[Senate Hearing 110-714]
[From the U.S. Government Publishing Office]
S. Hrg. 110-714
HEARING ON SHARING OF VA/DOD ELECTRONIC HEALTH INFORMATION
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 24, 2008
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Arlen Specter, Pennsylvania
Barack Obama, Illinois Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio Lindsey O. Graham, South Carolina
Jim Webb, Virginia Johnny Isakson, Georgia
Jon Tester, Montana Roger F. Wicker, Mississippi
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
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September 24, 2008
SENATORS
Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........ 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 34
Prepared statement........................................... 34
Murray, Hon. Patty, U.S. Senator from Washington................. 68
Wicker, Hon. Roger F., U.S. Senator from Mississippi............. 52
WITNESSES
Melvin, Valerie C., Director, Human Capital and Management
Information Systems, U.S. Government Accountability Office..... 2
Prepared statement........................................... 4
Kussman, Michael, M.D., Under Secretary for Health, U.S.
Department of Veterans Affairs; accompanied by Paul A. Tibbits,
M.D., Deputy Chief Information Officer, Enterprise Development,
U.S. Department of Veterans Affairs; Cliff Freeman, Acting
Deputy Director, DOD/VA Interagency Program Office; and Ross
Fletcher, M.D., Chief of Staff, VA Medical Center, Washington,
DC............................................................. 39
Prepared statement........................................... 43
Response to written questions submitted by:
Hon. Daniel K. Akaka....................................... 46
Hon. Patty Murray.......................................... 48
Hon. Roger F. Wicker....................................... 49
Casscells, S. Ward, M.D., Assistant Secretary of Defense for
Health Affairs, U.S. Department of Defense; accompanied by
Charles Campbell, Chief Information Officer, Military Health
System, U.S. Department of Defense............................. 52
Prepared statement........................................... 54
Response to written questions submitted by:
Hon. Daniel K. Akaka....................................... 59
Hon. Patty Murray.......................................... 60
Hon. Roger F. Wicker....................................... 61
HEARING ON SHARING OF VA/DOD ELECTRONIC HEALTH INFORMATION
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WEDNESDAY, SEPTEMBER 24, 2008
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:32 a.m., in
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka,
Chairman of the Committee, presiding.
Present: Senators Akaka, Murray, Burr, and Wicker.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman Akaka. The hearing of the U.S. Senate Committee on
Veterans' Affairs is now in order.
Good morning, aloha, and welcome to all of you to today's
hearing on the state of health information sharing between the
Departments of Veterans Affairs and Defense. This is historic.
I will tell you that Veterans Affairs and also the Department
of Defense have been talking to each other, have been working
together, and here is another area that we are getting to where
we are working together. And so, this is why I said historic.
Even in the waning days of this Congressional session, we
must continue to strive to improve care for servicemembers and
veterans. An essential ingredient to reaching that goal is the
sharing of personal health care information between the two
Departments.
The merits of Electronic Health Records are well
documented. While VA is considered to be a leader in using
Electronic Health Records, much work remains before the two
Departments can achieve the ultimate goal--the goal of sharing
medical information in real time. Until this goal is reached,
military and VA medical practitioners simply will not have
access to the most accurate personal medical information on
their patients.
Technology is not necessarily the problem. The technology
exists, as we will see today. Indeed, the Electronic Health
Record systems of the two Departments are each remarkable in
their own right. The biggest challenge is the development of
common standards so the two systems can talk to each other
easily and in real time.
DOD and VA have been working toward achieving interoperable
systems for over a decade at a rate that can charitably be
described as glacially slow. Only recently has there been
significant progress. It appears that, for the first time,
there is the needed commitment for full data sharing of
electronic medical information; and the results of that
commitment are visible.
I encourage the Departments to continue to work together in
order to extend the progress we have already observed. When VA
and DOD finally have the ability to fully exchange medical
information in real time, the best interests of servicemembers
and veterans will be served.
I look forward to hearing from our witnesses today and
learning their views on the most effective way forward on this
important issue and what this Committee can do to reach our
shared goal.
We are delighted to have joining us this morning on our
first panel Valerie Melvin, who is the Director of Human
Capital and Management Information Systems Issues at the
Government Accountability Office. For me, human capital really
rings a big bell because we really need to help develop that,
and I am glad we have somebody in that kind of position here.
GAO recently released a Congressionally-mandated report on data
sharing between VA and DOD.
I want to say aloha, Ms. Melvin. I am pleased that GAO is
actively tracking the Departments' progress in this area. We
look forward to hearing from you this morning. So, will you
please begin with your statement now.
STATEMENT OF VALERIE C. MELVIN, DIRECTOR, HUMAN CAPITAL AND
MANAGEMENT INFORMATION SYSTEMS, U.S. GOVERNMENT ACCOUNTABILITY
OFFICE
Ms. Melvin. Thank you, Mr. Chairman. I am pleased to
participate in today's hearing to discuss the sharing of
electronic medical information between DOD and VA. As you know,
the two Departments have been pursuing initiatives to share
data between their Health Information Systems for the last
decade. However, while important progress has been made,
questions have remained concerning when and to what extent the
intended electronic sharing capabilities will be fully
achieved.
To expedite the Departments' efforts to exchange electronic
medical information, as you mentioned, the National Defense
Authorization Act for fiscal year 2008 directed DOD and VA to
jointly develop and implement by September 30, 2009, electronic
health records systems or capabilities that are compliant with
applicable interoperability standards and it established an
interagency program office to be a single point of
accountability for the Departments' efforts.
Further, the Act directed GAO to semiannually report on the
Departments' efforts. Thus, on July 28, as you have stated, we
issued our first report highlighting the Departments' progress
in sharing electronic health information, developing electronic
records that comply with national standards, and establishing
the Interagency Program Office. As you have requested, my
testimony today summarizes our report findings in these three
areas.
In brief, DOD and VA are sharing selected electronic health
information at different levels of interoperability. Pharmacy
and drug allergy data on almost 19,000 shared patients are
exchanged at the highest level of interoperability, that is in
computable form or a standardized format that a computer
application can act on to, for example, alert clinicians of a
drug allergy.
In other cases, data can be viewed at a lower level of
interoperability, but one that also provides clinicians
valuable information, which has been achieved through various
short-term initiatives involving the Departments' existing
systems. Among these, the Laboratory Data Sharing Interface
Project has produced an application that allows the Departments
to share medical laboratory resources. Another, the
Bidirectional Health Information Exchange, has enabled a two-
way almost instantaneous view of selected categories of health
data on shared patients.
The Departments have agreed on numerous standards that
enable them to share data and are participating in initiatives
led by HHS's Office of the National Coordinator for Health IT
that are aimed at promoting broader use of Electronic Health
Records, which is important to aligning their Electronic Health
Records with emerging Federal standards.
Nonetheless, questions remain concerning the extent to
which the Departments will achieve full interoperability by
next year, as they have not yet articulated an interoperability
goal. This is significant, as not all health information is
currently shared electronically and information is still being
captured in paper records at many DOD facilities. Further, not
all shared patients who could benefit from these electronic
exchanges have been identified and activated.
The DOD/VA Information Interoperability Plan that the
Departments recently completed is supposed to address these and
other issues, including the establishment of schedules and
benchmarks for developing an interoperable health record
capability. However, while an important accomplishment, on
preliminary review, the plan's high-level content provides only
a limited basis for understanding and assessing the
Departments' progress toward full interoperability by the
September 2009 date.
Further, once fully established, a new Interagency Program
Office is to play a crucial role in accelerating the
Departments' efforts. However, this office is not expected to
be fully operational until the end of this year and some
milestones in the office's plan for achieving interoperability
have yet to be determined.
Thus, Mr. Chairman, through all of their efforts, DOD and
VA have made important progress in sharing electronic health
information. Moreover, they are sharing more data than ever
before. Nonetheless, work remains to plan and implement new
capabilities that could further the Departments' efforts and a
clearer understanding of the extent to which these capabilities
are expected to be in place by September 2009 is essential. The
Departments could benefit from more detailed planning and
benchmarks for measuring progress and success toward achieving
their intended electronic sharing capabilities.
This concludes my prepared statement. I would be pleased to
respond to any questions that you have.
[The prepared statement of Ms. Melvin follows:]
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Chairman Akaka. Thank you very much, Ms. Melvin, for your
statement.
I must tell you that I am thrilled at the progress that has
been made and certainly encourage that here. Let me ask you, in
your view and based upon the recent progress, are VA and DOD on
the right track for fully sharing electronic medical
information by September 2009, the date set by Congress?
Ms. Melvin. They are on a good track, and I would say it is
a positive track and a track in the right direction. The
concern that I have at this time is that the definition of full
interoperability remains unclear. In my statement, I made the
point that VA and DOD had not yet defined an interoperability
goal. For us at GAO, that is a very important step that needs
to be taken from the standpoint of really knowing what it is
that the Departments intend to have in place by September 2009.
I think they have made critically important progress as far
as moving in the direction of interoperable sharing. They are
sharing at various levels of interoperability, as I have
stated. However, how much more they intend to share, across
what facilities and across what percentage of their population
of patients is still unclear. Once that is defined, I believe
that there will be a better case for stating whether or not
they will be able to reach the September 2009 date for full
interoperability.
Chairman Akaka. Well, you just mentioned interoperability
as being unclear. Ms. Melvin, GAO identified one of the major
challenges for DOD and VA as the ability to develop common
standards for shared data. Please explain for the Committee why
these common standards are so necessary.
Ms. Melvin. I might start by saying that in developing
standards, that is a difficult task, not just for VA and DOD,
but even at the national level in which the Office of the
National Coordinator for Health Information Technology is
involved and which DOD and VA are, by the way, involved with.
Identifying standards and agreeing to standards across multiple
entities--in this case, two very large Federal agencies--is a
complex task that does involve understanding the data that each
agency views or deems as most important to meet their needs in
caring for veterans and in caring for active duty patients.
But, common standards are essential from the standpoint of
allowing VA and DOD systems essentially to talk to each other.
At the very basic, these standards are needed so that if you
are talking about a particular type of medication--for example,
let us say an aspirin--in terms of sharing data and being able
to have computerized data, for example, where we have talked
about being able to provide alerts for allergies to certain
medications. It is important that VA's system be able to read
an aspirin as aspirin and see that data in DOD's system, and
know that that is the same aspirin or the same type of
medication.
At the same time, standards are important for establishing
how data is communicated between those two computers. For
example, from the standpoint that there are standards for
messaging, there are standards for establishing specific data
elements for how data transmits and what order specific types
of information comes over to another computer or is read by
another computer. It is important, for example, that if VA's
computer is looking at information on a patient and they are
looking for a date of birth, that they, in fact, understand
where--that that system understands where to read that date of
birth from DOD's information--that reads it as a date of birth,
not perhaps as a Social Security number.
So, having standards allowed those systems to have a common
way to talk to each other and to make sure that they understand
those systems can read the data from each other and produce
results that are informative in making decisions.
Chairman Akaka. I know you have made some progress in
reaching the common standards of interoperability. Let me
further ask, how far do the Departments have to go toward
achieving these common standards for shared electronic health
information? Are we a year away, or is it closer to 5 or 10
years before complete standardization can be achieved?
Ms. Melvin. That is really a question that the agencies
will have to answer. It really goes to the heart of the work
that those agencies are undertaking and will have to continue
to undertake to really establish what their needs are. It is
rooted in their need to understand what the user's requirements
are, rooted in understanding how best to serve their patient
population. And so knowing what their needs are will have to
drive what types of data they want--will have to drive the
harmonization related to that data--and, ultimately, what they
decide will be the standards that establish the specific data
and how it is communicated.
Chairman Akaka. What about the levels? Again, back to these
common standards----
Ms. Melvin. Yes.
Chairman Akaka [continuing]. Are DOD and VA developing
standards in a vacuum or are they in line with emerging Federal
standards? We obviously don't want a situation whereby VA and
DOD won't be able to interact with the private sector where so
many patients receive their care. Are we in a vacuum or are we
in line with emerging Federal standards?
Ms. Melvin. Based on our work, I think they are in line
with Federal standards. Certainly, VA and DOD were out in front
of the Federal Government overall in preparing, or in terms of
defining standards, because they have been at work for about a
decade on trying to find ways to share their data. So, at the
same time that they have identified standards that are unique
to their capabilities, both agencies have been working and
continue to work with the Office of the National Coordinator
for Health IT in establishing and defining standards.
So, no, they are not working in a vacuum, and your point is
perfectly correct: that they don't want to work in a vacuum
because it is important that their standards are aligned with
the national standards so that, as we move forward in the
future, their systems are consistent with the other systems and
those in the private sector as well as their own.
Chairman Akaka. Thank you very much.
Let me invite my good friend, Senator Richard Burr, for his
statement and questions.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Thank you, Mr. Chairman. I would ask
unanimous consent that my opening statement be included in the
record.
Chairman Akaka. Without objection, it will be included in
the record.
[The prepared statement of Senator Burr follows:]
Prepared Statement of Hon. Richard Burr, Ranking Member,
U.S. Senator from North Carolina
Thank you, Mr. Chairman, for holding this very important hearing.
And welcome to our witnesses for being here today. I appreciate you all
being here to discuss your progress in the sharing of VA/DOD electronic
health information.
Mr. Chairman, we have been talking about electronic health
information-sharing between VA and DOD since November 2001, when the
DOD first began to send selected pieces of electronic health
information to VA for separated servicemen and women. Unfortunately, it
wasn't until late 2006 that we began to see the first real signs of
movement toward robust electronic health information-sharing. I single
out late 2006 because it was at that time when new programs came online
to enable both Departments to view DOD inpatient discharge summaries,
electronic post-deployment health reassessments, and computable
outpatient pharmacy medication allergy data.
Mr. Chairman, there is still much work to be done, but I am pleased
to hear about the steady progress in 2007, as DOD began sharing its
patient tracking data with VA, and DOD began sending radiology images
and scanned medical records to VA polytrauma centers.
A year ago, Assistant Secretary Robert Howard provided this
Committee with a list of seven priorities that he was using as
benchmarks to guide the realignment process. On a scale of one to ten,
he rated where he believed the Departments were on each of those
priorities. This year, I'd like to find out about what progress has
been made on those benchmarks.
