the Department of Veterans Affairs (VA). But, until now, these two giant agencies maintained separate EHR systems, even though everyone in the DOD system ultimately winds up in – or is at least eligible for – VA care.

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That is now coming to an end. In September 2018, DOD and the VA announced they will be adopting the same Millennium® EHR system, provided by Cerner Corp. DOD’s new Military Health System GENESIS (MHS GENESIS) is currently in its pilot phase, while the first component replacing the VA’s 40-year-old Veterans Health Information Systems and Technology Architecture (VistA) is being installed in the Pacific Northwest.

John H. Windom, executive director of the VA’s Office of Electronic Health Record Modernization, spoke with Veterans Affairs & Military Medicine Outlook’s J.R. Wilson about the new EHR system, how the transition is going, and what it will mean for veteran health care in the future.

John H. Windom, executive director of the Department of Veterans Affairs’ Office of Electronic Health Record Modernization.

Veterans Affairs & Military Medicine Outlook: What is the status of the EHR modernization (EHRM) effort?

John H. Windom: We’re on time and on budget and will go live in March 2020 at our initial operating capability site, the Mann-Grandstaff VA Medical Center [VAMC] in Spokane, Washington, and the VAMC’s four community-based outpatient clinics [CBOCs], part of its satellite network. We have migrated successfully, moving an incredible amount of data successfully.

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We’ve also completed seven of eight national workshops, where we’re training in excess of 500 clinicians and users at any point of time on the Cerner Millennium solution.

We continue to work collaboratively with DOD to solidify best practices, not only industry but benchmark practices, as part of the DOD deployment, [to] ensure the lifetime seamless movement of information as part of the longitudinal health record we’re seeking to establish in support of interoperability objectives.

At what point do you anticipate the entire effort being completed?

The contract projects nine years and six months since the May 2018 contract award – 2028 – but we’re always looking for a way to accelerate. In addition, we will be deploying a best-of-suite module of the solution separately at sites that are further down the road [first in Columbus, Ohio].

John H. Windom talks to an attendee during an industry day event May 29, 2019, at the Crystal Gateway Marriott in Arlington, Virginia. The industry day was an opportunity for the Office of Electronic Health Record Modernization to provide attendees with an update about VA’s effort to replace its current electronic health record systems with the commercial-off-the-shelf solution – Cerner Millennium – now being deployed by the Department of Defense (DOD). The EHRM initiative will leverage an existing commercial solution to achieve interoperability within VA, with DOD, and with community care providers. A single interoperable solution across VA and DOD will facilitate the secure transfer of active-duty service members’ health data as they transition to veteran status.

We think we can get the scheduling solution deployed in five years to those areas that have not received the entire package within that five years. We want to give the entire enterprise some form of Cerner capability sooner, so an entity does not have to wait the entire nine years and six months to get anything.

Will the new EHRs be available to private physicians as well as VA clinicians?

EHRM is focused on getting the right data to the right place at the right time, ensuring continuity of care and patient safety. It will provide interoperability across the VA, DOD, and community sites of care. The VA community care providers will be able to share data through a health information exchange [HIE] network called CommonWell, which is used by many community providers, and another HIE called Carequality, a framework that enables health data sharing between and among networks.

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Will veterans have access to their personal EHRs to review, copy, and, if necessary, request information be updated or corrected?

Absolutely. VA is establishing a new patient portal as part of the EHRM for veterans to access, review, and make copies of their own health records as well as work with the VA to update or correct those records. The new patient portal will be available to veterans after their VA medical center goes live and the new EHR is activated in conjunction with the go live of a VA medical center. Veterans who receive care at sites that have not gone live with the new EHR will continue to use the current My HealtheVet patient portal until their facility goes live. The Office of Electronic Health Record Modernization is currently working with Mann-Grandstaff and the VA Puget Sound Health Care System in Seattle to ensure veterans and their health care teams receive timely access to tools and resources for the new patient portal.

This has been referred to as an “enlistment-to-grave” system, incorporating all medical information about the individual from initial physical to exit physical by his or her service branch, then picking up with all subsequent VA data. Is that still the case and how well is the integration proceeding?

DOD and VA remain committed to working together in support of the transition throughout a person’s military and veteran history to provide a single longitudinal health record from DOD and VA that incorporates all health encounters while serving in the active or veteran community. The initial migration of VA data – 23.5 million veterans’ health records and over four decades’ worth of patient information – was transferred into the Cerner data center, where DOD health care data is stored, this past summer.

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The new EHR solution will be a single source of Veteran health information for patients and providers

The new EHR solution will:

1. Eliminate the cumbersome manual transfer of records when a service member transitions from military service to Veteran status.

2. Present clinicians with role-based information to drive better health outcomes and provide Veterans with enhanced access to their complete health record.

3. Enhance collaboration and improve health information sharing with DoD and community providers.

When will the Cerner Millennium system be fully activated for the VA and integrated with its DOD counterpart?

We have that projected for 2028.

Does this also cover National Guard members, reservists, and Coast Guard personnel?

