MHS Genesis Background and Issues for Congress October 28 2019 Congressional Research Service https crsreports congress gov R45987 SUMMARY MHS Genesis Background and Issues for Congress R45987 October 28 2019 Bryce H P Mendez Since 1968 the Department of Defense DOD has developed procured and sustained a variety Analyst in Defense Health Care Policy of electronic systems to document the health care services delivered to servicemembers military retirees and their family members DOD currently operates a number of legacy electronic health record EHR systems Each system has separate capabilities and functions as a result of new or changing requirements over the past five decades The primary legacy systems include the Composite Health Care System CHCS Armed Forces Health Longitudinal Technology Application AHLTA Essentris and the Corporate Dental System DOD also still uses paper medical records that are later scanned and digitally archived Currently only certain components of DOD’s health records are accessible to the Department of Veterans Affairs VA In the early 1990s concern grew about deficient interoperability between DOD and VA This led to recommendations by various commissions on military and veterans health care calling for greater coordination and data sharing efforts between the two departments Between 1998 and 2008 DOD and VA developed several capabilities to exchange patient health information across each department’s EHR systems However Congress did not view these systems as an adequately integrated approach This led to several congressional mandates being issued between 2008 and 2014 including for the development of an interoperable EHR including a deadline to implement such system for certain capability requirements and for the creation of an interagency program office After several strategy changes to meet Congress’s mandates DOD opted to acquire a commercial-off-the-shelf EHR product to replace its legacy EHR systems The new system would be called MHS Genesis In July 2015 DOD awarded the MHS Genesis contract to Leidos Partnership for Defense Health LPDH The contract includes a potential 10-year ordering period and an initial total award ceiling of $4 3 billion DOD selected several MTFs in Washington to serve as Initial Operational Capability IOC sites and began fielding MHS Genesis in 2017 The designated IOC sites included Madigan Army Medical Center Fairchild Air Force Base Naval Hospital Bremerton and Naval Health Clinic Oak Harbor The purpose of fielding MHS Genesis at the IOC sites before full deployment was to observe evaluate and document lessons-learned on whether the new EHR was usable interoperable secure and stable During initial deployment DOD evaluators and IOC site personnel identified numerous functional and technical challenges In particular the Defense Department’s Director of Operational Testing and Evaluation found that MHS Genesis was “not yet effective or operationally suitable ” Technical challenges included cybersecurity vulnerabilities network latency and delayed equipment upgrades and operational testing Functional challenges included lengthy issue resolution processes inadequate staff training and capability gaps and limitations DOD acknowledged these issues implemented follow-on testing ongoing corrective actions and revised its training approach for future fielding DOD plans to implement MHS Genesis at all military treatment facilities MTFs in 23 waves through 2024 Each wave spans 18 months with a new wave commencing every three months at designated MTFs The first deployment wave began in September 2019 at MTFs in California Oregon and Idaho As DOD moves to fully implement MHS Genesis Congress may choose to address various issues including    how oversight can be conducted on a program that spans three federal departments what kind of interdepartmental governance structure is needed to implement the program and how to ensure fair and open competition in future procurement decisions Congressional Research Service MHS Genesis Background and Issues for Congress Contents Introduction 1 Background 1 Brief History of DOD’s Electronic Health Record EHR 2 DOD Legacy EHR Systems 3 Composite Health Care System CHCS 3 Armed Forces Health Longitudinal Technology Application AHLTA 4 Essentris 4 Corporate Dental System CDS 5 Paper Medical Records 5 Developing an EHR Modernization Solution 6 Congress Mandates Interoperability 8 Establishing Interoperability Goals 9 The Integrated EHR Initiative 9 Congressional Mandate for an EHR 10 MHS Genesis 11 DOD Acquisition Strategy 11 Requirements Development and Solicitation 12 Source Selection Process 13 Contract Award 14 Leidos Partnership for Defense Health LPDH 15 Capabilities 15 Governance 16 Program Executive Office Defense Healthcare Management Systems PEO DHMS 17 Defense Health Agency DHA 18 Military Service Medical Departments 18 Senior Stakeholders Group SSG and the Configuration Steering Board CSB 19 Executive Steering Board ESB 19 Office of the Chief Health Informatics Officer OCHIO 20 Deployment 20 Pre-Deployment Activities 20 Initial Deployment 21 Selected Initial Deployment Issues 26 Future Deployments 27 Issues for Congress 28 Congressional Oversight 28 Interagency Governance 29 Limited Competition in Future Procurement 29 Figures Figure 1 Recent Highlights in DOD’s Electronic Health Record Systems Deployment 3 Figure 2 DOD’s Guiding Principles for EHR Modernization 12 Figure 3 Overview of the Source Selection Process for MHS Genesis 14 Congressional Research Service MHS Genesis Background and Issues for Congress Figure 4 Leidos Partnership for Defense Health 15 Figure 5 DOD Governance for MHS Genesis 17 Figure 6 Senior Oversight Working Groups for MHS Genesis 19 Figure 7 EMRAM Scores 23 Figure 8 O-EMRAM Scores 23 Figure C-1 Stages of Electronic Medical Record EMR Adoption 34 Figure D-1 IOT E Measures of Effectiveness and Measures of Performance 35 Figure F-1 MHS Genesis Deployment Schedule FY2018-FY2024 38 Figure G-1 DOD and VA EHR Joint Commitment Statement 39 Tables Table 1 DOD VA Data-Sharing and EHR Modernization Recommendations 7 Table 2 Initial Operational Capability Sites 21 Table B-1 Summary of MHS Genesis Functional Capability Requirements 33 Appendixes Appendix A Acronyms 31 Appendix B MHS Genesis Functional Capability Requirements 33 Appendix C Stages of Electronic Medical Record Adoption and Utilization 34 Appendix D IOT E Summary Results 35 Appendix E Methodology for CRS Focus Groups on MHS Genesis 36 Appendix F MHS Genesis Deployment Schedule 38 Appendix G DOD and VA EHR Joint Commitment Statement 39 Contacts Author Information 40 Congressional Research Service MHS Genesis Background and Issues for Congress Introduction This report provides background on Department of Defense’s legacy Electronic Health Record EHR systems reviews previous EHR modernization efforts and describes DOD’s process to acquire and implement a new EHR system known as MHS Genesis DOD’s new EHR system presents several potential issues for Congress including how to conduct oversight on a program that spans three federal departments how to ensure an adequate governance structure for the program and how to monitor the program’s cost and effectiveness Although this report mentions EHR modernization efforts by the Department of Veterans Affairs VA and U S Coast Guard USCG as well as DOD’s Joint Operational Medical Information System JOMIS it does not provide an in-depth discussion of these programs Appendix A provides a list of acronyms used throughout this report Background For decades the Department of Defense DOD has developed procured and sustained a variety of electronic systems to document the health care services delivered to servicemembers military retirees and their family members DOD currently operates a number of legacy EHR systems and is at the direction of Congress in the process of implementing a new EHR called MHS Genesis DOD’s new EHR system is to be integrated with other EHR systems utilized by the VA USCG and civilian health care providers DOD operates a Military Health System MHS that delivers to military personnel retirees and their families certain health entitlements under chapter 55 of Title 10 U S Code The MHS administers the TRICARE program 1 which offers health care services worldwide to over 9 5 million beneficiaries in DOD hospitals and clinics – also known as military treatment facilities MTFs – or through participating civilian health care providers i e TRICARE providers 2 There are currently 723 MTFs located in the United States and overseas that provide a range of clinical services depending on size mission and level of capabilities 3 Health care services delivered in MTFs or by TRICARE providers are documented in at least one of the following components of the DOD health record   service treatment record STR – documentation of all medical and dental care received by a servicemember through their military career nonservice treatment record NSTR – documentation of all medical and dental care received by a nonservicemember beneficiary i e military retiree family member and For more on the TRICARE program see Question “4 What is TRICARE ” in CRS Report R45399 Military Medical Care Frequently Asked Questions by Bryce H P Mendez 2 Department of Defense Evaluation of the TRICARE Program Fiscal Year 2019 Report to Congress April 8 2019 p 19 https health mil Reference-Center Congressional-Testimonies 2019 04 08 TRICARE-Program-Effectiveness 3 Ibid MTFs include Department of Defense DOD inpatient hospitals medical centers ambulatory care and occupational health clinics and dental clinics 1 Congressional Research Service 1 MHS Genesis Background and Issues for Congress  occupational health civilian employee treatment record OHTR – documentation of all occupational-related care provided by DOD typically to DOD civilian or contractor employees 4 DOD maintains numerous legacy EHR systems that allow health care providers to input share and archive all documentation required to be in a beneficiary’s health record 5 MTF or TRICARE providers can document medical and dental care directly in a DOD legacy EHR system or can scan and upload paper records Servicemembers and their families frequently change duty stations the DOD health record can be accessed at most MTFs However sometimes beneficiaries are relocated to an area that lacks access to DOD’s legacy EHR systems In such cases beneficiaries are required to maintain a paper copy of the health record 6 What is an Electronic Health Record EHR Although the definition of EHRs can vary substantially there are generally four core components of an EHR electronic clinical documentation usually physician nurse and other clinician documentation electronic prescribing e g computerized provider order entry results reporting and management e g clinical data repository and clinical decision support Many EHRs also include barcoding systems and patient engagement tools The Office of the National Coordinator for Health Information Technology ONC defines an EHR as “a real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decision-making The EHR can automate and streamline a clinician’s workflow ensuring that all clinical information is communicated It can also prevent delays in response that result in gaps in care The EHR can also support the collection of data for uses other than clinical care such as billing quality management outcome reporting and public health disease surveillance and reporting ” Source Institute of Medicine Health IT and Patient Safety Building Safer Systems for Better Care Washington DC 2012 p 38 Brief History of DOD’s Electronic Health Record EHR Since 1968 DOD has used various electronic medical information systems that automate and share patient data across its MTFs Between 1976 and 1984 DOD invested $222 million to “acquire implement and operate various stand-alone and integrated health-care computer systems ”7 Over the next three decades DOD continued to invest and to implement numerous electronic medical information systems to allow health care providers to input and review patient data across all MTFs regardless of military service or geographic location In 1998 DOD began to incorporate a series of efforts to increase interoperability with the VA’s EHR systems see Figure 1 DOD Instruction 6040 45 “DOD Health Record Life Cycle Management ” updated April 11 2017 https www esd whs mil Portals 54 Documents DD issuances dodi 604045p pdf ver 2019-03-22-095342-773 5 DOD Instruction 6040 45 outlines the documentation required in the DOD health record 6 For example servicemembers assigned to remote duty stations do not have reasonable access to an MTF and are required to seek health care from a civilian health care provider participating in TRICARE Participating TRICARE providers do not have access to DOD legacy EHR systems and would not be able to review or contribute to the DOD health record unless the servicemember provides a hard copy After leaving a remote duty station servicemembers are required to check-in their DOD health record at an MTF to ensure all new documentation is uploaded to a DOD legacy EHR system 7 U S Government Accountability Office Acquisition Strategy for DOD Hospital