[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
SHARING OF ELECTRONIC MEDICAL RECORDS
BETWEEN THE U.S. DEPARTMENT OF DEFENSE AND
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND
INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
MAY 8, 2007
__________
Serial No. 110-20
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio GINNY BROWN-WAITE, Florida,
TIMOTHY J. WALZ, Minnesota Ranking
CIRO D. RODRIGUEZ, Texas CLIFF STEARNS, Florida
BRIAN P. BILBRAY, California
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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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
__________
May 8, 2007
Page
Sharing of Electronic Medical Records Between the U.S. Department
of Defense and the U.S. Department of Veterans Affairs......... 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 34
Hon. Ginny Brown-Waite, Ranking Republican Member................ 2
Prepared statement of Congresswoman Brown-Waite.............. 34
Hon. Timothy J. Walz............................................. 3
Hon. Ciro D. Rodriguez........................................... 4
Hon. Cliff Stearns, prepared statement of........................ 35
WITNESSES
U.S. Government Accountability Office, Valerie C. Melvin,
Director, Human Capital and Management Information Systems
Issues......................................................... 4
Prepared statement of Ms. Melvin............................. 36
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D.,
FAAFP, Acting Principal Deputy Under Secretary for Health,
Veterans Health Administration................................. 15
Prepared statement of Dr. Cross.............................. 48
U.S. Department of Defense, Stephen L. Jones, DHA, Principal
Deputy Assistant Secretary of Defense (Health Affairs)......... 17
Prepared statement of Dr. Jones.............................. 54
SHARING OF ELECTRONIC MEDICAL RECORDS
BETWEEN THE U.S. DEPARTMENT OF DEFENSE
AND THE U.S. DEPARTMENT OF VETERANS AFFAIRS
----------
TUESDAY, MAY 8, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:03 a.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Space, Walz, Rodriguez,
Brown-Waite, Stearns, Bilbray.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Good morning and welcome to the Oversight and
Investigations Subcommittee for the Committee on Veterans'
Affairs. At this particular hearing we are dealing with sharing
electronic medical records between the U.S. Department of
Defense (DoD) and the U.S. Department of Veterans Affairs (VA).
This meeting will come to order. And let me just give my
opening statement and then I will ask Ms. Brown-Waite to give
hers.
One of the concerns I have heard from veterans is how
difficult the process can be in the transition from their
active duty status to veteran status. One of the great
difficulties they experience is having their full and complete
medical records from the Department of Defense available to
their VA doctors. This problem isn't new.
In 1998, President Clinton called on the VA and DoD to
develop a ``comprehensive, life-long medical record for each
servicemember.'' That was nearly 10 years ago. But up to this
point, progress has been painfully slow and increasingly
expensive. That is why we are having this hearing today, so
that this Subcommittee can continue its efforts to provide an
oversight and do what we can do to speed up the process and
make electronic medical records sharing a reality.
We all know that there are many benefits to this. First, we
will be making sure that veterans receive better medical care
by saving time and avoiding errors. And second, we will also
lower costs so taxpayer dollars are more wisely spent. That is
a worthy goal as well. I am glad to know that the VA and DoD
are working on some demonstration projects in this area and I
am eager to get an update on it.
I want to take a moment to acknowledge the VA and DoD's
progress in the long-term efforts to achieve a two-way
electronic data exchange capability. They have implemented
three or four earlier U.S. government Accountability Office
(GAO) recommendations, including developing an architecture for
the electronic interface between DoD clinical data repository
and VA's health data repository, selecting a lead entity with
final decisionmaking authority for the initiative and
establishing a project management structure. That is a good
start, but there is much more to do.
One of my greatest concerns is that the VA and DoD have not
yet developed a clearly defined project management plan that
provides a detailed description of the technical and managerial
process necessary to satisfy project requirements as the GAO
has repeatedly suggested in the past.
For example, all the way back to December 2004, the VA/DoD
Joint Executive Council annual report found that the cost for
government computer-based patient record Federal Health
Information Exchange (FHIE) was approximately $85 million
through fiscal year 2003. But here we are 4 years later, the
cost continuing to grow and the consequences for today are
growing too. We want to know why this isn't getting done and
how much longer our veterans have to wait. I believe they have
already waited too long.
I look forward to today's testimony and before I recognize
the Ranking Member for her remarks, I would like to swear in
our witnesses. Would all the people who are presenting, all
panelists please rise and be all sworn in at one time?
[All witnesses were sworn.]
[The prepared statement of Chairman Mitchell appears on p.
34.]
Mr. Mitchell. Thank you. I will now recognize Ms. Brown-
Waite for her opening remarks.
OPENING STATEMENT OF HON. GINNY BROWN-WAITE
Ms. Brown-Waite. Thank you, Mr. Chairman. This Committee
has held at least 16 hearings since 2002 to try to push the
sharing of critical medical information on patients being
transferred between the Department of Defense and the
Department of Veterans Affairs. The movement of this
information is vital to the safety and well-being of our
veterans and military active duty servicemembers as they
transfer between the two agencies and become finally integrated
back into civilian life.
Our staff and Members have visited many VA and DoD medical
centers. Of particular interest are the four VA polytrauma
units where servicemembers sustaining severely disabling
injuries to include traumatic head, traumatic brain injury,
rather, TBI, and spinal cord injuries are being cared for,
while still in service as well as many after discharge in VA
facilities.
We have frequently heard the concerns of VA doctors and
medical personnel at these facilities that the information they
are receiving isn't timely enough or missing critical data
necessary to properly treat these severely injured and disabled
servicemembers.
Throughout the past 20 years, the VA and DoD have spent
billions of dollars working on independently stove-piped
electronic medical record systems that would provide better
care to those serving on the frontline of our Nation's efforts
to freedom. Yet to date, neither seems to work together in a
coordinated effort of care.
On April 10th, 2007, an article appeared in the Washington
Post which touted the VA's VistA System as a means to lower
cost and provide better treatment to our Nation's veterans. Can
the VistA System receive information from the Department of
Defense?
We have also heard about the joint patient tracking system
which permits the transmission of patient care notes from the
battleground up the line to the patient's final destination,
whether for continued care at a VA facility or to prepare for
redeployment. However, in January, the Department of Defense
temporarily cut off access of this critical data to the VA.
Today we have sitting before us both departments. It is my
sincere hope that after two decades, that finally there is good
news on the horizon and we will see a system that will permit
the exchange of critical medical information that is
interoperable, bidirectional and occurs in real time. The care
for those who serve our country does not stop at the exit door
of the Department of Defense, but continues through the doors
of the VA. And the hand-off between the two medical systems
should be seamless, not a fumble. Our Nation's heroes deserve
no less.
Mr. Chairman, I yield back the balance of my time.
[The prepared statement of Congresswoman Brown-Waite
appears on p. 34.]
Mr. Mitchell. Thank you. Mr. Walz.
OPENING STATEMENT OF HON. TIMOTHY J. WALZ
Mr. Walz. Well, thank you, Mr. Chairman, and in the sake of
time, I will make this brief and submit my written opening
statement. But I wanted to thank the witnesses for coming
today. I thank each and every one of you for being here. Our
job up here and Congress' job is to provide oversight and we
share in the teamwork between what you are trying to do and
what we are trying to do, is to care for our veterans in the
best possible way.
So I thank you for that ahead of time. But as it was
stated, and I would associate my comments with the Ranking
Member, of the time that it has taken and the cost, and yet,
still not being at the point where we need to be. My concern
from this comes from--I represent the district that is home to
the Mayo Clinic--and I have had many, many conversations on
this issue of medical records and have been given some great
advice on this. And I want to hear today in what direction we
are moving and what are the lessons learned with the private
sector, because trust me on that, I know they are not
infallible too. And one of the complaints I hear from the VA is
sometimes it is more difficult to get records from the private
sector than it is from DoD. So that is a fact too.
We are here today to try and solve this problem, to try and
do whatever we can. As the Ranking Member said, we have been at
this for nearly two decades and 16 hearings. At some point, the
group that is in this room has to decide that maybe it is time
to move forward and maybe we can get some things done. So I
look forward to your testimony. I look forward to whatever we
can do to help assist you to get that done. We are in this
together. And the bottom line is, if we get this done, we will
get it done right, and all of our veterans benefit. And that is
a positive.
I yield back, Mr. Chairman.
[No statement was submitted.]
Mr. Mitchell. Thank you.
Mr. Bilbray.
Mr. Rodriguez.
OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ
Mr. Rodriguez. Let me just thank you, Mr. Chairman, for
holding this hearing. And I also want to emphasize the
importance of moving as quickly as we can and of doing a good
job in the process. I know that technology exists out there
that can actually check all those that are in the Department of
Defense and follow up and anticipate what is going to be needed
medically. We can be on top of it, especially for proposals in
terms of what is needed, in terms of resources to be able to
meet those gaps for those soldiers that will become veterans in
the future.
So we are ready to work with you. I do feel that because I
had spent 8 years on this Committee before. I was gone for 2
years. I am back and we are still not where we want to be. And
so, I would hope that we would move as quickly as possible on
some of the information.
I know that it also deals with the whole issue of the new
technology that is out there that we can make it happen, which
is the same area that we have had difficulty with the VA in
terms of using some of that technology and not coming to grips
with that in terms of those records of some of those soldiers.
And so, somehow, we need to come to grips with that and also
make sure that whatever information we do have, that it is
available, but that it is also secure and hopefully strike that
balance.
Thank you very much and I yield back the balance of my
time.
Mr. Mitchell. Thank you, Mr. Rodriguez.
We will now proceed to panel one. Ms. Valerie Melvin is the
Director of Human Capital and Management Information Systems
Issues for the U.S. government Accountability Office. She will
be accompanied by her Assistant Director, Ms. Barbara Oliver.
We look forward to hearing your unbiased view of this
situation. Thank you.
STATEMENT OF VALERIE C. MELVIN, DIRECTOR, HUMAN CAPITAL AND
MANAGEMENT INFORMATION SYSTEMS ISSUES,
U.S. GOVERNMENT ACCOUNTABILITY OFFICE; ACCOMPANIED BY BARBARA
OLIVER, ASSISTANT DIRECTOR, HUMAN CAPITAL AND MANAGEMENT
INFORMATION SYSTEMS ISSUES, U.S. GOVERNMENT ACCOUNTABILITY
OFFICE
Ms. Melvin. Thank you. Mr. Chairman and Members of the
Subcommittee, I am pleased to be here to discuss VA's and DoD's
efforts to share electronic medical records. Sharing medical
information can help ensure that active duty military personnel
and veterans receive high quality healthcare and assistance
with disability claims, goals that are more essential than ever
in the face of current demands on our military.
For almost a decade, VA and DoD have been pursuing ways to
share medical information. These includes efforts focused on
the long-term vision a single, comprehensive, lifelong medical
record for each servicemember to allow a seamless transition
between the departments, and more near-term efforts to meet
immediate needs to exchange health information. Since
undertaking these efforts, however, the departments have faced
considerable challenges leading to repeated changes in the
focus of and target dates of their initiatives, and in our
recommending greater project management and accountability.
Currently, each department is developing its own modern
health information system to replace existing systems and they
are now collaborating on the development of an interface to
enable these systems to have interoperable electronic medical
records. The modernized systems are based on using computable
data; that is, data in a format that a computer application can
act on, for example, to alert clinicians of a drug allergy or
of significant changes in vital signs such as blood pressure.
The departments have made some progress toward their long-
term objectives. They have begun implementing the first release
of an interface between their modernized data repositories. Now
at seven DoD sites, the interface allows the departments to
exchange computable outpatient pharmacy and drug allergy data.
Although the data being exchanged are limited, this interface
is an important milestone. Nonetheless, the departments still
need a project management plan that is sufficiently detailed to
effectively guide this effort and ensure its full
implementation as we have previously recommended and as you
have noted here today.
In parallel with their long-term objective, VA and DoD are
also pursuing short-term initiatives to share information in
their existing health information systems. One of these, the
laboratory data sharing interface project, has developed an
application that allows the departments to share medical
laboratory resources. This application is currently implemented
at nine sites. The other, the bidirectional health information
exchange, or BHIE, has developed an interface that provides a
two-way, almost instantaneous view of selected categories of
health data on shared patients from VA's existing systems, and
from those DoD sites where the interface is implemented.
Current BHIE capabilities are available throughout VA and
DoD plans to make these capabilities available throughout its
department by next month. Further, responding to a demand for
more access to health data, the departments have begun
expanding BHIE's capabilities and implementation, in effect
using the interface to connect not only VA and DoD, but also
DoD's multiple legacy systems which were not previously linked.
In this way, the depart-
ments plan to share more of their current information more quick
ly.
Beyond these two efforts, the departments have also
established various ad hoc processes to provide data on
severely wounded servicemembers to VA's polytrauma centers
which specialize in treating such patients. These processes
included manual work-around such as scanning paper records to
transfer records to incompatible systems. While particularly
significant to the treatment of servicemembers who sustain
traumatic injuries, such laborious processes are generally
feasible only because the number of polytrauma patients is
small.
Mr. Chairman, although the departments are sharing some
health information, including certain computable data, they
still face considerable work and challenges to achieve this
long-term goal. Their multiple initiates and ad hoc processes,
while significant, highlight the need for continued efforts to
integrate information systems and automatic information
exchange. However, it is not yet clear how all the initiatives
that VA and DoD have undertaken are to be incorporated into an
overall strategy focused on achieving the ultimate goal of a
comprehensive, seamless exchange of health information.
This concludes my prepared statement. I would be happy to
respond to any questions that you might have.
[The prepared statement of Ms. Melvin appears on p. 36.]
Mr. Mitchell. Thank you very much. Do you have any idea,
Ms. Melvin, why there has not been a clearly defined project
management plan? What do they tell you?
Ms. Melvin. Throughout our reviews over the years--and we
have been reviewing this since approximately 2001 in detail--
one of the concerns that we have noted, as you have said, is
the project management plan and what we learned is that VA and
DoD do, in fact, recognize the need for such project
management. However, the actions relative to actually putting
those plans in place and specifying in detail, the level of
detail, what is necessary is where they tend to fall short.
We have seen efforts on their part to, in fact, indicate or
develop project plans in some respects for some of the systems.
However, as they move forward, we don't see the detail that
would show how these plans would move beyond perhaps the
immediate systems that they are looking at, or certainly to
show how they would integrate future systems and how they would
then manage and ensure the outcomes of those initiatives.
Mr. Mitchell. Do they give you any reasons why they are not
doing what they should be doing? Do they say they don't have
money, they don't have staff? What are the reasons they give
you for not moving ahead and doing this? You know, this is a
long time coming.
Ms. Melvin. Yes. It is a long time project. In our
discussions with VA and DoD, there is continual recognition
that there is a need to move forward on these systems. We have
not gotten explanations from VA or DoD that suggest that they
don't feel that they can move forward. However, what we do not
see in the work that we have conducted has been the--I guess
the overall recognition of the specific requirements that it
would take to have the project planning in place for these
systems.
Mr. Mitchell. Do you think they are making any progress
toward this? And if they are--I don't want to hold these
hearings just to hear everybody talk and then we leave and
nothing happens. Is there some type of a time line or something
you might be able to suggest that we ought to have another
hearing say, 6 months from now or a year from now, or whatever
it may be, and ask what has happened? Do they not recognize the
importance of what you are suggesting?
Ms. Melvin. I believe they do recognize the importance.
However, through the work that we have conducted over the
years, one of the things that we found is that your continued
oversight has been critical to making sure that both
departments move forward on this effort. We don't see that the
departments don't have a common understanding of the goal that
they are trying to achieve. However, we do feel that they fall
short relative to the particular actions that they take
relative to planning for this initiative, the particular
strategies that they identify.
One of the key things in the work that we have noted is
that VA and DoD have--their systems development efforts toward
the modernized systems that they are trying to put in place are
initiatives that have always been on separate tracks. So it is
very critical for those departments to be able to develop the
type of collaboration, or have the type of collaboration that
will be geared toward making sure that the strategy that is put
in place identifies clearly and acknowledges the steps and the
timeframes that are necessary to get them to a shared type of
capability.
We have seen action on their part relative to the Clinical
Data Repository/Health Data Repository (CHDR) interface that
the departments are putting in place. However, as our work has
shown, we do still feel that there is a need for a more defined
time line or more specific risk management and certainly for
more performance-based measures to guide their efforts.
Mr. Mitchell. One last question on my part. As I noted in
my statement, President Clinton called for VA and DoD to
develop ``a comprehensive lifelong medical record for each
servicemember.'' Do you think that these two branches, the DoD
and VA, believe in this mission? Because I think that is what
we are all here trying to do. A lifelong medical record for
each servicemember that follows them through, that is what we
are trying to accomplish.
Do you think that they view this as one of their goals, one
of the things that they are trying to accomplish? And if so,
why are they taking so long? In the meantime, there are many,
many veterans and servicemembers who are falling through the
cracks because of the lack of a lifelong medical record that
follows each person.
Ms. Melvin. Each of these organizations certainly have had
its own objectives relative to creating its systems. We have
not heard anything from VA or DoD to suggest that they don't
believe in this mission. However, I think that there are
organizational cultures that do have to be overcome on the part
of VA and DoD relative to achieving the particular capability
that they desire as far as a lifelong medical record.
VA certainly has developed a comprehensive record that
includes inpatient and outpatient data. DoD's systems are set
up much different in the way that they currently exist. There
are a number of multiple systems that are not integrated in the
same capacity. So for each of these agencies to move forward,
there has to--first of all, the Department of Defense, for
example, has to deal with its own internal issues of how it
will manage and address the multiple systems that it has in
place. And then beyond that, both of these departments must
have a dedicated collaboration on how they will either develop
one common record or at least have systems that are
interoperable and can exchange data in the way that would be
needed to develop a seamless transition in the exchange of
records.
Mr. Mitchell. Thank you. It seems to me that they are
really more concerned about defending their own system instead
of the ultimate goal of taking care of these veterans.
Ms. Melvin. Organizational culture of each department must
be considered, yes.
Mr. Mitchell. Thank you.
Ms. Brown-Waite.
Ms. Brown-Waite. I thank the Chairman.
And I thank the witnesses for being here. You know, I think
this gives new meaning to Yogi Berra's ``this is deja vu all
over again.'' There is a report that was dated the first year I
came to Congress, and this is my fifth year here. And that
report is dated November of 2003.
It was also from the Subcommittee on Oversight and the
response from the DoD from your predecessor was that they were
still working on it. Then there was an Executive Order,
Executive Order 13410, which gave a deadline for implementation
of a joint system of January 1, 2007. This tells me that not
only are the agencies dragging their feet, they are ignoring
Congress, they are ignoring the President. And in the meantime,
people at the polytrauma unit down in Tampa and other
polytrauma units, the spinal cord injury units, those injured
warriors who are coming back are suffering.
The foot-dragging is inexcusable. It absolutely is. It is
like--it is deja vu all over again. Tell me why I shouldn't be
cynical that you are just giving Congress lip service and
ignoring an Executive Order.
Ms. Melvin. Through the work that we have conducted,
certainly one of the critical issues that we have emphasized
has been the repeated change in strategy, the repeated change
in milestones of the initials that VA and DoD have undertaken
to get their systems in place. I think that over the years,
because you do see the multiple changes, the multiple projects,
first of all, that have come into play, as well as the
strategies and the lack of clarity relative to how they plan to
get to the end results of the record, does in fact raise
skepticism in the minds of those who look at the actions being
taken on these systems.
