In a surprisingly candid conversation about iEHR, CIOs of the Military Health System and the U.S. Navy offered a glimpse into how their organization makes large IT decisions, most notably concerning the EHR it is looking to acquire.

“Our legacy systems are eating us alive in terms of cost of support and maintenance,” MHS CIO David Bowen said. “We’re spending 95 percent on legacy systems which only gives us 5 percent for modernization. That’s pretty deplorable.” 

What’s more, Bowen explained during the Government Health IT Conference and Exhibition closing keynote, sequestration could mean taking another $5 billion out of the MHS budget in 2014 – creating an obviously challenging backdrop against which MHS and the DoD are trying to address the whole issue around its EHR and the joint iEHR project with the VA, as well the department’s role in other military health IT initiatives such as the Healtheway HIE, the OSEHRA open source custodial agent, and the Virtual Lifetime Electronic Record (VLER).

“There’s some confusion … people said ‘you are moving away from the VA,’ That’s not true, we’re an extension of the VA,” said CDR Cayetano S. Thornton, chief information officer, Navy Medicine, (M6) deputy chief, Bureau of Medicine and Surgery, explaining that the VA’s VistA EHR system works for that department while the DoD has its own “somewhat unique” requirements. “And that bridge may be too far to actually create a data repository … it doesn’t mean we’re not talking to the VA; it’s actually the opposite.”

Thornton continued that the top priority remains information access, giving providers necessary patient data to enable continuity of care, even if the approach has changed since the onset of iEHR.

“It’s the same challenge,” he said. “Is it possible it could be VistA? Maybe. But I’ll say there are commercial grade solutions we could literally plug and play and provide the utility we need in terms of health information, and there are a couple that have market share. We’ve had at least four come in and independently analyze our needs and hands down it’s the best for us.”

Although Thornton stopped short of naming those vendors or specifying exactly how many could fulfill the DoD’s requirements, Undersecretary of Defense for Acquisition Frank Kendall said on May 22 that the department has identified 20 such EHR makers that could fit — a number that raised some eyebrows as perhaps overly optimistic. 

Bowen added that where things stand today, they don't know how long the procurement and implementation processes will take, but they do have a concept of what that core EHR will look like, though finalizing it depends on vendor responses, what suggestions the contract winner brings, and other feedback the DoD gets. 

“Another issue we’re dealing with is the fact that more than 50 percent of care is provided by the private sector,” Bowen continued. “We’re really struggling with how to get data back from those care providers.”

Whereas the VA have been on the leading-edge with Healtheway, the eHealth Exchange HIE formerly known as NwHIN-Exchange, a non-profit entity boasting some 40 members effectively sharing medical records between public agencies and private sector providers, despite being listed as a member the DoD has been perceived as largely absent from the activities.

Back from a recent visit to Florida, Thornton explained that is changing. “They’re doing some really cool stuff in little bitty Pensacola,” he said, adding that the Naval facility down there is working on exchanging data not just with the VA but also commercial counterparts “in ways we’ve not done before,” and similar practices are underway in the James A. Lovell Federal Health Care Center, otherwise known as North Chicago. 

Bowen added that MHS is in the process of transitioning to Direct secure messaging to deliver data to any providers that want to participate in Healtheway. Calling for a Congressional mandate regarding eHealth Exchange across all states, Thornton vowed: “I am going to do everything within my power to ensure that DoD is in that.”

When an attendee asked if DoD is backing away from using open source software and contributing back to the OSEHRA community, Bowen acknowledged that the DoD is not as active in that realm as the VA but it does intend to evaluate any open source options that come forward.

“We recognize it. I know our providers — and we exist because of our doctors, nurses and paraprofessionals — I know they want it. I anticipate us to play in that realm,” Thornton added.” I think we’ll get back to it.”

HIMSS vice president of government relations Tom Leary, the keynote’s moderator, asked about the Patient Protection and Affordable Care Act’s impact on MHS and the Navy. Both CIOs said that because of their unique self-insured model, the ACA requires less of them than the private sector, though President Obama’s earlier direction to create a Virtual Lifetime Electronic Record (VLER) for all service members furthers the department’s emphasis on health information access, rather than exchange. Thornton explained that with VLER if he asks 10 providers what they like about it or expect from it, he invariably receives 10 different answers.

And while VLER is inextricably linked to iEHR, be that VistA or a commercial system, Thornton said he does not expect that whatever the DoD purchases will contractually specify requirements for the software to integrate with VLER out of the gate.

“In the end, I anticipate we're going to have a world class system,” Thornton said of the EHR, “that allows us to capture and exchange health information not only within DoD but with VA and our commercial partners.”