Department of Veterans Affairs Secretary David Shulkin has committed to a decision about the use of a commercial approach to the VA’s electronic health record by July of this year. Several options are under consideration including: 1) using a commercial vendor to develop and maintain the Veterans Information Systems and Technology Architecture (VistA) electronic health record and provide VistA back to the VA using a Software as a Service (SaaS) model or 2) purchasing a proprietary commercial-off-the-shelf (COTS) electronic health record.
Using my perspective of more than a decade of support to various parts of the VA, work in the open source software community, and my broad health IT domain experience, I have looked at this choice from eight different business case perspectives.
Software Acquisition Cost
The software acquisition cost for open source VistA maintained and developed by a commercial vendor is likely significantly lower than a COTS electronic health record solution. VistA is already an open source software product, used by a variety of non-VA healthcare systems including the Indian Health Service, State of New York, a variety of community hospitals and the country of Jordan. Additional modules will be added over time based on open source community development and sharing.
The acquisition of a COTS electronic health record will likely require billions in software licensing costs across VA (DoD’s initial contract award to the Leidos/Cerner team was $4.3 billion). There will be an additional cost for enhancements and new functionality.
Time to Value
For commercial VistA, the value provided to the VA will be nearly immediate as VistA will continue to be used and evolved over time from commercial / open source enhancements. VA can leverage its current software enhancements efforts including initial investments in the electronic Health Management Platform (eHMP) and Digital Health Platform (DHP).
There will be a long contracting period (with potential bid protests) if the VA chooses to procure a commercial EHR. (For example, after developing the EHR RFP, DoD released its RFP in August 2014, made the award in July 2015, and announced a delay in September 2016. A pilot was finally deployed in February 2017, with full deployment in 2022 – 8 years after the RFP was released.) This will be followed by studies to define change management requirements and address the business process changes associated with the complex transition. New system implementation will likely take 2-3 years to initiate, and 3-5 years to be implemented system-wide. In the meantime, the VA’s current VistA will need to be maintained.
Build vs. Buy
The “build” versus “buy” equation is more complex now than in previous years. Forward leaning EHR vendors will offer components and ask VA to build a little. “Builds” that consider use of open source instead of commercial components are more relevant now than they were a few years ago. Value for VA could be obtained from open source and components that compete in the commercial market. The key is to make sure the open source ecosystem remains large and robust to keep pace with required new software. VA’s recent public-private partnership with the Digital Health Platform (DHP) was a good proof of concept. However, to be successful, the VA culture and strategy of open source must become fundamental to VA and the concept of open collaboration with the community must impact the entire information technology lifecycle.
[Also: Congress presses VA secretary on VistA interoperability, costs]
Proprietary COTS vendors will push customers to “buy.” Then the customer is generally “locked in” and cannot take advantage of evolving technology available in the marketplace that is not provided by the COTS vendor. Functionality that the vendor does not provide will have to be built by VA or another contractor. The advantage of “buy” is that the VA will be able to easily use software advances developed by the COTS vendors for other customers. The key is to pick the COTS vendor that is the market leader now and into the future. Switching costs in the future are likely to be high.
Functionality
VistA provides the functionality that VA requires, which includes functionality well beyond the electronic health record. Nearly 50% of VistA modules enable supporting services at VA that are not directly related to clinical support services typical of commercial EHRs. The VA is also exploring additional Health IT software to address needs including clinical workflow and supply chain management.
Proprietary COTS health record software currently lacks the enabling services support functionally that VA has built into VistA over the last 40 years. In the future, proprietary COTS may have additional features and functionality that would be useful to VA. As the COTS vendor enhances functionality for other commercial clients, the VA will be able to take advantage of these new features when they are developed. The VA will still be highly dependent on the business decisions made by the COTS vendors based on their technology roadmaps and business positioning in the commercial hospital marketplace.