These benchmarks overlap with a new ``DOD/VA Interoperability
Plan'' that charts the way forward. This plan identifies over twenty
essential software systems, computer programs, networks, new management
offices and other initiatives where work needs to be done to achieve
our interoperability goals.
I believe we're on the right path, but DOD and VA must continue to
take advantage of changes in the rapidly evolving world of information
technology if we are to continue to provide state-of-the-art health
care to our servicemen and women and to veterans. The two Departments
must work together as they adopt new patient records technologies.
Regardless of what new health care information technologies are
adopted, the days of DOD and VA working independently to develop and
adopt new health care data collection systems should be a thing of the
past. Close collaboration between the two Departments is essential to
solving the interoperability challenges of today, and it is equally
essential to ensuring that we don't run into similar problems in the
future.
Mr. Chairman, I look forward to hearing today about the
coordination that the two Departments have been engaged in to solve
both the near-term and the mid-term interoperability challenges.
Senator Burr. I apologize to Ms. Melvin for missing her
testimony, and thank GAO for a very complete review. This is
not the first time GAO has been asked to look at this, is it?
Ms. Melvin. No. We have actually been looking at this issue
since about 2001 across the whole spectrum of VA and DOD
sharing. The report that we issued on July 21, however, was the
first one in response to the National Defense Authorization Act
for 2008.
Senator Burr. You haven't been involved since 2001, though,
have you?
Ms. Melvin. I have not personally been involved through all
of it, but through most of it, yes.
Senator Burr. Share with us what is different today.
Highlight the progress. Highlight why we should be optimistic
that they are headed in the right direction.
Ms. Melvin. I think that what we have seen in the way of
growth has certainly been in terms of their ability to find
solutions that have enabled them to share increasing amounts of
information. I stated earlier that the Departments are now
sharing more data than ever before, and that has come through
the ability for these two Departments to come to more common
understandings, relative to collaborating on the issues that
are important, understanding what their data needs are across
the spectrum of the two agencies.
One caveat that I would introduce, however, is that even as
they have done this, there is more work to be done from the
standpoint of collaboration. We do see the need for them to
continue. This is an important establishment in terms of being
able to talk to each other; and we will be looking to see how
these organizations continue to collaborate, to speak as one
voice. I think that is going to be the most critical aspect.
Senator Burr. I am not sure that any of us believe that GAO
would come in and say, ``You know what? They are there. They
have completed the whole process.'' I don't think----
Ms. Melvin. No, we haven't said that.
Senator Burr [continuing]. VA or DOD would have suggested
that. What I am after, though, is: one, you have assessed that
they have made progress.
Ms. Melvin. They have made progress.
Senator Burr. Two, is there a private sector blueprint that
you compare where they are in the progress that they have made,
that you compare it to the private sector blueprint, or have we
really designed a pathway that we think we need to go, but
there is no real understanding yet of--whether it is DOD and VA
or whether it is the private sector and a hospital--how long it
takes you to get there?
Ms. Melvin. We have looked at, on some limited basis, the
private sector. Obviously, with the work that the National
Coordinator is doing, there isn't a blueprint that we have
used. Most of our work has been driven by what VA and DOD have
established as their goals for increasing their sharing
capabilities. Over this time we have seen their progress grow,
in large measure out of the need to establish interim short-
term solutions to meet immediate needs for serving their
patient populations.
But, at the same time, they are working in a way that they
are actually able to provide some type of input to what the
national level is trying to do, and I think it is important
that VA and DOD continue to be in a place where they can
actually use their experiences as an example to help form the
blueprint, if you will, for how the national sharing of data is
accomplished and how the private sector actually interacts in
that.
Senator Burr. You stated a very important thing. They had a
plan as to how they were going to proceed, right?
Ms. Melvin. VA and DOD?
Senator Burr. Yes.
Ms. Melvin. We have actually had concerns with VA and DOD's
planning across the years. That is one other area that we have
consistently stressed increased effort be placed on. I continue
to feel that there is a stronger need for planning.
I mentioned earlier that in terms of the concept of full
interoperability, one of our concerns is: how is full
interoperability defined? I think when we get to September
2009, DOD and VA will certainly be in a position that they are
sharing interoperable data and they are sharing it at different
levels, because they are already doing that.
What we would like to see, though, is a clearer plan for
how they plan to put discipline around all the various
initiatives that are enabling them to, at this point, achieve
that capability, and at the end of the day on September 30,
2009, to have established benchmarks to have a path that
clearly shows the milestones, the timeframes, the activities,
and how they all match up to some established end state that
the Departments say they want to have at that point.
So, planning is still critical. It is important. Where we
have seen them integrate planning very heavily into their
various activities, there has been a success with those
efforts, going all the way back to their early initiatives to
put the FHIE system in place. We want to see that continue at
this point.
Senator Burr. From the standpoint of the current effort----
Ms. Melvin. Yes?
Senator Burr [continuing]. Would you agree that VA and DOD
are on a pathway to meet their goals on the time line that they
have agreed to?
Ms. Melvin. They are on a pathway to meeting a goal. I am
not sure what that time line is, to be quite honest with you.
They have high-level milestones at this point. What we are
looking for are more detailed ones. We do believe that when
September 2009 gets here, that yes, they will be in a position
of saying they have interoperable capability for sharing data.
There is no doubt with that because they are already there. How
much beyond where they are is still a question for us.
Senator Burr. OK. As I was preparing and the Chairman was
asking questions, you talked about standards, and again, I
think the only thing we have to compare this to is the private
sector. I guess my question would be this: are the standards
that they are having difficulty working out standards that have
been adopted by entities in the private sector, or are these
standards that the private sector is still debating and
discussing as to what the correct standard is going to be?
Ms. Melvin. We have not yet looked in depth at how they are
actually defining their standards; but, based on our
understanding of just the issue of standards in general, it is
a very difficult task to define standards within and also to
make sure that they complement those that are in the Federal
sector. So, I think it is a little bit of both in terms of what
they are doing. But, it is a difficult task and I don't want
to, by any means, discount the difficulty that goes into
actually making those determinations as to what is appropriate
for sharing data.
Senator Burr. Great. We have got a long period, Mr.
Chairman, so I want to proceed. I do want to make a statement,
even though I didn't make an opening statement.
I think what the Committee has asked DOD and VA to do is to
begin to make progress, to begin to establish where it is that
both are trying to go. I think it is safe to say--as involved
as I am in the private health care side of the policymaking--it
is very difficult to map every milestone that you are going to
hit along that road, but it is absolutely essential that both
parties know where the final point is that they are trying to
get to. I think that has been established.
It is going to be important that GAO work with us, as well
as VA and DOD, to try to acknowledge the completion of certain
steps. I do that with the full knowledge, Mr. Chairman, of
realizing that we can't even produce an IT bill for private
health care out of Congress. So, I know how difficult it is to
talk about the advances in technology and how we incorporate
those advances into medicine broadly. We have done it well in
the delivery of care. We have not done it well in the sharing
of the outcome of that delivery and that is what we are here
discussing; and it is something the private sector is still and
will continue to be challenged on how they get there.
I thank the Chair.
Chairman Akaka. Thank you very much, Senator Burr.
Let me continue on a second round here quickly, Ms. Melvin.
GAO has raised concerns about whether or not the Departments'
IT initiatives are plugged into a comprehensive strategy for
seamlessly sharing health information, and my friend and
partner here has asked about a road map. Along similar lines,
does the current data sharing plan address these concerns?
Ms. Melvin. At a high level, it does address the concerns.
Again, as I stated, what we would want to see, in addition to
what they have done, is to have some more details. I would
agree that they have identified their plan as a living
document, and, in essence, that is what a plan would have to
be, because you are making adjustments along the way. So, that
is very fair and that is very important to recognize.
At the same time, there must be a standard, or a starting
point, I should say, relative to specifically what milestones
from an interim nature the agencies work against to make sure
that as they move forward, they are coming to an end state that
they have agreed to; and that they can do so successfully.
Without benchmarks, for example, to really gauge their
progress, there is no way to really know whether, at the end of
the day they will have achieved what it is that they set out to
achieve and whether it is accomplishing the objectives that
they intend to.
Chairman Akaka. I know that DOD does not have an integrated
inpatient electronic cord system. It would appear that this is
a major, let me say, stumbling block for the prospect of VA and
DOD fully sharing electronic medical information. Will you
please share your view on that?
Ms. Melvin. Well, we do understand that they have now
developed or completed a study that relates to their joint
inpatient record. Certainly, that is a critical piece of
information that must be weighed, or should be weighed, I
should say, in terms of having a complete assessment or a
complete picture of the patient's health history. We look
forward to examining their study in more detail to understand
more clearly just what their plan is at that point, to look
more closely at what types of solutions they are considering to
make this happen.
Chairman Akaka. Thank you. Thank you very much.
Senator Burr?
Senator Burr. No further questions.
Chairman Akaka. Well, I want to thank you so much. You have
done a splendid job here representing GAO. We certainly
appreciate it and thank you for your statement and your
responses.
Ms. Melvin. Thank you, Chairman Akaka. I appreciated being
here.
Chairman Akaka. Let me introduce our second panel here. On
our second panel this morning are representatives from the
Department of Defense and Veterans Affairs. Joining us from VA
is Dr. Michael Kussman, Under Secretary for Health. From DOD,
we are pleased to welcome Dr. Ward Casscells, who is Assistant
Secretary of Defense for Health Affairs. I want to welcome both
of you.
This hearing is especially timely, given that the
Departments have recently completed their data sharing plan and
received recommendations on a joint inpatient record system
from an outside contractor.
Aloha, gentlemen. I see you each have a number of
individuals accompanying you this morning and would invite you
to introduce them to the Committee. Dr. Kussman?
Dr. Kussman. Aloha, Mr. Chairman, Mr. Ranking Member.
Chairman Akaka. Aloha.
Dr. Kussman. Thank you very much for inviting us. Let me
introduce the people to your right and my left. First is Dr.
Paul Tibbits, who is the Deputy Chief Information Officer for
Development in the Office of Information and Technology; and
Mr. Cliff Freeman, who works for us in IT in the VHA, but is
now the Acting Deputy Director for the Joint Integrated
Information Office which the GAO discussed and we will discuss,
as well.
I have a third person sitting back there: Dr. Ross
Fletcher, who is the Chief of Staff and a physician at the
Washington VA, who with your support and agreement, will give
us a demonstration this morning on the interoperability of IT
with DOD and the VA.
Chairman Akaka. Dr. Casscells?
Dr. Casscells. Thank you, Mr. Chairman, Senator Burr. I am
delighted to be here representing the Defense Department. With
me is our Chief Information Officer, Mr. Charles Campbell.
Chairman Akaka. Thank you. Thank you very much.
Will you please begin with your statement, Dr. Kussman.
STATEMENT OF MICHAEL KUSSMAN, M.D., UNDER SECRETARY FOR HEALTH,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY PAUL A.
TIBBITS, M.D., DEPUTY CHIEF INFORMATION OFFICER, ENTERPRISE
DEVELOPMENT, U.S. DEPARTMENT OF VETERANS AFFAIRS; CLIFF
FREEMAN, ACTING DEPUTY DIRECTOR, DOD/VA INTERAGENCY PROGRAM
OFFICE (IPO); AND ROSS FLETCHER, M.D., CHIEF OF STAFF, VA
MEDICAL CENTER, WASHINGTON, DC
Dr. Kussman. Again, aloha, Mr. Chairman and Mr. Ranking
Member. Thank you for the opportunity to update you on the
status of our efforts to exchange electronic medical
information with our partners at the Department of Defense. We
appreciate this Committee's continuing support of our efforts.
I would like to request my written statement be submitted
for the record.
Chairman Akaka. Without objection, it will be included in
the record.
Dr. Kussman. There was a time when clinical care was
recorded on paper and files had to be copied and transferred in
person. This system was fraught with inefficiencies and patient
care suffered as a result. Records were incomplete, unreadable,
or inaccurate. Our physicians recognized this and helped
develop VA's Electronic Health Record, which is now known the
world over as the standard for electronic medical records.
A similar phenomenon has happened in our collaboration with
DOD. We understand we share patients, and there are times when
VA treats active duty servicemembers and times when DOD treats
veterans. Our clinicians, again, have led the way through
forums like the Joint Clinical Information Board, where VA and
DOD providers discuss what they need and technical engineers
figure out how to meet those needs.
It is important to note that there is a difference between
the technical definition of interoperability and the functional
definition. If you will permit me to use a simple analogy, I
think you will understand my point a little more clearly. When
you pick up a cell phone and call someone, it doesn't matter if
you use one phone company or they use another. The cell call
connects just the same. Similarly, it really doesn't matter to
our providers if DOD uses AHLTA or VA uses VistA, as long as
the patient's needs are met and they can connect the
information they need. Delivering information across the
continuum of care in DOD and VA is the true priority.
In this regard, I think DOD and VA are succeeding. We have
come a long way. Almost all essential health information is
accessible across the systems. Providers can see pharmacy
information, surgical reports, lab results, allergies, vital
signs, and discharge summaries. This is true at every VA
medical center in the country.
We know there is still more to do, both in terms of
communicating these advances to our clinicians and filling in
gaps in the system. But some of the biggest hurdles have
already been passed. A VA provider in Dubuque, Iowa, can access
clinical data on a patient added to a health record by a
physician in Baghdad. Radiologic images and inpatient
information from Walter Reed or Bethesda Naval Medical Center
can be seen by our polytrauma facilities for seriously injured
veterans and servicemembers.
All of these efforts are made easier by the Veterans
Tracking Application, a case management tool used to track
patients and ensure they are receiving the care that they need,
even if it is not from us. And Healthy Vet will extend these
capabilities even further by supporting data sharing between
VA, DOD, and private providers.
Mr. Chairman, I would like to take a moment to do something
that is a little unconventional. I would like to share the view
of a clinical provider to show you how clinical care has
directly improved through advances in data exchange between VA
and DOD. Dr. Ross Fletcher, who I already acknowledged is the
Chief of Staff at the DC VA Medical Center and a primary care
physician there, will walk through a demonstration that shows
you the information our clinicians can see and how they use
that information to better provide care to our patients.
Dr. Fletcher?
Dr. Fletcher. One of the best ways to let you know how
things are going is to describe the care of some patients that
we take care of just down the road at the VA hospital in
Washington; and realize that what we can do in Washington can
be done across the system in San Francisco, Miami, anywhere in
the VA. This is not unique to our place at all.
