[House Hearing, 111 Congress]
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2010
EXAMINING THE PROGRESS OF ELECTRONIC
HEALTH RECORD INTEROPERABILITY BETWEEN
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
AND U.S. DEPARTMENT OF DEFENSE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
JULY 14, 2009
__________
Serial No. 111-33
__________
Printed for the use of the Committee on Veterans' Affairs
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 HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio DAVID P. ROE, Tennessee, Ranking
TIMOTHY J. WALZ, Minnesota CLIFF STEARNS, Florida
JOHN H. ADLER, New Jersey BRIAN P. BILBRAY, California
JOHN J. HALL, New York
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
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C O N T E N T S
__________
July 14, 2009
Page
Examining the Progress of Electronic Health Record
Interoperability Between the U.S. Department of Veterans
Affairs and U.S. Department of Defense......................... 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 40
Hon. David P. Roe, Ranking Republican Member..................... 2
Prepared statement of Congressman Roe........................ 40
Hon. Zachary T. Space............................................ 5
Hon. John J. Hall................................................ 6
WITNESSES
U.S. Government Accountability Office, Valerie C. Melvin,
Director, Information Management and Human Capital Issues...... 4
Prepared statement of Ms. Melvin............................. 41
U.S. Department of Defense/U.S. Department of Veterans Affairs
Interagency Program Office, Rear Admiral Gregory A. Timberlake,
SHCE, USN, Acting Director..................................... 18
Prepared statement of Rear Admiral Timberlake................ 48
U.S. Department of Defense, Mary Ann Rockey, Program Executive
Officer/Deputy Chief Information Officer (Acquisition),
Military Health System......................................... 20
Prepared statement of Ms. Rockey............................. 52
U.S. Department of Veterans Affairs, Hon. Roger W. Baker,
Assistant Secretary for Information and Technology, Office of
Information and Technology..................................... 22
Prepared statement of Mr. Baker.............................. 60
SUBMISSIONS FOR THE RECORD
Stearns, Hon. Cliff, a Representative in Congress from the State
of Florida, statement.......................................... 63
MATERIAL SUBMITTED FOR THE RECORD
Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe, Ranking
Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon. Gene L.
Dodaro, Acting Comptroller General, U.S. Government
Accountability Office, letter dated August 12, 2009, and
response from Valerie C. Melvin, Director, Information
Management and Human Capital Issues, letter dated October 13,
2009........................................................... 64
Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe, Ranking
Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon. Robert
M. Gates, Secretary of Defense, U.S. Department of Defense,
letter dated August 31, 2009, and DoD responses................ 67
Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe, Ranking
Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon. Eric K.
Shinseki, Secretary, U.S. Department of Veterans Affairs,
letter dated August 12, 2009, and VA responses................. 72
EXAMINING THE PROGRESS OF
ELECTRONIC HEALTH RECORD
INTEROPERABILITY BETWEEN THE
U.S. DEPARTMENT OF VETERANS AFFAIRS
AND U.S. DEPARTMENT OF DEFENSE
----------
TUESDAY, JULY 14, 2009
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight
and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Space, Walz, Adler,
Hall, Roe, and Bilbray.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Good morning. This meeting is July 14th, 2009
and this hearing will come to order. Welcome to the
Subcommittee on Oversight and Investigations. This is a hearing
on the Interagency Program Office (IPO) examining the progress
of the electronic health record interoperability between the
U.S. Department of Veterans Affairs (VA) and U.S. Department of
Defense (DoD).
I would like to thank everyone for attending today's
Oversight and Investigations Subcommittee hearing entitled the
Interagency Program Office examining the progress of electronic
health record interoperability between the VA and DoD.
Thank you especially to our witnesses for testifying today.
We are here today to examine the progress being made by the
DoD and the VA to achieve electronic health record
interoperability.
Currently there is no single VA/DoD electronic record that
captures all the information needed for delivery of health care
and benefits to servicemembers, veterans, and their
beneficiaries.
As many of you know, on April 9th, 2009, President Obama,
along with Secretary of Veterans Affairs Eric Shinseki and
Secretary of Defense Robert Gates, announced that the VA and
DoD would create a joint lifetime electronic record that would
contain information from the day the individual enters military
service through their careers and for the remainder of their
lives as veterans if they enter the VA system.
Mandated by the ``National Defense Authorization Act (NDAA)
of 2008,'' the Interagency Program Office was established to
act as the single point of accountability for DoD/VA electronic
health record interoperability.
As the September 30th deadline for electronic health record
interoperability approaches, it is imperative to ensure that
both the DoD and VA are organized and working together to
deliver a comprehensive system that will modernize and simplify
record sharing between Departments.
In 1982, under the VA and DoD ``Health Resources Sharing
and Emergency Operations Act,'' both DoD and VA were first
encouraged to find common ground to create a more efficient
health care system that would be worthy of the sacrifices our
men and women make every day.
Since then, although there have been significant
improvements in sharing patient record information, both the
DoD and VA have yet to find the common ground to achieve full
electronic health care interoperability.
The U.S. Government Accountability Office's (GAO's) report
on the state of DoD and VA's health record sharing initiatives
is not due until the end of July, but I am grateful that they
are here today to update us on the progress these two
Departments have made in meeting the statute's requirement.
As a growing number of men and women are returning from the
battlefields in Iraq and Afghanistan with more complicated and
more severe wounds, it is time to make their care and treatment
easier. It is time for us to improve upon a system that will
ensure the best and most complete care, efficient benefit
delivery, and a seamless transition back into civilian life.
Under the leadership of Director Rear Admiral Gregory
Timberlake and Deputy Director Cliff Freeman of the Interagency
Program Office, both here today, I am hopeful, I am expectant
that we will see headway toward the vision Congress and the
President have established for a VA of the 21st century.
[The prepared statement of Chairman Mitchell appears on p.
40.]
Mr. Mitchell. Before I recognize the Ranking Republican
Member for his remarks, I would like to swear in our witnesses.
If all witnesses from both panels would please stand and raise
their right hand.
[Witnesses sworn.]
Mr. Mitchell. Thank you.
I would now like to recognize Dr. Roe for opening his
remarks.
OPENING STATEMENT OF HON. DAVID P. ROE
Mr. Roe. Mr. Chairman, thank you for holding this hearing.
The issues of seamless transition and the interoperability
of the transfer of medical records between the Department of
Defense and Department of Veterans Affairs is one that Congress
has been working on for a number of years.
During the 109th Congress alone, the Committee on Veterans'
Affairs held a total of ten hearings on the issue of seamless
transition. Again last Congress, this Subcommittee held a
hearing on March 8, 2007, on seamless transition; on May 8,
2007, VA and DoD data sharing; on October 24, 2007, on the
status of sharing electronic medical records; and on June 24,
2008, VA and DoD cooperation in reintegrating the Guards and
Reserves.
Time and time again, the issue of interoperability and data
sharing of critical medical information between the DoD and VA
has been discussed, studied, and demoed, and the degree of
progress is dismally glacial.
This is one of the reasons that section 1635 was included
in the ``2008 National Defense Authorization Act.'' This
section revealed a plan of action for the two Departments to
create a schedule and set a deadline of September 30, 2009, and
issue requirements for, (1) establishment of the Interagency
Program Office (IPO); (2) establishment of the requirements for
electronic health records (EHR) systems or capabilities,
including coordination with the Office of the National
Coordinator for Health Information Technology (IT); (3) any
acquisition and testing required in the implementation of
electronic health record systems or capabilities that allow for
full interoperability; and, (4) implementation of electronic
health record systems or capabilities.
I am interested in learning the progress that DoD and VA
are making and moving forward with the interoperability
transfer of medical data between the two Departments.
In the past, this information has been held in what several
Members have called independently stovepiped electronic medical
record systems that had difficulty transferring data between
the two departments.
This issue is of great concern to me as well as other
Members of this Committee. I hope that measurable progress has
been made toward better communication and cooperation between
the two Departments.
The care of our Nation's servicemembers and veterans is of
primary importance to everyone at this hearing today. They have
served our country valiantly in the face of battle and should
not have to be worried about whether or not their health
providers have the tools and information they need to provide
care that is timely, medically appropriate, and necessary.
Mr. Chairman, I look forward to hearing from our witnesses
today and yield back the balance of my time.
[The prepared statement of Congressman Roe appears on p.
40.]
Mr. Mitchell. I ask unanimous consent that all Members have
5 legislative days to submit a statement for the record.
Hearing no objection, so ordered.
At this time, I would like to welcome Panel One to the
witness table. Joining us on our first panel is Valerie Melvin,
Director for Information Management and Human Capital Issues at
the U.S. Government Accountability Office.
I ask that all witnesses stay within 5 minutes for their
opening remarks. Your complete statements will be made part of
the record.
Thank you very much, Ms. Melvin.
STATEMENT OF VALERIE C. MELVIN, DIRECTOR, INFORMATION
MANAGEMENT AND HUMAN CAPITAL ISSUES, U.S. GOVERNMENT
ACCOUNTABILITY OFFICE
Ms. Melvin. Thank you, Mr. Chairman, Ranking Member Roe,
and Members of the Subcommittee. I am pleased to be here today
to discuss the VA/DoD Interagency Program Office and efforts
toward achieving interoperable electronic health records.
As you know, the Departments have been working for over a
decade to share data between their health information systems.
Yet, while they have made progress on a number of fronts,
questions have persisted concerning when and to what extent the
intended sharing capabilities of the two Departments will be
fully achieved.
As you have stated, to expedite their efforts, the
``National Defense Authorization Act'' for fiscal year 2008
directed VA and DoD to jointly develop and implement by
September 30th fully interoperable electronic health record
systems or capabilities and it established an Interagency
Program Office to be a single point of accountability for the
departments' efforts.
Also, the Act directed GAO to semiannually report on the
Departments' actions toward achieving interoperability.
Accordingly, we have previously issued two reports, in July
2008 and January 2009. We plan to issue a third report near the
end of this month, a draft of which is currently being reviewed
by the Departments.
At your request, my testimony today summarizes findings
from the draft report focusing on the Departments' progress in
setting up the Interagency Program Office and actions taken to
achieve fully interoperable capabilities.
Regarding the Interagency Program Office, VA and DoD have
taken important steps to make it operational by, for example,
recruiting and hiring staff for government and contractor
positions within the office.
Further, the Office has established a charter to articulate
its mission and functions with respect to attaining
interoperable electronic health data and it has developed
standard operating procedures in such areas as strategic
communication.
Nevertheless, key leadership positions for the Director and
Deputy Director continue to be filled on an interim basis as
the Departments attempt to hire permanent officials.
In addition, the Office has not yet performed key tasks
that are fundamental to effective IT management and that would
be essential to effectively functioning as the point of
accountability.
In particular, the Office has not implemented our earlier
recommendation that it establish results-oriented goals and
performance measures for the objectives identified to meet the
Departments' data sharing needs and fulfill interoperability
requirements.
However, early development and use of results-oriented
metrics is essential to providing a meaningful baseline against
which to measure the progress of the program and the outcomes
associated with its implementation.
Further, while the Office has begun to develop an
integrated master schedule as required by its charter, the
version provided for our review lacked critical information
that would be vital to managing these complex efforts, such as
detailed project tasks and associated start and completion
dates, as well as relationships between tasks.
Similarly, a project management plan is essential, but the
Office has not yet developed one. As we have noted in prior
work, without a plan that describes the project's scope,
resources, and key milestones, VA and DoD lack a key tool
needed to successfully guide their efforts.
With regard to their ongoing efforts, the Departments have
achieved plan capabilities for three of the six
interoperability objectives that they identified to meet their
data sharing needs, related to sharing social history and
physical exam data and the operation of secure network
gateways.
For three other objectives, related to sharing data from
health assessment questionnaires and self-assessment tools,
expanding DoD's inpatient medical record system, and
demonstrating initial document scanning, the Departments have
partially achieved plan capabilities with additional work
needed to fully meet clinicians' needs for health information.
To improve the management and the success of VA's and DoD's
efforts to achieve full interoperability, our draft report
recommends the Interagency Program Office's establishment of a
project plan and a complete and detailed integrated master
schedule. This is in addition to establishing performance
metrics as we have previously recommended.
Without these critical tools, the Office's ability to
effectively provide oversight and management, including
meaningful assessment of the progress and delivery of
interoperable capabilities, is jeopardized.
Mr. Chairman, this concludes my statement. I would be
pleased to respond to any questions that you or other Members
of the Subcommittee may have.
[The prepared statement of Ms. Melvin appears on p. 41.]
Mr. Mitchell. Thank you very much.
At this time, before we get to the questions, I would like
to defer to Mr. Space and then Mr. Hall.
OPENING STATEMENT OF HON. ZACHARY T. SPACE
Mr. Space. Thank you, Mr. Chairman.
And I hope you will accept my apologies for arriving late
and my advance apologies for having to leave. I have a very
important 10:30 meeting that I have to attend to regarding my
Energy and Commerce Committee assignment. But I do appreciate
the opportunity to deliver a brief statement.
I would like to thank you, Chairman Mitchell, for calling
this hearing and for giving me the opportunity to say a few
words about this important issue.
The interoperability of medical records between the VA and
the DoD is not a technical problem or a coordination problem.
Access to medical records is a quality of life problem for our
veterans.
And I did not have the benefit of hearing your statement,
Mr. Chairman, but I suspect you may have referenced Specialist
Travis Fugate. Okay. You will recall that Travis testified at a
Committee hearing earlier. Like so many other veterans of the
conflicts in Iraq and Afghanistan, he suffered a combat injury
that left him with severely impaired vision. His doctor at the
VA was unable to perform the necessary surgery because of the
complicated reconstruction his facial nerves had undergone in
prior operations under DoD care.
I believe that the U.S. Government failed Mr. Fugate by
effectively losing the records of his prior surgeries, leaving
him completely blind. This is just an example of the
significant quality of life issues faced by veterans because we
have not yet met this goal of fully sharing medical records.
I am frustrated at the lack of progress over the past
decade and even more frustrated that no law or directive seems
to have any impact on the speed of implementation.
I understand that there are significant financial,
technological, and logistical barriers to progress into the
completion of an entirely interoperable electronic medical
record. I also understand that there are multiple levels of
interoperability and that the office must balance competing
demands for both quality record sharing and faster
implementation.
However, I feel compelled to remind those responsible for
this project that every day that we do not overcome the
challenges to implementing this system is a day that we pass on
the hardship to our veterans. Their sacrifices and their
challenges are much greater and much more personal and heart
breaking than our challenges in establishing this system.
I look forward to hearing from the witnesses here today and
I hope that their testimony will illuminate a clear and
achievable path to success on this initiative.
And I yield back. Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
Mr. Hall.
OPENING STATEMENT OF HON. JOHN J. HALL
Mr. Hall. Thank you, Mr. Chairman and Ranking Member Roe,
for holding this hearing.
Ms. Melvin, Admiral Timberlake, and Assistant Secretary
Baker, thank you for being here today to testify.
One of the largest impediments facing the VA and the
veterans it serves is the handoff from DoD. In my conversations
with veterans, I have heard stories that simply astound me.
Veterans walking paper files from one office to another banded
together with rubber bands and covered in sticky notes.
It is hard to believe that in 2009 veterans must still
shlep their materials from a DoD doctor to a VA doctor as paper
files, costing time, money, and meaning that, as was mentioned
by Mr. Space, the quality of care is not what it should be.
I have been working on trying to fix this issue as have
many of us on the full Committee and the Subcommittee since I
was first elected to Congress and last year sponsored
legislation to require the VA to convert to electronic records
and modern information technology. I was proud to see it signed
into law, a good first step toward bringing the VA into the
21st century.
For more than a decade, Congress, the VA, and the DoD have
been trying to move this interoperability initiative forward.
We have finally made some progress on this common-sense, good
government initiative.
In January of last year, for instance, Congress established
the Interagency Program Office to allow the DoD and the
Department of Veterans Affairs to fully share personal health
information between the two agencies. It seems like the VA and
the DoD are making progress, but, unfortunately, things are not
moving as quickly as they should.
We laid down a deadline of September 30th, 2009, which is
less than 80 days away. And I hope that in the course of this
hearing, we will hear some good news about the progress being
made, learn about ways we can help to fix any problems that
have arisen, and work together to take steps to move the
process along.
I thank you and I yield back.
Mr. Mitchell. Thank you.
Ms. Melvin, I have a couple questions. In your testimony,
you state that though DoD and VA have generally made progress
toward making the IPO operational, the absence of performance
metrics and absence of a complete integrated master schedule
and an absence of a project plan limits the IPO's ability to
effectively report on the delivery of interoperability
capabilities.
Since the IPO was created, what actual and tangible
benefits has the Office brought to improve the quality of life
to our Nation's veterans?
Ms. Melvin. I would start by saying that it appears that
setting up and bringing the Office into operation has been the
main accomplishment of the Office thus far. It is important to
note that they have been recruiting staff for that Office. They
have been hiring staff and they have developed standard
operating procedures and an initial version of their master
schedule.
However, what we have seen beyond that has been primarily,
I think, focused on reporting to Congress in terms of meeting
the requirements of the Act for reporting out on what the
Office is doing.
We have not yet seen the evidence of any real linkage
between what they are doing and how this is really translating
into measurable progress as well as in terms of improvements in
quality of health.
I think it is important to note that in looking at
improvements in quality of health, that is probably something
that will require a while to get to because you have to have
the means in place to really start serving the clients in terms
of what they are giving them in capabilities.
However, it is important that they establish their
milestones and measures to make sure that they can look forward
to specifically what they are providing and serving the
clinicians' needs as well as the patients' needs and in terms
of the capabilities that they are offering to them.
So we have not seen the quality of care improvements yet.
Mr. Mitchell. Maybe this second question is not appropriate
then. According to your testimony, since the IPO has yet to
fully meet clinicians' needs for health information, has the
limited accomplishments, that is DoD and VA mainly meeting
three of the six interoperability objectives, given clinicians
everything they need to provide complete health care to our
Nation's veterans?
Ms. Melvin. I think it is important to point to and ask VA
and DoD relative to the clinicians' needs. They have been
relying on the Interagency Clinical Informatics Board to define
the patients' needs and, as I understand it, that is still an
ongoing process.
However, they have put some capabilities in place and VA
and DoD do maintain that relative to the capabilities that they
are providing to meet the interoperability objectives that they
have defined for September 2009, coupled with the initiatives
that they have put in place, the Federal Health Information
Exchange (FHIE), the Bidirectional Health Information Exchange
(BHIE), that, in fact, those will give them the capabilities
that they are looking to have in place by September 2009.
However, from our perspective, we cannot really tell
whether, in fact, that will truly meet their needs because we
have not seen the mechanisms in place yet for them to truly
measure performance against these particular goals.
It is only with understanding specifically what it is that
they are trying to achieve quantitatively and measurably will
we be able to assess that.
I would add, however, that both VA and DoD have
acknowledged that there is additional work that will need to be
undertaken after September 2009 to continue to provide
additional capabilities.
And across our work, we have seen instances or indications
that there are significant areas of work needed. For example,
the Essentris System, while that is one place that they, in
fact, did establish a measurable goal, they have also indicated
that a significant portion of that goal will have to be
accomplished after 2009, specifically, I think we include in
our testimony, 92 percent of the inpatient beds served by
September 2010.
Beyond that, we also know that a laboratory data sharing
capability that was supposed to be a computable capability by,
shortly after September 2009, it is our understanding that that
also has been pushed out to a later date.
So while they are making incremental increases in their
sharing of data, as far as how that collectively will meet
clinicians' needs, that is still in our view a bit uncertain.
Mr. Mitchell. Thank you.
I will defer to Dr. Roe.
Mr. Roe. Thank you, Mr. Chairman.
A couple things. This interoperability is not going to
happen by September 30th obviously. And let me just make a
couple of quick points.
Of the three things that you said you could get now, as a
physician, if I walk in to see a patient, I can pull up their
allergies. I can do that in 2 seconds. Are you allergic to
anything?
Number two, your social history. Do you smoke, drink? Do
you take prescription drugs? I can do that in 5 seconds.
And how much money have we spent? And what else can I find
when I pull this up because as a physician, when I see a
patient, and a very good point was made by Mr. Space, there are
some critical bits of information that you do need.
When I am in there and someone else has had three or four
previous surgeries or whatever that they may have had, that is
very critical to know what was done during those surgeries. It
is very critical to know their lab data, to know their X-rays,
those types of things. That is very critical.
Is that available when you walk in to see a patient? When
you walk in, I walk in as a doctor, sit down to talk to a
patient, some of these things you mentioned, I can get the
history in literally less than 15 seconds? I do not need a
record for that.
Ms. Melvin. I do not want to paint the picture that they do
not have any sharing capabilities. As I mentioned earlier, they
have had a number of initiatives that they put in place over
time, their Bidirectional Health Information Exchange, their
Federal Health Information Exchange, which allows information
from DoD to go to VA when a servicemember separates. They do
have a number of capabilities.
We have reported previously on, for example, them having
pharmacy and drug allergy, computable data which is what is
considered the highest level of interoperability. There are a
number of capabilities that they currently have in place.
One of the difficulties that we have, however, is in terms
of finding a place that we can truly look across both VA and
DoD and see how all of these various efforts are being put
together to work toward this----
Mr. Roe. Not to interrupt, but when a patient comes to see
me, if they bring a stack this big, at least I have something
to look at.
Ms. Melvin. Yes.
Mr. Roe. And when a patient gets out of the military and
they are severely injured as we have seen, all of us here have
seen the terrible injuries a lot of these soldiers have seen,
that information, I do not see how it can be all that hard to
get that information from Walter Reed if somebody ETSs
(expiration term of service) from the military to the VA at
Mountain Home in Johnson City, Tennessee.
How can it be that hard?
Ms. Melvin. It is hard if you have not established
specifically how you are going to go about doing that from the
standpoint of having specific plans for how the
interoperability will be achieved. We do know that they have
some sharing capability, as I was saying earlier.
You are right. We do understand that some patients come
into, for example, Walter Reed with their paper folders
attached to them. And VA and DoD have been working toward some
scanning capabilities to try to make that information
electronically available, but there is not a comprehensive
record at this point.
Mr. Roe. Well, here is the problem I have with this. And I
put an electronic medical record system into operation, our
group had done it for 70 providers. And I realize this is a
huge system. I understand, believe me, the stumbles and bumbles
that you go through in implementing. This is an incredibly
complex system.
But it really all comes down to taking care of a patient.
So when a soldier leaves, I do not know--I cannot understand up
here yet after all this. I have read all this testimony. I
still cannot understand when a soldier leaves the military why
that soldier could not leave with a memory stick or a DVD or
whatever and have all that information right there. You can
walk in my office. I can plug a DVD in, a memory stick or
whatever you want to and you can walk out with your complete
medical record in your hand.
Now, why can we not do that?
Ms. Melvin. Mr. Roe, that is a very good question. I think
it is one that has to be directed to VA and DoD.
Again, I would go back to they have not set the basic
mechanisms in place to make sure that they have a program that
looks across all of the different initiatives that they have
and that builds them collectively to make sure that they have
the capability that you are asking for.
They have made steps in that direction. But, again, we have
not seen the progress that we feel is necessary for them to
really have one collective record across VA and DoD to
accomplish just what you are saying.
Mr. Roe. I think, and I will not take much more time, but I
think in Great Lakes Naval and VA venture had a joint venture
in 2002.
Are they are able to do that where there was a joint
venture?
Ms. Melvin. We have not looked specifically at them, but I
do understand that they are taking some initiatives toward
creating that type of capability.
However, within the documentation that we have reviewed so
far, we have not seen specifically how they are doing that. We
have not seen the evidence of how that is being achieved or
what they have actually accomplished.
It is my understanding that a lot of the milestones that
are necessary for accomplishing that are still due sometime
maybe next year.
So we understand that maybe they have done some project
initiation and some business requirements, but I am not certain
at this point as to exactly what they have achieved in that
capability and it is not specified in the documents that we
have seen thus far.
Mr. Roe. Thank you.
Mr. Chairman, I will need to leave early to go to another
meeting and I ask unanimous consent in absence of a Member of
the Minority Party, Counsel be permitted to ask questions of
the witnesses.
Mr. Mitchell. Mr. Space.
Mr. Space. Thank you, Mr. Chairman.
The goal in creating the IPO was to create this single
point of accountability for achieving the interoperable health
care data. And it strikes me as a bit ironic that with that as
its main goal, to this date as of right now, there are still
some serious concerns about its leadership and management.