Ms. Brown-Waite. Ma'am, let me point out that the title of
this is VA/DoD shared medical records, 20 years and waiting.
This report was November of 2003.
Ms. Melvin. Mm-hmm.
Ms. Brown-Waite. It was 20 years then. This is 2007. You
missed the deadline. Could we have from you a precise date when
these records are going to be easily transferable? Do you have
a date in mind? Do you have a contract out there? Is there a
system that is going to work? You know, this isn't rocket
science. Help me out here.
Ms. Melvin. I can't speak for DoD and VA. The work that GAO
has done does support the concerns that you raise about the
fact that these systems have been in play for a long time, that
the agencies are, in fact, pursuing a strategy or a series of
strategies that have been changed along the way, and that the
milestones accompanying those strategies have certainly changed
also.
We have not gotten specific reasons from VA and DoD to
suggest why, in fact, their strategies are different. We do
know, however, that again, each of these departments is working
on their separate systems and they are also working on multiple
systems in the short-term to address these initiatives, or at
least to address the immediate needs for data, which have to be
weighed against the overall long-term objective of a
comprehensive, lifelong medical record.
Ms. Brown-Waite. Is it your opinion that this will happen
in the next three years, 5 years, 1 year? You know, you have
looked at both systems, correct?
Ms. Melvin. We have not looked at DoD's system in detail.
We have only looked at DoD's system as it pertains to the
interface with VA systems. The majority of the work that we
have done has been for the Veterans' Affairs Committee
examining the VA system so far.
What I can tell you, though, in response to the early part
of your question about the timeframe, we don't feel positioned
to give you a timeframe for when VA and DoD can have this in
place. We have looked over the years at what they are doing to
develop these systems and we have seen multiple changes. And I
think by the very nature of the fact that we do not see an
integrated strategy or a defined project plan for the systems
at this point, we are not in a position to be able to say when
they would have these systems developed.
Ms. Brown-Waite. Thank you. I will ask that question of
others also in the future. Thank you.
Mr. Mitchell. Thank you.
Mr. Walz.
Mr. Walz. Well, thank you, Mr. Chairman.
And I too think that many of these questions will cut
between the two panels. But I do want to make it clear that in
my speaking with and having people come in and brief me,
specifically from the Mayo Clinic, I understand this was a
difficult prospect. I understand it is much more difficult than
a common software issue, that there are many things that have
to take place.
But I, too, share the concern of this Subcommittee that
this is a long time coming, especially when we have focused and
tried to put our emphasis on doing this. It is a very important
project. It is important for our veterans. It is important for
their care. But I think it is important also in that we can
prove that this can work on a scale that is large enough to get
the rest of the country moving in this direction.
But the one thing I want to make note of--and I am going to
ask a couple of specific questions. I am much more concerned
with quantifiable data, but I think this anecdotal evidence is
pretty telling.
I had the opportunity, about a month ago, to meet with a
high ranking General Officer in the Medical Corp of the Army
and had mentioned that that week I had just sat down for a 2-
hour briefing on electronic medical records. And this was again
with the Mayo Clinic and their top experts on this. They are
convinced that the VA has this figured out in a very, very good
way, and that it is very cost effective and it should be
adapted, that that is the starting point on this.
Now, I don't know that to be a fact and I didn't have
anything other than the two-hour briefing on this, but I
started to mention this to this officer and was cut short and
it became apparent that this person, without mentioning names
and they may be up here soon enough, had totally disregarded
anything that I had to share on that, that the official didn't
want to hear about that. And that made me very, very concerned.
And my civilian career before Congress was as a cultural
studies teacher. So I appreciate, Ms. Melvin, your bringing up
on cultural side of this, because this deeply concerns me.
A couple of questions for you. Obviously, we have to have
ad hoc solutions, in the short-term for the polytrauma centers.
Are those setting us back in the long-term goal of integration
here, in your opinion?
Ms. Melvin. The short-term initiatives are very critical to
helping the immediate needs of the servicemembers who are
severely wounded. So from the standpoint of setting us back, I
can't really say. What I do say, however, is that it is
important to examine what VA and DoD are doing relative to
implementing the short-term initiatives and how--what bearing
this does have on their plans and their strategies and
approaches for leading to the longer term goals.
What I would be concerned about seeing is the long-term
initiative of the comprehensive lifelong record being, for lack
of a better word, short-changed at the expense of immediate
needs. There is a need to balance on both of those areas. It is
important to serve the critical needs of the returning soldiers
now. At that same time, there needs to be continued effort,
continued dialog and collaboration relative to making sure that
they continue to move toward the longer term objective.
Mr. Walz. The last question I would have. Our job is
obviously oversight and guidance. We don't want to tell either
one of these agencies specifically how to do things. But in
your opinion, are we reaching a point on this where--I am
quoting outside experts on this, people who have no financial
gain in this, but have expertise, like the Mayo Clinic in this
record. Are we at the point now, in your opinion, where DoD
needs to start thinking about adapting the way the VA is doing
this? And is that where we need to give the guidance to start
moving in that direction? Would you be comfortable in saying
that that looks like it has the strongest possibility to get
this done?
Ms. Melvin. Because of the nature of the work, I wouldn't
say that it is definitely the way to go. But I would say,
however, that it is certainly an option that should be
considered by the agency as it proceeds with determining on how
it is going to integrate its systems, achieve the modernized
health system that it has been trying to develop, and work
toward the longer term goal with VA.
Mr. Walz. Thank you. I yield back.
Mr. Mitchell. Thank you.
Mr. Bilbray.
Mr. Bilbray. For the record, how long have we been working
on this project?
Ms. Melvin. How long have we been working on this project?
Mr. Bilbray. How long have the DoD and Veterans been
working at trying to have a consolidated record system?
Ms. Melvin. The start date that we have been using in our
work is 1998, and that was at the point in which the President
called for the comprehensive record. However, there were
efforts on the part of VA and DoD prior to that in the way of
developing modernized systems.
Mr. Bilbray. You know, my 18 years before coming to
Congress I was in local government and watched this type of
bureaucratic run around. Everybody wants to control their
record system and wants it to be their little possession
because it has traditionally been their possession. And to try
to break down the barriers of bureaucracy set-up is a major
challenge.
And, you know, when you are talking about--how long would
you predict it is going to take now to finally get the system
consolidated?
Ms. Melvin. How long would I predict that it is----
Mr. Bilbray. Yeah.
Ms. Melvin [continuing]. Going to take? I really cannot----
Mr. Bilbray. Working at the present pace.
Ms. Melvin. VA and DoD have indicated that they would have
their modernized health systems developed by, I believe, 2012
and 2011, respectively. However, in the work that we have done,
we have seen delays in their efforts, at least in the efforts
of VA--I am sorry, DoD to get its modernized system and all of
its systems put together.
And also, VA and DoD, I believe, recently have indicated
that they have now changed those milestones and don't have a
specific date for when those systems would be completed.
Lacking that and lacking more specifics relative to the
strategy that they are actually taking, I am not sure that
anyone could say at this point how long it is going to take
them to get there. We certainly are not in a position to do so
at GAO.
Mr. Bilbray. Okay. Let me shift around now. Were you
including--seeing what technology you are looking at, there is
not that many Bilbrays running around America right now. But
Mr. Rodriguez would agree that there is a whole lot of
Rodriguezes and that right now working with just a number and a
name, the potential that hospitals in the private sector run
into of mixing names and numbers up and going to biometric
confirmation. Are they including the concept of biometric
confirmation in the recordkeeping capability?
Ms. Melvin. We have not gotten any information on that
concept in the work that we have done.
Mr. Bilbray. Okay. And in the private sector more and more
is really looking at this as not only being a recordkeeping,
but an absolute lifesaver in a critical time to be able to
identify somebody when they are unconscious and to make sure
that you are not triaging the wrong person for a procedure. And
what I am worried about is we will get all the way down this
line and then all of the sudden someone says oops, we didn't
consider the cutting edge.
You know, Mr. Chairman, I really would suggest that we take
a look at the fact that if we continue to go the way we are
going, we are all going to be retired and gone by the time
somebody goes the promise. I am not one for commissions. But I
would strongly believe that we are probably looking at needing
direct oversight, a taskmaster here. And if I would--let me
just say flat out.
I would say that a five-member commission not made up of
veterans, but made up of three members of high tech information
specialists, one member from military hospital capabilities and
another member from a civilian hospital capability so we can
sort of intermix. But not being the focus of just complaining
about the system, but bringing people in with the expertise to
drive the system toward cutting edge approaches to
recordkeeping rather than always the defensive.
And I just think what we are looking at is, we need a
taskmaster that we can empower with the ability to hang over
them and say we want to see this report in six months. We want
to have another report and we want to see this product ready to
go in 2 years and somebody hounding over them to where they
have one and one purpose only, and that is to make sure the
bureaucracy works.
I only throw this out with no research on it, but I just
think that when I am told that a responsibility that has been
dragged on this long does not have a foreseeable sunset, it
tells me that we need to modify our approach to it and be a
little more hands-on to it and I just think it is something
that we may want to discuss as a Subcommittee and talk to the
Ranking Member and the Chairman about getting somebody to look
over the shoulder of these guys every week to finally get them
moving in the right direction.
And with that good information and that cheery news, I will
yield back to my Chair.
Mr. Mitchell. Thank you. You know, it is one thing to be
concerned about a bureaucracy and the cost. But what we are
really dealing with here are people's lives and bureaucracies
can go on and on and waste lots of money. The very fact that we
have got people's lives involved here I think is very
important.
Mr. Bilbray. Mr. Chairman, would you yield just on that
point?
Mr. Mitchell. Yes.
Mr. Bilbray. I think too often the cost is an issue because
it costs money to do things and if you waste money, that is
money you can't use for other work. But you have got the
private sector, you got local governments that are looking at
the same crisis. They all--this happens in government and
business all over America. And I assure you that there is a
privacy issue here, but that applies in private and public
sector. This challenge is not unique and we ought to be looking
around at all the things that are being done by everyone else
and finding ways to get over the barriers of privacy, funding
and other related--and getting the job done. And right now, we
just don't see that happening and I yield back. Thank you.
Mr. Mitchell. Thank you.
Mr. Rodriguez.
Mr. Rodriguez. Thank you very much for the testimony. And I
had indicated to you that I had been 8 years on this Committee
before and then gone for two years and then came back and we
are still talking about the same thing. And I remember getting
up here in 1997 and we were talking about this.
Would it help--and I am just throwing this out--if we did a
pilot program and included just the Marines or maybe just the
Air Force where we got someone to basically get that data and
transfer it over after they become veterans? Would it help in
any way that maybe--or an external group did that, because you
seem not to indicate that they still need a lot of
communicating among themselves because I know that technology
is there.
I have seen the technology there that can even get
different languages to be able to put it together and come up
with one system. And I have seen where you can get a soldier,
and even with a thousand soldiers, and know exactly what you
are going to be needing in terms of the access to the
healthcare that is there.
And so can you provide me feedback on that, please?
Ms. Melvin. I think that VA and DoD have a lot of
initiatives underway and they have already accomplished a lot
relative to the actions that they have taken. VA has an
integrated system which I believe there are a lot of lessons
that can be learned from relative to how to put together a
comprehensive medical record.
These agencies have also engaged in a previous effort to--
that has resulted in the one-way transfer of data from DoD's
computerized system into VA's to give VA the capability to see
critical data elements related to patients. So I would hesitate
to say that a pilot project necessarily would be the answer,
but I would say that I believe it is very important that these
two departments borrow on the experiences that they have
already undertaken.
They have a--DoD in particular is engaged in a number of
short-term initiatives to provide critical health information
on servicemembers at this time. And I think coupled with what
VA has already accomplished in its way, there should be room
for very serious and very productive dialog on how to take the
lessons learned from what they have already accomplished and
what they have learned about their needs and capabilities and
to allow that to move them forward in deciding what strategy--
--
Mr. Rodriguez. But apparently the will has not been there.
So do you have any suggestions? There were suggestions that
maybe we have an external group come in and force them to do
that. Do you have any other recommendations?
Ms. Melvin. I think there is certainly room for continued
oversight and for holding VA and DoD accountable for making,
for coming to a point where they have a definite strategy on
this. I believe that there is certainly room for continued
oversight. Perhaps there is room for lessons learned from other
bodies, private entities that have been involved in looking at
the development of electronic medical records. But again, I
would stress that these agencies have a wealth of information,
or should have a wealth of information.
I believe, though, that they have to held accountable for--
--
Mr. Rodriguez. But you don't----
Ms. Melvin [continuing]. Deciding how to move forward----
Mr. Rodriguez. Yes, because it is extremely costly for them
to--when the Department of Defense has done some work already
with the soldiers and you have all these documents that are
already on the soldiers, a packet, and then you have to start
from scratch in the VA to redo some of the stuff because of the
fact that they don't communicate and they don't pass that
information on.
It not only hurts the soldier in terms of the access to
quality care, but it also costs the taxpayer money in terms of
having to redo a lot of the stuff that maybe has already been
done. From your perspective, what can you do or what kind of
direction can we give you that would help in this process to
force them to communicate and force them to come up with an
approach?
Ms. Melvin. What we have seen in the past is where we have
been asked to conduct continued oversight and comprehensive
oversight relative to the actions that VA and DoD have taken.
We have seen some progress relative to their identifying the
lead entities for their efforts and trying to clarify
strategies. At least on some of the prior initiatives that have
been undertaken from our role as an oversight body, I would
suggest that continued oversight on our part----
Mr. Rodriguez. Let me ask you, if it is okay with the
Chairman, to submit to the Chairman those guidelines that would
allow you that opportunity to have that oversight that would
force them to move quicker in coming together to make this
happen, because then maybe they might have it by 2011, 2012
when they started and, you know--but they started before 1998.
You started to look at it in 1998----
Ms. Melvin. That is correct.
Mr. Rodriguez [continuing]. But they started before then.
So it is going to be, what, 14, 15 years, and maybe we might
have something by 2011, 2012. That is not satisfactory. It has
been 15 years or more, and I would ask that you submit some
specific recommendations to the Chairman and we will see if we
can help in this process, to expedite that, and see what other
things we can come up with in addition to the possibility of a
Committee that can do the oversight and ask them to come up
with additional recommendations.
Ms. Melvin. We would be happy to respond to any requests
that you have for additional work on our part to support you in
that effort.
Mr. Rodriguez. Thank you very much.
Mr. Mitchell. Thank you. Thank you.
Mr. Space, would you like to----
Mr. Space. I don't have any----
Mr. Mitchell. Okay. Thank you.
Thank you very much. We appreciate your testimony and
hopefully you do keep on this and help us out.
Ms. Melvin. We look forward to working with you.
Mr. Mitchell. Thank you.
At this time we will have the second panel. And I want to
welcome the second panel to the witness table. Dr. Gerald Cross
is here to represent the viewpoints of the VA. Dr. Stephen
Jones is here on behalf of the Department of Defense. And I
welcome the opportunity to hear both sides of this issue in
this setting.
Dr. Cross and Dr. Jones are accompanied by key IT and
transition officers from their central offices, as well as Dr.
Gordon Starkebaum and Dr. Glenn Zwinger from the Seattle VA
Medical Center and Puget Sound VA Health Care System, and
Lieutenant Colonel Keith Salzman from the Madigan Army Medical
Center in Seattle, Washington.
There is an interesting electronic sharing process taking
place in Seattle and I am eager to learn more about this
program.
I would also like to welcome Lieutenant Colonel Michael
Fravell. He is not representing either the views of the VA or
the Department of Defense, but is here at the request of the
Subcommittee to answer questions about the Joint Patient
Tracking Application (JPTA). I welcome his views on this issue.
Dr. Cross, if you would. You are recognized for 5 minutes.
STATEMENTS OF GERALD M. CROSS, M.D., FAAFP, ACTING PRINCIPAL
DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY CHARLES CAMPBELL, ASSISTANT CHIEF OFFICER FOR
HEALTH INFORMATION, VETERANS HEALTH ADMINISTRATION; CLIFF
FREEMAN, DIRECTOR, VA/DOD HEALTH INFORMATION TECHNOLOGY
SHARING, OFFICE OF INFORMATION TECHNOLOGY; GORDON STARKEBAUM,
CHIEF OF STAFF, PUGET SOUND VETERANS AFFAIRS HEALTHCARE SYSTEM,
SEATTLE, WA, VETERANS HEALTH ADMINISTRATION; GLENN ZWINGER,
CHIEF INFORMATION OFFICER, PUGET SOUND VETERANS AFFAIRS
HEALTHCARE SYSTEM, SEATTLE, WA, VETERANS HEALTH ADMINISTRATION;
AND STEPHEN L. JONES, DHA, PRINCIPAL DEPUTY ASSISTANT SECRETARY
OF DEFENSE (HEALTH AFFAIRS), U.S. DEPARTMENT OF DEFENSE;
ACCOMPANIED BY CHARLES HUME, DEPUTY CHIEF INFORMATION OFFICER,
MILITARY HEALTH SERVICE. U.S. DEPARTMENT OF DEFENSE; LOIS
KELLETT, DIRECTOR OF INTERAGENCY AND COMMUNICATIONS FOR THE
TRICARE MANAGEMENT ACTIVITY (TMA), U.S. DEPARTMENT OF DEFENSE;
LIEUTENANT COLONEL KEITH SALZMAN, CHIEF OF THE WESTERN REGIONAL
COMMAND INFORMATICS, MADIGAN ARMY MEDICAL CENTER, SEATTLE, WA,
U.S. DEPARTMENT OF DEFENSE; LIEUTENANT COLONEL MICHAEL FRAVELL,
JOINT PATIENT TRACKING APPLICATION SPECIALIST, U.S. DEPARTMENT
OF DEFENSE
STATEMENT OF GERALD M. CROSS, M.D., FAAFP
Dr. Cross. Well, good morning, Mr. Chairman and Members of
the Subcommittee. Accompanying me are Charles Campbell, VHA's
Assistant Chief Officer for Health Information, Cliff Freeman,
VHA's Director of VA/DoD Health Information Technology Sharing,
and behind me I have Gordon Starkebaum, Chief of Staff at the
VA Puget Sound and Glenn Zwinger, Chief Officer of Information
at the Puget Sound VA Medical Center.
The VA is fully committed to ongoing collaboration with DoD
in the development of interoperable electronic health records.
Until that is achieved, we are using technology and processes
to exchange information. We, VA and DoD, share patients and we
must effectively share the clinical information necessary for
their care.
Now, relevant to injured servicemembers, the starting point
for the electronic transfer of clinical information from DoD to
VA is in Iraq and Afghanistan. Information from that point on
is entered in the Joint Patient Tracking Application, JPTA.
When the patient is ready to be transferred to a VA medical
center, VA staff working at the military hospital copy the
record and fax it to the VA facility which prepares to receive
the patient.
VA now has a version of JPTA called Veterans Tracking
Application. This contains all of the information in JPTA
except that information deemed sensitive to military
activities. Also, DoD has begun to transform other key portions
of their medical records into electronic documents that are
accessible to us in our program called VistA. This reduces the
number of documents that must be copied and faxed back and
forth.