[Dr. Fletcher begins projecting a slideshow for all to
see.]
Dr. Fletcher. The first patient I am going to describe is a
dual-use patient. He actually came over when he was still a
servicemember and we treated him for his Traumatic Brain
Injury. He was, as he told me, exposed to blasts at least 11
times--the last one in Afghanistan rupturing his eardrum, the
tympanic membrane, and causing the TBI that we were treating
him for.
This is the way I view his chart, and this is actually
redacted, but is the way it would come to me just as I would
see him. If I see this button up above saying, ``remote data is
available,'' I merely click on it and see this list of where
that data is present, and the Defense Department is frequently
an area that I can check off and then see. When I do that and
then go to ``reports,'' I see the list of things I can get from
the DOD, including the progress notes. You can see that in this
progress note--this is from the field hospital in Afghanistan--
describing his original operation to remove fragments of
shrapnel from his right scalp and describing him able to hear,
but later in his course he became unable to hear, as well, and
had a ruptured tympanic membrane, which was repaired.
I can see it this way or I can see it through the VistA
website. On the VistA Web, everywhere across is present. Over
here, there is DOD data. This is the standard way I look at any
patient's films and records anywhere in the VA, whether it is
in Miami or DOD. It is seamless to me as a doctor to look at
the data I see from DOD.
I can pick up his pharmacy orders, and initially I will
pick up the local orders. It is done in Baltimore, so there
were none. The Defense Department is still new, but, as I move
forward, on the next line, you can see that the Defense
Department is now done and a whole list of medicines from
Bethesda Navy, Walter Reed appear. I just simply click on this
button. It opens up to show me that in July 2008, we can see
all of his active medications. He is now a veteran and I am
treating him. If I were unable to see which drugs he was
getting from VA, it would be a very dangerous situation for us,
indeed. And the other thing that it assures me is these drugs
are available on the database, which allows me to give the
right prescriptions.
If I go down on the list showing ``DOD and third party
medications,'' I can see that Landstuhl, Germany, Walter Reed,
Eisenhower, Camp Shelby, even a CVS pharmacy in the private
sector are medications that are available. There is an
agreement with DOD that if the patient gets medications from
the private sector, they need to be sent to them
electronically. Needless to say, I am delighted when I am
seeing them sent to me, as well, over at the VA. It is
automatic. I am seeing all of the medications from Washington
and everywhere else in the same list.
If I go to another patient on the next slide, where there
were many--there are about 4.2 million such patients where DOD
has sent their data over to the VA, and I can simply look at
the list of, say, pharmacy outpatients, as well. This patient
got his medications at Costco, CVS pharmacy, and the DiLorenzo
TRICARE Health Clinic at the Pentagon. I like to show this
because I worked with Colonel DiLorenzo for many years when I
was in the Army several years ago.
This is the same patient. If I simply click the flag, I can
isolate the abnormal lab values. All the lab values are in a
line, whether they are from DOD or Washington, and any of the
abnormally high or low values I can see immediately. I don't
have to look at the rest of the list, which now is normal. So,
it is a very easy way for me to take care of the patient and
see his lab chemistries.
This next patient is a severely wounded warrior. He is one
of the patients, when he goes from Walter Reed to one of our
polytrauma sites, they send all of his images as well as all of
his tests to us. This particular patient suffered an IED blast,
causing Traumatic Brain Injury and a fractured spine.
If I go to allergies, I can see that Washington has not
assessed them yet because he has not arrived at our place. But
if he had come into the emergency room and I looked at this
list and waited for the initialization to stop at DOD and
become done, I can see that he had a penicillin allergy at
Brooke, at Martin, and Bethesda. The beauty is that this fact
is in our combined health data repository, the Clinical Health
Data Repository, which allows me--when I am giving him or
trying to give him penicillin--to have the next window come up
saying that wasn't assessed at my place, but at remote sites.
Penicillin is an allergy that is noted, and I would immediately
then cancel the order and go forward. This is computable data
in the CHDR, as we now call it, the combined database that
exists on both sides--the DOD and the VA--for immediately
taking computable data and guiding what I do for writing
orders.
The images that are sent over in the Severely Wounded
Warrior Program are seen here. This is his abdomen, and I can
manipulate this just like I can manipulate it on the VA side.
They sent it to Richmond, but there is a remote image view,
which means that if the patient was seen in my hospital, I can
see into Richmond or anywhere else in the VA. Notice that I can
see actually where the screws are placed into his spinal
column. As a matter of fact, here is an intact vertebra and
down here it is split, so the fracture of the vertebra is easy
for me to see on the films that were originally taken in Walter
Reed, now distributed across the entire VA, because they were
simply sent to one of our hospitals.
There is an Acrobat file, 1,658 pages, as I recall, which I
won't show you today, but that comes across with all of the
data to the VA. And as a matter of fact, I have been told that
some of the--we see it nicely at our site, and now the Walter
Reed doctors want to see this same file on their site. So, we
might have to send it back to them and we would be delighted to
do so.
This third patient is a dual-care patient, now with the VA.
She was hit by a truck in Kuwait, suffered severe Traumatic
Brain Injury, was in a coma for many months and hydrocephalus
was diagnosed and was relieved and she woke up, and I will go
through that story.
Again, this is the way we see the patient. The Department
of Defense data is available and I can see the chemistries and
hematologies from anywhere she is, Bethesda Navy or the Palo
Alto VA. I can see remote consults. This is Landstuhl, Germany.
I can see discharge summaries from the military or Palo Alto.
They are both seen. And I can see radiology reports.
If I activate Richmond to see the films from Richmond, I
can compare at my hospital the earlier March 18 films against
the later August 21, 2005, films. Notice there are these big
openings in the brain. These are the ventricles and they are
markedly dilated. They should look more like this. You can see
that dilatation is putting pressure on the brain and this
patient is staying in a coma. But once we saw this, we knew
there was a way out for this particular individual. A catheter
was placed inside the ventricle and a shunt to the outside was
then established, decompressing this area and allowing the
brain to not be under pressure. She woke up. She could then
talk, move around. That was 2005.
I got an e-mail from this patient just this month saying
that she was leaving Livermore VA; she had gone out to Palo
Alto and is going home. So, this is a real good story. Her coma
changed to a much better function.
This is an x-ray that we are now able to see into DOD just
like we can see into Albuquerque or Miami. If you weren't able
to see the films across the entire spectrum where they were
taken, you would not be able to follow them well; and now
simply by clicking on DOD, we see ``DOD films,'' which shows us
the knee on the right side with the prosthesis and the knee on
the left side without. This is very, very valuable. I can
actually go to the Albuquerque films and see that this knee is
not lining up properly and I am going to have to worry about
the fact that this knee could go the same course as the one
that had a replacement. But, being able to follow them all
allows me to see the patients quite well.
Using all of these techniques, which I won't elaborate on,
we are now able to see a large amount of data. Not only can we
access it easily and well, but we are able to see a lot more of
it and are able to return the veteran to his best possible
recovery with this high degree of interoperability that we are
already seeing and is available to us as clinicians. Thank you
very much.
Chairman Akaka. Thank you very much, Dr. Fletcher. I am
very encouraged by your view that you have some excellent
clinical tools to work with, and we are delighted to see this.
Dr. Kussman, anything else to add before we move to Dr.
Casscells?
Dr. Kussman. Yes, Mr. Chairman. Thank you, Ross, for that
presentation. I hope that you and the Ranking Member and other
people here found this presentation helpful in the degree of
interoperability of information.
This is an area obviously that is vital to patient care,
and sometimes it is easy to forget what this is all about,
focusing on the delivery of care from one system to another. At
the end of the day, we believe that the interoperability that
exists has made the care much better. It is an exciting
opportunity for us to lead the Nation, and the VA and DOD's
leadership are equal to the task. When we establish a common
consensus, an infrastructure for interoperability of records,
millions of patients, veterans and non-veterans alike, will
benefit.
Mr. Chairman, thank you again for your time. I am prepared
to answer any questions you may have. Aloha nui loa.
[The prepared statement of Dr. Kussman follows:]
Prepared Statement of Hon. Michael J. Kussman, M.D., Under Secretary
for Health, Veterans Health Administration, Department of Veterans
Affairs
Mr. Chairman, Thank you for the opportunity to update you on the
status of our efforts to exchange electronic medical information with
our partners at the Department of Defense (DOD). This Committee has
always been supportive of our efforts and I look forward to providing
you the information you need. Accompanying me today are Dr. Paul
Tibbits, VA Deputy Chief Information Officer for Enterprise
Development, and Mr. Cliff Freeman, Acting Deputy Director of the newly
formed DOD/VA Interagency Program Office (IPO).
VA and DOD continue to work toward improving the exchange of
medical information to best serve our active duty servicemembers and
veterans who come to us for medical care. Today, we are sharing more
information than ever before. Although our data exchanges are
unprecedented in the scope and amount of data we share, we realize
there is more work to be done and believe we are taking the steps
necessary to meet our goals and comply with the direction provided by
the National Defense Authorization Act (NDAA), Section 1635. I will
address some of the issues facing VA as we work with DOD to expand our
access to shared electronic medical information.
The NDAA mandates that both Departments achieve full
interoperability of electronic health record capabilities and systems
by September 2009. The NDAA includes the requirement to establish a
DOD/VA Interagency Program Office (IPO) to oversee the development of
interoperable electronic medical record systems by September 2009.
interagency program office and information interoperability plan
The Government Accounting Office report GAO-08-954 recommended that
VA and DOD give priority to fully establishing the IPO and finalizing
the implementation plan. The IPO is operational, has developed high
level milestone activities, is fully engaged with the appropriate
offices in VA and DOD, and is developing a detailed implementation plan
to assist the Departments in meeting the NDAA data sharing goal by
September 2009.
The DOD/VA Information Interoperability Plan (IIP) was recently
signed and delivered to Congress. It was also released to GAO. The IIP
describes the current state of electronic data sharing between the
Departments and identifies the gaps that must be addressed to achieve
the level of information interoperability necessary to support the
clinical and benefits needs of our veterans and members of the Armed
Forces. The IIP provides the strategic organizing framework for current
and future work and establishes the scope and milestones necessary to
measure progress toward intermediate and long term goals.
The IIP also emphasizes leveraging our existing data exchanges
through which we already share almost all essential health information
in viewable format. By September 2009, we will enhance the existing
data exchanges to share those additional types of information
identified and prioritized by our newly formed Joint Clinical
Information Board (JCIB). The JCIB is comprised of clinicians from both
DOD and VA. It is responsible for identifying and prioritizing the
types and format of electronic medical information that needs to be
shared by DOD and VA to care
for our patients. This group ensures our data sharing is focused on
needs identified and prioritized by clinicians for clinicians. Thus, we
have used our clinician community to define for us those high priority
items that must be shared by September 2009. Once prioritized and
approved by the Health Executive Council, the requirements are handed
off to requirements definition teams and then to our information
technology teams to develop applications and tools to put these
requirements into operation.
DOD and VA have seen an increase in the types of electronic data
shared and the availability of tools to view this information. Now more
than ever, it is critical that we inform our clinical community of our
good work in this area and the availability of this information. Recent
visits to some of our local facilities have shown us we can do a better
job of getting out the good news about these new capabilities and
training our providers on how to access this information. Both DOD and
VA providers are busy with their number 1 priority, taking care of
patients. However, it is incumbent upon us to ensure our providers are
not only aware of the health care data available to them for viewing
but are skilled in using the tools to obtain this data. VA is
developing comprehensive communication and training strategies to
remove some of these process-based barriers to using the excellent
tools available to access DOD information on our patients. I will
discuss the specific types of data sharing occurring in more detail
below.
exchange of electronic medical information
VA and DOD are successfully sharing electronic medical information
on separated servicemembers and shared patients who come to both VA and
DOD for care and benefits. Since 2001, the Federal Health Information
Exchange or ``FHIE'' has accomplished the one-way transfer of all
clinically pertinent electronic information on more than 4 million
separated individuals--approximately half of these individuals have
come to VA for health care or benefits as veterans. In addition to
FHIE, VA and DOD clinicians are using the Bidirectional Health
Information Exchange or ``BHIE'' to view medical data on shared
patients, including veterans, active duty personnel and their
dependents from every VA and DOD facility. Today, VA and DOD continue
to share bidirectional viewable outpatient pharmacy data, allergy
information, inpatient and outpatient laboratory results (including
chemistry, hematology, microbiology, surgical pathology, and cytology),
inpatient and outpatient radiology reports, ambulatory progress notes,
procedures, and problem lists.
Most recently, at the end of 2007 and in 2008, we enhanced our
bidirectional exchange by adding vital sign data (including blood
pressure, heart rate, respiratory rate, temperature, height, weight,
oxygen saturation, pain severity, and head circumference) from all VA
and DOD facilities, DOD Theater clinical data (including inpatient
notes, outpatient encounters, and ancillary clinical data such as
pharmacy data, allergies, laboratory results, and radiology reports),
and inpatient discharge summaries from 18 of the largest military
treatment facilities.
Additionally, to support our most seriously injured wounded
warriors, DOD is transferring digital radiological images and scanned
inpatient information for every patient being transferred from Walter
Reed and Brooke Army Medical Centers and Bethesda National Naval
Medical Center to one of our four polytrauma centers in Richmond,
Tampa, Palo Alto and Minneapolis. Our polytrauma doctors find this
information invaluable for treating our most seriously injured patients
and we are continuing to work to improve the presentation of this
information.
In addition to the viewable text and scanned information we receive
and share with DOD, VA and DOD are sharing computable allergy and
pharmacy information on patients who use both health care systems. The
benefit of sharing computable data is each system can use information
from the other system to conduct automatic checks for drug interactions
and allergies. In VA, we have implemented this capability at seven of
our most active locations where patients simultaneously receive care
from both VA and DOD facilities. Once a patient is ``turned on'' with
this capability, his or her pharmacy and allergy information is
computable enterprise-wide in DOD and VA and available for this
automatic clinical decision support.
Finally, our social workers, transition patient advocates, and
other military liaison staff continue to use the Veterans Tracking
Application or ``VTA'' successfully in order to improve the
coordination of care for patients transitioning from DOD to VA. VTA
provides our staff with key patient tracking and patient coordination
information on a near real-time basis.
details of the dod/va information interoperability plan (iip)
The DOD/VA Information Interoperability Plan was developed in
response to the NDAA directing the Departments to develop a single
point of accountability in the rapid development and implementation of
capabilities that allow for full interoperability of personal health
care information. The IIP provides a roadmap to guide our Departments'
information technology investment decisions and establish a shared
understanding of interoperability principles, practices, enablers, and
barriers.
