LAS VEGAS -- In his keynote speech at HIMSS18 on Friday, U.S. Secretary of Veterans Affairs David Shulkin, MD, confessed: "I always believed I would be the last doctor in America to go an electronic health record. I loved my paper."

Today, he sits atop an agency amid one of the largest EHR transitions in history -- with a ticket price to match. And three months ago, Shulkin hit pause on contract negotiations with Cerner because he was "concerned that way we were approaching this interoperability, the way that the industry was approaching this, was not going to get us where we needed to go.”

For the past three months, VA has been focused on working with "many in the community, and many in the industry, to get this issue of interoperability correct. This work has been extremely productive, and we'll end up with a very important result for veterans and hopefully for everyone else in the country,” Shulkin said. "This is too big of an opportunity, too big of a contract, too important to our veterans and the country, not to get this right.” 

[UPDATE: Shulkin doubles-down on EHR modernization as price tag swells]

One of the results of that effort is that VA has issued a new RFP for an API gateway, through its new Lighthouse platform.

"In addition to the EHR, we recognize that there's going to need to be new analytics capabilities to integrate this information, and we're going to work with the API gateway to accomplish this capability," said Shulkin. "I have to tell you the cooperation we've been getting from the major vendors, and particular the Cerner Corp., has been extraordinary."

He said VA is seeking a model EHR incidence, with common data standards published in the public domain, like the National Library of Medicine. 

“We're going to be able to map the electronic medical record to the FHIR APIs,” he said. “We're asking industry to help us build this API gateway, asking industry to open API access to all developers and are working with industry to stop the practice of information blocking."

[UPDATE: VA Secretary Shulkin taps UPMC exec to lead agency’s open API project]

Part of the momentum has to come from the provider side, and Shulkin called on them "to open your API gateways to VA, so we can access all the veteran data in a bi-directional way. We want to work together on patient mediated data exchanges, and it's essential that we work together to share all of these best practices as we do this."

He said VA is "committing to an open API pledge – committing to accelerating the mapping of health data to the industry standards, committing to make all FHIR resources, to provide APIs available to developers and to provide a common data set available to everyone who wants to work with us."

So far, 11 leading health systems – including Geisinger, Cleveland Clinic, Mayo Clinic, Rush and UPMC – that have also taken that pledge.

"We want this coalition to be much bigger, much better. Because when providers take this commitment it's a clear signal to industry that we need them to step up and move in this direction," said Shulkin. "When your organization makes this pledge, you're giving up on this belief that you can use your data in a proprietary way – that this is a business advantage to keep your patient data within your organization. You're opening things up. Once you do that, there's no looking back."

[UPDATE: With VA Secretary David Shulkin under fire, what could happen to EHR modernization project?]

But ultimately, it's "the right thing to do," said Shulkin. "It's what's been needed for years. And if we say we need it, the industry will come along with us."

"This task at hand is not a usual task," he said. "But this is the time for us. This is the opportunity that so many of you have worked toward for years. This is the momentum we need to be able to get this done."

What began as an underground mission ...

VA is a longtime IT leader, of course, having developed its own pioneering VistA system back in the 1970s. Clinicians have been generally very happy with the EHR.

"The reason why it worked so well is that the VA administrators at first forbade it from happening," said Shulkin. "This was an underground mission by the clinicians in VA. They were called the Hardhats. And while they would see patient during the day, they would code at night, slowly building the system."

Since then, many great things have happened because of it. Shulkin cited the first barcoding of medications discovered by a VA nurse and the fact that VistA is open source, as examples. 

"If you ask many clinicians, including myself, this is a very good system," said Shulkin. "It's easy to use. It's worked extremely well and has had tremendous benefits."

But the challenge is that over the years, VistA has evolved into 130 different systems, each working a bit differently, customized to the needs of its particular clinical environment.

"Looked at in the context of today's way of operating systems, you can understand the challenges," he said. "We have been able to keep 130 systems going, but as you can imagine, that is getting more challenging. We're sort of holding them together with band-aids. It's getting extremely costly to maintain them and extremely difficult to get the coders to keep them up and running."

So Shulkin this past year used a determination of findings to make a direct contract solicitation to Cerner, to put VA on the same system being rolled out by the Department of Defense – something he said is in the public interest.

There were four reasons he made that decision, said Shulkin.

"The first is, I could not convince myself that it benefited veterans for the VA to be in the software business. That is not one of our core competencies. We have spent billions and billions of dollars trying to do that. And looking into the future, this was going to be an issue for us."

The second was that "having 130 different instances is not a contemporary approach to managing a modern healthcare system," he said. "We need to be able to start focusing on what works, and processes that are similar across the country. In order to do that, we need to go from 130 instances to one instance."

The third issue, of course, was DoD and VA interoperability: "For 17 years there have been calls from Congress, from blue-ribbon commissions, white papers, saying that we needed to have true interoperability if we're going to protect the health of our veterans as they transition out of the military,"

And the fourth reason is that "to meet veterans' needs, we are increasingly working with our community and academic partners," said Shulkin. "Today, 36 percent of care for our veterans happens out in the community. If we can't get information to our community health partners and back from them, we're not going to be able to get veterans the best care and coordinate it the way that we need to."

As it starts to roll out its own MHS Genesis project in the Pacific Northwest, DoD has been "extraordinarily helpful in sharing lessons with us," he said. But it's a "very complex implementation strategy," and that interoperability is much easier said than done.

DoD lessons so far: Workflow matters

Sharing the stage with Shulkin at HIMSS18 was Navy Vice Admiral Raquel Bono, director of the Defense Health Agency.

"The more that we can set our sights on the collective goal of integrating across all the elements of healthcare, to include the DoD and the VA, the more we're able to define what we need for interoperability and be able to leverage each other's expertise to be able move forward," she said.

Mayo Clinic Chief Information Officer Cris Ross, who interviewed Shulkin and Bono, asked her what have been some initial lessons learned from the MHS Genesis project.

There have been many so far, and "we don't have time for all of them," she said.

But two keys in the early going were that "you need to make sure that your governance process is intact, and you need to understand how you're going to make decisions about what you're going to do. That's extremely important,” she said.

"And when you talk about governance, it's not who reports to whom, or who's the boss of whom," she added. "It's how you make decisions. Make sure you're making decisions for what's best for the enterprise, not individual sites."

Another big lesson has been that "you can't do too much training for workflow adoption," she said. "Workflow adoption is the crux of the change management that's needed to successfully deploy an EHR system. One of the areas we're working on with VA is identifying those areas and making sure we have unanimity of those workflows because that will be a large part of that."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com