Open letter to the federal government: Let’s be SMART and continue to support clinical effectiveness and innovation during the VA/DOD medical record transition

Authors: Narath Carlile MD MPH, David Rosenthal MD

Summary

The Department of Veterans Affairs (VA) and the Department of Defense (DOD) together manage the nation’s largest integrated health system. The VA and DOD are both transitioning from their current medical records (AHLTA and VistA) to a new commercial medical record (Cerner) and this process is estimated to take up to 10 years. An unprecedented and unique opportunity exists for the federal government to allow innovation and important local adaptations to continue for our service members and veterans during this long transition. This is critical if the VA and DOD are to continue to provide excellent and efficient care to our active service members and veterans.

Background

Since the 1970s the VA has developed, iterated and innovated within a medical record that they developed themselves. The Veterans Information Systems and Technology Architecture (VistA) is a unified architecture of over 180 applications for clinical, financial, and administrative functions in an integrated database. This system is not only integrated across the nation, but has supported local adaptations that allowed VA teams to lead the nation in quality improvement.

In 1997 following a Presidential Directive, DOD developed their own longitudinal patient medical record system, the Armed Forces Health Longitudinal Technology Application (AHLTA). In July of 2015, the DOD selected Cerner as their new medical record platform, and in June 2017 the VA made the decision to adopt the same system as the DOD. As the VA/DOD prepare to transition to new unified medical record system, there will be many difficult choices made about how best to support and incorporate legacy applications. It is likely given the long transitional period, that there will be a chilling effect on existing application development. The inability to adapt the system to respond to necessary local needs especially in areas of substance abuse, mental health, care management, research, population health and social services to support veterans may result in manual workarounds and a slowdown in current development projects which could have an effect on clinical efficiency and possibly on veterans care.

There are many examples of tremendous innovation at the interface of technology and care delivery within VA/DOD both at the centralized level and at the level of local adaptation. Just a few examples include a robust centralized corporate data warehouse for reporting and research, sophisticated care coordination and risk assessment tools, elaborate disease-specific registries, “anywhere to anywhere” telehealth programs, clinical decision support tools and reminders, the largest genomic database in the world, and the Homeless Operations Management System. One recent innovative example is that of a Coordinated Cancer Tracker System (CCTS) started in West Haven VA (Connecticut) in 2010 and now has spread to ten other sites. The CCTS application is a web-based, VistA linked application designed for rapid cancer case ascertainment and care coordination to prevent delays and losses to follow-up. The system utilizes a natural language processing tool that double checks all radiology reports within VistA for important findings such as lung and liver nodules that need follow-up and creates a care management dashboard for clinician and care coordinators to help ensure adequate timely care for their patients. It is possible that legacy applications such as these will not be available at all, or will only be integrated years after the transition.

To help mitigate such risks, we recommend that the VA and DOD embrace the open standards SMART Health IT framework, and apply this framework to the legacy AHLTA and VistA systems during the transition period. SMART Health IT is “an open standards based technology platform that enables innovators to create apps that seamlessly and securely run across the healthcare system.” In simple terms, this is a set of technology protocols that allows applications to be embedded inside a medical record. The framework helps to ensure that appropriate authorization information for the current provider is transferred securely to the application, and that the current patient context is shared with the application.

The commercial electronic medical record selected by the DOD and the VA is Cerner. Cerner, based in Kansas City, MO, has committed to an open API approach to healthcare and supports both the FHIR standard and SMART on FHIR applications. Cerner has developed significant capabilities that support SMART on FHIR applications within their system.

The opportunity

If the current legacy medical record systems were SMART enabled now, then SMART apps could be used to continue to allow innovation and local adaptation to occur during the transition to Cerner without having to modify the underlying system. These same SMART apps could then be used within the Cerner system once rollout was completed.

The costs

What would it take to allow this to happen? Here are the steps that would be involved:

• First, VistA (the current EMR) will have to be FHIR enabled — which appears already to have been done by OSHERA
• Next, the FHIR-capable VistA would be SMART-enabled (portions of World VistA have previously been SMART enabled by the SMART Health IT team)
• Deployment to VA clinics
• Establish app governance policies for SMART apps connecting to legacy systems during the transition period (such policies will also be required for SMART apps in the new Cerner environment)

Since the VistA system is available publicly, the possibility exists that we could utilize crowd-sourced contributions to help develop and test the SMART enablement of VistA.

Conclusion

Given the maturation of the SMART on FHIR framework — which is open, standards based, and supported by ONC and the HL7 organization — and the selection of a SMART-capable medical record such as Cerner, the unique opportunity exists for the federal government to allow continued innovation for our active service members and veterans during the upcoming long transition period. This likely will require an initial development investment but may yield tremendous dividends for the VA, DOD and our veterans.

About the Authors:

Dr David Rosenthal is Medical Director H-PACT, VACT, Assistant Professor, Yale School of Medicine and Director, Integrated Clinical Medicine, Yale School of Medicine.

Dr Narath Carlile is Chief Medical Officer and Chief Information Officer for ACT.md (a digital health startup), Associate Physician, Brigham And Women’s Hospital, and Instructor, Harvard Medical School.

Disclosures:

Dr David Rosenthal is employed at the VA Connecticut Healthcare System. The views contained herein are his own and do not represent those of the Department of Veteran’s Affairs nor any other part of the federal government.

Dr Narath Carlile is employed at ACT.md, a SMART enabled commercial software platform for healthcare organizations. The views contained herein are his own and do not represent those of the company, hospital or medical school.