The IIP is a living document whose ultimate purpose is to identify
and address the information needed by the Departments to improve
continuity of care and benefits administration for our Nation's
servicemembers, veterans, and their beneficiaries. To that end, the
plan aligns our goals with twenty-two specific initiatives that make up
the pathway to information interoperability. Eleven initiatives focus
on the goal of improving continuity of patient care. Five initiatives
focus on the goal of improving benefits administration. Three
initiatives focus on the goal of improving the information technology
infrastructure, and two initiatives focus on the goal of improving
population health and research. One initiative cuts across all four
goals, establishing an Interagency Program Office to help ensure our
efforts remain coordinated, focused, and responsive to the direction
received in the NDAA.
Each initiative has a description and high level implementation
timeline. While we are moving forward to flesh out the specifics for
all of the initiatives, the Interagency Program Office, as specifically
mandated in the NDAA, is almost completed. As discussed earlier, the
Interagency Program Office is operational, functioning within its
charter, and is on target to complete the few remaining implementation
action items in the next few months.
In addition to identifying those actions necessary to achieve
inter-Departmental interoperability, the IIP also identifies the
barriers to success that need to be overcome. These barriers include
concerns about data standardization and quality, information privacy
and confidentiality, the investment cost to implement the initiatives,
and the investment cost to upgrade legacy systems and infrastructure.
interoperability by september 30, 2009
VA is committed to working with our DOD partners to implement the
provisions of the NDAA requiring interoperability by September 2009.
Our main commitment is to ensure doctors and health care staff from
both Departments have the information they need from each other to
treat our common patients. Prior to the passage of the NDAA, the Dole-
Shalala Presidential Commission on Care for America's Returning Wounded
Warriors recommended the VA and DOD accelerate efforts to share data by
ensuring all essential health information is viewable, bidirectional,
between our providers. The departments anticipate that by the end of
fiscal year 2008, we will meet this goal. This is not to say all
electronic medical data will be shared; only to emphasize that
everything deemed essential by our clinicians will be shared.
With respect to the September 2009 target, the JCIB plays a key
role by determining from a clinical perspective, the categories and
priorities of clinical information that must be shared to most
effectively treat our beneficiaries and meet the NDAA requirements. The
JCIB recommends to the DOD/VA Health Executive Council the types and
format of health information that is necessary to provide top quality,
effective care to shared patients, wounded warriors coming to us for
treatment and rehabilitation, and veterans transitioning to VA for care
and benefits. The HEC approves/disapproves the JCIB recommendations.
To attain full interoperability of electronic health record
capabilities and systems by September 2009, the HEC approved the JCIB
recommendation to add to the list of essential data requirements,
family and social history data, and expanded types of patient
questionnaires and forms. DOD has undertaken plans to pilot test a
capability to scan paper documents and associate them with a specific
patient so that providers are aware that the documents are available.
In addition, DOD intends to implement their inpatient clinical
documentation system at additional military treatment facilities in
fiscal year 2009, enabling VA providers to view inpatient clinical
documentation on a greater number of patients. Additional inpatient
documentation such as operative notes, inpatient consultations,
transfer summary notes, and inpatient history and physical reports,
currently piloted in the Puget Sound area, will also be viewable by VA
sites.
Under the purview of the Senior Oversight Committee or ``SOC,'' and
in conjunction with the ongoing efforts of the DOD/VA Joint Executive
Council, we are continuing to accelerate efforts to meet the immediate
needs of the seriously injured transitioning to VA as a result of the
current operations in theater settings. All transitioning
servicemembers will benefit from this work. Line of Action 4 under the
SOC continues to focus on data sharing needs in the areas of disability
evaluation, Traumatic Brain Injury and Post Traumatic Stress Disorder,
case management, and reserve component records. The SOC has been
instrumental in defining requirements and implementing acquisition
activities to support these key critical business needs.
Despite these accomplishments, we realize our work is not done and
continue to expand the types of electronic medical data we share. For
example, we have expanded a pilot program to share digital radiology
images bidirectionally, beyond the initial test site in El Paso, Texas,
to Evans Army Community Hospital and VA Eastern Colorado Health Care
System and Naval Health Clinic Great Lakes and North Chicago VA Medical
Center where images are key to critical medical sharing programs. Over
the next several months, we will expand this capability to additional
sites including Washington DC, VA Medical Center, Walter Reed Army
Medical Center, and National Naval Medical Center where VA providers
will use DOD radiology images to conduct service disability rating
examinations.
Additional work is being done to expand the excellent work done in
the Puget Sound area to develop the capability to share key inpatient
documentation. Another example of our ongoing efforts is the expansion
of the ability to share computable health data beyond the initial seven
locations listed below. The capability enabling the exchange of
computable outpatient pharmacy and medication allergy data for shared
patients was made available to all DOD sites in December 2007.
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/VA Southern Nevada
Health Care System
VA and DOD will enhance this capability by adding computable
laboratory (chemistry and hematology) results in 2009.
I am pleased to inform you that VA and DOD have received the third-
party study that evaluated our options for developing joint electronic
inpatient capability and provided the complete report to this committee
on September 19th, 2008. As we consider the report's recommendations
for approval by the DOD/VA Joint Executive Council, we are
simultaneously exploring a forward moving strategy.
meeting the ndaa requirements
VA and DOD's current plan to meet NDAA requirements includes
leveraging existing data exchanges to support the expansion of
additional data sharing capabilities. Most importantly, VA appreciates
the continued support of this Committee and those at the national
level, including the National Coordinator for Health Information
Technology, as we work to ensure VA health care remains state-of-the-
art and that our IT tools are capable of supporting our workflow.
HealtheVet will be the foundational tool allowing us to not only
deliver top quality care to our patients, but to support data sharing
capabilities with DOD and eventually other health care partners that
treat our veterans. A significant number of our veterans receive care
from not only VA and DOD, but private providers as well. Our vision is
to ensure their medical information is available wherever and whenever
it is needed. To achieve this goal, we must continue developing
HealtheVet and therefore, continued funding and support of this
comprehensive initiative is needed.
Thank you once again for the opportunity to address this Committee
and provide you with an update on the important work we are doing to
improve medical record sharing with DOD. I and my colleagues will
attempt to address any additional questions you might have.
______
Responses to Written Questions Submitted by Hon. Daniel K. Akaka to
Michael Kussman, M.D., Under Secretary for Health, U.S. Department of
Veterans Affairs
Question 1. Doctors Kussman and Casscells, I understand that
currently 65 percent of the care provided by DOD and 40 percent of the
care provided by VA is purchased from the private sector. Only 9
percent of the physicians in private outpatient practice use electronic
medical records. How will you overcome this reality and ensure the
medical information from this care is included in the servicemembers/
veterans electronic health record.
Response. The Department of Veterans Affairs (VA) believes that the
growth of the nationwide health information network (NHIN) an
initiative led by the Office of National Coordinator for Health
Information Technology (ONC) within the Department of Health and Human
Services is the best way to get veterans' data from the private sector.
VA participated in the NHIN demonstration at the American Health
Information Community (AHIC) meeting in September of this year, where
it showed real-time transmittal of actual medical records. NHIN uses a
secure, private, standards-based approach to interoperability between
Federal and private sector health providers. When NHIN enters into its
production phase, any provider who has joined the ``trusted network''
of NHIN will have access to VA/Department of Defense (DOD). This
document is a list of clinician-approved data elements pertinent to the
health care of a veteran or servicemember. Included on the list of data
elements are items such as an up-to-date list of medications, a list of
recent lab tests and results, a list of known allergies and demographic
information. Both VA and DOD have accepted this standard data set for
interoperable data exchange.
As the availability of health information expands and reflects that
VA/DOD are participating in the development of NHIN, VA believes that
private sector providers will request their respective networks and
health systems to adopt NHIN-compliant software. VA has limited ability
to influence the information technology (IT) preferences and purchases
among private sector providers. We do know, however, that there is
interest in the provider community to improve the quality of care
through electronic interoperability among VA/DOD and the private
sector.
Question 2. Doctors Kussman and Casscells, I believe we all can
agree that VA currently has a world class inpatient electronic health
records system. My question for the both of you is, what impact would
the development of a new joint VA/DOD inpatient health records system
have on VA's current system?
Response. The joint VA/DOD electronic health record solution common
services strategy has the potential to improve upon VA's current
system. Common services, as well as an organizational and technology
neutral approach, will allow the departments to develop data and
business services once, and expose those services to organizations
within and beyond the DOD/VA continuum. It will engender the level of
collaboration and commitment most likely to institutionalize DOD/VA
data sharing and process integration for the long-term. Further, it
will allow the departments to conduct business with providers outside
DOD/VA efficiently. The DOD/VA investment could lead to a
groundbreaking solution that accelerates national strategic objectives
for patient-focused health care and population health. The terms
``business services'' and ``conduct business'' refer to those clinical
activities and processes that are common to all care environments. For
example, admitting patients, tracking bed availability, ordering
pharmaceuticals, securing health data, etc. are services that are
common to health care environments, including VA, DOD and private
sector. A common services approach permits individual environments to
use and re-use common technology packages that support common business
activities, while simultaneously using other technologies that support
individual needs. In the long term, such an approach provides more
flexibility in technology resource planning and improves cost
effectiveness for sharing partners.
Question 3. Doctors Kussman and Casscells, as a result of merging
the Great Lakes Naval Hospital and the North Chicago VA Medical Center
in 2010, the number of shared VA/DOD patients will increase roughly
five-fold from 18,000 to 100,000. Isn't this the real test of VA/DOD
interoperability? And how are we doing to ensure that it works.
Response. VA does not anticipate the increase in shared patients to
be an issue. VA and DOD have teamed up on information sharing
initiatives since 2000 and currently share a significant amount of
health information, however, the North Chicago Federal Health Care
Center (FHCC) initiative is very different from previous VA/DOD sharing
efforts due to the challenges of addressing local information sharing
requirements as a combined facility treating both VA/DOD beneficiaries.
To ensure success, VA/DOD will continue to work with local and
enterprise teams to address the highest priority needs and ensure FHCC
is successful.
Question 4. Dr. Casscells, I understand from recent news reports
that DOD is actively pursuing alternatives to its current electronic
health records system. Will the problems you have identified with DOD's
current electronic health record system affect VA/DOD's ability to
share data in the near- or long-term?
Response. To be provided by DOD.
Question 5. Doctors Kussman and Casscells, I understand electronic
health records for Reserve soldiers are less than complete. How do we
address the issue of establishing a comprehensive electronic health
record for these part-time soldiers.
Response. The health care provided to the Reserve/Guard when they
are deployed with the active duty forces, is documented in the Armed
Forces health longitudinal technology application (AHLTA). If the
Reserve/Guard soldier receives care in VA post-deployment, DOD is able
to access that data. When reserve members come to VA for care while on
reserve status, their medical information is captured electronically in
VA's VistA computerized patient record system (CPRS). By way of
existing data exchanges such as bi-directional health information
exchange (BHIE), VA's electronic health record (EHR) information is
already available to DOD if that reserve member returns to active
status.
For care received in the private sector, in fiscal 2009, DOD will
provide an image scanning capability to enable DOD to scan information
from the managed care support contractors, such as specialty care
consults, so it is available to DOD providers. For the long term, DOD
will continue to support Department of Health and Human Services'
efforts to foster health information sharing with the private sector.
Specifically, VA/DOD will support NHIN activities to leverage
recognized interoperability standards and promote the exchange of
health information with private health care organizations and provider
networks. These efforts will help to ensure the capture of private
sector health care information to enhance the overall quality of DOD's
longitudinal health record.
______
Responses to Written Questions Submitted by Hon. Patty Murray to
Michael Kussman, M.D., Under Secretary for Health, U.S. Department of
Veterans Affairs
Question 1. If access control alone will not insure the security of
the core database information, what steps have been taken by the VA to
protect the integrity of the core information once it has been
accessed?
Response. In VA's veterans health information systems technology
architecture (VistA) environment, access control mechanisms currently
in place limit a user's access to specific applications, files, and
data fields, and security keys limit a user's ability to take actions
in specific application areas. Once a user is in the system, there is
limited data field auditing functionality in place in VistA to record
information on who and when changes are made to audited data fields.
When data fields are ``set'' to be audited, the date and time the
change was made, the user's name, and the old and new data values are
stored in an audit file that can be queried and/or printed to obtain
the audit data. This functionality enables an ongoing chronological
list of who made what changes to data values of fields that have been
selected to be audited.
Another step being taken by VA to expand on the limited auditing
functionally described above, is an audit service project. It will
provide the capability to document and maintain a permanent record of
all authorized and unauthorized access to health information systems,
as well as disclosure of confidential health care information. A
workgroup has been formed to identify and implement an enterprise audit
solution consistent with Federal, regulatory, and VA policies.
Techniques used to protect VA databases include authentication,
password security, logging and auditing. Role-based access and
biometrics initiatives are also being incorporated into VA's
application design and development strategies. Finally, certification
and accreditation through VA's Certification Program Office ensure
security controls are implemented and working as intended with respect
to information security. This includes a review of controls to ensure
the integrity of the data and publishing an assessment report to
document the current level of security.
Question 2. Has the VA considered augmenting the encryption access
with standalone security within the database that would force
compliance with policy and procedures as a self governing action
embedded into the very content that is being protected?
Response. VA has implemented several encryption solutions. One
solution encrypts hard drives on laptops, and another encrypts the
content of email messages and attachments and is used to transmit
sensitive data across the VA network and to our business partners.
While these are point solutions, they can be combined with other
security controls to provide for a defense-in-depth environment for VA
information systems and data.
VA is very active in the NHIN and the Organization for the
Advancement of Structured Information Standards (OASIS) health care
profile efforts, and is leveraging those efforts in the current and
future specifications and design for the electronic health record (EHR)
interoperability that is underway with DOD. These initiatives are aimed
at development of standard formats for secure exchange of health care
data to further the interoperability of information systems in both the
public and private sectors.
Question 3. Would the VA consider the combination of Encryption and
``self governing content'' to create a total security protocol.