And I cannot help but be stricken by the fact that if this
were a private company, and I know it is not and I know its
intents and purposes are much different, but if this were a
large corporation and 10 years ago their IT Director were
dispatched to achieve interoperability, I am wondering how many
IT directors in that 10-year period would have been fired for
failing to get this job done.
To this day, it is my understanding that the IPO does not
have a Director and it does not have a Deputy Director.
Ms. Melvin. That is correct, sir.
Mr. Space. Can you give us, and I know your report touches
on it, but can you give us some idea as to why they have waited
so long to engage in this process of assigning permanent
leadership as opposed to interim directors, number one?
And, number two, what kind of time table we can expect for
the appointment of a Director and a Deputy Director under the
IPO?
Ms. Melvin. It is our understanding that there were a
couple of factors in play. I would actually go back to about
December, which is December of 2008, which is when we
understand that the office finally got an approved delegation
of authority to be able to operationalize itself. So I would
say that that is one factor.
We do understand that they have been trying to hire. And in
speaking with them, what we understand is that they have had a
number of candidates come across and it seems that in some
cases, they have withdrawn their nomination, at least in one
instance that I know of.
It is my understanding that currently, however, they do
have a candidate whose name has been sent forward and an
application has been sent forward to OPM and that they are
awaiting a decision from the Office of Personnel Management
(OPM) on that.
In the interim, they have an interim Director whose
appointment has been extended through at least the time of
hiring or September 30th. I am not sure whether it is one or
the other, but at least at that point.
With regard to the Deputy Director, it is our understanding
from VA that they are also in the process of selecting someone
for that position. And we have been told that they intend to
have someone in place by the end of July.
However, I have no more specifics relative to whether that
is going to actually occur as intended at this point.
Mr. Space. Do you believe that they are exercising proper
diligence in the creation of a leadership team and a management
team in this process or have they been lax or failed to
properly prioritize this issue?
Ms. Melvin. It appears that they have given priority to it.
However, I would say that it has been a very slow process in
terms of what they have done and the appointments that they
have tried to make to the positions so far.
If you separate it from the staff positions, they have put
those positions in place, the hires for those positions or at
least selected them, but for the leadership positions, I would
say that we do question how long it is taking them to get them
in place. I do not think that it has been a particularly
expeditious process.
Mr. Space. Right. I think that is pretty obvious from the
face of things.
And has the VA or the DoD given you any specific reasons as
to why they have failed to appoint permanent leadership at the
very top of this program that is supposed to achieve
interoperability within 80 days? It just seems to me to be a
complete lack of responsibility and prioritization.
Ms. Melvin. No other than indicating that they were trying
to hire individuals, that they had selected individuals who
subsequently withdrew their application and that they had to go
back out through the recruiting and rehiring process
subsequently to find a person for that position.
Mr. Space. Thank you.
Ms. Melvin. You are welcome.
Mr. Space. I yield back the balance of my time.
Mr. Mitchell. Mr. Bilbray.
Mr. Bilbray. Thank you, Mr. Chairman.
Since 1992, the Departments had latitude to be able to
address this issue. How long have you been working on this
project?
Ms. Melvin. We have been looking at VA----
Mr. Bilbray. You personally.
Ms. Melvin. How long have I personally? Since about 2001, I
think.
Mr. Bilbray. Two thousand one?
Ms. Melvin. Yes.
Mr. Bilbray. How long has the Department been into it?
Ms. Melvin. Since 1998, they have been working on
electronic sharing capabilities.
Mr. Bilbray. And are we going to reach our September 30th
goal?
Ms. Melvin. It depends on how that is defined. We have
concerns about the clarity of the definition for fully
interoperable and what it means at September 30th to say that
they have full interoperability.
They will achieve something. It will likely be perhaps a
measure more than what they have had in the past relative to
incremental increases in sharing in terms of increased
scanning, for example, increased sharing of social history
data, and the like.
What we have not been able to get from VA and DoD to date
has been a clear quantitative and measurable definition of what
it is that they will have at that point.
If you look at the interoperability objectives that are in
place right now, they talk about establishing an initial
scanning capability or expanding a capability. For us, that
does not convey in terms of what you will actually have as far
as a measurable capability.
Mr. Bilbray. Now, you are talking about over the Internet,
not this issue that the client has to bring in a package,
basically the ability to access a system over the Internet no
matter where you are and be able to access this?
Ms. Melvin. They have varying initiatives. We have not seen
yet that big picture relative to how all of these projects are
going to come together to create that one----
Mr. Bilbray. Well, before we go on, let me just really lay
down a marker. If you do not have this data available on the
Internet to where anybody anywhere basically if they have the
right access systems can access this because, frankly, I just
think that, you know, I would love to talk about details,
things like the biometrics. Any patient comes in, you know, and
we can biometrically read them. We can get to their CO. We can
find out if they want to be a donor, this, this, and this.
Ms. Melvin. Yes.
Mr. Bilbray. Those are all issues. What scares me is that
we are not even getting around to that modem. Is this a
technical problem or is this a bureaucratic problem to reaching
our goals?
Ms. Melvin. I think it is largely a bureaucratic problem
from the standpoint of managing the overall initiatives. They
have a number of initiatives that allow them to share data.
Again, I do not want to paint the impression that they are not
sharing. They are sharing data. But from the standpoint of
having one longitudinal, if you will, electronic health record
across these two Departments, that does not currently exist in
the form that I believe perhaps was intended or was thought
about in terms of the legislation.
Underlying all of that is the fact that the Departments do
not have the necessary planning in place to explain how they
will take all of the multiple projects that they have that
allow them to share capabilities on some level at this point,
bring them all together into one package that enables them to
share in the way that you are describing.
Mr. Bilbray. Ms. Melvin, do you understand that, though,
for 20 years, Congress has been looking for this, the new
President, this is one of his top priorities he talks about.
When he talks about all this other, with health care, he starts
off with this. And, you know, this is the vanguard for the
national data system.
If we cannot make it work here, how in the world is the new
President going to make it work with 350 million people?
Ms. Melvin. I understand exactly where you are coming from
in terms of that. At this point, though, I do not believe that
they will be able to produce the type of system that is
intended unless they have done more in terms of looking across
what they have and they have established more of a convincing
approach to how they are going to bring all of these
initiatives together.
Mr. Bilbray. Do we have a prototype that we see over the
horizon? We see somebody that seems to have a system that will
work. Do we have a prototype that we can build our assumptions
around?
Ms. Melvin. There are systems. VA actually has a great
system in terms of what it provides. The difficulty is in terms
of looking for examples of interoperability from the standpoint
of bringing together different systems and making them work and
deciding how you are going to do that from a technical
standpoint. And that is the part that VA and DoD have not done.
I cannot point to a specific example of one that has worked
successfully, but I do not believe that technically--technology
is the problem with their ability to do this. I do believe that
it is a management problem.
Mr. Bilbray. Thank you.
Let me just say to my colleagues as we design the system,
you know, I operated a supervised health care system for 3
million people, and if I can leave you with one thing, if we do
not have a system that allows a veteran to go into an emergency
room and for us to biometrically be able to pull up his files,
be able to know what their health is, know little things like
do they want to be a donor, all those things need to be in the
system. If you do not have a system to where you can
automatically, a physician in an emergency can pull up these
files, then the system is deficient.
And I just ask you to keep an eye on that as we come and go
as policymakers, but this is one of the goals, sort of a
minimum goal. We want to make sure that every veteran, thus in
the long run every citizen, will be able to have their files
drawn up by a physician in an emergency room just because they
are able to pull the biometrics and pull those files. And I
hope that we keep that as a goal.
Thank you very much, Mr. Chairman.
Mr. Mitchell. Mr. Hall.
Mr. Hall. Thank you, Mr. Chairman.
And thank you, Ms. Melvin.
And I would just comment on Mr. Bilbray's remarks. I agree.
And, you know, my family who are and friends who are in
TRICARE because they are either in service or working still for
DoD are quite happy with the care they receive there and the
ability, in fact, to go to any DoD medical facility and have
their record pulled up.
And as you said, Ms. Melvin, once they are in the Veterans
Health Administration (VHA) system and have their veterans'
health card can go to any VA facility in the country and have
their electronic record pulled up. The problem as I see it is
the handoff from DoD to VA.
And, you know, I have the honor of chairing a Subcommittee
on Disability Assistance and Memorial Affairs as well as the
honor of serving on this Committee. And one of the things that
we are most concerned about is this interoperability and the
electronic handoff because it is the beginning of being able to
establish whether there should be a claim granted or not,
especially with our new veterans.
Our Operation Enduring Freedom/Operation Iraqi Freedom
(OEF/OIF) vets who are emerging now into civilian or VA world
and leaving active duty, they really need, especially facing
the injuries that the Chairman referred to, you know, some
severe injuries, they need to be able to have hopefully at the
speed of light their electronic medical record transferred to
the VA so that we can go ahead and process their claims
expeditiously.
In your testimony, you stated that the Interoperability
Office still has not established quantifiable and measurable
goals and performance measures and that the office has cited a
number of different reasons for the delay.
As of today, less than 80 days from the deadline, there are
still 4 vacant positions. That means it has taken more than a
year and a half for the Office to get staffed up. This does run
back into the previous Administration and when the ``Claims
Modernization Act'' was passed as part of our veterans omnibus
bill in the last term.
So, in fact, it seems that the Office is likely not to be
fully staffed up until after September 30th.
So my question, I guess, to you is, the unemployment rate
in this country is teetering close to 10 percent. I have
personally spoken to dozens of veterans who are looking for
work, including some who are quite qualified in engineering,
computer technology, et cetera.
Can we not find qualified people, even qualified veterans
to fill these jobs? And what do you believe is causing the
delay in hiring staff? Is there something we in Congress can do
to speed up that process?
Ms. Melvin. One of the points I would like to make about
hiring the staff, it is very important that they get those in
place, and you are right that it has taken a while to do that.
I think it is important, though, to also recognize that as
they put staff in place and define what exactly it is that they
are going to do, it is important for them to have put the other
basics in place as far as what this office is going to be doing
relative to achieving interoperability.
Right now without having the basics relative to a project
plan to really define their resource needs, the timelines,
their financial needs, it is very difficult to say whether they
are choosing the right people for the right jobs. So there is
probably a need for an element of caution in what they are
doing.
Having said that, since they have moved ahead, it does
appear that there has been an effort on their part to try to be
careful about who they are hiring. However, it is not very
clear yet as to why they really--it is not clear to us as to
why they have not been able to secure all the positions. I
believe it is four positions within the government type
positions that they have.
It is our understanding they have all of the contractor
positions. But, again, I would ask the question more
importantly do they know what these individuals are going to be
doing that they are putting in place.
Mr. Hall. Last year, VA commissioned a study by IBM to look
into the electronic handoff and the compatibility of different
systems. Apparently they were dissatisfied with that and toward
the end of last year, before our new Secretary was sworn in, I
believe, contracted with Booz Allen Hamilton to do another
study of how the systems should be structured.
Have you seen that study? Are you aware of it? I think it
was commissioned by Veterans Benefits Administration (VBA), but
it has a bearing on VHA as well.
Ms. Melvin. I am vaguely familiar, but I do not feel that I
am informed enough today about the details on it to speak to it
very effectively.
Mr. Hall. We are waiting to see it and hopefully will soon.
And it is, I understand, an attempt to come up with the correct
or the most expeditious approach to this compatibility problem.
Any more suggestions you can make to speed the process
along? In terms of hiring, for instance, you said a number of
candidates have withdrawn. Is that because of issues that they
did not want aired in confirmation or is it because of other
factors? Do you know what the reasons are?
Ms. Melvin. I do not know the reasons for that. I would
say, however, that it is very important that the leadership be
put in place for this Office. The tone from the top is all
important for setting the stage for how effective any
organization is going to operate.
I think it is very important that the IPO, the Interagency
Program Office, be not just another layer in the process of
what they have already had, but that it be an effective office
and that it have an established and defined definition of what
it really is going to be as far as achieving interoperability
and its role from an accountability standpoint.
Mr. Hall. Thank you very much.
Thank you, Mr. Chairman.
Mr. Mitchell. Mr. Walz.
Mr. Walz. Well, thank you, Mr. Chairman, again for a long
line of very pertinent and important oversight responsibilities
here.
And, Ms. Melvin, thank you again. In my short time here, I
found your reports to be very helpful, very informative, and
helping us move us in the right direction. So thank you for
that.
I do want to note that on the positive side of things
today, we have both VA and DoD setting in the same room. That
is positive for around here. But you do not see Members of the
Armed Services Committee here with us.
So this issue of seamless transition for many of us, and I
see many folks setting out there, have worked on this thing for
decades. There is a cynicism that pervades this issue because
we all know that the fundamental reason for wanting to get
seamless transition is better care for our veterans, more
accountability over the system, and cost savings in the long
run. So it is in everybody's best interest to get there.
So I do want to make note that under the Chairman's
leadership and Chairman Filner and the Ranking Member, I think
you are right. We are making some progress.
I wanted to note one thing. You did talk about in here we
are starting to share on allergy data that is going back and
forth. The one thing I did note, though, is you said between
June 2008 and January 2009, we got 9,000 more patients on that.
Ms. Melvin. Yes.
Mr. Walz. At that rate, the current military will be
enrolled in 78 years.
Ms. Melvin. My understanding is that they are at about
33,000 or 34,000 now. It is a slow process, yes.
Mr. Walz. That might be an understatement. The point of
that hearing is, is that the best we can do is where I am
trying to get at. If that is the best we can do, when I think
of the President's declaration in April of this year when he
talked about the virtual lifetime electronic record (VLER) that
many of us see as the holy grail of fixing the backlog in
claims that Mr. Hall's Subcommittee deals with on a daily
basis, the care that veterans get, the timely delivery of not
only medical services but medals that were deserved and all of
that, was he just making a pie-in-the-sky suggestion or the way
I am treating it is, is this was a Presidential Directive that
needs to be done? And are we moving toward that in a fashion
that is attainable?
Ms. Melvin. I think that obviously there are a lot of
questions about where they are going to be by any particular
date and especially the September 30th date.
VA and DoD have a lot of experience. I mean, we talked
earlier about the fact that, you know, they have been at this
data sharing, since about 1998. And from that standpoint, there
should be a lot of lessons and experiences learned that they
can bring to bear in terms of how they move forward.
Having said that, I think again it is important that you
have the necessary foundation in place to guide your efforts.
And until the two Departments really can come together very
convincingly to show how they are working together differently
and better than they did on previous initiatives to achieve
this, advance achieving the interoperability, the questions
will remain in terms of----
Mr. Walz. And I think both organizations know the
skepticism that is out there amongst the veteran's community.
As you said, you have been tracking progress on this yourself
for 8 years. You will do this long enough to retire and the
next person will track progress.
And at the point right now I think many of us are saying we
are willing to draw the line in the sand.
I do have a question. The staff, we were just discussing
this, the interesting part of this. Mr. Space brought up a good
part about the staffing and staffing up. We do not have all of
the staff positions filled. We do not have all the government
positions filled.
All 16 private contractors already hired, what are they
doing if we do not even have the vision?
Ms. Melvin. That is the question and that is a concern for
us in terms of who they have brought in to work right now and
really not having the overall project planning in place to
really guide that effort.
It is a very valid question. It is a question of concern
relative to how you use these individuals effectively to
accomplish the goal that you have and that you do so in a cost-
efficient way.
Mr. Walz. Okay. I am old schoolteacher, so that is called a
preparatory set for the next panel.
Ms. Melvin. Okay.
Mr. Walz. So thank you.
Ms. Melvin. You are welcome.
Mr. Mitchell. Thank you.
And thank you, Ms. Melvin, for your work and we appreciate
very much your testimony.
Mr. Bilbray. Mr. Chairman.
Ms. Melvin. Thank you very much.
Mr. Mitchell. Yes.
Mr. Bilbray. Can I just ask one last question, one
statement?
Mr. Mitchell. Yes.
Mr. Bilbray. How many times have you testified before this
Committee, ma'am?
Ms. Melvin. You know, I have to provide you a number for
the record, but it has been numerous.
Mr. Bilbray. Is that numerous or countless?
Ms. Melvin. No, I would not say countless.
Mr. Bilbray. Okay. Close to it, though, huh? Thank you.
Ms. Melvin. But a number of times, yeah.
Mr. Mitchell. Thank you very much.
Ms. Melvin. You are welcome.
Mr. Bilbray. Thank you, Mr. Chairman.
Mr. Mitchell. At this time, I would like to welcome Panel
Two to the witness table.
For our second panel, we will hear from Rear Admiral
Gregory Timberlake, Acting Director of the Interagency Program
Office. Rear Admiral Timberlake is accompanied by Cliff
Freeman, Deputy Director of the Interagency Program Office.
Also joining us is Mary Ann Rockey, Deputy Chief
Information Officer, Military Health System, U.S. Department of
Defense. She is accompanied by Captain Michael Weiner, Chief
Medical Officer, Defense Health Information Management System.
Also with us is the Honorable Roger Baker, Assistant
Secretary for Information and Technology, U.S. Department of
Veterans Affairs. Assistant Secretary Baker is accompanied by
Dr. Paul Tibbits, Deputy Chief Information Officer, Office of
Enterprise Development; Scott Cragg, Executive Director and
Program Manager for the Virtual Lifetime Electronic Record
Program, U.S. Department of Veterans Affairs; Dr. Douglas
Rosendale, Enterprise System Manager for Joint Interoperability
Ventures in the Office of Health Information, Veterans Health
Administration; and Dr. Ross Fletcher, Chief of Staff of the
Washington, DC, VA Medical Center.
Please be seated.
At this time, I would like to recognize Admiral Timberlake,
Ms. Rockey, and Assistant Secretary Baker for up to 5 minutes
each. And I just want you to know that your testimony will be
as submitted in the record.
Thank you.
STATEMENTS OF REAR ADMIRAL GREGORY A. TIMBERLAKE, SHCE, USN,
ACTING DIRECTOR, U.S. DEPARTMENT OF DEFENSE/U.S. DEPARTMENT OF
VETERANS AFFAIRS INTERAGENCY PROGRAM OFFICE; ACCOMPANIED BY
CLIFF FREEMAN, DEPUTY DIRECTOR, U.S. DEPARTMENT OF DEFENSE/U.S.
DEPARTMENT OF VETERANS AFFAIRS INTERAGENCY PROGRAM OFFICE; MARY
ANN ROCKEY, PROGRAM EXECUTIVE OFFICER/DEPUTY CHIEF INFORMATION
OFFICER (ACQUISITION), MILITARY HEALTH SYSTEM, U.S. DEPARTMENT
OF DEFENSE; ACCOMPANIED BY CAPTAIN (SELECT) MICHAEL WEINER, MC,
USN, CHIEF MEDICAL OFFICER, DEFENSE HEALTH INFORMATION
MANAGEMENT SYSTEM, U.S. DEPARTMENT OF DEFENSE; HON. ROGER W.
BAKER, ASSISTANT SECRETARY FOR INFORMATION AND TECHNOLOGY,
OFFICE OF INFORMATION AND TECHNOLOGY, U.S. DEPARTMENT OF
VETERANS AFFAIRS; ACCOMPANIED BY PAUL A. TIBBITS, M.D., DEPUTY
CHIEF INFORMATION, OFFICE OF ENTERPRISE DEVELOPMENT, OFFICE OF
INFORMATION AND TECHNOLOGY, U.S. DEPARTMENT OF VETERANS
AFFAIRS; SCOTT CRAGG, EXECUTIVE DIRECTOR AND PROGRAM MANAGER,
VIRTUAL LIFETIME ELECTRONIC RECORD PROGRAM, U.S. DEPARTMENT OF
VETERANS AFFAIRS; DOUGLAS E. ROSENDALE, DO, FACOS, ENTERPRISE
SYSTEM MANAGER FOR JOINT INTEROPERABILITY VENTURES, OFFFICE OF
HEALTH INFORMATION, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND ROSS D. FLETCHER, M.D.,
CHIEF OF STAFF, WASHINGTON, DC, VETERANS AFFAIRS MEDICAL
CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS
STATEMENT OF REAR ADMIRAL
GREGORY A. TIMBERLAKE, SHCE, USN
Admiral Timberlake. Thank you very much, Chairman Mitchell,
Ranking Member Roe, and distinguished Members of the
Subcommittee. I appreciate this opportunity to discuss the role
of the IPO in the ongoing data sharing activities of the
Department of Defense and the Department of Veteran Affairs.
As has been previously mentioned in recent months, the IPO
has been focused on two central areas, first facilitating the
efforts of the two Departments to develop capabilities that
will allow for full interoperability of their electronic health
records by the end of September of this year and, two, working
with the Departments to develop an effective governance and
management model for the new virtual lifetime electronic record
project announced by the President. These two areas will be the
focus of my testimony today.
Let me begin by providing you with a very brief overview of
the DoD/VA Interagency Program Office or the IPO. Since its
inception in 2008, the main objective of the IPO has been to
provide management oversight of joint DoD/VA information
sharing efforts.
Specifically the IPO works with the DoD and VA to ensure
that by September of this year, as previously mentioned,
electronic health record systems or capabilities have been
developed that allow for full interoperability of personal
health care information between the Departments.
DoD and VA began laying the foundation for this full
interoperability in 2001 when the first patient health
information was shared electronically using the Federal Health
Information Exchange or FHIE.
Since that time, both Departments have continued to enhance
and expand the types of information that is shared as well as
the manner in which it is shared. By building upon the prior
accomplishments of the Departments to develop interoperable,
bidirectional electronic health records, the IPO and the
Departments have been successful in formulating a plan to meet
the requirements of section 1635 of the FY 2008 ``National
Defense Authorization Act.''
As part of this plan, VA's and DoD's ability to utilize
well-known interoperability capabilities like the FHIE and the
Bidirectional Health Information Exchange have been greatly
expanded. At the same time, new capabilities like the clinical
data repository, health data repository or CHDR have been
added, allowing even more medical data to be transferred
between DoD and VA. These systems are enabling unprecedented
amounts of medical data to be transferred between DoD and VA.
My colleagues on the panel have included detailed
information about these and other interoperability capabilities
in their written testimony.
Today I am pleased to report that we are on target to
achieve the capabilities that allow for full interoperability
of personal health care information for the delivery of
clinical care by September 2009 as defined by our DoD/VA
Interagency Clinical Informatics Board.
The future promises even greater possibilities for data
sharing as we work to fulfill the President's vision to develop
a virtual lifetime electronic record or VLER. The VLER will
serve as a single source of health care, benefits, and
personnel information on the servicemember and veteran from the
time of accession through the entire military career and the
veteran continuum up to and including burial.
The effort to create a VLER is a monumental undertaking
representing one of the largest projects that any two Federal
departments have collaborated on in recent years. As with any
undertaking of this magnitude, proper planning and governance
is absolutely critical to success.
To begin, new IT conceptual frameworks must be established
to provide health and benefits data sharing architecture to
which both Departments can connect their electronic health
record.
To date, discussions between the Departments have focused
on leveraging common services architecture framework to support
modernized tools. The strategy for VLER implementation has been
agreed upon by DoD and VA at a Joint Executive Council meeting
on the 26th of June. This plan will allow expansion beyond the
current level of interoperability to bring it in line with the
President's direction in his speech of April 9th.
In addition to discussions on the scope of VLER, the IPO
also plays an active role in efforts to reach interdepartmental
consensus on broad technical requirements issues. In this area,
progress is being made on the Departments' efforts to agree to
use a nationally recognized set of uniform and open standards
for information exchange.
This approach would enable DoD and VA to create an
architectural framework capable of interconnecting systems from
both the private sector and the government.
Thank you very much for the opportunity to address the
Committee and to provide you with an update on the important
work that is being done by both Departments to advance
electronic data sharing between the DoD and VA. I look forward
to answering any questions you may have.
[The prepared statement of Admiral Timberlake appears on p.
48.]
Mr. Mitchell. Thank you.
Ms. Rockey.
STATEMENT OF MARY ANN ROCKEY
Ms. Rockey. Thank you, Chairman Mitchell, Ranking Member
Roe, and Members of the distinguished Subcommittee. Thank you
for inviting me to discuss the substantial progress made to
date with VA/DoD electronic health record interoperability. I
am pleased to join my dedicated colleagues from the VA and IPO.
Our electronic data sharing efforts have gained undeniable
momentum since we first began sharing data in 2001. The scope
of these efforts has increased steadily, improving the delivery
of health care and administration of benefits to our Nation's
servicemembers and veterans.
