VA EHR Decision: Charting a New Course

Earlier this week, VA Secretary Dr. David Shulkin, announced that VA would adopt the same Cerner Millennium platform that DOD is in the process of implementing, replacing its forty year old in-house VistA EHR. Although, Shulkin praised the development of VistA which has led to many achievements and accomplishments, he stated, “…our current VistA system is in need of major modernization to keep pace with the improvements in health information technology and cybersecurity, and software development is not a core competency of VA.”

Shulkin arrived at his decision by talking with clinicians, using his own personal experience using VistA as a VA physician, consulting US health system CIOs and CEOs, and reviewing GAO and VA oversight and IT reports.  He stated, “I can count no fewer than 7 Blue Ribbon Commissions, and a large number of congressional hearings that have called for VA to modernize its approach to IT.”

Congress has been urging VA and DOD for more than 17 years to more closely integrated their EHRs and share more data.  In fact in 2008, DOD and VA formed the DOD/VA Interagency Program Office (IPO) in order to rapidly development and implement an EHR system between the departments. In 2013, DOD decided to break away from this concept and acquire its own EHR to replace its current AHLTA system. 

Although, both departments have reached a certain level of interoperability between EHRs using the Joint Legacy Viewer (JLV), they have not achieved “the ability to trade information seamlessly for … veteran patients and seamlessly execute a shared plan of care with smooth handoffs.”

Shulkin stated, “VA’s adoption of the same EHR system as DoD will ultimately result in all patient data residing in one common system and enable seamless care between the Departments without the manual and electronic exchange and reconciliation of data between two separate systems.”

Not only is Shulkin’s decision to implement Cerner’s solution a departure from the VA norm, his decision to rapidly acquire this solution without full and open competition is a bold and radical decision.  Shulkin cited that DOD’s acquisition process for their Cerner EHR, called MHS Genesis, took 26 months. He believes there is a public interest exception to the requirement for full and open competition due to the critical nature and urgency of VA’s need.

Shulkin has signed an authorization document known as a Determination and Findings (D&F). The FAR defines a D&F as “a special form of written approval by an authorized official that is required by statute or regulation as a prerequisite to taking certain contract actions. The ‘determination’ is a conclusion or decision supported by the ‘findings.’’ The findings are statements of fact or rationale essential to support the determination and must cover each requirement of the statute or regulation.”  

The FAR’s general description of a D&F is as follows:

• A D&F shall ordinarily be for an individual contract action. Unless otherwise prohibited, class D&F’s may be executed for classes of contract actions. The approval granted by a D&F is restricted to the proposed contract action(s) reasonably described in that D&F. D&F’s may provide for a reasonable degree of flexibility. Furthermore, in their application, reasonable variations in estimated quantities or prices are permitted, unless the D&F specifies otherwise.
• When an option is anticipated, the D&F shall state the approximate quantity to be awarded initially and the extent of the increase to be permitted by the option.

Shulkin stated in his announcement that the D&F notes that there is a public interest exception to the requirement for full and open competition, and determines that the VA may issue a solicitation directly to Cerner Corporation for the acquisition of the EHR system currently being deployed by DOD.

Shulkin also stated that VA has unique needs apart from DOD. So, the decision to implement Cerner is just the beginning of the process. He went on to make the following points:

• VA will not simply be adopting the identical EHR that DOD uses, but intends to be on a similar Cerner platform.
• VA clinicians will be very involved in how the process moves forward and in the implementation of the system.
• In many ways VA is well ahead of DOD in clinical IT innovations and they will not discard their past work.  And in turn their work will help DOD.
• VA must obtain interoperability with DOD but also with our academic affiliates and community partners, many of whom are on different IT platforms.
• VA is embarking on creating something that has not been done before — that is an integrated product that, while utilizing the DOD platform, will require a meaningful integration with other vendors to create a system that serves veterans in the best possible way.
• The solution will take the cooperation and involvement of many companies and thought leaders, and can serve as a model for the federal government and all of health care.

Much work remains to be done on planning the Cerner acquisition and implementation.  Many questions remain, such as, will VA hire an integrator to facilitate the implementation, possibly Leidos who is working on the DOD project?  Will Cerner’s prime competitor, Epic, attempt to protest VA’s decision?  What will be the cost and timeline for acquisition and implementation?

Now that VA has a direction, we should expect to see answers to these questions unfold in the coming months.