Response. VA will be leveraging the work done by subject-matter
experts in both the public and private health care sectors relative to
the NHIN and OASIS health care profile efforts. Development of
security, privacy and information assurance requirements for the
electronic health record (EHR) interoperability, underway with DOD,
will be in accordance with common standards and certification criteria
that will enable secure exchange of health care data, furthering
interoperability of information systems in both the public and private
sectors. The goal is to create a total security protocol associated
with interoperability and data exchange between public and private
section health information systems.
______
Responses to Written Questions Submitted by Hon. Roger F. Wicker to
Michael Kussman, M.D., Under Secretary for Health, U.S. Department of
Veterans Affairs
Question 1. Please provide for the committee an overview of the
decisionmaking and governance structure currently employed by and
scheduled to be used by the departments with regard to health
information technology.
Response. VA/DOD health information technology initiatives are
jointly governed at the highest levels of the Departments. The VA/DOD
Joint Executive Council (JEC), co-chaired by the Under Secretary of
Defense for Personnel and Readiness and the Deputy Secretary of
Veterans Affairs, is comprised of senior leaders from VA/DOD. The JEC
was chartered to enhance VA/DOD information sharing and collaboration
activities, to ensure the efficient use of Federal services and
resources, and to identify opportunities such as policy, operations,
and capital planning to advance seamless transition initiatives. The
JEC provides leadership oversight of the Health Executive Council and
Benefits Executive Council, and all other councils or workgroups
designated by the co-chairs. Through a joint strategic planning
process, the JEC makes recommendations to the Secretaries regarding the
strategic direction for the joint coordination and sharing efforts
between the agencies, and oversees the implementation and progress of
those efforts through the VA/DOD joint strategic plan.
The VA/DOD Health Executive Council (HEC), co-chaired by the
Assistant Secretary of Defense (Health Affairs) and VA's Under
Secretary for Health, was created to establish a high-level program of
interagency cooperation and coordination in a joint effort to improve
health care and reduce costs for VA/DOD beneficiaries. The HEC is
responsible for identifying changes in health care-related policies,
procedures, and practices and assessing further opportunities for the
coordination and sharing of health-related services and resources.
The VA/DOD Benefits Executive Council (BEC) is co-chaired by the
DOD's Principal Deputy Under Secretary of Defense (Personnel and
Readiness) and VA's Under Secretary for Benefits. The BEC collaborates
on initiatives to expand and improve information sharing, refine the
process of records retrieval, and identify procedures to improve the
benefits claims process.
Since 2003, the VA/DOD joint strategic plan (JSP) has served as a
roadmap for the JEC and its sub-councils to guide the implementation of
the goals and objectives related to sharing data and improving care and
benefits administration. The JSP articulates a vision for
collaboration, establishes priorities for partnering, launches
processes to implement interagency policy decisions, develops joint
operation guidelines, and institutes performance monitoring to track
the progress in meeting the specific goals and objectives defined in
the plan.
Under the leadership of the JEC and the clear goals contained in
the JSP, VA/DOD have successfully met JSP health data-sharing
milestones in fiscal 2008.
The HEC information management/information technology (IM/IT) work
group, co-chaired by the chief information officers (CIOs) of the
Military Health System (MHS) and Veterans Health Administration (VHA),
maintains day-to-day responsibility for health data-sharing and
electronic health record (EHR) interoperability initiatives. The HEC
IM/IT work group was established to ensure that appropriate beneficiary
and medical data is visible, accessible, and understandable through
secure and interoperable information management systems.
The Senior Oversight Committee (SOC), co-chaired by the Deputy
Secretary of Defense and the Deputy Secretary of Veterans Affairs
directly engages senior military and civilian officials to ensure
interagency collaboration to effectively respond to the recommendations
of the various commissions and review groups looking at wounded warrior
issues to include: the task force on returning Global War on Terror
heroes; the independent review group on rehabilitative care and
administrative processes at Walter Reed Army Medical Center and
National Naval Medical Center; the President's Commission on Care for
America's Returning Wounded Warriors; the DOD task force on mental
health; and the Veterans' Disability Benefits Commission. Underneath
the SOC, VA/DOD organized several lines of actions (LOA), with one
specifically focused on data sharing.
In April 2008, the departments established the VA/DOD interagency
program office (IPO) to provide direct operational oversight and
management of EHR interoperability initiatives and ensure compliance
with jointly coordinated, prioritized, and approved VA/DOD
requirements. Additionally, the VA/DOD interagency clinical informatics
board (ICIB) was established to enable clinicians to have a direct
voice in the prioritization of recommendations for VA/DOD
interoperability initiatives. The ICIB is a VA/DOD clinician-led group
with the Deputy Assistant Secretary of Defense for Clinical and Program
Policy and VHA's Chief Patient Care Services Officer as proponents. The
ICIB guides clinical priorities for what electronic health information
the departments should share next.
Question 2. Are these structures capable of enforcing the timelines
presented in the IIP?
Response. Yes, these structures are capable of ensuring that the
items that have been jointly approved, funded, and scheduled are met.
The VA/DOD information interoperability plan (IIP) is a ``vision''
document, not an ``execution'' document. Not all initiatives described
in appendix D of the IIP are approved and funded.
The IIP is a roadmap that the two departments will follow to
improve interoperability. It establishes an organizing framework for
dialog and strategic direction between the department's senior
leadership. As such, the initiatives described in the IIP project an
overall direction with incremental targets. It provides a mechanism to
guide prioritization discussions and enables technologists to propose
potential solutions to incrementally enhance interoperability. Some
targets will not have fully defined technical approaches, nor will some
be funded. However, the document provides the pathway for facilitating
the decisionmaking process to fully define the incremental technical
solutions; identify the amount and source of funds required to
implement those solutions; and in turn codify them in execution project
plans.
Question 3. What mechanisms are available to these groups to
enforce the IIP.
Response. The items in the VA/DOD IIP that have been approved and
funded are incorporated into the VA/DOD joint strategic plan. The VA/
DOD JEC provides the necessary leadership oversight over the Health
Executive Council (HEC), Benefits Executive Council (BEC), and all
other councils and work groups responsible for the implementation and
progress of the VA/DOD joint strategic plan. The scope of these
responsibilities includes oversight of joint strategic plan performance
measures and associated project timelines. The VA/DOD Interagency
Program Office (IPO), established April 17, 2008, provides joint
management and oversight for the IIP to help ensure the agencies meet
interoperability compliance requirements.
Question 4. Can any of these groups veto the creation or
implementation of a non-interoperable or less-than-ideal system in
either department.
Response. The JEC is the senior executive managing authority for
achieving interoperability. Per the legislative mandate established by
Section 1635 of the 2008 National Defense Authorization Act, the IPO
was established to provide management oversight of the implementation
plan to achieve interoperability. The IPO is organizationally aligned
under the umbrella of the JEC.
Question 5. What are the incentives to compliance with the IIP?
Response. The Departments are committed to creating interoperable
systems that support the individual business needs of both
organizations. This strategy will improve patient care and ensure the
seamless transition of military servicemembers from active to veteran
status. The IIP is not an execution document for which the departments
seek compliance. It is a strategy or blueprint that documents key long
term initiatives that will contribute to VA/DOD information
interoperability as defined by the clinical and administrative/business
functional communities.
Question 6. How many programs or systems currently exist within the
DOD for capturing patient health data? Please provide a simple
description of these systems.
Response. To be provided by DOD.
Question 7. How many programs or systems currently exist within the
VA for capturing patient health data?
Response. Currently, VA uses VistA, which is our hospital
information system. VistA consists of more than 100 modules, which are
described in the soon-to-be released 2008 VistA monograph, a copy of
which will be forwarded to the Committee by November 30, 2008.
Question 8. I am concerned that the more interfaces and systems
there are, the higher the potential to for failure and the harder it
will be have seamless interoperability. After decades of independent
pathways to electronic record keeping, I want to be certain that by
allowing these two departments to continue to develop multiple systems
we are not setting ourselves up for failure. I would like to know how
we are making sure that the mistakes of the past are not repeated.
Response. With respect to implementing Section 1635 of the NDAA and
the IIP, VA/DOD have a joint plan to achieve interoperability, and are
no longer engaging in unrelated activities for electronic record
keeping.
Question 9. I hope that we will soon arrive at the day when a
servicemember can grow-up as a dependent in one service, join another
service in adulthood, be deployed around the world, stationed across
the country, retire, and have a record that he or she can view and that
each doctor and facility along the way can have full access to without
the involvement of paper records or the requirement of data dumping
from one system to another. I believe our servicemembers and veterans
deserve this kind of seamless treatment. We must be sure that we are
creating a system that does not place a burden on the patient.
Response. This is a goal to which the VA vigorously subscribes.
Though a significant amount of work remains in the areas of data
standards and terminology, the VA is at the forefront of efforts to
accomplish this work. Within the IPP, the initiative to develop the
nationwide health information network (NHIN) is targeted as a major
step toward achieving this vision. Over time, as standards mature and
EHR products implement those standards, the NHIN architecture will
provide the framework within which a lifetime record will grow.
Question 10. In this push to force these two huge agencies to work
together and achieve parity in the area of electric health records, I
am concerned that the ``customer,'' our veterans, the men and women of
our Armed Forces, and all the families that rely on these health care
systems might see a reduction in the quality of the service they are
provided. What steps are being taken so that our effort to improve
services to the ``customer'' does not do more harm than good?
Response. VA has an extensive quality program that continually
monitors the quality of care provided. VA is a leader in the delivery
of quality care as exemplified by performance measures and by the
results of the customer surveys that are conducted on a continual
basis.
VHA established an office that focuses on monitoring the safety of
the systems in the health care and in application of usability
principles and best practices to future development. The Information
Technology Office of Patient Safety works closely with VHA's National
Center for Patient Safety and VA's Office of Information Technology to
ensure the technology that is introduced into health care promotes the
safe delivery of care.
Question 11. The ability to utilize non-military providers is
especially important for veterans (who live far away from VA
facilities), servicemembers with special needs children (who need
expert care only available in the private sector), and servicemembers
stationed more than 50 miles from treatment facilities (who are
required to rely on the private sector). Secure portals that allow
private doctors who accept TRICARE to access the VA/DOD health records
system is essential for ensuring that our servicemembers, their
families, and our veterans have the highest quality of care possible.
Please explain the departments' efforts to achieve interoperability
with the private sector.
Response. As part of the NHIN, VA/DOD are pursuing the ability of a
servicemember or veteran to authorize the release of a standards-based
``summary of care'' electronic document to the provider/system of his
or her choice. When privacy and security protections are in place
within VA, it will be on the My HealtheVet personal health record web
portal and the veteran will be able to elect to ``send'' the document
to another personal health record. The veteran will also have the
ability to authorize family, friends, providers, and advocates access
to as little or much VA health and benefits information through the
delegation feature. By becoming early participants in the NHIN, VA/DOD
hopes to achieve interoperability with private sector providers. VA/DOD
are working on ways to make data available from both electronic health
records and personal health records as a standard document. It will
also expect a return of data from private networks in standard.
Chairman Akaka. Aloha and thank you so much for the
presentation from your team.
Let me call on Senator Wicker, who is here, for any
statement or questions.
STATEMENT OF HON. ROGER F. WICKER,
U.S. SENATOR FROM MISSISSIPPI
Senator Wicker. I will waive an opening statement in lieu
of listening to the testimony.
Chairman Akaka. Thank you, Senator Wicker.
Let me call on Dr. Casscells for your presentation.
STATEMENT OF S. WARD CASSCELLS, M.D., ASSISTANT SECRETARY OF
DEFENSE FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE;
ACCOMPANIED BY CHARLES CAMPBELL, CHIEF INFORMATION OFFICER,
MILITARY HEALTH SYSTEM, U.S. DEPARTMENT OF DEFENSE
Dr. Casscells. Mr. Chairman, Senator Burr, and Senator
Wicker, thank you again for this opportunity to represent the
Defense Department specifically in the capacity as Assistant
Secretary of Defense for Health Affairs with our Chief
Information Officer, Charles Campbell, to my right.
Sir, I would like to ask that my written statement be
submitted for the record----
Chairman Akaka. Without objection, it will be included.
Dr. Casscells [continuing]. And I would like to just speak
informally, if I may, and first say that we take no exception,
no disagreement with the GAO testimony and certainly are
appreciative of Dr. Kussman and Dr. Fletcher's testimony and
demonstration.
I also want to acknowledge, sir, your term ``glacial.'' It
is, in fact, an apt term for something that really began in
2001 and could have proceeded faster than it has. I think it is
also worth acknowledging that Congressional guidance to the
Veterans Department and the Department of Defense have been
instrumental in getting us to work more closely together, and
having been forced to do so, we found out we like it. In fact,
Dr. Kussman and I spent almost all of yesterday together and
now all of this morning. We have actually learned, I would have
to say, more from the VA than they have from us, and that
should also be acknowledged.
But, we are in catch-up mode. We had lost our way a bit. We
have, perhaps, too long been inclined to go with what the big
contractors recommend, and more recently, we have empowered our
clinicians, our practicing doctors, to take a more active role,
and that is the Joint Clinical Integration Board that we have
put together with the VA starting last May.
In addition, sir, we have had tremendous guidance from HHS.
The AHIC (American Health Information Community), has really
taken the lead in setting these standards, including standards
of interoperability that you asked about earlier of GAO and of
Dr. Kussman. And indeed, the analogy, I think, is very apt that
it doesn't matter whether my e-mail is AOL and yours is Gmail.
We can still communicate using standards. But, as you well can
imagine, it is more complicated than that.
People frequently say to me, and they said it very loudly
in a town hall that we had on our website a few months back,
why don't you just yank the system and replace it with this
commercial system or that one? And my response is, you know, I
am as frustrated sometimes with AHLTA as a military doctor, an
Army Reserve doctor, and as a military patient. And I have
worked with the systems at Harvard where I trained, and the
University of Texas, and demo-ed the systems at the Cleveland
Clinic, at Kaiser Permanente, and Mayo. And indeed, some of
these commercial systems are simpler to use and simpler to
learn.
But, as you can imagine, we have unique requirements
related to the war zones and related to the frequency and
ferocity of the cyber security attacks on our system. So, our
requirements are more demanding even than those of the average,
say, Cleveland Clinic patient, for example. So, this has been a
challenge for us.