The patient may ultimately be cared for at several VA
military facilities. The VA is increasingly using VTA, Veterans
Tracking Application, to track patients through each of these
steps. Let me emphasize that we do not exclusively rely on any
electronic system to ensure the transfer of information. We
have VA staff at military facilities working with their DoD
counterparts to assist the patient and family during the
transfer and to ensure the information we need is sent.
The development of information exchange systems like JPTA
and VTA for tracking, the Federal Health Information Exchange,
called FHIE, which is for separating servicemembers, and the
Bidirectional Health Information Exchange, BHIE, for two-way
exchange of information represents significant milestones VA
and DoD have accomplished together. However, none of these
systems by themselves are sufficient. Neither JPTA, nor FHIE,
nor BHIE contain the complete set of clinical information. Work
is continuing to expand the reach of these systems.
An example of this cooperation is the work done at VA's
Puget Sound Regional Center and the Madigan Army Medical
Center. Once the veteran is enrolled in the VA healthcare
system, all clinical information related to VA care is
available at every VA medical facility. Using a secure virtual
private network called VPN and a web browser, our doctors can
assess a patient's record on the Internet from anywhere. VA,
through its affiliation with 107 medical schools, has already
trained many of the Nation's doctors and other providers on
VA's electronic health record system.
In addition to the electronic pathways I discussed, we are
taking additional steps, including stationing VA staff at the
military hospitals to ensure we have redundant capabilities.
And we are adding 100 transition patient advocates and placing
them across the country at VA medical centers. When seriously
injured servicemembers arrive at military hospitals, the
advocate closest to the patient's home will fly to the military
hospital to meet the patient and the patient's family. The
advocate will stay in contact with the patient as he or she
seeks additional care and the advocate will enter information
about the care received into VTA. Ultimately, the advocate will
greet the patient upon arrival at their hometown VA medical
center.
VA and DoD are collaborating at the highest levels to
determine that progress is made toward our ultimate goal, fully
interoperable electronic health records. Together, VA and DoD
can lead the way toward the adoption of electronic health
records throughout the Nation's healthcare system. Indeed, VA's
VistA System was awarded the Innovations in American government
Award in July 2006 by Harvard University.
I would like to submit my written statement for the record.
My colleagues and I look forward to your questions.And, sir, we
have given you two documents in addition for each of the
members. One is a list of acronyms. I note we use a lot of
acronyms and I apologize for that. But there are lots of
acronyms. And then a simple diagram that shows how information
is exchanged. And it also has some dates and numbers on there.
[The prepared statement of Dr. Cross, along with the
attachments, appears on p. 48.]
Mr. Mitchell. Thank you.
Dr. Jones.
STATEMENT OF STEPHEN L. JONES, DHA
Dr. Jones. Mr. Chairman, thank you very much. Members of
the distinguished Subcommittee, I appreciate your inviting us
here today to discuss the sharing of electronic health records
between the Department of Defense and the Veterans
Administration.
DoD and VA currently share a significant amount of health
information data. I know you are frustrated and we are
frustrated also. But we are making progress. And I guess you
have heard that before, but I think in this case it is correct.
I am aware, however, of your concerns regarding the time it
has taken to establish this level of sharing and recognize
there is room for continued improvement. By 2008, DoD and VA
will achieve all of our current health information exchange
goals.
Mr. Mitchell. Excuse me, Dr. Jones. Could you move the
microphone closer--is it on? Do you see a green light there?
Dr. Jones. Yeah, I am sorry.
Mr. Mitchell. Okay. Thank you.
Dr. Jones. No one recognizes the need for information
sharing more than DoD and VA. Our ability to share information
affects the quality of healthcare delivery and sometimes
determines the benefits earned by veterans and servicemembers.
We have to get it right. DoD and VA have the ability to enhance
clinical processes and workflow through technology, and to
collaborate on better processes for our deserving
beneficiaries.
But digitization and automation are only the first part of
the solution. DoD and VA are also prepared to collaborate on a
new level for our shared patients, to create a better paradigm
for care. No single organization has all the answers to these
technological challenges and at DoD we are melding our
expertise with the VA and other experts, both in the private
and public sector.
This collaboration will continue to ensure that our systems
and our partner's systems support the continuum of care and
stay ahead of the technological curve.
Dr. Chu, our Under Secretary for Personnel and Readiness
and Mr. Mansfield with the VA have two top priorities; first
addressing the continuity of care for returning wounded
warriors, and second, modernizing our inpatient systems
together through a joint acquisition development effort over
the next several years.
As one who has spent many months traveling and visiting VA
and DoD medical centers, including the VA's polytrauma center,
I know from personal experience that our wounded warriors are
best served by our specialized care. As you know, our shared
patients sometimes begin treatment at a DoD facility and
transferred to a VA polytrauma center and sometimes returned to
a DoD facility for necessary medical procedures. Recently, to
better support the transition of care, we began sending
radiology images and scanned medical records to the four VA
polytrauma centers.
Today, DoD and VA providers are able to view data from each
of those departments for their shared patients. The health data
elements we currently share include outpatient pharmacy data,
inpatient and outpatient laboratory and radiological results,
allergy data, pre and post-deployment health assessments and
post-deployment health reassessment.
If you have ever spent time in a hospital, you know how
important a discharge summary is to your personal physician.
Today, five DoD sites share electronic discharge summaries with
VA and we will soon expand this capability to 13 of our largest
DoD inpatient facilities.
As I said earlier, collaboration is the right thing to do
and it is the only way that organizations can ensure that they
take advantage of the expertise necessary to be leaders. In
this spirit, we recently announced that DoD and VA will
modernize our inpatient systems together through a joint
acquisition development effort over the next several years.
Both departments believe the timing is right for this
initiative. VA is planning to modernize the inpatient portion
of its electronic health record and DoD is poised to
incorporate documentation of inpatient care into a fully
deployed Armed Forces Health Longitudinal Technology
Application (AHLTA) electronic health record. Over the next
year, DoD and VA will analyze the requirements of this
convergence. Our goal is to concurrently support the needs of
the clinicians of both departments and enhance continuity of
care for our patients.
In addition, DoD and VA are driving forces in the national
level activities to support the President's Executive Order to
require Federal agencies to use recognized health exchange
standards to promote the direct exchange of health information
between agencies with non-Federal entities.
Before I close, I will mention that the certification
commission for healthcare information technology recently
awarded premarket conditional certification of a version of
AHLTA that will be released this fall. This certification of
quality and safety is a giant step and shows that our
electronic health records meet expected industry standards.
Thank you for the opportunity to appear before you today
and we look forward to your questions, Mr. Chairman.
[The prepared statement of Dr. Jones appears on p. 54.]
Mr. Mitchell. Thank you. I would like to ask my first
question to both Dr. Cross and Dr. Jones. Are you aware of any
negative impacts that have occurred to veterans and/or
servicemembers because of the lack of compatibility of those
two systems, the recordkeeping systems?
Dr. Cross. What we have done--yes, I know of one case
that----
Mr. Mitchell. Just one?
Dr. Cross. I know of one case that has caused me concern as
being an issue in this. And that is why as a result we have put
in this redundant capability with our people on site to make
sure that we have every aspect of every piece of information
that we need.
Mr. Mitchell. But if you are just aware of one--what about
you Dr. Jones? If there have been no negative impact, then
maybe there is no need to share this information. But I get the
feeling, and I think everybody up here does too, that there has
been a number of negative impacts on veterans and
servicemembers because of a lack of shared information.
Dr. Jones. Mr. Chairman, I am not aware, but--as you know
our America's healthcare recordkeeping has been based on a
paper record and our providers tend to communicate to ensure
when a hand-off occurs that, you know, the appropriate
information is shared. Electronic data when it works, of
course, enhances that communication. So while I am not aware of
any specifics, I mean I think electronic data will help provide
better quality care.
Mr. Mitchell. Do you think it is a waste of time to go
through all of this then? If there has really been only one
case between the two of you, a negative case, because of a lack
of compatibility of records, maybe we are wasting our time and
money on bringing all these records together.
Dr. Cross. No, sir. That is not how I see it. I don't think
that is how Dr. Jones sees it either. We are moving on a
pathway toward interoperability. And quite frankly, it has been
an incremental path. But a great deal of progress has been
made. We talk about an end point. I don't really see an end
point as being what we are aiming for. There is going to be a
progressive interoperability over a period of time, step-wise
making more and more progress. The systems are going to change.
They are going to modernize throughout that period of time and
we will have to adjust.
But I think if you look at what we have achieved so far, we
are getting more and more data electronically and exchanging it
back and forth. If you look at the diagram, you will see what
those pathways are. This isn't the end point though. We are not
there yet. We have to keep working on this and there is much
more to be done. As you will see some of the dates on here, we
have some goals coming up very shortly.
Mr. Mitchell. I understand and I understand about the IT
and interoperability and so on, but you are talking about
people's lives. That is what this is all about. And I think
that you are going to say well, we are going to meet these
goals because we have got to do this because there is new
technology and electronic medical records are important and so
on. But in the meantime, there are people's lives who are being
affected by this, very real lives.
I just find it--you know, when I heard from Ms. Melvin and
she talked about your plan is to have everything working right
by the year 2012 and it started in 1983. That is what, 29
years. I think a person can retire after 20 years in the
military. There are people who will go through this whole
system with an inadequate medical record transfer.
I see some people out here in uniform. I would think they
would feel--and one of these days you are going to be out of
uniform and you are going to be a veteran and you are going to
go into the veterans' program. I would think that these people
would feel that they would like the very best records kept.
They would like to be--have the very best care.
I just don't understand how this thing can drag on and drag
on. And as Ms. Melvin said, it seems like the only way this is
going to get anywhere is continual oversight and
accountability. Otherwise, you know, nothing seems to be
happening. Thirty years to finally get to what you want. In the
meantime, the electronic and the IT information, or the
processes are all going to change.
Are you satisfied, either one of you, with the way this is
going?
Dr. Cross. Sir, we can't wait until 2012. We are----
Mr. Mitchell. That is what Ms. Melvin said is going to
happen the way you are headed.
Dr. Cross. We are providing medical care today. I am a
family physician. I understand this. We have to have certain
pieces of information. That is why--because we can't wait and
because we are providing that care today, we have our people on
the ground at--working with our DoD colleagues at the military
treatment facilities, ten of them, to make sure that whatever
information we need as that patient transfers, they are there
on the spot in person to make sure that gets to us. Whether it
is electronic or other means, I have got to have the
information and they are doing it.
Mr. Mitchell. If the panel will indulge me a second. One of
the things that Ms. Melvin also said is there is a culture you
have to go through. And it seems to me, from what I have heard,
that the DoD has about three or four systems they are using.
Each branch has their own. DoD is trying to create one that
will talk with the VA.
All these--I know it is important for the culture. But, you
know, we are talking about, again, individuals, where it
doesn't matter what uniform you are in. You are a veteran. You
have served your country. And these people ought to be not
concerned about the culture. And I get the impression--and I
know neither one of you are going to point the finger at each
other--that the real problem here is in the DoD because they
have got so many different systems that they are trying to
coordinate with that doesn't coordinate with the VA.
I would hope that, as the rest of the questions are
answered here and we investigate this, that there--I mean you
take into the fact you are dealing with human beings, not
figures and not a system. And I think that is vital.
I will yield to Ms. Brown-Waite.
Ms. Brown-Waite. I thank the gentleman and I thank the
panel for being here.
You know, what we are really talking about here is
continuity of care. And certainly, both Dr. Cross and Dr. Jones
realize how important that is.
Dr. Cross, I believe you were previously with DoD; is that
correct?
Dr. Cross. Twenty-five years.
Ms. Brown-Waite. Twenty-five years, a little less time than
what Congress has been promised that there would be some
interoperability here.
While the statement was made--and I apologize. I was
writing. I don't know which one made it--that there was only
one medical problem. I think what the term should have been was
maybe one death. I am sure there have been other medical
problems because of lack of information being transferred. Do
you have a handle on what kind of medical problems, perhaps the
loss of a limb, a diagnosis that went unknown? Could you supply
the Committee with this information?
Dr. Cross. The kind of problem that we face every day is
quite frankly the labor intensity that it requires to assemble
the information that we have to transfer on each patient, that
we have our staff in those facilities putting that together
every day doing this, to make sure that that happens. I think
that is really the challenge.
The one case I referred to, I am not sure if any of the
information issue or electronic issue played a definitive role
in that or not. But it did cause me some concern. I will ask
Dr. Jones.
Dr. Jones. Of course, as you know, DoD and VA monitors
quality and outcome very carefully. You know, we believe that
electronic health records will expedite communications,
encourage communications and the lack of miscommunications,
allergy information, pharmacy potential misuse. I mean there is
a number of studies, long-term studies that show that safety is
assisted by having adequate information and electronic health
records help with this.
Ms. Brown-Waite. Sir, the VA is the receiving entity of the
veterans that need this information. For years we have known
that VA systems have been excellent, indeed far superior to
those in the private sector. The private sector is finally
catching up.
I think our real problem here is with the foot dragging at
DoD. And, you know, long before I got here--as I look around
this panel, except maybe for Mr. Stearns and staff who have
been here, this is an ongoing situation.
Dr. Cross. Well----
Ms. Brown-Waite. 2012 is when DoD thinks that it will be up
and operating. Have you asked for any outside help or is this
just the people in DoD who are wed to their system that aren't
willing to accept change? Because having been involved in the
installation of a major new IT system at a government agency, I
know we ended up having to fire some people who would not
adjust to the new system that was there. They continued using a
dual system.
Why in God's name has it taken so long? And I would say
that would be Dr. Cross. And I am not picking on you. I know
simultaneously DoD is running a war.
Dr. Cross. I want to say that in working with my DoD
colleagues, I think we have the closest working relationship
that I have ever heard of in the history of the two
organizations in terms of the interactions that we have, the
frequency and the structure with which we do that. And I think
we are both committed to the same goal.
I would like to ask a couple of my colleagues now--as I
said, I am a family physician. I am the receiver of the
information. I have two IT experts that I think might want to
provide just a bit more information for you, ma'am.
Ms. Brown-Waite. I would like to hear from Dr. Jones
because I believe the foot dragging is actually taking place at
DoD. And is there some reason why Executive Order 13410 calling
for this to be developed by January of this year has not been
met? And did you notify the President it wasn't going to be
met?
Dr. Jones. Let me comment on the culture and the foot
dragging. I would just like to echo Dr. Cross' comments. I have
only been with DoD two and a half years, but I mean we work
closely with VA. I know the IT people work closely. We have a
joint strategic plan. Of course, IT is a part, an integral part
of that strategic plan. We are building trust among our
representatives and VA representatives are trying to work as
one system when it comes to health information IT.
So while I can understand you may--and it may appear that
there is a foot dragging, I can assure you from our part, from
our leadership in working with Dr. Cross and his colleagues,
that is not the case. I mean we would like to see this process
move forward just as rapidly as you would----
Ms. Brown-Waite. I appreciate your building trust, sir. I
would like to see you build a system that is interoperable. I
am glad that you are building trust. That makes me feel very
good. However, I don't think that the families of the veterans
feel very good that there isn't a system there of record
transfer the way that it should be.
Dr. Jones. Well, if you look at, as you said--I mean as I
have assessed the situation now, we have built a foundation. I
say we. DoD has built a foundation which we now can exploit and
start those timbers coming up and if you will look at the
charts and even, I think, look at the GAO report that was in
the press today, you will see that we are making more progress,
you know, each year more rapidly than we were the year before.
So----
Ms. Brown-Waite. Sir, I will summarize this. This Dubuy has
built huge cities in the amount of time that DoD cannot build
an operable system to help our military. That, sir, is just
unacceptable.
With that, I yield back the balance of my time.
Mr. Mitchell. Thank you.
Mr. Walz.
Mr. Walz. Well, thank you both for your testimony. And one
thing I would say--and this is an area that I am trying my best
to get more expertise in. I would agree, it is an incredibly
complex undertaking. It absolutely is. But I would also
associate with the Ranking Member. It can be done. There are
challenges here. There are barriers. And we do need to figure
out a way. And my goal is to try and see what we can do to get
you there.
So I just had a couple of questions. How close are we on
standardizing the categories of information that should be
shared? Is that part of what we are working on? Is that part of
what the delay is, or is that part figured out?
Mr. Freeman. One of the harder pieces to the work that we
are doing together is the standard----
Mr. Walz. Yes.
Mr. Freeman. As the Members know, there is a national
effort under the umbrella of Health and Human Services. Both
the VA and DoD play very active leadership roles in that
effort.
Without the standardization at the national level, one of
the risks we take is to go ahead and standardize something and
then the national agenda go in a different direction.
So--and I guess, if I could, I will give you a couple of
examples. There is a standard for moving the data between the
two. However, within a standard, you also have to implement it
in a uniform way. And so that is another complicating factor.
It is not just standardizing the data, but it is also agreeing
to how you are going to implement it.
Some standards that don't exist, for instance, with the
CHDR project, the computable data that we move bidirectionally.
There were no national standards for allergy. And so VA and DoD
had to develop those ourselves in order to move that data and
it was very time consuming to do that work.
Mr. Walz. Do we have the ability to interject in that from
a national standards perspective, the private sector or Health
and Human Services? Can they help you with that?
Mr. Freeman. I believe that the private sector is a key
player in this effort also.
Mr. Walz. Okay. Very good.
Dr. Jones, I had a question on this as we are developing
these programs. The AHLTA, why that over JPTA? When we looked
at some of the research in my office, we saw that they were
very, very similar. But the one we have chosen to implement is
much more expensive. Can you tell me what we are getting for
our money, or if that is true, what we are looking at?
Mr. Hume. Sir, JPTA was designed to support the tracking of
patients as they are evacuated through the echelons of care. It
was intended to provide a snapshot of the healthcare
information relative to that transfer, both back to the
referring facility and to the facility the patient is being
referred to. It doesn't contain the workflow, the physician
workflow, the orders management, the longitudinal care
capabilities that AHLTA does. AHLTA is deployed across our
fixed facilities and then a version of AHLTA is also deployed
in theater to support the care delivered in theater.
Mr. Walz. All right. Very good. Now, I am asking you to be
somewhat subjective here on this one, but we brought you here
to get your opinions on this. My experts at the Mayo Clinic
have come to the assessment that DoD simply needs to adopt the
way the VA is doing it. It is the most effective. It is the
best for care and it is the most efficient in terms of use of
resources. How would you respond to that, when they tell me
that?
Mr. Hume. Sir, I think VistA is designed to meet the needs
of VA very well and it does meet those needs. DoD has some
unique requirements that drove us in a different direction. I
would say the principal difference is the mobility of our
patient population. The typical DoD patient over a career in
the military will have records from ten or more facilities.
DoD's requirement was to have a single central data repository
which all of the DoD facilities would feed the records to.
The other area where we differ somewhat is the requirement,
particularly in theater, to have a note, have a clinical
encounter note that contains structured data elements so that
we can use that clinical data record for disease surveillance,
biomedical, bio and chemical disease surveillance both in
theater and frankly, back here in the United States also. Those
are some of the principal drivers for why DoD and VA chose
separate paths.
