[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
SHARING OF ELECTRONIC MEDICAL INFORMATION
BETWEEN THE U.S. DEPARTMENT OF DEFENSE
AND THE U.S. DEPARTMENT OF
VETERANS AFFAIRS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
OCTOBER 24, 2007
__________
Serial No. 110-57
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
39-466 PDF WASHINGTON DC: 2008
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio GINNY BROWN-WAITE, Florida,
TIMOTHY J. WALZ, Minnesota Ranking
CIRO D. RODRIGUEZ, Texas CLIFF STEARNS, Florida
BRIAN P. BILBRAY, California
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
October 24, 2007
Page
Sharing of Electronic Medical Information Between the U.S.
Department of Defense and the U.S. Department of Veterans
Affairs........................................................ 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 52
Hon. Ginny Brown-Waite, Ranking Republican Member................ 2
Prepared statement of Congresswoman Brown-Waite.............. 52
WITNESSES
U.S. Department of Defense:
Brigadier General Douglas J. Robb, M.D., Commander, 81st
Medical Group, Keesler Air Force Base, Biloxi, MS, Department
of the Air Force............................................. 4
Prepared statement of General Robb........................... 53
Colonel Keith Salzman, M.D., MPH, FAAFP, FACHE, Chief of
Informatics, Western Region Medical Command and Madigan Army
Medical Center, Tacoma, WA, Department of the Army........... 19
Prepared statement of Colonel Salzman........................ 65
Lieutenant Commander James Lawrence Martin, Regional
Information Systems Officer, Navy Medicine East, Medical
Service Corps, Department of the Navy........................ 23
Prepared statement of Commander Martin....................... 71
Colonel Gregory Andre Marinkovich, M.D., Data Management
Product Line Functional Manager, Clinical Information
Technology Program Office, Military Health System, Medical
Service Corps, Department of the Army........................ 25
Prepared statement of Colonel Marinkovich.................... 73
Stephen L. Jones, DHA, Principal Deputy Assistant Secretary of
Defense (Health Affairs)..................................... 39
Prepared statement of Dr. Jones.............................. 79
______
U.S. Government Accountability Office, Valerie C. Melvin,
Director, Human Capital and Management Information Systems
Issues......................................................... 13
Prepared statement of Ms. Melvin............................. 54
______
U.S. Department of Veterans Affairs:
Howard B. Green, PMP, Deputy, Operations Management, Veterans
Health Information Technology, Office of Enterprise
Development, Office of Information and Technology............ 21
Prepared statement of Mr. Green.............................. 68
Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary
for Health, Veterans Health Administration................... 37
Prepared statement of Dr. Cross.............................. 74
MATERIAL SUBMITTED FOR THE RECORD
Post Hearing Questions and Responses for the Record:
Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite,
Ranking Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon. David
M. Walker, Comptroller General, U.S. Government
Accountability Office, letter dated February 5, 2008, and
response from Valerie C. Melvin, Director, Human Capital and
Management Information Systems Issues, U.S. Government
Accountability Office, letter dated March 7, 2008............ 83
Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite,
Ranking Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon.
Robert M. Gates, Secretary, U.S. Department of Defense,
letter dated February 5, 2008, and DoD responses............. 92
Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite,
Ranking Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon. James
B. Peake, Secretary, U.S. Department of Veterans Affairs,
letter dated February 5, 2008, and VA responses.............. 96
The Health Executive Council Highlights, FY 2003-First Quarter
for FY 2008, dated June 10, 2008............................. 98
SHARING OF ELECTRONIC MEDICAL
INFORMATION BETWEEN THE U.S.
DEPARTMENT OF DEFENSE AND THE
U.S. DEPARTMENT OF VETERANS AFFAIRS
----------
WEDNESDAY, OCTOBER 24, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice at 10:03 a.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Space, Walz, Rodriguez,
and Brown-Waite.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Good morning and this hearing will come to
order. This is the Subcommittee on Oversight and
Investigations. And today's hearing is on Sharing of Electronic
Medical Information between the U.S. Department of Defense
(DoD) and the U.S. Department of Veterans Affairs (VA).
I want to thank everyone for being here today and I am very
pleased that so many people could attend this oversight hearing
on Sharing Electronic Medical Information between the
Departments of Defense and Veterans Affairs.
This is a critically important issue. Thousands of our
service men and women require and will continue to require
significant medical care as a result of the conflicts in Iraq
and Afghanistan. The most seriously injured of our Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
veterans may need a lifetime of care. But even veterans
returning with no visible injury may need assistance with Post
Traumatic Stress Disorder (PTSD) or mild Traumatic Brain Injury
(TBI).
The DoD and VA are sharing more and more patients. For
example, the patients at the VA's four polytrauma
rehabilitation centers are almost always still on active duty.
And active-duty servicemembers will be veterans sooner or
later.
A review by the VA's Inspector General shows that of the
500,000 or so servicemembers who left active duty in fiscal
year 2005, 92 percent had an encounter with a military health
system while on active duty that resulted in a diagnostic code.
In other words, nearly all of the veterans who go to the VA to
get medical care will have military medical records that should
be available to VA healthcare providers.
If anyone can convince the American people of the
importance of electronic medical records, it is our first
panel. Specialist Channing Moss is an Army soldier who was shot
with a rocket propelled grenade that lodged in his body. He is
alive and walking today because the medical evacuation team and
the combat surgeons who operated on him put their own lives in
danger in order to remove live ordnance from Specialist Moss.
Brigadier General Douglas Robb was Chief Surgeon of United
States Central Command (CENTCOM) at the time. And he will
discuss how important it was that a copy of the x-ray taken at
the forward field hospital was available to the clinicians at
Landstuhl before Specialist Moss arrived.
DoD and VA have been working on electronic exchange of
medical information for many years. For most of that time, the
story is not a happy one. I am nevertheless pleased to be able
to say that DoD and VA have made more progress in the past 12
to 18 months than they have made in the preceding decade.
But there is still much to be done. There is no reason why,
in this day and age, that DoD and VA cannot electronically
share the information necessary to treat our servicemembers and
veterans. We should not have to wait any longer.
I hope and I expect that DoD and VA will tell us today that
by no more than a year from now clinicians at DoD and VA will
have full electronic access to the medical information they
need to treat their patients whether that information resides
in computers owned by DoD or the VA.
[The prepared statement of Chairman Mitchell appears on p.
52.]
Mr. Mitchell. Before I recognize the Ranking Republican
Member for her remarks, I would like to swear in our witnesses.
I would ask all the witnesses from all the panels to please
rise and raise your right hand.
[Witnesses sworn.]
Mr. Mitchell. Thank you.
I would now like to recognize Ms. Brown-Waite for her
opening remarks.
OPENING STATEMENT OF HON. GINNY BROWN-WAITE
Ms. Brown-Waite. Thank you very much, Mr. Chairman, and I
thank you for yielding.
It is a good idea to hold this hearing to review the status
of the electronic medical record sharing between DoD and VA.
This Subcommittee has already held two hearings in the 110th
Congress on the issue of seamless transition of our
servicemembers. And in the 109th, various hearings were also
held. It is a very important issue.
The first hearing of this Committee was held in March and
the second one in May, both of which focused primarily on the
sharing of critical medical information of wounded
servicemembers and the sharing of that information between DoD
and the VA.
I want to assure the witnesses here today this issue is of
the utmost importance to Members of this Committee and
certainly the full Committee and I believe every Member of
Congress.
I am very pleased that the Chairman requested that
representatives from DoD testify here today. It will be
important to hear their perspective on the timely exchange of
critical medical information between DoD and VA for the
seamless continuum of delivering healthcare to our
servicemembers.
I look forward to hearing the steps DoD has taken to allow
critical medical information to be reviewed by VA when active-
duty servicemembers are transferred to VA facilities.
In addition, I will be interested in hearing from VA on
whether technological obstacles or bureaucratic intransigence
prevent this from occurring today.
This past week, staff members visited Keesler Air Force
Base and the VA medical center in Biloxi, Mississippi, to see
how the Air Force and VA are coming together in VA/DoD resource
sharing.
Unfortunately, the progress in this area is a result of the
devastation of Hurricane Katrina and the dynamic personalities
of senior leadership at these facilities and not the ``Veterans
Administration and the Department of Defense Health Resources
Sharing and Emergency Operations Act 1982.''
It does appear, Mr. Chairman, I agree with you, that the
ball has moved forward more in the last, say, 24 months than
the last 25 years. It is a shame that it took Hurricane
Katrina, the debacle at Walter Reed, and the devastating wounds
of war to expedite progress between the two largest Federal
bureaucracies.
I am also looking forward to hearing from representatives
of both departments about how they plan to implement the
recommendations of the recently released Dole-Shalala
Commission report and the Veterans Disability Benefits
Commission report.
Again, thank you very much, Mr. Chairman, for holding this
hearing. The issue is very important to every Member of
Congress and I believe every American. And with that, I yield
back the balance of my time.
[The prepared statement of Congresswoman Brown-Waite
appears on p. 52.]
Mr. Mitchell. Thank you.
I ask unanimous consent that all Members have 5 legislative
days to submit a statement for the record. Seeing no
objections, so ordered.
Before we hear from our first panel, we are going to take a
look at a short video about Channing Moss, the soldier that I
spoke about in my opening statement. The Subcommittee
appreciates the cooperation of the Army Times in making this
video available.
If you would like to move around to see this, please do.
[Video shown.]
Mr. Mitchell. General Robb will speak to us in a minute
about the importance of the electronic transmission of
Specialist Moss' medical records.
But before we hear from General Robb, the Subcommittee
would like to thank the Army Times and in particular Gina
Cavallaro, James Lee, and Chris Brass who put this video
together.
Ms. Cavallaro, would you please stand? We want everybody to
know that she was the first one to report this story more than
a year ago and I would like to thank her on behalf of the
Subcommittee and indeed on behalf of the country for bringing
this truly inspiring story to light. Thank you.
At this time, we will hear from General Robb and he will
have 5 minutes to make his presentation. Thank you.
STATEMENT OF BRIGADIER GENERAL DOUGLAS J. ROBB, M.D.,
COMMANDER, 81ST MEDICAL GROUP, KEESLER AIR FORCE BASE, BILOXI,
MS, DEPARTMENT OF THE AIR FORCE, U.S. DEPARTMENT OF DEFENSE
General Robb. Mr. Chairman and Members of the distinguished
Subcommittee, thank you for inviting me here today. I am
Brigadier General Douglas J. Robb and I served as the Command
Surgeon, United States Central Command from 2004 to 2007.
Currently, I am serving as the Keesler Medical Center
Commander and as the Senior Market Manager for the Gulf Coast
Multi-Service Market Office, Keesler Air Force Base, Biloxi,
Mississippi.
Thank you for the opportunity to express my advocacy for a
healthcare information systems platform and an electronic
medical record that supports the world-class quality healthcare
that our military and Veterans Administration healthcare
facilities provide to our DoD and VA beneficiaries.
In my previous assignment as the CENTCOM surgeon, I had the
opportunity to witness the evolution of our deployed healthcare
information systems platforms that support access to patient
care data as our wounded warriors move through the continuum of
care from our combat casualty care lifesavers to our forward
surgical teams, to our theater hospitals, and then on to our
definitive care facilities at hospitals such as Landstuhl,
Walter Reed, Bethesda, Wilford Hall, and our VA polytrauma
centers.
As you saw in the video, on March 16, 2006, Specialist
Channing Moss was severely injured in an attack in southeastern
Afghanistan. The lifesaving care performed by the combat
lifesavers in his unit and the subsequent and surgical
stabilization by the forward surgical team and the Bagram
Theater Hospital saved his life.
What was also lifesaving was the ability of the surgeons at
Landstuhl Hospital in Germany who would receive Moss less than
24 hours after his initial injury and the surgeons at Walter
Reed to be able to view his operative notes and his x-rays
before the patient arrived at their hospitals. This was
accomplished via the Joint Patient Tracking Application (JPTA),
which is part of the DoD's deployed healthcare information
systems platform.
As an aside here, and you noticed in the video, that Moss
said he was going to fight to live. And it is our task as
medics in the combat environment to give him that opportunity
to fight to live. And I was privileged to serve with those men
and women, our medics in the Area of Rescue (AOR) who saved
Moss' life, and especially to Dr. Oh did a great job there with
the forward surgical teams.
Earlier that year, and again in Afghanistan, a general
surgeon and the Commander of one of our other forward surgical
teams commented on his excitement when he was able to send
completely digital trauma resuscitation and operative reports
to the Bagram Combat Support Hospital, again before the patient
arrived.
This is something that had been his vision for our forward
surgical teams for a long time. During his previous assignment,
he had been a surgeon at Landstuhl, Germany, and was frustrated
by the lack of medical data from the forward surgical teams'
initial surgical resuscitation. He was happy that this had been
corrected.
Now, currently in my position as the Senior Market Manager
for the Gulf Coast Multi-Service Market through the
collaborative and joint DoD and VA initiatives, we are
entrusted with the in-garrison care of our DoD and VA
beneficiaries. In this capacity, we also require a healthcare
information system platform that supports access to real-time
patient data for our shared population.
Our patients are from the Gulf Coast and are treated in the
DoD and VA hospitals and clinics that are often located in
proximity from Biloxi to Panama City. Our goal is to provide
quality services in a seamless manner. This requires an
integrated healthcare information systems platform that is user
friendly for our jointly operating DoD and VA healthcare
facilities.
Significant progress has been made in the past few years to
bridge this gap of electronic information flow. Just last
month, our staffs were excited when the Bidirectional Health
Information System (BDHI) became available at some of our
facilities. Although not at its full capability yet, it is a
very positive step in the right direction in our ability to
view patient care data from both VA and DoD facilities.
In conclusion, as a former Combatant Command Surgeon and
currently as the Multi-Service Market Manager, I continue to be
a strong advocate for healthcare information systems. We need
to support heroes like Channing Moss as they move through our
deployed and garrison-based continuum of care from the combat
casualty to the forward surgical resuscitation, to theater
hospitalization, and finally our DoD and medical centers and
clinics.
The current capability has proven itself in contributing to
the quality of care for our beneficiaries and with your
support, I believe we can continue to improve upon our already
existing and evolving capability and further share and make
available the full spectrum of electronic health information
between our Department of Defense and Department of Veterans
Affairs.
Mr. Chairman, Committee Members, thank you again for
allowing me this opportunity to appear before you.
[The prepared statement of General Robb appears on p. 53.]
Mr. Mitchell. Thank you, General Robb.
I have just got a couple questions and I am not sure I
understand all the acronyms or all the----
General Robb. Yes, sir.
Mr. Mitchell [continuing]. Things that I am going to throw
out and ask you about, but I am sure you do. It is our
understanding that the Joint Patient Tracking Application is
currently used to get inpatient information from the theater
but that some in DoD are trying to require clinicians in the
theater to use an application called Tactical Command and
Control (TC2).
In your expert opinion, will doctors in the theater
actually use this application, TC2, for inpatient documentation
of clinical notes? That is one question.
And if use of the JPTA for documenting encounters in
theater is stopped, could this negatively impact delivery of
healthcare for our most seriously injured as they travel
through the continuum of the VA?
General Robb. Well, sir, as far as the TC2, which is the
current inpatient platform documentation system, that was
implemented and introduced into the theater of operations after
I left as the Combatant Surgeon. And as a result, in my current
capacity, I have not been keeping up as much as I maybe should
with my previous job, but my views on it in general are this.
The initial inpatient module that was introduced into the
theater did not accomplish what it was intended to do for a
couple of reasons. Primarily it was because it was not user
friendly for the providers. So if something is not user
friendly by the providers and also providing a useful note to
convey patient care information and data from one provider to
another provider, then the providers are probably not going to
accept that as a platform to use to take care of, remember,
their patients.
Number two, another reason was I believe at the time that
was a stand-alone system and it did not allow information to
flow. And as a result, when the Joint Patient Tracking
Application was introduced into the theater to track patients
from level two, level three, all the way back to the United
States, the clinicians, the providers themselves figured out
that they can put patient care data on that platform that, as
we described in Moss' case, we are able to move patient care
data along the continuum before and during and after the
patient moved through the system.
So that is the system that needs to be in place. The
current inpatient module, if it is user friendly, and the
providers decide that it is a useful note, okay, and it is
real-time accessible, then it will be successful, yes, sir.
Your second question about JPTA if it stopped right now, I
think, again, my direction when I was the Command Surgeon was
when the inpatient module is user friendly, provides a useful
note, and provides real-time patient care data, and we can view
inpatient data from real-time, before, after, and during their
movement, then we can switch from the Joint Patient Tracking
Application over to whatever system is going to work for us on
the Armed Forces Health Longitudinal Technology Application
(AHLTA) deployed platforms.
But until then, I think we need to allow the providers the
opportunity to move the patient care data that is useful to
them.
Mr. Mitchell. Thank you.
After seeing this video about Specialist Moss, I can
imagine that great things are happening like that all over
today.
General Robb. Yes, sir.
Mr. Mitchell. However, I understand that there still may be
some problems getting information from the field medics to
hospitals and to the VA.
What more can be done to ensure that this process goes
smoothly?
General Robb. Well, again, as I described in my testimony,
we have some monumental, I think, steps that have occurred,
nothing occurs as fast as we want it to, but that have
occurred. One of them is the Bidirectional Health Information
System.
And, again, when we demonstrated that, I mean, we received
it the day before and the next day, we flicked the switch and
we got everybody together. But the opportunity for us through a
bridge portal to view AHLTA data in VistA, which is the DoD
system, view it in the Veterans Administration system, and then
look from the Veterans Administration system into the DoD
system to be able to see outpatient notes, lab, x-rays,
pharmacy, allergies, we are there.
The inpatient piece of it, that is going to be fielded
here. At some places, it is already fielded. But the ability to
field it at my particular location will be by next summer. That
will be a tremendous milestone for us to accomplish. And for us
in the Gulf Coast region and the patients that we share with
our veterans to be able to look at each other's healthcare
data, I am excited about that.
The opportunity that we have had for the connections
between the outpatient modules and then as we watch the
evolution of the inpatient module, if that becomes connected, I
know the outpatient is, we can view outpatient data from the
field from any of our DoD locations and now through BDHI into
the VA system.
And once the inpatient module becomes successful, then the
ability to view that again will advance again and contribute to
the healthcare of our veterans.
Mr. Mitchell. Thank you.
Ms. Brown-Waite?
Ms. Brown-Waite. Thank you, Mr. Chairman.
By the way, congratulations on your recent promotion to
Brigadier General. It certainly is refreshing to see that the
military still rewards leaders for their candor and their
refreshing approach to real-life problems.
Let me ask you, if JPTA did not exist in the combat
theater, how would, for example, the operative notes and x-rays
be sent with the patient within 24 hours from, for example, in
the video that we saw from Afghanistan to Landstuhl, Germany to
be used by the accepting surgeon there, whether it is a
situation like we just saw or whether it is TBI? How would that
information be transmitted?
General Robb. Well, under the old paradigm and the paradigm
that I lived in when I first came to U.S. Central Command was
we were moving paper records. In other words, if you had the
opportunity to--I will regress a little bit. The patients move
so fast through our system today. From the time of wounding on
the battlefield to the time you are under the knife, it is
sometimes as little as 20 minutes to your forward surgical
team.
And then you are usually in a combat theater hospital
within an hour, sometimes two or three. And then you are at
Landstuhl usually under 24 hours and sometimes you are at
Walter Reed in 24 hours.
And so you can imagine that under the old paradigm with the
paper record, that may not keep up with the patient. And so,
you know, a lot of times, physicians are moving, especially in
the mass casualty situation, are moving so fast through the
system that you complete the paperwork after the patient
leaves. And so then it is hard to give the hard copy to move
with the patient.
So that was a dilemma we faced. And that is why it is
important that we have a deployed healthcare information system
platform that allows it so that you can enter the data. It is
okay to enter the data after the patient leaves, but then it
needs to be able to be viewed.
So, you know, hypothetically you could put the data in or
do the op note or whatever while the patient is being shipped
to the next level. And so by the time they get to the next
level, whether it is the theater hospital or to Walter Reed or
to Landstuhl, it is in the system for the receiving physicians
to see. And, again, that prepares that team for what is coming
with them. They can anticipate the specialties.
And so the clinicians, actually specifically the joint
theater trauma system team, and the directors embraced this
platform, the Joint Patient Tracking Application platform to be
able to hang that type of data so that they could inform their
colleagues along the continuum of care what was coming to them
so they could better prepare for the care when they received
them.
Ms. Brown-Waite. Obviously that is a giant step forward.
We have heard from providers in the combat theater that the
current effort to document inpatient medical notes useable or
very difficult at best that these actually were discouraged.
This was after two failed implementations of the Composite
Healthcare System (CHCS) legacy system.
To the best of your recollection from your time in theater,
was JPTA discouraged and, if so, by whom? And I guess we hope
that candor is still there.
General Robb. Well, I am a physician by trade. And so I
understand how physicians talk to each other and I understand
what needs to be passed from one physician to another.
My staff, myself, and then the joint theater trauma system
embraced the capability that the joint theater tracking
application brought to us besides just the patient tracking
application piece of it.
And as a result, we made a decision that this was the way
that we were going to support the movement of data for en route
patient care because it was the right thing to do. And so we
supported it from my staff and then subsequently through the
component surgeons and then down to the different levels. That
was the direction that we gave them for inpatient
documentation. And that is what we executed.
Did everybody accept it? It was something different. And
change is always difficult.
Ms. Brown-Waite. But was it actually discouraged?
General Robb. Was it actually discouraged? There were some
locations that did not embrace it as much as others, yes,
ma'am.
Ms. Brown-Waite. If you are not comfortable saying it now,
I would like to know those locations so that we can make sure
that regardless of where the injury takes place that we have
the best records being transferred. It is not about the staff.
General Robb. Right.
Ms. Brown-Waite. With all due respect, it is not about the
doctors who do wonderful work. It is about making sure that it
is a system----
General Robb. Yes, ma'am.
Ms. Brown-Waite [continuing]. That works well on behalf of
the patient.
General Robb. Yes, ma'am.
Ms. Brown-Waite. Thank you very much, General.
General Robb. Yes, ma'am.
Ms. Brown-Waite. I yield back.
Mr. Mitchell. Thank you.
Congressman Walz?
Mr. Walz. Thank you, Chairman.
And thank you, General. A special thank you for your
service in where you are at in providing medical care which I
think is without a doubt the best surgical and the best medical
care ever given to warriors in the history of mankind. And that
has been an amazing success story.
And this issue and this topic of medical records is
critically important. I understand, and many of us, I think,
oversimplify what goes into this, what data needs to be on
there. And I represent the part of Minnesota that has the Mayo
Clinic and this is a conversation I have had many, many times
on this, on a broader area of healthcare in general, and what
is going to be done.
Now, it looks like and what I am hearing is I am very
optimistic, too, that massive progress has been made. I think
for our perspective here in Congress, the end result, the
progress, the improved medical records, it is going to help in
terms of patient care, cost, research, all of those things that
go with medical records.
My question to you is, and I know again some of these have
to be subjective, what do you attribute what appears to be an
increased pace of change, an increased pace of trying or a
sense of urgency to implement this idea of data sharing and
electronic medical records, or do you think it has just been on
a continuum and it is finally reaching fruition where it has
gotten to where we can get the types of things you are talking
about?
General Robb. Well, I think, of course, you know it was the
President's vision that we go this direction as a Nation. And
as I spend time also in my professional capacity with my state
organizations and associations from the State of Florida, they
are wrestling again with how are they as a state going to come
up with an electronic medical record or healthcare information
systems platform to support that vision.
If it were easy, I think one of the states would have
figured this out already. And so I applaud the Department of
Defense again for leading the charge. You know, sometimes we
make some of our best advances in crisis and I think that has
probably been part of the addition to the momentum of where we
are going, the sense or urgency, because there is a lot of
competing priorities out there.
I believe, as we all believe, that we have the interest of
our patients, whether they are civilian, whether they are
veterans, or whether they are active duty, at heart. And I
believe as a Nation and with the Department of Defense and with
the Department of Veterans Affairs and the Federal Government
in the lead on this, I think we have the opportunity to set the
standard for what is an electronic health record or, even
bigger, what I call a health information systems platform to
support patient care as we want it to be in the future.
Mr. Walz. One of the questions that always comes up here is
the Congress' role in providing not only oversight but
resources. In your experience now, are the resources there to
make this transition because many of us up here understand it
is a scarce amount of resources and what we are getting out of
it?
But this issue is so broad and so important and especially
in the care of our veterans and seamless transition. I kind of
ask the question, the last question with a little bit of
leaning toward, did Walter Reed wake us all up and those types
of things? Was this one part of it?
And I guess my question to you is, do you feel that the
resources are there, the commitment is there to get this right
this time?
General Robb. I think the oversight and the emphasis is
there, absolutely. This is a tremendous monumental paradigm
shift from where we were and to where we are going. And it is
taking a lot of resources, probably more than we maybe had
anticipated.
I think we have the brain power to do it. I think we have
some of the solutions. In fact, I think we have most of the
solutions, at least to get us through the interim. The next
generation of platform is something that we need to work on.
But for the interim, for the next 12 to 18 to 24 months, I
believe we have some solutions in place.
Could we accelerate that with resources? The answer is
potentially. But I am not in that business, so I do not know if
we can go any faster if, let us say, either more manpower or
money was thrown at it. Sir, I do not know that.
But I know that they have a road map way ahead which you
will hear later that I am very optimistic about in making this
happen. And if they can have the opportunity to answer that
question later, then they can probably tell you whether or not
the resourcing piece of it is something that could either
accelerate this or slow it down, yes, sir.
Mr. Walz [presiding]. Very good. Thank you, General.
Mr. Rodriguez?
Mr. Rodriguez. Thank you very much. And I apologize for not
being here, although I hear my colleague is very optimistic.
This is my ninth year on this Committee with the absence of
2 years, and about 5 or 8 years prior to me getting on here, we
had been talking about this process. And so I am pleased and
glad that we are finally making some inroads, although it has
taken a long time.
And we talk about it is monumental, but it is monumental
from our part when we have been talking about this for a
significant amount of time. And, you know, until I see it, in
all honesty, I will not believe it. I can only react based on
the fact that we know the Department of Defense has been
stonewalling us on a couple of items on this area and not you
personally, General.
And I want to personally thank you for your efforts. But,
you know, we have to get this straight because there are a lot
of other things that took us 20 years to finally tell some of
our veterans from Project 112 that when they told us there was
no experimental, you know, exercises being done on our own
soldiers then we found out that was the case.
So I would like to be able to get that documentation and
also go back and addressing some of the needs of those soldiers
in the sixties and seventies that we did some of those things
and experimented with some of those gases and other things with
them that the Department of Defense failed to--not failed--
actually denied us that information for over 20 years. And, you
know, I experienced that on this Committee.
Now, I have also witnessed that the process to get there
is, you know, because one after another have shown us some
models of how we can do that and make that happen, and I want
to throw a question to you in terms of--because at one point, I
was just, you know--well, I am frustrated with both and that we
need almost an external group to come in here and take care of
it for you guys, both the Department of Defense and the VA when
it comes to our computers, especially in terms of what happened
with the loss of the information in the VA.
And so I was wondering if in terms of expediting this,
would it help to get some external groups to come in and take
care of it in terms of the high tech stuff that is required?
General Robb. That is kind of out of my area of expertise.
I am an operator and an executor. And I am the one that
executes what you all give me. And I am not in what I will call
the developmental arena. So, sir, I have to pass that question
on to----
Mr. Rodriguez. The second question, as we speak now, we
hear the Department of Defense doing some diagnosing already on
some 20 something thousand personality disorders which
automatically identifies preexisting condition.
Are we having any other of those kind of things occurring
at the present time, that we are going to have some additional
problems in the future? Are there some problems specifically
with some of that might be occurring at the Department of
Defense?
General Robb. Sir, I do not think I understand your
question.
Mr. Rodriguez. There was a group of some 20,000 soldiers
that were identified with personality disorders. And when that
occurs, when that soldier leaves, and I had a couple of them
come and visit me, that presupposes a preexisting condition
which means they do not qualify for any kind of benefits or
anything when they try to go if that is their diagnosis. And so
the Department of Defense, it is my understanding, did these
diagnoses.
Where are we at on that kind of stuff?
General Robb. Sir, that is again probably out of my area of
expertise because you are talking about accession standards in
the way we access our individuals' preexisting conditions, of
course, or conditions that the medical profession and through
the administrative channels also believe existed prior to
service. And then that particular condition arises or surfaces
when they are in the military.
But as far as what we are doing to better pick up on some
of those preexisting conditions, that, sir, again, is out of my
area of expertise.