One of the things we have done is to recognize that the
popularity of the CPRS VistA System used by the VA is a
function of two things: first, the fact that the doctors were
involved early on in the design; and, second, the graphical
user interface--the way you look at it and can navigate it--is
more intuitive. Mr. Campbell has now made it a priority to make
AHLTA look like the CPRS VistA System. It has been very popular
with the VA doctors.
Another issue that I think is terribly important is that he
is developing for the first time the watchdog capabilities to
really hold our contractors as accountable as the soldiers, the
sailors, the Marines, the taxpayers deserve. When you build an
enormous enterprise and you have basically only one or two
bidders, it becomes difficult to hold them to account in some
ways. As a consequence, I want to applaud what Mr. Campbell has
done in getting outside opinions, outside contractors to
assess, with no possibility of their competing for the other
business, how we are doing. So, like the GAO contract, having
an independent contractor assess our work with the VA has been
very helpful.
And to my surprise, they did not come back and say, yank
the whole system and replace it with a commercial system. They
said, frankly, that is a bit dangerous to do that and it would
be actually more billions in the end. So, the recommendation
has been to continually upgrade these systems, both of which
have, frankly, antiquated infrastructure and software basis--
what I call convergent evolution--to grow them toward common
standards, again, consistent with the Health and Human Services
standards, which will be applicable in the private sector, as
Senator Burr alluded to.
So, this is our direction, sir. We recognize that an
electronic health system will be legible, secure, and must be
private. It must fail rarely, if ever. Ideally, it should be
easy to learn and easy to use.
We are getting there. We are not there. I used it this
morning as a practicing doctor; and I actually had a visit with
my doctor today, so I was on the other end of AHLTA, as a
patient. I was pleased in asking my doctor, could you see my
records from theater? He said, ``Yes, I see you twisted your
ankle in Iraq and you also had an operation on your elbow.'' I
said, thank heaven. I need to be able to say that today in my
testimony.
[Laughter.]
Dr. Casscells. Because 2 years ago, sir, when I came back
from Iraq as a doctor-soldier, my records did not come back
with me. We used to load patients into the C-17s and give them
a CD-ROM and paper copies of their chart, and we would roll
them over on their side and put the chart under their hip. We
would often write on the cast with a magic marker what had
actually been done. These days are behind us now. Patients'
electronic records are preceding the patient to Landstuhl. They
are viewable from the VA. I can see my own records as a patient
in Iraq.
With the acknowledgement that it has been glacial, sir, I
would submit that we are making progress; and I do believe over
the next 5 years that we will have such a totally different
system that we won't even use the same name. I also would like
to commit that by the end of next September--a year and a week
from now--the deadline of the NDAA 2008, we will be fully
interoperable in every sense that is important to the
practicing doctor and to the patient.
Sir, with that, I would like to thank you again for this
opportunity to tell you about our progress and look forward to
your questions and guidance.
[The prepared statement of Dr. Casscells follows:]
Prepared Statement of Dr. S. Ward Casscells, Assistant Secretary of
Defense (Health Affairs) and Mr. Charles Campbell, Military Health
System, Chief Information Officer, U.S. Department of Defense
introduction
Mr. Chairman and members of this distinguished committee, thank you
for this opportunity to discuss the sharing of electronic health care
information between the Department of Defense (DOD) and Department of
Veterans Affairs (VA). We continue to make great strides in sharing
electronic health care information--and have plans to do even more in
the near future.
Cooperation between DOD and VA in the area of health care
information sharing is vital for effective management and efficient
delivery of programs and benefits that our Nation's Veterans and
Servicemembers deserve. DOD recognizes Congressional concerns regarding
the time it has taken the two Departments to establish the current
level of interoperability. Let me assure you that DOD and VA share the
ultimate goals of this and other Congressional bodies seeking to
address the needs of the Nation's heroes. We have been working together
in earnest and have made significant progress in sharing electronic
health care information since our first efforts in 2001. Today, I would
like to provide a historical overview of our joint efforts, outline
some of the initiatives that form the foundation for sharing efforts
moving forward, offer some details regarding the draft DOD/VA
Information Interoperability Plan, and discuss some other steps we have
taken to accelerate initiatives to lead us to ``full interoperability
of personal health care information'' by September 30, 2009, as
mandated in section 1635 of the National Defense Authorization Act for
Fiscal Year 2008.
historical overview
DOD and VA began laying the foundation for interoperability in 2001
when our Departments first shared health care information
electronically, and we have continually enhanced and expanded the types
of information we share as well as the ways in which we share. At times
it has not been an easy road, and there is always room for improvement
in an effort as large and as crucial as this one. Nonetheless, DOD and
VA have come a long way in the areas of health information technology,
interoperability standards, and health care information sharing. By
working together at the top levels of DOD and VA, we have established
policies that enable each Department to address its unique requirements
while also addressing requirements that we share. We have now taken
this coordination and cooperation to new levels with oversight and
governing bodies formed to ensure that our sharing efforts continue to
move in the right direction at a pace that meets and, we hope, exceeds
the expectations and needs of all our stakeholders.
the foundation for interoperability
The foundation of current and future health care information
sharing includes initiatives that have enhanced continuity of care for
our patients, enabled our providers at the point of care to view health
care information originating in the other Department's electronic
health record, and even provided real-time safety checks and alerts at
some sites.
Continuity of Care for Shared Patients
For patients treated at both VA and DOD facilities, providers can
view electronic health data from both Departments. The Departments
anticipate the addition of family history and social history by the end
of fiscal year 2008, all ``essential'' health data, as determined by a
team of DOD and VA health care providers, will be immediately viewable
by clinicians, at a DOD or VA facility as called for by the President's
Commission on Care for America's Returning Wounded Warriors. Health
data accessible by DOD and VA providers includes allergy information,
outpatient medications, inpatient and outpatient laboratory results,
radiology reports, demographic details, clinical notes, procedures,
problem lists, and vital signs. In addition to those typical bits of
health care information, DOD and VA exchange Pre- and Post-Deployment
Health Assessments and Post-Deployment Health Reassessments as well as
vital clinical data captured in the Theater of operations. Health care
information from Theater includes inpatient notes, outpatient
encounters, and ancillary clinical data, such as pharmacy data,
allergies, laboratory results, and radiology reports. Exchanging this
Theater clinical information is a significant accomplishment in our
efforts to enhance continuity of care for Servicemembers returning from
Iraq, Afghanistan, Kuwait, and other forward locations.
DOD also now has an inpatient documentation system in use at 20 of
its inpatient facilities, accounting for more than half of our
inpatient beds, with plans to expand use of the current system to
additional facilities in the next year. This capability is now in place
at Landstuhl Regional Medical Center, which, as the primary receiving
location for patients coming out of Theater, is a critical link in the
electronic health care information chain.
Drug-Drug and Drug-Allergy Interaction Checking
Beyond having viewable data available, DOD and VA are also
exchanging some data at the highest, most complex level of
interoperability. Outpatient pharmacy and drug allergy data are now
available in a standardized format for patients receiving treatment
from both DOD and VA. This standardization enables our information
systems to run vital safety checks. Drug-drug interaction and drug-
allergy checks can now be run using data from both Departments, further
enhancing patient safety. Currently, this capability is operational in
the following seven locations:
William Beaumont Army Medical Center/El Paso VA Health
Care System;
Eisenhower Army Medical Center/Augusta VA Medical Center;
Naval Hospital Pensacola/VA Gulf Coast Health Care System;
Madigan Army Medical Center/VA Puget Sound Health Care
System;
Naval Health Clinic Great Lakes/North Chicago VA Medical
Center;
Naval Hospital San Diego/VA San Diego Health Care System;
and
Mike O'Callaghan Federal Hospital/VA Southern Nevada
Health Care System.
For this capability to work properly, the individual must have a record
in the Defense Manpower Data Center/Defense Enrollment and Eligibility
Reporting System (DEERS). More than 6 million veterans, primarily those
who separated from Service prior to the establishment of DEERS, were
added to the DEERS database this year. With that completed, DOD sent
instructions that allow any DOD site to now utilize this capability of
dug-drug and drug-allergy interaction checking. In addition, all DOD
and VA facilities--not just those listed above--have access to the
shared DOD and VA pharmacy and allergy data for a patient if that
patient should present to their facility for care. To further expand
the use of this functionality, DOD will begin implementation of an
automated process for identifying patients receiving care at both DOD
and VA so manual intervention for this level of data exchange is no
longer necessary.
Continuity of Care for Polytrauma Patients (Wounded Warriors)
In response to the urgent need for VA providers at Polytrauma
Centers to have as much information as possible on inpatients
transferring to their care, DOD sends electronic health care
information directly to the Polytrauma Centers. When providers
determine that a severely wounded, injured, or ill patient should be
transferred to a VA Polytrauma Center for care, DOD sends radiology
images and scanned paper medical records electronically to the
receiving facility. This effort began in March 2007 with a pilot
project, sharing information from one DOD facility to one VA Polytrauma
Center, and quickly expanded to include the three primary DOD
facilities treating incoming severely wounded warriors--Walter Reed
Army Medical Center, National Naval Medical Center, and Brooke Army
Medical Center--and the four level 1 VA Polytrauma Centers-Tampa,
Richmond, Palo Alto, and Minneapolis.
Separated Service Members (Potential VA Patients)
More than 4 million former Servicemembers eligible for VA health
care now have electronic health care information accessible to their
new provider should they seek care at a VA facility. In 2001, DOD
transmitted electronic health care information for Servicemembers who
had separated since 1989. Monthly transfers of health care information
for newly separated Servicemembers began in 2002 and continue today.
Historical electronic health care information available to VA providers
includes the following data elements:
Outpatient pharmacy data, laboratory and radiology
results;
Inpatient laboratory and radiology results;
Allergy data;
Consult reports;
Admission, disposition, transfer data;
Standard ambulatory data record elements (including
diagnosis and treating physician);
Pre- and post-deployment health assessments; and
Post-deployment health reassessments.
When the former Servicemember presents to VA for care or evaluation,
the VA provider can access this information from within the VA
electronic health record.
national defense authorization act for fiscal year 2008
DOD and VA have worked hard to implement, enhance, and expand
health care information sharing initiatives to support all of our
beneficiaries since we first started sharing data in 2001. In the past
couple of years, with evolving needs and technological advances, we
have accelerated our collaborative efforts. Although DOD and VA both
want to do whatever necessary to provide our beneficiaries with the
best possible care, our Departments and our beneficiaries have
benefited from much-needed Congressional guidance and direction. We are
grateful for your devotion to our beneficiaries, the Nation's heroes,
and your assistance in helping us find ways to enhance the care we can
offer them. To that end, the National Defense Authorization Act for
Fiscal Year 2008 has set a timeframe for reaching the goal of full
information interoperability. The Act specifically calls for the
establishment of a DOD/VA Interagency Program Office whose function
``shall be to implement, by not later than September 30, 2009,
electronic health record systems or capabilities that allow for full
interoperability of personal health care information.'' To meet this
deadline, DOD and VA have taken a number of key steps that will help us
further accelerate our efforts to achieve interoperability, including
drafting an Information Interoperability Plan.
dod/va information interoperability plan
The DOD/VA Information Interoperability Plan serves as the
strategic organizing framework for current and future information
technology projects and information needs. The purpose of the
Information Interoperability Plan is to guide DOD and VA leadership,
policymakers, and information management and technology personnel in
achieving the shared vision for DOD and VA health, personnel, and
benefits information interoperability. The Plan discusses issues and
opportunities for interoperability: what it involves, why we should
care about it, and how it can be achieved. It explains the benefits for
stakeholders; identifies the main issues that lie on the road to
achievement; and provides an initiative-focused, problem-oriented,
phased implementation schedule, though not all initiatives described in
the Plan are funded. The Information Interoperability Plan specifically
seeks to accomplish the following objectives:
Define VA and DOD strategic interoperability maturation
and organizing framework;
Map the current and future health, administrative, and
benefit information sharing through a problem-oriented approach to
establish an interoperability roadmap;
Identify information capability gaps to guide future
investment portfolio decisions and prioritization of initiatives and
influence information technology design solutions;
Set milestones to measure progress of near-, mid-, and
long-term interoperability goals; and
Leverage the national standardization activities led by
the Department of Health and Human Services to foster health care
information sharing with the private sector.
To realize our shared vision of information interoperability, the two
Departments will leverage our current, robust information sharing
programs and infrastructure to close remaining gaps in information
coverage. We will expand upon existing initiatives and incrementally
implement greater capabilities as determined by the health, benefits,
and personnel communities and as technology advances. Wherever
possible, our solutions will leverage harmonized interoperability
standards recognized by the Secretary of Health and Human Services in
an effort to ensure we do not create a sharing solution that will work
between the DOD and VA but not with our private sector partners and
other Federal agencies. The initiatives outlined in the Plan address
the following constraints relating to the implementation of
interoperable systems between DOD and VA:
Incompatible legacy computing and communications
infrastructure.
Lack of a robust, joint architecture facilitating
interagency data sharing;
Existing data in unstructured formats difficult to
discover and access;
Undefined standards and maturing standards that are
neither implemented nor robust;
Large amounts of existing data with limited documentation
and non-standardized access mechanisms;
Workforce insufficiently trained regarding available
information;
Shared information often not effectively integrated into
the workflow of clinicians and administrators;
Different levels of policy and governance that vary based
on organizational culture;
Resource availability, both manpower and dollars;
Contracting and acquisition policies and vehicles; and
Industry and market place divergence.
In establishing this first version of the Information Interoperability
Plan, the two Departments agreed to goals that fall in four main
categories: continuity of care, benefits, infrastructure, and
population health and research. Each of the 23 interoperability
initiatives detailed in the Plan aligns with one of these four
categories as shown in the following table.