Mr. Walz. So you would say that Mayo's assessment of this
is wrong even though they tell me they think they share the
same issues you have because they receive patients from 176
foreign countries and try and integrate this together. So you
are telling me they don't have a handle on exactly what you
need in the environment that you work in?
Mr. Hume. Sir, I would have to see what the Mayo Clinic
said specifically to be able to respond.
Mr. Walz. Okay. I yield back.
Mr. Mitchell. Thank you.
Mr. Bilbray.
Mr. Bilbray. I have no----
Mr. Mitchell. Mr. Space?
Mr. Space. Thank you, Mr. Chairman.
And while I share my colleague's concern over the duration
and time lapse in the development of a more seamless transition
of data, I do have some questions about a more human component,
specifically, your reference to the advocates, the transition
patient advocates. I find that idea somewhat intriguing. But I
do have some questions.
The first question I have is, what steps, if any, have been
taken to ensure that these advocates are advocating on behalf
of the patient as opposed to a seemingly unending bureaucratic
process? In other words, I have concerns about maintaining no
conflict of interests are being paid presumably by the VA. So I
would be interested in your thoughts on ensuring that they are,
in fact, advocating for the patient. And second, whether there
are plans to extend the number of advocates beyond the current
number of one hundred. Thank you.
Dr. Cross. Thank you so much for that. The patient
advocates are going to be--we have already hired a bunch of
them, of the hundred. They are going to be paid for--paid
salary by the VA, of course. But they are going to have a case
mix of, I think, about 25 per. They are going to have human to
human contact with these compelling patients and their
families. And if nothing else works in that regard, that kind
of contact carries the imperative that they must be advocates
for that patient. And I think that is what they will do.
As far as expanding them, if they exceed that case mix that
we have assigned for them, that caseload, we would have to add
on more individuals. One more thing. The type of people that we
are selecting for these jobs, to the degree possible within,
you know, within the hiring regulations, we are looking for
people who had the experience of the people they are going to
be working with. We are looking for people that are coming back
from Iraq and Afghanistan, quite frankly.
Mr. Space. I yield back.
Mr. Mitchell. Thank you.
Mr. Stearns.
Mr. Stearns. Thank you, Mr. Chairman. I ask unanimous
consent my opening statement be part of the record.
Mr. Mitchell. So moved.
[The statement of Congressman Stearns appears on p. 35.]
Mr. Stearns. Dr. Jones, I guess a question--my first
question would be for you, I understand the DoD has seven
separate electronic health records system; is that true?
Mr. Hume. Sir, I am not familiar with the precise number--
the precise records that you are referring to. AHLTA is the
enterprise outpatient electronic record deployed across DoD
facilities. There are some legacy operations that that has
replaced and----
Mr. Stearns. Well, I mean----
Mr. Hume [continuing]. Are in the process of replacing.
Mr. Stearns. Well, isn't there seven legacy applications?
Just yes or no.
Mr. Hume. I don't know, sir.
Mr. Stearns. Okay. Well, we understand that--and my
question was going to be that I understand that the VA has
three separate electronic health record system; is that true?
Anybody know? Mr. Freeman?
Mr. Freeman. I believe that VistA is our primary
electronic----
Mr. Stearns. So you don't think----
Mr. Freeman [continuing]. Health record.
Mr. Stearns. There is not three sets. I guess the question
I have is within the VA or DoD, is there communication between
all of your electronic systems? And I guess that is for you,
Dr. Jones. You know, if we can't get communication between the
VA and DoD, can we get communication within the DoD? Is there
assurance here that you are getting communications within your
electronic systems within DoD?
Mr. Hume. The outpatient electronic medical record is AHLTA
and it is a single system deployed across all of DoD.
Mr. Stearns. Okay. Well, I have in front of me selected DoD
medical information systems. There is a Composite Healthcare
System, the CIS, the Clinical Information System, the ICDB, the
Integrated Clinical Database, the Theater Medical Data Store,
the Joint Patient Tracking Systems. There is two more. So you
have got one, two, three, four, five, six, seven. That is what
I am talking about. Is there communication between these seven
systems so that one system can talk to another? Is there
interoperability is what I am asking.
Mr. Hume. Between----
Mr. Stearns. Just yes or no.
Mr. Hume. Between most of those, yes.
Mr. Stearns. There is interoperability?
Mr. Hume. Yes, sir.
Mr. Stearns. Okay. Within DoD?
Mr. Hume. Yes, sir.
Mr. Stearns. Okay. And it is true in the VA that you have I
think three systems I could point out to you. Again, we have
interoperability between the three systems in the VA? You can
assure me that you have the Veterans Health Information System
and Technology Architecture, the HealtheVet VistA program and
you have the Health Data Repository (HDR). So those three
systems, is there interoperability between those three?
Mr. Freeman. Yes, sir.
Mr. Stearns. Okay. I think the concern that a lot of us
have is traumatic brain injury (TBI) that is so prevalent for
veterans coming back. Secretary Nicholson issued a report April
this year in which he talked about that all incoming veterans
returning from the Global War on Terror seen in the VA
healthcare facilities will be screened, from mild to moderate
traumatic brain injury. But the problem is that all this
information is in the DoD when they come out of--when they are
in the service.
So wouldn't you think all that information should be
available? I mean how effective is the Secretary's plan here to
actually screen veterans for mild to moderate traumatic brain
injury if there is no records being transferred from the
Department of Defense to the veterans so they can do this?
Dr. Cross. Sir, we are--the VA is actually the ones who are
screening all the Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF) for TBI.
Mr. Stearns. Yeah, but doesn't the DoD have all this
information when they come into Walter Reed? I mean don't they
do the same thing? And doesn't the active military do the same
thing? And shouldn't they take all their records and transfer
them to you so that the veterans have this before you start the
screening?
Mr. Hume. Sir, in the case of the polytrauma patients, we
are scanning that entire inpatient and--any paper and
electronic record we are consolidating along with the digital
imagery and sending that----
Mr. Stearns. So the Department of Defense is making that
available information to the veterans on traumatic brain
injury?
Mr. Hume. If they are going to a polytrauma center, yes.
Mr. Stearns. Well, could you take--that is only 300
patients I am told. Now, coming back from the military it is
much more than 300 patients. I think the problem I have here is
that you folks are sort of not too transparent. I mean here we
have the Secretary of Veterans Affairs saying we are going to
screen all these people and yet the DoD is not even providing
the information.
Let me ask you something. Could somebody in the VA just
walk over to the DoD or fly or go by train? Would the DoD allow
physicians to go over to the Department of Defense and look at,
let's say, a Cliff Stearns who came back from Iraq and he had
brain injury, traumatic brain injury? Would the DoD allow a
doctor to go over there? Yes, Dr. Cross?
Dr. Cross. Sir, let me give you a bit more detail, if you
don't mind.
Mr. Stearns. Okay. Don't make it too complicated. Just keep
it very simple for us.
Dr. Cross. The answer is we are getting the information
from the PDHRA. Now, I had to use so many acronyms, so I am
going to apologize. As to post-deployment health reassessment--
--
Mr. Stearns. So if I came back from Iraq and I was in
Walter Reed and then they made me--and then I became a veteran,
all the information on my traumatic brain injury is available
and DoD sends it to Veterans Affairs? Just yes or no.
Dr. Cross. Electronically, some of it, yes.
Mr. Stearns. Why not all of it?
Mr. Hume. Sir, it doesn't exist in electronic form across
all of the----
Mr. Stearns. No, but we have a got a Xerox machine. You
make copies of this and you can just make copies and give it to
me when I left and I could take it with me to Veterans Affairs.
Mr. Hume. We are currently doing that for the polytrauma
patients. That was a new initiative and we are certainly----
Mr. Stearns. When did you start with that?
Mr. Hume. March, sir.
Mr. Stearns. This long. We have been at this war now almost
four and a half years and the people have been coming back
steadily and you just started in----
Mr. Hume. Prior to that, sir, the data was being moved with
the patient on a compact disc. The VA facilities asked if they
could get it transferred to them electronically and we worked
together a system to do that.
Mr. Stearns. Well, Mr. Chairman, my time has expired. But
we can see right now the crucial problem with traumatic brain
injury. There is no interoperability between DoD and VA and
this is lifesaving information for the veterans and yet the
Secretary of the Veterans Affairs, Mr. Nicholson, thinks they
are going to start this screening process. It seems to me they
should have all the information from DoD first before they even
start the screening, Mr. Chairman.
So with that, I yield back.
Ms. Brown-Waite. Mr. Chairman?
Mr. Mitchell. Yes. Ms. Brown-Waite.
Ms. Brown-Waite. Colonel Fravell of the U.S. Army who is a
medical service corp officer is in the audience and I don't
know if he was sworn in or not, but I think that we may want to
ask him about the Joint Patient Tracking Application system.
Mr. Mitchell. Very good.
Ms. Brown-Waite. If we could perhaps call him up?
Mr. Mitchell. Colonel? I think--did you stand, I think,
when you----
Colonel Fravell. I did not, sir.
Mr. Mitchell. Would you raise your hand?
[Lieutenant Colonel Michael Fravell was sworn.]
Mr. Mitchell. Thank you.
Ms. Brown-Waite. Do you want to----
Mr. Mitchell. Excuse me. No, go ahead, Ms. Brown-Waite.
Ms. Brown-Waite. Thank you.
I understand that you are responsible for the Joint Patient
Tracking Application system. Could you tell me where it is and
the Xeroxing of records and giving them to a patient I don't
think is exactly what Congress had in mind. So could you tell
me what we can do to make the Joint Patient Tracking
Application system work so that it truly is a patient tracking
for both of the agencies?
Colonel Fravell. I think we are currently on the right
track, ma'am, for sharing the Joint Patient Tracking
Application and essentially its sister application, the
veterans tracking application, to the VA. We have great
cooperation between DoD and the VA for sharing all of the JPTA
records. I think there is a lot of potential to expand JPTA's
use within the DoD, specifically as an interim solution to
gather additional information from some of the seven disparate
systems that were mentioned by your colleague.
That information could be pushed into JPTA quite easily and
then as a result, shared quite easily, essentially overnight,
with the VA through the connection it has to the veterans
tracking application.
Ms. Brown-Waite. Is there resistance? Is there organization
resistance to doing that? Because as Mr. Stearns said, we have
a list of seven separate systems here. If six of them could be
combined into JPTA, it seems to me as if that would be the
answer here instead of reinventing the wheel. Am I missing
something?
Colonel Fravell. I think that we do want to strive toward
the health data repository and clinical data repository
interoperability in sharing computable data. JPTA could be
viewed, along with VTA, as an interim solution to bring the
other systems together. At the present time, six of the seven
systems, with the exception of Clinical Information System
(CIS), the inpatient system used in many State-side DoD
facilities, that data is already residing in large part within
JPTA. And as a result of the sharing initiatives in cooperation
between the DoD and the VA, that data is available to the VA.
So, for example, a severely injured servicemember--and by
and large, every severely injured servicemember has been
registered in the JPTA and data along the way from each of the
facilities that have treated the servicemembers and veterans is
now available to them in VTA on the VA side.
Ms. Brown-Waite. Are you still working on this system and
is there reluctance on DoD's part to have it in one system that
is supposed to be interoperable?
Colonel Fravell. I have been working on the veterans
tracking application. Control of the Joint Patient Tracking
Application is under the Office of Force Health Protection. And
I don't have purview over that system since developing it in
Landstuhl and moving into Force Health Protection in 2005.
However, this year, as a war college fellow at the VA, I have
presided over the project to build the veterans tracking
application.
On the DoD side I think things are sometimes very
territorial and there are a lot of initiatives for developing
other systems. JPTA has been latched onto by many providers and
providers have been able to provide a great deal of input in
terms of building the system and seeing very quick and
immediate results, resulting in a great deal of user buy-in and
increasing the accuracy and use of the JPTA in the theater
hospitals. It is a great tool for what it is now as an interim
solution.
Ms. Brown-Waite. Could you give me an idea of the cost of
developing JPTA?
Colonel Fravell. Over the course of JPTA's initial
development that started in September of 2003, with fielding
and production at Landstuhl Regional Medical Center on 1
January 2004 to the present, I think--and I don't have, again,
over side of the current contract mechanism and I have not
since 2005. I think the costs have been about $1.8 million
total. And I would estimate that an annual operating cost of
probably about $400,000 to $500,000, to continue maintenance.
If the application was expanded, you would look at some
additional costs to increase the hardware capacity, storage
capacity and things like that, but nothing too significant.
Ms. Brown-Waite. Perhaps that is part of the problem. It is
not expensive enough. Is it feasible that this one system, that
JPTA could be used and could be used effectively for
interoperability?
Colonel Fravell. I think it could easily be used
effectively for interoperability as it is now by serving as
essentially a window into the other existing systems. And while
development would likely need to occur on a parallel track for
the clinical data repository and health data repositories, JPTA
or an application like JPTA could very easily and quickly
provide a bridge between the two organizations, sharing data
essentially in both directions.
Ms. Brown-Waite. I thank you for your response and I yield
back the balance of my time.
Mr. Mitchell. Thank you.
Yes. Mr. Stearns.
Mr. Stearns. Mr. Chairman, my colleague from Florida just
asked Colonel Fravell questions.
Dr. Cross, I got more out of what the Colonel indicated,
substance stuff, than I got from you or Dr. Jones. It seems
like he is trying to solve the problem where the rest of you
are sort of feathering the answers and looking around. And just
in all honesty, I mean you are both M.D.'s. I would think you
would want to solve this problem, particularly dealing with
traumatic brain injury for these young men that are coming back
from the Global War on Terror and all their information can't
even be transferred from the Department of Defense to the
Veterans Affairs, and yet the Veterans Affairs is willing to
screen it.
I just think you would have to take a little advice from
Colonel Fravell that he is trying to solve the problem. I don't
hear that from your folks. And this thing goes on and on and
on. I think it is--frankly, it is a scandal that this
information is not being transferred 3 years ago. But the fact
is, one of your aides, Mr. Hume, mentioned that just March we
started this information.
So I think for the benefit of our young men and women that
are coming back, you have got to somehow set up a demonstration
project or something in place so that all this information is
transferred over to Veterans Affairs so when they do their
screening, they start with the record from DoD. Does that make
sense?
Dr. Cross.
Dr. Cross. The information that you asked about was
electronic. We are getting other information on paper. And let
me say something about TBI. We are leading the way on this. We
have trained 61,000 of our clinicians in our TBI supplemental
education program. We have done the screening questions and are
screening every OIF and OEF veteran coming through our system.
We have trained our staff and put them in place, our polytrauma
system of care, our level one, our level two, to get these
folks the care----
Mr. Stearns. But you are talking from the Veterans Affairs
standpoint. You are not talking from the DoD. I am talking--Dr.
Jones, I mean this information should at the very least be
transferred completely over to Veterans Affairs from the
Department of--DoD and it is not being done.
Dr. Jones. Mr. Congressman, we don't disagree with you at
all.
Mr. Stearns. So you are in total agreement that this
information should be transferred----
Dr. Jones. Yes. I mean----
Mr. Stearns [continuing]. Electronically and whatever means
possible. So why can't we just put a pilot program in and start
doing it immediately?
Dr. Jones. Well, I mean our vision, as you say, is to be
able to have an interoperable--and be able to transfer all the
information. And of course, that is what we have been doing. I
mean we have developed a number of demonstration projects and
enterprise initiatives and that has allowed us to move forward
the way we have. In FHIE, you know, we are transferring 3.8
million unique patients' information right today.
Mr. Stearns. When would you say it would be totally
complete, the transfer interoperability between DoD and
Veterans Affairs on traumatic brain injury? When could I
actually put this date in concrete and say it will be
accomplished?
Dr. Jones. I would have to get back with you on that, sir.
Mr. Stearns. Well, just give me an approximate date. Mr.
Hume, I mean are you talking about----
Mr. Hume. For the primary driver for the comprehensive
solution is the--where once we have the joint----
Mr. Stearns. You are talking about 2012?
Mr. Hume [continuing]. DoD/VA--well, we have to--the plan
is to build a joint DoD/VA inpatient application, the same
application used by both organizations. Until that time, DoD
won't have a comprehensive inpatient solution across all of
DoD.
Mr. Stearns. So the transfer of traumatic brain injury will
not be accomplished--this interoperability will not be
accomplished in the next five years?
Mr. Hume. We will work on interim solutions.
Mr. Stearns. But you are not willing to give a date this
morning about a date when it will be accomplished?
Mr. Hume. I can't give a date when the comprehensive
solution will be accomplished.
Mr. Stearns. Will it be more than 5 years or less than 5
years?
Mr. Hume. Right now there is--we have contracted out for a
independent study of the two departments' requirements for an
inpatient application and for that organization to come back
with a way forward on that development. Until we have that way
forward, I can't forecast a date.
Mr. Stearns. Well, that is 2008, staff said. So you are
projecting this at least another year?
Mr. Hume. And in the interim we will have to come up with
interim solutions and I think that Colonel Fravell suggested
one of the interim solutions we are considering.
Mr. Stearns. Okay. Mr. Chairman, I will just conclude by
saying that Mr. Hume or Dr. Jones or Dr. Cross, if you had a
son or daughter that was fighting Global War on Terrorism and
they came back with traumatic brain injury, I think you would
want that son or daughter to have all that information that DoD
has immediately transferred to Veterans Affairs when they
became a veteran. And I am sure in your heart of hearts, you
would like this done as soon as possible. Thank you.
Mr. Mitchell. I would just like to close with a few
comments. First of all, things that happen with the VA and the
negative impact on the VA may not be your fault. Now, it may be
because you don't have--you mentioned you only knew of one case
that there might be any negative impact for lack of records.
But I think there is a lot more anecdotal evidence about that.
And in order for--because as soon as anyone is hurt badly
enough or is sick, they will be transferred out of the DoD and
it will become your problem. So you are going to get them very
quickly, those who have lost limbs, those who have suffered
traumatic brain injury, whatever it may be. They become your
problem and the DoD gets rid of them. So it is really in your
best interest to push for every bit of information you can get.
And with the Department of Defense, I think if we don't
take care of the people who serve in uniform and give them what
they expect, we are going to find it much more difficult to
recruit when all of the sudden they find that they are not
getting the kind of service they need after they leave your
purview and become part of the VA. They can say, you know, no
one is really looking out for our interest.
I will feel embarrassed as will every Member of this
Committee, if we find another booklet like this one that says
``Shared Medical Records, 20 Years and Waiting.'' And 20 years
from now and my name is on here and they are still having the
same hearing. Is there anything that you can give us, any
timeframe that you say well--I don't know what your next steps
are, either one of you, on this recordkeeping.
But whatever they are, when do you expect the next leap to
be made? Because I would like to have another hearing. I want
to know when that should be. Are we going to not have anything
happen for the next--for this term of Congress, the 110th
Congress, or is there something else planned between now and
the end of this Congress? Do you have any idea, either one of
you? What are the next steps? I would hate to have another
hearing and have you say exactly the same thing again. I would
like to see some progress.
Ms. Brown-Waite. Mr. Chairman, while they are preparing, I
would just ask for unanimous consent to request that GAO
continue to follow up on this with the Department of Veterans
Affairs and the Department of Defense. And I would also perhaps
suggest that if either department wrote to the President as to
why the Executive Order dates were not met, that the Committee
also get a copy of that ``please excuse me for my tardiness''
letter.