Computer System GAO IMTEC-8612 March 1986 p 1 https www gao gov assets 210 208368 pdf 4 Congressional Research Service 2 MHS Genesis Background and Issues for Congress Figure 1 Recent Highlights in DOD’s Electronic Health Record Systems Deployment 1998-2018 Source CRS graphic based on information from CRS Report R42970 Departments of Defense and Veterans Affairs Status of the Integrated Electronic Health Record iEHR by Sidath Viranga Panangala and Don J Jansen out of print available to congressional clients on request Secretary of Defense Memorandum “Integrated Electronic Health Records ” OSD005932-13 May 21 2013 https health mil ReferenceCenter Policies 2013 05 21 Memorandum-on-the-Integrated-Electronic-Health-Record Department of Veterans Affairs VA Secretary announces decision on next-generation Electronic Health Record press release June 5 2017 https www va gov opa pressrel includes viewPDF cfm id 2914 and U S Coast Guard “Electronic Health Records Acquisition ” accessed October 10 2019 https www dcms uscg mil Our-Organization AssistantCommandant-for-Acquisitions-CG-9 Programs C4ISR-Programs Electronic-Health-Records-Acquisition Notes AHLTA Armed Forces Health Longitudinal Technology Application CDS Corporate Dental System CHCS Composite Health Care System iEHR Integrated Electronic Health Record IPO Interagency Program Office LPDH Leidos Partnership for Defense Health TMIP-J Theater Medical Information Program – Joint DOD Legacy EHR Systems DOD operates numerous legacy EHR systems as described below Together health care data documented and archived in the legacy EHR systems contribute to a beneficiary’s overall medical and dental record also known as the DOD health record MHS Genesis is intended to replace these legacy systems and produce one comprehensive EHR Composite Health Care System CHCS CHCS is a medical information system that has been in operation since 1993 8 CHCS primarily functions as the outpatient component of the EHR with additional capabilities to order record and archive data for laboratory radiology and pharmacy services Administrative functions such as patient appointment and scheduling medical records tracking and quality assurance checks were also incorporated into CHCS In March 1988 DOD awarded Science Applications 8 Between 1988 and 1993 select MTFs utilized CHCS In 1993 DOD began deploying CHCS in all MTFs CHCS deployment was completed in 1998 For more on CHCS see Department of Defense Military Health System Reference Center February 2018 https www health mil Reference-Center Fact-Sheets 2019 03 14 CompositeHealth-Care-System Congressional Research Service 3 MHS Genesis Background and Issues for Congress International Corporation SAIC a contract to “design develop deploy and maintain CHCS ”9 SAIC continues to provide ongoing sustainment and technical support for CHCS The estimated life-cycle cost of CHCS is $2 8 billion 10 Armed Forces Health Longitudinal Technology Application AHLTA After deploying CHCS DOD identified a need for integrated health care data that could be portable and accessible at any MTF CHCS was developed as a facility-specific system that archived its data using regional network servers However accessing data across each server became a “time- and resource-intensive activity ”11 In 1997 DOD began planning for a new “comprehensive lifelong computer-based health care record for every servicemember and their beneficiaries ”12 The program would be known as CHCS II later renamed the Armed Forces Health Longitudinal Technology Application AHLTA 13 DOD intended to replace CHCS with AHLTA and initially planned to deploy the new system in 1999 However the program sustained several delays resulting from “failure to meet initial performance requirements” and changes to technical and functional requirements 14 The implementation plan was later revised to reflect AHTLA deployment from July 2003 to September 2007 In 2010 the Government Accountability Office GAO reported that DOD’s AHLTA life-cycle cost estimate through 2017 would be $3 8 billion 15 Essentris Essentris is the inpatient component of the current EHR that has been used in certain military hospitals since 1987 16 As a commercial-off-the-shelf COTS product developed by CliniComp International Inc CliniComp Essentris allows health care providers to document clinical care procedures and patient assessments occurring in the inpatient setting as well as in emergency departments In 2009 DOD selected CliniComp to deploy Essentris at all military hospitals 17 This deployment was completed in June 2011 18 DOD maintains an ongoing contract with 9 U S Government Accountability Office GAO Medical ADP Systems Defense Achieves Worldwide Deployment of Composite Health Care System GAO AIMD-96-39 April 1996 p 3 https www gao gov assets 230 222364 pdf 10 GAO estimated this amount based on then-year dollars U S Government Accountability Office Medical ADP Systems Defense Achieves Worldwide Deployment of Composite Health Care System GAO AIMD-96-39 April 1996 p 1 https www gao gov assets 230 222364 pdf 11 U S Government Accountability Office Opportunities Exist to Improve Management of DOD's Electronic Health Record Initiative GAO 11-50 October 2010 p 3 https www gao gov assets 320 310989 pdf 12 Ibid p 3 13 For more on AHLTA see Department of Defense “AHLTA 3 3 ” February 2018 https www health mil ReferenceCenter Fact-Sheets 2018 12 18 AHLTA-33 14 U S Government Accountability Office Opportunities Exist to Improve Management of DOD's Electronic Health Record Initiative GAO 11-50 October 2010 p 3 https www gao gov assets 320 310989 pdf 15 Ibid pp 4 and 6 16 For more on Essentris see Department of Defense “Essentris ” March 2018 https www health mil ReferenceCenter Fact-Sheets 2018 03 27 Essentris 17 CliniComp Intl CliniComp Intl Selected as Inpatient Clinical Documentation Solution Provider for Military Health System press release September 2009 https www clinicomp com pdf CliniComp_DHIMS091109 pdf 18 Department of Defense Essentris 100% Deployed The Beat June 2011 Volume IV Issue 3 https www clinicomp com pdf June2011Essentris100percntDeployed pdf Congressional Research Service 4 MHS Genesis Background and Issues for Congress CliniComp and LOUi Consulting Group Inc to provide sustainment technical and customer support training and ongoing updates for Essentris 19 Corporate Dental System CDS CDS formerly named the Corporate Dental Application is a web-based application that serves as DOD’s current electronic dental record system CDS allows DOD dental providers to document review and archive clinical information The system also serves several administrative functions such as tracking dental readiness of servicemembers patient appointments and scheduling and data reporting 20 CDS was initially developed as the Army’s alternative dental solution to the AHLTA dental module 21 In 2000 all Army dental clinics implemented CDS 22 By 2016 Navy and Air Force dental clinics also transitioned to CDS as their electronic dental record system 23 In the same year DOD awarded a four-year $30 million contract to the Harris Corporation to sustain CDS 24 Paper Medical Records Paper medical records are another component of the DOD health record While certain health care data are recorded and archived electronically some administrative processes and clinical documentation exist only on paper forms For example clinical documentation from TRICARE providers accession medical records or medical evacuation records are usually in paper form In such cases DOD policy requires the scanning and archiving of paper medical records in an electronic repository called the Health Artifact and Image Management Solution HAIMS 25 After being digitized certain paper medical records are submitted to the National Archives and Records Administration while other documents are disposed of locally Other DOD legacy systems document and archive various administrative and clinical data such as 19 DOD awarded an Essentris sustainment and support contract to CliniComp on September 30 2014 The five-year contract is worth $29 9 million Department of Defense Contracts September 30 2014 https dod defense gov News Contracts Contract-View Article 606697 Defense Heath Agency Justification and Approval for Other Than Full and Open Competition J A Number JA0015 October 14 2014 https www fbo gov utils view id faf48f757ee4bd177c223ea7eac8c607 DOD also awarded an Essentris sustainment and support contract to the LOUi Consulting Group Inc on February 8 2019 The two-year contract is worth $7 1 million LCGI LCGI Awarded GSA Task Order to Provide Essentris Support press release February 22 2019 http www lcgi net news 202-lcgi-awarded-gsa-task-order-to-provide-essentris-support 20 Department of Defense Privacy Impact Assessment Corporate Dental System May 22 2018 pp 1-2 https go usa gov xVuKk 21 DOD encountered certain “performance problems” with developing and implementing the AHLTA dental module and placed a “strategic pause in its further deployment ” U S Government Accountability Office Opportunities Exist to Improve Management of DOD's Electronic Health Record Initiative GAO-11-50 October 2010 p 6 https www gao gov new items d1150 pdf 22 Steven Eikenberg Robert Keeler and Thomas Green Use of the Army Dental Command Corporate Dental Application as an Electronic Dental Record in the Iraq Theater of Operations U S Army Medical Department Journal January-March 2011 pp 51-57 23 Harris Corporation Harris Corporation Awarded $30 Million IT Systems Support Contract by US Army Dental Directorate press release June 2 2016 https www harris com press-releases 2016 06 harris-corporation-awarded30-million-it-systems-support-contract-by-us-army 24 Ibid 25 Department of Defense Instruction 6040 45 “DoD Health Record Life Cycle Management ” updated April 11 2017 https www esd whs mil Portals 54 Documents DD issuances dodi 604045p pdf ver 2019-03-22-095342-773 Congressional Research Service 5 MHS Genesis Background and Issues for Congress    Referral Management System RMS An administrative information system that allows MTF staff to create and track referrals between health care providers HAIMS An electronic repository that stores DOD health care data including digitally transmitted or scanned medical documentation 26 Data housed in HAIMS is also incorporated into a servicemember’s official service treatment record which is accessible to the VA 27 Medical Readiness Tracking Systems Each military department utilizes an electronic information system that documents and tracks certain medical and dental readiness requirements such as periodic health assessments immunizations dental exams and laboratory tests 28  Theater Medical Information Program–Joint TMIP-J A suite of electronic systems including modules for health care documentation and review patient movement and medical intelligence used in deployed or austere environments 29  Joint Legacy Viewer JLV A web-based read-only application that allows DOD and VA health care providers to review certain real-time medical data housed in each department’s EHR systems 30 Armed Forces Billing and Collection Utilization Solution ABACUS A webbased electronic system that allows MTFs to bill and track debt collection for health care services provided to certain beneficiaries 31  Developing an EHR Modernization Solution After Operation Desert Storm concluded in 1991 concern about deficient interoperability between DOD and VA health record systems began to grow A number of committees and commissions issued reports highlighting the need for DOD and VA to standardize record-keeping to improve health data sharing and to develop a comprehensive life-long medical record for servicemembers Table 1 summarizes their recommendations For more on the Health Artifact and Image Management Solution see Department of Defense “Health Artifact and Image Management Solution HAIMS ” February 2018 https health mil Reference-Center FactSheets 2019 04 05 HAIMS-Fact-Sheet 27 The DOD health record is also known as a service treatment record STR An STR includes a servicemember’s medical and dental records from their military tenure When a servicemember separates from the military DOD uploads the STR into HAIMS and retires any paper components of the STR to the National Personnel Records Center 28 Each military department uses different medical readiness tracking systems The Department of the Army uses Medical Protection System MEDPROS The Department of the Navy uses Medical Readiness and Reporting System MRRS The Department of the Air Force uses Aeromedical Services Information Management System ASIMS 29 DOD intends to replace most TMIP-J capabilities with the Joint Operational Medicine Information Systems JOMIS a version of MHS Genesis that is be used in deployed or austere environments For more on TMIP-J and JOMIS see DHMS Program Executive Office “Joint Operational Medicine Information Systems ” March 2019 https www health mil Reference-Center Fact-Sheets 2019 03 26 Joint-Operational-Medicine-Information-Systems 30 For more on the JLV see Department of Defense “Joint Legacy Viewer ” July 2019 https www health mil Reference-Center Fact-Sheets 2019 07 30 Joint-Legacy-Viewer-Fact-Sheet 31 For more on ABACUS see Department of