Mr. Rodriguez. Okay. And I would also want to go back as we
move on this to some of our previous veterans. We want to do
the right thing now, but we also want to go back to Vietnam and
some of those areas where we did have and at one point had
identified some 5,600, maybe even more, because I was gone for
a couple of years, so close to 6,000 soldiers that we used, you
know, nerve gas and other things on our own soldiers, and
wanted to see from the Department of Defense, you know, later
on, maybe we can get, Mr. Chairman, a little status report on
those assessments that were done in the 1960s and 1970s on our
soldiers because I know they first said that they only
identified some 30 projects and then it went to 40 and the last
I heard, it was close to 50-something projects where we had
done experimental stuff with our own soldiers, and I want to
just get, you know, and that is with the Department of Defense,
I just want to get some feedback on that.
General Robb. Sir, again, that is again out of my area of
expertise and I am not aware of that.
Mr. Rodriguez. Thank you very much for what you are doing,
sir. A lot of the Members feel optimistic, so you must have
said some good things.
General Robb. Well, I will tell you, the group of folks
that I had a chance to work with and work for are medical
professionals not only in the CENTCOM area of responsibility
but also back here at our, again, our major hospitals and our
clinics, and then my opportunity in my current capacity to work
with the Veterans Administration. You know, we have all heard
the expression from Secretary Nicholson this is not your
father's VA. There are a group of dedicated professionals out
there in the Veterans Administration that care for our
soldiers, sailors, airmen, Marines, coalition forces and they
are second to none. And I am proud to be part of that team,
yes, sir.
Mr. Rodriguez. And I hope the Department of Defense takes
it from the perspective that file belongs to that soldier.
General Robb. Yes, sir.
Mr. Rodriguez. And they be able to get a grasp of it and be
able to have it so that when they move into the VA, and it
would be more cost effective for us as a whole, and not to
mention in terms of that particular soldier. Thank you.
General Robb. Yes, sir.
Mr. Walz. Ranking Member Brown-Waite?
Ms. Brown-Waite. General, I just wanted to thank you very
much for being here, for your candor, and also for your ability
to accept and promote the kind of technology that will
certainly help the patient a whole lot more than the past. Lord
only knows where the paper trail system is that was there.
Thank you so much.
General Robb. Yes, ma'am.
Ms. Brown-Waite. And please encourage others to follow
suit.
General Robb. Yes, ma'am.
Mr. Walz. I would echo and associate myself with the
Ranking Member's comments generally. It is refreshing to hear
this. We have a lot of work to do. Please know that we sit up
here as representatives of the American people and we want
nothing more than to provide the highest quality care to our
soldiers and our warriors that are out there and as they become
veterans.
So you simply need to see us as partners in this. We are
glad to have you out there. And I thank you for your time.
General Robb. Thank you.
Mr. Walz. We will go ahead and seat the second panel,
please. Welcome to our witnesses. Our witness today, Ms.
Valerie Melvin, is Director of Human Capital and Management
Information Systems Issues for the U.S. Government
Accountability Office, the GAO. She will be accompanied by her
Assistant Director, Ms. Barbara Oliver. We look forward to her
unbiased view on this situation.
And, Ms. Melvin, you are recognized for 5 minutes.
STATEMENT OF VALERIE C. MELVIN, DIRECTOR, HUMAN CAPITAL AND
MANAGEMENT INFORMATION SYSTEMS ISSUES, U.S. GOVERNMENT
ACCOUNTABILITY OFFICE; ACCOMPANIED BY BARBARA OLIVER, ASSISTANT
DIRECTOR, HUMAN CAPITAL AND MANAGEMENT INFORMATION SYSTEMS
ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Melvin. Thank you. Members of the Subcommittee, I am
pleased to be here today to continue the dialog on VA's and
DoD's efforts to share electronic medical information and
attempts to ensure that active-duty military personnel and
veterans receive high-quality healthcare.
As you have mentioned, accompanying me today is Ms. Barbara
Oliver, Assistant Director.
As you know, VA and DoD have been pursuing ways to share
medical information for nearly a decade. And since 2001, GAO
has reported numerous times on their initiatives.
Our last testimony before you on May 8th highlighted the
key projects that the two departments have pursued and the
substantial work that remained to achieve comprehensive
electronic medical records.
At your request, my statement today further discusses the
history and status of these efforts.
In this regard, since 1998, VA and DoD have focused on the
long-term vision of a single comprehensive lifelong medical
record for each servicemember to achieve a seamless transition
between the departments.
However, they have faced considerable challenges in their
efforts to reach this goal, leading to repeated changes in the
focus of and target dates for their initiatives.
Our prior reviews noted weaknesses in project management,
oversight, and accountability, and we recommended that the
departments develop a comprehensive and coordinated project
management plan to guide their efforts.
Since we last testified, each Department has continued
developing its own modern health information system to replace
existing systems. The modernized systems are based on using
computable data, that is data in a format that a computer
application can act on, for example, to alert clinicians of a
drug allergy.
The departments have begun to implement the first release
of an interface between their modernized data repositories and
are currently exchanging computable outpatient pharmacy and
drug allergy data at seven VA and DoD sites.
At the same time, the departments have made progress on
short-term projects to share health information using their
existing systems. Of these, the Laboratory Data Sharing
Interface Application is currently implemented at nine sites,
allowing the departments to share medical laboratory results.
In addition, the Bidirectional Health Information Exchange
or BHIE interface is allowing a two-way view of selected
categories of health data on shared patients from VA's and
DoD's existing health information systems.
Because BHIE provides access to up-to-date information, the
departments' clinicians have expressed interest in its further
use. Accordingly, since May, the departments have been
expanding BHIE's capabilities and implementation using the
interface to connect not only VA and DoD but also DoD's
multiple legacy systems which were not previously linked. In
this way, the departments have begun sharing more of their
current information more quickly.
Beyond these two efforts, various ad-hoc processes that the
departments established to provide data on severely wounded
servicemembers to VA's polytrauma centers are being used. These
processes include manual work-arounds such as scanning paper
records for transfer to incompatible systems.
While particularly significant to the treatment of
servicemembers who sustain traumatic injuries, as we have
testified previously, such laborious processes are generally
feasible only because the number of polytrauma patients is
small.
Overall, through all of these initiatives, VA and DoD are
exchanging health information which is an important
accomplishment. However, these exchanges are limited and
significant work still remains to achieve the long-term goal of
a comprehensive electronic medical record.
Moreover, it remains unclear how all of the initiatives
that VA and DoD have undertaken are to be incorporated into an
overall strategy for a seamless exchange of health information.
The multiple projects and ad-hoc processes being discussed
today highlight the need for further efforts to integrate
information systems and automate information exchanges. Yet, VA
and DoD are continuing to proceed without a comprehensive
project plan and overall strategy to effectively guide their
efforts.
As we have previously recommended, the departments need
such a plan to help ensure success in reaching their goals.
This concludes my prepared statement. I would be pleased to
respond to any questions that you may have.
[The prepared statement of Ms. Melvin appears on p. 54.]
Mr. Walz. Thank you, Ms. Melvin.
In listening, and I think you heard on the last panel as we
were trying to assess where we are at on this progress, what is
GAO's assessment as far as a timeline of a real-time viewable,
useable platform for these medical records? Do you think it is
reasonable or are we a year, are we 2 years, or where are we at
from this being in place?
We saw, and heard General Robb talk about, that there has
been a momentum. There has been the resources necessary. We
have been moving toward it. We are seeing successes.
In your opinion, where are we at in terms of before this is
going to be up and running?
Ms. Melvin. We have seen definite progress in terms of the
short-term initiatives that were mentioned today relative to
the Bidirectional Health Information Exchange. There are other
initiatives related to the laboratory data sharing interface as
well as a number of ad-hoc processes that have been put in
place, in particular to serve the polytrauma patients who are
coming back into the country.
From our assessment, these initiatives definitely bring
additional capabilities and services to the clinicians by
providing them with more information. However, I am not able to
say when the departments would be at a point of having the goal
of a longitudinal, comprehensive electronic medical record,
which they have indicated was their long-term goal or mission
to have, because we have not yet seen their final plans for
actually doing that.
As of now, we cannot state when they would have those
systems in place. Both departments at this point have told us
that they do not have a date for their final modernized systems
which are key components of putting in place the overall
sharing capability that they have talked about having.
Mr. Walz. So no data has been expressed? It is just a goal
out there to try and get it done?
The reason I ask this is I am optimistic on this. The need
to get this done is very apparent, but I do not want to find
myself in the position of my colleague from Texas of being here
for 9 years and saying I can remember that conversation we had
back in October of 2007 and here we are in 2016.
Do you have that fear or do you think that there is a
difference now?
Ms. Melvin. There is a concern that we still have from two
perspectives. First of all, as I mentioned in my last response,
both departments are still in the process of developing their
modernized health information systems. Those are the two
systems that we no longer see specific completion dates for.
Beyond that, one of the concerns that we have repeatedly
raised in our work is that the departments did not articulate a
defined strategy for getting to this final mission. And within
that strategy, we would certainly hope that there would be
interim milestones as well as a final timeframe for
accomplishing this.
Mr. Walz. Thank you, Ms. Melvin.
Ms. Brown-Waite, the Ranking Member, is recognized.
Ms. Brown-Waite. Thank you very much.
I have been here. This is my fifth year here, not fifth
term, but fifth year, and served on the Veterans' Affairs
Committee. And this has been an ongoing issue and it is almost
to the point where it is like deja vu all over again because
the same issue has not yet fully been resolved.
I think we have come a long way. Of course, part of the
problem is we do not have any authority over DoD in this
Committee. But I think that there finally seems to be a working
relationship there and the belief that Congress is not going to
just drop this issue.
In your testimony, you stated that although there are
multiple initiatives between the VA and the DoD, there is an
important requirement to integrate and automate information
exchange. I think you further stated that there is not a clear
overall strategy to incorporate this in a seamless exchange of
information.
I have been here 5 years. Mr. Rodriguez has been here ten
total, nine total. How many times have you stated this same
finding?
Ms. Melvin. Well, we have been reporting on this issue
since 2001 and across the multiple reports that we have issued,
we have, in fact, made the recommendation and reemphasized that
recommendation a number of times.
Ms. Brown-Waite. Do you know offhand how many?
Ms. Melvin. I can provide you that for the record. I do not
know offhand at this moment, but we can certainly tell you
after this hearing.
[The response was provided in the Post Hearing Questions
and Responses for the Record, which appear on p. 83.]
Ms. Brown-Waite. Okay. Are you encouraged that there seems
to finally be the realization by DoD that this has to happen?
Ms. Melvin. We are encouraged in seeing the different
initiatives, the short-term initiatives that are being put in
place. We do see them as an opportunity to provide more
information to the clinicians in the immediate.
What we have not seen is the actual plan that VA or DoD
would be using to do this. So I hesitate to say that or to
speak or render a view of the plan that DoD has at this time
because we have not actually seen that plan. I am not familiar
with the road map that they have indicated that they have.
Ms. Brown-Waite. Have you asked to see it?
Ms. Melvin. We have asked for their strategies relative to
what they are doing. We have not been informed prior to today
that there was an actual road map.
Ms. Brown-Waite. Okay. With that, I yield back the balance
of my time.
Mr. Walz. Mr. Rodriguez is recognized.
Mr. Rodriguez. Let me ask you in terms of trying to get
this accomplished and get it done, do we need to give you any
additional leeway or any guidance, you know, or any additional
authority to go in? Are you going to be going in again and
reassessing where they are at or do you need that additional
guidance from us?
Ms. Melvin. We have previously responded to your request
for oversight in this particular area. So certainly to the
extent that you would want to have additional oversight, we
would certainly be willing to follow through with that.
Mr. Rodriguez. Because it has been an issue that I think we
have dealt with. I think they dealt with it for 4 or 5 years
prior to even going to GAO. And I am convinced that there is
some movement now, but I am concerned that you mentioned just
short term, I think mainly because our troops are coming in and
it is embarrassing to leave some of these seriously injured
troops out there and just transfer them out and fall through
the cracks the way they have been falling through the cracks.
And that is obvious now. But we have to come to grips and try
to come up with and require them to come up with a long-term
strategy.
So I would encourage the Chairman to look in terms of what
we might have to do in asking the GAO to continue on this issue
for further implementation of that and requiring the DoD to do
that and maybe getting the Armed Services Committee, getting
Chairman Skelton also aware of our concerns as it deals with
our servicemember.
And I am concerned not only with the existing one, but, you
know, we are not going back. I am just going back on my own
personal experience with them in terms of health. It is kind of
like they drop them and then they do not particularly care
anymore, you know, and they expect the VA to handle them. And
for good reason, you know, if we had that information and
follow the soldier, it would help us tremendously, not to
mention what it would do to the soldier.
So I would ask the Chairman to see if we can keep on this
track and hopefully 10 years from now, we will not be talking
about this, but maybe going after some of those other pockets
of concerns that I had with those other studies.
While I am here, and maybe you are not the one, we had
asked for studies on Project 112. I do not know if you heard me
talk about our soldiers that the Department of Defense had used
studies on, health studies, you know, where they used nerve gas
and other things on ship.
And maybe later on, I would like to see if, you know, we
can get a report as to where we are at on that because I have
not heard anything. And once again, it is my fault because I
have not been here. I was gone for 2 years. But I wanted to get
an assessment of that and if you get me that information as to
where we are at. And back then, we had identified, as I recall,
some 5,600 soldiers, but we were concerned that there might
have been more and maybe other projects that were not disclosed
where we could ID additional soldiers that might have been
impacted with certain forms of studies that were done with
plombage and other things because we knew that there were some
other exercises that took place that were not part of the 56
projects that were out there.
Ms. Melvin. Sir, I am not familiar with those studies, but
we would be glad to go back and share your concerns and
interest with others in our healthcare area who might be more
familiar and have them to be in touch with you on that matter.
Mr. Rodriguez. Okay. And also if you have done any studies
on the recent diagnosing of soldiers with personality disorders
because the other question that would come into play if they
did come in with preexisting condition, personality disorders,
you know, schizophrenia can have an onset around that age, but
those onsets are much earlier.
So the question would be, why did we allow them to get into
the military in the first place if that was the case? If you
have anything on that, I would appreciate it.
Ms. Melvin. Okay. Will do.
Mr. Rodriguez. Thank you.
Mr. Walz. The gentleman from Ohio, Mr. Space, is
recognized.
Mr. Space. I have no questions, Mr. Chairman. Thank you.
Mr. Walz. Ranking Member Brown-Waite?
Ms. Brown-Waite. Mr. Chairman, I have just one other
question for Ms. Melvin.
Have you, in pursuing this issue, had any indication that
perhaps part of DoD's reluctance to proceed with the
information sharing may be because of a concern with the
security of VA's system?
Ms. Melvin. We have not heard that concern expressed. I
would say that most of our studies have focused on the VA/DoD
sharing effort from looking within the Department of Veterans
Affairs and the relationships that it is having with DoD.
However, I would say that because we are talking about
sharing data across networks in particular and a number of
multiple systems involved, certainly the security aspect is
very critical to what they are doing.
However, we have not gotten specific statements rendered to
us relative to concerns with that at the moment.
Ms. Brown-Waite. Thank you very much.
And with that, I yield back.
Mr. Mitchell [presiding]. Thank you.
Mr. Rodriguez?
Mr. Rodriguez. Yes. One last question since the issue of
the VA and the documentation and security of that documentation
was raised, maybe later on, Mr. Chairman, not so much for the
GAO, but for the Chairman to see later on in the next coming
year, we get an assessment of where the VA is in terms of that
documentation because even then, I think we have talked about
trying to get external groups to come in and take care of the
computer stuff for them or try to correct that. But unless the
GAO has something that is more recent from the last testimony
we received, I would like to get some feedback on that.
Ms. Melvin. We have, if you are talking about their
computer security, in particular, we have issued a report. I
believe it was on September 19th. What I would like to do is
again have our Director who has the expertise relative to
security issues to contact you and provide you specific
information.
But we have identified some problems and concerns along
with progress relative to their overall information security
management program that we would be glad to share with you in
detail.
Mr. Mitchell. Thank you. All right. Thank you very much.
Ms. Melvin. You are very welcome.
Mr. Mitchell. I would like to welcome Panel Number Three to
the witness table. Colonel Keith Salzman is the Chief of
Informatics from Madigan Army Medical Center and the Western
Region Medical Command. He has been taking the lead with his
counterparts at the VA Puget Sound Healthcare System on
creating a pilot program for sharing electronic medical
information.
Lieutenant Commander James Martin fulfills a similar
function at the new truly Federal facility being created by the
U.S. Navy and VA out of the Great Lakes and North Chicago
Hospitals. Lieutenant Commander Martin has been instrumental in
helping create a way for DoD and VA to treat patients at the
same facility while fulfilling their missions.
Mr. Howard Green, the Deputy for the Operations Management
for Veterans Health Information Technology, Office of
Enterprise Development at the VA is here to discuss where the
VA stands in making sure all facilities can access medical
information from the DoD as needed.
Finally, Colonel Greg Andre Marinkovich is here
representing DoD's Clinical Information Technology Program
Office or CITPO which is the DoD organization responsible for
implementing sharing agreements throughout the service and
theater.
And I would like to thank each of these gentlemen for the
work they do on behalf of our veterans and Nation and will
recognize Colonel Salzman and all four panelists for 5 minutes.
Thank you.
STATEMENTS OF COLONEL KEITH SALZMAN, M.D., MPH, FAAFP, FACHE,
CHIEF OF INFORMATICS, WESTERN REGION MEDICAL COMMAND AND
MADIGAN ARMY MEDICAL CENTER, TACOMA, WA, DEPARTMENT OF THE
ARMY, U.S. DEPARTMENT OF DEFENSE; HOWARD B. GREEN, PMP, DEPUTY,
OPERATIONS MANAGEMENT, VETERANS HEALTH INFORMATION TECHNOLOGY,
OFFICE OF ENTERPRISE DEVELOPMENT, OFFICE OF INFORMATION AND
TECHNOLOGY, U.S. DEPARTMENT OF VETERANS AFFAIRS; LIEUTENANT
COMMANDER JAMES LAWRENCE MARTIN, REGIONAL INFORMATION SYSTEMS
OFFICER, NAVY MEDICINE EAST, MEDICAL SERVICES CORPS, DEPARTMENT
OF THE NAVY, U.S. DEPARTMENT OF DEFENSE; AND COLONEL GREGORY
ANDRE MARINKOVICH, M.D., DATA MANAGEMENT PRODUCT LINE
FUNCTIONAL MANAGER, CLINICAL INFORMATION TECHNOLOGY PROGRAM
OFFICE, MILITARY HEALTH SYSTEM, MEDICAL SERVICE CORPS,
DEPARTMENT OF THE ARMY, U.S. DEPARTMENT OF DEFENSE
STATEMENT OF COLONEL KEITH SALZMAN
Colonel Salzman. Thank you very much, Mr. Chairman,
Congressman Brown-Waite, and the distinguished Members of the
Subcommittee, for inviting me to testify.
I am, as said, Colonel Salzman from Madigan Army Medical
Center and have the privilege of leading in the newly emerging
discipline of informatics.
We have had a long history of command support at Madigan
for doing projects that are often funded out of hide. So having
the National Defense Authorization (NDA) funds to supplement
our efforts has propelled us down the path in sharing
information technology.
In the 3 years that we have had to complete the 4-year
project, we have delivered all the deliverables that we were
chartered to do in our business plan and all of those
deliverables are in use in the enterprise system. So it shows
the benefit of merging local development with enterprise
architecture to deliver rapid turnaround products that can be
used in the information systems.
In addition, we have added information requirements to
cater to polytrauma information needs as well as additional
requests from VA providers and DoD providers as we have
prioritized from critical information needs to less critical
but important needs.
At the outset of this testimony, I would underscore our
assessment that the choice on many levels that we face if it is
couched in an either/or strategy is misinformed, but we need to
look at both strategies in approaching the problems that we
face starting with having the local and the enterprise teams
meet together and work together so that both are working
together on the solution and not the local project as an
isolated project directing things or an enterprise solution
directing things that does not meet local needs.
The initial challenges surrounded learning required to
overcome the first either/or proposition of who drove the
project, enterprise or the local site. A critical lesson
learned was both. The local site had access to the clinical end
user community and the requirements necessary to improve the
flow of information while the enterprise had ownership of the
architecture and systems and which requirements would be built
and deployed.
At the outset, it is important to state that while this
project is a demonstration project, all of the deliverables are
being used by the enterprise systems of both the DoD and VA in
production in near real time and that is meaning in seconds,
not days, weeks, or months.
The strategy of development based on the priority of
information delivery shaped our work and the work cycles for
this project were generally in six- to nine-month increments.
The critical dialog between clinical end user and the
development team at the local level combined with an active
dialog between local and enterprise team members ensured that a
principle of software development, namely to correct functional
problems as they are identified in the design phase, proceeds
iteratively and cost effectively.
The savings can be significant over allowing major design
problems to persist into production. This exemplifies another
both solution to an either/or proposition.
As far as AHLTA or VistA, there are strengths and
weaknesses in both systems. That is another either/or
proposition, I think, that is better answered with both.
AHLTA is integrated worldwide and available 24/7. There are
functional problems that are being worked on to improve use at
the clinical and at the business level.
VistA shows the benefits of local design and its adoption
by end users who are more inclined to buy into products they
create.
The downside for the VA is the historic lack of
configuration management. I use management intentionally as
against configuration control. The VA faces big challenges in
reorganization and must be careful not to destroy the strategy
that delivered its success while addressing its Achilles heel
of decentralized, unmanaged growth.
The cost of imposing one system on both organizations now
would be prohibitive. Establishing interoperability and
designing a strategy of convergence over the next 10 to 20
years will allow both a solution and capitalize on best
practices and less disruptive to changes to either system.
These comments summarize what I would offer as a Steering
Committee Member engaged in this project from the start.
I would also encourage Congress to continue its support of
the VistA program and the agencies involved. Sustaining this
and other successful projects will enable the DoD and VA to
maintain forward momentum rather than losing the intellectual
capital that brought these results about.
And in addition to General Robb's testimony, I think
financial resources to maintain the intellectual momentum we
have gained are necessary. And I would say that we need those
to continue. Otherwise, we will get this far and then put on
hold until another round of money comes through and you have to
reassemble a team and start basically, go a few steps backward
before you can go forwards again.
I would like to thank the Committee for inviting me to
testify and welcome questions.
[The prepared statement of Colonel Salzman appears on p.
64.]
Mr. Mitchell. Thank you.
Mr. Green, you have 5 minutes.
TESTIMONY OF HOWARD B. GREEN
Mr. Green. Thank you, Mr. Chairman. I would like to thank
you for the opportunity to testify on sharing of electronic
medical information between the Department of Defense and
Department of Veterans Affairs, what is being done to
accomplish the objectives and the viability of the approach.
I have been a member of the Department of Veterans Affairs
Health Information Technology (IT) community for over 19 years,
serving in multiple capacities at the local, regional, and
national level.
Prior to joining the Office of Information and Technology
in 2004, I was the Chief Information Officer (CIO) for the VA
Heartland Network, Veterans Integrated Systems Network 15, and
was responsible for the introduction of VA's VistA system at
all facilities and clinics in the region.
Most recently, as Deputy for Operations Management within
the Veterans Health IT portfolio, I participated as a staff
member on the President's Commission for America's Returning
Wounded Warrior and was co-author of the Information Technology
chapter and final report recommendations.
Following that assignment, I have been given the
responsibility for coordinating many of the recommendations
from the President's Commission report.
Formal activities related to the sharing of clinical
information between VA and DoD have been ongoing since 2001.
Although there are a number of systems that have been developed
to support this function, for all intents and purposes, the
overarching goal is the bidirectional exchange of computable
information between VA and DoD in real time.
The following are a selection of the systems that are in
place to support the exchange of clinical information:
Bidirectional Health Information Exchange or BHIE supports the
functional interoperability between VA and DoD through the
exchange of textual patient health information. Through BHIE,
the two departments have transferred information for over 2.3
million unique patients who are active dual consumers. The
information is viewable through BHIE. The BHIE interface flows
to and from the following systems:
On the VA side, we pull data from 128 VistA systems and the
data is viewable through Computerized Patient Record System
(CPRS) and VistA web. On the DoD side, data is pulled from the
composite healthcare system, clinical data record, the clinical
information system (CIS), and theater medical data store. Data
is then viewable through the AHLTA share application.
Currently VA and DoD are bidirectionally sharing viewable
information supporting ten categories of clinically relevant
data including outpatient pharmacy data and anatomic
pathologies, surgical reports, radiology text reports, and
discharge summaries from several DoD sites running CIS.
By December 2007, the goal is to expand the amount of
clinical data exchange through BHIE to include encounter notes,
patient focus problems list, and theater level inpatient and
outpatient notes.
By September 2008, VA and DoD improvements will include the
addition of a polytrauma marker, an OIF combat veterans
identifier, electronic patient handoff indicators, DoD scanning
interface, the interagency sharing of essential health images,
and much more.
The clinical health data repository or CHDR is the clinical
data interface that supports the exchange of standardized and
computable data. This data can be used to support the automated
clinical decision support tools such as drug/drug and drug/
allergy order checking.
Currently data from the CHDR system interface is being used
at seven VA and DoD sites. The interface currently supports the
movement of pharmacy and medication allergy data and will be
upgraded to include chemistries and hematologies in the fourth
quarter of fiscal year 2008.
The key distinction between BHIE and CHDR is that the
applications leveraging the BHIE interface often require the
clinicians to look in several locations to retrieve health
record information from other points of care. This often
requires the clinician to interpellate based on approximation
when comparing data elements due to the different
terminologies.
By comparison, clinical information obtained through CHDR
can be incorporated into the same clinical view allowing for
automated computation and thus allowing the users to readily
compare like data.
Collaborations such as the one between the VA Puget Sound
Healthcare System and Madigan Army Medical Center focuses on
specific functionality and support of limited sharing
agreements and are vital partners in the process of
demonstrating new capabilities and functions.
By comparison, the Great Lakes Federal Healthcare Center
will eventually push the concepts of medical and administrative
data sharing to its limits. The goal at the Federal Healthcare
Center is to fully integrate the clinical and administrative
functions between the two healthcare systems.
Planning activities are underway to develop the local
project team to support this activity and, additionally, an
enterprise level of team resources is being assembled to
resolve technical and operational issues that are beyond the
local team's ability to address.
There are certainly advances in the application of
information technology that can be applied. However, the
process is complex and must be driven by key business decisions
and not by IT.
Mr. Mitchell. Could you----
Mr. Green. Mr. Chairman, this----
Mr. Mitchell. Okay.
Mr. Green [continuing]. Does conclude my opening remarks.
[The prepared statement of Mr. Green appears on p. 68.]
Mr. Mitchell. Thank you.
Lieutenant Commander Martin?
STATEMENT OF LIEUTENANT COMMANDER JAMES LAWRENCE MARTIN
Commander Martin. Mr. Chairman and Members of this
distinguished Subcommittee, thank you for inviting me to be
here today. I am Lieutenant Commander James L. Martin and I
serve as the Regional Information Systems Officer, Navy
Medicine East.
Thank you for this opportunity to talk about my personal
involvement in design and implementation of the composite
healthcare system, CHCS2, AHLTA, and the electronic medical
record sharing between the Department of Defense and the
Department of Veterans Affairs.
The present method of sharing electronic medical
information at Naval Health Clinic, Great Lakes is through the
Bidirectional Health Information Exchange, BHIE, and the
clinical health data repository, CHDR.
The Veterans Affairs' providers are granted read-only
access to the Department of Defense composite healthcare system
and AHLTA. The Department of Defense providers are granted read
and write privileges to the Veterans Affairs' computerized
patient record system which resides on the Veterans Health
Information System and Technology Architecture, VistA.
Specifically, access to the composite healthcare system,
AHLTA, and the computerized patient record system in North
Chicago is achieved through a single end user device with icons
on the desktop representing each of these applications. This
allows for seamless patient flow from the recruit processing
center clinic at recruit training center, Great Lakes, to the
emergency room and inpatient facility at the North Chicago
Veterans Affairs Medical Center.
Laboratory data sharing interoperability, LDSI, is used to
share laboratory information between these two systems. The
combination of these methods listed above allows complete
sharing of all clinical information between the Veterans
Affairs and the Department of Defense providers.
My personal involvement in this process dates back to 1992
when I assisted in the design and implementation of the
infrastructure and end user device placement and support, a
Composite Healthcare System, CHCS Legacy.
While serving as Assistant Department Head in Naval Medical
Information Management Center, Bethesda, my involvement
included personally visiting each naval healthcare treatment
facility prior to and during the system implementation.