Mr. Mitchell. So ordered.
Ms. Brown-Waite. I think it probably would be----
Mr. Mitchell. Absolutely.
Ms. Brown-Waite [continuing]. Appreciated by all of the
Committee Members. Thank you.
[The following was subsequently received from the U.S.
Department of Veterans Affairs regarding Executive Order
13410.]
Question 1: Did VA notify the White House it would be unable to
comply with the requirements of Executive Order 13410,
``Promoting Quality and Efficient Health Care in Federal
Government Administered or Sponsored Health Care Programs?''
Response: (19) Executive Order 13410, ``Promoting Quality and
Efficient Health Care in Federal Government Administered or
Sponsored Health Care Programs,'' included a deadline of
January 1, 2007; however, the deadline did not require
implementation of a single system. Instead, January 1, 2007,
was selected to mark the beginning of executive branch
commitment to the goals of the EO. The Office of Management and
Budget (OMB) is responsible for tracking executive branch
progress in implementing the initiative.
The Department of Veterans Affairs (VA) has moved forward on
many initiatives essential to the EO objectives, and VA has set
the benchmark in the area of electronic medical records with
its award-winning and internationally recognized VistA/CPRS
medical record system. VA is working with OMB, other Federal
agencies, the private sector, and internally to achieve the
President's vision of Promoting Quality and Efficient Health
Care in the Federal Government.
VA jointly collaborates with public/private organizations
including academia, professional organizations, and other state
and government agencies. VA is also coordinating and leading
several organizations committed to developing clear standards
for health information and interoperability. Working through
this many bodies requires compromise and consensus, which
sometimes take longer than expected, thus influencing the
Department's timeline for project completion. Were VA to
proceed without consulting other healthcare providers, either
public or private, VA would risk delaying national
interoperability.
Executive Order 13410 addresses four main components,
including clear systemic interoperability standards,
performance measurement, transparent pricing, and high quality,
efficient healthcare.
Health Information Technology--Interoperability Standards
VA works closely with the Secretary of Health and Human
Services (HHS) to support infrastructure and activities
essential to developing interoperable standards for new or
renovated Federal systems. These standards will be used for
exchanges of health information.
Transparency of Quality Measurement--Performance Measurement
The Veterans Health Administration's Chief Quality Officer is
leading a partnership with public/private entities in
developing standards for the measurement and collection of
quality measures. A Steering Committee, including VA, the
Department of Defense (DoD), and Indian Health Services (IHS),
was formed in October 2006 to begin developing quality measures
at both the facility and (where appropriate) the provider
level.
The Steering Committee created two subgroups. The first was
charged with identifying three to five measures proving 100%
electronic abstraction for facilities and providers. An example
of electronic abstraction for this purpose is ``pulling'' a lab
value for every member of a specific patient category (such as
diabetes). The second subgroup was directed to develop a plan
for communicating the quality of care VA provides, based on
objective quality measures, to providers and users.
In the future, VA will work with other agencies to modify the
current quality reporting initiatives.
Transparent Pricing Information
VA Health Service users do not pay market price for services.
Promoting High Quality and Efficient Care
The Department of Health and Human Services is leading the
effort to meet this EO goal.
Dr. Jones. Mr. Chairman, we do have a milestone chart here
that goes through 2008 which we will provide the Subcommittee
and we will also address the question for the record, if you
don't mind, about after that what does the prognosis look like
with----
Mr. Mitchell. Well, you can only expect to come back again
with some other answers, and not the same answers we have heard
today.
Dr. Jones. Yes, sir.
Mr. Mitchell. And I would also like the information that
Ms. Brown-Waite has asked for as well.
Dr. Jones. Yes, sir.
Mr. Mitchell. Thank you.
With no further comments, the meeting is adjourned.
[Whereupon, at 11:42 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Opening Statement of the Honorable Harry E. Mitchell, Chairman,
Subcommittee on Oversight and Investigations, and a Representative in
Congress from the State of Arizona
This hearing will come to order.
One of the concerns I have heard from veterans is how difficult the
process can be as they transition from their active duty status to
veteran. And one of the great difficulties they experience is having
their full and complete medical records from the Department of Defense
available to their VA doctors.
This problem isn't new.
In 1998, President Clinton called on the VA and D-O-D to develop
a--quote--``comprehensive, lifelong medical record for each
servicemember.'' That was nearly 10 years ago. But up to this point,
progress has been painfully slow and increasingly expensive.
That's why we're having this hearing today . . . so this
Subcommittee can continue its efforts to provide oversight, and do what
we can to speed up the progress and make electronic medical records
sharing a reality.
We all know that there are many benefits to this. First, we will be
making sure that veterans receive better medical care by saving time,
and avoiding errors. Second, we will also lower costs so taxpayer
dollars are more wisely spent. That's a worthy goal as well.
I'm glad to know that the VA and D-O-D are working on some
demonstration projects in this area, and I'm eager to get an update on
it.
I want to take a moment to acknowledge the VA and D-O-D's progress
in their long term efforts to achieve a two-way electronic data
exchange capability. They have implemented 3 of 4 earlier GAO
recommendations, including
Developing an architecture for the electronic interface
between D-O-D Clinical Data Repository and VA's Health Data Repository
Selecting a lead entity with final decisionmaking authority for the init
iative, and
Establishing a project management structure.
That's a good start, but there's much more to do.
One of my greatest concerns is that the VA and D-O-D have not yet
developed a clearly defined project management plan that provides a
detailed description of the technical and managerial process necessary
to satisfy project requirements as the GAO has repeatedly suggested in
the past.
For example, all the way back in December 2004, the VA/D-O-D
Executive Council Annual Report found that the cost for the Government
Computer Based Patient Record/Federal Health Information Exchange was
approximately $85 million through FY 2003.
But here we are, 4 years later . . . the costs continue to grow . .
. and the consequences for delay are growing too.
We want to know why this isn't getting done, and how much longer
our veterans have to wait. I believe they've already waited long
enough.
I look forward to today's testimony.
Opening Statement of the Honorable Ginny Brown-Waite, Ranking
Republican Member, Subcommittee on Oversight and Investigations, and a
Representative in Congress from the State of Florida
Thank you, Mr. Chairman.
This Committee has held at least 16 hearings since 2000, to try and
push the sharing of critical medical information on patients being seen
or transferred to VA between the Department of Defense and the
Department of Veterans Affairs. The movement of this information
between the two departments is vital to the safety and well-being of
our veterans and military active duty servicemembers as they transfer
between the two agencies and become finally integrated back to civilian
life.
Our staff and members have visited many VA and DoD Medical Centers.
Of particular interest are the four VA poly trauma centers where
servicemembers sustaining severely disabling injuries to include
traumatic brain injuries (TBI) and spinal cord injuries are being cared
for while still in service, as well as after discharge. We have
frequently heard the concerns of VA doctors and medical personnel at
these facilities that the information they are receiving isn't timely
enough, or missing critical information needed to properly treat these
severely injured and disabled servicemembers.
Throughout the past 20 years, the VA and DoD have spent billions
working on independently stove-piped electronic medical records systems
that would provide better care to those serving on the frontline of our
Nation's efforts for freedom. Yet, neither to date seem to work
together in a coordinated effort of care. On April 10, 2007, an article
appeared in the Washington Post, which touted the VA's VISTA system as
a means to lower costs and provide better treatment to our Nation's
veterans. Can the VISTA system receive information from the Department
of Defense? We have also heard about the Joint Patient Tracking
Application (JPTA), which permits the transmission of patient care
notes from the battleground up the line to the patient's final
destination, whether for continued care at a VA facility or to prepare
for redeployment. However, in January, the Department of Defense
temporarily cut off access to the VA to this critical data.
Today, we have sitting before us both departments. It is my hope
that after two decades, all these attempted starts that finally there
is good news on the horizon, and we will finally see a system that will
permit the exchange of critical medical information that is
interoperable, bi-directional, and occurs in real-time. The care for
those who serve our country does not stop at the exit door of the
Department of Defense, but continues through the doors of the VA, and
the hand off between the two medical systems should be seamless, not a
fumble. Our Nation's heroes deserve no less.
Opening Statement of the Honorable Cliff Stearns, a Representative in
Congress from the State of Florida
Over and over again, for several years now, we have held hearings,
heard testimony, and listened to a number of recommendations to make
the transition of active duty servicemembers to the Veterans'
Administration as smooth as possible. And here we are again today, with
many of the same issues outstanding, and numerous recommendations left
undone!
Last year's GAO report quoted VA officials as saying that the
transfer of servicemembers to their system from the DOD would be more
efficient if the Polytrauma Rehabilitation Center's (PRC) medical
personnel had real time access to the servicemembers' complete DOD
electronic medical records. As Yogi Berra said, this is deja vu all
over again! These are the same opinions we have heard from all medical
personnel in the VA system for years, and yet little has been
accomplished to provide access to patient's comprehensive medical
files.
Allow me a brief moment to recap the history of this issue. Back in
1982, Congress identified the sharing of medical records as a critical
need, and passed the `Veterans Administration and the Department of
Defense Health Resources Sharing and Emergency Operations Act' that
created the first interagency Committee to supervise those
opportunities to exchange information between the two departments. In
1996, the Presidential Advisory Committee on gulf war Veterans'
Illnesses reported on many deficiencies in VA's and DOD's data
capabilities for handling servicemembers' health information. In
November 1997, the President called for the two agencies to start
developing a ``comprehensive, lifelong medical record for each
servicemember,'' and in 1998 issued a directive requiring VA and DOD to
develop a ``computer based patient record system that will accurately
and efficiently exchange information.'' In 2003, President Bush
established the Task Force to Improve Health Care Delivery for Our
Nation's Veterans. The first recommendation of this task force 4 years
ago was that the VA and DOD should ``develop and deploy by fiscal year
2005'' electronic medical records that are interoperable for both
systems and standards based. We are 2 years beyond that deadline and
not much closer to its completion.
GAO has previously commented on the departments' initial project,
and described the results as ``disappointing progress, exacerbated by
inadequate accountability and poor planning and oversight.'' The VA has
3 separate electronic health records systems that it uses, and has
spent $76 million on this interoperability project since its inception.
The DOD has 7 separate electronic health records systems, and also has
spent $76 million for its portion of the interoperability project since
its inception. So we are left with $152 million in expenditures for 10
different systems, and none of them can effectively share information
as we have been requesting for over
a decade! I understand that the departments are now considering further
compromise by trying to provide `read-only' access to VA centers
instead of requiring full interoperability because the process has
become so complicated. This is simply unacceptable. DOD and VA must
come up with a plan, with clear assignments, timelines and
responsibilities to implement information sharing between the
departments. Our veterans' medical treatments are being delayed, our
patience is wearing thin, and we will not spend another decade in
fruitless hearings. Our veterans deserve better.
Thank you Mr. Chairman.
Statement of Valerie C. Melvin, Director,
Human Capital and Management Information Systems Issues,
U.S. Government Accountability Office
INFORMATION TECHNOLOGY--VA and DOD Are Making Progress In Sharing
Medical Information, But are Far From Comprehensive Electronic Medical
Records
Mr. Chairman and Members of the Subcommittee:
I am pleased to participate in today's hearing on sharing
electronic medical records between the Department of Defense (DOD) and
the Department of Veterans Affairs (VA). For almost 10 years, the
departments have been engaged in multiple efforts to share electronic
medical information, which is important in helping to ensure that
active-duty military personnel and veterans receive high-quality
healthcare. These include efforts focused on the long-term vision of a
single ``comprehensive, lifelong medical record for each
servicemember'' \1\ that would allow a seamless transition between the
two departments, as well as more near-term efforts to meet immediate
needs to exchange health information, including responding to current
military crises.
---------------------------------------------------------------------------
\1\ In 1996, the Presidential Advisory Committee on gulf war
Veterans' Illnesses reported on many deficiencies in VA's and DOD's
data capabilities for handling servicemembers' health information. In
November 1997, the President called for the two agencies to start
developing a ``comprehensive, lifelong medical record for each
servicemember,'' and in 1998 issued a directive requiring VA and DOD to
develop a ``computer-based patient record system that will accurately
and efficiently exchange information.''
---------------------------------------------------------------------------
Each department is developing its own modern health information
system to replace its existing (``legacy'') systems, and they are
collaborating on a program to develop an interface to enable these
modernized systems to share data and ultimately to have interoperable
\2\ electronic medical records. Unlike the legacy systems, the
modernized systems are to be based on computable data: that is, the
data are to be in a format that a computer application can act on, for
example, to provide alerts to clinicians (of such things as drug
allergies) or to plot graphs of changes in vital signs such as blood
pressure. According to the departments, such computable data contribute
significantly to patient safety and the usefulness of electronic
medical records.
---------------------------------------------------------------------------
\2\ Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
---------------------------------------------------------------------------
While working on this long-term effort, the two departments have
also been pursuing various near-term initiatives to exchange electronic
medical information in their existing systems. These include a
completed effort to allow the one-way transfer of health information
from DOD to VA when servicemembers leave the military, ongoing
demonstration projects to exchange particular types of data at selected
sites, and efforts to meet the immediate needs of facilities treating
veterans and servicemembers with multiple injuries.
As you requested, my testimony will summarize the history of the
two departments' efforts to develop the capability to share health
information, and provide an overview of the current status of the long-
and near-term efforts that the departments are making to share health
information.
The information in my testimony is based largely on our previous
work in this area. To describe the current status of VA and DOD efforts
to exchange patient health information, we reviewed our previous work,
analyzed documents on various health initiatives, and interviewed VA
and DOD officials about current status and future plans. The costs that
have been incurred for the various projects were provided by cognizant
VA and DOD officials. We did not audit the reported costs and thus
cannot attest to their accuracy or completeness. All work on which this
testimony is based was conducted in accordance with generally accepted
government auditing standards.
Results in Brief
VA and DOD have been pursuing ways to share data in their health
information systems and create comprehensive electronic medical records
since 1998, following the call for the development of a comprehensive
integrated system to allow the two departments to share patient health
information. However, the departments have faced considerable
challenges, leading to repeated changes in the focus of their
initiatives and target dates. In reviewing the departments' initial
project, we noted disappointing progress, exacerbated by inadequate
accountability and poor planning and oversight, which raised doubts
about the departments' ability to achieve a comprehensive electronic
medical record. We made recommendations aimed at enhancing management
and accountability by, among other things, the creation of
comprehensive and coordinated plans that included an agreed-upon
mission and clear goals, objectives, and performance measures. In
response, the departments refocused the project and divided it into
long- and short-term initiatives. The long-term initiative, still
ongoing, is to develop a common health information architecture that
would allow the two-way exchange of health information through the
development of modern health information systems. The short-term
initiative (the Federal Health Information Exchange) was to enable DOD
to electronically transfer to VA health information on servicemembers
when they leave the military; this initiative was completed in 2004.
Other short-term initiatives were subsequently established that were
similarly focused on sharing information in existing systems, an
important requirement until the departments' modern health information
systems are completed. In particular, two demonstration projects were
established in 2004 in response to congressional mandate, one of which
led the two departments to develop an interim strategy to connect
existing systems and allow information sharing among them. Finally, the
two departments announced in January 2007 a further new strategy: their
intention to jointly develop a new inpatient medical record system. The
departments have indicated that by adopting a joint solution, they
could realize significant cost savings and make inpatient healthcare
data immediately accessible to both departments.
VA and DOD have made progress in both their long-term and short-
term initiatives to share health information, but much work remains to
achieve the goal of a shared electronic medical record and seamless
transition between the two departments. In the long-term project to
develop modernized health information systems, the departments have
begun to implement the first release of the interface between their
modernized data repositories, and computable outpatient pharmacy and
drug allergy data are being exchanged at seven VA and DOD sites.
Although the data being exchanged are limited, implementing this
interface is a milestone toward the long-term goal of modernized
systems with interoperable electronic medical records. In the meantime,
the two departments have also made progress in their short-term
projects to share information in existing systems. Besides completing
the Federal Health Information Exchange, the departments have made
progress on two demonstration projects:
The Laboratory Data Sharing Interface, which allows DOD
and VA facilities serving the same geographic area to share laboratory
resources, is deployed at 9 localities to communicate orders for lab
test and their results electronically and can be deployed at others if
the need is demonstrated.
The Bidirectional Health Information Exchange, which
allows a real-time, two-way view of health data from existing
systems,\3\ provides this capability (for outpatient data) to all VA
sites and 25 DOD sites and (for certain inpatient discharge summary
data) \4\ to all VA sites and 5 DOD sites. Expanding this interface is
the foundation of the departments' interim strategy to share
information among their existing systems.
---------------------------------------------------------------------------
\3\ DOD's Composite Health Care System (CHCS) and VA's VistA
(Veterans Health Information Systems and Technology Architecture).
\4\ Specifically, inpatient discharge summary data stored in VA's
VistA and DOD's Clinical Information System (CIS), a commercial health
information system customized for DOD.
In addition to their technology efforts, the two departments have
undertaken ad hoc activities to accelerate the transmission of health
information on severely wounded patients from DOD to VA's four
polytrauma centers, which care for veterans and servicemembers with
disabling injuries to more than one physical region or organ system.
These ad hoc processes include manual workarounds such as scanning
paper records and individually transmitting radiological images. Such
processes are generally feasible only because the number of polytrauma
patients is small (about 350 in all to date).
Through all these efforts, VA and DOD are achieving exchanges of
health information. However, these exchanges are as yet limited, and it
is not clear how they are to be integrated into an overall strategy
toward achieving the departments' long-term goal of comprehensive,
seamless exchange of health information. To achieve this goal,
significant work remains to be done, including agreeing to standards
for the remaining categories of medical information, populating the
data repositories with all this information, completing the development
of their modernized systems, and transitioning from the legacy systems.
Consequently, it is essential for the departments to develop a
comprehensive project plan to guide this effort to completion, in line
with our earlier recommendations.
Background
In their efforts to modernize their health information systems and
share medical information, VA and DOD begin from different positions.
As shown in table 1, VA has one integrated medical information system,
VistA (Veterans Health Information Systems and Technology
Architecture), which uses all electronic records. All 128 VA medical
sites thus have access to all VistA information.\5\ (Table 1 also
shows, for completeness, VA's planned modernized system and its
associated data repository.)
---------------------------------------------------------------------------
\5\ A site represents one or more facilities--medical centers,
hospitals, or outpatient clinics--that store their electronic health
data in a single database.
Table 1. VA Medical Information Systems
----------------------------------------------------------------------------------------------------------------
System name Description
----------------------------------------------------------------------------------------------------------------
Legacy systems
----------------------------------------------------------------------------------------------------------------
VistA Veterans Health Information Existing integrated health information system.
Systems and Technology
Architecture
----------------------------------------------------------------------------------------------------------------
Modernized system and repository
----------------------------------------------------------------------------------------------------------------
HealtheVet VistA Modernized health information system based on
computable data.
----------------------------------------------------------------------------------------------------------------
HDR Health Data Repository Data repository associated with modernized system.
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of VA data.
In contrast, DOD has multiple medical information systems (see
table 2). DOD's various systems are not integrated, and its 138 sites
do not necessarily communicate with each other. In addition, not all of
DOD's medical information is electronic: some records are paper-based.
