Electronic Health Records: DOD Has Made Progress in Implementing a New System, but Challenges Persist

GAO-21-571 Published: Sep 20, 2021. Publicly Released: Sep 20, 2021.
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Fast Facts

The Department of Defense relies on multiple electronic systems implemented over the last 30 years to maintain health records. It is seeking to replace them with a modern, comprehensive system.

DOD has begun the phased deployment of and made progress on its new electronic health record system, called MHS GENESIS. DOD also improved system performance after the initial rollout.

However, some defects DOD identified remain unresolved and DOD doesn't have plans for additional testing to address them. System users also reported that training and communication about system changes were ineffective. Our recommendations address these issues.

Military ID tags and stethoscope atop American flag

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Highlights

What GAO Found

The Department of Defense (DOD) made progress toward implementing its new electronic health record system, MHS GENESIS. DOD deployed the new system to sites in six of 24 planned deployment phases (i.e., waves), which included about 41,600 users (see figure). DOD also improved system performance and addressed issues experienced at the initial sites. Even with this progress, incidents identified during testing—such as system defects—remain unresolved. DOD has not developed plans to conduct additional testing at future sites to ensure the remaining incidents are fully resolved. As a result, unaddressed incidents could lead to challenges at future sites.

Actual and Planned MHS GENESIS Deployments, 2017-2023, as of June 2021

Actual and Planned MHS GENESIS Deployments, 2017-2023, as of June 2021

Additionally, implementation of MHS GENESIS faced training and communication challenges. Test results and selected system users indicated that training for MHS GENESIS and the dissemination of system change information were ineffective. For example, the users stated that training was not consistent with the “live” system. Further, users reported that there were too many system changes to keep up with and that they were not adequately informed as changes were implemented. As a result, users were unaware of important changes to their roles or business processes, or to system revisions and improvements. These challenges could hinder users' ability to effectively use the system, impede their knowledge of new workflows, and limit the utility of system improvements. Regarding key program risks, DOD identified and was tracking risks and their associated mitigation plans.

Why GAO Did This Study

DOD relies on multiple legacy electronic health record systems to create, maintain, and manage patient health information. DOD has determined that these systems, implemented over the past 3 decades, require modernization and replacement. The department has sought to replace these legacy systems with a comprehensive, real-time electronic health record.

The conference report accompanying the Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019 included a provision for GAO to review DOD's electronic health record deployment. GAO's objectives were to (1) determine what progress DOD has made toward implementing a new electronic health record system, and (2) identify the challenges and key risks to MHS GENESIS implementation and what steps DOD is taking to address them.

To do so, GAO analyzed test reports, briefing materials, and incident report tracking documents. GAO also held discussion groups with 356 users at selected sites and interviewed relevant officials.

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Recommendations

GAO is making three recommendations, including that DOD develop an approach to retesting incidents, improve training, and develop a plan to ensure MHS GENESIS users are aware of system changes. DOD concurred with the recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense The Secretary of Defense should direct the Program Executive Officer of Defense Health Management Systems to develop an approach for retesting the incidents identified by testers to ensure that the incidents have been resolved. (Recommendation 1)
Open
The Department of Defense (DOD) concurred with and has begun taking steps to address our recommendation. As of November 2021, the Defense Health Agency and Joint Interoperability Test Command had closed a combined 61 of 301 incident reports through this approach. The department reported that retesting activities are ongoing and will continue into fiscal year 2022. We will continue to monitor the department's actions to ensure that the remaining incidents are resolved.
Department of Defense The Secretary of Defense should direct the Program Executive Officer of Defense Health Management Systems to improve the effectiveness of MHS GENESIS training by ensuring it is relevant to user roles. (Recommendation 2)
Open
The Department of Defense (DOD) concurred with, and has begun taking steps to address our recommendation. As of November 2021, DOD reported that it had implemented improvement projects and initiatives designed to increase users' understanding of MHS GENESIS, provide over-the-shoulder subject matter expert support, remove training redundancies, and increase the hands-on learning experience. DOD also reported that it is in development of a pilot study that will move training away from step-by-step memorization and instead focus it on applying the system to complete users' day-to-day workflows. We will continue to monitor the department's actions to improve the effectiveness of MHS GENESIS training.
Department of Defense The Secretary of Defense should direct the Defense Health Agency Chief Health Informatics Officer to ensure users are aware of system changes and to monitor users' awareness of changes. (Recommendation 3)
Open
The U.S Department of Defense (DOD) concurred with, and has taken steps to address our recommendation. DOD reported that it has begun taking actions that it believes will ensure users are aware of system changes and monitoring users' awareness of changes. Specifically, these actions include communicating weekly changes through Defense Health Agency weekly Sustainment Informatics Steering Committee meetings and through the Defense Health Agency User Impact Series Team; communicating major upgrades introducing new capabilities to the end user; proactively identifying end users who are struggling with MHS GENESIS and targeting them with training resources and job aids through the Defense Health Agency End User Engagement Reinforcement Optimization Team. We will continue to monitor the department's actions to improve users' awareness of system changes.

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