[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 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.























                            C O N T E N T S

                               __________

                              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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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).
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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.

                                 
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