Table 2. Selected DOD Medical Information Systems
----------------------------------------------------------------------------------------------------------------
System name Description
----------------------------------------------------------------------------------------------------------------
Legacy systems
----------------------------------------------------------------------------------------------------------------
CHCS Composite Health Care System Primary existing DOD health information system.
----------------------------------------------------------------------------------------------------------------
CIS Clinical Information System Commercial health information system customized for
DOD; used by some DOD facilities for inpatients.
----------------------------------------------------------------------------------------------------------------
ICDB Integrated Clinical Database Health information system used by many Air Force
facilities.
----------------------------------------------------------------------------------------------------------------
TMDS Theater Medical Data Store Database to collect electronic medical information
in combat theater for both outpatient care and
serious injuries.
----------------------------------------------------------------------------------------------------------------
JPTA Joint Patient Tracking Web-based application primarily used to track the
Application movement of patients as they are transferred from
location to location, but may include text-based
medical information.
----------------------------------------------------------------------------------------------------------------
Modernized system and repository
----------------------------------------------------------------------------------------------------------------
AHLTA Armed Forces Health Modernized health information system, integrated
Longitudinal Technology and based on computable data.
Application \a\
----------------------------------------------------------------------------------------------------------------
CDR Clinical Data Repository Data repository associated with modernized system.
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of DOD data.
\a\ Formerly CHCS II.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
VA and DOD Have Been Working to Exchange Health Information Since 1998
For almost a decade, VA and DOD have been pursuing ways to share
data in their health information systems and create comprehensive
electronic records.\6\ However, the departments have faced considerable
challenges, leading to repeated changes in the focus of their
initiatives and target dates for accomplishment.
---------------------------------------------------------------------------
\6\ Initially, the Indian Health Service (IHS) was also a party to
this effort, having been included because of its population-based
research expertise and its longstanding relationship with VA. However,
IHS was not included in a later revised strategy for electronically
sharing patient health information.
As shown in figure 1, the departments' efforts have involved a
number of dis-
tinct initiatives, both long-term initiatives to develop future
modernized solutions, and short-term initiatives to respond to more
immediate needs to share information in existing systems. As the figure
---------------------------------------------------------------------------
shows, these initiatives often proceeded in parallel.
The departments' first initiative, known as the Government
Computer-Based Patient Record (GCPR) project, aimed to develop an
electronic interface that would let physicians and other authorized
users at VA and DOD health facilities access data from each other's
health information systems. The interface was expected to compile
requested patient information in a virtual record (that is, electronic
as opposed to paper) that could be displayed on a user's computer
screen.
In 2001 and 2002, we reviewed the GCPR project and noted
disappointing progress, exacerbated in large part by inadequate
accountability and poor planning and oversight, which raised doubts
about the departments' ability to achieve a virtual medical record. We
determined that the lack of a lead entity, clear mission, and detailed
planning to achieve that mission made it difficult to monitor progress,
identify project risks, and develop appropriate contingency plans.\7\
We made recommendations in both years that the departments enhance the
project's overall management and accountability. In particular, we
recommended that the departments designate a lead entity and a clear
line of authority for the project; create comprehensive and coordinated
plans that include an agreed-upon mission and clear goals, objectives,
and performance measures; revise the project's original goals and
objectives to align with the current strategy; commit the executive
support necessary to adequately manage the project; and ensure that it
followed sound project management principles.
---------------------------------------------------------------------------
\7\ GAO, Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results, GAO-02-703 (Washington, D.C.:
June 12, 2002) and Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-
01-459 (Washington, D.C.: Apr. 30, 2001).
In response, the two departments revised their strategy in July
2002, refocusing the project and dividing it into two initiatives. A
short-term initiative (the Federal Health Information Exchange or FHIE)
was to enable DOD, when servicemembers left the military, to
electronically transfer their health information to VA. VA was
designated as the lead entity for implementing FHIE, which was
successfully completed in 2004. A longer term initiative was to develop
a common health information architecture that would allow the two-way
exchange of health information. The common architecture is to include
standardized, computable data, communications, security, and high-
performance health information systems (these systems, DOD's CHCS II
and VA's HealtheVet VistA, were already in development, as shown in the
figure).\8\ The departments' modernized systems are to store
information (in standardized, computable form) in separate data
repositories: DOD's Clinical Data Repository (CDR) and VA's Health Data
Repository (HDR). The two repositories are to exchange information
through an interface named CHDR.\9\
---------------------------------------------------------------------------
\8\ DOD's existing Composite Health Care System (CHCS) was being
modernized as CHCS II, now renamed AHLTA (Armed Forces Health
Longitudinal Technology Application). VA's existing VistA system was
being modernized as HealtheVet VistA.
\9\ The name CHDR, pronounced ``cheddar,'' combines the names of
the two repositories.
In March 2004, the departments began to develop the CHDR interface,
and they planned to begin implementation by October 2005.\10\ However,
implementation of the first release of the interface (at one site)
occurred in September 2006, almost a year later. In a review in June
2004, we identified a number of management weaknesses that could have
contributed to this delay \11\ and made a number of recommendations,
including creation of a comprehensive and coordinated project
management plan. In response, the departments agreed to our
recommendations and improved the management of the CHDR program by
designating a lead entity with final decisionmaking authority and
establishing a project management structure. As we noted in later
testimony, however, the program did not develop a project management
plan that would give a detailed description of the technical and
managerial processes necessary to satisfy project requirements
(including a work breakdown structure and schedule for all development,
testing, and implementation tasks), as we had recommended.\12\
---------------------------------------------------------------------------
\10\ December 2004 VA and DOD Joint Strategic Plan.
\11\ 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).
\12\ GAO, Computer-Based Patient Records: VA and DOD Made Progress,
but Much Work Remains to Fully Share Medical Information, GAO-05-1051T
(Washington, D.C.: Sept. 28, 2005) and Information Technology: VA and
DOD Face Challenges in Completing Key Efforts, GAO-06-905T (Washington,
D.C.: June 22, 2006).
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In October 2004, the two departments established two more short-
term initiatives in response to a congressional mandate.\13\ These were
two demonstration projects: the Laboratory Data Sharing Interface,
aimed at allowing VA and DOD facilities to share laboratory resources,
and the Bidirectional Health Information Exchange (BHIE), aimed at
allowing both departments' clinicians access to records on shared
patients (that is, those who receive care from both departments).\14\
As demonstration projects, both initiatives were limited in scope, with
the intention of providing interim solutions to the departments' need
for more immediate health information sharing. However, because BHIE
provided access to up-to-date information, the departments' clinicians
expressed strong interest in increasing its use. As a result, the
departments began planning to broaden BHIE's capabilities and expand
its implementation considerably. Until the departments' modernized
systems are fully developed and implemented, extending BHIE
connectivity could provide each department with access to most data in
the other's legacy systems. According to a VA/DOD annual report \15\
and program officials, the departments now consider BHIE an interim
step in their overall strategy to create a two-way exchange of
electronic medical records.
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\13\ The Bob Stump National Defense Authorization Act for Fiscal
Year 2003 (Pub. L. 107-314, 2002) mandated that the departments conduct
demonstration projects to test the feasibility, advantages, and
disadvantages of measures and programs designed to improve the sharing
and coordination of healthcare and healthcare resources between the
departments.
\14\ To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project. Unlike FHIE, which provides a one-way transfer of information
to VA when a servicemember separates from the military, the two-way
system allows clinicians in both departments to view, in real time,
limited health data (in text form) from the departments' current health
information systems.
\15\ December 2004 VA and DOD Joint Strategic Plan.
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Most recently, the departments have announced a further change to
their information-sharing strategy. In January 2007, they announced
their intention to jointly develop a new inpatient medical record
system. According to the departments, adopting this joint solution will
facilitate the seamless transition of active-duty servicemembers to
veteran status, as well as making inpatient healthcare data on shared
patients immediately accessible to both DOD and VA. In addition, the
departments consider that a joint development effort could allow them
to realize significant cost savings. We have not evaluated the
departments' plans or strategy in this area.
Others Have Recommended Strengthening the Management and Planning of
the Departments' Health Information Initiatives
Throughout the history of these initiatives, evaluations beyond
ours have also found deficiencies in the departments' efforts,
especially with regard to the need for comprehensive planning. For
example, in fiscal year 2006, the Congress did not provide all the
funding requested for HealtheVet VistA because it did not consider that
the funding had been adequately justified. In addition, a recent
Presidential task force identified the need for VA and DOD to improve
their long-term planning.\16\ This task force, reporting on gaps in
services provided to returning veterans, noted problems with regard to
sharing information on wounded servicemembers, including the inability
of VA providers to access paper DOD inpatient health records. According
to the report, although significant progress has been made on sharing
electronic information, more needs to be done. The task force
recommended that VA and DOD continue to identify long-term initiatives
and define scope and elements of a joint inpatient electronic health
record.
---------------------------------------------------------------------------
\16\ Task Force on Returning Global War on Terror Heroes, Report to
the President (Apr. 19, 2007).
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VA and DOD Are Exchanging Limited Medical Information, but Much Work
Remains to Achieve Seamless Sharing
VA and DOD have made progress in both their long-term and short-
term initiatives to share health information. In the long-term project
to develop modernized health information systems, the departments have
begun to implement the first release of the interface between their
modernized data repositories, among other things. The two departments
have also made progress in their short-term projects to share
information in existing systems, having completed two initiatives and
making important progress on another. In addition, the two departments
have undertaken ad hoc activities to accelerate the transmission of
health information on severely wounded patients from DOD to VA's four
polytrauma centers. However, despite the progress made and the sharing
achieved, the tasks remaining to achieve the goal of a shared
electronic medical record remain substantial.
VA and DOD Have Begun Deployment of a Modernized Data Interface
In their long-term effort to share health information, VA and DOD
have completed the development of their modernized data repositories,
agreed on standards for various types of data, and begun to populate
the repositories with these data.\17\ In addition, they have now
implemented the first release of the CHDR interface, which links the
two departments' repositories, at seven sites. The first release has
enabled the seven sites to share limited medical information:
specifically, computable outpatient pharmacy and drug allergy
information for shared patients.
---------------------------------------------------------------------------
\17\ DOD has populated CDR with information for outpatient
encounters, drug allergies, and order entries and results for
outpatient pharmacy/lab orders. VA has populated HDR with patient
demographics, vital signs records, allergy data, and outpatient
pharmacy data; this summer, the department plans to include chemistry
and hematology laboratory data.
---------------------------------------------------------------------------
According to DOD officials, in the third quarter of 2007 the
department will send out instructions to its remaining sites so that
they can all begin using CHDR. According to VA officials, the interface
will be available across the department when necessary software updates
are released, which is expected this July.\18\
---------------------------------------------------------------------------
\18\ The Remote Data Interoperability software upgrade provides the
capability for the automated checks and alerts allowed by computable
data.
---------------------------------------------------------------------------
Besides being a milestone in the development of the departments'
modernized systems, the interface implementation provides benefits to
the departments' current systems. Data transmitted by CHDR are
permanently stored in the modernized data repositories, CDR and HDR.
Once in the repositories, these computable data can be used by DOD and
VA at all sites through their existing systems. CHDR also provides
terminology mediation (translation of one agency's terminology into the
other's). VA and DOD plans call for developing the capability to
exchange computable laboratory results data through CHDR during fiscal
year 2008.
Although implementing this interface is an important
accomplishment, the departments are still a long way from completion of
the modernized health information systems and comprehensive
longitudinal health records. While DOD and VA had originally projected
completion dates for their modernized systems of 2011 and 2012,
respectively, department officials told us that there is currently no
scheduled completion date for either system. Further, both departments
have still to identify the next types of data to be stored in the
repositories. The two departments will then have to populate the
repositories with the standardized data, which involves different tasks
for each department. Specifically, although VA's medical records are
already electronic, it still has to convert these into the
interoperable format appropriate for its repository. DOD, in addition
to converting current records from its multiple systems, must also
address medical records that are not automated. As pointed out by a
recent Army Inspector General's report, some DOD facilities are having
problems with hard-copy records.\19\ In the same report, inaccurate and
incomplete health data were identified as a problem to be addressed.
Before the departments can achieve the long-term goal of seamless
sharing of medical information, all these tasks and challenges will
have to be addressed. Consequently, it is essential for the departments
to develop a comprehensive project plan to guide these efforts to
completion, as we have previously recommended.
---------------------------------------------------------------------------
\19\ Inspector General, Army, Army Physical Disability Evaluation
System Inspection (March 2007).
---------------------------------------------------------------------------
VA and DOD Are Exchanging Limited Health Information through Short-Term
Projects
In addition to the long-term effort described above, the two
departments have made some progress in meeting immediate needs to share
information in their respective legacy systems by setting up short-term
projects, as mentioned earlier, which are in various stages of
completion. In addition, the departments have set up special processes
to transfer data from DOD facilities to VA's polytrauma centers, which
treat traumatic brain injuries and other especially severe injuries.
One-Way Transfer Capability Is Operational
DOD has been using FHIE to transfer information to VA since 2002.
According to department officials, over 184 million clinical messages
on more than 3.8 million veterans have been transferred to the FHIE
data repository as of March 2007. Data elements transferred are
laboratory results, radiology results, outpatient pharmacy data,
allergy information, consultation reports, elements of the standard
ambulatory data record, and demographic data. Further, since July 2005,
FHIE has been used to transfer pre- and post-deployment health
assessment and reassessment data; as of March 2007, VA has access to
data for more than 681,000 separated servicemembers and demobilized
Reserve and National Guard members who had been deployed. Transfers are
done in batches once a month, or weekly for veterans who have been
referred to VA treatment facilities.
According to a joint DOD/VA report,\20\ FHIE has made a significant
contribution to the delivery and continuity of care of separated
servicemembers as they transition to veteran status, as well as to the
adjudication of disability claims.
---------------------------------------------------------------------------
\20\ December 2004 VA and DOD Joint Strategic Plan.
---------------------------------------------------------------------------
Laboratory Interface Initiative Allows VA and DOD to Share Lab
Resources
One of the departments' demonstration projects, the Laboratory Data
Sharing Interface (LDSI), is now fully operational and is deployed when
local agencies have a business case for its use and sign an agreement.
It requires customization for each locality and is currently deployed
at nine locations. LDSI currently supports a variety of chemistry and
hematology tests, and work is under way to include microbiology and
anatomic pathology.
Once LDSI is implemented at a facility, the only nonautomated
action needed for a laboratory test is transporting the specimens. If a
test is not performed at a VA or DOD doctor's home facility, the doctor
can order the test, the order is transmitted electronically to the
appropriate lab (the other department's facility or in some cases a
local commercial lab), and the results are returned electronically.
Among the benefits of LDSI, according to VA and DOD, are increased
speed in receiving laboratory results and decreased errors from manual
entry of orders. The LDSI project manager in San Antonio stated that
another benefit of the project is the time saved by eliminating the
need to rekey orders at processing labs to input the information into
the laboratories' systems. Additionally, the San Antonio VA facility no
longer has to contract out some of its laboratory work to private
companies, but instead uses the DOD laboratory.
Two-Way Interface Allows Real-Time Viewing of Text Information
Developed under a second demonstration project, the BHIE interface
is now available throughout VA and partially deployed at DOD. It is
currently deployed at 25 DOD sites, providing access to 15 medical
centers, 18 hospitals, and over 190 outpatient clinics associated with
these sites. DOD plans to make current BHIE capabilities available
departmentwide by June 2007.
The interface permits a medical care provider to query patient data
from all VA sites and any DOD site where it is installed and to view
that data onscreen almost immediately. It not only allows DOD and VA to
view each other's information, it also allows DOD sites to see
previously inaccessible data at other DOD sites.
As initially developed, the BHIE interface provides access to
information in VA's VistA and DOD's CHCS, but it is currently being
expanded to query data in other DOD databases (in addition to CHCS). In
particular, DOD has developed an interface to the Clinical Information
System (CIS), an inpatient system used by many DOD facilities, which
will provide bidirectional views of discharge summaries. The BHIE-CIS
interface is currently deployed at five DOD sites and planned for eight
others. Further, interfaces to two additional systems are planned for
June and July 2007: An interface to DOD's modernized data repository,
CDR, will give access to outpatient data from combat theaters. An
interface to another DOD database, the Theater Medical Data Store, will
give access to inpatient information from combat theaters.
The departments also plan to make more data elements available.
Currently, BHIE enables text-only viewing of patient identification,
outpatient pharmacy, microbiology, cytology, radiology, laboratory
orders, and allergy data from its interface with DOD's CHCS. Where it
interfaces with CIS, it also allows viewing of discharge summaries from
VA and the fiveDOD sites. DOD staff told us that in early fiscal year
2008, they plan to add provider notes, procedures, and problem lists.
Later in fiscal year 2008, they plan to add vital signs, scanned images
and documents, family history, social history, and other history
questionnaires. In addition, at the VA/DOD site in El Paso, a trial is
under way of a process for exchanging radiological images using the
BHIE/FHIE infrastructure.\21\ Some images have successfully been
exchanged.
---------------------------------------------------------------------------
\21\ To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project.
---------------------------------------------------------------------------
Through their efforts on these long- and near-term initiatives, VA
and DOD are achieving exchanges of various types of health information
(see attachment 1 for a summary of all the types of data currently
being shared and those planned for the future, as well as cost data on
the initiatives). However, these exchanges are as yet limited, and
significant work remains to be done to expand the data shared and
integrate the various initiatives.
Special Procedures Provide Information to VA Polytrauma Centers
In addition to the information technology initiatives described,
DOD and VA have set up special activities to transfer medical
information to VA's four polytrauma centers, which are treating active-
duty servicemembers severely wounded in combat.\22\ Polytrauma centers
care for veterans and returning servicemembers with injuries to more
than one physical region or organ system, one of which may be life
threatening, and which results in physical, cognitive, psychological,
or psychosocial impairments and functional disability. Some examples of
polytrauma include traumatic brain injury (TBI), amputations, and loss
of hearing or vision.
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\22\ In particular, clinicians required access to discharge
notices, which describe the treatment given at previous medical
facilities and the status of patients when they left those facilities.
When servicemembers are seriously injured in a combat theater
overseas, they are first treated locally. They are then generally
evacuated to Landstuhl Medical Center in Germany, after which they are
transferred to a military treatment facility in the United States,
usually Walter Reed Army Medical Center in Washington, D.C.; the
National Naval Medical Center in Bethesda, Maryland; or Brooke Army
Medical Center, at Fort Sam Houston, Texas. From these facilities,
servicemembers suffering from polytrauma may be transferred to one of
VA's four polytrauma centers for treatment.\23\
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\23\ The four Polytrauma Rehabilitation Centers are in Richmond,
Tampa, Minneapolis, and Palo Alto.
At each of these locations, the injured servicemembers will
accumulate medical records, in addition to medical records already in
existence before they were injured. However, the DOD medical
information is currently collected in many different systems and is not
---------------------------------------------------------------------------
easily accessible to VA polytrauma centers. Specifically:
1. In the combat theater, electronic medical information may be
collected for a variety of reasons, including routine outpatient care,
as well as serious injuries. These data are stored in the Theater
Medical Data Store, which can be accessed by unit commanders and
others. (As mentioned earlier, the departments have plans to develop a
BHIE interface to this system by July 2007. Until then, VA cannot
access these data.) In addition, both inpatient and outpatient medical
data for patients who are evacuated are entered into the Joint Patient
Tracking Application. (A few VA polytrauma center staff have been given
access to this application.)
