Recently, FedHealthIT’s Executive Vice President, Susan Sharer, had the opportunity to speak with Colonel John Scott, Data Manager at Defense Health Agency, about the challenges of interoperability, EHR adoption and the ultimate advantage of MHS GENESIS. Part One of the Interview focuses on challenges, change management and what the Military Healthcare System will be able to do better with MHS GENESIS.
What Does Your Title Entail?
As a Data Manager, I act as the functional lead for data governance and essentially, connect the dots. DHA is a large organization with a lot going on. Having experience working in the space for a long time, as a user and from a management and policy view, I am able to help connect the concepts and people needed to bridge those governance and operational management gaps.
What are Some of the Challenges from Your Vantage Point?
People have a tendency to get focused on their particular piece of the mission, but our systems have impacts on one another in many complex ways; there are many important individual pieces to focus on, but we must also consider how they will fit together. For instance, when we consider how systems will present information within a workflow so that it supports clinical decisions, understanding that clinician perspective is extremely important. Unlike other industries, Healthcare’s highest paid employees – the physicians and nurses – are also put into the task of managing data entry. Our systems must make it easy for them to do that correctly without taking their time away from their patients. That particular specialty, clinical informatics, is particularly needed in military health and has been for a long time. It has only recently become a major focus here at the Defense Health Agency, though.
Several of my colleagues have been pushing the need for a Chief Health Informatics Officer for a while. A little over a year ago leadership agreed this was something to move forward and in the past few months we’ve seen positions filled. Now we have Health Informatics functioning as a component of the Office of the Functional Champion. Part of the effort moving forward will be ensuring there is an informatics steering committee in every facility, acting as the initial point of contact for knowledge management from the CHIO down to every facility. We now have several clinicians supporting the CHIO. There are between five and 10 military physicians working for DHA now who are board certified in Clinical Informatics, including me, and most are in these roles.
We are simultaneously facing a number of challenges in the Military Health System, including a huge cultural transformation involving a major leadership change management effort. Namely, DHA is taking over operational control of the hundreds of military treatment facilities that have historically been under the control of the Surgeons General.
Another current challenge for us is implementation of a new electronic health record system – there is much about that effort in the media now, but it is not my particular focus. And yet another is the ongoing work that began in 2014 when we took a deep dive to assess our quality in the MHS Review, which among other recommendations found we needed to improve our ability to collect and analyze data across our system.
In all of this, we must collaborate and coordinate with the VA and we are being pressed to save money on health IT spending all at the same time. So there are really five big things happening all at once, each a challenge in itself and together, a huge undertaking.
Change Management
Communication and coordination are also huge challenges. What we call change management involves technology, process, policy and people. I have colleagues who are informatics experts who have long realized the importance of change management and have been pushing its significance, but they have had to compete for attention and resources. There is recognition now the military can’t just put something out and expect it to be used well; we have to have ongoing attention to make sure new systems meet their intended purposes.
In 2003, when we first moved from paper records to an electronic health record, we interviewed people, and planned for the workflow changes; but the effort was largely unsuccessful. This was at least in part because we didn’t have adequate resources to sustain and improve training when we found the technology did not work well enough. We had got ahead of what the technology could do to keep work flows smooth. We lost a lot of traction between then and 2008 when the decision was reached to replace what we had with a commercial solution instead of building our own. We’re at the beginning of that replacement now.
The biggest change management issues for us now, as pertains to the EHR, have to do with the different ways the new record system collects information and the ways we can share that information through our administrative functions. It has different ways for clinicians to write their notes, but generally it is better than our current system and clinicians like it. But how the information is organized, and how it is communicated to the other parts of the Healthcare management functions – that changes a great deal, and adapting to that change will be challenging.
Where I think we also need to improve upon previous efforts is in appreciating how different some processes become for administrators. We need to acknowledge and address the change management required for them as well.
What Will the Military Healthcare System be Able to do Better by Adopting MHS GENESIS?
We know we need to collect information in a standardized way – that is how we continue to learn how to make Healthcare better. And MHS GENESIS will make a huge step forward in how well we collect usable data.
In military Healthcare, we saw really significant changes made as far back as the Civil War when the new Army Medical Department began to codify what belongs in the paper folder that becomes the outpatient longitudinal medical record. In 2010, we began to call that record the Service Treatment Record and defined it as the essential set of information needed to record a person’s health history and support decision making. It includes things like medications, diagnoses, documentation about procedures and so on. In 2010, we saw it needed much better maintenance. We had a strong focus with the VA around that time about redefining what was needed to make benefits determinations. And then we adapted that definition and policy to take a full accounting of the electronic health record. That, in 2015, became the DoD health record policy.
DHA has a large head start in standardizing the health record – we have had to do so because we have not only a very mobile patient population, we also have a very mobile Healthcare system staff. So when we began to update our policy to account for EHRs, we asked consultants for input and wrote sound policy around what a record is, what is covered by HIPAA, and what specifically is the “HIPAA designed record set” that is supposed to be made available to patients. The new EHR will be covered by this same policy.
Some of the questions for instance revolve around information acquired purely for research. Is that part of the record? We have seen there is “raw data” in what we realize is a HIPAA-covered space, but large amounts of that data are not part of the Treatment Record – and we haven’t quite spelled out in policy what to make of it yet. We are in the process of codifying all of that to make sense of it and I believe we are ahead of most Healthcare systems. Being clear about how all this data may be used allows us to write policy regarding information sharing that can use that raw data for discovery as part of performance improvement.
An example of this is the Million Veteran Program that will collect DNA and other information from a large number of Veterans in a research study. The subject consent in that study allows the researchers to access individual health records. And our policy work allows us to consider all of the raw data in our enterprise data warehouse as part of the health record. That we can share that with the VA is unique to the DoD and VA relationship, since the VA is already provided access to the DoD health record of all Veterans who get benefits there. Sharing the data in our data warehouse in this case can ultimately save time from re-abstracting data from paper records because it was thought of that way and policy has been set to support that.
Part Two of this interview focuses on collaboration, preserving the old information and sharing for improved patient care between departments and is available here.
About COL John S. Scott, MD
Colonel Scott is a pediatric cardiologist and board certified clinical informatics specialist with 29 years of experience in military medicine. His positions have included leadership roles in direct care pediatrics and pediatric cardiology, quality management, and information management. He was the Program Director for Clinical Informatics Policy in the Office of the Assistant Secretary of Defense for Health Affairs from January 2012 until July of 2017. Since then he has served as Data Manager in the Defense Health Agency, working to improve data governance and enterprise data management for the Military Health System.
