The Department of Defense (DoD) is in the market for an EHR solution… again. After a lengthy foray into building its own EHR from scratch (AHLTA), with miserable results, and another shorter detour through the fantasy land of an open-source integrated EHR (iEHR) with the Veteran Administration (VA), during which no material progress was made, other than spending taxpayers’ money of course, the DoD announced that it will begin looking for a commercially available product to suit the DoD’s unique needs. This decision is the source of much angst for some and much excitement for others, because no matter what the DoD decides to do, many more billions will be flowing out of taxpayers coffers and into the hands of a lucky few.
On one hand, since most people served by a DoD EHR will eventually be served by a VA EHR, it makes sense that these two government agencies should use the same product and aggregate a lifelong record for their patients. On the other hand, the VA EHR (VistA), although held in high esteem by its creators and users, is very old, and the VA itself is engaged in a major refurbishing effort through a public open-source framework. Answering to a highly frustrated House Committee on Veterans’ Affairs, looking for explanations and bemoaning the death of the iEHR, the DoD’s Frank Kendall reiterated the insurmountable costs and difficulties inherent in building a brand new EHR from scratch (better late than never, I guess) and highlighted the reasons why VistA is not as obvious a choice for the DoD as it is for the VA. Since the VA has VistA already deployed in all its facilities and it already employs an army of experienced VistA developers, a salvage operation for the aging VistA may make perfect sense for the VA, but none at all for the DoD which will be conducting a complete rip and replace program in the next couple of years.
Now that the self-developed iEHR delusion is dead, the technical controversy is focused on whether the DoD should select an open-source product, either VistA or a derivative thereof, or a proprietary system, such as Epic, Cerner, GE, Siemens, etc. The main arguments against a commercial solution are that the DoD should leverage the billions of dollars already invested in VistA, and that it should adhere to this administration’s preference for transparency and open-source technology. To better understand this conundrum, perhaps some terminology clarifications are in order.
Computer software comes in several flavors, and you may recognize most of these flavors if you researched your own EHR purchase recently:
Regardless of the model employed to obtain software, extensive APIs may or may not be available to third party developers who may be actual users, but most often are not. Software products that expose a good amount of well documented APIs are said to have an open architecture, which is based on accepted and open standards. APIs come in various flavors as well. Some are just plug-ins allowing third party developers to add minimal functionality that does not affect the main product in any way, and certainly does not affect the data layer. Tighter integration that may affect data integrity in the main product is harder to come by and usually requires approval from the original vendor if the software is proprietary. If you have access to the source code, either free or purchased, you can obviously do whatever you want, if you are reasonably certain that you can maintain the software on your own going forward. People or businesses without an IT department are rarely interested in tinkering with source code, so this conversation is really between IT shops, large businesses and true believers in this or that paradigm for software development.
Before returning to the DoD situation, one more word about vendor lock-in is in order. There is no doubt that having the source code (open source or purchased source), and particularly the database schema, makes transferring your data from one product to another a lot easier, if and only if, you have proper IT resources at your disposal. It is possible though, and most often very likely, that if your old product and your new product are very different, data loss will occur no matter how good your IT guys are and no matter how open both products are. Also, it is usually not necessary to have access to every line of code in order to migrate data from one system to another. A clean open architecture based on widely accepted standards is much more important for preventing vendor lock-in and for interoperability in general. Unfortunately none of the choices available to the DoD fit this bill currently, although some may be better than others. So what are the options available to the DoD?
Basically, no matter what the DoD chooses to do, they will have access to the source code, and significant programming effort will be required to tailor the product to DoD needs. Most products that could be considered by the DoD have some useful APIs and increasing adherence to standards, but open architecture is not a term that comes to mind in this context. The DoD could hope and pray that the open-source framework established for VistA will produce the software improvements the military needs, or most likely, the DoD will have to pay for all enhancements and new features. In addition to software programming, deploying an EHR requires funds for training and implementation which can easily exceed the software costs by orders of magnitude, particularly since the military has very unique deployment locales.
We may believe that software purchased or built with taxpayers money should reside in the public domain, which almost never happens by the way, but this entire discussion is not really about open-source vs. proprietary products, which is largely irrelevant for the DoD itself, but very much about the plum Pentagon contracts to oversee this mammoth change to its medical records system. The choices are: internally developed DoD resources, a ragtag team of VistA veterans, a newer service entity like Medsphere, a commercial EHR vendor like Epic, or an entrenched usual suspect like SAIC, and most likely a combination of a defense contractor with any one of the lottery winners above. No doubt that as is always the case, the Pentagon will be making a wise, frugal decision, free of biases and bereft of the undue influence of special interests.
Margalit writes regularly about intersection of healthcare & technology on her site: On Health Care Technology