Right now electronic health data is accessible to VA for
more than 4.8 million separated servicemembers. Each day,
health care providers and benefits specialists access
electronic data on patients as they deliver care and resolve
claims.
We also share real-time data on 3.3 million shared patients
and made it possible for DoD and VA providers to view real-time
electronic data from each Department's electronic health record
system.
Sharing data on care delivered in deployed settings is
critical to improve continuity of care for our wounded, ill,
and injured servicemembers.
Since 2007, we have shared data for care delivered in Iraq,
Afghanistan, and Kuwait. This theater outpatient and inpatient
data is accessed using the Departments' existing EHRs. Today
more than 2.4 million theater outpatient clinical encounters
are available to DoD and VA providers who treat these
servicemembers and veterans.
We have also made great strides in sharing servicemembers'
inpatient care records. As the Committee knows, Landstuhl
Regional Medical Center is the first stop for many wounded,
ill, and injured servicemembers. Interagency access to
inpatient discharge summaries from Landstuhl and other large
hospitals is a tremendous aid to the continuity of care.
Records are available from 21 military sites that account for
55 percent of our inpatient beds. We expect to share inpatient
records for 90 percent of our inpatient beds by 2010.
Today the Bidirectional Health Information Exchange
provides two-way, on-demand, viewable data exchanged between
all DoD and VA facilities in real time. This live data flow
became available enterprise-wide in July 2007 and includes data
from 1989 forward.
The data exchange includes allergy information, outpatient
pharmacy data, demographic data, inpatient and outpatient lab
results and radiology reports, procedures, vital sign data,
patient histories, questionnaires, and theater clinical data.
We are also transferring health data on separating
servicemembers to the VA through the Federal Health Information
Exchange. This comprehensive data flow began in 2002 and
includes data from 1989 forward.
The transferred data includes inpatient and outpatient lab
and radiology results, outpatient pharmacy data, allergy
information, discharge summaries, admission disposition and
transfer information, consultation reports and pre- and post-
deployment health assessments and health reassessments (PDHRA).
In September 2006, the Department established
interoperability between the data repositories used by the
respective EHR systems. This DoD/VA interface enables the
exchange of interoperable and computable outpatient pharmacy
and medication allergy data between the Departments on patients
who receive care from both health care systems. Information is
included from DoD pharmacies, retail pharmacies, and mail order
pharmacies. This functionality is available to all DoD
facilities enabling drug-drug interaction checking and drug
allergy checking using data from both Departments.
To ensure continuity of care for our polytrauma patients,
we are also exchanging radiology images and digital and scanned
medical records between Walter Reed Army Medical Center,
National Naval Medical Center, and Brooke Army Medical Center
to the four VA polytrauma centers. This capability began in
March 2007.
We are moving swiftly and surely toward full health care
information interoperability to support the provision of
clinical care by 30 September 2009. With the two Departments,
we look to a group of clinicians called the Interagency
Clinical Informatics Boards to identify specific mutual data
needs supporting care, continuity, and health-related benefits
administration.
Moving forward, we will build on this foundation to enhance
future electronic health care information sharing. We will
collaborate with the U.S. Department of Health and Human
Services (HHS) on national standards. These standards are
necessary for broader exchange of health information to realize
the President's vision of the virtual lifetime electronic
record and the Nationwide Health Information Network.
Clearly we have made much progress in enhancing and
expanding VA/DoD sharing and plan to continue these efforts.
Our interagency collaboration continues to support the
provision of the highest quality care for our Nation's heroes,
past, present, and future.
Thank you again for inviting me today. I am accompanied by
my Chief Medical Information Officer, Dr. Michael Weiner, who
is here to show you how our clinicians can access theater and
BA data within our EHR system. I will be happy to answer any
questions. Thank you.
[The prepared statement of Ms. Rockey appears on p. 52.]
Mr. Mitchell. Thank you.
Assistant Secretary Baker.
STATEMENT OF HON. ROGER W. BAKER
Mr. Baker. Thank you, Mr. Chairman. Thank you for the
opportunity to update you on the status of our efforts to
exchange electronic medical information with our partners at
the Department of Defense.
This Committee has always been supportive of our efforts
and I look forward to providing you the information you need.
And I would note that as this is the first time that I have
appeared before the Committee, I appreciate the opportunity to
come and testify and I look forward to seeing the Committee
numerous more times in my tenure. So thank you.
As you noted, I am accompanied by Dr. Paul Tibbits, Mr.
Scott Cragg, and Dr. Doug Rosendale, senior members of the team
working on this. And I would note that after my remarks, Dr.
Ross Fletcher, who is one of the fathers of the VistA system,
will demonstrate how DoD information is accessed and used by a
clinician from within VistA.
VA and DoD have made great progress in the exchange of
information necessary to provide services to our Nation's
veterans. For servicemembers who separate from the service,
electronic medical records are delivered to VA and incorporated
into VistA via a one-way transmission.
For servicemembers who are being seen at both DoD and VA
facilities, a bidirectional system makes their information
available to both services. And for our most seriously wounded
warriors, an exchange of information directly between the
polytrauma care facilities ensures that all necessary
information is available at the point of care.
As impressive as this interoperability is, our work cannot
stop. First, the current systems have shortfalls. VA clinicians
need further training to ensure they know when DoD information
is available and how to access it.
Second, performance for BHIE, the Bidirectional Health
Information Exchange, which is the system that accomplishes the
two-way transmissions, can be very slow and is sensitive to how
local computers are configured or how they are set up.
Some information that is available today in a viewable form
could also be made searchable and we recognize the need to do
that from our clinicians.
And while we are able to exchange information in electronic
forms, information that is not currently made electronic is
substantially less efficient for clinicians even if made
available later via scanning.
An example of further progress being made is our joint work
on the Captain James A. Lovell Federal health care Center.
The BHIE system that I mentioned earlier was designed to
share data collected between episodes of care for patients
receiving care in both VA and DoD systems. But a patient in the
collocated environment of North Chicago may see either or both
a DoD and VA clinician during a single episode of care.
We have determined that additional functionality is
required to ensure that data is exchanged seamlessly, including
a single patient registration for both VistA and Armed Forces
Health Longitudinal Technology Application (AHLTA), a single
sign-on to both systems for our clinician, and the ability to
easily move orders between the two systems.
VA and DoD information interoperability successes to date
have focused on applications that facilitate exchanging patient
information between the departments to individual electronic
medical record systems.
On April 9, 2009, the President along with Secretary
Shinseki and Secretary Gates announced that VA and DoD would
create a joint virtual lifetime electronic record or VLER. The
VLER will permit information vital to health care and other
benefits and services to be available seamlessly to both
Departments from the moment a servicemember enters the
military. I would say, gentlemen, I believe that means getting
beyond interoperability and into common use.
The potential benefits of the VLER are many and planning
and creating and implementing the VLER will be a challenging
endeavor. VA and DoD are working jointly together on an overall
strategy to achieve the President's vision and developing an
effective governance model to implement that strategy.
In closing, I would like to thank you again for your
continued support and the opportunity to testify before the
Subcommittee on the accomplishments and the important future
work of VA and DoD to improve medical record sharing between
us. I look forward to your questions. Thank you.
[The prepared statement of Mr. Baker appears on p. 60.]
Mr. Mitchell. Thank you.
The questions I have first are for both DoD and VA. For
both Departments, what obstacles or difficulties have you
encountered while working to increase electronic health care
interoperability? And what actions have the Departments taken
to address these obstacles? Again, what are the difficulties or
obstacles you face, and obviously you have some, and what have
you done to address them?
Admiral Timberlake. Sir, I may start just from my
observations. I was asked to come back on active duty in
January to be the interim Director and so I have had some
observations.
Some of them are just simply due to the fact that we are
trying to work between two separate Departments and those
Departments have different budgeting cycles and processes. They
have different contracting processes. They have different ways
by which they develop and define their requirements.
And in my personal opinion, some of the difficulty has been
in trying to find the ways to move smoothly when you have rules
and regulations set up for two different Departments, but you
are trying to bring them together.
I will now turn to my counterparts and see if they have
specific issues that they wish to share.
Mr. Baker. Certainly I would look to some of the experts
that came with me on this, but two things that I would observe
for you.
These are two huge, separately developed medical systems
that we are looking to bring together. And a key issue is that
representations of information in one system are not
necessarily the same as they are in the other system.
And so the Departments have created information exchange
systems to pull information out of one, translate it, and put
it into the other. What that means is while the maintenance and
development of the two main missions go forward, we also now
have the responsibility for bringing along those interchange
systems in between them.
It is not an easy process. Technically it is not simple and
requires an awful lot of work to bring forward. And as you look
at the individual types of information that need to come
forward, whether it be pharmacy records, whether it be viewable
information or computable information, determining what the
data standards are and how those will be represented as they
are exchanged from system A to system B is fairly complex.
And while I agree that the main issues facing us may well
be on the, you know, how do we continue to get along and define
things, you know, from a cooperative standpoint, technically
this is also a very challenging problem. And I do not think we
can lose sight of the fact that it is not an easy question that
is being asked here.
Mr. Mitchell. You suggested there are two large
bureaucratic organizations, two systems, but I think instead of
trying to defend and protect the particular base, if they look
at the ultimate goal, which should be the case, and that is
looking after the veteran, you should be able to overcome the
difference in cultures, the difference in systems, the
different things that have happened over time. And I would hope
that that would happen.
One other question for both DoD and the VA. Why have the
Departments not addressed the GAO's recommendations from the
January 2009 report to develop results-oriented performance
goals and measures for the achievement of full
interoperability?
Ms. Rockey. Currently we have an information
interoperability plan and a joint strategic plan. And the
Interagency Clinical Informatics Board (ICIB) sets the
priorities for the items in the IIP and JSP and those, the ICIB
requirements, I believe in the updates for the Information
Interoperability Plan (IIP) and Joint Strategic Plan (JSP), and
Rear Admiral Timberlake can confirm this for me, the updates of
those plans will have those measures in them for the next
version.
Admiral Timberlake. Yes. The JSP is actually a product of
the Joint Executive Council and it is the projects that have
been agreed upon between the two departments. And with the
revision that is going on now, we will have measurable goals,
all the things that were talked about by the GAO in their
report going forward.
And the IIP is actually, if you will, almost a look ahead,
the strategic goal. It is what we should be asking the ICIB or
the other work groups to I come up with next to be done by the
Departments. And obviously as those then roll, if and when they
roll into the JSP, they will be assigned measurable outcomes
and program guidance will occur. Yes, sir.
Sir, could I ask might it be appropriate at this time to
have the demonstration of what information we can share?
Mr. Mitchell. Sure.
Admiral Timberlake. Captain Weiner, if you would go first,
please.
Captain Weiner. Chairman Mitchell, Ranking Member Roe, and
Members of the distinguished Committee, thank you for allowing
us the opportunity to demonstrate the military health system
electronic health system.
What I would like to just spend 1 second is sort of showing
you what our clinicians see throughout our enterprise and then
the shared information in context for today that we are able to
view from our VA colleagues.
So we have been able to select a patient, a real-time
patient back in April that was ultimately seen in theater. That
data was captured back in Kuwait. He was then medevacked, air
evacked up into Balad in Iraq and then moved to Landstuhl where
he received further care. He came back to the States and then
was ultimately seen by the VA in Palo Alto.
[Slide.]
Captain Weiner. This first view is the view that a
clinician when they log on to our system and pull up a
particular patient, this is what they see. So just to sort of
orient everyone, up on the left is tabular bars and icons that
help navigate throughout the system.
Up on the top, we have selected previous encounters and you
can either select it on the left or up on the top for ease. And
it is a chronological order of care that has been delivered to
this patient in an outpatient setting.
You will see some other tabs up above, allergy, meds, DoD,
VA, theater which we will discuss in a bit.
And the other thing I would like to point out is just for
this particular patient, there is a T up in the upper right-
hand corner and then there are also Ts next to two different
encounters of care, demonstrating that this patient was seen in
a theater setting, so automatically letting the clinician, if
he is coming to see us, if we take a second and think that we
are seeing him, we are logging on, and he is coming to us for
follow on care, what previous care has he seen.
And then just as a separate note, you can see up here,
there is a little nose that demonstrates he has allergies and
then there is a little red flag that demonstrates he has
command interest and meaning that he is a wounded warrior and
that we want to ensure that we are able to review his entire
record.
So this particular gentleman, a 40-year-old, was seen in
Kuwait. You see in the big frame down below is actually the
care that was documented and the incident that was documented.
Looking up just a little above where we saw the T, the
theater notes, we also see that he was ultimately seen at
Landstuhl Regional Medical Center. He had an ophthalmology
appointment for some follow-up care and that care is all
documented down in the large pane.
But as we see this patient, he describes to us that he was
also air evacked. He was also seen by the VA. And we know by
the theater encounter that there is more data that can be seen.
So we click over to DoD/VA theater history, which is also
above and on the left. And you cannot really see right--well,
right there, the pointer, this entire column on the right helps
us demonstrate the chronologic order that the patient was seen
in.
So up at the top, if we slide this to the top, we are at
current care. This is care that was delivered back in April. So
we know that he was seen on April 24th and then we realize that
there is a discharge summary done on April 27th, but there are
also some ICU nursing notes from when he was seen. There is an
operative note and then there is his surgical note.
So all care that was seen and documented in theater is
here; we can click here to view note details of his discharge
summary. And what we see is the record, the discharge summary.
And, again, we are seeing him now as an outpatient, say at
Bethesda Naval Hospital, and we want a summary of what care
occurred in theater while he was an inpatient. And we see that
he was seen at Balad Air Base and we see what his admission
diagnosis is and we see what his discharge diagnosis is.
He also lets us know that he was seen just a few weeks ago
by our colleagues at the VA at Palo Alto. So we slide our bar
all the way up and in chronologic order with the top being the
most recent, we see he was seen at the prosthetics clinic. He
was seen by the speech pathology clinic and then also some
physical rehabilitation.
But we are interested in his neuropsychiatric assessment.
We click on to view details and here we see the entire
assessment conducted in the VA at Palo Alto.
So prior to leaving, though, we like to discuss with him
some new medications for the cause of his follow-up visit. We
can go up above and we can click medications and we want to
ensure that there will be no drug-drug interaction of any
medications that we give and to also know what current
medications he is taking.
And prior to closing out, we also want to make sure he does
not have any allergies with any of the medications that he has
been given or as we see down in other any medications he has
received in civilian pharmacies. So we click on the allergy tab
and as a final, we are able to see allergies that were
collected in both the DoD and in the VA.
And with that, we are able to get a full view from the
time, the point of injury from Kuwait to each movement
throughout the system to his final appointment within the VA.
Thank you for your time and we will be happy to entertain
any questions.
Mr. Mitchell. Thank you.
My understanding is the VA also has a presentation?
Admiral Timberlake. Yes. Dr. Fletcher would show you the
VistA system. Minor technical adjustment here.
Dr. Fletcher. It is my pleasure to be here to show the
system that we are using at the current moment. We obviously
are covering a lot of VA hospitals at one time, but also are
increasingly able to see a good deal of the information coming
over from DoD.
You have already been told about the FHIE, the BHIE, the
bidirectional view, the computable data, and the sharing of
data for severely wounded warriors, so I will not go into that
except to show you how it works in actual patients.
[Slide.]
Dr. Fletcher. The first patient is a dual user for VA and
DoD. He served in Bosnia, Iraq, and Afghanistan. It actually
says he was exposed to blasts at least 11 times, the last one
in Afghanistan, rupturing his tympanic membrane and probably
causing some TBI.
When he comes to our institution, the cover sheet looks
like this. If I click on remote data available, I will see that
there is Defense Department data as well as Baltimore data. And
simply clicking on that and I get a look-up of that
information. It will start out with new and then become done,
at which point I can click on the discharge summary and see
that.
If I click on other pieces of information, I will see the
progress notes. And you can see in this instance that the
progress note comes from the field hospital. As described
earlier, this is a note from Afghanistan at the time that he
had a shrapnel wound to his head which also caused the tympanic
membrane to be ruptured as we saw later. Even at this time, he
could still hear a whisper, however. But the exact details of
what was done is in this format.
If I clicked on viewable information, I could see it in a
Web-based site that was talked about earlier. We do have a Web-
based site that will show us all the information of the
patient, whether he has been seen in any other VA sites, but
also wherever there is a cruciform with the arrow, this
information is available for the DoD as well and this is the
DoD note you just saw pulled up in this Web-based viewable
form.
I can click on the pharmacy outpatient and, again, it will
be new for a while, but then as it is done I can see the whole
medication list from Bethesda, Walter Reed, and many other
sites if I go down the list. These are very important because
at the time we were seeing him, even after he left the service,
we were having to follow him on a daily basis with his
medications largely being given to him from Bethesda Navy. So
we needed to know exactly what he was on when we would see him
in our hospital. But simply using this Bidirectional Health
Information Exchange, we could see that updated real time
whenever we are seeing the patient.
Notice that if I go into older areas of his medication, we
see that I can view what was given to him in Landstuhl,
Germany, Walter Reed, Eisenhower, Camp Shelby, and even CVS
Pharmacy. So the TRICARE information that is coming over is
seen by us as well all in one site.
This is a different patient, but it also shows information
from the TRICARE health clinic, DeLorenzo Health Clinic at the
Pentagon. I like to show this because while I was in the Army,
I served in that health care clinic under Dr. DeLorenzo. It was
not called that at that time. He was well known in this city
because he had accompanied many people through the Bataan Death
March and helped a lot of people out at that time.
If we look at the laboratory data, we can simply by
clicking flag isolate all the abnormal lab data, so we do not
have to look at the whole list. We can look at the combined
data from the DoD sites and VA at the same time.
Second patient is a severely wounded warrior who went to
DoD polytrauma and then to our polytrauma sites and then to the
VA. This particular patient had an improvised explosive device
(IED) blast and suffered a fractured spine and had traumatic
brain injury as well.
When I go to remote data and find out if it is available, I
can initialize the Defense Department data and click on
allergies. The patient had not been seen in Washington, so it
was not assessed. But as the information became more available,
penicillin allergy was seen at every DoD site the patient was
seen, so Brooke, Martin, Bethesda, Navy all had that allergy
listed.
And as a matter of fact, if I tried to give penicillin to
the patient, which I simulate here, it would tell me that we
had not assessed the allergy as he walks in the emergency room
but that he has had adverse reactions to penicillin reported
over from the DoD sites. So this is computable data allowing me
to cancel that order and move on.
This is the same patient whose image has been shipped over
in the severely Wounded Warrior Program. All the images and all
the files in a PDF format have been sent over to the polytrauma
sites. The beauty of that is that in the VA, if it is in the
imaging system, I in Washington can easily see the records that
have been sent to Richmond or sent to Tampa. They are all
interchangeable and whenever I pick up images, all of these
images are available to me.
If I click on the zoom feature, you can see that in this
instance, he has screws into his spine. And at this point,
there is a fracture of the spine. The screws are not at that
level, but they are above and below that level. And this is
very helpful for me to see the image as well as the description
of the image.
I also can pull a PDF document up. In this instance, it was
about 1,600 pages, but it was well indexed and I can search
through that and see all the information that was available not
only at Walter Reed but all the sites prior to that, in
Landstuhl, Germany, as well.
If I go to the third patient, this is one that was dual
care initially, now with the VA. The patient was hit by a
truck, had severe traumatic brain injury and that the patient
was in coma when she came to our hospital. And we thought she
might well not live much less achieve any reasonable activity
in the future.
This is the way the record appears. And, again, I can pick
up the remote data and see that she has chemistries listed.
These are Palo Alto, Bethesda Navy, Richmond. I can also pull
up the consults which are seen in both places. And I can see
the discharge summaries. Again clicked on the discharge
summaries to see the discharge summaries from the DoD as well
as VA.
Here is a radiology report. Radiology reports have been
shared on the bidirectional health information system for quite
some time, but more recently the actual X-rays are now being
shared between our place and Walter Reed and between our place
and Beaumont and the North Chicago. We can see them so that if
this comes up, I can simply click on the image and now I can
see these two images.
This is the first one. These are some months apart. This
one is in March and the follow-up is in October of the same
year. Notice they are very different. And I can cycle through
these in a comparison mode. I see very large vacuous holes
inside the brain, which are the ventricles, which are quite
swollen, not swollen at the same level several months later.
I can go through them together and notice how much bigger
these are and how much the brain has been pushed up against the
skull. And the fact that she was not able to wake up was easily
judged by this problem.
Mr. Mitchell. Dr. Fletcher, can we wind this up?
Dr. Fletcher. Yes, I will.
Mr. Mitchell. I think we get the gist of this.
Dr. Fletcher. I will.
Mr. Mitchell. We are way over time.
Dr. Fletcher. Yes, I will.
We put a catheter inside the ventricle and decompress that.
And now you can see that she can wake up.
This is another example of sharing of the X-rays which I
will quickly click through and summarize by saying that I have
shown you some examples of the Federal Health Information
Exchange, the Bidirectional Health Information Exchange, the
CHDR Program which is computable data, the Wounded Warrior
Program, and the VIX Image Sharing Program.
Thank you very much.
Mr. Mitchell. Thank you.
Admiral Timberlake. Mr. Chairman, thank you very much for
your indulgence in allowing us to demonstrate this because one
thing I noticed when I came to the office was that there was a
lot more sharing going on than I had ever as a veteran before I
came back on active service ever understood.
I am not going to stand here and tell you it is perfect and
there is not more to do and this is not VLER, but certainly I
think there is more going on than many of us out in my
veterans' community ever understood.
Thank you.
Mr. Mitchell. Thank you.
Mr. Bilbray.
Mr. Bilbray. Thank you, Mr. Chairman.
You know, I want to just open up for discussion and I just
got to tell you looking at the task in front of us, I do not
see any way we are going to reach the threshold mandated in
2010. In fact, we have a new joint facility opening up in 2010.
Is that facility going to be able to share data files from
the two agencies, two Departments?
Mr. Baker. Sir, that facility will utilize the
Bidirectional Health Information Exchange, what we have right
now, and several new features that pull AHLTA and VistA more
closely together to allow exchange of orders, allow single
sign-on for doctors, and a single registration for patients.
So enhance interoperability at the facility from what we
currently have right now between AHLTA and VistA.
Mr. Bilbray. Well, the question is enhanced from what we
have now seems to be short of what we hope to have or thought
we were going to have as dictated by Congress.
Let me just tell DoD up front that if I was the manager and
I looked at this issue, I have to figure that not only is the
client going to be with the VA 20 to 30 years where you are
maybe 5 to 10, but that because Veterans is going to inherit
the client, any good manager would reverse engineer it from
where the files are going and then modify the source to reflect
that long term.
I just got to say right up front, and I want DoD to defend
yourself on this issue, a reasonable manager would say the lead
agency should be VA because they are the recipient and they are
going to be the custodians longer than DoD.
DoD, what is your argument to defend your turf here over
the fact that VA ought to be setting the standards and only if
you can show where it is not compatible with your active duty
should you be able to modify it?
Ms. Rockey. The Interagency Clinical Informatics Board sets
the priorities for sharing, on what information we are going to
share and that is based on clinical priorities. We are making
changes in our architecture to enable sharing not just with VA
but sharing also with private sector, which is a big component
of the lifetime electronic record that we discussed earlier.
I think it is critical the sharing not just with VA but
that we are able to use standards so that we can connect to the
Nationwide Health Information Network and be able to share
information with the private sector as well.
Between VA and DoD, over 50 percent of our care is in the
private sector and it is critical that we are able to share
information and get information from the private sector as well
as between VA and DoD.
Mr. Bilbray. When we right now have problems with Bethesda
talking to Walter Reed, I mean, it pretty well tells me that we
need some adult supervision here and that we need to set a
standard, somebody needs to set a standard. And right now you
are talking about the Committee setting a standard that
everybody lives with without one agency having the lead and the
other one basically being a support system.
You have a major problem with the Veterans Affairs
Department being the lead agency with this data system?
Ms. Rockey. The requirements for interagency sharing are
set by the Clinical Informatics Board, which has VA and DoD on
the Board. The IIP and the Joint Strategic Plan are developed
by both DoD and VA.
Mr. Bilbray. Ma'am, in all fairness, the system may sound
good on paper, but the results that we are seeing is not a
result that, you know, I do not think this Committee wants to
accept and I do not think the public will accept. The fact is
everybody seems to be basically passing around the process but
not getting to an outcome that reflects reality. And the issue
is somebody needs to be in command here to dictate it and at
least then set a standard that everybody else can work around
or ask for modification, a mainframe to build around.