Defense “Armed Forces Billing and Collection Utilization Solution ABACUS ” May 2019 https www health mil Reference-Center Fact-Sheets 2019 05 17 ABACUS 26 Congressional Research Service 6 MHS Genesis Background and Issues for Congress Table 1 DOD VA Data-Sharing and EHR Modernization Recommendations Commission Relevant Report Recommendations President’s Advisory Committee on Gulf War Veterans’ Illnesses 1996 a “DOD officials … should assign a high priority to dealing with the problems of lost or missing medical records A computerized central database is important Specialized databases must be compatible with the central database Attention should be directed toward developing a mechanism for computerizing medical data including classified information if and when it is needed in the field DOD and VA should adopt standardized recordkeeping to ensure continuity ” Congressional Commission on Service Members and Veterans Transition Assistance 1999 b “Require DOD and VA to ensure joint IT system replacements and enhancements in the future and maximize commercial off-the-self technology ” “Require DOD and VA to jointly offer a single solicitation for replacement of DOD’s and VA’s legacy medical systems with integrated and interoperable systems ” President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans 2003 c President’s Commission on Care for America’s Returning Wounded Warriors 2007 d DOD and VA should develop and deploy “interoperable bidirectional standard space electronic medical records … by the year 2005 ” “Make patient information available to all personnel who need it initially in readable form ” “Continue efforts for fully interoperable information system ” “Develop a user-friendly single web portal for service members and veterans ” Notes a Presidential Advisory Committee on Gulf War Veterans' Illnesses Final Report December 1996 p 19 b Congressional Commission on Servicemembers and Veterans Transition Assistance Final Report January 14 1999 p 20 c Testimony of Co-Chair Gail R Wilensky President’s Task Force to Improve Health Care Delivery for our Nation’s Veterans in U S Congress House Veterans Affairs Committee Report of the President’s Task Force to Improve Health Care Delivery for our Nation’s Veterans hearings 108th Cong 1st sess June 3 2003 d Serve Support Simplify Report of the President's Commission on Care for America's Returning Wounded Warriors July 1 2007 p 28 Between 1998 and 2009 DOD and VA established various methods to exchange limited patient health information across both departments including   Federal Health Information Exchange FHIE Completed in 2004 the FHIE enables monthly data transmissions from DOD to VA comprised of patient demographics laboratory radiology results outpatient pharmacy allergies and hospital admission data 32 Bidirectional Health Information Exchange BHIE Completed in 2004 the BHIE enables real-time two-way data transmissions DOD-to-VA and VA-toDOD comprised of FHIE information additional patient history and assessments theater clinical data and additional inpatient data 33 For more on the Federal Health Information Exchange FHIE see Department of Defense “Federal Health Information Exchange ” accessed June 20 2019 https www health mil media Files MHS Fact-SheetFiles DHCS DoD-VA-Sharing factsheetFHIE ashx la en 33 For more on the Bidirectional Health Information Exchange BHIE see Department of Defense “Viewing Inpatient and Outpatient Clinical Data with the Bidirectional Health Information Exchange ” accessed June 20 2019 https www health mil Military-Health-Topics Technology Military-Electronic-Health-Record DoD-and-VA32 Congressional Research Service 7 MHS Genesis Background and Issues for Congress   Clinical Data Repository Health Data Repository CHDR Completed in 2006 CHDR enables real-time two-way data transmissions comprised of pharmacy and drug allergy information and a capability to add information to the patient’s permanent medical record in the other department’s repository 34 Virtual Lifetime Electronic Record VLER Initiated in 2009 the VLER enables real-time health information exchange between DOD and VA as well as certain civilian health care providers 35 While these information exchange systems enable DOD and VA health care providers to view or modify limited health care data both departments continue to operate separate disparate health record systems Congress Mandates Interoperability In 2008 Congress began legislating mandates for DOD and VA to establish fully interoperable EHR systems that would allow for health care data sharing across departments Section 1635 of the National Defense Authorization Act NDAA for Fiscal Year FY 2008 P L 110-181 directed DOD and VA to jointly 1 “develop and implement electronic health record systems or capabilities that allow for full interoperability of personal health care information ” and 2 “accelerate the exchange of health care information” between both departments Additionally Congress directed the establishment of an interagency program office IPO that would serve as a “single point of accountability” for rapid development and implementation of EHR systems or capabilities to exchange health care information 36 The FY2008 NDAA also directed the IPO to implement the following no later than September 30 2009 “…electronic health record systems or capabilities that allow for full interoperability of personal health care information between the Department of Defense and Department of Veterans Affairs which health records shall comply with applicable interoperability standards implementation specifications and certification criteria including for the reporting quality measures of the Federal Government ” 37 In the conference report accompanying the Department of Defense Appropriations Act 2008 H Rept 110-434 P L 110-116 Congress also directed DOD and VA to “issue a joint report” by March 3 2008 that describes the “actions being taken by each department to achieve an interoperable electronic medical record EMR ”38 On April 17 2008 the IPO was established with temporary staff from DOD and VA 39 On December 30 2008 the Deputy Secretary of Defense delegated oversight authority for the IPO to Information-Exchange Viewing-Inpatient-and-Outpatient-Clinical-Data 34 For more on the CHDR see Department of Defense “Enabling Drug-Drug and Drug-Allergy Checks with DoD Clinical Data Repository VA Health Data Repository accessed June 20 2019 https www health mil Military-HealthTopics Technology Military-Electronic-Health-Record DoD-and-VA-Information-Exchange Enabling-Drug-Drug-andDrug-Allergy-Checks 35 For more on the VLER see Department of Defense “Virtual Lifetime Electronic Record Health Information Exchange Initiative ” accessed June 30 2019 https www health mil Military-Health-Topics Technology VLER-HIE 36 P L 110-181 §1635 37 Ibid §1635 d 38 H Rept 110-434 p 357 39 Department of Defense Department of Veterans Affairs DOD VA Interagency Program Office Annual Report to Congressional Research Service 8 MHS Genesis Background and Issues for Congress the Under Secretary of Defense for Personnel and Readiness USD P R The FY2008 NDAA also directed the Secretary of Defense SECDEF to appoint the IPO Director with concurrence of the Secretary of Veterans Affairs SECVA and the SECVA to appoint the IPO Deputy Director with concurrence of the SECDEF 40 Establishing Interoperability Goals To meet Congress’s mandate on interoperability the IPO established a mutual definition of interoperability They posited it as the “ability of users to equally interpret understand unstructured or structured information which is shared exchanged between them in electronic form ”41 Shortly after both departments identified and adopted six areas of interoperability capabilities intended to meet the requirements and deadline established by Congress   Expand Essentris implementation across DOD Demonstrate the operation of the Partnership Gateways in support of joint DOD and VA health information sharing 42   Enhance sharing of DOD-captured social history with VA Demonstrate an initial capability for DOD to scan medical documents into the DOD EHR and forward those documents electronically to VA Provide all servicemembers’ health assessment data stored in the DOD EHR to the VA in such a fashion that questions are associated with the responses   Provide initial capability to share with the VA electronic access to separation physical exam information captured in the DOD EHR 43 As a result of each department’s work on interoperable capabilities DOD and VA reported to Congress in 2010 that all requirements for “full” interoperability were met 44 The Integrated EHR Initiative DOD and VA continued to work on integrating their respective EHR systems through individual initiatives while considering a larger EHR modernization strategy Three strategy options were considered 1 develop a new joint EHR 2 upgrade and adopt an existing legacy system across both departments i e AHLTA or VistA 45 or Congress 2009 p 5 https health mil Reference-Center Reports 2010 04 20 DoD-VA-Interagency-Program-OfficeAnnual-Report 40 P L 110-181 §1635 c 41 Department of Defense Department of Veterans Affairs DOD VA Information Interoperability Plan September 2008 p 71 https health mil Reference-Center Reports 2008 09 15 DoD-VA-Information-Interoperability-Plan 42 Partnership Gateways were DOD-VA efforts to expand network bandwidth that support certain health information exchanges e g FHIE BHIE CHDR 43 DOD VA Interagency Program Office Annual Report to Congress 2009 pp 28-29 https www health mil Reference-Center Reports 2010 04 20 DoD-VA-Interagency-Program-Office-Annual-Report 44 Ibid 45 VistA is VA’s legacy EHR system Veterans Information Systems and Technology Architecture Congressional Research Service 9 MHS Genesis Background and Issues for Congress 3 pursue separate solutions that would have “common infrastructure with data interoperability ”46 In March 2011 the SECDEF and SECVA agreed to work cooperatively to develop an integrated electronic health record called the iEHR that would eventually replace each department’s legacy systems 47 The IPO was assigned the oversight role for the iEHR initiative which was then set to begin implementation no later than 2017 In February 2013 SECDEF and SECVA announced that they would no longer pursue the iEHR initiative In making this decision DOD and VA determined that the initial cost estimates for implementing the iEHR would be “significant ” given the “constrained Federal Budget environment ”48 After reevaluating their approach and considering alternatives both departments decided to pursue other ongoing efforts to “improve data interoperability” and to preserve and develop separate EHR systems with a core set of capabilities that would allow for integrated sharing of health care data between DOD VA and private sector providers 49 Congressional Mandate for an EHR After DOD and VA announced their change to the iEHR strategy in 2013 Congress expressed its sense that both departments had “failed to implement a solution that allows for seamless electronic sharing of medical health care data ”50 Given some Members’ apparent frustration Congress established a new deadline for both departments to deploy a new EHR solution Section 713 b of the NDAA for FY2014 P L 113-66 directed DOD and VA to implement an interoperable EHR with an “integrated display of data or a single electronic health record” by December 31 2016 see text box below National Defense Authorization Act for Fiscal Year 2014 P L 113-66 Section 713 b The Secretary of Defense and the Secretary of Veterans Affairs – 1 shall each ensure that the electronic health record system of the Department of Defense and the Department of Veterans Affairs are interoperable with an integrated display of data or a single electronic health record by complying with the national standards and architectural requirements identified by the Interagency Program Office of the Departments … in collaboration with the Office of the National Coordinator for Health Information Technology of the Department of Health and Human Services and 2 shall each deploy modernized electronic health record software supporting clinicians of the Departments by no later than December 31 2016 while ensuring continued support and compatibility with the interoperability platform and full standards-based interoperability 46 U S Government Accountability Office Electronic Health Records VA and DOD Need to Support Cost and Schedule Claims Develop Interoperability Plans and Improve Collaboration GAO-14-302 February 2014 pp 14-15 https www gao gov assets 670 661208 pdf 47 Lauren C Thompson and Yvonne Cole Achieving Seamless Care Through Health Data Interoperability DOD VA Interagency Program Office January 2019 p 5 https www healthit gov sites default files 201901 DoDVAIPOUpdate pdf 48 U S Congress House Committee on Veterans' Affairs Electronic Health Record U-Turn Are VA and DOD Headed in the Wrong Direction 113th Cong 1st sess February 27 2013 49 Department of Defense Remarks by Secretary Panetta and Secretary Shinseki from the Department of Veterans Affairs press conference February 5 2013 https archive defense gov transcripts transcript aspx transcriptid 