One of my favorite success stories of government accomplishment was the accomplishments of the MUMPS Underground within the VA to build an early electronic health record (EHR) in the 1980’s and 1990’s. Teams that were comprised of clinicians and programmers worked together to jointly design and develop a significant product that helped satisfy many of VA’s clinical needs and provide a foundation for the future technology within the VA. However, the product, the Decentralized Hospital Computer Program (DHCP), included the ability of VA Medical Center personnel to do substantial modifications to the code and code sets such that the eventual centralization of data across VA was a significant challenge. To this day, establishing standards across the enterprise is an on-going challenge at VA.

Somewhere in those early years, DoD chose to take a copy of DHCP and modify it to support DoD Military Treatment Facility needs. With significant outside assistance, most notably from SAIC, the Composite Health Care System (CHCS) had many of the same good ideas – and obstacles. AHLTA eventually provided broader enterprise-wide support including a centralized Clinical Data Repository (CDR). Vestiges of CHCS persist today.  More importantly, the culture of technical staff working with clinical staff to deliver exactly what is needed continued. While certainly laudable, this approach also came with a large amount of customization and, of course, maintenance expenses.The next generation DoD EHR, Genesis, is based on the Cerner EHR and was intended to move DoD away from a highly customized software environment into a commercial and presumably lower cost alternative. VA has also indicated that it is likely to go the Cerner route to minimize its procurement expenses and hopefully improve interoperability between DoD and VA. DoD is currently in a pause after successfully implementing four Initial Operating Capability sites to review status and priorities before proceeding. Although one of the initial guiding principles regarding the Cerner product acquisition was that DoD clinicians would have to “change their processes to fit the product” rather that have the “product change to custom-fit the DoD clinicians”, the implementations and the associated culture changes have not gone without challenges.

Assuming that an off-the-shelf commercial product would help was not a bad idea. But a health organization as large as DoD’s (or VA’s) is not like many others, and some customization would seem reasonable and even advisable. Reporting and coordinating across enterprises this large – and in a public sector environment – poses unique challenges. Increasingly, as technology encroaches more and more in all of our lives, we need to examine not just the technology but also the culture/workflow changes (and even sociological changes) that we find along the way.

DoD and the supporting vendors (Leidos, Cerner, Accenture, and Henry Schein) have embraced the notion of Change Management as a key aspect of these implementations, but the magnitude of these changes may be larger than anyone expected. More challenges are likely to come as more sites are implemented and Genesis scales up. There are important lessons to be learned through change management in the areas of training, user support, culture change, and workflow, and it would be seem wise to consider some amount of customization given the size and uniqueness of the DoD and VA implementations. Congress could assist by giving DoD and VA special consideration in how they deliver care. Most importantly, DoD and VA need to do what they can to promote innovation – even at the cost of customization – to recapture the excitement and accomplishments of the original underground that saw clinicians and technical personnel working together to deliver the best possible care for all military personnel, veterans, and their families.