You are saying the Committee is doing that. I have not seen
and I do not think this Committee has seen that as being an
outcome that is timely and appropriate.
Ms. Rockey. I think the establishment of the IPO in April
of 2008 is a big step forward and putting the leadership in
place at the IPO as was discussed with the GAO testimony is a
critical next step for moving that forward. But I think the IPO
will provide that leadership and is providing that leadership
now under the interim guidance of Admiral Timberlake.
And I see us continuing to move forward on interoperability
and, again, not just with VA, which is critical for our
servicemembers, but also with the private sector as the private
sector begins the sharing process and moves forward with the
sharing process as well.
Mr. Bilbray. Thank you very much.
And, Admiral, thank you for coming back. I mean, what a
thankless job. And hopefully we will when your successor will
be a permanent appointment, at least in the foreseeable future.
I yield back, Mr. Chairman.
Mr. Mitchell. Mr. Hall.
Mr. Hall. Thank you, Mr. Chairman.
Admiral, am I correct in surmising that the samples that we
just looked at of different servicemembers' records were
selected from the many others which may or may not be as
complete or be as interconnected? And, if so, what percentage
of those who have been separated from service in the last year
had this degree of interoperability and depth so that the
physician from VA or DoD or private sector, but especially VA,
can access all that information going back to when the injury
may have occurred?
Admiral Timberlake. I will take for the record the
percentage. But what I wanted to say was, you know, going back,
and it was mentioned earlier about Specialist Fugate, we have,
we, these two Departments have worked madly over the last few
years to be sure that more and more of the patient encounters
are recorded electronically. And the electronic patient
encounters that are recorded are now available between the two
Departments.
[The DoD subsequently provided the following information:]
For recently separating servicemembers, with the exception of
shared images, the samples shown are representative of the
electronic health data available to VA. Servicemembers who
separated several years ago may still have a significant
portion of their medical data that were not captured
electronically. While we are unable to provide a percentage of
separated servicemembers that would have the degree of
interoperability demonstrated, we can say the majority of
servicemembers separating in the last few years will have a
significant amount of health data available to VA.
Not all prior servicemembers will have Theater data available
electronically to VA. The ability for VA to access Theater data
became operational in October 2007. VA would not be able to
access Theater data on individuals in Theater prior to October
2007. Likewise, not all former servicemembers would have
digital radiology images available to VA at this time, since
that capability is operational at a limited number of pilot
sites.
VA has access to electronic health information on more than
4.8 million individuals. The earliest data, starting with
ancillary data, are from 1989. Since 2001, more and more data
have been made available electronically. At this time,
electronic health data are not available to private physicians.
In general, VA has access to:
Since 2001, for separated servicemembers, DoD has
provided VA with one-way historic information through the
Federal Health Information Exchange. On a monthly basis, DoD
sends laboratory results; radiology reports; outpatient
pharmacy data; allergy data; discharge summaries; consult
reports; admission, discharge, transfer information; standard
ambulatory data records; demographic data; Pre- and Post-
deployment Health Assessments; and Post-deployment Health
Reassessments.
For shared patients being treated by both DoD and
VA, the Departments continue to maintain the jointly developed
Bidirectional Health Information Exchange (BHIE) system, which
was implemented in 2004. Using BHIE, DoD and VA clinicians are
able to access each other's health data in real-time, including
the following types of information: allergy; outpatient
pharmacy; inpatient and outpatient laboratory and radiology
reports; demographic data; diagnoses; vital signs; family
history, social history, other history; questionnaires; and
Theater clinical data, including inpatient notes, outpatient
encounters, and ancillary clinical data such as pharmacy data,
allergies, laboratory results and radiology reports.
Admiral Timberlake. Now, having said that, you know, I
personally, this is my 36th year of Naval service, active and
Reserve, I think I have 8 years of electronic data, so I have
about 28 years of carrying around a big, thick record.
But if we are talking about what we are doing now, you
know, then I think in most instances, I am not going to tell
you it is a hundred percent because somebody is always going to
find the, you know, the----
Mr. Hall. Exception.
Admiral Timberlake. Yeah, that proves the thing. But if it
is entered electronically, then they can see it between. Now,
you know, there are some issues. I think it was brought up
earlier by Mr. Baker. Sometimes you go to a facility and
somebody does not understand how to do it.
DoD had an issue where if you do not get the functionals,
the business community, the physicians to tell you what, really
tell you what the requirements are, you know, they had a thing
for a while where the DoD people could not get to the VA data
because instead of a button that would be--you know, they just
said build us a button, so they built a button that said BHIE.
Well, techies did that. That is what the IT people are
supposed to do. But the functionals did not then teach the
clinicians that that is what that button meant. And so for a
long time you could go to somewhere like Walter Reed and a lot
of physicians would not know how to see the data. It was
available to exchange, but they did not understand how to do
it.
And let me turn to Mary Ann or----
Ms. Rockey. I do want to point out that that button is no
longer labeled BHIE, that that was what you saw in the
demonstration. It is VA information and theater information is
what it is labeled, now which is a better descriptor.
Also, a little different architecture for our electronic
health record system in which we have a central data
repository. So the capabilities you saw are accessible across
the DoD.
Mr. Hall. I do not want to minimize the progress that you
have shown us because this is the first time in my recollection
that we have seen this kind of electronically accessible record
for a servicemember, that is accessible from both Departments.
But I just wonder if anybody here at the table can tell me
what percentage, let us just say today, what percentage of
servicemembers leaving active duty today and being separated
and joining the Veterans Corps have records that look like that
and that have that degree of detail and accessibility and
interoperability?
Admiral Timberlake. You know, my understanding, sir, is
that when the serviceman separates, every bit of DoD electronic
information is transferred via the BHIE to the Veterans
Administration.
Now, the Veterans Administration does not access that until
a member comes in for care or treatment because of privacy
issues and Health Insurance Portability and Accountability Act
(HIPAA) and all, but it is transferred.
Mr. Baker. Sir, I think we would agree with that. Maybe a
statistic for you. May help or may not. The statistic I have is
that in April of 2009, there were 295,000 accesses of the BHIE,
of the bidirectional system.
The other statistic is that there are about 4.8 million
unique patients that have been transferred from the DoD to the
VA via the FHIE, the Federal Health Information Exchange.
I do not have the percentages for that. I just have the
statistics. We can certainly, I believe, come back to you with
what we believe the actual percentage is of DoD patients. We
believe it is a hundred percent, but we would like to make
certain that we do a little bit of analysis from the folks here
at the table and come back to you with the actual answer.
But of the people leaving service today, if they have any
electronic records from the DoD being seen, that information is
transferred into the VA.
Mr. Hall. Thank you very much.
Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
Mr. Walz.
Mr. Walz. Thank you, Mr. Chairman.
First of all, I would like to thank every one of you for
your service. I think all too often we get into the heart of
these and we forget the incredible work you are doing, the
incredible selfless service to the public sector, when all of
you could be in the private sector. I understand that.
And, Admiral, you came back out of that. So I think we want
to be very clear and also to be very clear that we are absolute
partners with you in this endeavor because you can be certain
when we go home, we set on the other side of the table and our
veterans set up here and grill us on everything that is there.
And that is the way a system is supposed to work.
But I do want to be very clear that we are all in this
together. It is absolutely understood that everyone in this
room wants the quality care for our veterans, timely manner, do
it in the most efficient and cost-effective manner. So I know
sometimes we lose that and we get lost in a little bit what
goes on.
A couple of question on this and I am impressed that we are
making progress on that. I think Mr. Hall asked some good
questions.
I as a 24-year veteran that retired in 2006, if I went to
the VA, what would my record look like?
Mr. Baker. Gentlemen, somebody who knows VistA----
Mr. Walz. Where would they get it? How would I find out
about it? I went in there. I was a 24-year artilleryman. I
cannot hear very well. What is going to happen?
Mr. Baker. I would ask Dr. Fletcher to address that one.
Dr. Fletcher. You would see a button that says remote data.
They would see a button and it is labeled remote data. And if
they clicked on that or went in VistA Web, it would
automatically come up if you had been seen in DoD and VA. And
all of that data in terms of radiology reports, all the labs,
all the medicines, most of the electronic notes would be
available to the doctor.
Mr. Walz. And I say this, I just have to say when we
deployed in 2006, I will be damned if I did not have to get
every shot again. No record, nothing. Nine of them. Oh, First
Sergeant, you do not have any records. How can I not have any
records?
So my question is still, and I know it has been maybe--
maybe 3 years ago is a lifetime, but I still just know from
personal experience that that 201 file that is this thick that
is in the safe in the bottom of my house, I am convinced that
is the only one at this point. And that makes me a little
nervous.
And I say this because I am passing on, yes, maybe
anecdotal from I see Vietnam veterans out there, I see Iraq
veterans out there. Our question is, is that I absolutely, I am
trying to get to where we are going and where this is
happening.
I want to come back to where the GAO was on this. And they
came to a different conclusion than I am hearing from you.
Now, the one thing was, as many of you--do not think I do
not underestimate the technical side of this. It is massive.
And I agree with, I think, Admiral, you said this or maybe it
was Mr. Baker, you are shooting for a hundred percent. And I
think, you know, we have to. This is a zero sum game. I do not
know if we will ever get there. The Secretary says that, but
anything less than that attempt is probably not right for our
veterans.
What I am trying to figure out is, is that they were very
clear. They stated three things. They think it is taking you
too long to hire staff. They think we forced you to come up
here and testify here where you should all be out doing your
job right now basically is what it said, and that you are
trying to align yourself with a time table.
And I agree, Admiral. You said our time tables are
different, our funding is different, and it would be easier if
we could just get those into alignment. Our job is to try and
help you get there.
So I want to see if maybe, Admiral, this might be for you
to respond first. The GAO wrong about that on why we are not
getting there?
Admiral Timberlake. I think that many of the things that
they have said are absolutely right on. Let me address your
first issue.
I tried to be specific that we can only transfer electronic
information that we have. If you are like me, you know, there
is a lot of your information that is on paper.
Mr. Walz. That is right.
Admiral Timberlake. We cannot transfer paper
electronically. That is a whole other discussion, but it is
outside of the electronic health record.
So your information may be limited depending upon how long
you were in the service after we started the transfer.
Mr. Walz. Right.
Admiral Timberlake. As far as the other, yes, it is taking
both Departments a long time in my opinion to bring personnel
on board. I am not sure why.
On the DoD side, part of it was that although the office
was stood up, and I would almost call it a virtual office, in
April with a couple of--Cliff was one and another, and a DoD
person that tried to start getting some of the program
descriptions written and the people hired. And they had a
couple of loaned military officers for a few months.
But on the DoD, they could not begin to officially hire
until this delegation of authority memo was signed which was
not done until December 30th. Once that happened, then the DoD
position descriptions could go out and we could start the
process of trying to hire. And we are continuing to do that.
The VA, they went out earlier, but with the change of
Administration relooking at what their--because each Department
hires the people and then gives them to me or my hopefully
successor soon. They had to look at their priorities.
And I might let--do you have something, Cliff? Let me let
Cliff----
Mr. Freeman. Yeah. It is not for lack of effort. The
position descriptions were written for the, what used to eight
positions, were written in May of 2008. That was a month after
we stood up the office. And then the seventh position was
written the next month when the Senior Oversight Committee
(SOC) decided that we would also oversee benefits and
personnel.
It has been a challenging experience and very frustrating.
We have had certs that came back with only one name on them.
Very nice people, but they were not the skill set that we
needed. We have offered jobs to people and they have turned
them down, either stay in the private sector or take other
government jobs. So I do not think it is for lack of effort.
And the one thing I would like to say is that although all
the positions have not been filled, what we have done is we
have borrowed very qualified folks from the two Departments to
come in and make sure that those skill sets we needed did not
go unfilled.
So DoD brought on people in uniform to help us. The VA
provided folks, some project managers and folks to help fill
those specific spots.
So I do not want to leave the Committee with the impression
that the work went undone because we did not fill the permanent
positions.
Mr. Walz. No. And I very much appreciate that.
And I would say, if the Chairman indulges me for an extra
minute, to just let you know these hearings are meant to be
bidirectional also. Our job is if these are things we can cut
through, and I am absolutely committed to this seamless
transition, we are starting to send out overtures and it is
difficult here to try and get Armed Services to work with VA,
but we are making that attempt and talking to members over
there of ways that we can make this happen.
So these are the things that need to be brought to our
attention, to the staff's attention if there are things that we
can help speed that up because I think any of us who have
worked in this environment know that what you are saying is
absolutely true. We just cannot allow those hurdles to get in
the way of making this happen, if there is anything we can do
to break them down.
I yield back. Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
Just indulge me, if the Committee would for just a second.
I heard Mr. Walz say that when he went back to be deployed
that there is no record of any of his shots. And I was just
talking to our counsel here. When he was first deployed in
1991, he had 25 shots. When he was redeployed in 2002 through
2004, there was no record of them again.
The problem with this, of course, is when a veteran tries
to apply for benefits, and I think that I heard, Ms. Rockey say
that every electronic record that DoD has is transferred to the
VA, but it looks to me like a lot of the problem is that DoD
does not have all this stuff on electronic records.
Our counsel here says that he had to carry them around with
a rubber band around them and he carried them around himself.
The real problem then occurs when they try to apply for
benefits. So it is just an observation.
If the Committee will indulge me, I want to ask two quick
questions of the Admiral.
First, will the Interagency Program Office meet its
statutory deadline on September 30th, 2009, to have an
interoperable electronic health record system?
Admiral Timberlake. Thank you, sir. I will take the first
crack at perhaps answering that.
My understanding in reading of H.R. 4986, the ``NDAA
2008,'' Public Law 110-181, section 1635 required, and I quote,
``By no later than September 30th, 2009, electronic health
record systems or capabilities that allow for full
interoperability of personal health care information between
the Department of Defense and the Department of Veterans
Affairs.''
The two Departments and then again the IPO when it was
subsequently set up turned to that expert working group we have
mentioned in the Health Executive Council called the Joint
Clinical Informatics Board at that time, subsequently called
ICIB, to define what these capabilities should be.
Those members examined the information sharing capabilities
currently extant between the Departments of Defense and
Veterans Affairs and identified a path toward reaching the next
level of integration, which they said would support this
interoperability for the provision of clinical care.
They used five criteria established by the Institute of
Medicine (IOM) that defined the core functionalities of an EHR.
The five criteria from the Institute of Medicine are improve
patient safety, support the delivery of effective patient care,
facilitate management of chronic conditions, improve efficiency
and feasibility of implementation.
Using the IOM model and prioritizing provider access to
clinically relevant information, the JSP now called ICIB
members made the determination that the sharing of this
additional set of capabilities, which have been talked about
between the VA and DoD in addition to currently shared
information would provide a level of clinical care sufficient
to reach the desired level of interoperability.
Adding these new capabilities to the already robust
information sharing occurring between the two Departments
provides a level of integration that far surpasses the level
generally observed between health care systems and the private
sector.
It should be noted that the Departments were looking at and
the ICIB were looking at interoperability from a functional
perspective. In other words, what is needed for the provision
of clinical care. They had not and I believe still have not
spent a lot of time and energy trying to define the term
interoperability from an academic perspective. As to whether
something is fully interoperable depends on the use case or
what the functional business community or medical community
says it needs to do with the data.
So the Departments considered the provision of clinical
care to be their first priority since that is in essence the
use case at a high level. And that is the priority they are
addressing now. And, thus, in addition to the current and
ongoing information exchange, they identified six additional
capabilities that they believed needed to be developed by
September 30, 2009, to meet the requirement for EHRs or
additional capabilities.
And those six by expansion of Essentris or provision of an
inpatient record component to AHLTA, demonstration of trusted
gateways so you can share the information, the social history
refined, as we talked about, demonstrate a capability to do
document scanning and expansion of the questionnaires that were
already mentioned and then showing the separation physical
exams are going back and forth.
As of today, three of those objectives have been met and
the other three appear to be en route to being achieved by
September 30th. So it is my opinion that we will meet that
deadline based upon these definitions which the departments
have come up with working together.
Mr. Mitchell. So the answer is yes?
Admiral Timberlake. My answer is at this time, it seems to
me we will.
Mr. Mitchell. I understand about the six interoperability
objectives. I thought the GAO said there was only one that was
met. You say there is three?
Admiral Timberlake. According to my most recent update
which is right here, we have three that seemed to have been met
and there are three that are still in process, but I believe
will be met.
Ms. Rockey. I can confirm it is the three. Social history,
separation physical exams, and the expanded gateways have been
completed.
Mr. Mitchell. One last question, if the Subcommittee will
indulge me.
According to the GAO, in early July, DoD and VA reported
they had selected 10 of 14 government positions. However, all
16, and this kind of goes back to what Mr. Walz said, all 16
designated contractor positions have been filled.
If there has not been established results-oriented goals
and performance measures for all six objectives yet, how does
the IPO measure whether the contractors are meeting their
requirements? What is the scope of work of the contractors and
what positions do they fill?
Admiral Timberlake. The contractors range from support
staff such as secretaries to specialists in program management
who work with our program manager to begin to gather the data
that was talked about.
Now, I will be the first to admit we are not fully where we
want to be. But, for example, in looking at and following the
status of the Essentris implementation, which is just one of
the six which is not complete, we were following what was the
contract, was the contract let, and then what were the outcomes
that the Departments had agreed upon would define success.
In that case, success was defined by selecting an inpatient
module, which ended up being Essentris, having the contract
let, and then deploying that contract, that capability at three
additional sites in DoD facilities, one from each service.
As of today, I believe two Army? I will ask Ms. Rockey.
Ms. Rockey. Yes, that is correct. We have two Army sites
complete and we are on track for at least one Air Force and one
Navy site by September.
Admiral Timberlake. And so at that level and that sort of a
rudimentary level of program management, I would be the first
to admit we have goals, we have objectives, and we are tracking
to see that the DoD and VA are meeting them.
Mr. Mitchell. Mr. Wu.
Mr. Wu. Thank you for your indulgence, Chairman Mitchell. A
couple questions.
Admiral Timberlake or the collective group, as a staff
member and as a Staff Director, it has been painful to listen
to this testimony.
The NDAA requirement on interoperable systems in our
opinion was not to identify the six objectives. It was to have
the system in place.
In looking back in former PowerPoint presentations, this
thing was supposed to have been in effect 2005. And if you will
indulge me, I will read you the quote from the press release
when this agreement came in place.
``In October of 2002, this joint initiative marks the
beginning of an era of renewed and I believe unprecedented
collaboration between the health care resources of VA and DoD.
This partnership is critical to our ability to continue to
deliver high quality care in our respective beneficiaries
across the country,'' quote, unquote.
Now it is 7 years later and we are just beginning to
identify what those objectives are to get there.
When you opened the doors in October of 2010 and you are
seeing DoD beneficiaries and veterans affairs' beneficiaries,
what are you going to be able to do?
I understand. I heard the testimonies saying you will have
joint sign-off. You will have this sharing. I personally do not
believe that you will be able to see the patients in the
seamless manner that the NDAA 2008, the spirit of what you were
supposed to do and where you are at right now. I hear a lot of
excuses. I do not think that is right.
I see in the NDAA language that the House Armed Services
Committee (HASC) put out after the joint hearing that they
recommended that all the money from DoD and from MHS be
stripped because there was no adult supervision.
Would you like to comment on that because we have not moved
forward in the manner that I think was in the spirit of what
the Members of Congress wanted?
Admiral Timberlake. I am going to allow my two colleagues
to comment on that because I think you have switched over to
talking about the North Chicago Federal Health Care----
Mr. Wu. Well, I think North Chicago has been touted to be
the poster child of interoperability and I see that it is
silent in the testimony of VA and DoD. Not silent. One line in
the testimony. And this was supposed to be the joint venture,
the demonstration of interoperability. I do not see that
happening.
Ms. Rockey. For North Chicago, the requirements for the six
baseline functional requirements for opening day, and this is
in addition to the current sharing we are already doing, of
that, we have completed one so far. We have the requirements
defined for the other five in detail. Those were delivered in
June.
We have a Joint Incentive Fund (JIF) package that we have
pending to work on single patient registration process, single
sign-on, phase one of single order entry, address rapid dental,
and work on outpatient appointment scheduling as well. Those
are the items that were identified as baseline functional
requirements for North Chicago and those are the ones we are
targeting for completion by October 2010.
Mr. Wu. Thank you, Chairman Mitchell, but I understand that
that JIF money is going to be VA money, not DoD money. That is
my last question. Thank you very much, Chairman Mitchell.
Mr. Mitchell. Thank you.
I want to thank all of you for appearing today. And I think
you realize how seriously we take this. And we understand you
are trying to work for this. It is very vital because many
people's lives and quality of life are dependent on these
records.
So, again, thank you very much, and this concludes the
hearing. It is adjourned.
[Whereupon, at 11:57 a.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
I would like to thank everyone for attending today's Oversight and
Investigations Subcommittee hearing entitled, the Interagency Program
Office: Examining the Progress of Electronic Health Record
Interoperability Between VA and DoD. Thank you especially to our
witnesses for testifying today.
We are here today to examine the progress being made by the
Department of Defense and Department of Veterans Affairs to achieve
electronic health record interoperability. Currently, there is no
single VA/DoD electronic record that captures all information needed
for delivery of health care and benefits to servicemembers, veterans
and their beneficiaries. As many of you know, on April 9, 2009,
President Obama, along with Secretary of Veterans Affairs Eric Shinseki
and Secretary of Defense Robert Gates, announced that the VA and DoD
would create a Joint Lifetime Electronic Record that would contain
information from the day individuals enter military service, through
their careers, and for the remainder of their lives as veterans if they
enter the VA system.
Mandated by the National Defense Authorization Act of 2008, the
Interagency Program Office was established to act as the ``single point
of accountability'' for DoD/VA electronic health record
interoperability. As the September 30 deadline for electronic health
record interoperability approaches, it is imperative to ensure that
both the DoD and VA are organized and working together to deliver a
comprehensive system that will modernize and simplify record sharing
between Departments.
In 1982, under the VA and DoD Health Resources Sharing and
Emergency Operations Act, both DoD and VA were first encouraged to find
common ground to create a more efficient health care system that would
be worthy of the sacrifices our men and women make every day. Since
then, although they have made significant improvements in sharing
patient record information, both the DoD and VA have yet to find the
common ground to achieve full electronic health record
interoperability. The GAO's report on the state of DoD and VA's health
record sharing initiatives is not due until the end of July, but I'm
grateful that they are here today to update us on the progress these
two Departments have made in meeting the statute's requirements.
As a growing number of men and women return from the battlefields
in Iraq and Afghanistan with more complicated and more severe wounds,
it is time to make their care and treatment easier. It is time for us
to improve upon a system that will ensure the best and most complete
care, efficient benefits delivery, and a seamless transition back into
civilian life. Under the leadership of Director Rear Admiral Gregory
Timberlake and Deputy Director Cliff Freeman of the Interagency Program
Office, both here today, I am hopeful--I am expectant--that we will see
headway toward the vision Congress and the President have established
for a VA of the 21st century.
Prepared Statement of Hon. David P. Roe, Ranking Republican Member,
Subcommittee on Oversight and Investigations
Mr. Chairman, thank you for holding this hearing.
The issue of Seamless Transition and the interoperability of the
transfer of medical records between the Department of Defense and the
Department of Veterans Affairs is one that Congress has been working on
for a number of years. During the 109th Congress alone, the Committee
on Veterans Affairs held a total of 10 hearings on the issue of
Seamless Transition. Again, last Congress, this Subcommittee held a
hearing on March 8, 2007 on Seamless Transition, on May 8, 2007 on VA/
DoD Data Sharing, on October 24, 2007 on the status of sharing
electronic medical records and on June 24, 2008 on VA and DoD
Cooperation in Reintegrating the Guards and Reserves.
Time and again, the issue of interoperability and data sharing of
critical medical information between the DoD and the VA is discussed,
studied and demo'ed and the degree of progress is dismally glacial.
This is one of the reasons that section 1635(e) was included in the
2008 National Defense Authorization Act.
This section revealed a plan of action for the two departments to
create a schedule and set a deadline of September 30, 2009, and issued
requirements for (1) the establishment of the Interagency Program
Office (IPO); (2) the establishment of the requirements for electronic
health records (EHR) systems or capabilities, including coordination
with the Office of the National Coordinator for Health Information
Technology; (3) any acquisition and testing required in the
implementation of electronic health record systems or capabilities that
allow for full interoperability; and (4) the implementation of
electronic health record systems or capabilities.