Thereafter, my role expanded in 1994 as Head Management
Information Department Naval Hospital, Pensacola, where I
managed the composite healthcare system host site for the
hospital and its remote facilities.
In 1997, while serving as the TRICARE Region 2 Regional
Information Systems Officer, Naval Medical Center, Portsmouth,
one of our commands was selected to be the test site for the
composite healthcare system 2, the predecessor to AHLTA.
From 2000 to 2004, I was the Information Systems Officer at
Navy Medical Center, Portsmouth overseeing the test and
implementation of the composite healthcare system 2 system,
AHLTA.
It was during this tour that Naval Medical Center,
Portsmouth first populated the clinical data repository with a
25-month data pool from the CHCS Legacy system, placing
demographic information and laboratory, pharmacy, and radiology
results in the clinical data repository.
From 2004 until 2006, I served as the Medical Liaison
Officer, Space and Naval Warfare System Center, Norfolk, where
I was in charge of design and testing of the theater medical
information program maritime, TMIPM, the Navy operational
version of the composite healthcare system 2 and AHLTA,
designated at the time CHCS2 and AHLTA-T.
Currently as the Regional Information Systems Officer for
Navy Medicine East, I oversee all the information management
and technology for the Navy military healthcare facilities that
fall under Navy Medicine East. Naval Healthcare Clinic, Great
Lakes is one of these commands.
I have made five site visits in direct support of the DoD/
VA initiative at Great Lakes. During these visits, I have
surveyed the existing facilities and assisted in the planning
and relocation of the Information Management/Information
Technology (IM/IT) equipment to its new location at the Federal
Healthcare Center.
I attend biweekly conference calls and engineering support
meetings where the design and layout of the actual IM/IT spaces
is discussed.
The other commands under Navy Medicine East that I am
presently assisting with DoD/VA IM/IT initiatives include Naval
Health Clinic, Charleston, Naval Hospital, Pensacola, Navy
Hospital, Jacksonville, and Naval Medical Center, Portsmouth.
I am also a member of the National Information Management
and Technology Task Group for the Department of Defense and
Department of Veterans Affairs Electronic Health Information
Sharing Initiative.
My responsibility as a member of this task force is to plan
and oversee the acquisition and implementation of information
systems that integrate VA and DoD healthcare processes at the
North Chicago Federal Healthcare Center.
Our goal is to have an interoperable information system
that supports clinical and business operations by June 2010. We
plan to create a single main computer room and a single main
telecommunications room.
Additionally, an information management and information
technology network trust between DoD and VA must be established
along with domain ownership and single electronic mail system.
We are presently gathering requirements in the functional
use so that a determination can be made on whether a
combination of the information systems or a new information
system is required to meet the functional user requirements.
The ultimate goal is to have a single point of entry to
support the missions of both DoD and VA patient populations. At
present, this goal is met by providing access to CHCS, AHLTA,
and CPRS using multiple icons on a single end user device.
Mr. Mitchell. Could you wrap up your testimony, please?
Commander Martin. Yes, sir.
In addition to the goal of the single point of entry, we
are also working on the consolidation of IM/IT systems of all
the functional areas in the Federal Healthcare Center. This
involves the management of development of functional
requirements, assisting with local site integration efforts,
assisting enterprise solutions, and communicating the status.
I would like to conclude by saying that one of our top
priorities is to continue finding ways for electronic medical
data sharing between DoD and VA.
Mr. Chairman, Committee Members, thank you again for this
opportunity to speak about our efforts. At this time, I would
be pleased to answer any questions you may have.
[The prepared statement of Commander Martin appears on p.
71.]
Mr. Mitchell. Thank you.
Colonel Marinkovich, you have 5 minutes.
STATEMENT OF COLONEL GREGORY ANDRE MARINKOVICH
Colonel Marinkovich. Mr. Chairman, Members of this
distinguished Subcommittee, thank you for inviting me here
today. I am Colonel Andre Marinkovich and I serve as the Data
Architect in the Clinical Information Technology Program
Office, that is CITPO, with the MHS, Military Health System.
Thank you for this opportunity to talk about the military's
electronic health record, AHLTA, and the strides we are making
in sharing information between the Department of Defense and
the Department of Veterans Affairs.
AHLTA is an enterprise-wide medical and dental outpatient
clinical information system. It currently is the military's
outpatient EHR or electronic health record that generates,
stores, and provides secure online access to longitudinal,
lifelong patient healthcare records for the more than 9.1
million MHS beneficiaries seen in our military treatment
facilities.
AHLTA ensures the continuity of the Department's health
information and patient centered healthcare delivery worldwide
with accessibility anywhere, any time. Worldwide deployment of
AHLTA which began in 2004 was successfully completed in
November of 2006. Implementation support activities span 11
time zones and trained over 55,000 users with more than 18,000
healthcare providers.
The current AHLTA functionality includes encounter
documentation, orders, results, retrievable coding, and alerts,
reminders, role-based security, master patient index, the
ability to do ad-hoc queries.
AHLTA use continues to grow at a significant pace. To date,
we have had 45 million outpatient encounters recorded. It is
growing approximately 120,000 to 112,000 per day, per workday.
DoD and VA are also taking the first steps toward a joint
electronic health system. There has recently been a contract to
assess the DoD and VA's business and clinical processes, design
features, and system constraints relative to the inpatient
component of an EHR.
This assessment will determine and describe in narrative
and graphic format the scope and elements of the joint
inpatient electronic health record and identify those clinical
and business capabilities and applications that interact with
the joint inpatient electronic health record.
An analysis of alternatives will then be conducted to
develop a recommendation for the best technical approach. We
will then implement that solution.
Based on feedback from several AHLTA user conferences, we
are making significant changes to the next version of AHLTA
that will be released in December 2007. Better performance and
better user friendliness are a couple of the things that we are
going to be providing. There will also be other enhancements
with the ability of people to use the system from multiple
sites and enable mobile providers to continue to use the system
seamlessly.
Looking ahead into 2008, we plan to begin worldwide
deployment of dental charting and eyeglass ordering.
I would like to conclude by saying that one of our top
priorities is to continue finding ways for AHLTA to seamlessly
transfer information between the DoD and the VA, ensuring
continuity of quality care for returning wounded warriors.
With your support, we will continue building on our
achievements and sharing electronic health information in
support of the men and women who serve and have served this
country.
Mr. Chairman, Committee Members, thank you again for this
opportunity to speak about our efforts. And at this time, I
would be pleased to answer any questions you may have.
[The prepared statement of Colonel Marinkovich appears on
p. 73.]
Mr. Mitchell. I want to thank all of you. And I wanted to
apologize before the bell rings that we are about to be called
for a vote which means we will take a vote and I am not sure
how many votes there will be. Okay. So it will be about a half
hour in between. But we can get started with some of the
questions anyway until the bell rings, but I wanted to
apologize. We will take a break and recess and come back.
The last two panels explained the importance and necessity
for electronically sharing medical records. You are all on the
ground doing it. And the question is for the DoD folks.
In your opinion, what obstacle is most responsible for
getting in the way of sharing electronic medical records with
the VA? Anyone?
Colonel Marinkovich. I think the biggest obstacle has been
that the DoD has been working to develop and deploy a system
that has only recently been finished. And I think since that
time, since basically December of 2006, we have made really
significant strides in terms of being able to share
information.
Our systems simply did not have all of the electronic
information that we wanted to share and I think now we are
beginning to have all that and have those capabilities. So I
think once things become electronic, the sharing becomes easier
and all the work that we have been doing with BHIE and with
CHDR are going to bear fruits.
Mr. Mitchell. Mr. Green, first of all, do you agree with
the assessment of what has been holding us up?
And, secondly, I know the VA has been actively researching
and implementing electronic medical records. I am also aware
that integrating these systems with DoD records has been
challenging.
What is standing in the way of getting all of this medical
information into a readable and computable format and how long
will that take to do that?
Mr. Green. Well, I would certainly agree with the
statements of Colonel Marinkovich.
The question is somewhat complex. As far as how long it
will take, we do have plans to complete delivery of the medical
record through the end of fiscal year 2008. However, and what
you have seen is, you know, a slow progression from 2001
forward.
Some of the issues are as Colonel Marinkovich stated, but
you also have to understand that the state of the industry is
not exactly rushing ahead of us to say this is how we should do
it. A lot of the territory that we are stepping into is new
ground.
There are no standards in certain spaces that we are
working with and we are having to derive those standards in
advance of, say, what the national interests may come to
conclude.
So there are a lot of technical challenges. I have seen a
lot of activity in the past 24 months which is extremely
pleasing and great to see. We have a long road to go. and we
are working as collaboratively as we have ever worked in the
past.
Mr. Mitchell. Thank you.
And one last question for anyone on the panel. Are there
any possible Health Insurance Portability and Accountability
Act (HIPAA) restraints or constraints that are standing in the
way?
Colonel Salzman. Well, I think both agencies probably need
to answer independently, but I know on our side, we follow all
the HIPAA requirements as everyone should. So I do not think
there are constraints. There are simply things we have to do to
make sure we cover those bases.
Mr. Mitchell. And the reason I ask that is because we have
heard before that the reason there is no sharing of these
records from DoD to VA is because of HIPAA and that it takes a
long time. I am just wanting to make sure that, if that is a
problem and that has held up any transfer of records that we
take care of that as quickly as we can.
Colonel Marinkovich. I think you are asking a question that
really should not be addressed necessarily to technical people.
We all believe, I think, and I think we would all agree that
there should be role-based security down to the level of an
individual patient.
And so our systems should be able to accommodate whatever
HIPAA tells us to do. And I think, historically, we have had
some issues with that because we have needed to get that kind
of ironed out.
Mr. Green. I would agree. Certainly we are progressing very
sensitively through this area. As a member of Dole-Shalala
Commission, we actually looked into that and did not see any
overwhelming HIPAA constraints that would preclude the sharing
of data. In fact, there are sharing agreements that support it.
But it is something that we do not take lightly. We do not
want to end up in a situation where we are jeopardizing the
privacy of either personal health or identifier information.
Mr. Mitchell. Thank you.
Would you like to ask some before we--as soon as Ms. Brown-
Waite gets through, we are going to take our recess and go
vote.
Ms. Brown-Waite. Just a couple of things. I believe that we
have held hearings in the past where it was absolutely
clarified that there are no HIPAA problems. So please,
gentlemen, do not use that as an excuse. That issue is off the
table. There are not any HIPAA problems.
Do you all agree?
Colonel Marinkovich. Absolutely, ma'am.
Ms. Brown-Waite. I think in the past, it was a great thing
to use as an excuse, but it should not be. That show is over.
Let me ask a question. I have been told this and I would
like a response. Do the various branches of the military use,
for example, the same kind of x-ray, magnetic resonance imaging
(MRI) equipment so that it can be even within the branches
shared? So if you all use separate systems, is that part of the
complicated problem here?
And, you know, there is certainly an ability to save money
by bulk purchasing. Why is this not done? I mean, why are all
these separate systems out there? And any one of you all can
just jump right in here.
Colonel Marinkovich. I think that is for me to answer. The
MHS, Military Health System, has not had an overarching
radiology PACS approach. And so it has been left up to the
responsibility of the services and the sites themselves to
procure those kinds of systems.
Now, part of the reason for that is that those systems are
medical devices and so they fall under a different set of rules
and regulations relative to electronic health records.
And so I think you are absolutely correct. If we had enough
money to go in and tear out everything we had and put in
something new, that would be a positive thing. But because
things have been bought over various periods of time, the life
cycles are completely out of step.
Ms. Brown-Waite. So the health system in DoD has been there
for----
Colonel Marinkovich. I am talking about PACS, ma'am.
Ms. Brown-Waite. I beg your pardon?
Colonel Marinkovich. I apologize. I am talking about the
radiology systems, what are called picture archiving----
Ms. Brown-Waite. Correct. It has been there. This is not
new technology, guys. Okay? It is not new. Why not consolidate?
Why suddenly say, gee, we have disparate systems?
Colonel Marinkovich. I think that is going to have to be
something I will have to leave to Mr.----
Ms. Brown-Waite. And, you know, this is not something that
today we should immediately change. It has been coming. You
know that the sharing issue, it is not new. It has been here
for a very long time.
And to have even this complicated system, these systems out
there that are not even--would it be accurate to say that, you
know, every time that it is transferred over to a hospital that
there is a problem? Would that be an accurate thing to say if
the receiving entity does not have the same ability?
Colonel Marinkovich. Well, once again, you are asking a
question that is a little bit outside of my expertise. I can
tell you that if you are talking about the access to these
kinds of radiology images for certain kinds of uses that we are
in the process of putting together an integration effort that
has made significant strides. We have also worked with the
folks down in El Paso who----
Ms. Brown-Waite. Colonel, I do not mean to be rude. I
really do want to hear your answer. We do have to go to vote.
Colonel Marinkovich. Not a problem, ma'am.
Ms. Brown-Waite. Mr. Chairman, if I am unable to come back
after the vote, I would ask that Art Wu, Minority Subcommittee
Counsel, take my place instead.
As you know, Mr. Bilbray is from California and he
rightfully went to be home with his constituents during the
tragic fires that are taking place.
Mr. Mitchell. So without objection.
Ms. Brown-Waite. Thank you.
Mr. Mitchell. Thank you.
This hearing is recessed.
[Recess.]
Mr. Rodriguez [presiding]. Thank you very much. I know the
Chairman hopefully will be making it pretty soon. Let me once
again just thank you not only for your service but for your
testimony.
Some of you, I gather, had the opportunity to listen to the
testimony of the GAO report. Do you all have any comments in
terms of their findings and the problems that were identified
from their findings?
Mr. Green. Having reviewed those findings in the past and,
you know, through many efforts, you know, we have made a lot of
progress. I have to agree. And we continue making progress.
Is there a need to focus our energy, create a strategic
direction between the two departments that is tangible, that we
can build to? I think that is the opportunity that exists.
And that is one of the points that I clearly take away from
the GAO report, that a combined plan is necessary that is
tangible, sets expectations, objectives, and that we can build
to. So I would be remiss if I said I did not agree.
Mr. Rodriguez. But the GAO has indicated that you have not
come up with a long-term plan. And I know the military. If they
are good for something, they are really good for planning. I
know you have them all over and I am sure you have some on the
shelf. So what is the problem?
Mr. Green. We have plans to deliver, and I invite my other
colleagues here to comment, but we have plans to deliver
specific functionality. How that equates into the long-term
strategy is somewhat vague.
But we are not doing the wrong things. There is absolutely
no question in my mind that the things that we do are the right
things. It is just how do they fit into the overall strategy of
how VA and DoD need to support our population into the future.
Mr. Rodriguez. Colonel, anyone else?
Colonel Marinkovich. Well, I was going to start by just
apologizing that I do not have full visibility to be able to
answer the question completely. But I know the 2 years that I
have spent at CITPO and the Military Health System has
demonstrated to me that there is just an increasing commitment
to share.
And I know that just in this last year, we have been
working to share electronic documents and radiology images for
regular providers between the DoD and the VA in a way that, you
know, is just very encouraging to me. I spent a lot of time
working with the VA people and our DoD colleagues to achieve
that. The visibility again is just not----
Mr. Rodriguez. And, by the way, I was glad that Colonel is
it Salzman?
Colonel Salzman. Salzman.
Mr. Rodriguez [continuing]. That you indicated the need for
resources in order to make that happen. Although, as I recall,
we have pumped a good amount of--I cannot quote you the amount
in the past--whether it has gone for that purpose, I do not
know--but we have kicked in some resources in the past.
But you need to let us know the amount of resources that
are needed in order to make this happen because I think it can
be more cost effective in the long term, not to mention that it
would be much better for our soldiers for them to be able to
have that folder and make better decisions when it comes to
benefits and other types of treatment.
Yes, sir. Go ahead, Colonel.
Colonel Salzman. Thanks for that support. The problem is
that where the money is allocated makes a difference in what
programs get supported and how it goes forward. There are so
many requirements out there that are dedicated and focus on one
area. To sustain, that requires some intention, you know, from
Congress through DoD and VA to the specific projects.
Mr. Rodriguez. And it is my understanding that your program
is running out of money. Is it because it was not allocated
sufficient resources or what?
Colonel Salzman. No, no. It is not that. It is ending as
far as fiscally. That is the end of that project. And therein
lies the problem that if you identify toward the end of a
project something that has been successful, the lag time in
getting legislation to support that in the future----
Mr. Rodriguez. That is why the GAO has indicated that you
have not come up with a plan, a long-term plan that would go
beyond a year, 2 years, 3 years, whatever. And that is why that
is essential so that those resources can continue to flow.
Colonel Salzman. And part of it is the lessons learned that
you gain as you go through the process. The feedback loop to
Congress to legislate specifically, that lag time does not
inform the legislative process, I think.
Mr. Rodriguez. And, Lieutenant Commander Martin, did you
want to make any comments on the GAO and the fact that I know
you have been engaged for a good 15 years? You know, what has
been the problem?
Commander Martin. Well, sir, it is my opinion that we do
have a schedule. It depends on what we are working specifically
on. If you take North Chicago for an example, you know, our
timeline is 2010. So we have built a schedule to have your
facility operational in 2010 with the systems that the
functional users are identifying.
Mr. Rodriguez. Okay. Let me go ahead and get, Mr. Wu, do
you have any questions?
Mr. Wu. Yes, I do, Mr. Rodriguez. Thank you very much.
Commander Martin, looking at your testimony--and, Mr.
Rodriguez and Chairman Mitchell, appreciate the opportunity for
the Ranking Member to have the questions asked through her
Counsel--you have been working at this since 1992. Can you tell
me what the original deployment date was for CHCS1 and 2?
Commander Martin. The original deployment date for CHCS1?
Mr. Wu. Its implementation.
Commander Martin. I do not know that off the top of my
head, sir. I know what my schedule was in the Navy and we had
CHCS1 implemented on the Navy side on schedule. I mean, we
followed it. I did that for 24 months between 1992 and 1994.
Mr. Wu. Don't you think the original, or maybe someone else
out there may know, don't you think that implementation date
was supposed to have been probably a decade ago? Anyone?
Colonel Marinkovich. I think the answer to that question
may be able to come more easily from the next panel. But are
you asking CHS1, sir, or CHS2?
Mr. Wu. When do you think CHS1 started?
Colonel Marinkovich. I know when I was in Tripler, it was
one of the beta sites and that was 1989.
Mr. Wu. Right. It originally started in 1987. We are in
2007. We are talking about 2010. And VA has got to follow the
lead of DoD in order to get that integrated system, correct?
Mr. Green. Sir, if you are asking that VA has plans to
create an integrated system that go out several years, I think
the current year target is 2014 or so and that we have been in
the process of doing this for several years. That is correct.
Mr. Wu. All right. Commander Martin, I have another
question for you if you do not mind. You stated in your
testimony that your mutual goals with VA is to have an
interoperable information system that supports joint clinical
and business operations at the joint venture at Great Lakes
Naval Training Center in North Chicago by June 2010.
And I think we all look forward to that happening. I think
that will be the model on a lot of the governance issues
between VA and DoD that can be ironed out, at least at that
test site, maybe not uniquely, geographically unique to that.
My question to you is, right now does DoD trust VA's IT
security measures?
Commander Martin. In my opinion, sir, they trust them. The
issue is whether or not the VA is recognized as a trusted agent
with DoD which is separate.
Mr. Wu. Okay. Are they a trusted agent?
Commander Martin. As of today, sir, in my opinion, no.
Mr. Wu. And I also understand the DoD's distrust of VA's IT
issues and vulnerabilities has resulted in DoD placing its own
servers in VA's four polytrauma centers. Is this true?
Commander Martin. I am not an expert in that area, sir. I
could not answer that one.
Mr. Wu. Mr. Green?
Mr. Green. I am not an expert either. There may be somebody
in the panel behind me that can address that.
Mr. Wu. So you are punting?
Mr. Green. I am punting, yes, sir.
Mr. Wu. Let us say that it is true. What does that indicate
to you?
Mr. Green. The placement of servers in the VA application
in order to support or VA environment in order to support DoD
applications, it would indicate that we are adding layers of
complexity in order to achieve the end goal.
Mr. Wu. Okay. A question collectively for the panel, not to
put any of you on the spot. This whole issue of
interoperability exchange and timely exchange of information,
do you think this is a technological barrier that is taking
this 20-year tango down this path or is there a cultural will
issue?
Colonel Marinkovich. I would have to say from my vantage
point, it is a little bit of a combination of both because the
question is what data do you want to share. And if the answer
is, well, what you put in CHCS, then I agree completely. It
should not have taken us 20 years to share what is in CHCS with
what is in VistA, basically being very similar systems.
But if you are talking about the rest of the EHR, I think
that has only begun in the last 5 or 6 years to be truly an
industry in itself and I think we are pretty close to being
able to deploy that kind of capability between the two agencies
or the readability, the readable electronic health record.
Mr. Wu. Anyone else? Colonel Salzman.
Colonel Salzman. Yes, sir. As far as interoperability, and
I did not get to those comments in my testimony, but I think
that that is where we are now capable of doing that
technologically.
But if you look at the private healthcare sector, they are
facing the same problem. And I think by breaking ground, the
DoD and VA are leading in the efforts to demonstrate
interoperability and that the private sector will follow that
path as we extend it into Regional Health Information
Organizations (RHIOs) and into the national health information
network. So I do not see us in looking at private healthcare
sector as being behind. I think we are in the lead. And that--
--
Mr. Wu. I do not think there is an argument there even
though I have seen a couple meltdowns on the RHIO attempts.
Colonel Salzman. Right.
Mr. Wu. Is that not correct? San Diego melted. I mean, as
the private sector, public sector initiatives and DoD and VA
are leading the way.
I am just asking after 15, 20, however many years you want
to call it, the GAO says a decade, we say two decades, some say
25 years, is why have we not moved, or as the opening statement
of Ms. Brown-Waite is we have seen probably more movement and
in Chairman Mitchell's statement as citing more movement in the
last 24 to 18 months than we have in the last 20 years? What do
you attribute that to?
Mr. Green. Well, the standards are being developed kind of
by Health Level 7 and different organizations, so there is, I
think somebody mentioned it before, we are kind of charting
uncharted territory, and so there is a learning curve that has
to happen in doing that.
Colonel Marinkovich. I would say, too, I mean, from my
vantage point, it is because we are being pushed to do that. I
mean, I appreciate visionary leaders like General Dunn, who
used to lead us at Madigan, who would set the bar way out in
front and say make it happen. And I think it is leadership that
makes these things happen. So we appreciate it.
Commander Martin. Yes, sir. I have to agree. I think in my
opinion, anything is technically possible. Now it is defining,
meeting the mission of the VA and meeting the mission of DoD
and deciding what are those data fields and elements that we
absolutely have to share and now we are finally at the point
where those are being defined by the functional providers. And
once we have that information, the technology will follow,
giving them the information they need as the functional
experts.
Mr. Wu. Thank you. And I appreciate the latitude that the
Chair has offered us.
And piggybacking on Ms. Brown-Waite's questioning of you,
Colonel Marinkovich, you know, talking about the PACS system,
talking about the multiple MRI, ophthalmoradiography
capabilities we have within the services and even within the
VA, multiple, multiple systems that do not communicate with
each other, what would be your reaction, and I am not asking
you to speak for the Department, about an interoperable clause
in the procurement of major medical IT or medical devices with
an IT component of both DoD and VA purchases where there is a
standard utilized where there has to be a sign-off that there
is an interoperability issue or possibility that that is
addressed during the procurement phase?
Colonel Marinkovich. I am strongly in favor of such a
thing. I have to tell you. I devoted much of the last maybe 6
or 7 years to standards organizations and the reason we do not
follow standards is we do not have discipline. I mean, that is
what you need to have to follow standards.
But I think that is only part of it. Once we have done
that, we then still need to have an overarching governance and
an overarching management structure to make the systems that
could talk to each other actually connect. So I agree with you.
You are absolutely----
Mr. Wu. I appreciate that.
Your indulgence one more time, Mr. Rodriguez. I have a
question for this panel and the next panel is an issue that you
see in the press quite a bit now as we talk about our wounded
warriors come back from OIF and OEF is TBI, mental health
component, PTSD, and how they are related perhaps sometimes,
many times.
What are we doing about capturing that information and
sharing that information? I do not see any of that in anyone's
testimony, in any of the briefings we have had on what we are
doing as these soldiers and servicemembers transition to the
VA.
How do they get treated if there is no PTSD record or
record of medical annotation or any other mental health issue
or what you need to capture on the requirements under TBI if
you are going to screen? How is the VA going to do that or how
does VA work a compensation and pension claim for those
diagnoses if that information is not being transferred in some
format? I am not even talking electronically to the VA. How
does the VA do their job if they do not get the information?
I know that mental health records are held separately. I
used to be in the Army, an inpatient admin, and those mental
health records are kept separately or retired separately. I do
not see where they are merged. So if they are not merged, where
do they go to and how does VA get access to them?
Colonel Salzman. If I could answer from how we do that
locally and we are trying to design a model for expanding to
the enterprises, which we always keep in sight, we have a swap
process. I do not know if you were able to see that when you
were out there, but that interview process captures all the
survey information.
Mr. Wu. Actually, we did see that, Colonel Salzman. Is that
Madigan specific?
Colonel Salzman. Yes, sir. And that----
Mr. Wu. And what about the other 65 facilities?
Colonel Salzman. Well, the DoD is looking at that. What
happened was there was a mandate to come up with a solution but
no overarching process to do that. And so of necessity, which
is what usually happens, and particularly with TBI, you have a
new requirement and you have to address it. And there is not an
enterprise process that addresses it effectively to deliver a
solution that handles the soldier in front of you.
Mr. Wu. It was pretty impressive what you did at Madigan on
that issue, but what you are saying, I do not know, Mr.
Rodriguez, is if you have PTSD or TBI, then we should send you
to Madigan then because no other place can screen you well?
Colonel Salzman. Well, the benefit of doing it there is
that you can develop a model, test it, see how it works, and
then you can share it enterprise-wide. And so the TBI question
is not a simple question. It is complicated for the
neuropsychologist to answer.
So thinking that we can diagnose and have a treatment plan
that is cookie cutter and you can spread across the enterprise
at this point, I think, oversimplifies the problem. And so what
we are doing is going through the steps to validate like the
screening process. If you take the two screening questions that
were supposed to be put into the post-deployment interview----
Mr. Wu. Right. Are there any other military treatment
facilities (MTFs) that are doing this or just----
Colonel Salzman. Yes, sir.
Mr. Wu [continuing]. Madigan?
Colonel Salzman. No. There are other MTFs.
Mr. Wu. How many?
Colonel Salzman. Colorado kind of had the lead because they
had done it before we did it and they used the Air Force
Academy, the psychiatrists there as their referral. So they had
one provider to refer to.
But the problem is if your filter is too open, you would
get 80 percent of people coming through. If you refine that
filter with background questions, you can cut it down to 16 to
20 percent which we did in our pilot program. So----
Mr. Wu. I appreciate that. We are looking to see exactly
what the requirement is and how you implement that or address
that enterprise-wide though.
Thank you very much, Mr. Rodriguez.
Mr. Rodriguez. Okay. Thank you very much.
And let me, one quick question or maybe two, yes or no on
the part of each of you.
In your opinion, could the Department of Defense and the VA
start to share all the noncomputable data that exists right now
on our soldiers' healthcare and pull that off within 12 months?
Yes or no? All the data that is not in the computers,
paperwork, information.
Colonel Marinkovich. Yes.
Mr. Rodriguez. Okay.
Colonel Marinkovich. It is currently in our EHR systems,
yes.
Mr. Rodriguez. Within 12 months, you say yes. Thank you.
Mr. Green. The electronic data, the plans are to share
that, yes.
Mr. Rodriguez. Within 12 months, you think you can pull it
off?
Mr. Green. That is the plan, yes.
Commander Martin. In my opinion, yes, sir.
Mr. Rodriguez. The question is, can you do it, can you pull
it off within 12 months?
Mr. Green. Yes.
Commander Martin. In my opinion, yes, sir.
Colonel Salzman. I will agree, yes, sir.
Mr. Rodriguez. Okay. We will probably have a hearing in 12
months and see where we are at, in 6 months.
Let me ask you one additional. And, Colonel Marinkovich----
Colonel Marinkovich. Marinkovich, yes, sir.
Mr. Rodriguez. Yeah. Sorry about pronunciation. You
indicated that leadership was one of the obstacles in putting
the document files and the imaging and the progress or the lack
of progress in development of the Department of Defense
electronic medical record systems and being able to get that
through.
Any other obstacles there besides leadership?