5187 50 P L 113-66 §713 a Congressional Research Service 10 MHS Genesis Background and Issues for Congress The law also required DOD and VA to “jointly establish an executive committee” to support development of systems requirements integration standards and programmatic assessments to ensure compliance with Congress’s direction outlined in Section 713 b 51 MHS Genesis Given Congress’s new mandate for both departments to implement an interoperable EHR DOD conducted a 30-day review of the iEHR program in order to “determine the best approach” to meeting the law 52 While conducting its review DOD identified two EHR modernization options that would support healthcare data interoperability with the VA 1 adopt VistA and 2 acquire a commercial EHR system 53 DOD Acquisition Strategy On May 21 2013 the Secretary of Defense issued a memorandum directing the department’s pursuit of “a full and open competition for a core set of capabilities for EHR modernization ”54 The directive also delegated certain EHR responsibilities to various DOD leaders    Under Secretary of Defense for Acquisition Technology and Logistics USD AT L whose office was later reorganized as the Under Secretary of Defense for Acquisition and Sustainment USD A S 55 Responsible for exercising milestone decision authority MDA and also holds technical and acquisition responsibilities for health records interoperability and related modernization programs 56 Under Secretary of Defense for Personnel and Readiness USD P R Lead coordinator on DOD health care interactions with the VA Assistant Secretary of Defense for Health Affairs ASD HA Responsible for functional capabilities of the EHR Given the significant investments required to modernize DOD’s EHR MHS Genesis is a designated Defense Business System DBS 57 Because it is a DBS certain decision reviews and 51 Ibid §713 h Secretary of Defense Memorandum “Integrated Electronic Health Records ” OSD005932-13 May 21 2013 https health mil Reference-Center Policies 2013 05 21 Memorandum-on-the-Integrated-Electronic-Health-Record 53 U S Congress House Committee on Veterans' Affairs Electronic Health Record U-Turn Are VA and DOD Headed in the Wrong Direction 113th Cong 1st sess February 27 2013 54 Secretary of Defense Memorandum “Integrated Electronic Health Records ” OSD005932-13 May 21 2013 https health mil Reference-Center Policies 2013 05 21 Memorandum-on-the-Integrated-Electronic-Health-Record 55 In 2018 DOD disestablished the role of the Under Secretary of Defense for Acquisition Technology and Logistics and reassigned responsibilities to other senior defense officials Responsibilities and milestone decision authority were reassigned to the newly created Under Secretary of Defense for Acquisition and Sustainment USD A S 56 10 U S C §2366a defines milestone decision authority as a DOD official with “overall responsibility and authority for acquisition decisions for the program or subprogram including authority to approve entry of the program or subprogram into the next phase of the acquisition process ” 57 10 U S C §2222 defines Defense Business System as an information system that is “operated by for or on behalf of the Department of Defense ” and “expected to have a total amount of budget authority over the period of the current future-years defense program submitted to Congress under section 221 of Title 10 U S Code in excess of $50 000 000 ” For more information see Department of Defense Instruction 5000 75 “Business Systems Requirements and Acquisition ” August 31 2018 https www esd whs mil Portals 54 Documents DD issuances dodi 500075 pdf ver 2018-11-14-081055-240 52 Congressional Research Service 11 MHS Genesis Background and Issues for Congress milestones are required as part of the overall acquisition process DBS programs are subject to significant departmental and congressional oversight activities Requirements Development and Solicitation From June 2013 to June 2014 USD AT L directed the Defense Healthcare Management Systems Modernization Program Management Office DHMSM PMO to oversee the EHR requirements development process draft an acquisition strategy and request for proposal RFP and conduct activities required by DOD policy for DBS acquisitions The ASD HA directed the Defense Health Agency DHA to establish various working groups to identify and develop the clinical and nonclinical functional requirements for the new EHR The DHA led each working group which included representatives from each military service medical department Keeping in alignment with DOD’s guiding principles for EHR modernization see Figure 2 the working groups identified approximately 60 overarching capabilities to be required of a new EHR An initial draft RFP incorporated functional capability requirements with certain technical requirements for interoperability information security and suitability with DOD infrastructure Figure 2 DOD’s Guiding Principles for EHR Modernization Source Department of Defense “EHR Guiding Principles ” accessed May 2019 https health mil MilitaryHealth-Topics Technology Military-Electronic-Health-Record EHR-Modernization-Interoperability EHR-GuidingPrinciples The DHMSM PMO published three draft RFPs between January and June 2014 for interested contractors to review provide comments and submit questions for clarification on functional requirements Additionally the DHMSM PMO hosted four industry days that allowed interested contractors to “enhance their understanding of the DHMSM requirement ” gain insight on DOD’s Congressional Research Service 12 MHS Genesis Background and Issues for Congress requirements development process and provide feedback on particular aspects of the draft RFP 58 These activities also allowed the DHMSM PMO to conduct market research that would inform further revision of MHS Genesis functional requirements or its overall acquisition strategy Between June 2014 and August 2014 DOD leaders certified that certain acquisition milestones had been achieved allowing DOD to proceed with the solicitation process including finalizing and approving all user-validated function requirements approving the overall acquisition strategy and issuing an authority to proceed 59 On August 25 2014 DOD issued its official solicitation for proposals 60 The solicitation period concluded on October 9 2014 Source Selection Process The source selection process took place from October 2014 to July 2015 DOD reportedly had received five proposals during the solicitation period 61 Most of the proposals were from partnered vendors consisting of health information management electronic medical records information technology and program management organizations These partnerships included      Allscripts Computer Sciences Corporation and Hewlett-Packard IBM and Epic Systems Cerner Leidos and Accenture Federal PricewaterhouseCoopers General Dynamics DSS Inc MedSphere and InterSystems 62 Consistent with DOD source selection procedures DOD experts were assigned to review and apply the evaluation criteria published in the RFP to each proposal 63 Figure 3 illustrates a general overview of the evaluation and source selection process 58 U S Congress Senate Committee on Armed Services Subcommittee on Readiness and Management Support Department of Defense Authorization of Appropriations for Fiscal Year 2015 and the Future Years Defense Program Hearing Transcript 113th Cong 2nd sess February 26 2014 p 53 https www armedservices senate gov imo media doc readiness_defense_information_technology_02-26-14 pdf 59 Authority to Proceed is a decision point made by a milestone decision authority or their delegate to move to the next phase in the DOD acquisition process 60 Department of Defense Healthcare Management System Modernization DHMSM Program “Cover Letter for Request for Proposals ” Solicitation No N00039-14-R-0018 August 25 2014 61 See DoD Down-Selects Proposals for DHMSM EHR Project HIMSS News February 27 2015 https www himss org news dod-down-selects-proposals-dhmsm-ehr-project Frank R Konkel DOD's procurement team has established a competitive range for the contract leaving only bids from three teams remaining NextGov February 23 2015 https www nextgov com cio-briefing 2015 02 pentagon-narrows-down-battle-multibillion-dollarhealth-records-contract 105906 62 Ibid 63 DOD’s source selection procedures including general cost technical and past performance evaluation criteria are outlined in the Defense Federal Acquisition Regulation Supplement “Procedures Guidance and Information ” Subpart 215 3—Source Selection March 31 2016 https www acq osd mil dpap policy policyvault USA004370-14DPAP pdf Congressional Research Service 13 MHS Genesis Background and Issues for Congress Figure 3 Overview of the Source Selection Process for MHS Genesis Source PEO DHMS Presentation “DoD EHR Modernization Effort Acquisition Lessons Learned ” HIMSS 2016 Conference and Exhibition March 2 2016 p 17 https www himssconference org sites himssconference files pdf 162 pdf Notes Graphic adapted by CRS Service Provider Integrator means the vendor and their submitted proposal ONC Office of the National Coordinator for Health Information Technology Contract Award On July 29 2015 DOD awarded the MHS Genesis contract to Leidos Partnership for Defense Health LPDH to replace its legacy EHR systems with a commercial-off-the-shelf COTS EHR system 64 The contract has a potential 10-year ordering period that includes a two-year base period two three-year optional ordering periods and an award term period of up to two years 65 The initial total award ceiling for MHS Genesis was $4 3 billion 66 On June 15 2018 DOD approved a contract modification to increase the award ceiling by $1 2 billion 67 According to the Justification and Approval for Other than Full and Open Competition documentation the purpose of this increase was to “support the incorporation of the United States 64 Jim Garamone DoD Awards Contract for Electronic Health Records DOD News July 29 2015 https dod defense gov News Article Article 612714 65 DHMSM Program “Attachment 15 Award Term Plan ” Contract Award No N00039-15-D-0044 p 2 66 Defense Health Agency Justification and Approval for Other than Full and Open Competition J A No JA18-0052 June 15 2018 67 Ibid Congressional Research Service 14 MHS Genesis Background and Issues for Congress Coast Guard USCG into the DOD MHS Genesis Electronic Health Record EHR implementation” and “establish a common standardized EHR baseline with the USCG and the VA ”68 The current award ceiling for MHS Genesis is more than $5 5 billion Leidos Partnership for Defense Health LPDH Leidos leads LPDH with its core partners Accenture Federal Services Cerner and Henry Schein One The full partnership through sub-contracts of the core partners is comprised of over 34 businesses see Figure 4 69 Figure 4 Leidos Partnership for Defense Health Source LPDH “Our Partners ” accessed May 23 2019 http leidosdefensehealth com about-us meet-theteam our-partners Capabilities According to a redacted version of DOD’s contract award documents LPDH is required to meet the following overarching contract requirements   “unify and increase accessibility of integrated evidence-based healthcare delivery and decision making” “support the availability of longitudinal medical records for 9 6 million DoD beneficiaries and approximately 153 000 MHS personnel globally” 68 Ibid Leidos Partnership for Defense Health “Our Partners ” accessed May 21 2019 http leidosdefensehealth com about-us meet-the-team our-partners 69 Congressional Research Service 15 MHS Genesis Background and Issues for Congress   “enable the application of standardized workflows integrated healthcare delivery and data standards for improved and secure electronic exchange of medical and patient data between the DoD and its external partners including the VA and other Federal and private sector healthcare providers” and “leverage data exchange capabilities in alignment with the IPO for standardsbased health data interoperability and secure information sharing with external partners to include the VA ”70 Additionally there are over 95 specific capability requirements across four concepts of operations i e health service delivery health system support health readiness and force health protection that MHS Genesis must support see Appendix B 71 Governance Ultimately the Secretary of Defense is accountable for MHS Genesis Various DOD entities described below have assigned responsibilities for MHS Genesis oversight implementation and sustainment see Figure 5 While each entity has a separate chain of command DOD chartered numerous governance groups to synchronize efforts across the department delegate certain decisionmaking authorities and provide direction on implementation and use of MHS Genesis 70 Redacted contract award documents for MHS Genesis are publicly accessible at https go usa gov xpCGM DHMSM Program “Attachment 1 IDIQ PWS ” Contract Award No N00039-15-D-0044 p 2 71 DHMSM “Attachment 8 Health Service Delivery Concept of Operations CONOPS ” Contract Award No N00039-15-D-0044 p 3 DHMSM “Attachment 9 Health System Support Concept of Operations CONOPS ” Contract Award No N00039-15-D-0044 p 2 DHMSM “Attachment 10 Health Readiness Concept of Operations