I am interested in learning the progress that DoD and VA are making
in moving forward with the interoperable transfer of medical data
between the two departments. In the past, this information has been
held in what several members have called ``independently stove-piped
electronic medical records systems'' that had difficulty transferring
data between the two departments. This issue is of great concern to me
as well as other members of the Committee. I hope that measurable
progress has been made toward better communication and cooperation
between the two departments.
The care of our Nation's servicemembers and veterans is of primary
importance to everyone at this hearing today. They have served our
country valiantly in the face of battle, and should not have to be
worried about whether or not their health care providers have the tools
and information they need to provide care that is timely, medically
appropriate, and necessary.
Mr. Chairman, I look forward to hearing from our witnesses today,
and yield back the balance of my time.
Prepared Statement of Valerie C. Melvin, Director,
Information Management and Human Capital Issues,
U.S. Government Accountability Office
ELECTRONIC HEALTH RECORDS
Program Office Improvements Needed to Strengthen Management of
VA and DoD Efforts to Achieve Full Interoperability
GAO Highlights
Why GAO Did This Study
For over a decade, the Department of Veterans Affairs (VA) and the
Department of Defense (DoD) have been working on initiatives to share
electronic health information. To expedite their efforts, Congress
mandated in the National Defense Authorization Act for Fiscal Year 2008
that VA and DoD establish a joint interagency program office to act as
a single point of accountability in the development of electronic
health records systems or capabilities that allow for full
interoperability (generally, the ability of systems to exchange data)
by September 30, 2009.
In this statement, GAO summarizes findings from its upcoming
report, focusing on progress in setting up the interagency program
office and the departments' actions to achieve fully interoperable
capabilities by September 30, 2009. To do so, GAO analyzed agency
documentation on project status and conducted interviews with agency
officials.
What GAO Recommends
GAO's draft report recommends that the Secretaries of Defense and
Veterans Affairs emphasize the interagency program office's
establishment of a project plan and integrated master schedule to guide
their interoperability activities.
What GAO Found
VA and DoD have made progress in setting up the interagency program
office; however, the office is not yet effectively positioned to be
accountable for the departments' efforts to achieve fully interoperable
electronic health record systems or capabilities. The departments have
taken the important steps of completing personnel descriptions and
hiring necessary staff to perform the office's functions, but key
leadership positions (for the Director and Deputy Director) continue to
be filled on an interim basis. In addition, the office has established
a charter and begun to demonstrate responsibilities outlined within
this document. Nonetheless, the office is not yet fulfilling key
information technology management responsibilities in the areas of
performance measurement, project planning, and scheduling--all of which
are essential to establishing the office as a single point of
accountability for the departments' interoperability efforts.
VA and DoD continue to take steps toward achieving full
interoperability by the September deadline. In this regard, the
departments have achieved planned capabilities for three of six
interoperability objectives (see table) that they identified to meet
their data sharing needs--refine social history data, share physical
exam data, and demonstrate initial network gateway operation. For the
remaining three objectives--expand questionnaires and self assessment
tools, expand DoD inpatient medical records system, and demonstrate
initial document scanning--the departments have partially achieved
planned capabilities, with additional work needed to fully meet
clinicians' needs for health information.
Description of VA and DoD Interoperability Objectives
------------------------------------------------------------------------
Objective Description
------------------------------------------------------------------------
Refine social history data DoD will begin sharing with VA
social history data currently
captured in the DoD electronic
health record. Such data
describe, for example,
patients' involvement in
hazardous activities and
tobacco and alcohol use.
------------------------------------------------------------------------
Share physical exam data DoD will provide an initial
capability to share with VA its
electronic health record
information that supports the
physical exam process when a
servicemember separates from
active military duty.
------------------------------------------------------------------------
Demonstrate initial network gateway DoD and VA will demonstrate the
operation operation of secure network
gateways that provide expanded
bandwidth to support
information sharing between DoD
and VA health care facilities.
------------------------------------------------------------------------
Expand questionnaires and self DoD will provide all periodic
assessment tools health assessment data stored
in its electronic health record
to the VA such that
questionnaire responses are
viewable with the questions
that elicited them.
------------------------------------------------------------------------
Expand DoD inpatient medical records DoD will expand its inpatient
system medical records system to at
least one additional site in
each military medical
department (one Army, one Air
Force, and one Navy for a total
of three sites).
------------------------------------------------------------------------
Demonstrate initial document scanning DoD will demonstrate an initial
capability for scanning
servicemembers' medical
documents into its electronic
health record and sharing the
documents electronically with
the VA.
------------------------------------------------------------------------
Source: GAO based on VA and DoD data.
View GAO-09-895T or key components. For more information, contact
Valerie Melvin at (202) 512-6304 or [email protected].
__________
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today to discuss the Departments of
Veterans Affairs' (VA) and Defense's (DoD) interagency program office
and efforts toward advancing the use of health information technology
to achieve interoperable electronic health records. As you know, VA and
DoD have been working for over a decade on initiatives to share data
between their health information systems; yet, while they have made
progress in a number of areas, questions have persisted concerning when
and to what extent the intended electronic sharing capabilities of the
two departments will be fully achieved. To expedite their efforts, the
National Defense Authorization Act for Fiscal Year 2008 \1\ included
provisions directing VA and DoD to jointly develop and implement, by
September 30, 2009, fully interoperable electronic health record
systems or capabilities that are compliant with applicable Federal
interoperability \2\ standards. It further established an interagency
program office to be a single point of accountability for the
departments' efforts.
---------------------------------------------------------------------------
\1\ Pub. L. No. 110-181, Sec. 1635 (2008).
\2\ Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged. Further discussion of levels of interoperability is
provided later in this testimony.
---------------------------------------------------------------------------
Also, the act directed us to report semiannually on VA's and DoD's
progress in implementing their electronic health record systems. In
this regard, we have previously issued two reports (in July 2008 and
January 2009). We plan to issue a third report near the end of this
month--a draft of which is currently with the departments for their
review and comments. At your request, my testimony today summarizes
findings from this latest draft report, focusing on the departments'
progress in setting up the interagency program office as a point of
accountability for the implementation of interoperable electronic
health records, and actions being taken to achieve these capabilities
by September 30, 2009.
In developing this testimony, we relied on our previous work
supporting the draft report. We conducted our work from April 2009
through July 2009, in the Washington, D.C. metropolitan area. All work
on which this testimony is based was performed in accordance with
generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.
Background
The use of information technology (IT) to electronically collect,
store, retrieve, and transfer clinical, administrative, and financial
health information has great potential to help improve the quality and
efficiency of health care and is important to improving the performance
of the U.S. health care system. Historically, patient health
information has been scattered across paper records kept by many
different caregivers in many different locations, making it difficult
for a clinician to access all of a patient's health information at the
time of care. Lacking access to these critical data, a clinician may be
challenged to make the most informed decisions on treatment options,
potentially putting the patient's health at greater risk. The use of
electronic health records can help provide this access and improve
clinical decisions.\3\
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\3\ An electronic health record is a collection of information
about the health of an individual or the care provided, including
patient demographics, progress notes, problems, medications, vital
signs, past medical history, immunizations, laboratory data, and
radiology reports.
---------------------------------------------------------------------------
Key to making health care information electronically available is
interoperability--that is, the ability to share data among health care
providers. Interoperability enables different information systems or
components to exchange information and to use the information that has
been exchanged. This capability is important because it allows
patients' electronic health information to move with them from provider
to provider, regardless of where the information originated. If
electronic health records conform to interoperability standards, they
can be created, managed, and consulted by authorized clinicians and
staff across more than one health care organization, thus providing
patients and their caregivers the necessary information required for
optimal care. In the health IT field, standards may govern areas
ranging from technical issues, such as file types and interchange
systems, to content issues, such as medical terminology. Unlike paper-
based documents, electronic health records can also provide automatic
alerts about a particular patient's health, or other advantages of
automation.
In prior reports, we have discussed the different levels of
interoperability that agencies can achieve.\4\ At the highest level,
electronic data are computable (that is, in a format that a computer
can understand and act on to, for example, provide alerts to clinicians
on drug allergies). At a lower level, electronic data are structured
and viewable, but not computable. At still a lower level, electronic
data are unstructured and viewable, but not computable. With
unstructured electronic data, a user would have to find needed or
relevant information by searching uncategorized data. Beyond these,
paper records also can be considered interoperable (at the lowest
level) because they allow data to be shared, read, and interpreted by
human beings. According to VA and DoD officials, not all data require
the same level of interoperability, nor is interoperability at the
highest level achievable in all cases. For example, unstructured,
viewable data may be sufficient for such narrative information as
clinical notes.
---------------------------------------------------------------------------
\4\ These levels were identified by the Center for Information
Technology Leadership, which was chartered in 2002 as a research
organization to help guide the health care community in making more
informed strategic IT investment decisions. According to VA and DoD,
the different levels of interoperability have been accepted for use by
the Office of the National Coordinator for Health Information
Technology.
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VA and DoD Are Required by Law to Establish an Interagency Program
Office and Achieve Full Interoperability
As previously noted, the National Defense Authorization Act for
Fiscal Year 2008 \5\ called for VA and DoD to jointly develop and
implement fully interoperable electronic health record systems or
capabilities by September 30, 2009, and established an interagency
program office to be accountable for the departments' efforts in this
regard. The departments have been working to set up this office since
April 2008. In January 2009, the office completed its charter,
articulating, among other things, its mission and functions with
respect to attaining interoperable electronic health data. The charter
further identified the office's responsibilities in carrying out its
mission, in areas such as oversight and management, stakeholder
communication, and decision-making.
---------------------------------------------------------------------------
\5\ Pub. L. No. 110-181, Sec. 1635 (2008).
---------------------------------------------------------------------------
Further, to help meet the intent of the act, the Interagency
Clinical Informatics Board,\6\ made up of senior clinical leaders from
both departments who represent the user community, began establishing
priorities for health data sharing between VA and DoD. The board
subsequently identified six interoperability objectives for meeting the
departments' data sharing needs, as reflected in table 1.
---------------------------------------------------------------------------
\6\ This board was originally named the Joint Clinical Information
Board.
Table 1: Description of VA and DoD Interoperability Objectives
------------------------------------------------------------------------
Associated
Objective Description interoperability
level
------------------------------------------------------------------------
Refine social history data DoD will begin Structured,
sharing with VA viewable
the social history electronic data
data that is
currently captured
in the DoD
electronic health
record. Such data
describe, for
example, patients'
involvement in
hazardous
activities and
tobacco and
alcohol use.
------------------------------------------------------------------------
Share physical exam data DoD will provide an Structured,
initial capability viewable
to share with VA electronic data
its electronic
health record
information that
supports the
physical exam
process when a
servicemember
separates from
active military
duty.
------------------------------------------------------------------------
Demonstrate initial network VA and DoD will There is no
gateway operation demonstrate the interoperability
operation of the level associated
secure network with this
gateways a to objective.
support joint DoD-
VA health
information
sharing.
------------------------------------------------------------------------
Expand questionnaires and self DoD will provide Structured,
assessment tools all periodic viewable
health assessment electronic data
data stored in its
electronic health
record to the VA
in such a fashion
that questionnaire
responses are
viewable with the
questions that
elicited them.
------------------------------------------------------------------------
Expand DoD inpatient medical DoD will expand its Unstructured,
records system inpatient medical viewable
records system electronic data
(CliniComp's
Essentris b
product suite),
also called the
clinical
information
system, to at
least one
additional site in
each military
medical department
(one Army, one Air
Force, and one
Navy for a total
of three sites).
------------------------------------------------------------------------
Demonstrate initial document DoD will Unstructured,
scanning demonstrate an viewable
initial capability electronic data
for scanning
servicemembers'
medical documents
into its
electronic health
record and sharing
the documents
electronically
with the VA.
------------------------------------------------------------------------
Source: GAO Analysis of VA and DoD data.
a Secure network gateways provide expanded bandwidth to support
information sharing and ensure secure and reliable data communications
between VA and DoD health care facilities.
b Essentris is a commercial health information system customized to
support inpatient treatment at military medical facilities.
According to the former acting director of the interagency program
office, VA and DoD consider achievement of these six objectives, in
conjunction with data sharing capabilities previously achieved (e.g.,
the Federal Health Information Exchange (FHIE),\7\ the Bidirectional
Health Information Exchange (BHIE),\8\ and the interface between DoD's
Clinical Data Repository (CDR) and VA's Health Data Repository (HDR),
known as CHDR),\9\ to be sufficient to satisfy the requirement for full
interoperability by September 2009.
---------------------------------------------------------------------------
\7\ FHIE, enhanced through its completion in 2004, provides a one-
way transfer of data that enables DoD to electronically transfer
servicemembers' electronic health information to VA when the members
leave active duty.
\8\ BHIE, established in 2004, was aimed at allowing clinicians at
both departments viewable access to records on shared patients--that
is, those who receive care from both departments. For example, veterans
may receive outpatient care from VA clinicians and be hospitalized at a
military treatment facility. To create BHIE, the departments drew on
the architecture and framework of the information transfer system
established by the FHIE project. Unlike FHIE, BHIE is a two-way
interface that allows clinicians in both departments to view, in real
time, limited health data (in text form) from the departments' existing
health information systems. The interface also allows DoD sites to see
previously inaccessible data at other DoD sites.
\9\ Combining the names of the two repositories, the Clinical Data
Repository/Health Data Repository (CHDR) interface, pronounced
``cheddar,'' implemented in September 2006, linked the department's
separate repositories of standardized data to enable a two-way exchange
of computable health information. These repositories are a part of the
modernized health information systems that the departments have been
developing--DoD's AHLTA and VA's HealtheVet.
---------------------------------------------------------------------------
DoD/VA Interagency Program Office Has Made Progress in Becoming
Operational, but Is Not Fully Functioning as a Single Point of
Accountability
As our report later this month will note, VA and DoD have taken
important steps to make the interagency program office operational.
However, more work is needed to solidify its leadership and management
capabilities if the office is to effectively function as a single point
of accountability for achieving interoperable electronic health data.
In particular, the departments have completed personnel
descriptions and recruited and hired staff for government positions and
obtained necessary contractor staff to perform the office's functions.
As of early July, the departments reported that they had selected staff
members for 10 of 14 government positions and that recruitment efforts
were underway to fill the remaining 4 positions by late September 2009.
Further, all of the 16 designated contractor positions had been filled.
Nonetheless, VA and DoD continue to fill the office's key
leadership positions--that of director and deputy director--on an
interim basis. To their credit, the departments have taken steps to
hire a full-time permanent director and a deputy director to lead the
office. Earlier this month, DoD selected a candidate for the director
position, VA concurred with the selection, and the candidate's
application was sent to the Office of Personnel Management for
approval. In the meantime, the departments requested and received an
extension of the interim director's appointment until September 30,
2009, or until a permanent official is hired. Further, as of late June,
interagency program officials stated that actions were underway to fill
the deputy director position and that VA was interviewing candidates
for this position. The interim director stated that the departments
anticipate making a selection for the deputy director position by the
end of this month.
Beyond the need to appoint these key permanent leaders, the office
needs to fulfill a number of responsibilities identified in its January
2009 charter that are critical to its effectiveness. To this end, the
office has taken several steps. For example, it submitted its first
annual report to Congress that summarized the departments' efforts
toward achieving full interoperability and the status of key activities
completed to set up the office. Further, the office developed 11
standard operating procedures in areas such as program management
oversight, strategic communications, and process improvement.
However, the office has not yet carried out other key
responsibilities identified in its charter that are fundamental to
effective IT program management and that would be essential to
effectively serving as the single point of accountability. For example,
the office has not yet established results-oriented (i.e., objective,
quantifiable, and measurable) goals and performance measures for all
six of the interoperability objectives discussed previously.
In particular, early development and use of results-oriented
metrics is an important IT program management activity. Performance
goals and measures, if effectively implemented, can provide a
meaningful baseline against which to measure the progress of a program
and the outcomes associated with its implementation. VA and DoD agreed
with our previous recommendation calling for the development of such
goals and measures.\10\ Further, the interagency program office charter
identified the development of metrics to monitor the departments'
performance against interoperability objectives as a responsibility of
the office. Nevertheless, the office has developed performance goals
for only one of the six identified interoperability objectives--the
expansion of DoD's medical records system (Essentris) to share
inpatient discharge summaries with VA. Department officials have stated
that results-oriented goals and measures for the other five
interoperability objectives will be included in the next version of the
DoD/VA Joint Executive Council Joint Strategic Plan, expected to be
completed by December 2009. To the extent that the departments
establish and effectively use results-oriented goals and measures for
their interoperability objectives, they will be better positioned to
gauge their progress toward achieving fully interoperable capabilities
and improving veterans' health care.
---------------------------------------------------------------------------
\10\ GAO, Electronic Health Records: DoD's and VA's Sharing of
Information Could Benefit from Improved Management, GAO-09-268
(Washington, D.C.: Jan. 28, 2009).
---------------------------------------------------------------------------
Further, development of an integrated master schedule is a key IT
program management activity, especially given the magnitude and
complexity of the departments' efforts to achieve full
interoperability. According to DoD guidance,\11\ an integrated master
schedule should identify detailed project tasks and the associated
start, completion, and interim milestone dates; resource needs; and
relationships (e.g., sequence and dependencies) between tasks.
---------------------------------------------------------------------------
\11\ DoD Integrated Master Plan and Integrated Master Schedule
Preparation and Use Guide, Version 0.9, October 21, 2005.
---------------------------------------------------------------------------
While the program office has begun to develop an integrated master
schedule as required by its charter, the current version does not
include the attributes of an effective schedule. For example, the
schedule included limited information--only the name of the objective
and a completion date of September 30, 2009--for three of the six
interoperability objectives (i.e., refine social history data, share
physical exam data, and expand questionnaires and self assessment
tools). The schedule did not include information on tasks to be
performed to meet the objectives, nor start dates, resource needs, or
relationships between tasks for any of the six objectives. Without a
complete and detailed integrated master schedule, the departments are
devoid of critical information that could be vital to their ability to
appropriately respond to project needs and guide project efforts.
Similarly, development of a project plan is an important activity
for IT program management. Industry best practices and IT program
management principles stress the importance of sound planning for any
project. Inherent in such planning is the development and use of a
project management plan that describes, among other things, the
project's scope, resource needs, and key milestones. The interagency
program office charter identified the need to develop a project plan
but, as of late June, the office had not yet done so. As we have noted
in our prior work,\12\ without a project plan, the departments lack a
key tool that could be used to guide their efforts in achieving full
interoperability.
---------------------------------------------------------------------------
\12\ 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).
---------------------------------------------------------------------------
In discussing these activities, the interagency program office's
interim director and former acting director cited three reasons for why
performance measurement, scheduling, and project planning
responsibilities had not been accomplished. First, they stated that
because it has taken longer than anticipated to hire staff, the office
has not been able to perform all of its responsibilities. Second, the
office's interim leadership and staff have focused their efforts on
providing interested parties (e.g., Federal agencies and military
organizations) with briefings, presentations, and status information on
activities the office is undertaking to achieve interoperability, in
addition to participating in efforts to develop a strategy for
implementation of the Virtual Lifetime Electronic Record, which the
President announced in April 2009. Finally, according to the officials,
the office waited until June to begin the process of developing
performance metrics so that it could do so in conjunction with the
departments' annual update to the Joint Strategic Plan that is
scheduled for completion in December 2009.
In the absence of sufficient metrics to monitor progress, a
complete integrated master schedule, and a project plan, the
interagency program office's ability to effectively provide oversight
and management, including meaningful reporting on the progress and
delivery of interoperable capabilities, is jeopardized. As importantly,
the absence of these critical management tools calls into question the
effectiveness of this office in functioning as the single point of
accountability for achieving full interoperability, and the
departments' overall success in meeting this goal.
VA and DoD Are Taking Steps To Meet Their Objectives, but Activities To
Meet Clinicians' Needs Are Expected To Remain After the
Deadline for Achieving Full Interoperability
VA and DoD continue to take steps toward achieving full
interoperability by September 30, 2009. In this regard, the departments
have achieved planned capabilities for three of the objectives--refine
social history data, share physical exam data, and demonstrate initial
network gateway operation. Specifically, with regard to these
objectives, the departments have accomplished the following
capabilities:
The sharing of viewable social history data captured in
DoD's electronic health record, thus providing VA with additional
clinical information on shared patients that clinicians could not
previously view. These data describe, for example, patients'
involvement in hazardous activities and tobacco and alcohol use.
The sharing of physical exam data, allowing VA to view
DoD's medical exam data through the BHIE interface, which supports the
physical exam process when a servicemember separates from active
military duty. VA clinicians are able to view outpatient treatment
records, pre- and post-deployment health assessments, and post-
deployment health reassessments.
The operation of secure network gateways to support
health information sharing between the departments, thus facilitating
future growth in data sharing. As of early July, the departments
reported that five network gateways were operational and that data
migration to two of the operational gateways had begun.\13\ The
departments believed these five gateways satisfy the intent of the
objective and will provide sufficient capacity to support health
information sharing between VA and DoD as of September 2009.
---------------------------------------------------------------------------
\13\ The five operational gateways are located in Dallas, Texas;
Reston, Virginia; Kansas City, Missouri; North Chicago, Illinois; and
Santa Clara, California.
For the remaining three objectives--expand questionnaires and self
assessment tools, expand Essentris in DoD, and demonstrate initial
document scanning--the departments have partially achieved planned
capabilities, with additional work needed to fully meet clinicians'
needs.
Specifically, for the objective to expand questionnaires and self
assessment tools, the departments intend to provide all periodic health
assessment data stored in the DoD electronic health record to VA in a
format that associates questions with responses. Health assessment data
is collected from two sources: questionnaires administered at military
treatment facilities and a DoD health assessment reporting tool that
enables patients to answer questions about their health upon entry into
the military. Questions relate to a wide range of personal health
information, such as dietary habits, physical exercise, and tobacco and
alcohol use. While the departments have established the capability for
VA to view questions and answers from the questionnaires collected by
DoD at military treatment facilities, they have not yet established the
additional capability for VA to view information from DoD's health
assessment reporting tool. Department officials stated that they intend
to provide this capability by September 2009.
However, the other two objectives--expand Essentris in DoD and
demonstrate initial document scanning--are expected to require
substantial additional work beyond September to meet clinicians' needs.
By September 30, DoD intends to expand its Essentris system to at least
one additional site for each military medical service and to increase
the percentage of inpatient discharge summaries that it shares
electronically with VA to 70 percent. According to the interim director
of the interagency program office, as of late June 2009, the
departments had expanded the system to two Army sites (but not yet to
an Air Force or Navy site) and were sharing 58 percent of inpatient
discharge summaries. The interim director stated that the departments
expect to share 70 percent of inpatient discharge summaries and expand
the system to an Air Force and a Navy site by the September deadline.
Nevertheless, the official added that to better meet clinicians' needs,
DoD will need to further expand the inpatient medical records system.
In this regard, the department has established a future goal of making
the inpatient system operational for 92 percent of DoD's inpatient beds
by September 2010.
The departments also expect to demonstrate an initial capability to
scan servicemembers' medical documents into the DoD electronic health
record and share the documents electronically with VA by September
2009. According to the program office interim director, the departments
were in the process of setting up an interagency test environment to
test the initial capability to query medical documents associated with
specific patients as of late June 2009. He stated that the departments
expect to begin user testing at up to nine sites by September 2009.
According to this official, these activities are expected to
demonstrate an initial document scanning capability. However, after
September 2009, the departments anticipate needing to perform
additional work to expand their initial document scanning capability
(e.g., completion of user testing and establishment of the scanning
capability at all DoD sites).
In conclusion, VA and DoD have continued to increase electronic
health information interoperability, and have taken steps to meet the
six objectives that they identified as necessary to achieve full
interoperability by September 30, 2009. However, for two of the six
interoperability objectives, the departments subsequently plan to
perform significant additional activities that are necessary to meet
clinicians' needs. Further, the departments' lack of progress in
establishing fundamental IT management capabilities that are the
specific responsibilities of the interagency program office contributes
to uncertainty about the extent to which they will achieve full
interoperability by the deadline. Although the departments have
generally made progress toward making the program office operational,
the absence of performance metrics, and a complete integrated master
schedule and a project plan, limits the office's ability to effectively
manage and provide meaningful progress reporting on the delivery of
interoperable capabilities that are deemed critical to improving the
quality of health care for our Nation's veterans.