Colonel Marinkovich. If I could be so bold as to correct a
little bit. What I said was that leadership is what makes us
move forward. And I do not think it is an obstacle. It is just
a requirement. You cannot work in an organization like ours or
the VA, I would think, without the leaders agreeing and the
leaders having a vision.
And I think the point I was trying to make is that over the
last maybe 3 years, I have just seen an enormous amount of
leadership and vision from the leaders that I have had to work
for. And I think that is why we have made a lot of progress to
this point.
Mr. Rodriguez. Is it safe to say it just has not been a
priority on the part of the Defense, DoD?
Colonel Marinkovich. If you are asking prior to that, sir,
I just cannot answer. It is outside of my experience. But I
know now the people that I work with within my experience,
there is no doubt it is the highest priority.
Mr. Rodriguez. Any of you want to comment? Have you all
seen the reports of the GAO on your lack of performance in that
area? Have you all seen it? Say yes or no.
Colonel Marinkovich. Yes, I have seen it, sir.
Colonel Salzman. Yes.
Mr. Green. Yes.
Commander Martin. Yes, sir.
Mr. Rodriguez. So all of you have seen that lack of
performance in that area? Okay. And so we are saying that
within 12 months, we can try to pull off some major things and
that you are going to let us know if you need additional
resources.
Colonel Salzman. Yes, sir.
Colonel Marinkovich. Yes, sir.
Commander Martin. Yes, sir.
Mr. Green. Yes.
Mr. Rodriguez. Mr. Wu, any last questions?
Mr. Wu. No, sir.
Mr. Rodriguez. Thank you very much. Thank you for being
here. Thank you.
Let me welcome panel four to the witness table. Dr. Gerald
Cross is the Principal Deputy Under Secretary for Health at the
Department of Veterans Affairs. Dr. Stephen Jones is the
Principal Deputy Assistant Secretary of Defense for Health
Affairs at the Department of Defense.
Gentlemen, we welcome you for your insight and I would ask
for each of you to introduce yourselves when you make your
comments. I want to recognize Dr. Cross.
STATEMENTS OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY PAUL
TIBBITS, M.D., DEPUTY CHIEF INFORMATION OFFICER, OFFICE OF
ENTERPRISE DEVELOPMENT, OFFICE OF INFORMATION AND TECHNOLOGY,
U.S. DEPARTMENT OF VETERANS AFFAIRS, AND CLIFF FREEMAN,
DIRECTOR, VA/DOD INTERAGENCY PROGRAMS, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND
STEPHEN L. JONES, DHA, PRINCIPAL DEPUTY ASSISTANT SECRETARY OF
DEFENSE (HEALTH AFFAIRS) U.S. DEPARTMENT OF DEFENSE;
ACCOMPANIED BY CHARLES CAMPBELL, ACTING CHIEF INFORMATION
OFFICER, TRICARE MANAGEMENT ACTIVITY, U.S. DEPARTMENT OF
DEFENSE, AND DAVID GILBERTSON, PROGRAM MANAGER, CLINICAL
INFORMATION TECHNOLOGY PROGRAM OFFICE, U.S. DEPARTMENT OF
DEFENSE
STATEMENT OF GERALD M. CROSS, M.D., FAAFP
Dr. Cross. Sir, I am pleased to be here today.
And I wanted to point out that we have given you some
handouts. We have two that we provided to the Members and I
believe we have a poster for the audience over here behind us
that reflects our timelines.
Good morning, Mr. Chairman and Members of the Subcommittee.
Accompanying me are Dr. Paul Tibbits to my right, Mr. Cliff
Freeman farther to the right.
VA is working with DoD to move efficiently to exchange
medical information to better serve our clinicians caring for
servicemembers and veterans. And although we have recently made
significant progress in sharing health data, we realize that we
still have more work to do together.
Today my comments will focus on five components of data
exchange, video teleconferencing, scanned information,
bidirectional exchange of text, and the exchange of computable
data, and case tracking using a veterans tracking application
called VTA.
First, my staff report that video teleconferences for
physicians and nurses at VA polytrauma centers with their
colleagues at Walter Reed and periodically those at Bethesda
are very effective, offering a format where the clinicians can
directly exchange information and ask questions. These
conferences also enhance collaborative relationships.
VA level one polytrauma centers now receive digital
radiographic images and scanned inpatient information for all
patients transferred from several military treatment
facilities. These facilities include Walter Reed and Bethesda.
The inpatient information arrives at our polytrauma centers
level one in the form of nonsearchable PDF files.
The bidirectional health information exchange supports the
real-time bidirectional exchange of current medical----
[Bells ring for votes in the House.]
Mr. Rodriguez. It reminds you that you still might be in
school.
Dr. Cross. Yes, sir. It is interesting to compete with
that.
The Bidirectional Health Information Exchange supports the
real-time bidirectional exchange of current medical data in the
form of noncomputable text between VA and DoD treatment
facilities for all of our shared patients. These data include,
here is what it includes, discharge summaries, emergency room
reports, theater data, inpatient and outpatient laboratory
data, pharmacy data, radiological text reports.
In addition, BHIE functionality is being expanded, and here
is a key point, to facilitate the sharing of additional key
data to include clinical encounter notes, problem list, and
vital signs.
In 2008, we plan to have more viewable data. Viewable data
will include vital signs, scanned documents, and family and
social history reports.
The interface between the DoD clinical data repository and
VA health data repository known as CHDR permits us to share
computable allergy and pharmacy data between the departments.
By computable, we mean these data augment automatic
decision support capability so that VA and DoD providers
treating the same patients see automatic alerts when a
prescription order would result in adverse drug or allergy
interaction.
This interface is being used by DoD and VA providers at
seven locations where large populations of patients receive
care from both VA and DoD healthcare systems.
The work to make data computable between two different
healthcare systems is very complex and requires complete
standardization of data. VA and DoD with the U.S. Department of
Health and Human Services and others are leading the national
effort to identify standards that are robust and mature enough
to support full interoperability between computer systems. This
work is also dependent upon the prioritization of these data by
our clinical communities within VA and DoD and the ability of
each department to get these data into our data repositories in
a standardized format.
Despite these complexities, the IT staff has informed me
that jointly we are doing the work to begin sharing laboratory
data in computable format by the end of 2008. Beyond
laboratory, we are analyzing the feasibility of sharing vital
signs, orders, radiology reports, encounters, immunizations,
and problem list in computable format. The order in which these
domains are standardized and shared in computable format will
be prioritized by both VA and DoD clinicians.
As you aware, sharing inpatient data is a particular
challenge since most of the historical data is not in
computable standardized electronic format. VA and DoD now have
a study underway that will address sharing inpatient data. VA
and DoD have agreed that any joint inpatient record will
utilize the look and feel of VA's award-winning VistA records
as a benchmark or target system.
I want to emphasize that in my view, it is important to
build on VA's electronic health record that has clinical
functionality, highly praised by doctors and nurses, and is
credited with helping VA achieve national benchmarks for
quality as well as national award recognition.
VA has achieved the ability to assess patient tracking data
enterprise-wide using Veterans Tracking Application. VTA is a
modified version of DoD's Joint Patient Tracking Application.
Our case managers can now access VTA to assist with tracking
patients treated at both VHA and DoD facilities. VTA is
compatible with DoD's JPTA allowing overnight electronic
transfer of clinical data on medically evacuated patients.
Finally, our departments are collaborating in the
development of an information interoperability plan. The IT
staff expect this to be drafted as early as 2008 and proceed
toward the concurrence and clearance for a final plan later in
2008. This plan will be recommended to the deputy secretaries
of both departments and subsequently overseen by the Joint
Executive Council (JEC), Health Executive Council (HEC), and
the Benefits Executive Council (BEC).
This plan will serve as the strategic organizing framework
for current and future work to set the scope and milestones
necessary to measure progress toward the intermediate goals and
an end state needed to continuously improve service to veterans
and members of the Armed Forces.
Sir, my colleagues and I stand ready to answer your
questions.
[The prepared statement of Dr. Cross appears on p. 74.]
Mr. Rodriguez. Dr. Jones?
STATEMENT OF STEPHEN L. JONES, DHA
Dr. Jones. Thank you, Mr. Chairman.
It is a pleasure to be here and I would like to go on
record and join your comments and that of the Chairman as to
thanking those great men and women who serve in the Military
Health System and serve our folks in harm's way and also for
the veterans healthcare workers that do such a great job in
treating wounded warriors. So thank you, sir.
Joining me today is Chuck Campbell, the MHS CIO, and
Colonel Gilbertson, who is a technical individual, particularly
in theater programs.
Thank you for inviting me to update you on activities to
improve sharing of electronic health information between the
Department of Defense and Department of Veterans Affairs.
Since I last spoke to you in May of this year, we have made
substantial progress in sharing information and it is
gratifying to know that even the GAO recognize that progress is
being made. Yet, we know that much work lies ahead.
Today across town, our military medical leaders are meeting
with former Senator Dole, with each other, and with VA
participation to help move organizations to the next level of
service coordination and systems integration on behalf of our
veterans, particularly our wounded warriors returning from Iraq
and Afghanistan.
We know we need to cut through the bureaucratic barriers
and that has become quite evident to all of us in this room.
Today I will let you know about the aggressive actions underway
to do exactly that.
DoD recently directed a significant change. As you have
heard, as of October 6, VA providers now can access theater
clinical data for patients who transfer to the VA for care or
evaluation. The theater clinical data includes inpatient notes
and outpatient encounters, as well as pharmacy, laboratory,
radiology, and other important clinical information. This means
that VA doctors are able to see clinical information on and
better prepare for treating severely injured patients before
they arrive in VA facilities.
We have also taken steps to better integrate and understand
our two cultures. In addition to sharing information, we are
sharing people.
Just a few weeks ago, we exchanged our most senior
Information Technical Officer. Chuck Hume, our former Deputy
CIO for the Military Health System, moved over to the VA. And
Chuck Campbell, the former Deputy CIO for Health for the
Veterans Health Administration, joined us as our new Chief
Information Officer.
This exchange is about more than two people. It signals a
new level of trust, respect, and commitment for change that is
evident in DoD and VA staff alike and provides an intensified
focus on improving our service to wounded warriors.
Here are the major points of progress we have achieved or
will achieve this year. One, continuity of care. For patients
treated at both VA and DoD facilities, providers can view
electronic health data from both departments.
By the end of 2007 calendar year, all essential health data
will be, in the words of the President's Commission on Care for
America's Returning Wounded Warriors, ``Immediately viewable by
any clinician, allied health professional, or program
administrator who needs that at a VA or DoD facility.''
Two, continuity of care for polytrauma patients. In
response to the urgent need for VA providers at polytrauma
centers to have as much information as possible on inpatients
transferring for their care, DoD began sending electronic
health information such as----
Mr. Rodriguez. Dr. Jones, I apologize. I have less than 4
minutes to go vote. Let me recess and I will be right back.
Dr. Jones. All right, sir. Thank you, sir.
Mr. Rodriguez. Thank you. I apologize.
[Recess.]
Mr. Rodriguez. Would you like to continue with your
testimony? Do you want to continue with your testimony?
Dr. Jones. Thank you, sir. And thank you for your quickness
in getting over and getting back.
Mr. Rodriguez. There were two votes.
Dr. Jones. Sir, we were talking about the polytrauma
centers and I would just like to echo Dr. Cross' comments.
Having visited each of the polytrauma centers, it has been
operational and working well. And one of the reasons is because
they do include VTC conferences between the sending and
receiving hospitals which enhance communication between the
caregivers and the family members and patients.
Three, medical services coordination. DoD and VA have
extended the sharing concept to include coordination of our
other medical services. For example, when a DoD and VA medical
facility does not have the equipment or personnel needed to
process certain types of lab tests, DoD can send the test to a
VA lab for processing or VA can send the test to a DoD lab. The
end result is expedited testing and results shared
electronically enhancing the quality of care for our patients.
Four, a joint inpatient electronic health record. Since our
announcement in March to assess the feasibility of DoD and VA
developing a joint electronic inpatient health record, we have
awarded a joint contract to conduct a study and we will see
those findings in the next several months.
We know that DoD medical staff require a flexible, mobile,
and highly scalable electronic information system in the combat
theater that we describe as one system in garrison and one in
theater.
We will also ensure our unique theater medical systems work
with the VA to support continuity of care for our veterans. It
is the agency's goal to take the best from the DoD and VA
systems in designing this joint inpatient system.
Five, joint governance. VA and DoD electronic health
information collaboration is a major component of the
Department's joint strategic plan. The Under Secretary of
Defense for Personnel and Readiness and the VA Deputy
Secretary, Co-Chair the Joint Executive Council. Supporting the
JEC is the Health Executive Council Co-Chaired by the Assistant
Secretary for Defense of Health Affairs and the VA Under
Secretary for Health.
In addition, the Chief Information Officers of the Military
Health System and the VHA Co-Chair the Health Executive
Council's Information Management/Information Technology Work
Group.
Through these joint governance efforts, an unprecedented
degree of collaboration between VA and DoD is occurring. We
understand each other's mission and we are ensuring change
occurs at the right levels.
Six, standards adoption. According to many experts,
together DoD and VA lead the Nation in health information
technology, implementation of interoperable standards, and
electronic health information sharing.
The Certification Commission of the Healthcare Information
Technology, an independent, nonprofit organization, that serves
as the Department of Health and Human Services certification
entity for electronic health records systems recently certified
AHLTA, our electronic health system, assuring our users,
partners and patients that our information system meets all
basic criteria for functionality, interoperability, and
security.
In conclusion, as always, we appreciate the insights and
recommendations and guidance of this Committee. We are all
working toward the same end, to provide the highest quality
care for our Nation's heroes, past and present. And we
recognize that we need to work together to achieve our goals as
efficiently and effectively as possible.
Thank you for allowing me the opportunity to appear before
you and to testify about DoD/VA electronic health information
sharing achievements, goals, and plans. Thank you.
[The prepared statement of Dr. Jones appears on p. 79.]
Mr. Rodriguez. Thank you, Dr. Jones.
And both, Dr. Jones and Dr. Cross, do you want any of the
individuals that are with you to make any comments or
testimony?
Dr. Jones. No, sir.
Dr. Cross. No, sir.
Mr. Rodriguez. Okay. Thank you.
Good to see, David, Colonel Gilbertson. I know that we have
a good friend in common back in San Antonio, so good seeing
you. Okay? And thank you for being here with us.
And all of you, thank you for your service and what you
have done for us.
Let me quickly ask: The Chairman of the Committee, full
Committee and the Ranking Member also of the full Committee
requested that I ask you this question and it is in reference
to, I think, Lieutenant Colonel Mike Fravell that we ask to
stay in Washington and remain engaged in the development of the
JPTA and VTA.
And it is our understanding that the VA wants Mr. Fravell
to continue to consult on the VTA, but that he has been shut
out of the future efforts with JPTA. And the question would be
that some of us felt that, in fact the Chairman and others,
that would not be advantageous to keeping him managing the
program since he contributed to much of the success. Do you
want to comment on that?
Dr. Jones. Sir, the individual you speak of did a great job
in helping develop JPTA. But as you know, decisions as to
assignments are made by the services. So I will be glad to get
back on the record to you and pass your question to the service
if that is appropriate, sir.
[The following was subsequently received:]
Lieutenant Colonel (LTC) Michael Fravell will remain assigned
in Washington in a position where he can make an impact to the
information technology enterprise as the Director of
Engineering for AHLTA. In his role, he is not only assisting
with Joint Patient Tracking Application (JPTA), but he is
contributing to the entire Department of Defense (DoD)
electronic health record. Since the Assistant Secretary for
Health Affairs oversees the DoD component of the joint venture
with the Department of Veterans Affairs (VA), LTC Fravell is
involved in projects with the VA. LTC Fravell has also been
made available to the VA as a consultant on the Veterans
Tracking Application, and he is involved with developing
additional functionality in the JPTA.
Mr. Rodriguez. Okay. And then let me also, Dr. Jones,
compared to other Department of Defense and VA applications,
the JPTA and VTA are relatively inexpensive, almost no new
development has been done since the JPTA, in the 18 months,
even though the user community is asking for new
functionalities.
So why hasn't the Department of Defense medical health
systems embraced this technology and expanded its capabilities?
Dr. Jones. Let me ask Colonel Gilbertson if he would
address that question, please.
Colonel Gilbertson. Sir, on the development of JPTA, the
continued efforts from theater in terms of growing the JPTA
application are indeed continuing. JPTA is part of the DoD
family of systems or is now part of the enterprise solution.
In fact, we are now building out the functionality of JPTA
so that all of the information that is in JPTA becomes part of
the medical record. That was the primary challenge with JPTA is
it was its own system, a separate stovepipe system. So that
information never made it into that longitudinal health record.
So by keeping the functionality of JPTA is really what the
providers wanted and making it part of the enterprise system,
we are now able to make sure that all of that information is
captured in the electronic health record so that it can be
shared to all DoD and VA providers. So that is really where our
effort is at.
So we are definitely still developing against JPTA, the
current application, and we are trying to enhance it based on
the feedback that we got from Landstuhl and other providers. We
were just out there last week and we are very much engaged with
the actual users to make sure that what we are building
continues to meet their needs.
Mr. Rodriguez. Thank you.
Mr. Wu?
Mr. Wu. Thank you, Mr. Rodriguez.
Dr. Jones, piggybacking on Mr. Rodriguez's question here on
Lieutenant Colonel Fravell, and not to beat a dead horse to
death here, is if my memory serves me correctly, I have a copy
of a letter from Dr. Kussman, our now Under Secretary of
Health, and Admiral Cooper, our Under Secretary of Benefits,
letter that went to DoD asking for an extension on Lieutenant
Colonel Fravell.
And there is a subsequent letter signed by Chairman Filner
and Mr. Buyer to then acting Secretary Garens saying that they
would like an extension of Lieutenant Colonel Fravell, I am not
sure if we ever got a response to that or not, to continue the
work of JPTA and VTA.
I do not know if you would like to comment on that at all.
Colonel Gilbertson. As I was saying, the JPTA is part of
our enterprise solution. And as you know, AHLTA ultimately,
because AHLTA is going to collect the whole patient record, is
a critical part of what we are doing throughout the entire MHS.
Lieutenant Colonel Mike Fravell is assigned in a position
where he can make the greatest impact to the enterprise over
the long run as the Director of Engineering for AHLTA. So in
his role, he is not only affecting the future evolution of
JPTA, he is now affecting the entire product, the entire DoD
electronic health record.
And because we also oversee the DoD component of the joint
venture with the VA, the DoD/VA sharing, he is intimately
involved in all sharing information projects with the VA to
include VTA.
And I have made him available to the VA as a consultant on
future developments of the Veterans Tracking Application and he
is intimately involved with the developer of the additional
functionality in JPTA which is Colonel Hines, who is also in
this room.
So in his current role, he is positioned to go beyond what
he has been able to do before and actually make a huge impact
on the entire DoD and the entire VA as the Director of
Engineering for our electronic health record.
Mr. Wu. Is he working on VTA, JPTA interface right now?
Colonel Gilbertson. Yes, he is. Well, he is working as a
consultant. The VA has their own program office and their own
way of developing. And he is intimately involved in identifying
the requirements for not only VTA, but also he was with us last
week when we went to Landstuhl and he helped understand what
our future is for JPTA and its integration into AHLTA.
Mr. Wu. Well, maybe you can shed some light. We have been
looking at this issue for some time, especially when it came to
light, and there was a Washington Post article where JPTA was
abruptly cut off from the polytrauma center in Richmond while
the doctor was on--I think that has been resolved. I think they
all said it was a security issue. It was just shut off in the
middle of a program.
JPTA, actually I saw JPTA being demonstrated by Colonel Dr.
Rhonda Cornum probably 2 years ago at a conference. She was at
a Commanders' conference. Said you want to see medical
information being transferred, I will show you. It is not a
medical record, but it is a tracking application, but essential
medical information tracked on that is attached to it as a PDF.
Now, Dr. Jones, AHLTA, AHLTA-T, this year, how much has DoD
TRICARE Management Activity going to spend on AHLTA and the
deployment? Three hundred million dollars plus, I think; is it
not?
Dr. Jones. The program manager should have it.
Mr. Wu. The program manager should have it right down to
the penny, right?
Colonel Gilbertson. The life cycle cost for AHLTA right now
is at $5 billion, but that also is going to include the
inpatient and the ancillary replacements for the Legacy. So to
date, we have spent just over $1 billion on AHLTA and the
sustainment of CHCS which is now part of AHLTA.
Mr. Wu. CHCS1, 2, AHLTA, AHLTA-T, the rebranding. Is there
any difference between AHLTA and CHCS2?
Colonel Gilbertson. Yes. They are totally different
applications. AHLTA is an enhancement upon CHCS. So it sits on
top of CHCS. It does not survive without CHCS. So the Legacy
CHCS is part of AHLTA. You cannot have one without the other.
Mr. Wu. Okay. Then someone needs to correct what we were
hearing as that there is no difference. It is just a
rebranding.
Colonel Gilbertson. No. There is a significant difference.
What AHLTA does is it now documents the clinical encounter.
CHCS was primarily an ancillary system that supported our labs,
pharmacy, radiology, admissions, discharge, transfers, billing.
Now we have a tool that took it from 101 different locations
and brought all that data together and made it semantically
interoperable across the entire enterprise.
It used to be when I moved from one station, when I left
San Antonio and went to Hawaii, I had a blank record in Hawaii.
There was no electronic information available in Hawaii because
all of our systems were disconnected. AHLTA brought those all
together. So now when I moved here from San Antonio, my entire
medical record moved with me. And that is what AHLTA did.
Mr. Wu. All right. Would you describe AHLTA as in Dr.
Jones' words, to track healthcare most effectively in theater,
a flexible, mobile, and highly scalable electronic information
system is necessary? Does that describe AHLTA?
Colonel Gilbertson. Can you repeat the question, sir?
Mr. Wu. I am taking the text right out of Dr. Jones'
testimony. I am just asking if that is AHLTA where he says to
track healthcare most effectively in theater, a flexible,
mobile, and highly scalable electronic information system is
necessary? Is that AHLTA?
Colonel Gilbertson. I think today that it is becoming more
AHLTA than it was 2 years ago. AHLTA was----
Mr. Wu. Does JPTA do that?
Colonel Gilbertson. Say again, sir.
Mr. Wu. Does the medical attachments, the PDFs to JPTA,
would that describe Dr. Jones' statement there?
Colonel Gilbertson. JPTA, if you have the infrastructure.
When JPTA was implemented in theater, the theater had matured
to a point where they had the bandwidth and it provided a
connectivity all the way back to the United States.
What Dr. Jones was talking about is a system that can work
on a ship, it can work on initial deployments when you have no
communications, and it can work far forward on the battlefield
in the hands of a medic. JPTA is not that system. AHLTA is that
system.
Mr. Wu. If we had the Channing Moss issue today with the
surgical team forward Afghanistan and Dr. Oh, that information
and what was captured there, could that be captured under AHLTA
today? Since it came under JPTA, I am just wondering what the
evolution is here.
Colonel Gilbertson. Today without JPTA, that information
can be captured. It would be captured through the current TMIP
suite and the radiology images would be captured and moved as
they are today from a PACS server in theater, that is called
Med Web, to Landstuhl. So, yes, today without JPTA, all that
information could have been captured and moved. At the time,
the answer is no.
Mr. Wu. Okay. Thank you very much.
Now, under the current system that you are describing, if a
Channing Moss situation happened again today, are you saying
that Landstuhl's accepting physician as that patient is
arriving from the mobile air staging facility out of theater
would have all that information that you just described?
Colonel Gilbertson. If the systems were used as designed,
in other words, if the system that was used to enter that
information was the AHLTA solution in theater, that information
would have been available to the Landstuhl provider today.
Mr. Wu. If that situation happened today, would the current
system be able to capture that information as depicted in that
video clip?
Colonel Gilbertson. The current systems in place would
capture that information and move it back.
Mr. Wu. Thank you.
I think we heard you talk about taking JPTA data and
populating AHLTA. Are we saying, and I think that Ms. Embry may
have said this to Mr. Buyer last year, is that there is no
further money and further development of any other applications
under JPTA? Is that true or false?
Colonel Gilbertson. That is not true. We just invested in
JPTA integration into the electronic health record. So----
Mr. Wu. I understand that. But besides the integration
effort, any other applications?
Colonel Gilbertson. Additional dollars specifically to
JPTA?
Mr. Wu. Right. Correct.
Colonel Gilbertson. Well, once it is part of the
enterprise, the dollars that are spent on JPTA modifications
will come out as modifications to the DoD TMIP suite. So there
could be depending on the requirement. And JPTA brings
functionality that will be used and if that functionality needs
to be expanded, then investment will be made in that
functionality. So----
Mr. Wu. To the best of your knowledge, there is no new
money earmarked to new JPTA applications as of today, is there?
Colonel Gilbertson. Well, JPTA will cease to be its own
application. So as we invest in AHLTA and AHLTA-T, we will
invest in enhancing JPTA along with the rest of the AHLTA
suite.
Mr. Wu. Okay. Thank you very much.
Dr. Cross, in your testimony, you stated that DoD and VA
have funded a study to study the mutual development of a joint
inpatient electronic health record. I understand that
initiative took place this year.
Dr. Cross. Correct.
Mr. Wu. Can you tell why it has taken 15, 20 years to get
to this point?
Dr. Cross. I think this is a point in time where the
situation was right to do this. I think you can certainly argue
that it should have been looked at before.
I will ask my colleagues here to comment on that as well.
Mr. Wu. I mean, I could go back and look at the
congressional intent, the legislation, all the way back to
1982, the various legislative initiatives we had.
I have asked GAO to go back on our recess break to look at
how many studies they have done and maybe a GAO study of all
the GAO studies to see how many recommendations on this issue
have been issued in the last decade where the recommendations
have not been implemented.
I am just wondering. What was the impetus to all of a
sudden January 2007 to do this?
Dr. Cross. Actually, there was a good meeting between Dr.
Jones and myself in my office where we discussed what we could
do next and we moved that forward.
Mr. Wu. Okay.
Dr. Jones. I think it is a number of factors. One is, as
Dr. Cross said, we are working more closely together than we
ever had before. I mean, we switched. You know, we have Chuck
Campbell, who was working over at the VA, and Chuck Hume was
working over. So we are working more closely together.
We realized the need, as somebody mentioned earlier,
because of the Walter Reed issues and all the various task
forces and committees puts additional impetus on making it
happen and making it happen faster and making it happen right.
And then thirdly, I think with us, we were getting ready to
invest more heavily into our inpatient record. We now, as you
heard by an earlier person that testified, the AHLTA which was
started as an outpatient record was only implemented into each
of our medical centers last December, so we are the next phase
was to move more aggressively into the inpatient.
And it is my understanding that the VA was looking at VistA
to upgrade because it was time that they needed to refresh
because of the Legacy system they have. So all those factors, I
think, came together to, you know, make this time is right.
And this is not just a study to inform us. This is a study
to inform us so that we can take action. And I would be
surprised if we do not take the information from that study and
make it happen.
Mr. Wu. I have one question and one more than that. I think
that Mr. Rodriguez asked the question. Do you think you will be
able to implement Dole-Shalala within the timeframe?
Dr. Jones. Well, again, I think it depends on, you know,
all of the issues of Dole-Shalala I cannot speak of. The thrust
of both agencies and Secretary England, Secretary Gates, and I
know on our VA counterparts is to implement as much as we can
between the two agencies under existing law.
Of course, those things that we cannot implement because of
law or because of legislative packages will be considered by
this body and the Senate. But we are----
Mr. Wu. Sir, do you see those legislative initiatives
coming up any time soon?
Dr. Jones. It is my understanding that those packages have
been delivered last week or the week before, I am not certain
of the time, by the two secretaries.
Mr. Wu. Thank you, sir.
Dr. Cross. May I echo that we take that very seriously.
Great emphasis and importance is given to that project. Some of
the testimony that I included in my oral statement today
related to time factors and so forth of what we are doing, I
think, relate to that. And on many issues outside of the IT
world, which is probably mostly outside of the IT world, we are
moving forward aggressively as we can to implement those
things.
Dr. Tibbits. Let me add to that since I am the Co-Chair of
Lines of Action 4 (LOA4) (eBenefits portal) which is the IT
portion of this senior Oversight Committee process with Dr.
Jones. And for just the IT slice of your question, yes, we are
very committed to it.
We have a very aggressive series of meetings going on right
now this month to gather requirements from all the other lines
of action. We are now deeply engaged in costing out those
requirements from an IT perspective, the IT support to all
those other lines of action.
We will be presenting that IT plan sometime in the month of
November whenever we are told to go present it to both deputy
secretaries and that will subsequently result in certain
decisions and actions with respect to funding and monitoring
with a scoreboard-like approach of our progress.
