Defense Health Information System as a case study for national health IT

The National Forum on the Future of Defense Health Information Systems (National Forum) held in Washington, DC in March 2008 provided a unique opportunity to conduct a case study of developing a large complex health information system. The concept of the health information system has evolved from the days to electronic hospital information system (HIS) to longitudinal health record (LHR) which refers to a complete information system that adequately captures what occurs to service persons from “cradle to grave”, including but not limited to the clinical record. As originally imagined after the first Gulf War, the LHR is supposed to serve many functions in occupational health, medical logistics, health planning, and medical surveillance as well as clinical care. The LHR has become central to both DoD and VA health systems. As LHR emerges, the interoperable national health information system is becoming critical for the future. DoD and VA collaboration has accelerated in the last two years as exemplified by current efforts to exchange information between AHLTA (DoD Health IT system) and VistA (VA health IT system). With almost 70% of defense and veteran healthcare happening outside of the DoD/VA system, the LHR must accept information from the private sector not only Government sources. Given their size and position, DoD and VA have the potential to lead the nation in supporting standards for national health information network (NHIN). With that in mind, the VA and DoD are coordinating their efforts with the Office of the National Coordinator Health Information Technology (ONCHIT) that is leading the nation's interoperability and information exchange effort. Knowledge discovery and management is vital to bringing benefits of data repository to the clinicians and researchers. The growth of clinical data, image files, physiologic data, and omic data among others has produced an information explosion in healthcare and forced successful organizations to become knowledge-driven enterprises. Moreover, the recent IOM Roundtable on “Data for the Public Good” discussed the current challenges of aggregating large sets of data while taking the position that exploiting large databases would significantly accelerate science. Although DoD and VA have numerous databases and two of the largest growing clinical data tissue repositories in the world, they lack a common healthcare data model to link the databases together and sponsor no significant effort to create an infrastructure to make this data available for research. The MHS currently also lacks a strategy for managing its growing amount of data. Recently, MHS has worked with TATRC and IBM to develop a roadmap for developing a strategy but much more work remains. There are increasing needs for efficient software engineering and ability to integrate innovations in IT development process. Many participants expressed dissatisfaction with the current performance of AHLTA. Slow and awkward to use, AHLTA delays clinical work at a time when maximizing physician throughput really matters. The IT development occurred in a closed environment, insulated from evolving new ideas and best practices outside the DoD. As a result, while the previous efforts developed and implemented software for health care applications, global advances in information technology render it obsolete by the time it becomes available for use. With these problems and consequences in mind, participants in the National Forum consistently called for more open process of software engineering, program management and knowledge sharing to allow lessons learned to flow freely among government, academic and industrial partners in the software development process. As the health IT and personal health records (PHR) have become important national agenda, the experiences gained from the development and deployment of health IT systems in DoD and VA should provide important lessons for the national community.