To better improve the management of VA's and DoD's efforts to
achieve fully interoperable electronic health record systems, our draft
report recommends that the Secretaries of Defense and Veterans Affairs
emphasize the interagency program office's establishment of a project
plan and a complete and detailed integrated master schedule.
Mr. Chairman, this concludes my prepared statement. I would be
pleased to respond to any questions that you or other Members of the
Subcommittee may have.
Contact and Acknowledgments
If you have any questions on matters discussed in this testimony,
please contact Valerie C. Melvin, Director, Information Management and
Human Capital Issues, at (202) 512-6304 or [email protected]. Other
individuals who made key contributions to this testimony are Mark Bird,
Assistant Director; Rebecca Eyler; Michael Redfern; J. Michael Resser;
Kelly Shaw; Eric Trout; and Merry Woo.
Prepared Statement of Rear Admiral Gregory A. Timberlake, SHCE,
USN, Acting Director, U.S. Department of Defense/U.S.
Department of Veterans Affairs Interagency Program Office
INTRODUCTION
Chairman Mitchell and distinguished Members of the Committee, thank
you for the opportunity to discuss the role of the DoD/VA Interagency
Program Office (IPO) in the ongoing data-sharing activities of the
Department of Defense (DoD) and the Department of Veterans Affairs
(VA). Collaboration between the two Departments on information
technology issues has grown exponentially in recent years, enabling the
Departments to explore ways in which they may benefit jointly from
data-sharing innovations in the private sector, as well as helping to
foster bold new government-driven information-sharing capabilities,
like the development of a ``Virtual Lifetime Electronic Record'' (VLER)
for servicemembers and veterans. Working on behalf of the DoD/VA Joint
Executive Council, the IPO plays a key role in facilitating these
efforts, and in providing oversight of various data-sharing initiatives
between the Departments. In recent months, the IPO has been focused on
two central areas: (1) facilitating the efforts of the two Departments
to achieve full interoperability of their electronic health records by
September of this year, as defined by the VA and DoD clinicians that
rely on this data to treat patients, and (2) working with the
Departments to develop an effective governance and management model for
VLER. These two areas will be the focus of my testimony today.
IPO BACKGROUND
In April 2008, DoD and VA formed the ``DoD/VA Interagency Program
Office'' (IPO) in response to section 1635 of the National Defense
Authorization Act for fiscal year 2008, which required the creation of
an entity to serve as a single point of accountability for the rapid
development and implementation of electronic health record (EHR)
systems or capabilities between the Departments. Section 1635 further
mandated that full interoperability of personal health care information
between the DoD and VA be achieved by September 2009. Since its
inception, the IPO has worked diligently to achieve this mandate,
providing the Departments with reliable, effective management oversight
of potential risks involving the identification, coordination, and
review of information sharing requirements, and informing stakeholders
about the impact these processes may have on DoD/VA information sharing
progress.
The responsibility for developing requirements and executing
technical information technology solutions remains with the respective
DoD and VA organizations, using the Departments' established statutory
and regulatory processes for acquisition, funding, management control,
information assurance, and other execution actions. The differences
between the Departments in these areas can pose challenges to effective
collaboration on joint DoD/VA information sharing projects. In order to
overcome such challenges, the IPO has worked closely with the existing
leadership of the Joint Executive Council to provide focused assistance
and oversight to ensure the Departments achieve their goals. Our work
includes facilitating discussions between DoD and VA functional
business communities on areas such as supporting the definition of DoD/
VA data-sharing requirements, promoting effective synchronization of
DoD/VA schedules for the technical execution of joint data-sharing
initiatives, assisting in the coordination of funding considerations,
and assisting in obtaining the input and concurrence of stakeholders.
The nature of the IPO's work requires a professional staff that
possesses a wide scope of varied, but complementary, skills and
knowledge. The initial staff of the IPO consisted of an Acting Director
from the DoD, an Acting Deputy Director from the VA, and four military
personnel that were briefly detailed to the IPO as a final assignment
before retirement. In the early stages of the IPO's formal existence,
this small staff focused most of their energies on acquiring office
space and equipment, determining permanent staffing requirements and an
office governance structure, advertising for and recruiting permanent
staff, drafting the IPO charter, writing the first IPO report to
Congress, and setting in place procedures to gather information that
would enable the IPO to provide informed oversight of the
interoperability efforts of the two Departments.
The staffing model that the IPO developed consists of two Senior
Executive Service positions, fourteen DoD and VA civilian government
positions, and a small contingent of contracted employees (up to
sixteen). Filling these positions with the most highly qualified
personnel possible has been challenging and time-consuming, because all
of the government employees had to go through an extensive formal
hiring process. This process includes the development of detailed
position descriptions; advertising the positions on USA Jobs;
processing applications based on relevant knowledge, skills, and
abilities; selection of candidates for interviews; formal job offers;
and security clearance vetting. The hiring process was the same for all
job applicants regardless of whether the applicant was already a
Federal employee or was hired from the private sector. Approximately
half of the candidates that were selected came from the private sector;
the remaining candidates were already Federal employees, but not all of
them were executive branch Federal employees.
The hiring process is now nearing completion. The current status of
our staffing posture is as follows: Ten of the fourteen government
positions are now hired and on staff. This includes the Chief of Staff,
two Audit Analysts (DoD & VA), one Senior Program Analyst for Health
(DoD), a Configuration Management expert (VA), a Public Affairs
Specialist (DoD), a Budget Analyst (VA), a Portfolio Analyst (DoD), and
two Senior Financial Program Analysts (DoD & VA). In addition, three
civilian government positions have accepted job offers, but are not yet
on staff. These include a Senior Program Analyst for Benefits (DoD), a
Senior Program Analyst for Health (VA), and a Senior Management Analyst
(VA). The only position that remains unfilled is a Senior Program
Analyst for Benefits (VA). The IPO is currently evaluating candidates
for this position. The anticipated target date for filling this
position is late summer of this year.
Advertising for the Senior Executive Service (SES) Director
position closed on March 17, 2009. The SES screening board convened on
April 16, 2009, to rank the candidates and select those to be
interviewed. The process for selection is on-going.
The SES Deputy Director's position announcement closed April 17,
2009. Initial interviews have occurred, with additional interviews of
the top one or two candidates to follow. After a selection is made, the
candidate will be referred to DoD for concurrence. Upon concurrence
from DoD, a formal offer will be made, contingent on a security
background check. The anticipated start date for the new Deputy
Director is late summer 2009.
HEALTH DATA SHARING AND INTEROPERABILITY
The Departments began laying the foundation for interoperability in
2001, when the first patient health information was transferred
electronically from DoD to VA using the Federal Health Information
Exchange (FHIE). Since that time, both Departments have continued to
expand the types of information that is shared, as well as the manner
in which information is shared. By leveraging the prior accomplishments
of VA and DoD, the IPO and the Departments have been successful in
formulating a plan to achieve full interoperability for the provision
of clinical care by the September 2009 target date. This plan centers
on meeting the data-sharing requirements of treating clinicians in the
two Departments as defined by the DoD/VA Interagency Clinical
Informatics Board (ICIB).
From an early point in the planning process, the IPO and the
Departments agreed to turn to the ICIB to assist in the prioritization
of DoD/VA health data interoperability initiatives. The ICIB is an
organization comprised of clinicians from both DoD and VA. The Deputy
Assistant Secretary of Defense for Clinical and Program Policy and the
Chief Patient Care Services Officer, Veterans Health Administration,
serve as its lead functional proponents. Through the ICIB, we enabled
the clinical community to define the items that must be shared by
September 2009 in order to achieve full interoperability. Once the ICIB
identified and prioritized its needs for electronic data-sharing, their
recommendations were forwarded to the Health Executive Committee (HEC)
for review and approval. Upon approval by the HEC, the list of
priorities was handed off to requirements and definition teams, and
then to our information technology teams to develop applications and
tools to put them into operation.
Detailed information about the Departments' ongoing data-sharing
initiatives appears in the prepared testimony of Mr. Charles ``Chuck''
Campbell, Chief Information Officer, Military Health System (MHS) and
Mr. Roger Baker, VA Assistant Secretary for Information and Technology.
As a general overview, however, VA and DoD have continued to improve
upon the successes of existing data exchange initiatives like the
Federal Health Information Exchange (FIDE) and the Bidirectional Health
Information Exchange (BHIE), and have expanded the type of data that is
available through the Clinical Data Repository/Health Data Repository
(CHDR interface). To add further capability, new pilot programs such as
the BHIE Imaging Pilot have been developed. This pilot is now deployed
and operational at several major military and VA medical centers across
the country.
While much progress has been made toward our current
interoperability goals, some challenges still remain. The key
challenges include the following:
Developing, adopting, and maturing standards at the
national level to ensure efficient operational use.
Updating capabilities, systems, infrastructure, and
technology consistent with emerging standards.
Identifying and prioritizing information requirements for
sequential upgrade to new technologies and common services, as defined
by the business process owners and the functional community.
In addition to this list of challenges, the Departments must
continually work together to overcome difficulties created by different
acquisition and funding cycles, different contracting processes, and
differences in information assurance certification processes. The
Departments and the IPO continue to engage in collaborative efforts to
ensure that any impediment that may arise from these differences is
resolved in an efficient manner. In spite of these challenges, the IPO
and the two Departments are on track to achieve full interoperability
for the provision of clinical care by September 30, 2009, as defined by
the Interagency Clinical Informatics Board.
THE VIRTUAL LIFETIME ELECTRONIC RECORD:
THE VISION AND THE BROAD CONCEPTUAL CHALLENGES
On April 9, 2009, the President, along with Secretary Gates and
Secretary Shinseki, announced that DoD and VA have taken the first step
in creating a joint Virtual Lifetime Electronic Record (VLER).
President Obama pointed out the largest challenge that the two
Departments face in their continuing efforts to modernize their
electronic health and benefits records systems, declaring that ``there
is no comprehensive system in place that allows for a streamlined
transition of health care records between DoD and the VA.'' Creating
such a capability would mark a departure from data-sharing efforts in
the past, which have centered on developing an ever-proliferating array
of information-sharing programs that allow one Department to access
patient data captured in the electronic health record system of the
other Department. While this strategy has allowed DoD and VA to share
unprecedented amounts of patient health care data, the adoption of new
technologies can provide even more efficiencies in the collection,
retrieval, and use of patient health care data across the Departments.
Recognizing this, the President directed the two Departments to ``work
together to define and build a seamless system of integration with a
simple goal: When a member of the Armed Forces separates from the
military, he or she will no longer have to walk paperwork from a DoD
duty station to a local VA health center; their electronic records will
transition along with them and remain with them forever.'' These
activities will be carried out in coordination with the health IT
implementation going on nationwide and headed by the Department of
Health and Human Services.
In a press release that was issued shortly after the President's
speech, the White House highlighted the importance of creating a
comprehensive virtual lifetime electronic records capability between
DoD and VA, and noted some of the advantages that would likely result
from the establishment of a VLER: ``Access to electronic records is
essential to modern health care delivery and the paperless
administration of benefits. It provides a framework to ensure that all
health care providers have all the information they need to deliver
high-quality health care while reducing medical errors. The creation of
this joint Virtual Lifetime Electronic Record by the two organizations
would take the next leap to delivering seamless, high-quality care, and
serve as a model for the Nation.''
As the White House pointed out, the potential benefits of a VLER
are indeed monumental, but so is the effort required in order to plan,
create, and implement a VLER. This effort represents one of the largest
projects that any two Federal Departments have made in recent years,
and there are a number of challenges that must be overcome to achieve
the President's vision. To begin, new IT conceptual frameworks must be
established to provide a health and benefits data-sharing architecture
to which both Departments can connect their electronic records systems.
To date, discussions between the Departments have been focused on
leveraging a common services architecture framework to support
modernized tools and technologies on both sides.
In addition to the over-arching conceptual issues on the technical
side, the Departments must establish an effective governance model and
collaborative strategy for the VLER. Each Department has unique
processes for funding, management, and oversight for information
technology projects. These processes must be brought into alignment in
key areas in order for successful planning and development to occur on
the VLER initiative.
The IPO also plays an active role in efforts to reach inter-
Departmental consensus on broad technical requirements issues. Progress
is being made on the Departments' efforts to agree to use a nationally
recognized set of uniform and open standards for information exchange,
such as those being implemented by the Department of Health and Human
Services' Nationwide Health Information Network. This approach will
enable DoD and VA to create an architectural framework that is capable
of sharing electronic health data from both the private sector and the
government. Ultimately, such an information-sharing architecture may
serve as a model for national electronic records data sharing.
CONCLUSION
The IPO and the Departments are engaged in many efforts to ensure
that full interoperability for the provision of clinical care is
achieved by September of this year. We recognize that interoperability
does not have a discrete end point, as technologies and standards
continue to evolve. Our efforts in the future will continue to build
upon our past successes, allowing the Departments' to maintain their
standard of providing the highest quality care for our servicemembers,
veterans and their beneficiaries.
That future is beginning to come into focus as we make progress on
joint efforts to plan the Virtual Lifetime Electronic Record. Creating
and implementing the VLER will require an unprecedented amount of
effort, coordination, and interagency cooperation. The IPO is committed
to this work, and looks forward to continuing to facilitate the efforts
of the Departments on the VLER. When operational, the VLER will provide
our servicemembers, veterans, and service providers with the health and
benefits data they need, when and where they need it, thereby
ultimately improving the quality of both health care and benefits
services.
Thank you for the opportunity to address the Committee, and to
provide you with an update on the important work that we are doing to
advance electronic data-sharing between the DoD and VA. I look forward
to keeping you apprised of our progress toward our shared goal of
improving the quality of services for our servicemembers, veterans and
their families.
Prepared Statement of Mary Ann Rockey, Program Executive
Officer/Deputy Chief Information Officer (Acquisition),
Military Health System, U.S. Department of Defense
INTRODUCTION
Chairman Mitchell, Ranking Member Roe, and Members of this
distinguished Committee, thank you for the opportunity to discuss with
you the progress that is being made toward creating an interoperable
electronic health record (EHR) for the provision of clinical care
between the Department of Defense (DoD) and Department of Veterans
Affairs (VA).
Great strides forward have been made in electronic data sharing
between the Departments during the past few years. The Departments
currently experience a level of interoperability unsurpassed by other
health care delivery partners. This shared information supports the
delivery of high-quality health care and the administration of benefits
to our Nation's servicemembers and Veterans. The EHR interoperability
achieved by the Departments is a showcase and a precursor for U.S.
electronic health data sharing and interoperability initiatives such as
the Nationwide Health Information Network (NHIN). This network of
networks is being developed to provide a secure, nationwide,
interoperable health information infrastructure that will connect
providers, consumers, and others involved in supporting health and
health care. Like our DoD/VA sharing solutions, the NHIN will enable
health information to follow the patient, ensuring it is available for
clinical decision-making, and supporting appropriate use of health care
information beyond direct patient care.
The Departments are committed to evolving and expanding the
appropriate sharing of health information to enhance care delivery and
continuity of care for our patients. Efforts are underway to deliver
full interoperability, as defined by DoD and VA clinicians who rely on
data to treat patients, for the provision of clinical care by September
2009, and to provide expanded interoperability capabilities beyond
September 2009. As with any large information technology initiative,
the Departments have met and resolved challenges and will continue to
do so in the future.
Today, I will discuss our joint efforts, highlighting the level of
data sharing achieved through the data sharing solutions that form the
foundation for EHR interoperability.
OVERVIEW--ELECTRONIC DATA SHARING
DoD and VA began laying the foundation for interoperability in 2001
when our Departments first shared health care information
electronically. Since that time, we have enhanced and expanded the
types of information we share, as well as the ways in which we share;
created increased organizational transparency; and formed oversight and
governing bodies to ensure our sharing efforts progress at a pace
meeting or exceeding the needs and expectations of our stakeholders.
The foundation of current and future health care information
sharing includes data sharing initiatives that have enhanced continuity
of care for separated servicemembers and shared patients; enabled our
providers to view health care information originating in the other
Department's EHR; and alerted providers to the potential for severe
allergic reactions or drug interactions before an electronic
prescription was issued.
Continuity of Care for Separated Servicemembers (Potential VA
Patients). Since 2001, DoD has transferred electronic health
information on separated servicemembers to a jointly developed data
repository known as the Federal Health Information Exchange (FHIE). VA
providers and benefits specialists access the data in FHIE daily for
use in the delivery of health care and resolution of claims.
As of May 2009, DoD has transferred health information for over 4.8
million patients to the FHIE data repository. Of these 4.8 million
patients, approximately 3.3 million patients have presented to VA for
care, treatment, or claim determination. The amount of data available
to VA continues to grow as health information on recently separated
servicemembers is extracted and transferred to VA. Transfer of data to
VA is executed in a manner that is compliant with Health Insurance
Portability and Accountability Act (HIPAA) privacy regulations.
The transferred data includes: inpatient and outpatient laboratory
results and radiology reports; outpatient pharmacy data from military
treatment facilities (MTFs), retail network pharmacies, and DoD mail-
order pharmacy; allergy information; discharge summaries; admission,
disposition, and transfer information; consultation reports; standard
ambulatory data record information such as diagnostic codes, primary
care physician, treating physician; patient demographic information;
and Pre/Post-Deployment Health Assessment (PPDHA) and Post-Deployment
Health Reassessment (PDHRA) forms. As of May 2009, over 2.5 million
PPDHA and PDHRA forms on more than 1.0 million individuals have been
sent from DoD to VA.
DoD also transfers data to FHIE for VA patients treated in DoD
facilities under local sharing agreements, making that data accessible
to VA providers. As of May 2009, over 4 million cumulative patient
messages containing laboratory, radiology, pharmacy, and consult
information have been transmitted on VA patients treated in DoD
facilities.
Continuity of Care for Shared Patients. For shared patients being
treated by both DoD and VA, the Departments continue to use the
Bidirectional Health Information Exchange (BHIE) which enables real-
time bidirectional sharing of allergy information; outpatient pharmacy
data; demographic data; inpatient and outpatient laboratory results and
radiology reports; ambulatory encounters/clinical notes; procedures;
vital sign data; patient histories; questionnaires; and theater
clinical data including inpatient notes, outpatient encounters, and
ancillary clinical data, such as pharmacy data, allergies, laboratory
results, and radiology reports.
AHLTA, the DoD's EHR, serves as the enterprise foundation for
information interoperability with VA. Access to BHIE data is available
through AHLTA and through VistA, VA's EHR, for patients treated by both
Departments. As of May 2009, information on more than 3.3 million
shared patients, including over 117,980 theater patients, is available
through BHIE.
To increase the availability of clinical information on a shared
patient population, VA and DoD leveraged BHIE functionality to allow
bidirectional access to inpatient documentation from DoD's inpatient
documentation system. This capability is operational at some of DoD's
largest inpatient facilities, representing more than 55 percent of
total DoD inpatient beds. By the end of Fiscal Year (FY) 2010, this
capability will be operational for approximately 90 percent of total
DoD inpatient beds.
In addition to sharing viewable text data, VA and DoD are
leveraging the BHIE infrastructure to support the exchange of digital
radiology images to support continuity of care. The Departments will
continue to monitor and evaluate this capability.
For our most seriously wounded, ill, and injured servicemembers
transferring to VA Polytrauma Rehabilitation Centers (PRCs) for care,
the Departments continue to send radiology images and scanned medical
records electronically from three major DoD trauma centers at Walter
Reed Army Medical Center, Brooke Army Medical Center, and Bethesda
National Naval Medical Center to VA PRCs located in Tampa, Florida,
Richmond, Virginia, Minneapolis, Minnesota, and Palo Alto, California.
To date, scanned medical records for 230 patients and digital images
for 167 patients have been sent.
Computable Data for Shared Patients. In September 2006, the
Departments established interoperability between AHLTA's Clinical Data
Repository (CDR) and VA's Health Data Repository (HDR). The DoD/VA
Clinical Data Repository/Health Data Repository (CHDR) interface
enables the first exchange of interoperable and computable outpatient
pharmacy and medication allergy data between the Departments on
patients who receive care from both health care systems. DoD's
outpatient pharmacy data exchange includes information from MTF
pharmacies, retail pharmacies, and mail order pharmacies. This
functionality is available to all DoD facilities.
For patients with pharmacy and allergy data exchanged through CHDR,
DoD providers view a combined medication and allergy list without
having to access a separate application or making any changes to how
they typically view medication or allergy data within AHLTA. The
exchange of computable outpatient pharmacy and medication allergy data
enables drug-drug interaction checking and drug allergy checking using
data from both Departments. In FY 2008 alone, DoD providers were
presented with more than 19,600 Level 1 and Level 2 drug-drug alerts;
these are the most severe potential drug alerts provided to clinicians
for decision support. This capability significantly enhances patient
safety and quality of care.
Clinicians are actively using CHDR and we are currently exchanging
outpatient pharmacy and medication allergy data on more than 34,000
patients who receive health care from both DoD and VA. These patients
are referred to as Active Dual Consumers (ADCs). In September 2008, DoD
implemented a process to automatically identify patients being treated
in both Departments and began setting the ADC flag on approximately 50
patients per day. When the ADC flag is activated, medication and drug
allergy data is exchanged between the repositories. Subsequently, when
a new medication or drug allergy is recorded by a provider in either
Department, the new data is sent to the other Department's repository.
This capability is being implemented in a phased approach to enable the
Departments to monitor the impact on system performance and perform
capacity planning.
Virtual Lifetime Electronic Record. On April 9, 2009, the
President, along with Secretary Shinseki and Secretary Gates, announced
that VA and DoD have taken steps toward creating a joint Virtual
Lifetime Electronic Record (VLER). VA and DoD are working together on
an overall strategy to achieve the President's VLER vision and jointly
developing an effective governance model. The VLER will permit
information vital to health care, benefits, and services, to be
available seamlessly to both Departments from the moment a
servicemember enters into the military until the servicemember's or
Veteran's death. The testimony by the Acting Director of the
Interagency Program Office will address the Departments' collaborative
work on this important interagency effort.
It is important to note that the DoD EHR ``way ahead'' dovetails
with the plans being discussed for the virtual lifetime electronic
record, which will leverage the investments made in the Departments'
existing electronic record systems. DoD is making a number of
improvements to our EHR to enhance its performance, reliability, and
usability. Those improvements include an improved flexible graphical
user interface and architecture that uses a common services approach.
MEETING THE INTEROPERABILITY DEADLINE
The Departments expect to achieve by no later than September 30,
2009, electronic health record systems or capabilities that allow for
full interoperability of personal health care information between the
Department of Defense and the Department of Veterans Affairs to support
the provision of clinical care. The DoD/VA Interagency Clinical
Informatics Board (ICIB) has played a critical role in defining the
priorities for the Departments in meeting the September 2009
interoperability deadline and will guide our continued progress in
electronic data sharing after the initial interoperability goals are
achieved.
DoD Coordination with the Interagency Program Office. Achieving our
electronic data sharing goals requires increased agency transparency.
To increase DoD's organizational transparency, the DoD/VA Interagency
Program Office is involved in internal DoD and cross-organizational
DoD/VA meetings hosted by the Military Health System Office of the
Chief Information Officer (CIO) focused on DoD/VA electronic data
sharing initiatives. This level of involvement and access to DoD
information ensures the Interagency Program Office is able to provide
management oversight of potential risks involving the identification,
coordination, and execution of information sharing requirements.
Further, to ensure open lines of communication are maintained, I
have designated an Interagency Program Office liaison within the Office
of the CIO. This knowledgeable senior staff member has access to the
Department resources necessary to ensure the Interagency Program Office
receives timely responses to requests for information and assistance.
DoD/VA ICIB. To ensure clinically relevant information is shared
electronically between the Departments, the ICIB was formed. The ICIB
is an organization comprised of clinicians from both DoD and VA.
Through the ICIB, we enabled the clinical community to define the items
that must be shared by September 2009 in order to achieve full
interoperability. The Deputy Assistant Secretary of Defense for
Clinical and Program Policy and the Chief Patient Care Services
Officer, Veterans Health Administration, serve as the lead functional
proponents. The ICIB guides clinical priorities for what electronic
health care information the Departments should share next and reviews
planned clinical information system solutions for DoD/VA sharing to
ensure alignment to clinical sharing priorities as defined by the ICIB.