2. At Landstuhl, inpatient medical records are paper-based (except
for discharge summaries). The paper records are sent with a patient as
the individual is transferred for treatment in the United States. At
the DOD treatment facility (Walter Reed, Bethesda, or Brooke),
additional information will be recorded in CIS and CHCS/CDR.\24\
---------------------------------------------------------------------------
\24\ Pharmacy and drug information would be stored in CDR; other
health information continues to be stored in local CHCS databases.
When servicemembers are transferred to a VA polytrauma center, VA
and DOD have several ad hoc processes in place to electronically
---------------------------------------------------------------------------
transfer the patients' medical information:
DOD has set up secure links to enable a limited number of
clinicians at the polytrauma centers to log directly into CIS at Walter
Reed and Bethesda Naval Hospital to access patient data.
Staff at Walter Reed collect paper records, print records
from CIS, scan all these, and transmit the scanned data to three of the
four polytrauma centers. DOD staff said that they are working on
establishing this capability at the Brooke and Bethesda medical
centers, as well as the fourth VA polytrauma center. According to VA
staff, although the initiative began several months ago, it has only
recently begun running smoothly as the contractor became more skilled
at assembling the records. DOD staff also pointed out that this
laborious process is feasible only because the number of polytrauma
patients is small (about 350 in all to date); it would not be practical
on a large scale.
Staff at Walter Reed and Bethesda are transmitting
radiology images electronically to three polytrauma centers. (A fourth
has this capability, but at this time no radiology images have been
transferred there.) Access to radiology images is a high priority for
polytrauma center doctors, but like scanning paper records,
transmitting these images requires manual intervention: when each image
is received at VA, it must be individually uploaded to VistA's imagery
viewing capability. This process would not be practical for large
volumes of images.
VA has access to outpatient data (via BHIE) from 25
military hospitals, including Landstuhl.
Although these various efforts to transfer medical information on
seriously wounded patients are working, and the departments are to be
commended on their efforts, the multiple processes and laborious manual
tasks illustrate the effects of the lack of integrated health
information systems and the difficulties of exchanging information in
their absence.
In conclusion, through the long- and short-term initiatives
described, as well as efforts such as those at the polytrauma centers,
VA and DOD are achieving exchanges of health information. However,
these exchanges are as yet limited, and significant work remains to be
done to fully achieve the goal of exchanging interoperable, computable
data, including agreeing to standards for the remaining categories of
medical information, populating the data repositories with all this
information, completing the development of HealtheVet VistA and AHLTA,
and transitioning from the legacy systems. To complete these tasks, a
detailed project management plan continue to be of vital importance to
the ultimate success of the effort to develop a lifelong virtual
medical record. We have previously recommended that the departments
develop a clearly defined project management plan that describes the
technical and managerial processes necessary to satisfy project
requirements, including a work breakdown structure and schedule for all
development, testing, and implementation tasks. Without a plan of
sufficient detail, VA and DOD increase the risk that the long-time
project will not deliver the planned capabilities in the time and at
the cost expected. Further, it is not clear how all the initiatives we
have described today are to be incorporated into an overall strategy
toward achieving the departments' goal of comprehensive, seamless
exchange of health information.
Mr. Chairman, this concludes my statement. I would be happy to
respond to any questions that you or other Members of the Subcommittee
may have.
__________
Contacts and Acknowledgments
If you have any questions concerning this testimony, please contact
Valerie C. Melvin, Director, Human Capital and Management Information
Systems Issues, at (202) 512-6304 or [email protected]. Other individuals
who made key contributions to this testimony include Barbara Oliver,
Assistant Director; Barbara Collier; and Glenn Spiegel.
Attachment 1: Supplementary Tables
Types of Data Shared by DOD and VA Are Growing but Remain Limited
Table 3 summarizes the types of health data currently shared
through the long- and near-term initiatives we have described, as well
as types of data that are currently planned for addition. While this
gives some indication of the scale of the tasks involved in sharing
medical information, it does not depict the full extent of information
that is currently being captured in health information systems and that
remains to be addressed.
Table3. DataElementsMadeAvailableandPlannedbyDOD-VAInitiatives
----------------------------------------------------------------------------------------------------------------
Data Elements
Initiative ----------------------------------------------------- Comments
Available Planned
----------------------------------------------------------------------------------------------------------------
CHDR Outpatient pharmacy LaboratoryComputable data are
Drug allergy exchanged between one
department's data
repository and the other's.
----------------------------------------------------------------------------------------------------------------
FHIE Patient demographics None One-way batch transfer of
Laboratory results text data from DOD to VA
Radiology reports occurs weekly if discharged
Outpatient pharmacy patient has been referred
information to VA for treatment;
Admission discharge transfer otherwise monthly.
data
Discharge summaries
Consult reports
Allergies
Data from the DOD Standard
Ambulatory Data Record
Pre- and post-deployment
assessments
----------------------------------------------------------------------------------------------------------------
LDSI LaboratMicrobiology Noncomputable text data are
Laboratory Anatomic(chemistry transferred.
and hematology only) pathology
----------------------------------------------------------------------------------------------------------------
BHIE Outpatient pharmacy data Provider notes Data are not transferred
Drug & food allergy information Procedures but can be viewed.
Surgical pathology reports Problem lists
Microbiology results Vital signs
Cytology reports Scanned images
Chemistry & hematology anddocuments
reports Family history
LaborSocial history
Radiology text reports Other history
Inpatient discharge summaries questionnaires
and/or emergency room notes Radiology images
from CIS at five DOD and all
VA sites
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of VA and DOD data.
Reported Costs
Table 4 shows costs expended on these information sharing
initiatives since their inception.
Table 4. Costs of DOD and VA Initiatives Since Inception
----------------------------------------------------------------------------------------------------------------
Project VA Expenditure DOD Expenditure
----------------------------------------------------------------------------------------------------------------
HealtheVet $514 million through FY 2005 --
VistA
----------------------------------------------------------------------------------------------------------------
AHLTA -- $755 million through FY 2006
(estimated)
----------------------------------------------------------------------------------------------------------------
Joint initiatives:
----------------------------------------------------------------------------------------------------------------
CHDR 5.3 million through about DOD does not account for these projects
----------------------------------------------------
April 2007 separately.
FHIE 62.4 million
----------------------------------------------------
LDSI 1.5 million
----------------------------------------------------
BHIE 7.0 million
----------------------------------------------------------------------------------------------------------------
Total $76.2 million $72.6 million through FY 2006
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of DOD and VA data.
Related GAO Products
Computer-Based Patient Records: Better Planning and Oversight by
VA, DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459.
Washington, D.C.: April 30, 2001.
Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results. GAO-02-703. Washington, D.C.:
June 12, 2002.
Computer-Based Patient Records: Short-Term Progress Made, but Much
Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD
Health Systems. GAO-04-271T. Washington, D.C.: November 19, 2003.
Computer-Based Patient Records: Sound Planning and Project
Management Are Needed to Achieve a Two-Way Exchange of VA and DOD
Health Data. GAO-04-402T. Washington, D.C.: March 17, 2004.
Computer-Based Patient Records: VA and DOD Efforts to Exchange
Health Data Could Benefit from Improved Planning and Project
Management. GAO-04-687. Washington, D.C.: June 7, 2004.
Computer-Based Patient Records: VA and DOD Made Progress, but Much
Work Remains to Fully Share Medical Information. GAO-05-1051T.
Washington, D.C.: September 28, 2005.
Information Technology: VA and DOD Face Challenges in Completing
Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
DOD and VA Exchange of Computable Pharmacy Data. GAO-07-554R.
Washington, D.C.: April 30, 2007.
__________
GAO HIGHLIGHTS
INFORMATION TECHNOLOGY--VA and DOD Are Making Progress In Sharing
Medical Information, But are Far From Comprehensive Electronic Medical
Records
Why GAO Did This Study
The Department of Veterans Affairs (VA) and the Department of
Defense (DOD) are engaged in ongoing efforts to share medical
information, which is important in helping to ensure high-quality
healthcare for active-duty military personnel and veterans. These
efforts include a long-term program to develop modernized health
information systems based on computable data: that is, data in a format
that a computer application can act on--for example, to provide alerts
to clinicians of drug allergies. In addition, the departments are
engaged in near-term initiatives involving existing systems.
GAO was asked to testify on the history and current status of these
long- and near-term efforts to share health information.
To develop this testimony, GAO reviewed its previous work, analyzed
documents, and interviewed VA and DOD officials about current status
and future plans.
What GAO Recommends
GAO has previously made several recommendations on these topics,
including that VA and DOD develop a detailed project management plan to
guide their efforts to share patient health data. The departments
agreed with these recommendations.
What GAO Found
For almost a decade, VA and DOD have been pursuing ways to share
health information and create comprehensive electronic medical records.
However, they have faced considerable challenges in these efforts,
leading to repeated changes in the focus of their initiatives and
target dates. Currently, the two departments are pursuing both long-
and short-term initiatives to share health information. Under their
long-term initiative, the modern health information systems being
developed by each department are to share standardized computable data
through an interface between data repositories associated with each
system. The repositories have now been developed, and the departments
have begun to populate them with limited types of health information.
In addition, the interface between the repositories has been
implemented at seven VA and DOD sites, allowing computable outpatient
pharmacy and drug allergy data to be exchanged. Implementing this
interface is a milestone toward the departments' long-term goal, but
more remains to be done. Besides extending the current capability
throughout VA and DOD, the departments must still agree to standards
for the remaining categories of medical information, populate the data
repositories with this information, complete the development of the two
modernized health information systems, and transition from their
existing systems. While pursuing their long-term effort to develop
modernized systems, the two departments have also been working to share
information in their existing systems. Among various near-term
initiatives are a completed effort to allow the one-way transfer of
health information from DOD to VA when servicemembers leave the
military, as well as ongoing demonstration projects to exchange limited
data at selected sites. One of these projects, building on the one-way
transfer capability, developed an interface between certain existing
systems that allows a two-way view of current data on patients
receiving care from both departments. VA and DOD are now working to
link other systems via this interface and extend its capabilities. The
departments have also established ad hoc processes to meet the
immediate need to provide data on severely wounded servicemembers to
VA's polytrauma centers, which specialize in treating such patients.
These processes include manual workarounds (such as scanning paper
records) that are generally feasible only because the number of
polytrauma patients is small. These multiple initiatives and ad hoc
processes highlight the need for continued efforts to integrate
information systems and automate information exchange. In addition, it
is not clear how all the initiatives are to be incorporated into an
overall strategy focused on achieving the departments' goal of
comprehensive, seamless exchange of health information.
Statement of Gerald M. Cross, M.D., FAAFP,
Acting Principal Deputy Under Secretary for Health,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and Members of the Subcommittee. I am
pleased to discuss sharing electronic medical records between the
Department of Defense (DoD) and the Department of Veterans Affairs (VA)
and the significant progress VA has made toward the development of a
secure, interoperable and bidirectional electronic health data sharing
with DoD.
Overview
This progress includes the development of one way and bidirectional
data exchanges to support servicemembers who are separated and retired
from active duty service. In addition, the data exchanges support
active duty servicemembers and veterans who receive care from both VA
and DoD healthcare facilities. VA's achievements in the area of
electronic health data sharing with DoD directly support the efforts to
seamlessly transition our service men and women as they move from DoD
facilities to VA facilities and Centers of Excellence to continue their
care and rehabilitation. Striving to provide world class healthcare to
the wounded warriors returning from Iraq and Afghanistan remains one of
VA's top priorities.
In March 2007, VA added a personal touch to seamless transition by
creating 100 new Transition Patient Advocates (TPA). They are dedicated
to assisting our most severely injured veterans and their families. The
TPA's job is to ensure a smooth transition to VA healthcare facilities
throughout the nation and cut through red tape for other VA benefits.
Recruitment to fill the TPA positions began in March, and to date VA
medical centers have hired 46 TPAs. Interviews are being conducted to
fill the remaining 54 positions. Until these positions are filled, each
medical center with a vacant TPA position has detailed an employee to
perform that function. We believe these new patient advocates will help
VA assure that no severely injured Iraq or Afghanistan veteran falls
through the cracks. VA will continue to adapt its healthcare system to
meet the unique medical issues facing our newest generation of combat
veterans while locating services closer to their homes. DoD and VA
sharing electronic medical records facilitate this process.
It should be noted that sharing electronic medical records between
DoD and VA is a longstanding issue, which has been the subject of
several GAO reviews. Developing an electronic interface to exchange
computable data between disparate systems is a highly complex
undertaking. Let me assure the Committee that VA is fully committed to
ongoing collaboration with DoD and the development of interoperable
electronic health records. While significant and demonstrable progress
has been made in our pilots with DoD, work remains to bring this
commitment to systemwide fruition. VA is always mindful of the debt our
Nation owes to its veterans, and our healthcare system is designed to
fulfill that debt. To that end VA is committed to seeing through the
successful development of interoperable electronic health records.
As part of our commitment to being veteran centric, we recently
deployed the Veterans Tracking Application (VTA). It brings data from
three sources, DoD, the Veterans Health Administration (VHA) and the
Veterans Benefits Administration (VBA) together for display on one
platform creating the beginning of a truly veteran-centric patient
tracking record.
Active Joint Governance
VA and DoD maintain an active joint governance structure at the
highest levels of each department. This joint governance ensures
ongoing collaboration and commitment to advance the further development
of interoperable electronic health records. The records will be
bidirectional, seamless, and available to support the care of our
beneficiaries wherever and whenever treatment is sought.
The DoD/VA Joint Executive Council (JEC), co-chaired by the VA
Deputy Secretary and the DoD Under Secretary of Defense for Personnel
and Readiness, continues its ongoing active executive oversight of
collaborative activities, including health data sharing initiatives. VA
and DoD have documented a Joint Strategic Plan (JSP) that is maintained
by the JEC. The JSP contains the strategic goals, objectives and
milestones for VA/DoD collaboration, including VA and DoD health data
sharing activities. Under the leadership of the JEC, VA and DoD
realized significant success in meeting JSP health data sharing
milestones.
VA and DoD also chartered the DoD/VA Health Executive Council
(HEC), cochaired by VA's Under Secretary for Health and the DoD
Assistant Secretary of Defense for Health Affairs. The HEC serves to
ensure full cooperation and coordination for optimal health delivery to
our veterans and military beneficiaries. Through the HEC Information
Management and Information Technology Work Group, co-chaired by the VHA
Chief Officer, Health Information Technology Systems and the MHS Chief
Information Officer HEC maintain management responsibility for the
implementation of electronic health data sharing activities. These data
sharing activities are largely governed by the DoD/VA Joint Electronic
Health Records Interoperability (JEHRI) Plan, approved in 2002, which
serves as the overarching strategy around which these data sharing
activities are managed.
Supporting Separated Servicemembers and Shared Patients
VA and DoD began JEHRI implementation by developing the capability
to support the one-way and bidirectional transmission of all clinically
pertinent electronic health data between DoD's system, the Composite
Health Information System (CHCS) and VA's medical record, VistA
Computerized Patient Record System. These initial data exchanges
permitted VA clinicians and claims staff to access data on separated
and retired servicemembers coming to VA for medical care and disability
benefits. This exchange allows VA and DoD clinicians to share data on
patients who receive care from both systems. These initial data
exchange initiatives remain an integral component of the ongoing
partnership with DoD to share health data.
To date, DoD transferred electronic health data on almost 3.8
million unique separated servicemembers to VA. Of these individuals, VA
provided care or benefits to more than 2.2 million veterans. On
separated servicemembers, DoD is providing VA with outpatient pharmacy
data, allergy information, laboratory results, consults, admission,
disposition and transfer information, medical diagnostic coding data,
and military pre- and post-deployment health assessment and
reassessment data. Since mid 2006, when DoD first began transferring
pre- and post-deployment health assessment and post deployment health
reassessment data to VA, DoD made approximately l.6 million of these
forms available for viewing by VHA clinicians and VBA staff.
VA and DoD are bidirectionally exchanging electronic medical data
that are viewable and computable on shared patients. In 2004, VA
achieved the ability to match patient identities for active DoD
military servicemembers and their dependents with their electronic
medical records at VA facilities, and deliver care to these patients
whether they present for care at VA or DoD facilities. Currently, VA
and DoD are bidirectionally sharing viewable outpatient pharmacy data,
anatomic pathology/surgical reports, cytology results, microbiology
results, chemistry and hematology laboratory results, laboratory order
information, radiology text reports and food and drug allergy
information.
There are a number of ongoing pilot programs that have developed
into operational capabilities to share increased amounts and types of
viewable data being exchanged between VA and DoD. After a successful
pilot in El Paso, Texas, VA and DoD are now sharing digital images at
this location. The same is true in the Puget Sound area, Hawaii and San
Antonio, Texas where VA and DoD can now share narrative text documents,
such as inpatient discharge summaries. VA successfully implemented
bidirectional capability at every VA medical facility. Bidirectional
Health Information Exchange data is now available to DoD from all of
these facilities. DoD implemented the capability at 25 DoD host
locations. This means VA is receiving these data from 15 DoD medical
centers, 18 DoD hospitals and over 190 DoD outpatient clinics. These
sites include the Walter Reed Army Medical Center and the Bethesda
National Naval Medical Center, the Landstuhl Regional Medical Center in
Germany and the Naval Medical Center, San Diego. VA is working closely
with DoD to increase the scope of data available between DoD and VA and
to ensure the data are available from all DoD medical facilities. By
June 2007, VA and DoD will be sharing data bidirectionally between all
facilities. Throughout the remainder of the year and into 2008, the
types of data shared bidirectionally will increase by adding domains
such as progress notes and problem lists.
In 2006, VA and DoD began sharing bidirectional computable data on
our active dual consumers of both healthcare systems. This capability
is now deployed to seven locations where patients receive care from
both VA and DoD facilities and allows the sharing of computable
pharmacy and allergy data. As a result of this capability, VA providers
benefit by having DoD prescription and allergy data instantly available
to check for medication interactions or medication allergies on
patients who are active dual consumers of both healthcare systems. VA
is also working with DoD to share standardized computable laboratory
data.
In addition to the one way and bidirectional exchange of electronic
medical information, VA and DoD successfully developed a number of
other applications that support information sharing and improve the way
both Departments care for beneficiaries. For example, one of the joint
software initiatives permits VA and DoD to serve as reference
laboratories for one another at locations where VA and DoD use each
other's facilities to order and conduct chemistry laboratory tests and
results reporting. The software is operational at nine locations where
VA and DoD provide laboratory support to one another
Sharing Inpatient Data and Support for the Seriously Wounded
VA and DoD's earliest efforts focused on the sharing of outpatient
data in support of transitioning servicemembers and shared
beneficiaries receiving care from both systems. VA and DoD are now
making significant progress toward the sharing of inpatient data and
data from the theater of operations to support the wounded warriors
coming to us for care. As is commonly understood, much of the DoD
inpatient data exists on paper and is not available electronically. To
ensure VA is fully supporting the most seriously ill and wounded
servicemembers transferred to VA polytrauma facilities, VA social
workers are embedded in designated military treatment facilities to
ensure all pertinent inpatient records are copied and transferred with
the patient.
