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Accountable Care, EHR Interoperability Vital for DOD Healthcare

By Jennifer Bresnick

- Adopting an EHR infrastructure based on open-source technologies and embracing the private industry’s enthusiasm for accountable care will be critical for the Department of Defense if it wishes to continue providing cost-effective, quality care for military personnel, according to a new report by the Center for a New American Security.

The brief, written by Dr. Peter Levin, Retired Army General H. Hugh Shelton, and Dr. Stephen Ondra, asserts that nimble health IT infrastructure and an emphasis on value-based care is the only way the DOD can break its “unsustainable spiral” of rising fee-for-service costs inflated by a decade and a half of continuous military action overseas.

The inflated expenses of traditional fee-for-service care affect the military health system in the same way as they impact private industry, causing the DOD to spend 10% of its base budget on healthcare costs, up from 6% in 2000.  “The core problem is that TRICARE’s fee-for-service approach is subject to the same perverse incentive structures that have driven up healthcare costs in the United States by explicitly connecting payment to volume of care, not value of care,” the report says.

High levels of contracted care, a growing retiree population, and the unique requirements of maintaining a deployment-ready cadre of healthcare professionals working in challenging care sites around the globe have driven up spending to untenable levels.  “Bold steps must be taken to bring the costs of DOD provided healthcare coverage under control, while keeping the nation’s promise to those who serve, retirees and their families,” the brief states. “DOD leadership should… seize the opportunity to build upon the framework already launched by the Centers for Medicare and Medicaid Services (CMS) and many private sector payers.”

Modernizing the DOD’s health IT infrastructure it a crucial step for achieving cost-cutting reforms, but the well-documented history of failure after failure to bring an innovative and interoperable EHR into play has frustrated the report’s authors and industry onlookers alike.

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“The corroding effects of institutional inertia and resistance to change any aspect of DOD’s healthcare procurement are acute and plainly visible. A prime example of obstruction is the tortured history of DOD’s electronic health record (EHR),” the authors say.

The DOD’s $4 billion Armed Forces Health Longitudinal Technology Application (AHLTA) system, in place since 2005, “has been pilloried by DOD’s own doctors and nurses as inefficient and poorly designed.  It is not integrated to – nor can it seamlessly share data with – other health record systems, including the VA’s EHR system, which serves an important and overlapping population alongside DOD, and for which the seamless transfer of health information would greatly assist in health care and service-related benefits delivery.”

The DOD is currently undertaking a lengthy and expensive procurement process for a new infrastructure with a focus on EHR interoperability, with a number of prominent vendors vying to win the $11 billion contract.  But standard commercial software geared towards traditional hospitals and health systems won’t do the trick for the military’s sprawling obligations, the report says.

“Given the fast pace of technology changes, we hope that DOD will not repeat the mistaken multi-billion dollar decision that will hold it captive to the innovations of any single company or the services of a solitary vendor. Because of how enterprise systems are deployed, a poor selection at the first stage will inexorably lower performance and restrict enhancement choices for more than a decade. Alternatively, the DOD could choose a platform that is extensible, flexible and easy to safely modify and upgrade as technology improves and interoperability demands evolve.”

“We are concerned that a process that chooses a single commercial ‘winner’, closed and proprietary, will inevitably lead to vendor lock and health data isolation,” the authors add.

Of the teams currently in contention for the prize, only PricewaterhouseCooper, which recently added Google as a partner, is offering a system founded primarily on open-source principles.  Yet all of the companies hoping to secure the contract, including Cerner Corporation, Leidos, and Accenture, Allscripts and Hewlett-Packard, and Epic and IBM, have a history of innovation in the enterprise health IT market, and have long experience with EHR interoperability and large-scale deployments.

The DOD is taking its time to announce which collaboration will be working on its EHR modernization over the next decade, but that might not be a bad thing.  Making the right choice for the long-term contract will be an important step towards ensuring that much-needed reforms, both technical and financial, are rolled out appropriately to meet the needs of one of the biggest healthcare systems in the world.

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