To support efforts to meet the September 2009 deadline, the ICIB
submitted clinical priorities to the Interagency Program Office and
DoD/VA Health Executive Council. For future years, the ICIB will
prioritize additional health related sharing requirements to
continually advance DoD/VA interoperability in a manner that supports
clinicians in health care delivery.
As the Departments work together to enhance data sharing by
September 2009 and to achieve the vision for the virtual lifetime
electronic record agreed to by the Secretaries, there will be key
interoperability challenges, including:
1. Developing and adopting standards at the national level and the
maturing of those standards for operational use;
2. Updating systems, infrastructure, and technology consistent
with emerging standards;
3. Identifying and prioritizing information sharing requirements;
and
4. Making the business process changes necessary to support
increased electronic data sharing.
The Departments and the Interagency Program Office will continue to
collaborate with the Department of Health and Human Services, and
others, on the development and adoption of the national standards
required to enable health information to follow the patient regardless
of the point of care. Our beneficiaries receive health care from the
private sector so the ability to exchange health information between
the public and private sectors is critical to both Departments. In
addition, fulfillment of our goal of the virtual lifetime electronic
record requires that it include complete administrative and medical
information from all points of care. We look forward to future
opportunities to present this Committee with our progress toward
increased health data sharing and interoperability.
CONCLUSION
Mr. Chairman and distinguished Members of the Committee, the
efforts of DoD and VA to share health care information have gained
undeniable momentum. We continue to build on this momentum, leveraging
our EHR and our solid foundation of electronic data sharing initiatives
as we move toward this September and the goal of full interoperability
for the provision of clinical care and beyond. Further, our EHR way
ahead will rapidly increase our data sharing capabilities with VA as
well as our private sector care delivery partners through both the
virtual lifetime electronic record and NHIN.
I value your insight, recommendations, and guidance. We are all
working toward the same end--to provide the highest quality care for
our Nation's heroes, past and present--and we must continue to work
together to achieve our goals as efficiently and effectively as
possible. Thank you again for the opportunity to discuss the
significant progress achieved toward DoD/VA interoperable electronic
health record.
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Prepared Statement of Hon. Roger W. Baker,
Assistant Secretary for Information and Technology,
Office of Information and Technology, U.S. Department of Veterans
Affairs
Mr. Chairman, thank you for the opportunity to update you on the
status of our efforts to exchange electronic medical information with
our partners at the Department of Defense (DoD). This Committee has
always been supportive of our efforts and I look forward to providing
you the information you need. Accompanying me today are Dr. Paul
Tibbits and Mr. Scott Cragg.
VA and DoD continue to work toward improving the exchange of
medical information to best serve our active duty servicemembers and
Veterans who come to us for medical care. Today, we are sharing more
information than ever before. Although our data exchanges are
unprecedented in the scope and amount of data we share, we realize
there is more work to be done and are taking the steps necessary to
meet our goals and comply with section 1635 of the National Defense
Authorization Act (NDAA). I will address some of our recent successes,
as well as some of the issues facing VA, as we work with DoD to expand
our access to shared electronic medical information.
I think you will agree that the current level of data sharing
between VA facilities and between VA and DoD facilities is without
equal anywhere else in the country. VA's award-winning electronic
medical record system, VistA, is recognized world-wide as a model for
integrated health information technology systems. Developed by VA from
a clinical perspective, VistA is successfully deployed and used by
administrative and clinical staff working in more than 1,200 VA medical
centers, clinics, and nursing homes across the country. VA hospitals
using VistA are one of only three hospital systems that have achieved
the qualifications for the Healthcare Information and Management
Systems Society (HIMSS) stage 7, the highest level of electronic health
record integration, while a non-VA hospital using VistA--the Midland
Memorial Hospital in Midland, TX--is one of only 42 U.S. hospitals that
have achieved HIMSS stage 6. VistA was awarded the prestigious
Innovations in American Government Award by Harvard University's Ash
Institute for its estimated annual efficiency improvement rate of 6
percent. One of the key modules facilitating VistA's information
availability,
My HealtheVet, is the recipient of numerous government and industry
accolades, including the CIO 100 award and first place in the 2009 TEPR
(Toward the Electronic Patient Record) personal health record
competition. Open-source versions of VistA are widely deployed in
private health systems, public hospitals, and medical offices in the
U.S. and overseas.
The NDAA mandates that both Departments achieve full
interoperability of electronic health record capabilities and systems
by September 2009. The NDAA also includes the requirement to establish
the DoD/VA Interagency Program Office (IPO), which today provides vital
coordinating linkages as envisioned by the NDAA legislation.
Information Interoperability Plan
The DoD/VA information interoperability plan (IIP) continues to
serve as our interoperability roadmap. The IIP describes the current
state of electronic data sharing between the Departments and identifies
the gaps that must be addressed to achieve the level of information
interoperability necessary to support the clinical and benefits needs
of our Veterans and members of the Armed Forces. The IIP provides the
strategic organizing framework for current and future work and
establishes the scope and milestones necessary to measure progress
toward intermediate and long term goals.
The IIP also emphasizes leveraging our existing data exchanges
through which we already share almost all essential health information
in viewable format. By September 2009 we will enhance the existing data
exchanges to share those additional types of information identified and
prioritized by the Interagency Clinical Information Board (ICIB). The
ICIB comprises clinicians from both DoD and VA. It is responsible for
identifying and prioritizing the types and format of electronic medical
information that needs to be shared by DoD and VA, to care for our
patients. This group ensures that our data sharing is focused on needs
identified and prioritized by clinicians for clinicians. Thus, we have
used our clinician community to define for us those high priority items
that must be shared by September 2009.
I will now discuss the specific types of data sharing occurring in
more detail.
Exchange of electronic medical information
VA and DoD are successfully sharing electronic medical information
on separated servicemembers and shared patients, who come to both VA
and DoD for care and benefits. Since 2001, the Federal Health
Information Exchange (FHIE) has accomplished the one-way transfer of
all clinically pertinent electronic information on more than 4.8
million separated individuals--approximately 3.3 million of these
individuals have come to VA for health care or benefits as Veterans. In
addition to FHIE, VA and DoD clinicians are using the Bidirectional
Health Information Exchange (BHIE) to view current medical data on
shared patients, including Veterans, active duty personnel, and their
dependents from every VA and DoD facility. Today, VA and DoD continue
to share bidirectional viewable outpatient pharmacy data, allergy
information, inpatient and outpatient laboratory results (including
chemistry, hematology, microbiology, surgical pathology, and cytology),
inpatient and outpatient radiology reports, ambulatory progress notes,
procedures, and problem lists.
Our most recent enhancements in bidirectional exchange added vital
sign data (including blood pressure, heart rate, respiratory rate,
temperature, height, weight, oxygen saturation, pain severity, and head
circumference) from all VA and DoD facilities, DoD Theater clinical
data (including inpatient notes, outpatient encounters, and ancillary
clinical data such as pharmacy data, allergies, laboratory results, and
radiology reports), and inpatient discharge summaries from DoD's
largest military treatment facilities, representing more than 55
percent of total DoD inpatient beds.
DoD and VA continue to improve our efficiency in transferring
digital radiological images and scanned inpatient information for every
patient being transferred from Walter Reed and Brooke Army Medical
Centers and Bethesda National Naval Medical Center, to one of our four
polytrauma centers in Richmond, Tampa, Palo Alto, and Minneapolis. Our
polytrauma doctors find this information invaluable for treating our
most seriously injured patients.
In addition to the viewable text and scanned information we receive
and share with DoD, VA and DoD are sharing computable allergy and
pharmacy information on patients who use both health care systems. The
benefit of sharing computable data is that each system can use
information from the other system to conduct automatic checks for drug
interactions and allergies. In VA, we have implemented this capability
at seven of our most active locations where patients simultaneously
receive care from both VA and DoD facilities. Once a patient is
``turned on'' with this capability, his or her pharmacy and allergy
information is computable enterprise-wide in DoD and VA and available
for this automatic clinical decision support.
Our social workers, transition patient advocates, and other
military liaison staff continue to successfully use the Veterans
Tracking Application (VTA) to improve the coordination of care for
patients transitioning from DoD to VA. VTA provides our staff with key
patient tracking and patient coordination information on a near real-
time basis.
Finally, VA and DoD are dedicated to ensuring that transitioning
servicemembers receive the benefits they have earned in a timely
manner. The information critical to the provision of benefits is
obtained through the One VA/DoD data sharing initiative, which
consolidates the transfer of data between DoD and VA and will
eventually eliminate the need for paper copies of DD-214s. The Defense
Enrollment Eligibility Reporting System (DEERS) supports that transfer,
and the VA Defense Information Repository (VADIR), serves as the secure
and authoritative database for a servicemember's demographic, personal
identity information, and military history. This longitudinal
electronic eligibility record can be used by all VA entities to
administer benefits and care for a transitioning servicemember.
Details of the DoD/VA Information Interoperability Plan (IIP)
The DoD/VA IIP provides a roadmap to guide our Departments'
information technology investment decisions and establish a shared
understanding of interoperability principles, practices, enablers, and
barriers.
The IIP is a living document whose ultimate purpose is to identify
and address the information needed by the Departments to improve
continuity of care and benefits administration for our Nation's
servicemembers, Veterans, and their beneficiaries. To that end, the
plan aligns our goals with 22 specific initiatives that make up the
pathway to information interoperability.
In addition to identifying those actions necessary to achieve
inter-Departmental interoperability, the IIP also identifies the
barriers to success that need to be overcome. These barriers include
concerns about data standardization and quality, information privacy
and confidentiality, the investment cost to implement the initiatives,
and the investment cost to upgrade legacy systems and infrastructure.
Interoperability by September 30, 2009
VA is working closely with our DoD partners to implement the
provisions of the NDAA requiring interoperability by September 2009.
Our main commitment is to ensure doctors and health care staff from
both Departments have the information they need from each other to
treat our common patients. This is not to say all electronic medical
data will be shared; only to emphasize that everything deemed essential
by our clinicians will be shared.
With respect to the September 2009 target, the ICIB plays a key
role by determining, from a clinical perspective, the categories and
priorities of clinical information that must be shared to most
effectively treat our beneficiaries and meet the NDAA requirements. The
ICIB recommends to the DoD/VA Health Executive Council (HEC) the types
and format of health information that is necessary to provide top
quality, effective care to shared patients, wounded warriors coming to
us for treatment and rehabilitation, and Veterans transitioning to VA
for care and benefits. The HEC approves or disapproves the ICIB
recommendations.
To attain the interoperability of electronic health record
capabilities and systems recommended by the ICIB by September 2009, the
HEC approved six ICIB recommendations. Working collaboratively with
DoD, three of these recommendations are already complete (share refined
social history data, expand sharing of questionnaires/self assessment
tools, and share information to support separation physical exams). A
fourth recommendation to establish trusted network gateways is well
underway. DoD and VA have approved implementing four enterprise
gateways and up to five Federal health care center (FHCC) gateways. The
focus of these gateways is to support VA/DoD general purpose health
data traffic (i.e., CHDR, LDSI, FHIE/BHIE, imaging). All four
enterprise gateways are operational, as is the FHCC gateway supporting
the Captain James A. Lovell FHCC (North Chicago).
A fifth recommendation, document scanning, is also well underway.
DoD has piloted the capability to scan paper documents and associate
them with a specific patient so that providers are aware that the
documents are available. Interagency testing of this pilot capability
is on schedule for September 2009. The sixth initiative focuses on
DoD's expansion of their inpatient electronic medical record system.
Under the purview of the Senior Oversight Committee (SOC) and in
conjunction with the ongoing efforts of the DoD/VA Joint Executive
Council (JEC), we are continuing our efforts to meet the immediate
needs of seriously injured servicemembers transitioning to VA as a
result of the current operations in theater settings. All transitioning
servicemembers will benefit from this work. Toward this end, VA and
DoD, working with the IPO, are continuing to define information and
technology requirements to support disability evaluation, assessment,
and documentation of traumatic brain injury and Post-traumatic stress
disorders, case management tools, and automated solutions for reserve
component records. Additionally, work continues on development of the
eBenefits portal that will support unified and secure Web access to
benefits and services that support wounded warriors. The SOC has been
instrumental in defining requirements and implementing acquisition
activities to support these key critical business needs.
Despite these accomplishments, we realize our work is not done and
continue to expand the types of electronic medical data we share. For
example, we are now sharing digital radiology images bidirectionally
beyond the initial test site in El Paso, Texas. This capability is now
available at several sites, including the Washington, DC, VA Medical
Center, Walter Reed Army Medical Center, and National Naval Medical
Center, where VA providers now use DoD radiology images to conduct
service disability rating examinations.
Another example of our ongoing efforts is the enhancement of our
ability to share computable health information. The capability enabling
the exchange of computable outpatient pharmacy and medication allergy
data for shared patients was made available to all DoD sites in
December 2007.
VA and DoD will enhance this capability by adding computable
laboratory (chemistry and hematology) results in the summer of 2010.
The Path to Information Interoperability in the Future
To date, VA and DoD information interoperability successes have
focused on developing a suite of applications that facilitate
exchanging patient information between the two Department's individual
electronic medical record systems. However, on April 9, 2009, the
President, along with Secretary Shinseki and Secretary Gates, announced
that VA and DoD have taken steps toward creating a joint Virtual
Lifetime Electronic Record (VLER). The VLER will permit information
vital to health care, benefits, and services, to be available
seamlessly to both Departments from the moment a servicemember enters
into the military until the servicemember's or Veteran's death. The
potential benefits of the VLER are many and planning, creating, and
implementing the VLER will be a challenging endeavor. VA and DoD are
working together on an overall strategy to achieve the President's VLER
vision and jointly developing an effective governance model.
Concurrent with the VLER effort, VA continues to develop HealtheVet
as our foundational tool, to deliver top quality health care to our
patients and share important medical information with DoD and
eventually, other health care partners that treat our Veterans. VA
appreciates this Committee's past support of this project and its
continued funding, which is vital to our success.
In closing, I would like to thank you again for your continued
support and the opportunity to testify before this Subcommittee on the
important work we are undertaking to improve medical record sharing
between the VA and DoD. I would now like to address any questions you
might have.
Statement of Hon. Cliff Stearns,
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman.
Thank you for holding this very important hearing. As a
Representative from the State of Florida, which is home to the second
largest veterans population in the country, this is an issue I have
been particularly concerned about, and I am glad to be here this
morning to receive the latest updates from the VA and DoD on their
efforts to achieve full interoperability of their electronic health
records.
September 30, 2009, as we all know, is the deadline set for VA and
DoD to achieve interoperability of personal health care information.
Achieving this interoperability is essential to ensuring our returning
servicemen and women receive the care they need and the seamless
transition they deserve.
Many of my own constituents have had to suffer through the frenetic
and often frustrating transition from DoD to VA, and I commend the
progress that has been made thus far to achieve interoperability.
However, we are just three short months away and we are not at a point
where all electronic health information is being shared, and it appears
that we won't have full and complete interoperability by the September
30th deadline.
One important component of achieving interoperability is the
ability of DoD to scan medical documents of servicemembers into its
Electronic Health Record (EHR) and then share these important documents
electronically with the VA. This document scanning and sharing
initiative is reported to be ``on schedule'' and I sincerely hope this
component of interoperability is deliverable by the deadline.
Additionally, I am concerned about reports of incomplete staffing
at the Interagency Program Office for key information technology
management positions and the management challenges reported by the GAO.
Any potential problems must be identified and addressed immediately.
Our veterans have waited long enough, we can't afford significant
delays--our veterans' quality of life depends upon it.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigation
Washington, DC.
August 12, 2009
Honorable Gene L. Dodaro
Acting Comptroller General
U.S. Government Accountability Office
441 G Street, NW
Washington, DC 20548
Dear Comptroller General Dodaro:
Thank you for the testimony of Valerie C. Melvin, Director of
Information Management and Human Capital Issues, U.S. Government
Accountability Office at the U.S. House of Representatives Committee on
Veterans' Affairs Subcommittee on Oversight and Investigations hearing
that took place on July 14, 2009 on ``Examining the Progress of
Electronic Health Record Interoperability Between the U.S. Department
of Veterans Affairs and U.S. Department of Defense.''
Please provide answers to the following questions by COB on
Wednesday, September 16, 2009 to Todd Chambers, Legislative Assistant
to the Subcommittee on Oversight and Investigations.
1. How would the GAO grade the efforts of both the Department of
Defense (DoD) and the Department of Veterans Affairs (VA) on their
efforts toward interoperability of systems?
2. VA and DoD have been meeting for decades on interoperability
and resource sharing. The law permitting them to address this issue
goes as far back as 1982. Why are we just now seeing a description of
VA and DoD interoperability objectives? Is this a technology or a
bureaucratic cultural issue?
3. In your testimony, you state the progress is being made, but do
you feel that under the circumstances, IPO, VA and DoD are maximizing
their time and effort in moving forward as expeditiously as possible?
If not, how do you propose they make changes to fulfill the intent of
the NDAA and maximize production?
4. What plans do DoD and VA have for continuity as key leadership
positions are permanently filled? What challenges to do you foresee?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers. If you have any
questions concerning these questions, please contact Subcommittee on
Oversight and Investigations Majority Staff Director, Martin Herbert,
at (202) 225-3569 or the Subcommittee Minority Staff Director, Arthur
Wu, at (202) 225-3527.
Sincerely,
Harry E. Mitchell
Chairman
David P. Roe
Ranking Republican
Member
MH/tc
__________
U.S. Government Accountability Office
Washington, DC.
October 13, 2009
The Honorable Harry Mitchell
Chairman
Subcommittee on Oversight and
Investigations
House Veterans' Affairs Committee
335 Cannon House Office Building
Washington, D.C. 20515
The Honorable David Roe
Ranking Member
Subcommittee on
Oversight and
Investigations
House Veterans' Affairs
Committee
335 Cannon House Office
Building
Washington, D.C. 20515
Subject: Program Office Improvements Needed to Strengthen Management of
VA and DoD Efforts to Achieve Fully Interoperable Electronic
Health Records: Responses to Post-Hearing Questions
This letter responds to your August 12, 2009, request that we
answer questions relating to our testimony on July 14, 2009.\1\ During
that hearing, we discussed the Departments of Veterans Affairs' (VA)
and Defense's (DoD) interagency program office and efforts toward
achieving fully interoperable electronic health record capabilities.
Your questions, along with our responses, follow.
---------------------------------------------------------------------------
\1\ GAO, Electronic Health Records: Program Office Improvements
Needed to Strengthen Management of VA and DoD Efforts to Achieve Full
Interoperability, GAO-09-895T (Washington, D.C.: July 14, 2009).
---------------------------------------------------------------------------
1. How would the GAO grade the efforts of both the Department of
Defense (DoD) and the Department of Veterans Affairs (VA) on
their efforts toward interoperability of systems?
Based on their accomplishments as of late July 2009,\2\ we would
grade the departments' efforts toward achieving fully interoperable
electronic health record systems as incomplete. As noted in the
testimony, DoD and VA identified six objectives for achieving full
interoperability in compliance with applicable standards by September
30, 2009. When we last reported on their efforts in late July, the
departments had achieved planned capabilities for three of the
objectives--refine social history data, share physical exam data, and
demonstrate initial network gateway operation. For the remaining three
objectives, the departments had partially achieved planned
capabilities, with additional work needed to fully meet the objectives.
Regarding an objective to expand questionnaires and self-assessment
tools to provide VA all periodic health assessment data stored in DoD's
electronic health record, department officials stated that they
intended to complete the additional work by September 2009. The
officials stated that they also intended to meet objectives to expand
DoD's inpatient medical records system for each military medical
service and to demonstrate an initial capability to scan
servicemembers' medical documents; however, they noted that additional
work related to these objectives would be required beyond September to
achieve the fully interoperable capabilities necessary to meet
clinicians' needs for health information.
---------------------------------------------------------------------------
\2\ GAO, Electronic Health Records: DoD and VA Efforts to Achieve
Full Interoperability Are Ongoing; Program Office Management Needs
Improvement, GAO-09-775 (Washington, D.C.: July 28, 2009).
---------------------------------------------------------------------------
Further, we reported in late July that the DoD/VA Interagency
Program Office had not yet been effectively positioned to serve as the
single point of accountability for the implementation of fully
interoperable electronic health records. While the departments had made
progress in setting up the office by recruiting and hiring staff to
fill government and contractor positions, they lacked full-time
permanent leadership for the office and had not fulfilled key
information technology management responsibilities in the areas of
performance measurement, project planning, and scheduling. Thus, the
office was limited in its ability to effectively manage and provide
meaningful progress reporting on the delivery of interoperable
capabilities that are intended to improve the quality of health care
provided to our Nation's veterans.
2. VA and DoD have been meeting for decades on interoperability and
resource sharing. The law permitting them to address this issue
goes as far back as 1982. Why are we just now seeing a
description of VA and DoD interoperability objectives? Is this
a technology or a bureaucratic cultural issue?
While VA and DoD have been working to exchange patient health
information electronically since 1998, the departments undertook key
steps to define their interoperability objectives only within the last
2 years. Specifically, it was not until December 2007 that the
departments established the Interagency Clinical Informatics Board \3\
(made up of senior clinical leaders from both departments who represent
the user community) to be responsible for determining clinical
priorities for electronic data sharing between VA and DoD. The
departments included the six interoperability objectives identified by
the board in the September 2008 DoD/VA Information Interoperability
Plan (Version 1.0), which was developed to address the requirements for
interoperable electronic health records set forth in the National
Defense Authorization Act for Fiscal Year 2008 (NDAA). The departments
produced a draft of the plan in March 2008, completed their reviews of
the plan approximately 6 months later, and issued the plan in September
2008.
---------------------------------------------------------------------------
\3\ This board was originally named the Joint Clinical Information
Board.
---------------------------------------------------------------------------
Our reviews of VA's and DoD's efforts to electronically share
health data have generally identified managerial, rather than
technical, deficiencies as a key factor hindering the departments'
progress toward achieving interoperability. For example, in reporting
on the departments' initial efforts to ``share clinical information via
a comprehensive, lifelong medical record'' in 2001, we noted that
accountability for the initiative \4\ was blurred across several
management entities, and that basic principles of sound information
technology (IT) project planning, development, and oversight had not
been followed, creating barriers to progress. In June 2004, we reported
that the two departments lacked an established project management
structure and a lead entity with final decision-making authority to
guide the investment in and implementation of this capability, and a
project management plan that defined the technical and managerial
processes necessary to satisfy project requirements.\5\ Also, in June
2006, we noted that although VA and DoD had developed an interagency
project management plan, this plan had not specified the authority and
responsibility of organizational units for particular tasks, and the
work breakdown structure was at a high level and lacked detail on
specific tasks and time frames.\6\ Further, with regard to their more
recent efforts to meet the NDAA's requirement for full
interoperability, we reported in July 2008 that the departments lacked
a fully established program office and a finalized implementation plan
with milestones for setting up the office and for carrying out
activities, such as validating and establishing requirements for
interoperable health capabilities.\7\ In January 2009, we reported that
the departments had not established results-oriented (i.e., objective,
quantifiable, and measurable) performance goals and measures to be used
as a basis for reporting interoperability progress.\8\ In July of this
year, we noted that the departments' lack of progress in establishing
fundamental IT management capabilities that are specific
responsibilities of the interagency program office had contributed to
uncertainty about the extent to which the departments would progress
toward achieving full interoperability.\9\ We recommended actions to
address these deficiencies and improve the departments' efforts to
electronically share health data.
---------------------------------------------------------------------------
\4\ This initiative was called the Government Computer-Based
Patient Record. See GAO, 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).
\5\ 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).
\6\ GAO, Information Technology: VA and DoD Face Challenges in
Completing Key Efforts, GAO-06-905T (Washington, D.C.: June 22, 2006).
\7\ GAO, Electronic Health Records: DoD and VA Have Increased Their
Sharing of Health Information, but More Work Remains, GAO-08-954
(Washington, D.C.: July 28, 2008).
\8\ GAO, Electronic Health Records: DoD's and VA's Sharing of
Information Could Benefit from Improved Management, GAO-09-268
(Washington, D.C.: January 28, 2009).
\9\ GAO-09-775.
---------------------------------------------------------------------------
3. In your testimony, you state that progress is being made, but do
you feel that under the circumstances, IPO, VA, and DoD are
maximizing their time and effort in moving forward as
expeditiously as possible? If not, how do you propose they make
changes to fulfill the intent of the NDAA and maximize
production?