Change Management
Since VistA is already in use at VA and current work is taking place to standardize VistA across all the VA sites, there would be limited clinical or business process changes at the outset and any enhancements downstream will be incremental, requiring a manageable change management process. There will be a cost for change management on the technology side to convert from in-house to commercial VistA support and operations.
VA currently provides care at 1,233 health care facilities, including 168 VA Medical Centers and 1,053 outpatient sites. VHA has 310,000 employees as of September 2015 (per VHA Workforce Plan 2016). For a proprietary COTS EHR, there will be an extremely high cost for business process change management. There will be a learning curve for physicians, other clinical staff, and administrative support users to become accustomed to the new proprietary solution. Caregiver resistance may be an issue. There will still be a cost for change management on the technology side to convert from in-house to the COTS vendor support and operations.
Business Operating Risk
If commercial VistA is chosen, continuity and quality of care will remain high with limited disruption since the supporting business processes and software will not change dramatically. The enabling commercial VistA software will evolve over time with a lower rate of change over a longer period, resulting in minimal business operational impact and lower risk.
VA’s healthcare system operates as a single provider network for nearly 9 million
Veterans. Continuity and quality of care could be disrupted due to the substantial clinical business process changes required to use new a proprietary COTS EHR. There is also a significant risk of health care provider resistance to change. Business risk will need to be managed carefully. Additionally, medical data may be located at a commercial vendor owned site, not under direct government control, and the proprietary COTS commitment would be difficult to exit from or change in the future. (For example, in 2016, DoD awarded Cerner an additional $50.7 million for data hosting after competitor appeals were lost.)
Software Maintenance and Evolution / Enhancement Risk
There are big changes coming in health care workflows to manage and track clinical and business operations across communities of care. It is not clear yet how this market is going to evolve and which vendors will likely lead. Open source products such as VistA allow system allow VA to avoid vendor lock-in, leverage community enhancements, and reduce the cost of product lifecycle management. A powerful global community has accelerated innovation in VA and the private sector through the Open Source Electronic Health Record Alliance (OSEHRA).
By picking one vendor, VA would be making a bet with the associated risks by purchasing one vendor’s R&D and enhancement schedule. Propriety vendors will invest in whatever enhancements will make money in the commercial marketplace; they will not be exclusively focused on VA’s needs. However, the vendor will likely address many of VA’s requirements as part of any contract.
Support for Health Care Delivery Transformation / Interoperability
VA’s real challenge is to transform how care is delivered to Veterans – this goes well beyond rebuilding the electronic health record and focuses on expanding the capability of digital health services. Technology beyond the health record is needed to enable the transformation. VA’s DHP provides some of that vision. An open source commercial VistA could easily accommodate transformational changes such as using blockchain (a transformative technology) to secure, manage, and share health records). For example, the Hyperledger open source project provides blockchain code for community use. Interoperability with DoD and community providers will ideally be standards-based, which a commercial VistA will need to support.
Interoperability with community providers has become a critical need for VA. The VA Community of Care will require VA IT systems to exchange health data with virtually every electronic health record (EHR) system in use today. Data integration remains an issue with all potential solutions, and the community care integration issue is not solved by any of the providers. Since this is a need across the health care space, proprietary vendors are working on these solutions. Some solutions may be proprietary and not work outside of the vendor’s and other specifically selected health record products. A vendor would be unlikely to incorporate well developed open source code into their software as the open source portion is available to the community. Vendors are working on transformative technologies, but what will be available to VA depends on which vendor is selected.
Congressional frustration is real regarding a perceived slow pace of health IT progress at VA and that a course adjustment is needed. Despite the frustration, a full scope business case analysis considering all business case elements must be conducted to come to the best decision for VA and the government overall. A commercially supported VistA (VA employees not part of software development, maintenance, and VistA operations) provided as a service, has some advantages. VA should carefully consider all elements of the business case before making its electronic medical record decision.
Ira S. Sachs is the President of I. S. Sachs and Associates, LLC. He can be reached at irstsa@gmail.com. He has worked on a number of VA and VistA contracts throughout his career and is currently working on a VistA-related contract.