CONOPS ” Contract Award No N00039-15-D-0044 pp i-ii DHMSM “Attachment 11 Force Health Protection Concept of Operations CONOPS ” Contract Award No N00039-15-D-0044 p 2 Congressional Research Service 16 MHS Genesis Background and Issues for Congress Figure 5 DOD Governance for MHS Genesis Source CRS graphic based on Email communication with DOD officials January 2019 and DHMS “Fiscal Year 2018 Annual Report ” p 8 https health mil Reference-Center Reports 2019 02 22 Defense-HealthcareManagement-Systems-Fiscal-Year-2018-Annual-Report Notes USD Under Secretary of Defense ASD Assistant Secretary of Defense PEO DHMS Program Executive Office for the Defense Healthcare Management Systems JOMIS PMO Joint Operational Medical Information Systems Program Management Office IPO Interagency Program Office DHMSM PMO Defense Healthcare Management Systems Modernization Program Management Office Program Executive Office Defense Healthcare Management Systems PEO DHMS PEO DHMS was established in 2013 72 Its mission is to “transform the delivery of healthcare and advance data sharing through a modernized electronic health record for service members veterans and their families ”73 It responsible for implementing MHS Genesis as the assigned acquisition authority and currently reports to the Under Secretary of Defense for Acquisition and Sustainment USD A S 74 Under the PEO DHMS three program management offices PMOs are tasked with modernizing DOD’s EHR system and ensuring health data interoperability with the VA 72 Testimony of Program Executive Officer Defense Healthcare Management Systems Christopher A Miller in U S Congress Senate Committee on Appropriations Subcommittee on Defense Defense Health Programs hearings 113th Cong 2nd sess April 9 2014 https www appropriations senate gov imo media doc hearings Miller%20testimony pdf 73 DHMS “Fiscal Year 2018 Annual Report ” p 6 https health mil Reference-Center Reports 2019 02 22 DefenseHealthcare-Management-Systems-Fiscal-Year-2018-Annual-Report 74 In 2018 USD AT L was disestablished and its functions were reassigned to the USD A S and the Under Secretary of Defense for Research and Engineering Congressional Research Service 17 MHS Genesis Background and Issues for Congress  DOD Healthcare Management System Modernization DHMSM PMO “Oversees the deployment of MHS Genesis and the operations and sustain of the Joint Legacy Viewer ”  DOD VA Interagency Program Office IPO “Oversees the efforts of the DOD and VA to implement national health data standards for interoperability ” Joint Operational Medicine Information Systems JOMIS PMO “Develops deploys and sustains MHS Genesis and other integrated operational medicine information systems to deployed forces ”75  Defense Health Agency DHA In 2013 the Secretary of Defense established the DHA to manage the TRICARE program execute appropriations for the Defense Health Program coordinate management of certain multiservice health care markets and MTFs in the National Capital Region exercise management responsibility for shared services functions and activities within the Military Health System and support DOD’s medical mission 76 DHA is a designated Combat Support Agency77 that is scheduled to soon administer and manage all MTFs 78 DHA serves as the lead entity for MHS Genesis requirements development in coordination with the military service medical departments and currently reports to the ASD HA 79 Military Service Medical Departments The military service medical departments are established under each respective military department to organize train and equip military medical personnel maintain medical readiness of the Armed Forces and administer manage and provide health care in MTFs The medical departments are led by a Surgeon General who also functions as the principal advisor to their respective military service secretary and service chief for all health and medical matters 80 The three service medical departments are the Army Medical Command MEDCOM the Navy Bureau of Medicine and Surgery BUMED and the Air Force Medical Service AFMS Each service medical department provides subject-matter expertise functional support and consultation to the DHMSM PMO 81 75 Ibid p 12 Department of Defense Instruction 5136 13 “Defense Health Agency DHA ” September 30 2013 https www esd whs mil Portals 54 Documents DD issuances dodd 513613p pdf 77 A Combat Support Agency is designated either in 10 U S C §193 or by the Secretary of Defense to “fulfill combat support functions for joint operating forces across the range of military operations and in support of Combatant Commanders CCDRs executing military operations ” Department of Defense Instruction 3000 06 “Combat Support Agencies CSAs ” July 8 2016 https www esd whs mil Portals 54 Documents DD issuances dodd 300006p pdf 78 Section 702 of the National Defense Authorization Act NDAA for Fiscal Year 2017 P L 114-328 directed DOD to transfer the administration and management of MTFs from the military services to the DHA Section 703 requires the transfer of MTFs to the DHA no later than September 31 2021 79 For more on the DHA see Question “1 How is the Military Health System Structured ” of CRS Report R45399 Military Medical Care Frequently Asked Questions by Bryce H P Mendez 80 Service Surgeons General are typically general or flag officers in the grade of Lieutenant General Vice Admiral Statutory duties assigned to the Surgeons General are described in 10 U S C §§3036 5136 8036 81 For more on the Military Service Medical Departments see Question “1 How is the Military Health System Structured ” of CRS Report R45399 Military Medical Care Frequently Asked Questions by Bryce H P Mendez 76 Congressional Research Service 18 MHS Genesis Background and Issues for Congress Senior Stakeholders Group SSG and the Configuration Steering Board CSB The SSG and the CSB are DOD-chartered working groups established to provide oversight recommendations and “direction on health-related acquisition programs ” including those within PEO DHMS 82 The SSG is chaired by the USD A S and is responsible for receiving updates on DHMS acquisition programs ensuring adherence to DOD’s EHR guiding principles and providing recommendations and feedback on key EHR and interoperability decisions The CSB is co-chaired by the USD A S and the USD P R and is specifically responsible for oversight on DHMSM and JOMIS programs Figure 6 outlines the membership of each group Figure 6 Senior Oversight Working Groups for MHS Genesis Source DOD “Department of Defense Electronic Health Record Senior Stakeholders Group and Defense Healthcare Management Systems Configuration Steering Board Charter ” April 8 2018 Executive Steering Board ESB The ESB previously named the Functional Champion Leadership Group FLCG is a governance body led by the DHA’s Chief Health Informatics Officer with representation from each service medical department 83 The ESB’s role is to    consider changes to standardized clinical business or technical processes serve as a forum to validate prioritize and recommend modifications or new functional requirements for MHS Genesis and oversee numerous working groups of subject matter experts and end-users 84 Department of Defense “Department of Defense Electronic Health Record Senior Stakeholders Group and Defense Healthcare Management Systems Configuration Steering Board Charter ” April 8 2018 83 The ESB membership is primarily military officers in at least the rank of O-7 or members of the senior executive service 84 Defense Health Agency presentation at the HIMSS 2016 Conference “Military Health System Functional Champions Enabling Transformation ” March 1 2016 82 Congressional Research Service 19 MHS Genesis Background and Issues for Congress Office of the Chief Health Informatics Officer OCHIO The OCHIO represents the “voice of the customer” to PEO DHMS 85 The office solicits input and recommendations from the ESB and coordinates with PEO DHMS to revise or modify MHS Genesis contract requirements OCHIO is also responsible for “change management early adoption activities standardization of functional workflows functional collaboration with the VA management of configuration changes to MHS Genesis adjudication of functional trouble tickets sustainment training current state workflow assessments and coordination of DHA policy to support the use of MHS Genesis ”86 Deployment DOD is using a phased implementation strategy to deploy MHS Genesis Deployment began with its initial operational capability IOC sites in 2017 After the IOC sites MHS Genesis is to be deployed at over 600 medical and dental facilities grouped geographically into 23 waves see Appendix F 87 DOD anticipates “full operational capability” and implementation of MHS Genesis at all MTFs by the end of 2024 88 Pre-Deployment Activities During the approximately 17 months between the July 2015 contract award date and Congress’s December 2016 deadline to implement a new EHR system DOD conducted certain predeployment activities e g systems engineering systems integration and testing prior to deploying MHS Genesis DOD acquisition policies and certain contract requirements mandate these activities Some of the initial requirements include   contractor site visits to “analyze operations infrastructure and detailed information for EHR System design and testing” gap analyses between existing site infrastructure system requirements and the contractor’s system architecture    development of solutions to fill identified infrastructure gaps testing interoperability with legacy systems delivering various contractor plans to the government e g integrated master plan risk management plan data management plan disaster recovery plan and cybersecurity vulnerability management plan  EHR system testing in government approved labs including those conducted by the contractor government independent testing and evaluation teams and operational test agencies and https www himssconference org sites himssconference files pdf 42 pdf 85 Email communication with DOD officials January 2019 86 Ibid 87 Testimony of Principal Deputy Assistant Secretary of Defense Stacy A Cummings in U S Congress House Committee on Appropriations Subcommittee on Defense Defense Health Programs hearings 116th Cong 1st sess April 3 2019 H Hrg 116-AP02 https www appropriations senate gov download 040319_-cummings-testimony 88 Ibid DOD plans to begin MHS Genesis deployment at wave 23 sites by the end of 2023 and conclude post go-live activities in 2024 Congressional Research Service 20 MHS Genesis Background and Issues for Congress  receiving authorization to proceed ATP with limited fielding at the IOC sites and to conduct an Initial Operational Test and Evaluation IOT E 89 Concurrently the DOD Inspector General DODIG conducted a performance audit on the DHMSM PMO The purpose of the audit was to determine if DOD had approved system requirements and if the MHS Genesis acquisition strategy was “properly approved and documented ”90 The audit was conducted from June 2015 through January 2016 with a final report issued on May 31 2016 Overall the DODIG found that the MHS Genesis requirements and acquisition strategy were properly approved and documented However the report raised concerns about the program’s execution schedule i e implementation timeline not being “realistic” to meet Congress’s deadline 91 The DODIG recommended that the PEO DHMS conduct a “schedule analysis” to determine if IOC would be achievable by December 2016 and to continue monitoring program risks and report progress to Congress quarterly 92 In response to the DODIG’s recommendation the PEO DHMS asserted “we remain confident we will achieve IOC later this year in accordance with the NDAA ”93 Initial Deployment As part of the implementation strategy DOD selected MTFs in the Pacific Northwest as its IOC sites see Table 2 On February 9 2017 MTFs at Fairchild Air Force Base Washington were the first sites to transition to MHS Genesis Table 2 Initial Operational Capability Sites Pacific Northwest Multi-Service Market Medical Facility Location Go-Live Date 92nd Medical Group Fairchild Air Force Base WA February 9 2017 92nd Aeromedical-Dental Squadron Fairchild Air Force Base WA February 9 2017 Naval Health Clinic Oak Harbor Oak Harbor WA July 21 2017 Naval Hospital Bremerton Bremerton WA September 22 2017 Naval Branch Health Clinic Bangor Silverdale WA September 22 2017 Naval Health Clinic Everett Everett WA September 22 2017 Requirements listed in Task Order 0001 are from DOD’s request for proposals Finalized Task Order 0001 incorporated into the awarded contract is publically available at https go usa gov xVuKE DOD’s initial predeployment activity requirements are described in its request for proposals documentation DHMSM Program “Attachment 17 Task Order 0001 ” Solicitation No N00039-15-D-0044 March 18 2015 90 Department of Defense Inspector General Audit of the DoD Healthcare Management System Modernization Program March 31 2016 p i https media defense gov 2019 Apr 09 2002111514 -1 -1 1 DODIG-2016-094 PDF 91 Ibid 92 Ibid The Program Executive Officer for the Defense Healthcare Management Systems PEO DHMS oversees the DHMSM PMO as the assigned acquisition authority for MHS Genesis PEO DHMS reports