So the Administration is very committed to that and we, I
think, have everybody engaged as much as we possibly could in
trying to make that happen at all levels of both the
departments.
Mr. Wu. Dr. Tibbits, would it be safe to assume that in the
requirements identification that you would have a TBI component
there, a mental health, and a PTSD component there?
Dr. Tibbits. That is correct. There is a line of action,
too, which is specifically focused on that.
Mr. Wu. Okay. Dr. Cross, one last question.
Thank you for indulging me, Mr. Rodriguez.
Dr. Cross, you also stated VA and DoD are committed to
ensuring an ongoing partnership to optimize health delivery to
veterans and military beneficiaries. Probably for the record, I
would say here, it be a little onerous to do that now.
Could you highlight since 2003 when we created the HEC and
the JEC all initiatives emanating from DoD, VA's Health
Executive Committee, direct cost of these initiatives, specific
measurable outcomes, everything that has been accomplished?
Dr. Cross. Certainly I think we could do that for the
record.
[The Health Executive Council Highlights, FY 2003-First
Quarter for FY 2008, dated June 10, 2008, appears on p. 98.]
Mr. Wu. Thank you very much.
Thank you, Mr. Rodriguez.
Mr. Rodriguez. Thank you very much.
And both, Dr. Jones and Dr. Cross, thank you very much for
your testimony.
Let me, as you have indicated, that we seem to have made
some significant progress with your dialog. I would just
encourage you to keep dialoguing with each other. This is
really essential for our soldiers and our veterans to try to
make this happen as smoothly as possible and as quickly as
possible.
And so that it just makes sense for anyone who is providing
access to healthcare to our soldiers that data and that folder
or whatever the documentation is with that soldier that they
have access after they leave the military and become veterans
so that we can best not only treat them but see what we can do
in terms of meeting their needs. And I think it would behoove
us to try to move as quickly as possible.
And I would ask you once again, I guess, Dr. Jones and Dr.
Cross, are there any other obstacles out there that we as a
Congress can look at to try to make that happen as quickly as
possible?
Dr. Cross. Let me say very clearly that we support the
generosity that Congress has shown with us. The cooperation
that we have had, there is a new atmosphere, I think, between
DoD and VA. We meet very frequently. We know each other on a
first name basis. We are taking all of these initiatives very
seriously and in many ways, it is a new world.
Mr. Rodriguez. Thank you.
Dr. Jones. And I would just echo that, Mr. Chairman. I
believe that Congress has been more than adequate and has
already given us some funding in DoD to address TBI, PTSD, and
mental health, and we are aggressively moving forward in those
areas.
Mr. Rodriguez. Because I would think that hopefully our
next step, I know in some of the areas already, I know in El
Paso, both the VA and the DoD, they are in the same facility.
They might not communicate as much, but at some point,
hopefully they will start communicating when they are providing
access to healthcare.
And I have other communities and there are some throughout
the country where it would be ideal for both, you know, the
Department of Defense and the VA to get together in providing
access to healthcare not only to our soldiers but also to our
veterans. And where they could do that together, it just makes
all the sense in the world in terms of being cost effective,
not to mention in terms of getting access to our soldiers.
And so are there any now in terms of, I asked you what we
could do, are there any obstacles there that both the
Department of Defense and the Department of Veterans Affairs
have that you still feel that you need to overcome?
Dr. Jones?
Dr. Jones. I think our main areas that we need to continue
to pursue aggressively, which we are, the challenges that are
before us are to ensure that we have funding at the same time
that the VA has funding so that we can move forward with the
various projects in tandem.
Secondly, on our side, it is helpful for us to--as you
know, we have different color money in Washington and we have
to have research and development money, sustained money,
implementation funds, so there is different funds.
So we just need to make sure that we have adequate funding
in the appropriate categories that can allow us to rapidly move
forward as we come forward with our plans that Dr. Tibbits
mentioned to ensure that we are meeting the needs, to implement
Dole-Shalala. That is going to take funding. Congress, we hope
you will consider that.
And, secondly, once we get the plan to have the joint
inpatient record, that is going to take funding. So, again, we
will be able to provide you the necessary justifications so
that you will see fit to make that funding available. Those
would be my comments, sir.
Mr. Rodriguez. Thank you.
Dr. Cross?
Dr. Cross. I will ask my IT colleagues, Dr. Tibbits, and
others to comment as well.
But this is plowing new ground. We are out in front of our
many civilian healthcare systems where they are still using
paper records, where they are still transferring information by
mail. And we are way out in advance of that. We are pioneering
for the country, I think, on how to do this.
And I just hope that we can have the understanding that we
are on, I think, the cutting edge of learning how to do this.
I will ask my IT colleagues to comment as well.
Dr. Tibbits. Well, thank you, Dr. Cross, and thank you for
the question. The learning is a key piece of this.
[The chart is attached to Dr. Cross' statement, which
appears on p. 79.]
Dr. Tibbits. Dr. Cross pointed out that as you look at the
chart there on the easel, the dots get closer together as you
go from left to right. The activity is becoming much more
intense.
But the learning also has to happen and learning at all
levels anywhere from setting requirements all the way down to
deep in the bows of how a server is configured and not so much
HIPAA, but more so the information security policies of both
departments. A lot of exploration and learning has to happen
there.
There is, however, a great interest, a great commitment on
the part of the Administration to do so. The need could not be
greater to serve our Nation's heroes which would bring me to my
sort of last point here while I have the microphone for this
time, this question.
And that is taking the need of our Nation's heroes, taking
the need and formulating that into a plan. I think you have
heard a lot of conversation, particularly from the GAO, but
others also, about the importance of such a plan. If we were
and which we are doing now, by the way, once we have properly
depicted that need, the high priority needs for information
exchange to best serve our active-duty members and veterans,
then we will have a framework to better explain how all this
activity that you see here fits together, how the remaining
activity that is already scheduled that you see there fits
together, and what is the gap with respect to the need and what
you do not see on that chart. That plan we will have together
probably, let us say, by spring of next year. I would call that
an information interoperability plan.
I want to be very careful to emphasize that information
interoperability, the sharing of data, can jumpstart, as you
see there on that board, can jumpstart the service to the way
we treat, care for servicemembers and veterans before we ever
decide to jointly develop software.
So while this study is going on and we are trying to figure
out from a cost perspective will it save money and can it move
the departments forward to jointly develop software, the data
plan can help us now in the short term, in the medium term, and
in the long term to meet veterans' needs and servicemembers'
needs.
So that is the last piece of not just talking about the
need, but actually using the need itself as a planning factor
to put that integrated plan together. That is the next phase of
sophistication we are going to get to and that should drive a
lot of the prioritization activities to learn what it is we
need to learn throughout that entire stack of layers of
information processing that I just alluded to earlier.
Mr. Rodriguez. Thank you.
Mr. Freeman?
Mr. Freeman. As Mr. Wu knows, I have been working with this
for 10 years and I can honestly say in the last 3 or 4 years,
the progress we have been able to make has moved forward
astronomically actually in my opinion.
And I think one of the things the earlier panel said about
the leadership, there is true leadership support. As both Dr.
Cross and Dr. Jones have said, they worked very closely
together.
And I think that as we have moved forward, it is not that
we have created some of these applications, but I think the
important point is that they are actually being used and they
are benefiting the clinical care that we are providing
veterans.
The Bidirectional Health Information Exchange that was
discussed earlier with you, it gets over 3,700 queries a day in
the VA. It is being used by the provider to provide quality
clinical care for our wounded warriors and our veterans. And I
think that says a lot about some of the work that we have done.
Thanks.
Mr. Rodriguez. Let me just indicate I want to thank you and
also just indicate there is no doubt that we will be having
another hearing based on the Chairman's comments, next year.
And so we are hoping that we can make up some ground in that
area.
And I am going to ask Mr. Wu if he has got any additional
comments. No additional questions?
Thank you very much. And I hope that you continue to dialog
together. I also am one of the few that not only sits on the
authorizing Committee, but I sit on the Appropriations
Committee, so I would hope that you come to me and let me know
if you need any more money. Okay?
Thank you.
[Whereupon, at 1:44 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Harry E. Mitchell, Chairman,
Subcommittee on Oversight and Investigations
Thank you all for coming today. I am pleased that so many people
could attend this oversight hearing on sharing of electronic medical
information between the Departments of Defense and Veterans Affairs.
This is a critically important issue. Thousands of our service men and
women require and will continue to require significant medical care as
the result of the conflicts in Iraq and Afghanistan. The most seriously
injured of our OEF and OIF veterans may need a lifetime of care, but
even veterans returning with no visible injury may need assistance with
PTSD or mild Traumatic Brain Injury.
DOD and VA are sharing more and more patients. For example, the
patients at the VA's four polytrauma rehabilitation centers are almost
all still on active duty. And active duty service members will be
veterans sooner or later. A review by the VA's Inspector General of the
500,000 or so service members who left active duty in fiscal year 2005
shows that 92 percent had an encounter with the military health system
while on active duty that resulted in a diagnostic code. In other
words, nearly all of the veterans who go to the VA to get medical care
will have military medical records that should be available to VA
health care providers.
If anyone can convince the American people of the importance of
electronic medical records, it is our first panel. Specialist Channing
Moss is an Army soldier who was shot with a rocket propelled grenade
that lodged in his body. He is alive and walking today because the
medical evacuation team and combat surgeons who operated on him put
their own lives in danger in order to remove live ordnance from
Specialist Moss. Brigadier General Douglas Robb was chief surgeon of
CENTCOM at the time, and he will discuss how important it was that a
copy of the x-ray taken at the forward field hospital was available to
the clinicians in Landstuhl before Specialist Moss arrived.
DOD and VA have been working on the electronic exchange of medical
information for many years. For most of that time, the story is not a
happy one. I am nevertheless pleased to be able to say that DOD and VA
have made more progress in the past 12 to 18 months than they made in
the preceding decade. But there is still much to be done. There is no
reason why, in this day and age, DOD and VA cannot electronically share
the information necessary to treat our service members and veterans. We
should not have to wait any longer. I hope and I expect that DOD and VA
will tell us today that, by no more than a year from now, clinicians in
DOD and VA will have full electronic access to the medical information
they need to treat their patients, whether that information resides in
computers owned by DOD or by VA.
Prepared Statement of Hon. Ginny Brown-Waite, Ranking Republican
Member, Subcommittee on Oversight and Investigations
Mr. Chairman, Thank you for yielding.
Mr. Chairman, I would like to thank you for calling this hearing to
review the status of the electronic medical records sharing between DOD
and VA. This Subcommittee has already held two hearings in the 110th
Congress on the issue of seamless transition of our servicemembers.
The first hearing was held in March and the second in May, both of
which focused primarily on the sharing of critical medical information
of critically wounded servicemembers between DOD and VA.
I would like to assure the witnesses here today, that this issue is
of the utmost importance to all Members of this Committee, regardless
of political affiliation. I am pleased the Chairman has requested that
representatives from DOD testify here today. It will be important to
hear their perspective on the timely exchange of critical medical
information between DOD and VA for the seamless continuum of delivering
healthcare to our servicemembers.
I look forward to hearing the steps DOD has taken to allow all
critical medical information to be viewed by the VA when active duty
servicemembers are transferred to VA facilities. In addition, I will be
interested in hearing from VA on whether technological obstacles or
bureaucratic intransigence prevent this from occurring today.
This past week, staff members visited Keesler Air Force Base and
the VA Medical Center in Biloxi, Mississippi to see how the Air Force
and the VA are coming together in VA/DOD resource sharing.
Unfortunately, the progress in this area is a result of the
devastation of Hurricane Katrina and the dynamic personalities of
senior leadership at these facilities, and not the Veterans
Administration and the Department of Defense Health Resources Sharing
and Emergency Operations Act 1982.
It appears that the ball has moved forward more in the last 24
months than the last 25 years. It is a shame that it took Hurricane
Katrina, the debacle at Walter Reed, and the devastating wounds of war
to expedite progress between the two largest federal bureaucracies.
I am also looking forward to hearing from representatives of both
departments about how they plan to implement the recommendations of the
recently released Dole/Shalala Commission Report, and the Veterans
Disability Benefits Commission Report.
Again, I would like to thank you, Mr. Chairman for holding this
hearing. This issue is a top priority for our Subcommittee, and look
forward to continuing our oversight responsibilities.
Prepared Statement of Brigadier General Douglas J. Robb, M.D.,
Commander, 81st Medical Group, Keesler Air Force Base, Biloxi, MS,
Department of the Air Force, U.S. Department of Defense
INTRODUCTION
Mr. Chairman and members of this distinguished Subcommittee, thank
you for inviting me here today. I am Brigadier General Douglas J. Robb
and I served as the Command Surgeon, United States Central Command from
2004 to 2007. Currently I am serving as the Keesler Medical Center
Commander and as the Senior Market Manager, Gulf Coast Multi-Service
Market Office, Keesler Air Force Base, Biloxi, Mississippi. Thank you
for the opportunity to express my advocacy for a Healthcare Information
Systems platform and electronic medical record that supports the world
class quality healthcare that our military and Department of Veterans
Affairs veterans healthcare facilities provide to our DoD and VA
beneficiaries.
HISTORICAL OVERVIEW
In my previous assignment as the CENTCOM Surgeon, I had the
opportunity to witness the evolution of our deployed healthcare
information systems platforms that support access to patient care data,
as our wounded warriors move through the continuum of care: from our
combat casualty care life savers, to our forward surgical teams, to our
theater hospitals, and then onto our definitive care facilities at
Landstuhl, Walter Reed, Bethesda, Wilford Hall, and VA Polytrauma
Centers.
On 16 March 2006, Spc. Channing Moss was severely injured in an
attack in southeastern Afghanistan. The lifesaving care performed by
the combat lifesavers in his unit and the subsequent surgical
stabilization by the forward surgical team and the Bagram Theater
Hospital saved his life. What was also lifesaving was the ability of
the surgeons at Landstuhl Hospital, Germany, who would receive Spc.
Moss less than 24 hours after his initial injury, and the surgeons at
Walter Reed to be able to view his operative notes and x-rays, before
the patient arrived at their hospitals. This was accomplished via the
Joint Patient Tracking Application, part of the DoD's deployed
healthcare information systems platform.
Earlier that year, again in Afghanistan, a general surgeon and
commander of one of the forward surgical teams, commented on his
excitement when he was able to send completely digital trauma
resuscitation and operative reports to the Bagram Combat Support
Hospital, again before the patient arrived. This is something that had
been his vision for our forward surgical teams for a long time. During
his previous assignment, he had been a surgeon at Landstuhl, Germany,
and was frustrated by the lack of medical data from the forward
surgical teams' initial surgical resuscitation.
CURRENT ACTIVITIES
In my current position as the Senior Market Manager, Gulf Coast
Multi-Service Market Manager, through collaborative and joint DoD and
VA initiatives, we are entrusted with the in-garrison care of our DoD
and VA beneficiaries. In this capacity, we also require a healthcare
information system platform that supports access to real-time patient
care data for our shared patient population. Our patients from the Gulf
Coast Multi-Service Market are treated in DoD and VA hospitals and
clinics that are often located in close proximity anywhere from Biloxi,
to Pensacola, and continuing along the Florida Panhandle to Panama
City. Our goal is provide quality services in a seamless manner. This
requires an integrated healthcare information systems platform that is
user friendly for our jointly operating DoD and VA healthcare
facilities. Significant progress has been made in the past few years to
bridge the gap of electronic information flow. Just last month, our
staffs were excited when the bi-directional health information (BDHI)
system became available at some of our facilities. Although not at its
full capability yet, it is a very positive step in the right direction
in our ability to view patient care data from both VA and DoD
facilities.
CONCLUSION
In conclusion, as a former Combatant Command Surgeon and currently
as the Senior Market Manager for the Gulf Coast Multi-Service Market
Office, I continue to be a strong advocate for a healthcare information
systems platform and electronic medical record that provides real time
access to patient care data for our DoD and VA beneficiaries, heroes
like Spc. Canning Moss, as they move through our deployed and garrison
based continuum of care: combat casualty care, forward surgical
resuscitation, in-theater hospitalization and finally our DoD and VA
medical centers and clinics. The current capability has already proven
itself in contributing to the quality of care for our beneficiaries.
And with your support I believe we can continue to improve upon our
already existing and evolving capability to further share and make
available the full spectrum of electronic health information between
the Department of Defense and the Department of Veterans Affairs. Mr.
Chairman, Committee Members, thank you again for allowing me the
opportunity to appear before you.
Prepared Statement of Valerie C. Melvin, Director,
Human Capital and Management Information Systems Issues,
U.S. Government Accountability Office
GAO Highlights
Information Technology--VA and DOD Continue to Expand Sharing of
Medical Information, but Still Lack Comprehensive Electronic Medical
Records
Why GAO Did This Study
The Department of Veterans Affairs (VA) and the Department of
Defense (DOD) are engaged in ongoing efforts to share medical
information, which is important in helping to ensure high-quality
health care for active-duty military personnel and veterans. These
efforts include a long-term program to develop modernized health
information systems based on computable data: that is, data in a format
that a computer application can act on--for example, to provide alerts
to clinicians of drug allergies. In addition, the departments are
engaged in short-term initiatives involving existing systems.
GAO was asked to testify on the history and current status of the
departments' efforts to share health information. To develop this
testimony, GAO reviewed its previous work, analyzed documents about
current status and future plans and interviewed VA and DOD officials.
What GAO Recommends
GAO has previously made several recommendations on this topic,
including that VA and DOD develop a detailed project management plan to
guide their efforts to share patient health data. While the departments
agreed with these recommendations, a comprehensive overall strategy
that incorporates all of the ongoing activities still needs to be
implemented.
What GAO Found
For almost a decade, VA and DOD have been pursuing ways to share
health information and to create comprehensive electronic medical
records. However, they have faced considerable challenges in these
efforts, leading to repeated changes in the focus of their initiatives
and target completion dates. Currently, the two departments are
pursuing both long- and short-term initiatives to share health
information. Under their long-term initiative, the modern health
information systems being developed by each department are to share
standardized computable data through an interface between data
repositories associated with each system. The repositories have now
been developed, and the departments have begun to populate them with
limited types of health information. In addition, the interface between
the repositories has been implemented at seven VA and DOD sites,
allowing computable outpatient pharmacy and drug allergy data to be
exchanged. Implementing this interface is a milestone toward the
departments' long-term goal, but more remains to be done. Besides
extending the current capability throughout VA and DOD, the departments
must still agree to standards for the remaining categories of medical
information, populate the data repositories with this information,
complete the development of the two modernized health information
systems, and transition from their existing systems.
While pursuing their long-term effort to develop modernized
systems, the two departments have also been working to share
information in their existing systems. Among various short-term
initiatives are a completed effort to allow the one-way transfer of
health information from DOD to VA when service members leave the
military, as well as ongoing demonstration projects to exchange limited
data at selected sites. One of these projects, which builds on the one-
way transfer capability, developed an interface between certain
existing systems that allows a two-way view of current data on patients
receiving care from both departments. VA and DOD are now expanding the
sharing of additional medical information by using this interface to
link other systems and databases. The departments have also established
ad hoc processes to meet the immediate need to provide data on severely
wounded service members to VA's polytrauma centers, which specialize in
treating such patients. These processes include manual workarounds
(such as scanning paper records) that are generally feasible only
because the number of polytrauma patients is small. While these
multiple initiatives and ad hoc processes have facilitated degrees of
data sharing, they nonetheless highlight the need for continued efforts
to integrate information systems and automate information exchange. At
present, it is not clear how all the initiatives are to be incorporated
into an overall strategy focused on achieving the departments' goal of
comprehensive, seamless exchange of health information.
__________
Mr. Chairman and Members of the Subcommittee:
I am pleased to be a part of today's continuing dialog on efforts
by the Department of Veterans Affairs (VA) and the Department of
Defense (DOD) to share electronic medical information. Over most of the
past decade, the departments have been pursuing initiatives to share
electronic medical information to help ensure that active-duty military
personnel and veterans receive high-quality health care. The
departments' efforts have included working toward a long-term vision of
a single ``comprehensive, lifelong medical record'' \1\ that would
allow each service member to transition seamlessly between the two
departments, as well as more short-term efforts focused on meeting
immediate needs to exchange health information, including responding to
current military crises.
---------------------------------------------------------------------------
\1\ In 1996, the Presidential Advisory Committee on Gulf War
Veterans' Illnesses reported on many deficiencies in VA's and DOD's
data capabilities for handling service members' health information. In
November 1997, the President called for the two agencies to start
developing a ``comprehensive, lifelong medical record for each service
member,'' and in 1998 issued a directive requiring VA and DOD to
develop a ``computer-based patient record system that will accurately
and efficiently exchange information.''
---------------------------------------------------------------------------
Since 2001, we have reported or testified numerous times on the
various initiatives undertaken by the departments to develop the
capability to share health information. Our last testimony before this
Subcommittee on May 8, 2007, highlighted key projects that the
departments have pursued in this regard and the progress of their
activities.\2\ At your request, my statement today further discusses
the history and current status of the departments' efforts.
---------------------------------------------------------------------------
\2\ GAO, Information Technology: VA and DOD Are Making Progress in
Sharing Medical Information, but Are Far from Comprehensive Electronic
Medical Records, GAO-07-852T (Washington, D.C.: May 8, 2007).
---------------------------------------------------------------------------
The information in my testimony is based largely on our previous
work in this area. To describe the history and current status of the
departments' efforts to exchange patient health information, we
reviewed our previous work, analyzed documents on various health
initiatives, and interviewed VA and DOD officials about current status
and future plans. We conducted our work in support of this testimony
during October 2007 in the Washington, D.C., area. Information on costs
that have been incurred for the various projects was provided by
responsible officials at each department. We did not audit the reported
costs and thus cannot attest to their accuracy or completeness. All
work on which this testimony is based was conducted in accordance with
generally accepted government auditing standards.
Results in Brief
VA and DOD have been pursuing initiatives to share data between
their health information systems and create comprehensive electronic
medical records since 1998, following a call for the development of a
comprehensive, integrated system to allow the two departments to share
patient health information. However, the departments have faced
considerable challenges in project planning and management, leading to
repeated changes in the focus of their initiatives and target
completion dates. In prior reviews of their efforts, we noted
management weaknesses such as inadequate accountability and poor
planning and oversight and made recommendations for improvement,
including the development of a comprehensive and coordinated project
management plan that defines the technical and managerial processes
necessary to satisfy project requirements and to guide their
activities. In response, by July 2002, VA and DOD revised their
strategy, refocusing the project and dividing it into long-term and
short-term initiatives. For the long term, both departments are
modernizing their health information systems to replace their existing
(legacy) systems and enable the new systems to share data and,
ultimately, to have interoperable \3\ electronic medical records.
Unlike the legacy systems, the modernized systems are to be based on
computable data--data that can be automatically processed in a
healthcare system to, for example, provide alerts to clinicians on drug
allergies, or to plot graphs of changes in vital signs such as blood
pressure. For the short-term initiative, the departments focused on
sharing information in existing systems.
---------------------------------------------------------------------------
\3\ Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
---------------------------------------------------------------------------
VA and DOD have made progress in both their long-term and short-
term initiatives, but much work remains to achieve the goal of
interoperable electronic medical records and a seamless transition
between the two departments. In the long-term project to develop
modernized health information systems, the departments have begun to
implement the first release of the interface between their modernized
data repositories, and computable outpatient pharmacy and drug allergy
data are being exchanged at seven VA and DoD sites. However,
significant work remains, including agreeing to standards for the
remaining categories of medical information and populating the data
repositories with all this information. Regarding their short-term
projects to share information in existing systems, the departments
completed the Federal Health Information Exchange in 2004, and as of
this month reported transferring clinical data on more than 4 million
veterans. In addition, they have made progress on two demonstration
projects: (1) the Laboratory Data Sharing Interface, deployed at nine
localities, allows the departments to communicate orders for lab tests
and their results electronically and (2) the Bidirectional Health
Information Exchange allows a real-time, two-way view of certain
outpatient health data from existing systems \4\ at all VA and DoD
sites, and certain inpatient discharge summary data \5\ at all VA sites
and 13 large DOD sites. Further, the two departments have undertaken ad
hoc activities to accelerate the transmission of health information on
severely wounded patients from DOD to VA's four polytrauma centers,
which care for veterans and service members with severe traumatic brain
injuries or disabling injuries, to more than one physical region or
organ system. These ad hoc processes include manual workarounds, such
as scanning paper records and individually transmitting radiological
images, which are generally feasible only because the number of
polytrauma patients is small (according to VA officials, about 460 with
traumatic brain injuries to date).
---------------------------------------------------------------------------
\4\ DOD's Composite Health Care System (CHCS) and VA's VistA
(Veterans Health Information Systems and Technology Architecture).
\5\ Specifically, inpatient discharge summary data stored in VA's
VistA and DOD's Clinical Information System (CIS), a commercial health
information system customized for DOD.
---------------------------------------------------------------------------
Through all of these efforts, VA and DOD are exchanging health
information. However, these exchanges have been limited, and it is not
yet clear how they are to be integrated into an overall strategy to
reach the departments' long-term goal of a comprehensive, seamless
exchange of health information. Accordingly, as we have previously
recommended, it remains critical for the departments to develop a
comprehensive project plan that can guide their efforts to completion.
Background
In their efforts to modernize their health information systems and
share medical information, VA and DoD start from different positions.
As shown in table 1, VA has one integrated medical information system--
the Veterans Health Information Systems and Technology Architecture
(VistA)--which uses all electronic records. All 128 VA medical sites
thus have access to all VistA information.\6\ (Table 1 also shows, for
completeness, VA's planned modernized system and its associated data
repository.)
---------------------------------------------------------------------------
\6\ A site represents one or more facilities--medical centers,
hospitals, or outpatient clinics--that store their electronic health
data in a single database.
Table 1: VA Medical Information Systems and Data Base
------------------------------------------------------------------------
------------------------------------------------------------------------
System name Description
------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Legacy systems
----------------------------------------------------------------------------------------------------------------
VistA Veterans Health Information Existing integrated health
Systems and Technology information system
Architecture
----------------------------------------------------------------------------------------------------------------
Modernized system and repository
----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------
------------------------------------------------------------------------
HealtheVet VistA Modernized health information
system based on computable data
------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
HDR Health Data Repository Data repository associated with
modernized system
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of VA data.
In contrast, DOD has multiple medical information systems (table 2
illustrates certain selected systems). DOD's various systems are not
integrated, and its 138 sites do not necessarily communicate with each
other. In addition, not all of DOD's medical information is electronic:
some records are paper-based.
Table 2: Selected DoD Medical Information Systems and Data Bases
------------------------------------------------------------------------
------------------------------------------------------------------------
System name Description
------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Legacy systems
----------------------------------------------------------------------------------------------------------------
CHCS Composite Health Care System Primary existing DoD health
information system
----------------------------------------------------------------------------------------------------------------
CIS Clinical Information System Commercial health information system
customized for DoD; used by some DoD
facilities for inpatients
----------------------------------------------------------------------------------------------------------------
ICDB Integrated Clinical Database Health information system used by
many Air Force facilities
----------------------------------------------------------------------------------------------------------------
TMDS Theater Medical Data Store Database to collect electronic
medical information in combat
theater for both outpatient care and
serious injuries
----------------------------------------------------------------------------------------------------------------
JPTA Joint Patient Tracking Application Web-based application primarily used
to track the movement of patients as
they are transferred from location
to location, but may include text-
based medical information
----------------------------------------------------------------------------------------------------------------
Modernized system and repository
----------------------------------------------------------------------------------------------------------------
AHLTA Armed Forces Health LongitudiModernized health information
Technology Application \a\ system, integrated and based on
computable data
----------------------------------------------------------------------------------------------------------------
CDR Clinical Data Repository Data repository associated with
modernized system
----------------------------------------------------------------------------------------------------------------
\a\ Formerly CHCS II.
Source: GAO analysis of DOD data.
VA and DOD Have Been Working to Exchange Health Information Since 1998
For nearly a decade, VA and DOD have been undertaking initiatives
to exchange data between their health information systems and create
comprehensive electronic records.\7\ However, the departments have
faced considerable challenges in project planning and management,
leading to repeated changes in the focus and target completion dates of
the initiatives.
---------------------------------------------------------------------------
\7\ Initially, the Indian Health Service (IHS) was also a party to
this effort, having been included because of its population-based
research expertise and its longstanding relationship with VA. However,
IHS was not included in a later revised strategy for electronically
sharing patient health information.
---------------------------------------------------------------------------
As shown in figure 1, the departments' efforts have involved both
long-term initiatives to modernize their health information systems \8\
and short-term initiatives to respond to more immediate information-
sharing needs.