------------------------------------------------------------------------
Initiatives to Achieve Our Shared Vision
-------------------------------------------------------------------------
Image Sharing
Inpatient Electronic Health Information
Reserve Component Access to Electronic Health Information
Enhancements to Health Information Exchange between Clinical Information
Systems
Clinical Case Management
Psychological Health Treatment and Care Records
Immunizations Records and History
Integrated Personal Health Data with Patient Self-Assessment
Nationwide Health Information Network
Personalized Health care (Family History)
Interagency Program Office
Integration of Interagency Data Sharing into DOD and VA architectures
Trusted Partnership and Communication Infrastructure
Exposure History (Environmental and Occupational Hazards)
Data marts to support Clinical Research, Quality, and Population Health
Management
Knowledge sharing for Psychological Health and Traumatic Brain Injury
e-Benefits Portal
Disability Evaluation System
Non-Clinical Case Management
Pay Systems Enhancements
Identity Management
Federal Health Center Information Technology Support
------------------------------------------------------------------------
The DOD/VA Information Interoperability Plan is an implementation
roadmap of potential phased initiatives that will help the Departments
achieve a shared vision. The success of this roadmap will depend on
many factors and will require collaboration at all levels of both
Departments. The Plan is only the first step in the process. As we move
forward, the continuing diligence of governing bodies and the
functional and technical communities will be vital to identifying and
bridging all information gaps.
meeting the interoperability deadline
Drafting the DOD/VA Information Interoperability Plan is one of
several recent steps the Departments have taken to meet the deadline
set forth in the National Defense Authorization Act for Fiscal Year
2008. Other steps designed to accelerate sharing efforts include
establishing the DOD/VA Interagency Program Office and the DOD/VA Joint
Clinical Information Board.
Interagency Program Office
The Interagency Program Office was established in April 2008 to
``act as a single point of accountability'' for cross-organizational
coordination and collaboration to support health, personnel, and
benefits data sharing. This office will report progress to the DOD/VA
Joint Executive Council and incorporate key milestones into the DOD/VA
Joint Strategic Plan. The Interagency Program Office will be
responsible for management and oversight but will not be the technical
execution organization. It will help resolve conflicts in the DOD and
VA sharing requirements for health, personnel, and benefits functional
communities; ensure DOD and VA schedules are coordinated for technical
execution of initiatives; assist in coordinating funding
considerations; obtain input and concurrence of other DOD and VA
stakeholders; and report to Congress on progress and plans. Technical
execution remains in the appropriate DOD and VA offices using the
established Departmental statutory and regulatory processes for
acquisition, funding, management control, information assurance, and
other execution actions, which are significantly different for each
Department.
Joint Clinical Information Board
The Joint Clinical Information Board enables clinicians to have a
direct voice in the prioritization of recommendations for DOD/VA
interoperability initiatives. The Deputy Assistant Secretary of Defense
for Clinical and Program Policy and the Chief Patient Care Services
Officer, Veterans Health Administration, serve as the lead functional
proponents. The Board guides clinical priorities for what electronic
health care information the Departments should share next and reviews
planned clinical information system solutions for DOD/VA sharing to
ensure alignment to clinical sharing priorities as defined by the
Board. To support efforts to meet the September 2009 deadline, the
Joint Clinical Information Board submitted recommendations to the
Interagency Program Office and DOD/VA Health Executive Council
Information Management/Information Technology Work Group in July 2008.
The Board will refine and prioritize new requirements to ensure
continued improvements in DOD/VA electronic health data sharing in a
manner that supports clinicians in health care delivery.
conclusion
The initial movement toward interoperability was a struggle. In the
past several years, however, the efforts of DOD and VA to share health
care information have gained undeniable momentum. We continue to build
on this momentum and a solid foundation of sharing initiatives as we
move toward next September and the goal of full interoperability of
health care information and beyond. The journey has been long and
arduous and will not end when we achieve interoperability. Rather, our
journey will continue as DOD and VA strive to enhance the care we
provide for all of our beneficiaries.
As always, we appreciate the insights, recommendations, and
guidance of this Congressional committee. We are all working toward the
same end--to provide the highest quality care for our Nation's heroes,
past and present--and we need to work together to achieve our goals as
efficiently and effectively as possible.
Thank you again for allowing us the opportunity to appear before
you and testify about DOD/VA electronic health care information sharing
achievements, goals, and plans.
______
Responses to Written Questions Submitted by Hon. Daniel K. Akaka to Dr.
S. Ward Casscells, Assistant Secretary of Defense for Health Affairs,
U.S. Department of Defense
Question 1. Doctors Kussman and Casscells, I understand that
currently 65 percent of the care provided by DOD and 40 percent of the
care provided by VA is purchased from the private sector. Only 9
percent of the physicians in private outpatient practice use electronic
medical records. How will you overcome this reality and ensure the
medical information from this care is included in the servicemembers/
veterans electronic health record?
Response. DOD fully supports efforts to exchange health information
with the private sector to ensure medical information is included in
the Servicemember's longitudinal health record. In fiscal year 2009,
DOD will provide an image scanning capability to enable DOD to scan
information from the Managed Care Support Contractors (MCSCs), such as
a Specialty Care Consultants, so it is available to DOD providers. The
private sector continues to mature in its use of electronic
documentation and DOD is committed to private sector health information
exchange coordinated through the Office of the National Coordinator
(ONC), Health and Human Services (HHS). Specifically, DOD, VA, and the
ONC are active partners with other Federal agencies and private health
care organizations deploying and expanding HHS's National Health
Information Network (NHIN). The NHIN private health care participants
currently include over 20 organizations geographically located across
the continental United States. Utilizing nationally recognized
standards, DOD and VA recently successfully tested the exchange of
health records with these entities and between each other. DOD plans on
using the NHIN as the communication device with our MCSCs in future
years.
Question 2. Doctors Kussman and Casscells, I believe we all can
agree that VA currently has a world class inpatient electronic health
records system. My question for the both of you is, what impact would
the development of a new joint DOD and VA inpatient health records
system have on VA's current system?
Response. The DOD defers to the VA regarding this question.
Question 3. Doctors Kussman and Casscells, as a result of merging
the Great Lakes Naval Hospital and the North Chicago VA Medical Center
in 2010, the number of shared DOD and VA patients will increase roughly
fivefold from 18,000 to 100,000. Isn't this the real test of DOD/VA
interoperability? And how are we doing to ensure that it works?
Response. We do not anticipate the increase in shared patients to
be an issue. The DOD and VA have teamed on information sharing
initiatives since 2000 and currently share a significant amount of
health information today. However, the North Chicago Federal Health
Care Center (FHCC) initiative is very different from previous DOD/VA
sharing efforts due to the challenges of addressing local information
sharing requirements as a combined facility treating both DOD and VA
beneficiaries. To ensure success, DOD/VA will continue to work with
local and enterprise teams to address the highest priority needs and
ensure FHCC is successful.
Question 4. Dr. Casscells, I understand from recent news reports
that DOD is actively pursuing alternatives to its current electronic
health records system. Will the problems you have identified with DOD's
current electronic health record system affect DOD and VA's ability to
share data in the near- or long-term?
Response. DOD is pursuing enhancements to AHLTA, not replacement of
AHLTA. DOD does not anticipate upcoming AHLTA-related enhancements will
adversely impact DOD/VA information interoperability goals and
objectives. We anticipate that the proposed architecture and usability
improvements will continue to support DOD/VA sharing initiatives. The
Department fully recognizes the importance of DOD/VA electronic health
information sharing and is including these requirements in the AHLTA
improvement and modernization efforts.
Question 5. Doctors Kussman and Cassells, I understand electronic
health records for Reserve soldiers are less than complete. How do we
address the issue of establishing a comprehensive electronic health
record for these part-time soldiers?
Response. The health care provided to the Reserve/Guard when they
are deployed with the active duty forces are documented in AHLTA. If
the Reserve/Guard soldier receives care in the Department of Veterans
Affairs (VA) post-deployment, the Department of Defense (DOD) is able
to access that data. For care received in the private sector, in fiscal
year 2009, DOD will provide an image scanning capability to enable DOD
to scan information from the Managed Care Support Contractors (MCSCs),
such as Specialty Care Consultants, so it is available to DOD
providers. DOD, VA, and the Office of the National Coordinator (ONC),
Health and Human Services (HHS), are active partners with other Federal
agencies and private health care organizations deploying and expanding
HHS's National Health Information Network (NHIN). The NHIN private
health care participants currently include over 20 organizations
geographically located across the continental United States. Utilizing
nationally recognized standards, DOD and VA recently successfully
tested the exchange of health records with these entities and between
each other. DOD plans on using the NHIN as the communication device
with our MCSCs in future years.
Question 6. Dr. Casscells, I have been told that DOD has objected
strongly to language in the 2009 Defense Authorization bill that would
require the Departments to be interoperable with their transaction
partners. I understand this to mean that the DOD and VA electronic
health record systems must maintain the flexibility to achieve
interoperability with other government agencies and private care
providers in the future. Please discuss your position on the importance
of future interoperability with potential transaction partners.
Response. The DOD fully supports interoperability with other
Federal agencies and our transaction partners. The Department is firmly
committed to working with the Department of Health and Human Services
(HHS) through the Office of the National Coordinator (ONC) to actively
collaborate on and advance the development, adoption, and
implementation of health information technology and standards. The
Department continues to actively support the efforts of the ONC. The
Department representatives contribute to ONC's Health Information
Technology Policy Council, Federal Health Architecture Managing and
Lead Partners Council and Leadership Council, and Health Information
Technology Standards Panel initiatives.
Currently, DOD is engaged in several initiatives to explore
alternative solutions to electronic information sharing with
transaction partners. DOD and Microsoft are exploring the use of the
Health Vault application as one possible solution that would allow
those who receive care via contract providers to store and organize
their health information and then share that information with trusted
entities such as physicians and hospitals. Pilot studies are underway
in Pensacola, Florida and Spartanburg, South Carolina and as part of
the National Health Information Network Trial Implementation to examine
the feasibility of sharing clinical data from DOD medical facilities
with non-Federal partners.
Question 7. Dr. Casscells, I understand from recent news reports
that DOD is actively pursuing alternatives to its current electronic
health records system. Will the problems you have identified with DOD's
current electronic health record system affect DOD and VA's ability to
share data in the near- or long-term?
Response. DOD is pursuing enhancements to AHLTA, not replacement of
AHLTA. DOD does not anticipate upcoming AHLTA-related enhancements will
adversely impact DOD/VA information interoperability goals and
objectives. We anticipate that the proposed architecture and usability
improvements will continue to support DOD/VA sharing initiatives. The
Department fully recognizes the importance of DOD/VA electronic health
information sharing and is including these requirements in the AHLTA
improvement and modernization efforts.
______
Responses to Written Questions Submitted by Hon. Patty Murray to Dr. S.
Ward Casscells, Assistant Secretary of Defense for Health Affairs, U.S.
Department of Defense
Question 8. If access control alone will not insure the security of
the core database information, what steps have been taken by the VA to
protect the integrity of the core information once it has been
accessed?
Response. The Department of Defense defers to the VA regarding the
answer to this question.
Question 9. Has the VA considered augmenting the encryption access
with standalone security within the database that would force
compliance with policy and procedures as a self governing action
embedded into the very content that is being protected?
Response. The Department of Defense defers to the VA regarding the
response to this question.
Question 10. Would the VA consider the combination of Encryption
and ``self governing content'' to create a total security protocol?
Response. The Department of Defense defers to the VA regarding the
response to this question.
______
Responses to Written Questions Submitted by Hon. Roger F. Wicker to Dr.
S. Ward Casscells, Assistant Secretary of Defense for Health Affairs,
U.S. Department of Defense
Question 11. Please provide for the committee an overview of the
decisionmaking and governance structure currently employed by and
scheduled to be used by the departments with regard to health
information technology.
Response. The Department of Defense (DOD) and Department of
Veterans Affairs (VA) health information technology initiatives are
jointly governed at the highest levels of the Departments. The DOD/VA
Joint Executive Council (JEC), co-chaired by the Under Secretary of
Defense for Personnel and Readiness and the Deputy Secretary of VA, is
comprised of senior leaders from DOD and VA. The JEC was chartered to
enhance VA and DOD information sharing and collaboration activities, to
ensure the efficient use of Federal services and resources, and to
identify opportunities such as policy, operations, and capital planning
to advance seamless transition initiatives. The JEC provides leadership
oversight of the Health Executive Council (HEC) and Benefits Executive
Council (BEC), and all other councils or work groups designated by the
co-chairs. Through a joint strategic planning process, the JEC makes
recommendations to the Secretaries regarding the strategic direction
for the joint coordination and sharing efforts between the agencies and
oversees the implementation and progress of those efforts through the
DOD/VA Joint Strategic Plan (JSP).
The DOD/VA HEC (HEC), co-chaired by the Assistant Secretary of
Defense for Health Affairs and VA Under Secretary for Health, was
created to establish a high-level program of interagency cooperation
and coordination in a joint effort to improve health care and reduce
costs for DOD and VA beneficiaries. The HEC is responsible for
identifying changes in health care-related policies, procedures, and
practices and assessing further opportunities for the coordination and
sharing of health-related services and resources
The DOD/VA BEC is co-chaired by the DOD's Principal Deputy Under
Secretary of Defense for Personnel and Readiness and VA's Under
Secretary for Benefits. The BEC collaborates on initiatives to expand
and improve information sharing, refine the process of records
retrieval, and identify procedures to improve the benefits claims
process.
Since 2003, the VA/DOD JSP has served as a roadmap for the JEC and
its sub-councils to guide the implementation of the goals and
objectives related to sharing data and improving care and benefits
administration for beneficiaries. The JSP articulates a vision for
collaboration, establishes priorities for partnering, launches
processes to implement interagency policy decisions, develops joint
operation guidelines, and institutes performance monitoring to track
the Departments' progress in meeting the specific goals and objectives
defined in the plan.
Under the leadership of the JEC and the clear goals contained in
the JSP, DOD, and VA have realized success in meeting JSP health data
sharing milestones in fiscal year 2008.
The HEC Information Management/Information Technology (IM/IT) Work
Group, co-chaired by the Chief Information Officers (CIOs) of the
Military Health System and Veterans Health Administration, maintains
day-to-day responsibility for health data sharing and electronic health
record interoperability initiatives. The HEC IM/IT Work Group was
established to ensure that appropriate beneficiary and medical data is
visible, accessible, and understandable through secure and
interoperable information management systems.
The Wounded, Ill, and Injured Senior Oversight Committee (SOC), co-
chaired by the Deputy Secretary of Defense and the Deputy Secretary of
Veterans Affairs, directly engages senior military and civilian
officials to ensure interagency collaboration to effectively respond to
the recommendations of the various commissions and review groups
looking at wounded warrior issues to include: the Task Force on
Returning Global War on Terror Heroes; the Independent Review Group on
Rehabilitative Care and Administrative Processes at Walter Reed Army
Medical Center and National Naval Medical Center; the President's
Commission on Care for America's Returning Wounded Warriors; the DOD
Task Force on Mental Health; and the Veterans' Disability Benefits
Commission. Underneath the SOC, DOD and VA organized several Lines of
Actions, with one specifically focused on data sharing.