In addition to ensuring the manual transfer of these inpatient and
paper-based records, we are now able to support the automatic
electronic transfer of inpatient data to VA clinicians who will treat
these patients upon their arrival at VA facilities. VA successfully
achieved the capability to electronically transfer DoD medical digital
images and electronically scanned inpatient health records to the VA.
This effort has been successfully piloted, between the Walter Reed Army
Medical Center and three of the four Level 1 VA Polytrauma Centers
located in Tampa, Richmond, and Palo Alto, California. We are working
now to add the polytrauma center at Minneapolis to this pilot project,
and anticipate this will be accomplished soon. VA is also working to
add this capability from Bethesda national Naval Medical Center and
Brooke Army Medical Center to the four VA polytrauma centers. The pilot
project currently provides VA clinicians, who receive these combat
veterans, with immediate access to critical components of their
inpatient care at DoD military treatment facilities. In the future, VA
hopes to add the capability to provide this data bidirectionally to
support any patients returning to DoD for further care. VA and DoD also
established direct connectivity between the inpatient electronic data
systems at Walter Reed Army Medical Center and Bethesda national Naval
Medical Center and clinicians at the four Level 1 VA Polytrauma
Centers. These direct connections are secure and closely audited to
ensure only authorized personnel at the VA facilities access the
electronic military data on the Operation Enduring Freedom and
Operation Iraqi Freedom servicemembers who are coming to or have
transferred to the VA Polytrauma centers. VA and DoD are finalizing a
long term strategy that will facilitate the expansion of this work
across the enterprise in both departments.
Finally, VA and DoD have undertaken a groundbreaking challenge to
collaborate on a common inpatient electronic health record. On January
24, 2007, the Secretaries of VA and DoD agreed to study the feasibility
of a common inpatient electronic health record system. The initial
phase of this work is expected to last between 6 and 12 months. VA and
DoD are working to identify the requirements that will define the
common VA/DoD inpatient electronic health record. The Departments are
working closely to conduct the joint study and report findings. The
analysis is currently scheduled to be completed in mid FY 2008. At the
conclusion of the study, work to develop the common solution will
immediately begin. A common inpatient electronic health record will
support the transfer of our most seriously injured patients between DoD
facilities and VA facilities as well as broad enterprise-level data
sharing between VA and DoD clinicians for all shared patients.
Veterans Tracking Application
VA also recently deployed a new application with the ability to
track servicemembers from the battlefield through Landstuhl, Germany,
to Military Treatment Facilities (MTFs) in the states, and on to VA
medical facilities. The new application, known as the Veterans Tracking
Application (VTA), is a modified version of DoD's Joint Patient
Tracking Application (JPTA)--a web-based patient tracking and
management tool that collects, manages, and reports on patients
arriving at MTFs from forward-deployed locations. VTA is completely
compatible with JPTA allowing the electronic transfer of DoD tracking
and medical data in JPTA on medically evacuated patients to VA on a
daily basis.
The VTA, also a web-based system, allows approved VA users access
to this near real-time case management information about servicemembers
and the ability to track injured active duty servicemembers as they
move through the medical evacuation and care system and transition to
veteran status. This additional information directly from the
battlefield assists VA in coordinating the transition of healthcare to
VA facilities and in providing high quality healthcare in those VA
facilities after the transfer has been completed. The application is
also designed to track the benefit claims process and greatly enhances
our benefits counselors' ability to assist the servicemember or veteran
with his or her benefit claims. VHA implemented the new system on April
23, 2007 and deployment across VBA is underway. Our VA Liaisons
stationed at ten MTFs now use this new tracking system to communicate
transfers of care to the OEF and OIF points of contact and case
managers at each VA Medical Center. In addition the system provides
electronic access to clinical information from the point of injury in
the combat theater assisting VA medical providers in providing ongoing
healthcare services. VTA brings data from three sources, DoD, VHA and
VBA together for display on one platform creating the beginning of a
truly veteran centric record.
Collaboration on Standards
VA and DoD's work to develop interoperable data exchanges are
closely aligned and dependent upon parallel developments in health data
standards. These efforts are led by the Department of Health and Human
Services (HHS) Office of the National Coordinator for Health
Information Technology (ONC) through which VA and DoD are closely
partnered. As standards and technologies mature, interoperability will
increase. Efforts to ensure the seamless exchange of data between
departments and eventually as part of a national infrastructure, is
dependent upon the adoption and implementation of health data and
communication standards.
VA and DoD played a significant leadership role in the work done
pursuant to the Consolidated Health Informatics (CHI) initiative, one
of the 24 e-gov initiatives that were previously identified on the
President's Management Agenda. Our successful efforts on CHI, under the
guidance of HHS, facilitated the informed and collaborative federal
identification and adoption of health information standards across the
government. Some of these CHI standards have since been incorporated
into our data exchanges. These standards adoption activities, including
CHI, have since been referred to the Health Information Technology
Standards Panel for inclusion in the standards harmonization process,
an activity informed by ONC and the American Health Information
Community (AHIC). VA is an active AHIC participant and will continue to
play a leading role in the national-level discussions on health data
standards adoption and implementation.
VA previously gave Congressional testimony about our close
collaboration with DoD and other partners on the Federal Health
Architecture initiative, known as ``FHA.'' FHA provides VA with a
framework in which we can operate to support the President's goal to
promote interoperable health technology to improve access to
information and efficiency of care across settings. VA remains actively
engaged in FHA activities and appreciates the opportunity to rally
around a unified strategy that ultimately will support provision of
care for all of our veterans, regardless of the private or public
setting. VA strongly believes every veteran's health information should
be available in a secure manner, with the veteran's permission,
wherever that information is needed to provide seamless high quality
healthcare to that veteran.
Conclusion
VA is fully committed to ongoing collaboration with DoD and the
development of bidirectional interoperable electronic health records.
VA also will continue to promote world-class health technologies to
improve healthcare for veterans. As an example, VistA, the VA's
electronic health record was awarded the Harvard University Innovations
in American Government Award in July 2006. VistA was the only
electronic health record to receive this award and was singled out for
its innovation and contribution to provision of high quality care. The
President is monitoring our progress in this area. The Task Force on
Returning Global War on Terror Heroes has made specific recommendations
to the President that DoD and VA continue to improve and ensure timely
electronic access by VA to DoD paper and electronic health records for
servicemembers treated in VA facilities. The President has accepted
these recommendations and directed Secretary Nicholson to report back
to him on how these measures are being implemented. My colleagues and I
are happy to answer any questions you or other Members of the
Subcommittee might have.
__________
VA/DoD Interoperability Acronyms
Healthcare Delivery Systems
AHLTA--Armed Forces Health Longitudinal Technology Application--DoD
Next
generation Electronic Record System--formerly CHCS II
CHCS--Composite Health Care System (DoD legacy system housing order
entry/
labs/radiology/allergy/meds, largely used for ambulatory care
CIS--Clinical Information System (new name is Essentris Clinicomp--
DoD's stand-
alone inpatient system installed in most major military treatment
facilities
CPRS--Computerized Patient Record System
HealtheVet--Next generation of VistA based on computable data
JPTA--DoD's Joint Patient Tracking Application
VistA--Veterans Health Information Systems and Technology Architecture
VistA Web--The VistA web-based application for viewing remote data (VA
and
DoD)
VTA--Veterans Tracking Application
Other
TPA--Transition Patient Advocates
Healthcare Exchange Systems
BHIE--Bidirectional Health Information Exchange
CHDR--Clinical Data Repository/Health Data Repository (Interoperability
Project)
FHIE--Federal Health Information Exchange (formerly GCPR)
LDSI--Laboratory Data Sharing & Interoperability
VPN--Virtual Private Network
Groups/Organizations/Plans
AHIC--American Health Information Community
CHI--Consolidated Health Informatics
HEC--DoD/VA Health Executive Council
JEC--DoD/VA Joint Executive Council
JEHRI--DoD/VA Joint Electronic Health Records Interoperability
JSP--Joint Strategic Plan
MTF--Military Treatment Facilities
ONCHIT--Office of the National Coordinator for Health Information
Technology
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Stephen L. Jones, DHA,
Principal Deputy Assistant Secretary of Defense (Health Affairs),
U.S. Department of Defense
INTRODUCTION
Mr. Chairman and Members of this distinguished Subcommittee, thank
you for inviting me to be here today to discuss the sharing of
electronic medical records between the Department of Defense (DoD) and
Department of Veterans Affairs (VA).
DoD recognizes that the programs and benefits earned by veterans
and servicemembers could not be delivered without the cooperation
between DoD and the VA in the area of information sharing. While we are
aware of the concerns regarding the time it has taken to establish the
desired level of interoperability, I am pleased to tell you today of
the many positive achievements we have made in sharing a significant
amount of electronic health information between DoD and VA. I am also
pleased to discuss with you the efforts we are taking to share more
data.
TOP DoD AND VA PRIORITIES
Dr. Chu, Undersecretary of Defense for Personnel and Readiness, and
Dr. Mansfield, Deputy Secretary for Veterans Affairs, recently
identified the continuity of care for returning wounded warriors and
the inpatient electronic health record project as two of their top
priorities for DoD and VA sharing.
HISTORICAL OVERVIEW
DoD and VA have been sharing electronic health information since
2001 and we continue to enhance and expand our efforts. We recognize
room for improvement remains. Nonetheless, we are leading the nation in
health information technology, implementation of interoperability
standards, and electronic health information sharing. By working
together at the top levels of each Department, we have established
effective policies for sharing. Under our joint governance process and
VA/DoD Joint Strategic Plan (JSP) goals (which I will discuss later in
my statement), we are collaborating in ways that enable each Department
to address unique requirements as well as common requirements.
CURRENT ACTIVITIES
Continuity of Care for Shared Patients. Today for our shared
patients, those treated at both VA and DoD facilities, VA and DoD
providers are able to view data from the other Department. By the end
of 2007, DoD and VA will share electronically many health record data
elements identified in our VA/DoD Joint Strategic Plan for health
information transfer. This means we will have largely established VA
and DoD health record interoperability as agreed to in the JSP by the
Departments' leadership. Specifically, at our fixed facilities we now
share electronic health data elements for outpatient pharmacy data,
laboratory and radiology results, allergy data, Pre- and Post-
Deployment Health Assessments and Post-Deployment Health Reassessments
for individuals referred to VA for care or evaluation. We also share
electronically discharge summaries at 5 sites currently, but will
expand to 13 DoD facilities with the greatest inpatient volume.
Additionally, we have planned near-term enhancements to add encounters/
clinical notes and problem lists, inpatient consultations and operative
reports. In June, all DoD medical facilities will share electronic
health information on shared patients with all VA facilities. In 2008,
we will be sharing the remaining health record data elements identified
in the VA/DoD Joint Strategic Plan including family history, social
history, other history, and questionnaires/forms. At this point we will
have achieved our current health information interoperability goals as
defined in our JSP.
Continuity of Care for Shared Patients: Drug-drug and drug-allergy
interaction checking
For our shared patients we also make outpatient pharmacy and drug
allergy data available in real-time to allow drug-drug and drug-allergy
interaction checking using data from both departments. This capability
is operational in seven locations:
William Beaumont Army Medical Center/El Paso VA Health
Care System
Eisenhower Army Medical Center/Augusta VA Medical Center
Naval Hospital Pensacola/VA Gulf Coast Health Care System
Madigan Army Medical Center/VA Puget Sound Health Care
System
Naval Health Clinic Great Lakes/North Chicago VA Medical
Center
Naval Hospital San Diego/VA San Diego Health Care System
Mike O'Callaghan Federal Hospital and VA Southern Nevada
Health Care System
All 65 DoD hospitals and 412 DoD medical clinics and all VA sites
have access to this data for patients presenting to them for care. This
capability will be deployed DoD-wide this fiscal year.
Continuity of Care for Polytrauma Patients (Wounded Warriors). For
severely wounded or injured patients transferred to VA polytrauma
centers, we begin sending information upon the decision to transfer a
patient to the VA. We already transmit digital radiology images and
scanned medical records between Walter Reed Army Medical Center and
each of the four VA Polytrauma Centers, and have partially implemented
this solution for the National Naval Medical Center, Brooke Army
Medical Centerand the four VA Polytrauma Centers. All three of our DoD
major trauma centers and the VA Polytrauma Centers will have this
capability to transfer images and scanned medical records this year.
Separated Servicemembers (Potential VA Patients). For more than 3.8
million former servicemembers eligible for care from VA, we have made
electronic health information available to VA. In 2001, we began
sharing historical information dating from as early as 1989. Monthly
transfers of electronic health information from DoD to VA began in
2002. The data elements transferred include:
Outpatient pharmacy data, laboratory and radiology
results
Inpatient laboratory and radiology results
Allergy data
Consult reports
Admission, disposition, transfer data
Standard ambulatory data record elements (including
diagnosis and treating physician)
Pre- and post-deployment health assessments
Post-deployment health reassessments
Business Practice Coordination. Where it makes sense or will
enhance quality of care, DoD and VA have collaborated on additional
sharing initiatives. For example, the Laboratory Data Sharing
Initiative established the bidirectional electronic exchange of
laboratory chemistry orders and results when one Department's lab acts
as a reference lab for the other. This means expedited lab testing and
results that enhance the quality of care for our patients. We are
exploring other opportunities such as charge master billing, eHealth
portals, and expanded image sharing, to expand our business practice
coordination.
A Health Information System Tailored to Meet the Needs of the
Warfighter and Military Families (Outpatient Medical Record System).
The question often asked is why do DoD and VA have separate electronic
health record systems. Simply put, DoD and VA have different
requirements.
The Readiness Requirement. DoD must track care in theater using
information systems that operate on desktop computers at a fixed
hospital, laptops at a deployed Combat Support Hospital in Theater, or
handheld devices on the battlefield. In addition, we must have an
electronic health record system that supports continuity of care
through availability in no- and low-communications environments.
Importantly, our medical systems must operate on the command and
control information technology infrastructure. Our requirement is to
use a single system at both fixed facilities and our deployed units so
our servicemembers will not have to learn a new system when they
deploy. Our guiding principle is that we ``train as we fight.'' In
addition, DoD requires highly structured medical data, enabling us to
conduct medical surveillance to identify potential natural disease
outbreaks and/or biological attacks in theater.
Our Beneficiary Population. Finally, the high mobility of both our
patient and provider populations led us to establish a centralized
clinical data repository.
JOINT INPATIENT ELECTRONIC HEALTH RECORD
Recently, we announced that DoD and VA will modernize our inpatient
systems together through a joint acquisition/development effort over
the next several years. Because we have similar inpatient requirements
there is a unique opportunity to explore a coordinated approach with
seamless transition built in. Both Departments believe the timing is
right for this initiative. VA is planning to modernize the inpatient
portion of its electronic medical record, and with the full deployment
of DoD's electronic health record--AHLTA--across the Military Health
System, DoD is poised to incorporate documentation of inpatient care
into AHLTA. Done right, this will support the needs of both Departments
and help ensure the continuity of care, better meet requirements for
joint facilities, and leverage economies of scale in terms of
development and/or integration costs, license fees, and hardware
purchases. To get it right, our approach is to document and assess DoD
and VA inpatient clinical processes, workflows, and requirements;
identify and analyze alternatives for acquisition or development
approaches; and determine benefits and impacts on each Department's
timelines and costs for deploying a common inpatient electronic health
record solution. I also would like to point out that the solution is
not yet defined, and that we should expect one system, not necessarily
one database. Regardless of the solution, we will implement in a way to
ensure data interoperability is built in. Once the requirements
analysis is completed in 2008, we will establish the acquisition/
development timeline based on our assessment of the alternatives.
JOINT GOVERNANCE
Our DoD/VA electronic health information collaboration efforts I've
described are a major component of the VA/DoD Joint Strategic Plan. The
goals of the DoD/VA Joint Executive Council (JEC) are described in the
VA/DoD Joint Strategic Plan for Fiscal Years 2007 through 2009 and
cover a full spectrum of DoD/VA health related sharing. The JECwas
established in January 2002 and cochaired by Under Secretary of Defense
for Personnel and Readiness and the VA Deputy Secretary. It includes
senior DoD and VA health managers involved in sharing initiatives and
meets quarterly. The JEC provides leadership oversight of
interdepartmental cooperation at all levels and to oversee the efforts
of the Health Executive Council and Benefits Executive Council. The
Health Executive Council (HEC) is cochaired by the Assistant Secretary
of Defense (Health Affairs) and VA Under Secretary for Health. It was
formed to establish a high-level program of DoD/VA cooperation and
coordination in a joint effort to reduce costs and improve healthcare
for VA and DoD beneficiaries. The HEC Information Management/
Information Technology (IM/IT) workgroup is co-chaired by Health Chief
Information Officers (CIOs) of the MHS and Veterans Health
Administration. The HEC IM/IT workgroup ensures that appropriate
beneficiary and medical data is visible, accessible and understandable
through secure and interoperable information management systems.
NATIONAL STANDARDS ADOPTION AND IMPLEMENTATION
As I mentioned earlier, we believe we are leading the nation in
health information technology, implementation of interoperability
standards, and electronic health information sharing. As an example of
our efforts to conform to national standards, the Certification
Commission for Healthcare Information Technology (CCHIT) announced on
April 30th that they awarded pre-market, conditional certification of
AHLTA version 3.3 (DoD's electronic health record system). CCHIT is an
independent, non-profit organization that sets the benchmark for
electronic health record systems. AHLTA 3.3 passed a rigorous
inspection process and met 100% of their criteria and we are very proud
of this accomplishment. DoD and VA have been and will continue to be
driving forces supporting the American Health Information Community
(AHIC), the Health IT Policy Council (HITPC), and the Health IT
Standards Panel (HITSP). Our efforts participating in these national
level activities support Executive Order 13410, issued August 2006,
which requires Federal agencies to use recognized health
interoperability standards to promote the direct exchange of health
information between agencies and with non-federal entities. We know
that together the Medicare beneficiaries, DoD beneficiaries, VA
beneficiaries, and Federal employees represents a significant
percentage of insured Americans. This means our efforts can have a
potentially dramatic effect on the private sector adoption of health IT
and will ultimately impact our ability to exchange electronic health
information with private sector providers.
CONCLUSION
I would like to reiterate that the continuity of care for returning
wounded warriors and the inpatient electronic health record project are
our top priorities for DoD and VA electronic health information
sharing. In the last several years, DoD and VA have made significant
progress and are leading the nation in many ways in the sharing of
electronic health information, but there is room for improvement. We
are accelerating our efforts to achieve a greater degree of health
information sharing to support our top priorities. The President is
monitoring our progress in this area. The Task Force on Returning
Global War on Terror Heroes has made specific recommendations to the
President that DoD and VA continue to improve and ensure timely
electronic access by VA to DoD paper and electronic health records for
servicemembers treated in VA facilities. The President has accepted
these recommendations and directed Secretary Nicholson to report back
to him on how these measures are being implemented. DoD and VA are
already working together to accomplish the recommendations made in the
area of electronic health information sharing. In addition, we have
jointly briefed the President's Commission on Care for America's
Returning Wounded Warriors on the current status of DoD/VA electronic
health information sharing and future plans. We look forward to
receiving their recommendations as well. With your support, we will
continue building on our achievements in sharing electronic health
information in support of the men and women who serve and have served
this country.