to the USD A S and also oversees the IPO and the Joint Operational Medicine Information Systems Program Management Office For more on PEO DHMS see Department of Defense Fact Sheet PEO DHMS accessed June 30 2019 https health mil Reference-Center Fact-Sheets 2019 01 23 PEO-DHMS-Fact-Sheet 93 Ibid p 22 Congress has also required DOD to provide quarterly reports on the status of MHS Genesis implementation Since 2017 the reporting requirement has been included in each explanatory statement accompanying the annual defense appropriations act For example see “Explanatory Statement Submitted by Mr Frelinghuysen of New Jersey Chairman of the House Committee on Appropriations Regarding the House Amendment to the Senate Amendment on H R 244 ” Congressional Record vol 163 May 3 2017 p H3641 89 Congressional Research Service 21 MHS Genesis Background and Issues for Congress Medical Facility Madigan Army Medical Center Location Joint Base Lewis-McChord WA Go-Live Date October 21 2017 Source DHMSM “Attachment 12 Segment 1 MTF List and MTF Codes ” Contract Award No N00039-15-D0044 p 13 Madigan Army Medical Center presentation at the American College of Emergency Physicians’ Government Services Symposium March 2018 p 4 http www gsacep org aws GSACE asset_manager get_file 189215 ver 2 Note Go-Live Date is the day an MTF began using MHS Genesis in day-to-day operations The purpose of fielding MHS Genesis at the IOC sites before full deployment was to observe evaluate and document lessons-learned on whether the new EHR was usable interoperable secure and stable DOD used several evaluation methods to measure MHS Genesis success at the IOC sites including the Health Information Management Systems Society’s HIMSS Electronic Medical Record Adoption Models EMRAM and the DOD IOT E The results of these assessments would later inform PEO DHMS in its decision to proceed with further deployments EMRAM Findings The EMRAM includes two commercially developed assessment tools that health systems and facilities can use to measure adoption of an electronic medical record EMR system The general EMRAM is for inpatient facilities and O-EMRAM is for outpatient facilities Both tools consist of a self-administered survey which is then analyzed by HIMSS to produce an EMRAM score The score ranging from Stage 0 to Stage 7 describes the level of adoption and utilization of an EMR within a health care organization see Appendix C Generally Stage 0 indicates minimal or no EMR adoption in a health care facility or clinic whereas Stage 7 indicates complete EMR adoption including demonstrated data sharing capabilities and eliminated use of paper charts Prior to the go-live dates at the IOC sites and while using its legacy systems DOD’s average score was 1 59 for the EMRAM and 2 38 for the O-EMRAM 94 After all IOC sites transitioned to MHS Genesis DOD reassessed each IOC site and observed increased EMRAM scores see Figure 7 and Figure 8 MTFs at Fairchild Air Force Base received a score of 6 13 on the OEMRAM whereas all other IOC sites scored 5 04 95 In comparison to U S civilian hospitals the IOC sites scored higher than the national average for the EMRAM 2 00 and O-EMRAM 3 00 96 However media reports on EMRAM scoring trends at the end of 2017 note that 66 7% of U S hospitals participating in the EMRAM reached “either Stage 5 or Stage 6 ”97 For the OEMRAM most participating outpatient facilities remained at Stage 1 98 PEO DHMS presentation at the HIMSS 2019 Conference “MHS Genesis Transforming the Delivery of Healthcare ” February 12 2019 p 17 https 365 himss org sites himss365 files 365 handouts 552803344 handout43 pdf 95 Ibid 96 Ibid While the EMRAM and O-EMRAM are standardized surveys used by DOD and civilian health systems the HIMSS-calculated scores do not account for variances in a health care facility’s pre-adoption baseline status the EHR system adopted the time periods in which the surveys were conducted change management processes or external factors affecting implementation For example DOD’s average EMRAM scores may be inflated because of its historical use of legacy EHR systems whereas the national average may reflect lower scores due to a more challenging adoption process at civilian health care facilities transitioning from a paper-based health record to an EHR system 97 Elizabeth Snell Two-thirds of US Hospitals Achieved Upper HIMSS EMRAM Adoption EHR Intelligence April 18 2018 https ehrintelligence com news two-thirds-of-us-hospitals-achieved-upper-himss-emram-adoption 98 Ibid 94 Congressional Research Service 22 MHS Genesis Background and Issues for Congress Figure 7 EMRAM Scores Before and After Deployment Source PEO DHMS presentation at the HIMSS 2019 Conference “MHS Genesis Transforming the Delivery of Healthcare ” February 12 2019 p 17 https 365 himss org sites himss365 files 365 handouts 552803344 handout-43 pdf Notes Graphic adapted by CRS NHOH Naval Health Clinic Oak Harbor NHB Naval Hospital Bremerton MAMC Madigan Army Medical Center Figure 8 O-EMRAM Scores Before and After Deployment Source PEO DHMS presentation at the HIMSS 2019 Conference “MHS Genesis Transforming the Delivery of Healthcare ” February 12 2019 p 17 https 365 himss org sites himss365 files 365 handouts 552803344 handout-43 pdf Notes Graphic adapted by CRS NHOH Naval Health Clinic Oak Harbor NHB Naval Hospital Bremerton MAMC Madigan Army Medical Center Congressional Research Service 23 MHS Genesis Background and Issues for Congress IOT E Findings DOD policy requires DBS programs to undergo an IOT E to determine program or systems effectiveness and suitability 99 IOT E findings provide the USD A S and relevant acquisition or functional leadership with recommendations on whether a program generally those with total contract values exceeding certain thresholds should proceed with further implementation Between September 2017 and December 2017 the Joint Interoperability Test Command JITC conducted an IOT E at each IOC site with the exception of Madigan Army Medical Center MAMC 100 PEO DHMS postponed the MAMC IOT E to 2018 in order to resolve issues identified at the other IOC sites While at each site the JITC conducted initial cybersecurity testing evaluated interoperability data observed MTF staff performing day-to-day tasks using MHS Genesis and administered user surveys on performance and suitability The Director of Operational Test and Evaluation DOT E reviewed JITC’s IOT E findings and applied them to the following criteria    Does MHS Genesis provide the capabilities to manage and document healthrelated services Do MHS Genesis interfaces support or enable accomplishment of mission activities and tasks Does MHS Genesis usability training support and sustainment ensure continuous operations On April 30 2018 DOT E issued a partial IOT E report asserting that MHS Genesis was “neither operationally effective nor operationally suitable ”101 DOT E found that MHS Genesis is not operationally effective because it does not demonstrate enough workable functionality to manage and document patient care Users successfully performed only 56 percent of the 197 tasks used as Measures of Performance MHS Genesis is not operationally suitable because of poor system usability insufficient training and inadequate help desk support Survivability is undetermined because cybersecurity testing is ongoing 102 See Appendix D for IOT E summary results by measure of effectiveness and measure of performance evaluation Based on these preliminary findings DOT E recommended to the USD A S a delay in further deployment of MHS Genesis until a full IOT E was completed and the DHMSM PMO corrected “outstanding deficiencies ”103 Additional recommendations for the DHMSM PMO included   “Fix all Priority 1 and 2 incident reports with particular attention given to those that users identified as potential patient safety concerns and verify fixes through operational testing Improve training and system documentation for both users and Adoption Coaches DOD Instruction 5000 75 “Business Systems Requirements and Acquisition ” updated August 31 2018 https www esd whs mil Portals 54 Documents DD issuances dodi 500075 pdf ver 2018-11-14-081055-240 100 For more information on JITC see http jitc fhu disa mil index aspx 101 DOT E Memorandum “Military Health System MHS GENESIS Initial Operational Test and Evaluation IOT E Report ” April 30 2019 p 1 102 Ibid 103 Ibid 99 Congressional Research Service 24 MHS Genesis Background and Issues for Congress         Increase the number of Adoption Coaches and leave them on site until users are more comfortable with the new processes Complete cybersecurity operational testing and continue to fix known deficiencies Work with users to document reduce and standardize operational workarounds Improve interoperability focusing on interfaces identified as problematic during IOT E Monitor reliability and availability throughout the system lifecycle Work with the Defense Health Agency and DISA to isolate network communications problems and reduce latency Conduct operational testing at MAMC to evaluate untested functionality and corrective actions taken by the DHMSM PMO Conduct follow-on operational testing at the next fielding site to evaluate revised training and Go-Live process improvements ”104 On November 30 2018 DOT E issued a final IOT E report incorporating results from delayed testing at MAMC DOD has not made the final report publicly available DOT E acknowledges ongoing improvements but maintains that MHS Genesis is “not yet effective or operationally suitable ”105 A summary of the IOT E released by the department describes several ongoing issue themes previously identified and described in the partial IOT E report e g continued incident reports staff training change management and workflow adoption 106 With regard to cybersecurity DOT E described MHS Genesis as “not survivable in a cyber-contested environment ”107 In conjunction with the IOT E DOD “successfully executed” three cyberspace test attacks against MHS Genesis highlighting potential security gaps and vulnerabilities with the new EHR system 108 Notwithstanding DOT E’s findings and recommendations the DOD Chief Information Officer issued a conditional Authorization to Operate valid for 12 months 109 Additionally PEO DHMS concurred with DOT E’s recommendation for a follow-on operational test and evaluation “at the next fielding to evaluate corrective actions and revised training to inform future fielding decisions ”110 104 Ibid Department of Defense DOT E FY 2018 Annual Report December 2018 p 21 https www dote osd mil pub reports FY2018 pdf other 2018DOTEAnnualReport pdf 106 PEO DHMS “Executive Summary MHS Genesis – Initial Operational Test Evaluation Report at Madigan Army Medical Center ” January 2019 107 Department of Defense DOT E FY 2018 Annual Report December 2018 p 21 https www dote osd mil pub reports FY2018 pdf other 2018DOTEAnnualReport pdf 108 Ibid DOD defines cyberspace attack as “actions taken in cyberspace that create noticeable denial effects i e degradation disruption or destruction …or manipulation that leads to denial that appears in a physical domain and is considered a form of fires ” Department of Defense Joint Publication 3-12 “Cyberspace Operations ” p GL-4 June 8 2018 https www jcs mil Portals 36 Documents Doctrine pubs jp3_12 pdf ver 2018-07-16-134954-150 109 An Authorization to Operate ATO is a certification issued by a designated DOD official that indicates a certain information system has adequately implemented all assigned information assurance controls to the point where residual risk is acceptable DOD CIO issued an ATO for MHS Genesis on November 29 2018 For more on ATOs see Department of Defense Instruction 8510 01 “DoD Information Assurance Certification and Accreditation Process DIACAP ” July 28 2017 https www esd whs mil Portals 54 Documents DD issuances dodi 851001_2014 pdf 110 Ibid 105 Congressional Research Service 25 MHS Genesis Background and Issues for Congress Selected Initial Deployment Issues Since February 2017 DOD has documented numerous issues requiring mitigation strategies prior to deploying the first wave Selected issues reported by various DOD entities LPDH MHS Genesis users and media outlets are summarized below Trouble Ticket Backlog During the initial deployment DHMSM PMO established a single process for all IOC sites to identify document and report MHS Genesis issues Users encountering system inconsistencies technical errors or clinical inaccuracies must submit a “trouble ticket” to a global service center GSC Users can also submit recommendations for changes to current workflows or system configurations to the GSC as well as through their chain of command The GSC is a contracted service that reviews sorts and assigns technical trouble tickets to LDPH or its sub-contractors for resolution The GSC also assigns trouble tickets relating to functional capabilities requirements or workflows to DHMSM PMO or DHA for further review and adjudication 111 In April 2018 PEO DHMS reported that 1 000 of approximately 7 000 total trouble tickets generated by users throughout all IOC sites from January 2018 to that point had been resolved 112 Of the remaining trouble tickets DHMSM PMO approved 2 000 for “work