Our studies suggest that neither VA and DoD, nor the interagency
program office have effectively maximized their time and effort to
expeditiously achieve interoperable electronic health records. Although
we have noted progress in the departments' sharing of patient health
data, we have also pointed out their need to address important
weaknesses in their data sharing efforts. This need is highlighted in
the history of management weaknesses (previously discussed) that have
persisted since our earliest reporting on the departments' efforts in
2001.
The reports that we have issued in response to the NDAA have
included recommendations to VA and DoD that are relevant to fulfilling
the intent of the act. For example, in our reports since July 2008, we
have recommended that the departments expedite efforts to put in place
permanent leadership, staff, and facilities for the interagency program
office. We have also recommended that they develop results-oriented
goals and associated performance measures for their interoperability
objectives, document these goals and measures in the department's
interoperability plans, and use the goals and measures as the basis for
future assessments and reporting of interoperability progress.
Similarly, we have recommended that the departments direct the
interagency program office to establish a project plan and a complete
and detailed integrated master schedule to guide their efforts to
achieve fully interoperable electronic health record systems. In the
absence of these important mechanisms, VA, DoD, and the interagency
program office are limited in their ability to effectively manage and
successfully deliver the intended interoperable capabilities.
4. What plans do DoD and VA have for continuity as key leadership
positions are permanently filled? What challenges do you
foresee?
At the time of our studies, VA and DoD planned to have acting
officials serve in key leadership positions (i.e., as director and
deputy director) until permanent officials could be hired. In this
regard, the departments had taken action toward hiring a full-time
permanent director and a deputy director to lead the office. However,
our July testimony and report noted that these positions continued to
be filled on an interim basis.\10\ As of early July, DoD had selected a
candidate for the director position, VA had concurred with the
selection, and the candidate's application had been sent to the Office
of Personnel Management for approval. In the meantime, the departments
requested and received an extension of the current acting director's
appointment until September 30, 2009, or until a permanent official was
hired. Additionally, the acting director had stated that the
departments anticipated making a selection for the deputy director
position. As we have previously noted, until the departments appoint
these key permanent leaders, the interagency program office will be
challenged to fulfill all of the responsibilities that are fundamental
to effective program management and that are essential to effectively
serving as the single point of accountability for achieving fully
interoperable capabilities.
---------------------------------------------------------------------------
\10\ GAO-09-895T and GAO-09-775.
__________
In responding to these questions, we relied on previously reported
information that was compiled in support of our July 14, 2009,
testimony and our July 28, 2009, report. Our work in support of those
products was performed in accordance with generally accepted government
auditing standards. Should you or your staffs have any questions on
matters discussed in this letter, please contact me at (202) 512-6304
or [email protected].
Valerie C. Melvin
Director, Information Management and Human Capital Issues
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigation
Washington, DC.
August 31, 2009
Honorable Robert M. Gates
Secretary of Defense
U.S. Department of Defense
1000 Defense Pentagon
Washington, D.C. 20301
Dear Secretary Gates:
Thank you for the testimony of Rear Admiral Gregory Timberlake,
SCHE, USN, Acting Director of the Interagency Program Office and Mary
Ann Rockey, Deputy Chief Information Officer, Military Health System,
U.S. Department of Defense at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Oversight and
Investigations hearing that took place on July 14, 2009 on ``Examining
the Progress of Electronic Health Record Interoperability Between the
U.S. Department of Veterans Affairs and U.S. Department of Defense.''
Please provide answers to the following questions by COB on
Tuesday, October 29, 2009 to Todd Chambers, Legislative Assistant to
the Subcommittee on Oversight and Investigations.
1. Who is the reporting authority for Admiral Timberlake? How long
has Admiral Timberlake been Acting Director of the IPO program?
2. When was the IPO charter finally approved by the Department of
Defense?
3. Should the Great Lakes Naval/North Chicago VA joint venture,
scheduled for opening in 2010 be considered the poster child for VA/DoD
interoperability?
4. Though only 10 out of 14 government positions have been filled,
how much have the 16 contractors cost the U.S. taxpayers? Since there
is no meaningful baseline to measure performance, how can you tell
whether the contractors are adding any value to the IPO?
5. What are DoD's plans, including a schedule, for expanding the
capability for scanning DoD documents into AHLTA?
6. What percentage of DoD's medical records is still in paper
format? What are the department's plans, including a schedule, for
transitioning medical records from paper to an electronic form?
7. What is the plan and timeline for DoD to expand Essentris to
100 percent of its sites and account for every inpatient bed in the DoD
system? What challenges does this create for clinicians and medical
providers between both DoD and VA medical systems?
8. Are we correct in surmising that the samples that the Committee
viewed during the hearing of different servicemembers' records were
selected from the many others in which may or may not be as complete or
be as interconnected? If so, what percentage of those who have been
separated from service in the last year had this degree of
interoperability and depth so that the physician from VA or DoD or
private sector, but especially VA, can access all that information
going back to when the injury may have occurred.
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers. If you have any
questions concerning these questions, please contact Subcommittee on
Oversight and Investigations Majority Staff Director, Martin Herbert,
at (202) 225-3569 or the Subcommittee Minority Staff Director, Arthur
Wu, at (202) 225-3527.
Sincerely,
Harry E. Mitchell
Chairman
David P. Roe
Ranking Republican
Member
MH/tc
__________
Questions for the Record
The Honorable Harry Mitchell, Chairman
Subcommittee on Oversight and Investigations
House Committee on Veterans' Affairs
July 14, 2009
Question #1: Who is the reporting authority for Admiral Timberlake?
How long has Admiral Timberlake been Acting Director of the IPO
program?
Answer: For purposes of executing the IPO mission, the IPO Director
is subject to the authority, direction and control of the Under
Secretary of Defense (Personnel and Readiness)(USD(P&R)) in the
USD(P&R)'s dual position as the Director, Defense Human Resources
Activity.
In performing IPO's oversight role, the IPO Director reports to the
Department of Veterans Affairs/Department of Defense Joint Executive
Council cochairs; namely, the USD(P&R) and Deputy Secretary of Veterans
Affairs.
Due to RADM Timberlake's active military status, his official
reporting chain follows Navy policy and includes the Chief of Naval
Operations.
RADM Timberlake's initial set of orders covered January 5, through
July 2, and the second set cover July 3, through August 29. We
anticipate orders will need to be extended through September 30.
Question #2: When was the IPO charter finally approved by the
Department of Defense?
Answer: The IPO charter was executed on January 16, by Deputy
Secretary of Veterans Affairs (VA), Gordon H. Mansfield, and Under
Secretary of Defense for Personnel and Readiness, Dr. David S. C. Chu.
On June 26, the VA/DoD Joint Executive Council directed IPO to revise
the statement of responsibilities and authority in its charter. A
revised and restated IPO charter is anticipated by September 30,
subject to review and approval by Deputy Secretary of VA, W. Scott
Gould, and Deputy Secretary of Defense, William J. Lynn III.
Question #3: Should the Great Lakes Naval/North Chicago VA joint
venture, scheduled for opening in 2010 be considered the poster child
for VA/DoD interoperability?
Answer: Member of Congress, VA, and DoD sought to address the need
to replace Naval Hospital Great Lakes (NHGL) and utilize excess patient
care capacity at nearby North Chicago Veterans Affairs Medical Center
(NCVAMC). In 2002, the decision was reached to create the first Federal
Health Care Center (FHCC), a fully integrated partnership between NHGL
and NCVAMC. Developing the first FHCC is a major initiative. A single
chain of command will manage inpatient and outpatient medical and
dental care at the new Captain James A. Lovell Federal Health Care
Center (JALFHCC); the new Federal ambulatory care clinic co-located on
the JALFHCC campus; DoD clinics at recruit and student training
centers; and VA Community-Based Outpatient Clinics. The Departments
expect to realize benefits in the simultaneous, non-duplicative
provision of accessible, high-quality health care for recruit, Active
Duty, dependent, retiree, and Veteran beneficiary populations.
JALFHCC has many unique business needs that require alternate
technology solutions. Future FHCCs also will have unique business
needs, which may or may not require development of alternate technology
solutions. For example, beneficiary population and catchment area,
local facility organizational structure, resources, funding, networks,
and specific Service requirements may all influence DoD/VA business
needs. Using a common services approach with service oriented
architecture establishes an environment in which functions can be
standardized and used across systems and processes, enabling the
Departments to develop common business and data services to utilize
across the DoD/VA continuum of care. Enterprise solutions developed for
JALFHCC will be exported to other joint ventures, whenever appropriate.
By October 2010, the Departments seek to achieve the following key
capabilities at JALFHCC:
building a single patient registration process that
unifies patient registration, so that registering a patient in either
system will begin the registration process in both systems;
creating a clinical single sign-on capability that
enables a clinical user to log securely into multiple clinical
applications with a single user name and password, and maintains the
patient context across applications;
developing the first phase of orders management/order
portability for:
laboratory
radiology
pharmacy and
consultations/referrals; and,
beginning the development of applications to support Navy
operational readiness requirements, such as mass rapid dental exams.
The Departments will also gather requirements and work flow data
for financial, quality, performance, and workload metrics processes,
and, explore cross agency outpatient appointment scheduling.
Question #4: Though only 10 out of 14 government positions have
been filled, how much have the 16 contractors cost the United States
taxpayers? Since there is no meaningful baseline to measure
performance, how can you tell whether the contractors are adding any
value to the Interagency Program Office (IPO)?
Answer: The IPO has filled 10 of 14 government positions with
personnel on staff. The status of the four remaining positions follows:
Senior Program Analyst--Benefits (DoD): Selection made;
anticipate security clearance process to be completed in August 2009;
anticipate report date to be September 28, 2009
Program Analyst (VA): Selection made; anticipate report
date to be August 20, 2009
Senior Program Analyst--Health (VA): Anticipate internal
and external advertisement to close by the end of Fiscal Year 2009
Senior Program Analyst--Benefits (VA): Anticipate
candidate selection by the end of Fiscal Year 2009
The work of the IPO spans a variety of skill sets and functional
areas, and relies on a team-like atmosphere to accomplish its mission.
Contractors provide critical support in each functional area.
Contractors at the IPO bring skill sets that augment work done by
government personnel. Skills provided by contractors at the IPO
include:
Subject Matter Expertise in Service Oriented Architecture
This contract support role has specific application to the VA/DoD
and Nationwide Health Information Network data sharing environments,
which have been described in documentation related to the Virtual
Lifetime Electronic Record (VLER). In this role, contractors at the IPO
provide experience and expertise that is scarce in both Departments.
The contractors also contribute to IPO with their understanding of
common services architecture, business users, client users, and use
cases, as applicable, in VA or DoD.
Quality Assurance and Risk Management
This role ensures an effective program operations management
process exists at the IPO. The purpose of such a process is to
adequately and quantitatively evaluate and identify risk. The
contractors also provide support to ensure that quality assurance
programs at the IPO are adequate. This is fundamental, foundational
work needed to build and implement standards specifications for VLER.
The work of this subject matter expert, coordinating with subject
matter experts from each Department, is critical.
Congressional Relations
The IPO is frequently asked to provide information about data
interoperability and the progress being made toward VLER. Contract
support staff in this role provide advice to IPO leadership and
government leads regarding audit and external oversight activities.
This position requires superior written and oral communications skills,
as well as knowledge of information technology and health program
delivery that contract staff is able to provide.
These positions, as well as other contract support at the IPO,
bridge gaps in existing resources to complete the IPO team quickly and
effectively. As of July 14, 2009, about $2.0 million has been spent on
16 contract support staff. The value of the contract for IPO contract
support is $4.9 million.
Question #5: What are DoD's plans, including a schedule, for
expanding the capability for scanning DoD documents into AHLTA?
Answer: The DoD Healthcare Artifact and Image Management Solution
(HAIMS) will enable DoD users to scan or import documents and
artifacts, associate those documents and artifacts with a patient's
record, and make them globally accessible to authorized DoD and
Department of Veterans Affairs users.
The initial evaluation of HAIMS, in a test environment, will be
completed by the end of September 2009. The first phase of HAIMS
implementation activities will begin at the end of Fiscal Year (FY)
2009 and will involve software systems integration testing and
deploying capabilities for limited user testing. Nine sites (three
Navy, three Army, and three Air Force) will be selected for limited
user testing, which is planned to run from December 2009 through March
2010. Based on the results of the limited user testing, enterprise-wide
deployment of HAIMS is anticipated to begin in FY 2010.
Question #6: What percentage of DoD's medical records is still in
paper format? What are the department's plans, including a schedule,
for transitioning medical records from paper to an electronic form?
Answer: In accordance with Strategy 3.5 of the VA/DoD Joint
Strategic Plan, signed January 2009, a Medical Records Working Group
(MRWG) has been established under the Benefits Executive Council. The
MRWG is involved in the systematic examination of all phases of the
Military paper service treatment record (STR) lifecycle management
process, with an emphasis on promptly providing accurate and complete
STR related information for all Servicemembers in all components and
veterans to DoD and VA designated benefits determination decision-
makers.
Analysis of the entire STR lifecycle conducted by the MRWG this
year generated more than 50 recommendations. Next steps include
implementing low cost/high impact recommendations and developing
business cases for other recommendations. Key recommendations included
interim means of eliminating costly and problematic paper-based
business processes associated with STR maintenance and transfer until
the Virtual Lifetime Electronic Record (VLER) is developed and
implemented. The interim solution must bridge the gap until VLER is in
place by leveraging existing records management system capabilities to
support the scanning of paper-generated documentation into a repository
that would either exist parallel to the AHLTA record or enable scanning
directly into the AHLTA record. DoD would then expand the use of its
Defense Personnel Records Information System to provide Veterans
Benefits Administration regional offices with ready access to this
medical documentation on a Servicemember.
It is important to consider, while DoD has achieved an increase in
the number of outpatient clinical encounters being documented in AHLTA
in recent years, some care continues to be documented on paper.
Additionally, even if today we capture 100 percent of data
electronically, for those personnel who were in the military prior to
full implementation of AHLTA, at least a portion of their records will
be paper-based. Further, at the time of a Servicemember's separation or
release from Active Duty, a hard copy of the STR (which includes the
outpatient medical record) must be sent to the VA Records Management
Center in St. Louis. This process involves manually printing any
encounters that were captured in AHLTA and reconciling them with the
hard copy outpatient medical records folder.
Question #7: What is the plan and timeline for DoD to expand
Essentris to 100 percent of its sites and account for every inpatient
bed in the DoD system? What challenges does this create for clinicians
and medical providers between both DoD and VA medical systems?
Answer: The DoD Military Health System continues to expand its use
of Essentris, an inpatient clinical documentation product. On March 26,
DoD awarded a contract for centrally funded implementation and
sustainment of Essentris to vendor, CliniComp International. DoD
anticipates that by the end of Fiscal Year 2009, DoD will be sharing
discharge summaries with VA from 24 Essentris sites which cover 59
percent of DoD's total inpatient beds. DoD plans to deploy Essentris to
cover more than 90 percent of its total inpatient beds by January 2011.
To realize the full value of Essentris, DoD and VA clinicians and
medical providers must be aware that information exists, must know how
to access it, and must actually access it. To facilitate access to
Essentris data, the DoD desktop icon through which DoD clinicians and
providers access the data has been relabeled to read VA information and
Theater information to be more intuitive.
Question #8: Are we correct in surmising that the samples that the
Committee viewed during the hearing of different servicemembers'
records were selected from the many others in which may or may not be
as complete or be as interconnected? If so, what percentage of those
who have been separated from service in the last year had this degree
of interoperability and depth so that the physician from VA or DoD or
private sector, but especially VA, can access all that information
going back to when the injury may have occurred.
Answer: VA has access to electronic health information on more than
4.8 million individuals. The earliest data, starting with ancillary
data, are from 1989. Since 2001, increasingly more data have been made
available electronically.
Not all prior Servicemembers will have Theater data available
electronically to VA. The ability for VA to access Theater data became
operational in October 2007. VA would not be able to access Theater
data on individuals in Theater prior to October 2007. Likewise, not all
former Servicemembers would have digital radiology images available to
VA at this time, since that capability is operational at a limited
number of pilot sites.
Additionally, VA and DoD are working to upgrade and enhance the
technical framework that supports data sharing and improve the
framework's capability to handle increasing amounts of shared data.
Contract awards for beginning these upgrades and enhancements are
expected in the next 2 months.
In general, VA has access to:
Since 2001, for separated Servicemembers, DoD has
provided VA with one-way historic information through the Federal
Health Information Exchange. On a monthly basis DoD sends laboratory
results; radiology reports; outpatient pharmacy data; allergy data;
discharge summaries; consult reports; admission, discharge, transfer
information; standard ambulatory data records; demographic data; pre-
and post-deployment health assessments; and post-deployment health
reassessments.
For shared patients being treated by both DoD and VA, DoD continues
to maintain the jointly developed Bidirectional Health Information
Exchange (BHIE) system, which was implemented in 2004. Using BHIE, DoD
and VA clinicians are able to access each other's health data in real-
time, including the following types of information: allergy; outpatient
pharmacy; inpatient and outpatient laboratory and radiology reports;
demographic data; diagnoses; vital signs; family history, social
history, other history; questionnaires; and Theater clinical data,
including inpatient notes, outpatient encounters, and ancillary
clinical data such as pharmacy data, allergies, laboratory results and
radiology reports.
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigation
Washington, DC.
August 12, 2009
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Shinseki:
Thank you for the testimony of the Honorable Roger W. Baker,
Assistant Secretary for Information Technology, U.S. Department of
Veterans Affairs, accompanied by Paul Tibbits, M.D., Deputy Chief
Information Officer, Office of Enterprise and Development, U.S.
Department of Veterans Affairs, Scott Cragg, Executive Director and
Program Manager, Virtual Lifetime Electronic Record Program, U.S.
Department of Veterans Affairs, Douglas E. Rosendale, DO, FACOS,
Enterprise System Manager for Joint Interoperability Ventures, Office
of Health Information, Veterans Health Administration, U.S. Department
of Veterans Affairs, and Ross D. Fletcher, M.D., Chief of Staff,
Washington, DC Veterans Affairs Medical Center, Veterans Health
Administration, U.S. Department of Veterans Affairs at the U.S. House
of Representatives Committee on Veterans' Affairs Subcommittee on
Oversight and Investigations hearing that took place on July 14, 2009
on ``Examining the Progress of Electronic Health Record
Interoperability Between the U.S. Department of Veterans Affairs and
U.S. Department of Defense.''
Please provide answers to the following questions by COB on
Wednesday, September 16, 2009 to Todd Chambers, Legislative Assistant
to the Subcommittee on Oversight and Investigations.
1. You stated that DoD and VA have come a long way in sharing
electronic medical records to serve our veterans, but please discuss
the challenges you see with fee-basis documents, test results, imaging,
etc. for our veterans that are referred out to civilian physicians. How
does this affect our Reserve/Guard forces, as well as our rural
veterans in need of medical care?
2. Please tell us how many patients get transferred to a
polytrauma center each year and what is the percentage of those
patients that are referred with their digital radiological images and
scanned inpatient information? Are any being transferred without these
electronic medical records at this point in time?
3. It is stated in testimony that the DoD and VA Information
Interoperability Plan (IIP) is a living document and that it has 22
initiatives that make up the pathway to information interoperability.
Would you define this document as fluid or certain? What challenges
exist with working on this ``living'' document? If the IIP is always
evolving, do you believe that you will ever reach a fully interoperable
state?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers. If you have any
questions concerning these questions, please contact Subcommittee on
Oversight and Investigations Majority Staff Director, Martin Herbert,
at (202) 225-3569 or the Subcommittee Minority Staff Director, Arthur
Wu, at (202) 225-3527.
Sincerely,
Harry E. Mitchell
Chairman
David P. Roe
Ranking Republican
Member
MH/tc
__________
Questions for the Record
The Honorable Harry Mitchell, Chairman
Subcommittee on Oversight and Investigations
House Committee on Veterans' Affairs
July 14, 2009
Examining the Progress of Electronic Health Record
Interoperability Between the U.S. Department of
Veterans Affairs and U.S. Department of Defense
Question 1: You stated that DoD and VA have come a long way in
sharing electronic medical records to serve our veterans, but please
discuss the challenges you see with fee-basis documents, test results,
imaging, etc. for our veterans that are referred out to civilian
physicians. How does this affect our Reserve/Guard forces, as well as
our rural veterans in need of medical care?
Response: Using the bidirectional health information exchange
(BHIE), the Department of Veterans Affairs (VA) and the Department of
Defense (DoD) currently share almost all pertinent clinical information
that is available electronically on shared patients. This includes
Veterans residing in rural areas since BHIE is available at every VA
medical center. Patient clinical test results, such as laboratory and
radiology reports, are included in this information and are available
in readable text format. Additionally, VA and DoD have made some
progress sharing images at select locations, and are working on the
capability to support image sharing enterprise-wide. Patients for whom
records are shared between VA and DoD include those Reserve and
National Guard forces who are serving on active duty and have military
health data available in DoD systems. It also includes those who are
fully separated or demobilized from service and who are referred to VA
for care or treatment.
With respect to sharing fee basis documents, test results and
images with private civilian clinicians, VA is working with DoD and
other civilian participants at a national level to develop the
Nationwide Health Information Network (NHIN) sponsored by the
Department of Health and Human Services (HHS). NHIN will leverage
recognized interoperability standards to support information sharing
among both government and private health care organizations. Within the
context of NHIN, VA and DoD will apply lessons learned from its data
sharing efforts to ensure that information is available to support
Veteran care where and when it is needed. The data sharing capabilities
using NHIN will be contingent on whether private sector providers
choose to use NHIN. When VA and DoD exchange data through NHIN it will
include all Veterans and servicemembers, including those in rural
areas.
Question 2: Please tell us how many patients get transferred to a
polytrauma center each year and what is the percentage of those
patients that are referred with their digital radiological images and
scanned inpatient information? Are any being transferred without these
electronic medical records at this point in time?
Response: On average, 100-125 active duty patients are referred
annually to a VA polytrauma rehabilitation center (PRC) from military
treatment facilities. From April 2008 to present, 103 active duty
patients were referred to a PRC from National Naval Medical Center
(NNMC), Walter Reed Army Medical Center (WRAMC) and Brooke Army Medical
Center (BAMC). All 97 of the patients referred from NNMC and WRAMC were
sent with both digital radiological images and scanned patient
information. The six patients referred from BAMC during this period
provided only digital radiological images (not scanned patient
information).
Additionally, for fiscal 2008 through June 30, 2009, 92 active duty
patients were referred to a PRC from other DoD military treatment
facilities and warrior transition units which are not yet sending
digital radiological images or scanned patient information.
Question 3: It is stated in testimony that the DoD and VA
Information Interoperability Plan (IIP) is a living document and that
it has 22 initiatives that make up the pathway to information
interoperability. Would you define this document as fluid or certain?
What challenges exist with working on this ``living'' document? If the
IIP is always evolving, do you believe that you will ever reach a fully
interoperable state?
Response: The information interoperability plan (IIP) is a fluid
living document intended to guide the interoperability efforts between
VA and DoD. The IIP does not represent ``funded'' or ``programmed''
projects but provides a necessary strategic blueprint VA and DoD can
work toward. VA and DoD define ``interoperability'' based on the
business needs to share information. For example, health data
interoperability is determined by the clinical priorities established
by VA and DoD clinicians on the Interagency Clinical Informatics Board
(ICIB). With respect to challenges, VA and DoD must work to achieve
interoperability while facing disparate funding cycles for information
technology development. The Departments are also faced with fulfilling
shared business requirements for information while simultaneously
meeting the unique mission needs of each organization (i.e., support
for DoD warriors and support for VA long term care facilities).
Additionally, achieving interoperability depends not only on technical
progress made by the Departments, but also on the availability of data
standards to support information exchange. The Departments must remain
aligned with national standards identification and development efforts
led by HHS while at the same time making progress to share data between
VA and DoD. To address challenges related to standards, VA and DoD
continue to participate on national standards development organizations
and have closely partnered with HHS and industry leaders for health
technology.
While the IIP evolves, so does the availability of data standards
and modern technologies that will continue to improve data sharing
between the Departments. In this regard, the Departments anticipate
that the level of interoperability will continue to evolve. The focus
of sharing information is on supporting the level of interoperability
that meets the information requirements identified by those who need
the information, such as clinicians treating Veterans and staff
adjudicating claims benefits. In this regard, VA and DoD believe the
goals of the IIP will be met.