---------------------------------------------------------------------------
\8\ DOD began efforts to modernize its existing health information
system (CHCS) in 1997 and VA began efforts to modernize its existing
health information system (VistA) in 2001.
---------------------------------------------------------------------------
Figure 1: Timeline of Selected VA/DOD Electronic Medical Records and
Data Sharing Efforts
[GRAPHIC] [TIFF OMITTED] 39466A.001
The departments' first initiative was the Government Computer-Based
Patient Record (GCPR) project, which aimed to develop an electronic
interface that would allow physicians and other authorized users at VA
and DOD health facilities to access data from each other's health
information systems. The interface was expected to compile requested
patient information in a virtual record (that is, electronic as opposed
to paper) that could be displayed on a user's computer screen.
We reviewed the GCPR project in 2001 and 2002, noting disappointing
progress exacerbated in large part by inadequate accountability and
poor planning and oversight, which raised questions about the
departments' abilities to achieve a virtual medical record. We
determined that the lack of a lead entity, clear mission, and detailed
planning to achieve that mission made it difficult to monitor progress,
identify project risks, and develop appropriate contingency plans.\9\
In both years, we recommended that the departments enhance the
project's overall management and accountability. In particular, we
recommended that the departments designate a lead entity and a clear
line of authority for the project; create comprehensive and coordinated
plans that include an agreed-upon mission and clear goals, objectives,
and performance measures; revise the project's original goals and
objectives to align with the current strategy; commit the executive
support necessary to adequately manage the project; and ensure that it
followed sound project management principles.
---------------------------------------------------------------------------
\9\ GAO, Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results, GAO-02-703 (Washington, D.C.:
June 12, 2002) and Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-
01-459 (Washington, D.C.: Apr. 30, 2001).
---------------------------------------------------------------------------
In response, by July 2002, the two departments had revised their
strategy, refocusing the project and dividing it into two initiatives.
A short-term initiative, the Federal Health Information Exchange
(FHIE), was to enable DOD to electronically transfer service members'
health information to VA when the members left active duty. VA was
designated as the lead entity for implementing FHIE, which was
completed in 2004. A longer-term initiative was to develop a common
health information architecture that would allow a two-way exchange of
health information. The common architecture is to include standardized,
computable data, communications, security, and high-performance health
information systems (these systems, DOD's Composite Health Care System
II and VA's HealtheVet VistA, were already in development, as shown in
the figure).\10\ The departments' modernized systems are to store
information (in standardized, computable form) in separate data
repositories: DOD's Clinical Data Repository (CDR) and VA's Health Data
Repository (HDR). The two repositories are to exchange information
through an interface named CHDR.\11\
---------------------------------------------------------------------------
\10\ DOD's existing Composite Health Care System (CHCS) was being
modernized as CHCS II, now renamed AHLTA (Armed Forces Health
Longitudinal Technology Application). VA's existing VistA system was
being modernized as HealtheVet VistA.
\11\ The name CHDR, pronounced ``cheddar,'' combines the names of
the two repositories.
---------------------------------------------------------------------------
In March 2004, the departments began to develop the CHDR interface.
They planned to begin implementation by October 2005; \12\ however,
implementation of the first release of the interface (at one site)
occurred in September 2006, almost a year beyond the target date. In a
report in June 2004, \13\ we identified a number of management
weaknesses that could have contributed to this delay and made a number
of recommendations, including creation of a comprehensive and
coordinated project management plan. The departments agreed with our
recommendations and took steps to improve the management of the CHDR
initiative, designating a lead entity with final decision-making
authority and establishing a project management structure. However, as
we noted in subsequent testimony, \14\ the initiative did not have a
detailed project management plan that described the technical and
managerial processes necessary to satisfy project requirements
(including a work breakdown structure and schedule for all development,
testing, and implementation tasks), as we had recommended.
---------------------------------------------------------------------------
\12\ December 2004 VA and DOD Joint Strategic Plan.
\13\ GAO, Computer-Based Patient Records: VA and DOD Efforts to
Exchange Health Data Could Benefit from Improved Planning and Project
Management, GAO-04-687 (Washington, D.C.: June 7, 2004).
\14\ GAO, Computer-Based Patient Records: VA and DOD Made Progress,
but Much Work Remains to Fully Share Medical Information, GAO-05-1051T
(Washington, D.C.: Sept. 28, 2005) and Information Technology: VA and
DOD Face Challenges in Completing Key Efforts, GAO-06-905T (Washington,
D.C.: June 22, 2006).
---------------------------------------------------------------------------
In October 2004, responding to a congressional mandate, \15\ the
departments established two more short-term initiatives: the Laboratory
Data Sharing Interface, aimed at allowing VA and DOD facilities to
share laboratory resources, and the Bidirectional Health Information
Exchange (BHIE), aimed at giving both departments' clinicians access to
records on shared patients (that is, those who receive care from both
departments).\16\ As demonstration projects, these initiatives were
limited in scope, with the intention of providing interim solutions to
the departments' needs for more immediate health information sharing.
However, because BHIE provided access to up-to-date information, the
departments' clinicians expressed strong interest in expanding its use.
As a result, the departments began planning to broaden this capability
and expand its implementation considerably. Extending BHIE connectivity
could provide each department with access to most data in the other's
legacy systems, until such time as the departments' modernized systems
are fully developed and implemented. According to a VA/DOD annual
report \17\ and program officials, the departments now consider BHIE an
interim step in their overall strategy to create a two-way exchange of
electronic medical records.
---------------------------------------------------------------------------
\15\ The Bob Stump National Defense Authorization Act for Fiscal
Year 2003 (Pub. L. No. 107-314, Sec. 721, Dec. 2, 2002) mandated that
the departments conduct demonstration projects to test the feasibility,
advantages, and disadvantages of measures and programs designed to
improve the sharing and coordination of health care and health care
resources between the departments.
\16\ To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project. Unlike FHIE, which provides a one-way transfer of information
to VA when a service member separates from the military, the two-way
system allows clinicians in both departments to view, in real time,
limited health data (in text form) from the departments' current health
information systems.
\17\ December 2004 VA and DOD Joint Strategic Plan.
---------------------------------------------------------------------------
The departments' reported costs for the various sharing initiatives
and the modernization of their health information systems through
fiscal year 2007 are shown in table 3.
Table 3: Reported Costs of VA and DOD Initiatives Since Inception
----------------------------------------------------------------------------------------------------------------
Project VA expenditure DOD expenditure
----------------------------------------------------------------------------------------------------------------
HealtheVet VistA $681.7 million through FY 2006 ----
----------------------------------------------------------------------------------------------------------------
AHLTA ---- $954.3 million through FY 2007
(estimated).
----------------------------------------------------------------------------------------------------------------
Joint initiatives:
----------------------------------------------------------------------------------------------------------------
CHDR 4.1 million DOD does not account for these
projects separately.
----------------------------------------------------------------------------------------------------------------
FHIE 65.5 million
----------------------------------------------------------------------------------------------------------------
LDSI 2.8 million
----------------------------------------------------------------------------------------------------------------
BHIE 6.3 million
----------------------------------------------------------------------------------------------------------------
Total $78.7 million $89.7 million through FY 2007.
----------------------------------------------------------------------------------------------------------------
Source: VA and DOD data.
Beyond these initiatives, in January 2007, the departments
announced a further change to their information-sharing strategy: their
intention to jointly develop a new inpatient medical record system. On
July 31, 2007, they awarded a contract for a feasibility study.\18\
According to the departments, adopting this joint solution is expected
to facilitate the seamless transition of active-duty service members to
veteran status, and make inpatient health care data on shared patients
immediately accessible to both DOD and VA. In addition, the departments
believe that a joint development effort could enable them to realize
significant cost savings. We have not evaluated the departments' plans
or strategy for this new system.
---------------------------------------------------------------------------
\18\ The contract is for a 6-month base period, with a follow-on 6-
month option period. The cost for the 6-month base period is about $2
million.
---------------------------------------------------------------------------
Other Evaluations Have Recommended Strengthening the Management and
Planning of the Departments' Health Information Initiatives
Throughout the history of these initiatives, evaluations besides
our own have found deficiencies in the departments' efforts, especially
with regard to the lack of comprehensive planning. For example, a
recent presidential task force identified the need for VA and DOD to
improve their long-term planning.\19\ This task force, reporting on
gaps in services provided to returning veterans, noted problems in
sharing information on wounded service members, including the inability
of VA providers to access paper DOD inpatient health records. The task
force stated that although significant progress has been made towards
sharing electronic information, more needs to be done, and recommended
that VA and DOD continue to identify long-term initiatives and define
the scope and elements of a joint inpatient electronic health record.
In addition, in fiscal year 2006, Congress did not provide all the
funding requested for HealtheVet VistA because it did not consider that
the funding had been adequately justified.
---------------------------------------------------------------------------
\19\ Task Force on Returning Global War on Terror Heroes, Report to
the President (Apr. 19, 2007).
---------------------------------------------------------------------------
VA and DOD Are Exchanging Limited Medical Information, but a Seamlessly
Shared Medical Record Will Require Much More Work
VA and DOD have made progress in both their long-term and short-
term initiatives to share health information. In the long-term project
to modernize their health information systems, the departments have
begun, among other things, to implement the first release of the
interface between their modernized data repositories. The departments
have also made progress in their short-term projects to share
information in existing systems, having completed two initiatives, and
are making important progress on another. In addition, the departments
have undertaken ad hoc activities to accelerate the transmission of
health information on severely wounded patients from DOD to VA's four
polytrauma centers. However, despite the progress made and the sharing
achieved, the tasks remaining to reach the goal of a shared electronic
medical record are substantial.
VA and DOD Have Begun Deployment of a Modernized Data Interface
In their long-term effort to share health information, VA and DOD
have completed the development of their modernized data repositories,
agreed on standards for various types of data, and begun to populate
the repositories with these data.\20\ In addition, they have now
implemented the first release of the CHDR interface. According to the
departments' officials, all DOD sites can now access the interface, and
it is expected to be available across VA when necessary software
updates are released. (Currently 103 of 128 VA sites have received
these updates.) \21\ At seven sites, VA and DOD are now exchanging
limited medical information for shared patients: specifically,
computable outpatient pharmacy and drug allergy information.
---------------------------------------------------------------------------
\20\ DOD has populated CDR with information for outpatient
encounters, drug allergies, and order entries and results for
outpatient pharmacy/lab orders. VA has populated HDR with patient
demographics, vital signs records, allergy data, and outpatient
pharmacy data; in July, the department added chemistry and hematology,
and in September, microbiology.
\21\ The Remote Data Interoperability software upgrade provides the
capability for the automated checks and alerts allowed by computable
data.
---------------------------------------------------------------------------
CHDR is the conduit for exchanging computable medical information
between the departments. Data transmitted via the interface are
permanently stored in each department's new data repository, CDR, and
HDR. Once in the repositories, these computable data can be used by DOD
and VA at all sites through their existing systems. CHDR also provides
terminology mediation (translation of one agency's terminology into the
other's). The departments' plans call for further developing the
capability to exchange computable laboratory results data through the
interface during fiscal year 2008.
Although implementing this interface is an important
accomplishment, the departments are still a long way from completing
the modernized health information systems and comprehensive
longitudinal health records. While DOD and VA had originally projected
completion dates of 2011 and 2012, respectively, for their modernized
systems, the departments' officials told us that there is currently no
scheduled completion date for either system. VA is evaluating a
proposal that would result in completion of its system in 2015; DOD is
evaluating the impact of the new study on a joint inpatient medical
record and has not indicated a new completion date.
Further, both departments have still to identify the next types of
data to be stored in the repositories. The departments will then have
to populate the repositories with the standardized data. This involves
different tasks for each department. Specifically, while VA's medical
records are already electronic, it must still convert them into the
interoperable format appropriate for its repository. DOD, in addition
to converting current records from its multiple systems, must also
address medical records that are not automated. As pointed out by a
recent Army Inspector General's report, some DOD facilities are having
problems with hard copy records.\22\ The report also identified
inaccurate and incomplete health data as a problem to be addressed.
Before the departments can achieve the long-term goal of seamless
sharing of medical information, all of these tasks and challenges will
have to be addressed. Accordingly, it is essential that the departments
develop a comprehensive project plan to guide these efforts to
completion, as we have previously recommended.
---------------------------------------------------------------------------
\22\ Inspector General, Army, Army Physical Disability Evaluation
System Inspection (March 2007).
---------------------------------------------------------------------------
Short-Term Projects Are Allowing VA and DOD to Exchange Limited Health
Information
In addition to the long-term effort previously described, the two
departments have made some progress in meeting immediate needs to share
information in their respective legacy systems through short-term
projects which, as mentioned earlier, are in various stages of
completion. They have also set up special processes to transfer data
from DOD facilities to VA's polytrauma centers in a further effort to
more effectively treat Traumatic Brain Injuries and other especially
severe injuries.
One-Way Transfer Capability Is Operational
DOD has been using FHIE to transfer information to VA since 2002.
According to DOD officials, 194 million clinical messages on more than
4 million veterans had been transferred to the FHIE data repository as
of September 2007, including laboratory results, radiology results,
outpatient pharmacy data, allergy information, consultation reports,
elements of the standard ambulatory data record, and demographic data.
Further, since July 2005, FHIE has been used to transfer pre- and post-
deployment health assessment and reassessment data; as of September
2007, VA had access to data for more than 793,000 separated service
members and demobilized Reserve and National Guard members who had been
deployed. Transfers are done in batches once a month, or weekly for
veterans who have been referred to VA treatment facilities. According
to a joint VA/DOD report, \23\ FHIE has made a significant contribution
to the delivery and continuity of care of separated service members as
they transition to veteran status, as well as to the adjudication of
disability claims.
---------------------------------------------------------------------------
\23\ December 2004, VA and DOD Joint Strategic Plan.
---------------------------------------------------------------------------
Laboratory Interface Initiative Allows VA and DOD to Share Lab
Resources
One of the departments' demonstration projects--the Laboratory Data
Sharing Interface (LDSI)--is now fully operational and is deployed when
local agencies have a business case for its use and sign an agreement.
It requires customization for each locality and is currently deployed
at nine locations. LDSI currently supports a variety of chemistry and
hematology tests, and, at one of the nine locations, anatomic pathology
and microbiology tests.
Once LDSI is implemented at a facility, the only nonautomated
action needed for a laboratory test is transporting the specimens. If a
test is not performed at a VA or DOD doctor's home facility, the doctor
can order the test, the order is transmitted electronically to the
appropriate lab (the other department's facility or in some cases a
local commercial lab), and the results are returned electronically.
Among the benefits of the LDSI interface, according to VA and DOD,
are increased speed in receiving laboratory results and decreased
errors from manual entry of orders. The LDSI project manager in San
Antonio stated that another benefit of the project is the time saved by
eliminating the need to rekey orders at processing labs to input the
information into the laboratories' systems. Additionally, the San
Antonio VA facility no longer has to contract out some of its
laboratory work to private companies, but instead uses the DOD
laboratory.
Two-Way Interface Allows Real-Time Viewing of Text Information
Developed under a second demonstration project, the BHIE interface
permits a medical care provider to query selected health information on
patients from all VA and DOD sites and to view that data onscreen
almost immediately. It not only allows the two departments to view each
other's information, but it also allows DOD sites to see previously
inaccessible data at other DOD sites.
VA and DOD have been making progress on expanding the BHIE
interface. As initially developed, the interface provided access to
information in VA's VistA and DOD's Composite Health Care System, but
it is currently being expanded to query data in other DOD systems and
databases. In particular, the interface has been expanded to DOD's:
Modernized data repository, CDR, which has enabled
department-wide access to outpatient data for pharmacy and inpatient
and outpatient allergy, radiology, chemistry, and hematology data since
July 2007, and to microbiology data since September 2007.
Clinical Information System (CIS), an inpatient system
used by some DOD facilities; the interface enables bidirectional views
of discharge summaries and is currently deployed at 13 large DOD sites.
Theater Medical Data Store, which became operational in
October 2007, enabling access to inpatient and outpatient clinical
information from combat theaters.
The departments are also taking steps to make more data elements
available through BHIE. VA and DOD staff told us that by the end of the
first quarter of fiscal year 2008, they plan to add provider notes,
procedures, and problem lists. Later in fiscal year 2008, they plan to
add vital signs, scanned images and documents, family history, social
history, and other history questionnaires. In addition, a VA/DOD
demonstration site in El Paso began sharing radiological images between
the VA and DOD facilities in September 2007 using the BHIE/FHIE
infrastructure.\24\
---------------------------------------------------------------------------
\24\ To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project.
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Types of Data Shared by DOD and VA Are Growing but Remain Limited
Although VA and DOD are sharing various types of health data, the
type of data being shared has been limited and significant work remains
to expand the data shared and integrate the various initiatives. Table
4 summarizes the types of health data currently shared via the long-
and short-term initiatives we have described, as well as additional
types of data that are currently planned for sharing. While this gives
some indication of the scale of the tasks involved in sharing medical
information, it does not depict the full extent of information that is
currently being captured in the health information systems at VA and
DOD.
Table 4--Data Elements Made Available and Planned by DOD-VA Initiatives
--------------------------------------------------------------------------------------------------------------------------------------------------------
Data elements
Initiative ---------------------------------------------------------------- Comments
Available Planned
--------------------------------------------------------------------------------------------------------------------------------------------------------
CHDR Outpatient pharmacy LabComputable data are exchanged
Drug allergy between one department's data
repository and the other's.
--------------------------------------------------------------------------------------------------------------------------------------------------------
FHIE Patient demographics None One-way batch transfer of text
Laboratory results data from DOD to VA occurs
Radiology reports weekly if discharged patient
Outpatient pharmacy has been referred to VA for
information treatment; otherwise monthly.
Admission discharge transfer
data
Discharge summaries
Consult reports
Allergies
Data from the DOD Standard
Ambulatory Data Record
Pre- and post-deployment
assessments
--------------------------------------------------------------------------------------------------------------------------------------------------------
LDSI Laboratory orders Microbiology Noncomputable text data are
Laboratory resAnatomic pathology transferred.
hematology and microbiology at
two localities)
--------------------------------------------------------------------------------------------------------------------------------------------------------
BHIE Outpatient pharmacy data Provider notes Data are not transferred but
Drug and food allergy Procedures can be viewed.
information Problem lists
Surgical pathology reports Vital signs
Microbiology results Scanned images and documents
Cytology reports Family history
Chemistry and hematology Social history
reports Other history questionnaires
Laboratory orderRadiology images
Radiology text reports
Inpatient discharge summaries
and/or emergency room notes
from CIS at 13 DOD and all VA
sites
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO analysis of VA and DOD data.
Special Procedures Provide Information to VA Polytrauma Centers
In addition to the information technology initiatives described,
DOD and VA have set up special procedures to transfer medical
information to VA's four polytrauma centers, which treat active duty
service members and veterans severely wounded in combat.\25\ Some
examples of polytrauma include Traumatic Brain Injury, amputations, and
loss of hearing or vision.\26\
---------------------------------------------------------------------------
\25\ In particular, clinicians require access to discharge notices,
which describe the treatment given at previous medical facilities and
the status of patients when they left those facilities.
\26\ Polytrauma centers care for veterans and returning service
members with injuries to more than one physical region or organ system,
one of which may be life threatening, and which result in physical,
cognitive, psychological, or psychosocial impairments and functional
disability.
---------------------------------------------------------------------------
When service members are seriously injured in a combat theater
overseas, they are first treated locally. They are then generally
evacuated to Landstuhl Medical Center in Germany, after which they are
transferred to a military treatment facility in the United States,
usually Walter Reed Army Medical Center in Washington, D.C.; the
National Naval Medical Center in Bethesda, Maryland; or Brooke Army
Medical Center, at Fort Sam Houston, Texas. From these facilities,
service members suffering from polytrauma may be transferred to one of
VA's four polytrauma centers for treatment.\27\
---------------------------------------------------------------------------
\27\ The four Polytrauma Rehabilitation Centers are in Richmond,
Virginia; Tampa, Florida; Minneapolis, Minnesota; and Palo Alto,
California.
---------------------------------------------------------------------------
At each of these locations, the injured service members will
accumulate medical records, in addition to medical records already in
existence before they were injured. According to DOD officials, when
patients are referred to VA for care, DOD sends copies of medical
records documenting treatment provided by the referring DOD facility
along with them. The DOD medical information is currently collected in
several different systems:
1. In the combat theater, electronic medical information may be
collected for a variety of reasons, including routine outpatient care,
as well as serious injuries. These data are stored in the Theater
Medical Data Store. As mentioned earlier, the BHIE interface to this
database became operational in October.
2. At Landstuhl, inpatient medical records are paper-based (except
for discharge summaries). The paper records are sent with a patient as
the individual is transferred for treatment in the United States. DOD
officials told us that the paper record is the official DOD medical
record, although AHLTA is used extensively to provide outpatient
encounter information for medical records purposes.
3. At the DOD treatment facility (Walter Reed, Bethesda, or
Brooke), additional inpatient information is recorded in CIS and
outpatient pharmacy and drug information are stored in CDR; other
health information continues to be stored in local CHCS databases.
When service members are transferred to a VA polytrauma center, VA
and DOD have several ad hoc processes in place to electronically
transfer the patients' medical information:
DOD has set up secure links to enable a limited number of
clinicians at the polytrauma centers to log directly into CIS at Walter
Reed and Bethesda Naval Hospital to access patient data.
Staff at Walter Reed, Brooke, and Bethesda medical
centers collect paper records, print records from CIS, scan all these,
and transmit the scanned data to the four polytrauma centers. DOD staff
pointed out that this laborious process is feasible only because the
number of polytrauma patients is small. According to VA officials, 460
severe Traumatic Brain Injury patients had been treated at the
polytrauma centers through fiscal year 2007. According to DOD
officials, the medical records for 81 patients planned for transfer or
already at a VA polytrauma center were scanned and provided to VA
between April 1 and October 11 of this year. Digital radiology images
were also provided for 48 patients.
Staff at Walter Reed and Bethesda are transmitting
radiology images electronically to the four polytrauma centers. Access
to radiology images is a high priority for polytrauma center doctors,
but like scanning paper records, transmitting these images requires
manual intervention: when each image is received at VA, it must be
individually uploaded to VistA's imagery viewing capability. This
process would not be practical for large volumes of images.
VA has access to outpatient data (via BHIE) from all DOD
sites, including Landstuhl.
These special efforts to transfer medical information on seriously
wounded patients represent important additional steps to facilitate the
sharing of information that is vital to providing polytrauma patients
with quality health care.
In summary, VA and DOD are exchanging health information via their
long- and short-term initiatives and continue to expand sharing of
medical information via BHIE. However, these exchanges have been
limited, and significant work remains to fully achieve the goal of
exchanging interoperable, computable data. Work still to be done
includes agreeing to standards for the remaining categories of medical
information; populating the data repositories with all this
information; completing the development of HealtheVet, VistA, and
AHLTA; and transitioning from the legacy systems. To complete this work
and achieve the departments' ultimate goal of a maintaining a lifelong
electronic medical record that will follow service members as they
transition from active to veteran status, a comprehensive and
coordinated project management plan that defines the technical and
managerial processes necessary to satisfy project requirements and to
guide their activities continues to be of vital importance. We have
previously recommended that the departments develop such a plan and
that it include a work breakdown structure and schedule for all
development, testing, and implementation tasks. Without such a detailed
plan, VA and DOD increase the risk that the long-term project will not
deliver the planned capabilities in the time and at the cost expected.
Further, it is not clear how all the initiatives we have described
today are to be incorporated into an overall strategy toward achieving
the departments' goal of a comprehensive, seamless exchange of health
information.
This concludes my statement. I would be pleased to respond to any
questions that you may have.
Contacts and Acknowledgments
If you have any questions concerning this testimony, please contact
Valerie C. Melvin, Director, Human Capital and Management Information
Systems Issues, at (202) 512-6304 or [email protected]. Other individuals
who made key contributions to this testimony are Barbara Oliver,
Assistant Director); Nancy Glover, Glenn Spiegel, and Amos Tevelow.
Related GAO Products
Computer-Based Patient Records: Better Planning and Oversight by
VA, DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459.
Washington, D.C.: April 30, 2001.
Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results. GAO-02-703. Washington, D.C.:
June 12, 2002.
Computer-Based Patient Records: Short-Term Progress Made, but Much
Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD
Health Systems. GAO-04-271T. Washington, D.C.: November 19, 2003.
Computer-Based Patient Records: Sound Planning and Project
Management Are Needed to Achieve a Two-Way Exchange of VA and DOD
Health Data. GAO-04-402T. Washington, D.C.: March 17, 2004.
Computer-Based Patient Records: VA and DOD Efforts to Exchange
Health Data Could Benefit from Improved Planning and Project
Management. GAO-04-687. Washington, D.C.: June 7, 2004.
Computer-Based Patient Records: VA and DOD Made Progress, but Much
Work Remains to Fully Share Medical Information. GAO-05-1051T.
Washington, D.C.: September 28, 2005.
Information Technology: VA and DOD Face Challenges in Completing
Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
DOD and VA Exchange of Computable Pharmacy Data. GAO-07-554R.
Washington, D.C.: April 30, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Are Far from Comprehensive Electronic Medical
Records, GAO-07-852T. Washington, D.C.: May 8, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Remain Far from Having Comprehensive
Electronic Medical Records, GAO-07-1108T. Washington, D.C.: July 18,
2007.
Prepared Statement of Colonel Keith Salzman, M.D., MPH, FAAFP, FACHE,
Chief of Informatics, Western Region Medical Command and Madigan Army
Medical Center, Tacoma, WA, Department of the Army, U.S. Department of
Defense
Chairman Mitchell, Congresswoman Brown-Waite and distinguished
Members of the Subcommittee, thank you for inviting me to discuss the
information technology sharing project between Madigan Army Medical
Center and VA Puget Sound. I am Colonel Keith Salzman, a physician and
a DoD/AMEDD leader in the newly emerging discipline of Informatics and
it is my privilege to serve as the Chief of Informatics at Western
Regional Medical Command/Madigan Army Medical Center where we enjoy a
long history of command support for our work in Informatics.
I arrived at Madigan as the announcement was made that Madigan and
VA Puget Sound would be working together to share electronic clinical
information. I joined the team as a steering Committee Member. While
the submission for the information sharing project occurred prior to my
arrival, I have been on the project since its inception and continue to
the present. We have completed all of the business plan objectives in 3
years of a 4 year project and are using the remaining funds to provide
additional requests for document exchange that support polytrauma
information needs as well as other key documents and data types that
contribute to extending interoperability, on the approval of the DoD-VA
oversight Committee Members.
The Madigan-VA Puget Sound project arose in response to
congressional requirements for the DoD and VA to each contribute set
aside funding for 4 years to collaborate on sharing clinical
information and care to improve healthcare services to shared patients.
At the outset of this testimony I would underscore our assessment that;
the choice on many levels between `either', `or' is more appropriately
answered as `both'. I will explain as I review this project.
This particular demonstration was undertaken in response to section
722 of the FY 2003 National Defense Authorization Act which required no
less than three demonstration projects of DoD/VA coordinated systems
involving budget/financial management; staffing/assignment; and
Information Management/Information Technology (IM/IT). Madigan and VA
Puget Sound were selected for this project based on the established
clinical sharing that was in place and the need to improve the exchange
of clinical information to provide care for the mutual patients cared
for at Madigan Army Medical Center, and the American Lake and Seattle
VA centers that make up the VA Puget Sound Healthcare System.
The initial challenges surrounded the learning required to overcome
the first `either-or' proposition of who drove the project: enterprise
or the local site. A critical first lesson learned was--`both'. The
local site had access to the clinical end user community and the
requirements necessary to improve the flow of information while the
enterprise had ownership of the architecture and systems in which
requirements would be built and deployed. At the outset it is important
to state that while this project is a demonstration project, all of the
deliverables are being used by the enterprise systems of both the DoD
and VA in production, in near real time (meaning seconds to minutes as
a rule, not instantaneous or days to weeks).
After the initial assembly of local and enterprise teams and review
and approval of a detailed business plan, the teams moved forward with
iterative delivery of tangible products implemented and delivered for
use in enterprise systems (SHARE for the DoD view) and Remote Data View
in the Computerized Patient Record System (CPRS the VA view) of the Bi-
Directional Health Information Exchange (BHIE) validated dual
beneficiary patients. The work cycles for this project were generally
6-9 months in duration.
A second lesson learned was that while each system had its own test
patients, shared test patients served the same purpose for
interoperability (that purpose being validating information compilation
and flow within the shared framework). While not as profound, the
benefit of `either-or' answered in `both' facilitated testing, training
and expansion of functionality.
