A Billion Here..And the New DOD EHR Contract


William A. Hyman
Professor Emeritus, Biomedical Engineering
Texas A&M University, w-hyman@tamu.edu
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Everett Dirkson, the Illinois Senator, did not actually say “A billion here, a billion there, pretty soon, you’re talking real money”, although he did say he wished he had. The billions, or $4.3 billion to be exact, that I have been thinking about is the Department of Defense two year contract with Cerner, Accenture Federal and Leidos to provide an EHR to 8 hospitals in the first year and eventually 55 hospitals and 600 clinics. This is the first phase of a $9 billion 10 year deal. I was comforted to learn that this is a 20% savings compared to the previously estimated $11 billion. The also-rans for this award were Epic and Allscripts, and their respective partners.

The $9 billion for seems to me to be a good deal of money. That’s $13.7 million per unit including the hospitals and clinics for the same EHR system for the same customer, but it does include training. This is seemingly not a high number for a hospital EHR, but it probably is for clinics although real costs are elusive. Beyond the cost there are two other aspects of the deal that caught my attention.

One was the announcement that this was going to be off-the-shelf version of Cerner’s existing product. A good quote relative to this from Undersecretary of Defense for Acquisition, Technology and Logistics Frank Kendall is “The trick … in getting a business system fielded isn’t about the product you’re buying, it’s about the training, the preparation of your people, it’s about minimizing the changes to the software that you’re buying” In other words, forget about usability and other issues with the software and instead try to force the users into compliance with the needs of the product. Maybe the high cost per unit takes into account the amount of training that is going to be needed to help people overcome their dislike for the system.

This take-the-software-as-is approach might be viewed in the context of recent news that 20% of community hospitals want to change their EHR vendor. This report also included that 54 percent of respondents were unhappy with the usability of their system and 53 percent said their system lacked functionality. One wonders if these hospitals will shop any more carefully when they seek to change vendors, and if they will like the new product any better than the old. The DOD approach also is in sharp contrast with recommendations from a recent AHRQ webinar on “Using Health IT to Support Improvements in Clinical Workflow”. Note that the title was not “Changing Clinical Workflow to Accommodate Health IT”. One such recommendation was to actually understand clinical workflow before you try to improve it and to use this understanding to design the IT component. This seemingly obvious recommendation is unfortunately an intellectual breakthrough.

Another interesting thing about the Cerner award is that Cerner was included in assertions that the major EHR vendors have not only failed to enable interoperability but have worked against it in support of their proprietary interests. National Coordinator for Health IT Karen DeSalvo was asked about this during a May Senate hearing. Her answers were basically that it was a solvable problem, which of course is different from a problem that will be solved.

It will take a few years until we find out of the $4.3 billion, or the $9 billion has been well spent, and if the DOD’s EHR will be able to talk to either the VA’s system or the private sector.

PS .Rick, in Casablanca, did not actually say “Play it again, Sam”.