The U.S. Defense Department's Deeply Flawed Electronic Health Records Program

A new report calls the early roll out of an electronic health records system “operationally unsuitable,” but its managers disagree

Photograph of caution tape on a tablet surrounded by medical items.
Photo-illustration: Michele Hadlow; Images: iStockphoto
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A US $4.3 billion electronic health records program for the U.S. Department of Defense is “neither operationally effective nor operationally suitable,” according to a recently released memo and report from the agency’s director of operational test and evaluation.

Robert Behler pulled no punches in his assessment of the new Military Health System Genesis program, also known as MHS Genesis, and its nascent roll out at three military treatment facilities.

“MHS GENESIS is not operationally effective because it does not demonstrate enough workable functionality to manage and document patient care,” he states. “MHS GENESIS is not operationally suitable because of poor system usability, insufficient training, and inadequate help desk support.”

In his report, Behler indicated that a fourth treatment facility wasn’t assessed because officials wanted a chance to fix the plethora of problems found at the other three sites first.

This may sound like a damning indictment of the program, but according to those in charge of MHS Genesis, everything is going according to plan.

Stacy Cummings, the program executive officer of the Defense Department’s Healthcare Management Systems, responded to Behler’s memo by saying that none of the problems raised were a surprise to her or her team. In fact, the problems encountered were part of the plan for testing and then improving MHS Genesis before it’s fully deployed across Defense Department healthcare facilities next year.

That deployment should be complete by 2023, at which point the EHR system will support (pdf) 9.4 million beneficiaries and 205,000 healthcare professionals. Cummings added that she doesn’t expect the issues Behler raised to delay that schedule.

MHS Genesis is meant to replace the Defense Department’s current $2 billion electronic health record system, which was launched in 2004 to great fanfare and is known as the Armed Forces Health Longitudinal Technology Application (AHLTA). Since then, AHLTA (pdf) has proven to be an operational albatross in the eyes of military healthcare practitioners. Its usability has consistently been ranked last among EHR systems. Those issues, along with the its high maintenance costs and inability to interoperate with the EHR system used by the Veterans’ Administration, were the prime drivers for the Defense Department’s decision to ditch AHLTA and go with MHS Genesis, which is based on Cerner’s commercial EHR system.

While few dispute the need for a new EHR system for the military, concerns with MHS Genesis stretch back to its acquisition in 2015, with many critics calling the effort a disaster in waiting. They questioned whether it would lock the Defense Department into a single vendor and an obsolete EHR, and whether the agency could successfully implement such a complex, large-scale EHR system given its very aggressive strategy and poor track record with health IT systems.

Cummings and others have justified the strategy by saying, “We challenged ourselves to a very, very aggressive schedule, because we know this system is going to work and it’s going to improve health care.” Ironically, Cummings made that optimistic statement as she announced that the roll out of MHS Genesis to its first users would be delayed by several months for technical reasons related to integrating Cerner’s software with military legacy health IT systems.

Rumblings last year that the initial deployments of MHS Genesis were experiencing difficulties were dismissed as the usual negative responses to organizational change, which is curious since ALHTA is so despised by those using it. However, by the end of November, Behler’s report (pdf) stated that were more than 14,000 help desk tickets filed against the EHR system by users, which overwhelmed those responsible for resolving them.

In January, it was reported that MHS officials “paused” the program to address the problems, but they denied it was a pause at all. Instead, they said it was a pre-planned 8-week “optimization period” meant to address issues raised during the initial go-live period.

However, in March, Politico magazine published a scathing review of the MHS Genesis roll out which quoted users who claimed technical and training issues were putting patients at risk. MHS officials rebuffed the Politico story, saying that they “we’re disappointed stakeholder feedback continues to be taken out of context to present an incomplete, inaccurate, and misleading narrative about the successful completion of the MHS GENESIS initial operating capability phase.” Cerner representatives called the problems encountered by users “normal.”

MHS officials did concede that there were training issues that still needed to be addressed—a somewhat surprising admission given that training was a deficiency identified more than a year ago when MHS Genesis went live at its first location of Fairchild Air Force Base in Spokane, Washington. At the time, Cummings indicated (pdf) that corrective actions were being taken to improve training.

Last month, Cummings testified (pdf) before the Senate Appropriations Committee and claimed that the MHS Genesis roll out to the four military treatment centers was a success. She told the committee that there were still about 7,000 help tickets outstanding, with 1,000 in the process of being closed, 2,000 more that should be closed out by the end of the year, and 2,500 that involve changes to functionality that would have to be assessed. The remaining tickets weren’t discussed, nor did she indicate the rate at which help tickets were still being filed.

Cummings argued in her testimony that the training, user adoption, and management issues being raised were “opportunities” for improvement, and would not delay deployment of MHS Genesis next year. However, Behler’s report is not so sanguine.

His assessment found that users had submitted more than 150 incident reports about MHS Genesis deficiencies that could affect patient safety, lending support to what appeared in the Politico article. Because of these and other issues uncovered during the assessment, Behler wants officials to delay future deployments until the EHR system at the fourth military treatment center is assessed, and all outstanding deficiencies with the system are corrected.

This is an absolute necessity since the Veterans Administration has this week agreed to spend $10 billion over 10 years on the same Cerner EHR solution to replace its current VistA EHR system and ensure an interoperable EHR  between the Defense Department and the Veterans Administration, which is a long-standing, but failed-to-be-achieved mandate from Congress. Recently, the Coast Guard also opted to use MHS Genesis after its failed EHR system project. It is critical that MHS Genesis works as promised and can be scaled without issue before it is deployed across both the Defense Department and the Veterans Administration.

A major question is whether officials, like a pilot who decides to land despite warning signs, are fixated on deploying MHS Genesis next year, regardless of the risks. When the contract was awarded, Defense Department officials assured everyone that unlike AHLTA, MHS Genesis wouldn’t be deployed until it passed “an incredible test regime, [one] digging deep into security, workflow, comprehensively testing the product to make sure it's ready.” Furthermore, senior officials flat out said the four initial deployments “will make or break the success of the program.

Given the current state of MHS Genesis as documented by Behler’s report, officials should put a six-month to a year delay into the schedule. Yes, it will be costly, and yes, it means using AHLTA for longer than desired, and yes, there will be strong criticism from all quarters. However, the Defense Department should do the right thing now.

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