The critical dialog between clinical end user and the development
team at the local level, combined with an active dialog between local
and enterprise team members, ensured that a principle of software
development (namely to correct functional problems as they are
identified in the design phase) proceeds iteratively and cost
effectively. The savings can be significant over allowing major design
problems to persist into production. This exemplifies another `both'
solution to an `either-or' proposition.
Regarding requirements specifications, we observed that keeping the
user requirements in sight while drafting the statement of work and
contracting progress will save re-doing a product after-the-fact. A
case in point is work on delivery of specified note types. The initial
requirement was for seven note types. Through a disconnected process of
contracting, the requirement was interpreted as all notes, creating an
information retrieval and storage problem, unintended consequences of
assumptions made by contractors making assumptions about what the end
users really needed. The experience was used later in our development
of requirements by keeping an open dialog between the end users and the
enterprise-another `both' solution.
With regard to the elephant in the room--establishing either AHLTA
or VistA across both Departments-we observed the following:
There are strengths and weaknesses in both systems that complement
each other. AHLTA is integrated world-wide and available 24/7. There
are functionality problems that are being worked to improve use at the
clinical and business level. VistA shows the benefits of local design
in its adoption by end users who are more inclined to buy into a
product they created. The downside is the historic lack of
configuration management. I use management intentionally as against
configuration control. The VA faces big challenges in reorganization
and must be careful not to destroy the strategy that delivered its
success while addressing its Achilles heel of decentralized, unmanaged
growth. The cost of imposing one system on both organizations now would
be prohibitive. Establishing interoperability and designing a strategy
of convergence over the next 10-20 years will allow a `both' solution
that capitalizes on best practices and less disruptive changes to
either system.
By using an interoperable approach, the DoD and VA, who own about
50% of the penetration of the Electronic Medical Record (EMR) on the
national level, can pave the way for interoperability as use of the EMR
extends from large organizations to the small provider groups and
individual patients who constitute the majority of the Nation and who
are not benefiting from an EMR. We are using the strategy of
interoperability to extend to our indirect care providers in TRICARE
and CHAMP-VA to capture the documentation that occurs outside of our
EMRs. The extension makes a natural bridge to Regional Health
Organizations.
A key to success in our strategy was to use messaging standards
(HL7 (Health Level 7), Clinical Document Architecture (CDA), Release 1
and 2), which conform to security documentation requirements and
integrate with the enterprise constraints from the local level. As
stated at the beginning, this partnership between a local development
cell immersed in the end user environment and the enterprise for
configuration management is a critical model/partnership to succeed in
developing software and hardware solutions for clinical-business
processes that support healthcare delivery for our beneficiaries.
An observation regarding COTS (commercial off the shelf) solutions
for federal agencies is that common products such as identity
management and Single Sign On/Context management solutions can be
purchased in bulk with significant efficiencies for the government.
In the end, we found that crossing new frontiers in collaborative
work between federal agencies and local/enterprise ends of those
agencies underscored our finding that `both' solutions work better than
`either-or' solutions.
These comments summarize what I would offer as a steering Committee
Member engaged in this project from the start. Subject to your
questions I would like to thank the Subcommittee again for allowing us
to share our insights on this critical work that is progressing
successfully. I would also encourage Congress to continue its support
of this program and each of the agencies involved. I look forward to
your questions.
__________
Appendix A: Data Currently Being Shared
Outpatient medications
Allergies
Lab--Chemistry, Hematology, Micro, Path, etc
Radiology Text Reports
Pre and Post Deployment Assessments
Post Deployment Health Re-Assessment
Discharge Summaries (DoD Essentris Sites and VA)
MAMC legacy outpatient notes to VA
Theater Clinical Data
Op Reports, Surgical Reports, History & Physical, Consult
Results and Progress Notes (Fall 2007)
__________
Appendix B:
[GRAPHIC] [TIFF OMITTED] 39466A.002
Prepared Statement of Howard B. Green, PMP, Deputy, Operations
Management, Veterans Health Information Technology, Office of
Enterprise Development, Office of Information and Technology, U.S.
Department of Veterans Affairs
Thank you, Mr. Chairman. I would like to thank you for the
opportunity to testify on the Sharing of Electronic Medical Information
between the Department of Defense and the Department of Veterans
Affairs, what is being done to accomplish the objectives, and the
viability of the approach.
I have been a member of the Department of Veterans Affairs Health
IT community for over 19 years serving in multiple capacities at the
local, regional Veteran Integrated Services Network (VISN) and national
level. Prior to joining the Office of Information and Technology in
2004, I was the Chief Information Officer for the Heartland Network
(VISN 15) and was responsible for the introduction of VA's VistA system
at all facilities and clinics in the region. Most recently, as Deputy
for Operations Management within the Veterans Health IT Portfolio, I
participated as a staff member on the President's Commission for
America's Returning Wounded Warriors, and with my DoD counterpart was
responsible for the creation of the information technology chapter and
final report recommendations. Following that assignment, I have been
given the responsibility for coordinating many of the recommendations
from the President's Commission report.
Systems Supporting the Exchange of Clinical Information
Formal activities related to the sharing of clinical information
between the Department of Veterans Affairs (VA) and the Department of
Defense (DoD) have been ongoing since 2001. Though there are a number
of systems that have been developed to support this function, for all
intents and purposes the overarching goal is to bidirectionally
exchange computable information between VA and DoD in real-time. The
following systems are in place to support this exchange of clinical
information.
Federal Health Information Exchange (FHIE): is the one-
way transfer of separated service member health data from DoD to VA.
Bi-Directional Health Information Exchange (BHIE):
supports functional interoperability between VA and DoD through the
exchange of textual patient health information such as provider notes,
non-computable test results, discharge summaries for all service
member/veterans known as active dual consumers.
Clinical Health Data Repository (CHDR): utilizes
established data standards, and terminology services to enable exchange
of standardized and computable health record data between VA and DoD.
Laboratory Data Systems Interchange (LDSI): supports the
lab reference model by providing an interoperable interagency
application for lab order entry and results reporting.
Imaging Pilots and Demonstrations: demonstrate the most
efficient approaches to the transmission of medical images and
clinically relevant documentation.
Effectiveness of Selected Clinical Information Exchange Systems:
The FHIE system has supported the transfer of more than 187 million
pieces of discharge related health information on over 3.8 million
patients who have separated from the military. FHIE continues to
exchange health record data for separated service members.
BHIE is currently the bidirectional medical exchange interface
having transferred information for over 2.3 million unique patients who
are active dual consumers of both healthcare systems. Currently, VA and
DoD are bidirectionally sharing viewable outpatient pharmacy data,
anatomic pathology/surgical reports, cytology results, microbiology
results, chemistry and hematology laboratory results, laboratory order
information, radiology text reports, food and drug allergy information,
and discharge summaries from several DoD sites running CIS. The
Information through the BHIE interface flows to and from the following
systems: VA's 128 VistA Systems and DoD's Composite Health Care System
(CHCS), Clinical Data Record (CDR), AHLTA Share, CIS, and Theater
Medical Data Store systems. There are plans to expand the amount of
clinical data exchanged through BHIE. Encounter notes, patient focused
problem lists such as on going treatment for diabetes or hypertension,
procedures, and theater level inpatient & outpatient notes will be
available by December 2007. By September 2008, VA and DoD improvements
will include the addition of a polytrauma Marker and OEF/OIF Combat
Veterans Identifier, Electronic Patient Handoff indicators, a DoD
Scanning Interface, the Interagency Sharing of Essential Health Images,
Provider Notes, Theater Data, Vital Signs, and Patient Histories. Site
specific information regarding the volume of data passed through BHIE
through September 2007 can be found at the end of this testimony.
CHDR is the clinical data exchange interface that supports the
exchange of standardized and computable data that can be used to
support automated clinical decision support tools such as drug/drug and
drug/allergy order checking. Currently CHDR data is viewable at all VA
sites and several DoD sites. In addition, VA drug-drug and drug-allergy
order checks are performed based on data from all VA systems and data
from CHDR. User interface applications leveraging the BHIE interface
often require the clinicians to look in several locations to retrieve
health record information from other points of care. This often
requires the clinician to interpolate based on approximation when
comparing data elements due to the use of different terminologies. By
comparison clinical information obtained through the CHDR interface can
be incorporated into the same clinical view, automated computations,
and edits allowing the user to readily compare like data. The CHDR
interface currently supports the movement of pharmacy and medication
allergy data and will be upgraded to include laboratory Chemistry and
Hematology data in the fourth quarter of FY 2008.
The Veterans Tracking Application (VTA) is the VA's interface to
DoD's Joint Patient Tracking Application (JPTA) and supports the
passage of information related to the location of wounded, injured or
ill service members being transferred from theater to Military
Treatment Facilities in the Continental United States (CONUS), who may
be transitioning to the VA. VTA is a critical tool used to support the
benefit claims and seamless transition processes.
The El Paso Clinical Imaging Demonstration leverages the existing
BHIE framework to exchange clinical images, descriptive data and
reports between the VA and DoD facilities. As a result of this
demonstration, six sites have been selected for installation and
testing of the El Paso Imaging prototype are (in order of
installation): Great Lakes/North Chicago, Evans Army Community
Hospital/Eastern Colorado Health Care System, Landstuhl Regional
Medical Center, National Capital Area (Walter Reed Army Medical Center,
National Naval Medical Center, Washington DC VA), VA Polytrauma Centers
at Richmond and Tampa, Keesler Medical Center/VA Gulf Coast Health Care
System.
In general, the volume of medical information that is being
exchanged is growing at a substantial rate. Every effort is being made
to meet the standard of ``essential'' data referenced in the report of
the President's Commission on America's Returning Wounded Warriors.
As it relates to achieving the stated objectives of the projects
referenced above, the impact of senior leadership in driving the two
organizations in the right direction can not be understated. The Joint
Executive Committee (JEC) has been a driving force in setting the long
term direction toward true electronic health record and veteran
benefits data interoperability. The addition of the Senior Oversight
Committee (SOC), the Overarching Integrated Project Team (OIPT) and
Lines of Action (LOA) sub-committees have sharpened the focus and
intensity of leadership engagement, expanded leadership engagement to
include Under Secretaries and top-level General and Flag Officers, and
elevated the topic to the level of the Deputy Secretaries of both
Departments, intended to achieve results by addressing cross-
organizational issues and dependencies related to returning wounded
service members and veterans.
The Role of Puget Sound Health Care System and Madigan Army Medical
Center, the Great Lakes Federal Health Care System, and other
sites in testing and supporting critical data exchange:
Sharing agreements such as the one developed in Tacoma, Washington,
between the Puget Sound Health Care System and Madigan Army Medical
Center (aka Team Puget Sound) demonstrate new capabilities and
functions within products such as BHIE and CHDR. In the Seattle/Tacoma
region the two sites are leveraging the BHIE interface in support of
inpatient services provided to VA at Madigan Army Medical Center. The
primary focus is the exchange of discharge summaries and other
clinically relevant inpatient notes. Through these efforts new
functionality can be fully tested and incorporated into future national
releases.
While collaborations such as the one in the northwest tend to focus
on specific functionality in support of limited sharing agreements, the
Great Lakes Federal Health Care Center will eventually push the
concepts of medical and administrative data sharing too its limits. The
goal in Federal Health Care Center is to fully integrate the clinical
and administrative functions between two health care systems. Planning
activities are underway to develop the local project team required to
manage the information technology requirements needed to support the
new organization. Initial activities include the preparation of an
integrated project schedule reflecting the expected delivery of local
and national capabilities so that the gaps can be evaluated and
resolved. Additionally, an enterprise-level team of resources is being
assembled to resolve technical and operational issues that are beyond
the local team's ability to address. The new Great Lakes System will
exercise every element of both clinical and administrative operations;
a planned and deliberate approach must be taken to ensure that the
business goals are met. There are certainly advances in the application
of information technology that can be applied, however, the process is
complex and must be driven by key business decisions and not by IT.
I would like to thank you Mr. Chairman for giving me the
opportunity to testify about the progress being made in clinical
information sharing between VA and DoD and I will gladly take any
questions at this point.
BHIE Statistics (as of 25 September 07)
----------------------------------------------------------------------------------------------------------------
Number of Number of Number of Number of
MTF correlated new MTF correlated new
Patients patients* Patients patients*
----------------------------------------------------------------------------------------------------------------
Tripler AMC 179,304 52,064 NACC Groton 78,321 33,833
----------------------------------------------------------------------------------------------------------------
Womack AMC 129,737 41,541 MacDill 70,025 40,028
----------------------------------------------------------------------------------------------------------------
Leonard Wood ACH 112,676 31,876 NCA 316,981 121,345
----------------------------------------------------------------------------------------------------------------
Irwin ACH 42,079 13,543 NH Camp Lejeu136,008 40,672
----------------------------------------------------------------------------------------------------------------
Eisenhower AMC 246,781 96,654 Wright-Patterson 101,188 47,201
----------------------------------------------------------------------------------------------------------------
Martin ACH 139,410 39,402 Wm Beaumont AMC 124,275 6,199
----------------------------------------------------------------------------------------------------------------
Fox AHC 25,061 10,753 NH Corpus Christi 39,399 19,202
----------------------------------------------------------------------------------------------------------------
Wilford Hall MC 601,170 227,103 Madigan AMC 201,519 63,392
----------------------------------------------------------------------------------------------------------------
Darnall ACH 135,239 40,465 Lands436,716C 100,922
----------------------------------------------------------------------------------------------------------------
Elmendorf 40,717 13,153 NMC Portsmouth 303,976 97,422
----------------------------------------------------------------------------------------------------------------
Keesler 171,436 70,101 NH Pensacola 112,551 40,413
----------------------------------------------------------------------------------------------------------------
O'Callaghan FH 75,777 22,619 NH Great Lakes134,931 36,955
----------------------------------------------------------------------------------------------------------------
Kirtland 77,066 55,796 NH Jacksonville 135,111 54,682
----------------------------------------------------------------------------------------------------------------
Lyster AHC 30,868 12,355 NMC San Diego 243,934 60,644
----------------------------------------------------------------------------------------------------------------
Bassett ACH 22,357 5,711 NH Lemoor23,752 8,711
----------------------------------------------------------------------------------------------------------------
David Grant MC 150,067 68,902 NH Charleston 119,450 36,356
----------------------------------------------------------------------------------------------------------------
Evans ACH 107,596 40,602 NH Camp Pendleton 165,589 49,444
----------------------------------------------------------------------------------------------------------------
Total # of Unique Patients ** 2,386,625 1,033,658
------------------------------------------------------------------------
* Patients not in the FHIE Domain.
** Columns do not add to the total, since patients have been seen at
multiple facilities.
Prepared Statement of Lieutenant Commander James Lawrence Martin,
Regional Information Systems Officer, Navy Medicine East, Medical
Service Corps, Department of the Navy, U.S. Department of Defense
Mr. Chairman and Members of this distinguished Subcommittee, thank
you for inviting me to be here today. I am LCDR James L. Martin and I
serve as the Regional Information Systems Officer, Navy Medicine East.
Thank you for this opportunity to talk about my personal
involvement in the design and implementation of the Composite
Healthcare System (CHCS), CHCS II, AHLTA and the Electronic Medical
Record Sharing between the Department of Defense and the Department of
Veterans Affairs.
Status of Electronic Medical Record Sharing Naval Health Clinic Great
Lakes
The present method of sharing electronic medical information at
Naval Health Clinic, Great Lakes, is through the Bi-Directional Health
Information Exchange (BHIE) and the Clinical Data Repository/Health
Data Repository (CHDR). The Veterans Affairs providers are granted read
only access to the Department of Defense (DoD) Composite Health Care
System (CHCS) and AHLTA. The Department of Defense (DoD) Providers are
granted read and write privileges to the Veterans Affairs Computerized
Patient Record System (CPRS) which resides on the Veterans Health
Information Systems and Technology Architecture (VistA).
Specifically, access to the Composite Health Care System, AHLTA and
the Computerized Patient Record System in North Chicago is achieved
through a single end user device with icons on the desk top
representing each of these applications. This allows for seamless
patient flow from the Recruit Processing Center Clinic at Recruit
Training Center, Great Lakes to the Emergency Room and Inpatient
Facility at North Chicago Veterans Affairs Medical Center. Laboratory
Data Sharing Interoperability (LDSI) is used to share Laboratory
information between these two systems. The combination of these methods
listed above allows complete sharing of all Clinical Information
between the Veterans Affairs and Department of Defense Providers.
Regional Information Systems Officer Involvement in this Process
My personal involvement in this process dates back to 1992 when I
assisted in the design and implementation of the Infrastructure and End
User Device placement in support of Composite Health Care System (CHCS
Legacy) while serving as Assistant Department Head, Naval Medical
Information Management Center, Bethesda. My involvement included
personally visiting each Naval Healthcare Treatment Facility prior to
and during system implementation.
Thereafter, my role expanded in 1994 as the Head, Management
Information Department, Naval Hospital Pensacola, where I managed the
Composite Health Care System Host Site for the Hospital and its remote
facilities. In 1997, while serving as the TRICARE Region II Regional
Information Systems Officer, Naval Medical Center Portsmouth, one of
our Commands was selected to be the Test Site for Composite Health Care
System II, the predecessor to AHLTA. From 2000 to 2004, I was the
Information Systems Officer at Naval Medical Center Portsmouth
overseeing the testing and implementation of the Composite Health Care
System II. It was during this tour that Naval Medical Center Portsmouth
first populated the Clinical Data Repository (CDR) with a 25 month data
pull from Composite Health Care System (Legacy CHCS) placing
demographic information and Laboratory, Pharmacy and Radiology results
in the Clinical Data Repository. From 2004 until 2006 I served as the
Medical Liaison Officer, Space and Naval Warfare Systems Center,
Norfolk, where I was in charge of the design and testing of the Theater
Medical Information Program-Maritime (TMIP-M) the Navy Operational
Version of Composite Health Care System II and AHLTA designated CHCS
II-T and AHLTA-T.
Currently, as the Regional Information Systems Officer for Navy
Medicine East, I oversee all Information Management and Technology for
the Navy Military Healthcare Facilities that fall under Navy Medicine
East. Naval Health Clinic Great Lakes is one of these Commands.
I have made five site visits in direct support of the DoD/VA
initiative at Great Lakes. During these visits I have surveyed the
existing facilities and assisted in planning of the relocation of the
IM/IT equipment to its new location at the Federal Healthcare Clinic. I
attend biweekly conference calls and engineering support meetings where
the design and layout of the actual IM/IT spaces is discussed.
The other Commands under Navy Medicine East that I am presently
assisting with DoD/VA IM/IT initiatives include Naval Health Clinic
Charleston, Naval Hospital Pensacola, Naval Hospital Jacksonville and
Naval Medical Center Portsmouth. I am also a member of the National
Information Management and Technology Task Group for the Department of
Defense and Department of Veterans Affairs Electronic Health
Information Sharing Initiative. My responsibility as a member of this
task force is to plan and oversee the acquisition and implementation of
information systems that integrate VA and DoD health care processes at
the North Chicago Federal Healthcare Clinic.
Future Activities
Our goal is to have an interoperable information system that
supports clinical and business operations by June 2010. We plan to
create a single (main) computer room and a single (main)
telecommunications room. Additionally, an Information Management and
Information Technology Network Trust between DoD and VA must be
established, along with domain ownership and a single electronic email
system.
We are presently gathering requirements from the functional users
so that the determination can be made on whether a combination of
information systems or a new information system is required to meet the
functional user requirements. The ultimate goal is to have a single
point of entry to support the missions of both DoD and VA patient
populations. At present, this goal is met by providing access to CHCS,
AHLTA and CPRS using multiple icons on a single end user device.
In addition to the goal of a single point of entry we are also
working on the consolidation of IM/IT systems for all of the functional
areas in the Federal Healthcare Clinic. This involves managing the
development of functional requirements, assisting with local site
integration efforts, assisting with enterprise solutions and
communicating the status.
Conclusion
I would like to conclude by saying that one of our top priorities
is to continue finding ways for Electronic Medical Data Sharing between
DoD and VA.
Mr. Chairman, Committee Members, thank you again for this
opportunity to speak about our efforts. At this time I would be pleased
to answer any questions you may have.
Prepared Statement of Colonel Gregory Andre Marinkovich, M.D., Data
Management Product Line Functional Manager, Clinical Information
Technology Program Office, Military Health System, Medical Services
Corps, Department of the Army, U.S. Department of Defense
Introduction
Mr. Chairman and Members of this distinguished Subcommittee, thank
you for inviting me to be here today. I am COL Gregory Andre
Marinkovich and I serve as the Data Management Product Line Functional
Manager in the Clinical Information Technology Program Office within
the Military Health System (MHS). Thank you for this opportunity to
talk about the military's electronic health record, AHLTA, and the
strides we are making in sharing information between the Department of
Defense and the Department of Veterans Affairs.
Historical Overview
AHLTA, an enterprise-wide medical and dental outpatient clinical
information system, is the military's current outpatient Electronic
Health Record (EHR). It generates, stores, and provides secure online
access to lifelong patient healthcare records for more than 9.1 million
MHS beneficiaries seen in military treatment facilities. AHLTA ensures
the continuity of the Department's health information and patient-
centered healthcare delivery with worldwide accessibility anytime,
anywhere.
Worldwide deployment of AHLTA, which began January 2004, was
successfully completed to all DoD military treatment facilities
worldwide in November 2006. Implementation support activities spanned
11 time zones and included training for over 55,000 users, to include
more than 18,000 health care providers. Current AHLTA functionality
includes encounter documentation, order entry/results retrieval,
encounter coding support, alerts and reminders, role-based security,
health data dictionary, master patient index, and ad hoc query
capability.
Current Activities
AHLTA use continues to grow at a significant pace.
To date, AHLTA has processed over 45 million outpatient
encounters.
AHLTA is currently processing approximately 112,000
outpatient encounters per workday.
DoD and VA also are taking the first steps toward a joint
electronic health record system. A contract to assess VA's and DoD's
business and clinical processes, design features, and system
constraints relevant to the inpatient component of an electronic health
record has been awarded. This assessment will determine and describe,
in narrative and graphic format, the scope and elements of a joint
inpatient electronic health record and identify those clinical and
business capabilities and applications that interact with the joint
inpatient electronic health record. An analysis of alternatives will
then be conducted to develop a recommendation for the best technical
approach. We will implement the solution in a manner that builds in
data interoperability.
Future Activities
Based on feedback from several AHLTA user conferences, we are
making changes to the next version that will be more provider-friendly.
This is scheduled to be released in December 2007. Enhancements that
are scheduled to begin deployment in December 2007 will include the
ability for patients to provide their signatures electronically for
medical forms, and multi-site user account access, which will enable
``mobile'' providers to use AHLTA from multiple locations.
Looking ahead to 2008, we plan to begin worldwide deployment of
dental charting and documentation, and eyeglass ordering and
management.
Conclusion
I would like to conclude by saying that one of our top priorities
is to continue finding ways for AHLTA to seamlessly transfer
information between DoD and VA, thereby ensuring continuity of quality
care for returning wounded warriors. With your support, we will
continue building on our achievements in sharing electronic health
information in support of the men and women who serve and have served
this country.
Mr. Chairman, Committee Members, thank you again for this
opportunity to speak about our efforts. At this time I would be pleased
to answer any questions you may have.
Prepared Statement of Gerald M. Cross, M.D., FAAFP, Principal Deputy
Under Secretary for Health, Veterans Health Administration, U.S.
Department of Veterans Affairs
Mr. Chairman, Madame Ranking Member Brown-Waite and Members of the
Subcommittee, thank you for providing the opportunity to report the
progress made by the Department of Veterans Affairs (VA) to share
electronic medical records with the Department of Defense (DOD). We
have made progress toward developing secure, interoperable electronic
medical record systems and I am here today to discuss the current
status of our efforts and the work that is underway to achieve
electronic health record interoperability.
Overview
Today, VA and DOD are sharing electronic health data
bidirectionally to support the care of shared patients. Additionally,
VA and DOD are sharing more data than ever before on our seriously
wounded service members and veterans who are transitioning from
military facilities to VA facilities and polytrauma centers. The
availability of these data to VA and DOD providers enhances our ability
to provide world class care to veterans, active duty service members
receiving care from both systems, and to our wounded warriors returning
from theaters of operation in Iraq and Afghanistan. Ensuring that we
have accurate, comprehensive and timely medical data to treat our
Nation's heroes remains a top priority of this department.
In recent months, we have built upon our earlier successful
development of one-way and bidirectional exchanges of text and
computable data. Today, VA providers are able to access more electronic
inpatient data from DOD than ever before. DOD also has a study
underway, funded by VA and DOD, to examine our development of a joint
inpatient electronic health record with DOD. Additionally, for the
first time, VA has access to critical medical electronic data from
current theater of operations, to treat wounded warriors coming to our
facilities. The challenges of sharing large amounts of data from
disparate electronic systems remain complex. Our processes are not
perfect, and I will discuss that below. However, we are working to
provide as much electronic data as possible as quickly as possible in
support of our returning warriors and shared patient populations. We
are now sharing data from multiple settings, including outpatient,
inpatient, and theater, as well as tracking information to improve our
case management and coordination. These accomplishments reaffirm our
commitment to develop interoperable electronic health records with DOD.
Moreover, we believe our current capabilities to share electronic
medical data demonstrate progress toward our goal.
Active Joint Governance
VA and DOD efforts to achieve interoperability are jointly governed
at the highest levels of our departments. Our VA Acting Secretary and
the Under Secretary of Defense for Personnel and Readiness continue to
cochair the DOD/VA Joint Executive Council (JEC). The JEC provides
Executive and overarching leadership of all VA/DOD collaborative
activities, including the development of interoperable electronic
medical records. Since 2003, VA and DOD have documented these
activities in the DOD/VA Joint Strategic Plan (JSP) that is maintained
by the JEC. The JSP contains measurable strategic goals, objectives and
milestones for our collaborative work with DOD, including electronic
medical data sharing. VA and DOD work to update the JSP each year and
progress under the JSP is reported to the JEC on a monthly basis. Under
the leadership of the JEC and the clear goals contained in the JSP, VA
and DOD realized success in meeting JSP health data sharing milestones.
VA's Under Secretary for Health and the DOD Assistant Secretary of
Defense for Health Affairs cochair the VA/DOD Health Executive Council
(HEC), a Subcommittee of the JEC. The HEC is responsible for
coordination of those joint activities related to health care and is
committed to ensuring that our ongoing partnership optimizes health
delivery to veterans and military beneficiaries. The HEC Information
Management and Information Technology Work Group, cochaired by the VHA
Chief Information Officer for Health Information Technology Systems and
the Military Health System Chief Information Officer, maintains day to
day responsibility for health information technology work and, most
importantly, for the implementation of our joint electronic health
record and data sharing initiatives.
Theater and Inpatient Data Supporting the Seriously Ill and Wounded
At no other time has it been more important for VA and DOD to
overcome some of the ongoing complexities of sharing disparate
electronic health data. VA and DOD are firmly committed to supporting
the seamless care of our injured men and women returning from the
battlefield to military facilities and eventually to VA facilities for
longer term care and rehabilitation. Our Nation's heroes deserve
nothing less. In cooperation with our sharing partner, our most recent
accomplishments to report have focused on the development of electronic
solutions to support these seriously ill and wounded patients.
VA and DOD have charted the Senior Oversight Committee (SOC) for
the Wounded, and Injured. Co-chaired by the Acting VA Secretary and the
DOD Deputy Secretary, the SOC works in conjunction with the JEC to
ensure targeted focus on the population of men and women injured in OEF
and OIF and now returning for treatment. Underneath the SOC, VA and DOD
have organized several Lines of Actions (LOAs), with one LOA
specifically focused on data sharing. The purpose of the data sharing
LOA is to ensure that appropriate beneficiary and medical information
is visible, accessible and understandable by each departments and that
available electronic information is shared. Since the formation of the
SOC and LOAs, the President's Commission on Care for America's
Returning Wounded Warriors (President's Commission) has recommended
that VA and DOD share all essential health, administrative and benefit
data in viewable format initially, within 12 months. Heeding this
recommendation, we have worked with DOD to accelerate and enhance our
existing data exchanging to meet this target. Today, VA and DOD are on
target to ensure that these essential data which are available
electronically will be viewable between the departments by October
2008. Additionally, VA and DOD are now actively developing a plan to
establish technology support for the newly formed position of Federal
Recovery Coordinator. This Recovery Coordinator will support seriously
ill and wounded patients by maintaining on the ground oversight and
coordination for all essential clinical and non-clinical aspects of the
recovery care plan. We anticipate documenting an information technology
plan to support this position by November of this year.