National Guardsmen and reservists are included as part of the DOD rollout. The Coast Guard recently announced their intent to join the rollout as well and have been added to the DOD contract. So as those locations are deployed, the health records of Guards, reserves, and Coast Guard members will be accessible to VA providers as well.

Will immediate family members (spouses and children) also have VA EHRs under the modernization program?

The veteran’s spouse and dependents who are eligible and receiving VA health care benefits or become eligible at a later date will have their records included in the EHRM solution. Those who are outside that community will not have their records moved into the VA portfolios.

Does the new EHR system impact or change any health care benefits veterans currently have?

No. The EHRM does not change veteran benefits as they relate to eligibility. By establishing a single EHR, DOD will be able to keep more accurate and complete health records for each service member, providing the VA with better information to make decisions regarding benefit eligibility. That’s a key element.

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The EHRM solution will impact the way VA delivers care. Veterans will be provided with an improved experience that leverages improvements in interoperability between VA, DOD, and VA community care providers; increases care provider efficiency; and data analytic innovations that will equip VA providers with tools and information for advanced clinical decision-making.

How will it affect the speed with which a veteran receives health care from the VA after transitioning from the military?

EHRM does not affect the speed of the established process to determine eligibility for VA care and benefits. However, it will be far more efficient for the active-duty service member’s transition. Because the EHRM solution aligns VA and DOD to a single instance, veterans will not experience lag time associated with health records being delivered from DOD to VA after separating from service. Veterans will also no longer have to carry paper records from DOD to VA providers, which means there will be no time required to manually transfer information into VA’s EHR from hard-copy documents.

When you say speed, there are efficient mechanisms that will drive decision-making to be more efficient. It is still about benefits determination, but access to that determination will be more readily available.

If a veteran left military service before the creation of EHRs or other computerized health care records, what is their status within the new system? Have EHRs already been created for them?

Veterans who left military service prior to the advent of EHRs but have since engaged with the VA for health care have an EHR as part of VistA. Any veteran eligible for VA care, but who has not previously engaged the VA for health care and does not have an EHR will be provided with an EHR upon engaging with the VA. We have data going back to 1981. There has to be a benefits consideration made when a veteran enters into the VA system (no matter how long it has been since leaving military service). So if you’ve ever interacted with the VA, your data will be there. If you’re eligible to use the system, records will be created and care provided.

How easy will it be to update – or even replace – the Cerner system in the future?

VA remains confident in our decision to replace VistA with an EHRM solution provided by Cerner. It generates that movement towards interoperability we’re seeking between VA, DOD, and the community providers who support us. We are on track for successful implementation.

Innovation is a critical aspect of the contract with Cerner. Not only will the system be updated regularly, it will be continually upgraded as technology advances and the needs of veterans evolve. Updates to the system will be made more easily and without disruption to veteran care. With every VA center on the same platform, updates are more efficient and there is no loss of productivity or additional training required. It also helps control costs – every implementation is not different. Innovation will not cease; we are in a very innovative environment here. Cerner is seeking to capitalize on what we know as well as we capitalize on the things they know.

Does the new system accommodate differences between military EHRs and the VA version (diagnosis and treatment codes, prescription records, private health care data, etc.)?

The new system will accommodate differences. The EHRM program is facilitating the requisition interactions between the VA, DOD, and Cerner, working collaboratively at both the national and local levels. The design of the new EHR solution will be a by-product of that collaborative effort. We’re leveraging best practices and what DOD already has experience doing.

Our movement is toward a commercial EHR, the cross-pollenization and alignment of SMEs [subject matter experts] on all sides to understand what the workflow requirements are in support of our veterans. We have workshops that include clinicians and other SMEs from across the continuum working in support of those interoperability objectives. The system absolutely allows for differences between the departments when necessary to meet workflow or mission variations. However, the underlying datasets will have the appropriate commonality to support our interoperability objectives.

What feedback have you gotten from clinicians and veterans?

We’ve held a series of workshops demonstrating the product across the enterprise to expose the various stakeholders to the new system. I’ve watched the movement of thought from skepticism, to uncertainty, to now excitement to be part of the solution set that is so highly thought of in the commercial environment, that supports their care provisions. The excitement is there, [and] it will be increased in the education process we’re employing.

We know uncertainly breeds concern, and we owe it to our veterans to put them at ease as much as we possibly can. The general consensus is people are eager and anxious and very much desire to be part of this implementation process. The veterans we have interviewed about EHRM have expressed excitement and relief that they will no longer need to keep multiple paper records from multiple providers and that their VA providers will be able to access their complete medical history in real time. And that’s huge.

Is there anything else you want to add?

This effort is about our veterans, about delivering the best care and capabilities we can. We’re proud of the effort ongoing today. We know we owe a solution set that will support our veterans, their transition from active duty to veteran service, and allow them to take their minds off of whether their information is accurately moving into their veteran lifetime of care. The VA will have a service member for a large portion of their lives, and we want them to have the most accurate information to support the best possible care.