by the Leidos Partnership ” while 2 500 were in review for further adjudication CRS is unable to ascertain the status of the remaining 1 500 trouble tickets and the timeline in which they may have been resolved In December 2018 PEO DHMS estimated that 3 607 open trouble tickets remained for resolution 113 As of October 14 2019 PEO DHMS estimated 3 238 open trouble tickets from the IOC sites and 787 open trouble tickets from the first wave sites remained for resolution 114 Lengthy Issue Resolution Process MHS Genesis users at IOC sites described the issue resolution process as lengthy and lacking transparency 115 User concerns included 1 tickets submitted to the GSC were resolved in a period of time that was “not acceptable for all issues” 2 the length of time for decisionmakers to determine a solution and 3 discovering that a solution had been implemented during a periodic system update rather than being notified by DHMSM PMO DHA or LPDH 116 Unlike DOD’s legacy systems MHS Genesis is to be a standardized EHR platform across all military treatment facilities and is not customizable for each site Technical or functional changes to MHS Genesis require DHA-led working groups and DHMSM PMO to review and approve such changes before directing LPDH to implement a solution Changes exceeding the scope of the 111 Email communication with DOD officials January 2019 U S Congress Senate Committee on Appropriations Subcommittee on Department of Defense Review of the FY2019 Budget Request for the Defense Health Program 115th Cong 2nd sess April 26 2018 113 PEO DHMS Information Paper “MHS Genesis Issue Resolution Process ” January 3 2019 114 Email communication with DOD officials October 2019 115 CRS focus groups conducted at Madigan Army Medical Center Naval Hospital Bremerton and Puyallup Community Medical Home July 8-14 2018 Madigan Army Medical Center “Madigan MHS Genesis Program Transition Implementation After-Action-Review AAR ” May 8 2018 Naval Hospital Bremerton “MHS Genesis Implementation After Action Report ” April 12 2018 For more on CRS focus groups see Appendix E 116 Ibid 112 Congressional Research Service 26 MHS Genesis Background and Issues for Congress MHS Genesis contract require additional review resourcing and approval by the acquisition authority 117 Inadequate Staff Training Users reported that initial training provided four months prior to go-live was inadequate and did not allow super users to “absorb fully grasp one role before being introduced to the next role ”118 Staff members were required to complete computer-based training followed by instructor-led courses Course curricula varied by user roles e g clinician clinical support administrative staff Users reported that the LPDH training focused primarily on navigating the various modules and features of MHS Genesis and did not include training on clinical or administrative workflows 119 For example primary care clinic nurses were trained on the applicable MHS Genesis modules that would likely be found in the primary care setting They said they were not trained on accessing other modules that would typically be used outside of the primary care setting as part of a patient assessment or development of a treatment plan Capability Gaps and Limitations Users reported having little or no ability to track military medical and dental readiness requirements in MHS Genesis 120 Pre-built reports to monitor certain health care quality and access metrics were available to MTF staff Users defaulted to developing local “home-grown” work-around tools in Microsoft Office products in order to meet specific DOD and military service requirements for tracking medical and dental readiness 121 For example certain dental data documented in MHS Genesis were not available for data-mining or viewing in legacy dental readiness reporting systems To compensate for this dental clinic staff at each IOC site transcribed or manually maintained dental readiness reports by reviewing dental data in both Dentrix MHS Genesis’ dental module and CDS the legacy dental system Future Deployments In reviewing the experience and challenges documented during MHS Genesis deployment at the IOC sites DOD noted that they “captured lessons learned collaborated with our stakeholders and optimized the system to enhance user adoption Specific areas of improvement include network optimization change management and training enhancements ”122 As such DOD commenced the first wave of MHS Genesis deployments in September 2019 The deployment began with four MTFs in California and Idaho 123 Each wave is to last 18 months and is to include 117 Ibid Naval Hospital Bremerton “MHS Genesis Implementation After Action Report ” April 12 2018 Super users are MTF staff members who receive additional training on MHS Genesis to serve as on-site peer-trainers 119 CRS focus groups conducted at Madigan Army Medical Center Naval Hospital Bremerton and Puyallup Community Medical Home July 8-14 2018 Madigan Army Medical Center “Madigan MHS Genesis Program Transition Implementation After-Action-Review AAR ” May 8 2018 Naval Hospital Bremerton “MHS Genesis Implementation After Action Report ” April 12 2018 For more on CRS focus groups see Appendix E 120 Ibid 121 Ibid For more on DOD medical and dental readiness requirements see Department of Defense Instruction 6025 19 “Individual Medical Readiness ” June 9 2014 https www esd whs mil Portals 54 Documents DD issuances dodi 602519p pdf 122 Email communication with DHMS officials September 2019 123 MHS Genesis Wave 1 sites include MTFs at Travis Air Force Base Naval Air Station Lemoore U S Army Garrison Presidio and Mountain Air Force Base PEO DHMS “Preparing for MHS Genesis ” The Scope Summer 118 Congressional Research Service 27 MHS Genesis Background and Issues for Congress three major phases pre-deployment planning with each MTF 3 months deployment activities 12 months and post go-live activities 3 months 124 As outlined in DOD’s deployment schedule see Appendix F a new wave is to begin every three months at designated MTFs through late 2022 with wave 23 scheduled to conclude in 2024 Issues for Congress Congressional Oversight Since mid-1980s Congress has kept abreast of DOD’s efforts to implement sustain or modernize its EHR systems 125 Previous congressional oversight activities have primarily focused on 1 understanding DOD’s EHR modernization strategy and how the strategy would integrate interoperability and improve coordination with the VA or 2 describing certain barriers that delayed previous modernization initiatives Currently 12 congressional committees may exercise oversight authority of the broader EHR modernization efforts taking place in DOD VA and USCG The committees include          House Appropriations Committee House Armed Services Committee House Committee on Oversight and Reform House Committee on Transportation and Infrastructure House Veterans Affairs Committee Senate Appropriations Committee Senate Armed Services Committee Senate Committee on Commerce Science and Transportation Senate Committee on Homeland Security and Governmental Affairs Given the complexity size and timeline of DOD’s EHR modernization effort as well as parallel efforts by the USCG and VA a coordinated oversight strategy may be necessary Such a strategy could allow Congress to conduct a wide range of oversight activities without creating redundancies for committee staff and executive branch officials and could facilitate informationsharing among congressional stakeholders Since the initial deployment of MHS Genesis there have been no congressional oversight hearings held solely on DOD’s EHR modernization effort On June 20 2018 the House Committee on Veterans’ Affairs established the Subcommittee on Technology Modernization 126 The role of the new subcommittee is to “focus on conducting oversight of the EHR 2019 https health mil About-MHS OASDHA Defense-Health-Agency Defense-Healthcare-Management-Systems 124 Deployment activities include but are not limited to staff training infrastructure and systems upgrades site testing and go-live Post go-live activities include but are not limited to site evaluation sustainment training on-site troubleshooting and after-action reports 125 U S Government Accountability Office Acquisition Strategy for DOD Hospital Computer System GAO IMTEC86-12 March 1986 p 1 https www gao gov assets 210 208368 pdf 126 House Committee on Veterans Affairs Chairman Roe Ranking Member Walz Announce EHR Oversight Hearing Create New Subcommittee to Focus on IT Projects press release June 20 2018 https veterans house gov news press-releases chairman-roe-ranking-member-walz-announce-ehr-oversight-hearingcreate-new Congressional Research Service 28 MHS Genesis Background and Issues for Congress Modernization program and other major technology projects at the Department of Veterans Affairs ”127 Both DOD and VA officials testified before the subcommittee at its June 2019 oversight hearing 128 Interagency Governance In September 2018 then-SECDEF James Mattis and current SECVA Robert Wilkie signed a joint statement see Appendix G that outlined each department’s commitment to “implementing a single seamlessly integrated EHR that will accurately and efficiently share health data … and ensure health record interoperability with our networks of supporting community healthcare providers ”129 On April 3 2019 DOD announced plans to re-charter the IPO into the “Federal Electronic Health Record Modernization FEHRM ” program office 130 The new office would serve as an interagency governance group that provides oversight on DOD and VA’s EHR modernization efforts and would have the “authority to direct each Department to execute joint decisions for technical programmatic and functional functions ”131 DOD stated that the FEHRM Director and Deputy Director will be appointed positions and will report to both the Deputy SECDEF and Deputy SECVA While Congress directed the creation of the IPO in 2008 neither DOD nor VA has indicated if additional authorities funding or changes to current law are required to sustain the FEHRM program office Congress may also examine the relationships between existing interagency governance groups e g Joint Executive Committee PEO DHMS VA EHR Modernization Office and the newly established FEHRM program office Limited Competition in Future Procurement Because MHS Genesis is being deployed across all MTFs and all USCG sites as well as VA sites transitioning to a Cerner-based EHR system observers have noted that this is the “largest EHR undertaking in the country ”132 Implementing a single EHR platform across three federal departments can produce certain economies of scale and standardization However the scale of these efforts can also result in future acquisition challenges particularly with conducting a full and open competition to procuring new requirements or with follow-on contracts to sustain each EHR 127 Ibid U S Congress House Committee on Veterans' Affairs Subcommittee on Technology Modernization Implementation of Electronic Health Record Systems at the Department of Veterans Affairs VA and the Department of Defense DoD 116th Cong 1st sess June 12 2019 129 Department of Defense and Department of Veterans Affairs “Electronic Health Record Modernization Joint Commitment ” September 26 2018 https www va gov opa publications docs EHRM-Joint-CommitmentStatement pdf 130 U S Congress House Committee on Appropriations Subcommittee on Defense Statement by Ms Stacy A Cummings Principal Deputy Assistant Secretary of Defense Office of the Assistant Secretary of Defense for Acquisition and Former Program Executive Officer for the Defense Healthcare Management Systems Fiscal Year 2020 Defense Health Program Budget Hearing 116th Cong 1st sess April 3 2019 p 8 https docs house gov meetings AP AP02 20190403 109223 HHRG-116-AP02-Wstate-CummingsS-20190403 pdf 131 U S Congress House Committee on Veterans' Affairs Subcommittee on Technology Modernization Statement by Dr Lauren Thompson Director of the Department of Defense Department of Veterans' Affairs Interagency Program Office Electronic Health Record Implementation Hearing 116th Cong 1st sess June 12 2019 p 4 https docs house gov meetings VR VR11 20190612 109593 HHRG-116-VR11-Wstate-ThompsonL-20190612 pdf 132 Jessica Davis Cerner reveals long list of VA EHR modernization partners Healthcare IT News October 4 2018 https www healthcareitnews com news cerner-reveals-long-list-va-ehr-modernization-partners 128 Congressional Research Service 29 MHS Genesis Background and Issues for Congress system Congress may seek to understand how DOD and VA exercised their statutory authorities provided through the Competition in Contracting Act of 1984 P L 98-369 to procure their EHR systems as well as the possible impact of limited competition in future procurement activities needed to sustain both MHS Genesis and the VA’s new EHR system 133 Generally all federal departments procuring property goods or services are required to employ an acquisition process that allows for full and open competition 134 This process permits all potential vendors to “submit sealed bids or competitive proposals on the procurement ”135 For MHS Genesis DOD’s initial acquisition process