Our most notable achievements demonstrating our commitment to
wounded warriors is the sharing of theater and inpatient data. For the
first time, DOD medical data captured electronically in the theater of
operations are now viewable in text format to any VA provider treating
these wounded warriors. We accomplished this in September of 2007 by
leveraging an existing bidirectional data exchange. Subsequently, we
are implementing a plan that will permit us to share unprecedented
amounts of the available inpatient electronic data from DOD. Currently,
VA providers are able to view electronic discharge summaries, emergency
department notes, and other narrative documents captured during
inpatient encounters at 13 major DoD facilities that use the Essentris
Clinical Information System (CIS)\TM\. These 13 facilities include the
Military Treatment Facilities that are key to supporting returning
combat veterans, such as Walter Reed Army Medical Center (Walter Reed)
and Bethesda national Naval Medical Center (Bethesda), and have greatly
contributed to our ability to provide seamless care to these wounded
warriors. This work was accomplished, due in large part, to the
innovation of our local clinicians and informatics professionals in the
field, at locations such as the Puget Sound VA Healthcare System and
Madigan Army Medical Center. Cooperative efforts between VA and DOD are
systemic, reaching all the way down to our facilities.
In addition to sharing available electronic documentation, DOD is
sending digital radiology images and scanned inpatient paper records
that do not originate in electronic format. These capabilities are in
place between the key military treatment facilities that receive these
patients in the Continental United States (CONUS), (Walter Reed,
Bethesda, and Brooke Army Medical Center), and VA polytrauma centers
located in Tampa, Richmond, Minneapolis and Palo Alto.
VA and DOD continue to maintain the highly secure and audited
direct connection allowing viewing access to the data in the inpatient
electronic data systems at Walter Reed and Bethesda by clinicians at
the four polytrauma centers. Using these connections allows authorized
VA clinicians to view real-time DOD data on wounded service members and
combat veterans who are coming to or have transferred to the VA from
these DOD facilities. VA and DOD are working to expand our electronic
capabilities enterprise wide. We have already successfully demonstrated
our capability to leverage bidirectional data exchange to support image
sharing with the El Paso pilot. We are now working to expand this pilot
to other active sharing locations and are on target to document a plan
to share images enterprise wide by March 2008. As is commonly
understood, much of the DOD inpatient data is not available
electronically. Despite this ongoing challenge, VA and DOD quickly
developed these capabilities as interim solutions to support these
patients while we work to expand our electronic capabilities. To ensure
that we provide full support in the face of these ongoing challenges,
VA continues to embed Transition Patient Advocates and social workers
at key facilities. At minimum, all pertinent medical records not
available electronically are at least copied and transferred with the
patient. Our enhanced inpatient capabilities support and bolster the
seamless transition of these patients. It is our goal that no patient
will fall through the cracks.
In January of 2007, VA and DOD announced a study to explore the
development of a joint inpatient electronic health record system. Since
that time, VA and DOD have actively pursued this initiative. We are now
under contract with a prominent and independent third party firm that
is conducting the analysis of alternatives. To date, we have made
progress by documenting the scope and elements of those joint inpatient
data elements that would need electronic support. This work includes
conducting comprehensive surveys of industry best practices in this
area. We anticipate we will have a final report by July 2008. A common
inpatient electronic health record will support the transfer of our
most seriously injured patients between DOD facilities and VA
facilities as well as broad enterprise-level data sharing between VA
and DOD clinicians for all shared patients.
Requirement to Share Psychological Health Data and TBI Data
In order to ensure comprehensive continuation of services, and to
better leverage the world-class care that is already available to
patients at VA's centers of excellence for Post Traumatic Stress
Disorder (PTSD), Traumatic Brain Injuries, and other diagnoses
impacting psychological health, it is necessary for VA and DOD to
improve routine and appropriate sharing of mental health data. VA has a
need to receive these data from DOD.
Sharing of information on mental health conditions and other
sensitive matters is important in a number of different contexts. Most
simply, they can be divided into areas where the sharing of information
is needed to facilitate clinical care of veterans or servicemembers who
receive care in both systems, either sequentially or in parallel, and
information used for administrative or command purposes.
For clinical purposes, our systems should work toward minimizing
barriers for transmittal to the greatest extent possible. Examples of
mental health information that would support the VA in serving veterans
include records of acute stress disorders, other mental health
conditions, and suicidal behaviors, as well as head trauma. Having this
information on returning veterans would be important to guide treatment
and monitoring plans.
For other purposes, VA, as an agency that functions in the
community in parallel to civilian providers of health care, the issues
may be more complex. For example, in developing principles about
disclosure of information about mental health conditions from VA to
DOD, VA must balance its responsibilities as a civilian community
health care provider with those as part of a DOD/VA system. Viewed from
community standards, it is important to honor patient privacy values,
while from the VA/DOD perspective, it is important to provide relevant
information to DOD that may have an impact on the efficiency of the
fighting force. This issue is being addressed in ongoing discussion
within VA.
Ongoing Support for Separated Service Members and Shared Patients
In addition to our accelerated efforts to support our most
seriously injured patients, VA and DOD continue the ongoing
implementation of our Joint Electronic Health Records Interoperability
(JEHRI) plan. The HEC IM/IT Work Group continues to manage the
implementation of JEHRI and the maintenance and enhancement of our one-
way and bidirectional data exchanges. Today, VA continues to receive
all clinically relevant data that are available in DOD's legacy system,
the Composite Health Information System (CHCS), on service members
separated from active military service. These data are viewable through
our shared Federal Health Information Exchange repository by VA
clinicians and disability claims staff using VA health and
administrative information systems. To date, DOD has transferred
electronic health data on over 4 million unique separated service
members to VA. Of these individuals, VA has provided care or benefits
to the more than 2 million veterans who have sought care or benefits
from VA. The data transferred for viewing includes outpatient pharmacy
data, allergy information, laboratory results, consults, admission,
disposition and transfer information, medical diagnostic coding data,
and military pre- and post-deployment health assessment (PPDHA) and
reassessment (PDHRA) data on separated and demobilized National Guard
and Reserve members. DOD has made almost 2 million of these PPDHA and
PDHRA forms available for viewing by VHA clinicians and VBA staff.
In addition to ongoing maintenance of our one-way data exchange, VA
and DOD continue to bidirectionally exchange viewable and computable
electronic data on shared patients. Currently, VA and DOD are
bidirectionally sharing viewable outpatient pharmacy data, anatomic
pathology/surgical reports, cytology results, microbiology results,
chemistry and hematology laboratory results, laboratory order
information, radiology text reports and food and drug allergy
information. We also are maintaining our ongoing exchange of computable
allergy and pharmacy data supporting automatic drug-drug and drug-
allergy interaction checks at seven locations. The development of this
joint capability is complete. The departments are now working together
to expand implementation across both enterprises by addressing issues
such as user training, site specific issues related to identification
and flagging of active dual consumers for whom this capability is in
place, and ongoing deployment of department system dependencies related
to HealtheVet.
As mentioned above, and in keeping with the recommendation of the
Presidential Commission, VA and DOD are leveraging our bidirectional
exchanges to expand the types of data shared and to share all essential
information by October 2008. By December of this year, our providers
will have access to viewable encounter notes, problem lists, and
procedures from DOD's modern system, AHLTA. By June 2008, we will add
vital signs and by October 2008 enterprise wide capability to view
scanned documents, such as paper inpatient records. By March 2008, VA
and DOD will document a plan to support the enterprise wide
bidirectional sharing of digital images. This work will leverage the
successful imaging pilot in El Paso and incorporate the work that will
soon get underway at expanded pilot locations. By the fourth quarter of
2008, VA and DOD will deploy our computable laboratory capability to
support automatic decision support using electronic laboratory result
data transferred bidirectionally.
Enhanced Tracking Capability (Veterans Tracking Application)
This month, VA achieved the ability to access patient tracking data
enterprise wide using the Veterans Tracking Application (VTA). As
reported previously, VTA is a modified version of the DOD developed
Joint Patient Tracking Application (JPTA). Our facility based liaisons,
such as case managers, can now access VTA from VistA Web to assist with
the coordination of care for patients treated at both VHA and DOD. This
coordination includes the tracking of these patients as service members
move from the battlefield through Landstuhl, Germany, to stateside
military treatment facilities and into our VA polytrauma and medical
centers. VTA is completely compatible with JPTA allowing overnight
electronic transfer of critical tracking data on medically evacuated
patients.
Previously, we testified that our JPTA/VTA interface would support
the transfer of medical data from the theater. DOD's recent successful
efforts to consolidate theater clinical data and to make it viewable to
VA through our bidirectional data exchange overcame that effort. As
mentioned above, VA clinicians access clinical data, including theater
clinical data, through the Bidirectional Health Information Exchange.
Our JPTA/VTA interface now supports the provision of viewable tracking
data. The VTA database of seriously injured OEF/OIF service members and
veterans is used as the authoritative source for the movement of
theater patients and supports and documents contacts with veterans and
service members. VTA is now a critical tool in the support of our
seamless case management of patients. VTA also continues to support the
benefit claims process and consolidates data from across all major
components, DOD, VHA and VBA into a veteran centric record enhancing
our case management capabilities.
Ongoing Collaboration and Dependence on Standards
VA and DOD' continue to work closely with the Department of Health
and Human Services (HHS) and other partners on national efforts to
align our groundbreaking work on data exchanges with the nationwide
effort to support health interoperability. These efforts are led by the
HHS National Coordinator for Health Information Technology and will
include ongoing efforts to identify mature standards, study
infrastructure interoperability, and work closely with commercial
healthcare providers to foster a global interoperability
infrastructure.
The President's Commission recognized the complexity of achieving
full data interoperability and tailored its recommendation to initially
share data in viewable format versus computable format. Mature
standards are necessary and evolved technologies are critical
dependencies to the seamless exchange of all data. As these health data
and communication standards mature and are identified, we will adopt
and implement the standards into the systems we are modernizing. VA and
DOD continue to play a leadership role in these efforts. Our VA/DOD
Health Architecture Interagency Group continues to participate in and
contribute to standards related organizations such as Healthcare
Information Technology Standards Panel (HITSP) and Health Level 7(HL7)
to improve the availability of shared health information. Current
efforts are focused on areas such as case management and disability
evaluation.
Conclusion
VA and DOD have achieved progress toward sharing all available
electronic data and remain committed to efforts that will help us to
reach our final goal. Under the leadership of the JEC and the HEC, we
are marching forward to implement enhancements to existing data
exchanges while identifying attainable opportunities to support our
most seriously ill and wounded warriors and combat veterans. We assure
you that we continue to work toward a long-term strategy that will
support full enterprise wide electronic data interoperability. Never
before have we been able to access data from the theater and provide
care to our veterans and rehabilitating service members using the
amount of inpatient data currently available from DOD. Our efforts are
subject to tremendous interest by the President and Congress, and we
are working hard to ensure that recommendations coming from bodies such
as the President's Commission, the Task Force on the Returning Global
War on Terror Heroes, chaired by our own Acting Secretary, and the
Veterans Disability Benefits Commission, are evaluated and
incorporated, where feasible, to ensure we form a complete and
comprehensive approach to sharing health data in support of our
veterans and service members
To continue our successes, we ask for your continued support as we
each work to modernize and update our existing technologies. VA has
been recognized many times over for the world-class care it provides to
veterans. Our electronic health record is second to none in its fully
integrated electronic capabilities across all settings of care. More
work is needed to update our world-class system and to ensure that it
uses state of the art technologies and tools that will better support
data interoperability. Thank you for the opportunity to appear before
you and provide you the status of our ongoing efforts. My colleagues
and I are happy to answer any questions you or other Members of the
Subcommittee might have.
__________
VA/DoD Interoperability Acronyms
Health Care Delivery Systems
AHLTA--Armed Forces Health Longitudinal Technology Application--
DoD's next generation Electronic Record System--formerly CHCS II
CHCS--Composite Health Care System--DoD legacy system housing order
entry/labs/radiology/allergy/meds, largely used for ambulatory care
CIS--Clinical Information System (new name is Essentris
Clinicomp)--DoD's standalone inpatient system installed in most major
military treatment facilities.
CPRS--Computerized Patient Record System
HealtheVet--Next generation of VistA based on computable data
JPTA--DoD's Joint Patient Tracking Application
TMDS--DoD's Theater Medical Data Store
VistA--Veterans Health Information Systems and Technology
Architecture
VistA Web--The VistA web-based application for viewing remote data
(VA and DoD)
VTA--Veterans Tracking Application
Other
TPA--Transition Patient Advocates
Health Care Exchange Systems
BHIE--Bidirectional Health Information Exchange
CHDR--Clinical Data Repository/Health Data Repository
(Interoperability Project)
FHIE--Federal Health Information Exchange (formerly GCPR)
Groups/Organizations/Plans
AHIC--American Health Information Community
CHI--Consolidated Health Informatics
BEC--DoD/VA Benefits Executive Council
HEC--DoD/VA Health Executive Council
JEC--DoD/VA Joint Executive Council
JEHRI--DoD/VA Joint Electronic Health Records Interoperability
JSP--Joint Strategic Plan
LOA--Line of Action
MTF--Military Treatment Facilities
ONCHIT--Office of the National Coordinator for Health Information
Technology
SOC--Senior Oversight Committee
[GRAPHIC] [TIFF OMITTED] 39466A.003
Prepared Statement of Stephen L. Jones, DHA, Principal Deputy Assistant
Secretary of Defense (Health Affairs), U.S. Department of Defense
INTRODUCTION
Mr. Chairman and members of this distinguished Subcommittee, thank
you for inviting me to discuss the sharing of electronic health
information between the Department of Defense (DoD) and Department of
Veterans Affairs (VA). We are making great strides in sharing
electronic health information, but we have more to do.
Cooperation between DoD and VA in the area of health information
sharing is vital for effective management and efficient delivery of
programs and benefits that our Nation's Veterans and Service members
deserve. DoD recognizes Congressional concerns regarding the time it
has taken the two Departments to establish the current level of
interoperability. Let me assure you that DoD and VA share the ultimate
goals of this and other Congressional bodies seeking to address the
needs of the Nation's heroes. We have been working together in earnest
and have made significant progress in sharing electronic health
information since our first efforts in 2001. In particular, I would
like to highlight current sharing activities, recent accomplishments,
and some of what we hope to accomplish going forward.
HISTORICAL OVERVIEW
DoD and VA began sharing electronic health information in 2001 and
have continually enhanced and expanded the types of information we
share as well as the ways in which we share the information. At times
it has not been an easy road, and there is always room for improvement
in an effort as large and as crucial as this one. Nonetheless, DoD and
VA have come a long way in the areas of health information technology,
interoperability standards, and health information sharing. By working
together at the top levels of DoD and VA, we have established policies
that enable each Department to address its unique requirements while
also addressing requirements that we share.
CURRENT ACTIVITIES
Continuity of Care for Shared Patients. For patients treated at
both VA and DoD facilities, providers can view electronic health data
from both Departments. By the end of 2007, all essential health data
will be, in the words of the President's Commission on Care for
America's Returning Wounded Warriors, ``immediately viewable by any
clinician, allied health professional, or program administrator who
needs it'' at a DoD or VA facility. Health data currently accessible by
DoD and VA providers includes allergy information, outpatient
medications, inpatient and outpatient laboratory results, radiology
reports, demographic details to identify the patient, Pre- and Post-
Deployment Health Assessments, and Post-Deployment Health
Reassessments. To that list we can now add, as of earlier this month,
vital clinical data captured in the Theater of operations, including
inpatient notes, outpatient encounters, and ancillary clinical data,
such as pharmacy data, allergies, laboratory results, and radiology
reports. This development is a significant accomplishment in our
efforts to enhance the continuity of care for Service members returning
from Iraq, Afghanistan, Kuwait, and other forward locations. Other
recent developments include expanding our efforts to share inpatient
information electronically. Specifically, over the past several months
we have expanded the sharing of electronic discharge summaries to
include the 13 DoD facilities with the greatest inpatient volume.
Previously only five DoD facilities had been capable of sharing
discharge summaries. This capability will be extended to include
Landstuhl Regional Medical Center in 2008. As the primary receiving
location for patients coming out of Theater, Landstuhl is a critical
link in the electronic health information chain.
By December 2007, we will be sharing encounters and clinical notes,
procedures, problem lists, inpatient consultations, and operative
reports, further enhancing continuity of care for our shared patients.
In 2008, we will add vital signs, family history, social history, other
history, and questionnaires and forms.
Drug-Drug and Drug-Allergy Interaction Checking. Outpatient
pharmacy and drug allergy data are now available in a standardized
format for patients receiving treatment from both DoD and VA. This
standardization enables our information systems to run vital safety
checks. Drug-drug interaction and drug-allergy checks can now be run
using data from both Departments, further enhancing patient safety.
Currently, this capability is operational in the following seven
locations:
William Beaumont Army Medical Center/El Paso VA Health
Care System;
Eisenhower Army Medical Center/Augusta VA Medical Center;
Naval Hospital Pensacola/VA Gulf Coast Health Care
System;
Madigan Army Medical Center/VA Puget Sound Health Care
System;
Naval Health Clinic Great Lakes/North Chicago VA Medical
Center;
Naval Hospital San Diego/VA San Diego Health Care System;
and
Mike O'Callaghan Federal Hospital and VA Southern Nevada
Health Care System.
For this capability to work properly, the individual must have a
record in the Defense Manpower Data Center/Defense Enrollment and
Eligibility Reporting System (DEERS)--DoD's ``gold standard'' for
person identification. More than 6 million veterans, primarily those
who separated from Service prior to the establishment of DEERS, were
recently added to the DEERS database. With that completed, we are now
ready for all DoD sites to implement this data sharing initiative. Even
now however, all DoD and VA facilities--not just those listed above--
have access to the shared DoD and VA pharmacy and allergy data for a
patient if that patient should present to their facility for care.
Continuity of Care for Polytrauma Patients (Wounded Warriors).
Earlier this year, in response to the urgent need for VA providers at
Polytrauma Centers to have as much information as possible on
inpatients transferring to their care, DoD began sending electronic
health information directly to the Polytrauma Centers. When providers
determine that a severely wounded, injured, or ill patient should be
transferred to a VA Polytrauma Center for care, DoD sends radiology
images and scanned paper medical records electronically to the
receiving facility. This effort began in March 2007 with a pilot
project, sharing information from one DoD facility to one VA Polytrauma
Center, and quickly expanded to include the three primary DoD
facilities treating incoming severely wounded warriors--Walter Reed
Army Medical Center, National Naval Medical Center, and Brooke Army
Medical Center--and the four level 1 VA Polytrauma Centers--Tampa,
Richmond, Palo Alto, and Minneapolis.
Separated Servicemembers (Potential VA Patients). More than 4
million former Service members eligible for VA health care now have
electronic health information accessible to their new provider should
they seek care at a VA facility. In 2001, DoD transmitted electronic
health information for Service members who had separated since 1989.
Monthly transfers of health information for newly separated Service
members began in 2002 and continue today. Electronic health information
available to VA providers includes the following data elements:
Outpatient pharmacy data, laboratory and radiology
results;
Inpatient laboratory and radiology results;
Allergy data;
Consult reports;
Admission, disposition, transfer data;
Standard ambulatory data record elements (including
diagnosis and treating physician);
Pre- and post-deployment health assessments; and
Post-deployment health reassessments.
When the former Service member presents to VA for care or
evaluation, the VA provider can access this information from within the
VA electronic medical record.
Business Practice Coordination. DoD and VA have extended the
sharing concept to include coordination of business practices. For
example, the Laboratory Data Sharing Initiative (LDSI) established
bidirectional electronic exchange of laboratory chemistry orders and
results when one Department's lab acts as a reference lab for the
other. In other words, when it will speed the process of getting a lab
result, DoD can send a test to a VA lab for processing or VA can send a
test to a DoD lab. The end result is expedited testing and results,
enhancing the quality of care for our patients. Expanding the LDSI
capability, DoD and VA have added laboratory anatomic pathology and
microbiology orders and results retrieval. This enhanced functionality
became operational at Brooke Army Medical Center and VA South Texas
Health Care System in May 2007. The LDSI capability can be expanded to
include other sites should they demonstrate that the capability would
enhance quality of care and make sense from a business perspective.
DoD and VA are also exploring other opportunities for coordinating
business practices to support Veterans and Service members and their
families. These opportunities include an eHealth portal to improve
accessibility of information for patients and expanded image sharing.
In both cases, DoD and VA will explore opportunities in search of the
best ways to coordinate business practices to achieve the greatest
benefit for the patients we serve.
DoD's Electronic Health Record Meets Unique Needs. Sharing
electronic health information with VA is just one function of the DoD
electronic health record. DoD has many unique requirements that have
shaped the development of its electronic health record system.
Theater. To track health care most effectively in Theater, a
flexible, mobile, and highly scalable electronic information system is
necessary. DoD's electronic health record operates on the full spectrum
of hardware, according to what is available or practical in a given
location or situation. DoD providers at fixed facilities--what most of
us think of as hospitals--can use desktop computers. Providers at
Combat Support Hospitals--sometimes nothing more than tents in the
desert--use laptops that can operate in a standalone mode or as part of
a small network. Medics in the field can use handheld devices that are
later synched with a laptop or desktop to add valuable information to
the patient's electronic health record. DoD's electronic health record,
on all platforms, is designed to collect highly structured medical
data, enabling us to identify potential natural disease outbreaks and
chemical or biological attacks much faster than ever before in Theater.
DoD's Theater health care mission also necessitates that an electronic
health record system be operational in situations and places where
external communications are often sporadic or unreliable. Additionally,
because health care information from Theater supports command and
control efforts, our electronic health record system needs to fit
within the greater DoD information technology infrastructure.
One System in Garrison and Theater. When our providers deploy, they
must be provided with familiar tools to maximize their readiness.
Therefore, we need to use one electronic health record system in
garrison and in Theater. Multiple systems could delay deployment of
health care providers as they learn the ``Theater'' system or could
negatively affect the quality of care in Theater as providers use a
system with which they are either unfamiliar or less familiar.
Our Beneficiary Population. DoD's beneficiaries include millions of
people who relocate every few years. To maintain accurate and complete
electronic health records for such a mobile population requires a
centralized clinical data repository. As DoD providers and patients
alike move from one part of the country to another, or from one end of
the world to another, they benefit from a system that maintains
complete records with information from more than 60 major hospitals and
medical centers and more than 400 clinics in a single, electronic
health record--accessible from DoD facilities around the globe.
JOINT INPATIENT ELECTRONIC HEALTH RECORD
DoD and VA have developed or acquired separate outpatient
electronic health record systems to meet unique needs. For inpatient
care, however, the Departments are exploring the possibility of a joint
electronic health record solution. The timing for examining this
potentially ground-breaking effort is right, as both Departments
currently plan to modernize, upgrade, or integrate inpatient records
with their outpatient electronic health records and must find an
interoperable solution. A joint inpatient solution that meets the needs
of both Departments could further enhance continuity of care, better
meet requirements for joint facilities, and leverage economies of scale
in terms of development and integration costs, license fees, and
hardware purchases.
We have taken the first steps in this effort to examine the
potential for a joint system by working closely to award a contract to
assess VA's and DoD's business and clinical processes, design features,
and system constraints relevant to the inpatient component of an
electronic health record. This assessment will determine and describe,
in narrative and graphic format, the scope and elements of a joint
inpatient electronic health record and identify those clinical and
business capabilities and applications that interact with the joint
inpatient electronic health record. An analysis of alternatives will
then be conducted to develop a recommendation for the best technical
approach. We will implement the solution in a manner that builds data
interoperability in as a fundamental precept. Our goal is for a
solution to address the information needs of the end users in all
inpatient care venues from the forward surgical units in Theater to the
domiciliary care facilities in VA. A joint solution could provide users
with all essential inpatient data--regardless of where in DoD or VA
that data was acquired--as the patient moves through the continuum of
care from Theater to home again. The requirements analysis will be
complete in 2008, after which we will establish an acquisition or
development timeline based on the assessment of alternatives.
INTENSIFIED FOCUS ON WOUNDED WARRIORS
In the words of Secretary Gates, ``Apart from the war itself, this
department and I have no higher priority'' than taking care of those
who have ``stepped forward to serve.'' Over the last several months DoD
and VA have accelerated our electronic health information sharing
initiatives to support America's heroes. We have received and are
responding to the recommendations of various commissions and task
forces, including the Independent Review Group, the Department of
Veterans Affairs Interagency Task Force on Returning Global War on
Terror Heroes, and most recently, the Veterans Disability Benefits
Commission. Under the auspices of a Senior Oversight Committee and
Overarching Integrated Product Team, I along with Dr. Paul Tibbits have
had the privilege of cochairing the team for DoD/VA Data Sharing. Not
only are we focusing on sharing health, personnel, and administrative
data electronically between DoD and VA, but we are also working with
other teams to determine the information technology needed to support
reengineered business processes that better support our wounded
warriors.
In addition, we are working to implement the recommendations of the
President's Commission on Care for America's Returning Wounded
Warriors. We will:
By next July, in order to implement our new Recovery
Plans for wounded, make patient data much more accessible--to begin
with, in viewable form. All essential health, administrative, and
benefits data must be immediately viewable by any clinician, allied
health professional, or program administrator who needs it.
Continue the work under way at present to create a fully
interoperable information system that will meet the long-term
administrative and clinical needs of all military personnel over time.
Develop a plan for a user-friendly, tailored, and
specific services and benefits portal for service members, veterans,
and family members.
Over the next several months, DoD/VA teams will define information
technology requirements, enabling the two Departments to begin the work
necessary to make all appropriate demographic, personnel, and medical
information on Service members, Veterans, and their beneficiaries
visible, accessible, and understandable through secure and
interoperable information management systems. We will work to provide
the information technology needed to care for and track the status of
our wounded warriors through their transition to Veteran status. DoD
and VA are now working more collaboratively across health and personnel
organizational lines than ever before. Our overall goal is to ensure
appropriate beneficiary and medical information is visible, accessible,
and understandable through secure and interoperable information
management systems.
JOINT GOVERNANCE
VA/DoD electronic health information collaboration is a major
component of the Departments' Joint Strategic Plan. The goals of the
Joint Executive Council are described in the Joint Strategic Plan for
Fiscal Years 2007 through 2009 and cover a full spectrum of VA/DoD
health-related sharing. The Under Secretary of Defense for Personnel
and Readiness and the VA Deputy Secretary cochair the Joint Executive
Council, whose members include senior DoD and VA health managers
involved in sharing initiatives. This Council was established in 2002
and now meets quarterly to provide leadership oversight of
interdepartmental cooperation at all levels and to oversee the efforts
of the Health Executive Council and Benefits Executive Council. The
Assistant Secretary of Defense (Health Affairs) and VA Under Secretary
for Health cochair the Health Executive Council, which was formed to
establish a high-level program of cooperation and coordination in a
joint effort to reduce costs and improve health care for all our
beneficiaries. The Chief Information Officers of the Military Health
System and the VA cochair the Health Executive Council's Information
Management/Information Technology workgroup.
NATIONAL STANDARDS ADOPTION AND IMPLEMENTATION
DoD and VA lead the Nation in health information technology,
implementation of interoperability standards, and electronic health
information sharing. DoD's electronic health record system has been
awarded pre-market, conditional certification by the Certification
Commission for Healthcare Information Technology, an independent, non-
profit organization that sets the benchmark for electronic health
record systems. Full certification for DoD's electronic health record
system is expected in December 2007 when we begin deploying the next
major enhancement. As we implement, acquire, or upgrade health
information technology systems used for the direct exchange of health
information between agencies and with non-Federal entities, we shall
utilize, where available, health information technology systems and
products that meet recognized interoperability standards.
DoD and VA will continue to be driving forces in National
initiatives such as the American Health Information Community, the
Health Information Technology Standards Panel, the Health Information
Technology Policy Council, and the Federal Health Architecture. DoD and
VA support Executive Order 13410, issued in August 2006, which requires
Federal agencies to use recognized health interoperability standards to
promote the direct exchange of health information between agencies and
with non-federal entities. Because such a significant portion of the
American population is eligible for health care through Medicare, DoD,
VA, and Federal employee health programs, our efforts can have a
dramatic effect on private sector adoption of health information
technology and will ultimately affect our ability to exchange
electronic health information with private sector providers.
CONCLUSION
Providing the best possible care for America's returning wounded
warriors is a top priority for DoD and VA. Electronic health
information sharing is unquestionably a key component of enhancing the
quality and continuity of the care both Departments deliver. We have
made great strides since our initial sharing efforts, building on the
foundation established beginning in 2001. We have accelerated our
expansion of the types of data shared and methods of sharing in recent
months to support urgent needs. In the coming month