included full and open competition However the process was not employed for subsequent requirements that were discovered after the initial award to LPDH These additional requirements included upgrading DOD network infrastructure incorporating USCG-specific requirements and clinic sites and establishing common standards among DOD VA and USCG The estimated value of the additional requirements was over $1 2 billion 136 DOD exercised its statutory authority to award a sole source contract modification to LPDH citing that contracting with any other vendor would potentially “create significant redundancies inefficiencies and other issues ”137 DOD’s acquisition strategy anticipates “one or more competitive follow-on contracts to sustain the EHR solution for which the Government owns a perpetual license at the conclusion of the performance of the basic contract ”138 However Cerner declined DOD’s request to enter into negotiations regarding the rights of its intellectual property 139 If DOD does not retain certain intellectual property rights on MHS Genesis the Department may be limited in what EHR vendors it can consider when it becomes necessary to solicit for an MHS Genesis sustainment contract 133 The Competition in Contract Act of 1984 P L 98-369 10 U S C §3301 and 41 U S C §2304 direct federal departments to use full and open competition in their procurement activities outlines certain procedures to increase competition and reduce costs Full and open competition is achieved when all capable prospective contractors are permitted to submit bids or proposals in response to a proposed contract action 134 Ibid 135 41 U S C §107 136 Department of the Navy Justification for Other Than Full and Open Competition J A No 17861 January 28 2016 Defense Heath Agency Justification and Approval for Other Than Full and Open Competition J A No JA180052 June 15 2018 137 10 U S C §2304 c 1 authorizes DOD to waive full and open competition if the property or services are “available from only one responsible source … and no other type of property or services will satisfy the needs of the agency ” Defense Heath Agency Justification and Approval for Other Than Full and Open Competition J A No JA18-0052 June 15 2018 p 4-5 138 Defense Heath Agency Justification and Approval for Other Than Full and Open Competition J A No JA180052 June 15 2018 139 Ibid On May 24 2018 Cerner declined DOD’s request for “business reasons ” Cerner indicated that “their intellectual property is proprietary and the result of private expenditures and research and development the Government does not have rights to access or use this intellectual property or provide it to other entities for use ” Congressional Research Service 30 MHS Genesis Background and Issues for Congress Appendix A Acronyms Glossary of Acronyms AFMS Air Force Medical Service FHIE Federal Health Information Exchange AHLTA Armed Forces Health Longitudinal Technology Application FEHRM Federal Electronic Health Record Modernization ASD HA Assistant Secretary of Defense for Health Affairs GAO Government Accountability Office ASIMS Aeromedical Services Information Management Systems GSC Global Service Center BHIE Bidirectional Health Information Exchange HAIMS Health Artifact and Image Management System BUMED Navy Bureau of Medicine and Surgery HEC Health Executive Council CDS Corporate Dental System HIMSS Health Information Management Systems Society CHCS Composite Health Care System iEHR Integrated Electronic Health Record CHCS II Composite Health Care System II i e AHLTA IOC Initial Operational Capability CHDR Clinical Data Repository Health Data Repository IOT E Initial Operational Test and Evaluation COTS Commercial-Off-the-Shelf IPO Interagency Program Office CRS Congressional Research Service JEC Joint Executive Committee CSB Configuration Steering Board JITC Joint Interoperability Test Command DHA Defense Health Agency JLV Joint Legacy Viewer DHMSM PMO Defense Healthcare Management Systems Modernization Program Management Office JOMIS Joint Operational Medical Information System DOD Department of Defense LPDH Leidos Partnership for Defense Health DODIG Department of Defense Inspector General MAMC Madigan Army Medical Center DOT E Director Operational Test Evaluation MDA Milestone Decision Authority EHR Electronic Health Record MEDCOM U S Army Medical Command EMR Electronic Medical Record MEDPROS U S Army Medical Protection System EMRAM Electronic Medical Record Adoption Model MHS Military Health System ESB Executive Steering Committee MRRS Medical Readiness Reporting System FCLG Functional Champion Leadership Group MTF Military Treatment Facility Congressional Research Service 31 MHS Genesis Background and Issues for Congress NDAA National Defense Authorization Act SSG Senior Stakeholder Group NSTR Non-Service Treatment Record STR Service Treatment Record OCHIO Office of the Chief Health Informatics Officer TMIP-J Theater Medical Information ProgramJoint O-EMRAM Federal Health Information Exchange USCG U S Coast Guard OHTR Occupational Health Civilian Employee Treatment Record USD A S Under Secretary of Defense for Acquisition and Sustainment PEO DHMS Program Executive Officer for the Defense Healthcare Management Systems USD AT L Under Secretary of Defense for Acquisition Technology and Logistics SAIC Science Applications International Corporation USD P R Under Secretary of Defense for Personnel and Readiness SECDEF Secretary of Defense VA Department of Veterans Affairs SECVA Secretary of Veterans Affairs VistA Veterans Information Systems and Technology Architecture Congressional Research Service 32 MHS Genesis Background and Issues for Congress Appendix B MHS Genesis Functional Capability Requirements Table B-1 Summary of MHS Genesis Functional Capability Requirements Health Service Delivery  Quality Assurance  Risk Management  Inpatient Radiology and Laboratory Diagnostic Services  Pharmacy Services  Radiology Diagnostic Services  Therapeutic Radiology Services  Patient Safety  Quality Improvement   Physical Therapy Non-Emergency Medical Transportation   Sensory Rehabilitation-Hearing and Audio-Vestibular Care  Screening  Health Counseling Emergency Medical Services   Vision Care Primary Care  Community Health Education  Routine Ambulatory Specialty Care and Dental  Occupational Therapy   Immunization Amputee Care   Preventive Dentistry Services  Ambulatory Surgery Burn Care  Public Health Laboratory Services  Medical Management  Occupational Rehabilitation   Ambulatory Diagnostic Medical and Dental  Inpatient Nonsurgical Treatment Disability Counseling and Coaching  Transitional Services  Intensive Care  Medical Support to Disability Evaluation  Total Medical Force Medical Professionals  Medical Information Management  Medical Research and Development  Public Health Veterinary Services  Casualty Management  Support to Homeland Defense and Civil Operations  Operational Medical Logistic Support Health System Support    Health Services Contract Development and Management  Partnership Development Joint and Service Medical Education and Training  Medical Financial Management  Medical Logistics Create and Sustain the Healing Environment Health Readiness  Joint Human Performance Enhancement   Non-Clinical Preventive Medicine Health Surveillance  Global Patient Movement  Shared Situational Understanding and Awareness  Support to Security Stability Transition and Reconstruction Operations  Detainee Medical Care Healthy and Fit Force Health and Wellness Force Health Protection  Joint Medical Logistics and Infrastructure Support  Public Health Veterinary Services  Medical Command and Control  Detainee Medical Care  Human Performance Optimization   Non-Clinical Preventive Medicine Health Surveillance Health and Fit Force Health and Wellness  Casualty Management  Global Patient Movement  Support to Stability Operations  Shared Situational Understanding and Awareness  Support to Homeland Defense and Civil Operations Source DHMSM “Attachment 8 Health Service Delivery Concept of Operations CONOPS ” Contract Award No N00039-15-D-0044 p 3 DHMSM “Attachment 9 Health System Support Concept of Operations CONOPS ” Contract Award No N00039-15-D-0044 p 2 DHMSM “Attachment 10 Health Readiness Concept of Operations CONOPS ” Contract Award No N00039-15-D-0044 pp i-ii DHMSM “Attachment 11 Force Health Protection Concept of Operations CONOPS ” Contract Award No N00039-15-D-0044 p 2 Congressional Research Service 33 MHS Genesis Background and Issues for Congress Appendix C Stages of Electronic Medical Record Adoption and Utilization Figure C-1 Stages of Electronic Medical Record EMR Adoption Health Information Management Systems Society Source HIMSS Analytics “EMRAM Information Sheet ” accessed June 4 2019 http www himssanalytics org sites himssanalytics files North_America_EMRAM_Information_2018 pdf Notes EMR Electronic Medical Record HIE Health Information Exchange CDS Clinical Decision Support CPOE Computerized Practitioner Order Entry eMAR Electronic Medication Administration PACS Picture Archiving and Communication System DICOM Digital Imaging and Communications in Medicine Congressional Research Service 34 MHS Genesis Background and Issues for Congress Appendix D IOT E Summary Results Figure D-1 IOT E Measures of Effectiveness and Measures of Performance Source DOT E Memorandum “Military Health System MHS GENESIS Initial Operational Test and Evaluation IOT E Report ” April 30 2019 Congressional Research Service 35 MHS Genesis Background and Issues for Congress Appendix E Methodology for CRS Focus Groups on MHS Genesis Background On July 8-13 2018 analysts from the Congressional Research Service CRS participated in a congressional staff delegation visit to various DOD facilities in the Puget Sound area of Washington State DOD facilities visited were Madigan Army Medical Center Naval Hospital Bremerton and the Puyallup Community Medical Home The purpose of the visit was to   review milestones achievements and challenges associated with the implementation of MHS Genesis and understand implementation and continuous improvement processes utilized at initial operational capability sites Methodology At each site CRS conducted numerous focus groups comprised of various MTF staff members Each focus group was comprised of 5–15 staff members selected by the MTF commander or his her designee Madigan Army Medical Center    Focus Group #1 Patient Administration Division Managed Care and Scheduling and Patient Satisfaction Department representatives Focus Group #2 Health care providers e g physicians dentists psychologists physicians assistants Focus Group #3 Nurses Naval Hospital Bremerton     Focus Group #1 Nurses Focus Group #2 Health care providers e g physicians dentists psychologists physicians assistants Focus Group #3 Enlisted personnel Focus Group #4 Patient Administration Referral Management and Patient Relations representatives Puyallup Community Medical Home  Focus Group #1 Health care providers nurses health care administrators enlisted personnel Prior to each site visit CRS provided each MTF with questions for discussion during each focus group CRS documented the themes and responses to each of the following questions    What challenges have you experienced with implementing MHS Genesis How have you locally mitigated these issues Are the mitigation processes in place working Congressional Research Service 36 MHS Genesis Background and Issues for Congress  Have these challenges impacted force readiness access to care quality of care cost of care or patient experience Congressional Research Service 37 MHS Genesis Background and Issues for Congress Appendix F MHS Genesis Deployment Schedule Figure F-1 MHS Genesis Deployment Schedule FY2018-FY2024 Source Defense Healthcare Management Systems May 2019 Notes Not all MTFs are listed within a wave Congressional Research Service 38 MHS Genesis Background and Issues for Congress Appendix G DOD and VA EHR Joint Commitment Statement Figure G-1 DOD and VA EHR Joint Commitment Statement Source Department of Defense and Department of Veterans Affairs “Electronic Health Record Modernization Joint Commitment ” September 26 2018 https www va gov opa publications docs EHRM-Joint-CommitmentStatement pdf Congressional Research Service 39 MHS Genesis Background and Issues for Congress Author Information Bryce H P Mendez Analyst in Defense Health Care Policy Disclaimer This document was prepared by the Congressional Research Service CRS CRS serves as nonpartisan shared staff to congressional committees and Members of Congress It operates solely at the behest of and under the direction of Congress Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has been provided by CRS to Members of Congress in connection with CRS’s institutional role CRS Reports as a work of the United States Government are not subject to copyright protection in the United States Any CRS Report may be reproduced and distributed in its entirety without permission from CRS However as a CRS Report may include copyrighted images or material from a third party you may need to obtain the permission of the copyright holder if you wish to copy or otherwise use copyrighted material Congressional Research Service R45987 · VERSION 2 · NEW 40