In April 2008, the Departments established the DOD/VA Interagency
Program Office to provide direct operational oversight and management
of electronic health record interoperability initiatives and ensure
compliance with jointly coordinated, prioritized, and approved DOD/VA
requirements. Additionally, the DOD/VA Interagency Clinical Informatics
Board (ICIB) was established to enable clinicians to have a direct
voice in the prioritization of recommendations for DOD/VA
interoperability initiatives. The ICIB is a DOD/VA clinician-led group
with the Deputy Assistant Secretary of Defense for Clinical and Program
Policy and the Veterans Health Administration's Chief Patient Care
Services Officer as proponents. The ICIB guides clinical priorities for
what electronic health information the Departments should share next.
Question 12. Are these structures capable of enforcing the
timelines presented in the IIP?
Response. Yes, these structures are capable of ensuring the items
that have been jointly approved, funded, and schedules are met. The
Department of Defense (DOD) and Department of Veterans Affairs (VA) IIP
is a ``vision'' document, not an ``execution'' document. Not all
initiatives described in Appendix D of the IIP are approved and funded.
The IIP is not an execution plan, but rather, a roadmap that the
two Departments will follow to improve interoperability. It establishes
an organizing framework for dialog and strategic direction between the
Departments' senior leadership. As such, the initiatives described in
the IIP project an overall direction with incremental targets. It
provides a mechanism to guide prioritization discussions and enables
technologists to propose potential solutions to incrementally enhance
interoperability. Some targets will not have fully defined technical
approaches, nor will some be funded. However, the document provides the
pathway for facilitating the decisionmaking process to fully define the
incremental technical solutions; identify the amount and source of
funds required to implement those solutions; and, in turn, codify them
in execution of project plans.
Question 13. What mechanisms are available to these groups to
enforce the IIP?
Response. The items in the Department of Defense (DOD) and
Department of Veterans Affairs (VA) IIP that have been approved and
funded are incorporated into the DOD/VA Joint Strategic Plan. The DOD/
VA Joint Executive Council provides the necessary leadership oversight
over the Health Executive Council, Benefits Executive Council, and all
other councils and work groups responsible for the implementation and
progress of the DOD/VA Joint Strategic Plan (JSP). The scope of these
responsibilities includes oversight of JSP performance measures and
associated project timelines. The DOD/VA Interagency Program Office,
established April 17, 2008, provides joint management and oversight for
the IIP to help ensure the agencies meet interoperability compliance
requirements.
Question 14. Can any of these groups veto the creation or
implementation of a non-interoperable or less-than-ideal system in
either department?
Response. The Department of Defense (DOD) and Department of
Veterans Affairs (VA) senior leadership and supporting councils and
work groups are charged with the responsibility and authority to ensure
compliance with DOD/VA information sharing policies and guidance,
plans, and agreements to improve health care benefits and services.
Based on the established governance structure, multiple levels of
oversight have been put in place to ensure the development and
implementation of interoperable health care information sharing
capabilities.
The DOD/VA Interagency Clinical Informatics Board (ICIB),
established in May 2008, ensures clinicians have a direct voice in the
prioritization of recommendations for DOD/VA interoperability
initiatives. The ICIB is responsible for identifying the essential
health information that will be shared between the DOD/VA and reviewing
all joint clinical information system solutions prior to development to
ensure alignment with clinical information sharing priorities.
These governance, oversight, and management mechanisms will help to
ensure compliance with joint interoperability requirements.
Question 15. What are the incentives to compliance with the IIP?
Response. The Department of Defense (DOD) and Department of
Veterans Affairs (VA) are fully committed to continuing efforts to
improve and expand information sharing capabilities to enhance health
care delivery and continuity of care for shared patients. The DOD/VA
Joint Executive Council Strategic Plan provides the necessary strategic
goals, objectives, strategies, and their corresponding performance
measures that will help ensure the Departments meet DOD/VA electronic
data sharing requirements, including those from the DOD/VA IIP that
have been approved and funded.
The DOD/VA Interagency Program Office, which was established on
April 17, 2008, provides joint management and oversight for the IIP to
help ensure the agencies continue to focus on further enhancing
electronic data sharing to meet the requirements of the Departments.
The DOD/VA Interagency Clinical Informatics Board (ICIB),
established in May 2008, ensures clinicians have a direct voice in the
prioritization of recommendations for DOD/VA health interoperability
initiatives. The ICIB is responsible for identifying and prioritizing
the essential health information that will be shared between DOD/VA.
Question 16. How many programs or systems currently exist within
the DOD for capturing patient health data? Please provide a simple
description of these systems.
Response. The DOD provides three key capabilities, AHLTA, AHLTA-
Theater (AHLTA-T), and Essentris, to capture outpatient and inpatient
health care information.
AHLTA is the military's electronic health record (EHR), an
enterprise-wide medical and dental clinical information system. AHLTA
generates, maintains, stores, and provides secure online access to
comprehensive patient records. This EHR began worldwide deployment in
January 2004 and is becoming a key enabler to military medical
readiness. It supports uniform, high-quality health promotion and
health care delivery to more than 9.2 million Military Health System
(MHS) beneficiaries. In response to health care provider feedback, the
MHS is upgrading AHLTA to improve the clinical encounter documentation
process and provide user-requested functional capabilities. Several of
these enhancements are designed to improve health care provider
workflow processes and minimize the time required to document clinical
encounters.
AHLTA-T, which is operational in Iraq, Kuwait, and Afghanistan,
collects and transfers inpatient and outpatient encounters to the
Theater Medical Data Store. Outpatient encounters are then transferred
to the AHLTA Clinical Data Repository for use in AHLTA worldwide, 24
hours a day, 7 days a week. AHLTA-T also provides DOD and the
Department of Veterans Affairs (VA) with online access to inpatient and
outpatient theater medical information.
Essentris, DOD's inpatient documentation capability, is operational
at 18 medical treatment facilities representing 47 percent of DOD's
inpatient workload. Fiscal year (FY) 2009 plans target expanding to 80
percent of DOD's inpatient workload. Currently, discharge summary data
is shared with the VA. Additional inpatient data has also been made
available to VA. In fiscal year 2009, VA will expand their ability to
see this data at their facilities. DOD and VA recently completed a
study to determine prioritized recommendations and potential technical
solutions for inpatient EHRs. These efforts have been extended through
December 2008 to support development of a DOD/VA inpatient EHR concept
of operations, common services framework, and action plan.
Question 17. How many programs or systems currently exist within
the VA for capturing patient health data?
Response. The Department of Defense respectfully defers to the VA
regarding the response to this question.
Question 18. I am concerned that the more interfaces and systems
there are, the higher the potential to for failure and the harder it
will be have seamless interoperability. After decades of independent
pathways to electronic record keeping, I want to be certain that by
allowing these two departments to continue to develop multiple systems
we are not setting ourselves up for failure. I would like to know how
we are making sure that the mistakes of the past are not repeated.
Response. Over the past few years, the Department of Defense (DOD)
and Department of Veterans Affairs (VA) have made significant progress
in sharing electronic health care information. DOD/VA senior
leadership, governance structures, and supporting councils and
workgroups are fully committed to providing secure, reliable, and
interoperable information sharing capabilities to enhance health care
delivery and continuity of care for shared patients. The current DOD/VA
electronic medical records, usage of these records, and health
information exchange capabilities function around the globe and are
well ahead of those of the private sector, enabling the exchange of
legible, accurate, and relevant electronic health information when and
where needed.
Question 19. I hope that we will soon arrive at the day when a
servicemember can grow-up as a dependent in one service, join another
service in adulthood, be deployed around the world, stationed across
the country, retire, and have a record that he or she can view and that
each doctor and facility along the way can have full access to without
the involvement of paper records or the requirement of data dumping
from one system to another. I believe our servicemembers and veterans
deserve this kind of seamless treatment. We must be sure that we are
creating a system that does not place a burden on the patient.
Response. The Department of Defense (DOD) is fully committed to
enhancing and expanding health information sharing capabilities that
will improve the delivery and continuity of health care services. We
believe that a number of key and significant initiatives have ensured
the continued advancement of DOD and Department of Veterans Affairs
(VA) information sharing efforts to benefit the continuity of care for
our patients. The DOD/VA Joint Executive Council and supporting
governance structure provide the senior leadership and oversight
necessary to ensure we achieve the goals and objectives of the DOD/VA
Joint Strategic Plan.
The DOD/VA Interagency Program Office, which was established April
17, 2008, provides joint management and oversight for the Information
Interoperability Plan (IIP) to help ensure the agencies continue to
focus on further enhancing electronic data sharing to meet the
requirements of the Departments. The DOD/VA Interagency Clinical
Informatics Board (ICIB), established in May 2008, ensures clinicians
have a direct voice in the prioritization of recommendations for DOD/VA
health interoperability initiatives. The ICIB is responsible for
identifying and prioritizing the essential health information that will
be shared between DOD/VA.
DOD is fully committed to working with the Department of Health and
Human Services (HHS) through the Office of the National Coordinator
(ONC) to help advance national health information sharing capabilities.
For example, DOD is currently engaged in several initiatives to explore
alternative solutions for sharing health information with the private
sector. Pilot studies are underway in Pensacola, Florida and
Spartanburg, South Carolina, to examine the feasibility of sharing
clinical information between DOD medical facilities and non-Federal
partners. DOD and Microsoft are exploring the use of the Health Vault
application as one possible solution that would allow those who receive
care via contract providers to store and organize their health
information and then share that information trusted entities such as
physicians and hospitals.
Question 20. In this push to force these two huge agencies to work
together and achieve parity in the area of electronic health records, I
am concerned that the ``customer'', our veterans, the men and women of
our Armed Forces, and all the families that rely on these health care
systems might see a reduction in the quality of the service they are
provided. What steps are being taken so that our effort to improve
services to the ``customer'' does not do more harm than good?
Response. The health care customers served by the Department of
Defense (DOD) represent a large, varied, and mobile population. The use
of electronic health records provide this customer base with health
records that are legible, available worldwide, accessible by multiple
providers simultaneously and are available 24 hours a day, 7 days a
week. In post-disaster situations such as hurricanes, beneficiaries
with electronic health records have been able to recover their health
histories and have been able to have needed prescriptions renewed or
refilled seamlessly due to our worldwide accessibility to the
electronic health record, regardless of where the care was originally
delivered. Often, prescriptions have been filled at locations far
removed from the beneficiaries' home location. Further interoperability
between DOD and Department of Veterans Affairs systems will continue to
support improved care to our ``customers.''
In response to health care provider feedback, DOD is enhancing
AHLTA to improve the clinical encounter documentation and workflow
process and provide the necessary architecture to ensure overall
performance and stability.
Question 21. The ability to utilize non-military providers is
especially important for veterans (who live far away from VA
facilities), servicemembers with special needs children (who need
expert care only available in the private sector), and servicemembers
stationed more than 50 miles from treatment facilities (who are
required to rely on the private sector). Secure portals that allow
private doctors who accept TRICARE to access the DOD/VA health records
system is essential for ensuring that our servicemembers, their
families, and our veterans have the highest quality of care possible.
Please explain the departments' efforts to achieve interoperability
with the private sector.
Response. DOD fully supports efforts to exchange health information
with the private sector to ensure medical information is included in
the Servicemember's longitudinal health record. In fiscal year 2009,
DOD will provide an image scanning capability to enable DOD to scan
information from the Managed Care Support Contractors, such as
Specialty Care Consultants, so it is available to DOD providers. For
the long term, DOD will continue to support Department of Health and
Human Services efforts to foster health information sharing with the
private sector. DOD is engaged in initiatives to explore alternative
solutions to electronic information sharing with the private sector.
DOD/VA support Nationwide Health Information Network (NHIN) ``pilot
projects'' to leverage recognized interoperability standards and
promote the exchange of health information with private health care
organizations and provider networks. Projects are underway in
Pensacola, Florida and Spartanburg, South Carolina and are part of the
NHIN Trial Implementation to examine the feasibility of sharing
clinical data from DOD medical facilities with non-Federal partners.
DOD and Microsoft are exploring the use of the Health Vault application
as one possible solution that would allow those who receive care via
contract providers to store and organize their health information and
then share that information with trusted entities such as physicians
and hospitals. These efforts will help to ensure the capture of private
sector health care information and enhance the overall quality of DOD's
longitudinal health record.
Chairman Akaka. Thank you very much, Dr. Casscells.
Let me ask my good friend, Senator Burr, for his questions
of this panel.
Senator Burr. Thank you, Mr. Chairman. I have a scheduling
problem, so I will be brief, and I thank the Chair for letting
me go first.
Doctors, both, thank you, and to the complement of folks
who surround you and to the other individuals that I know are
involved in this project, we are extremely pleased with the
progress that has been made. I will summarize what I take from
GAO: some progress, much left to do. I think we probably all
agree with that--it lacks clarity of plan and time line.
Agreements at the highest level needs to come down the chain.
That is where I might disagree with them.
I grabbed this document, DOD/VA Information
Interoperability Plan. I have had the opportunity to browse
through it. I won't tell you that I understand everything from
it, but, I want to point out a few things that are stated or
included in this.
In the Executive Summary, it says the Information
Interoperability Plan identifies more than 20 initiatives that
close the remaining gaps in information sharing and allows us
to achieve a shared vision of information interoperability.
Down further, it says the document is formed from a recent
comprehensive analysis of interdepartmental information
sharing. Not all defined initiatives are currently funded
programs, something sometimes we forget about. Independent of
resource constraints, implementation target milestones are
identified based upon their expected value as determined by the
functional committees and the feasibility of their
implementation.
It goes on to say, the plan has been approved by the line
of action co-leads, submitted to the Wounded Three, I think it
is, and Injured Senior Oversight Committee's overarching
integrated product team--that must have been a Defense piece--
--
[Laughter.]
Senator Burr [continuing]. And subsequently its
implementation will be overseen by DOD and VA governance
structure of the Joint Executive Council, Benefits Executive
Council, and the Health Executive Council. This plan serves as
the strategic organizing framework for current and future work
to set the scope and milestones necessary to measure progress
toward intermediate goals and a target state needed to
continuously improve service to veterans and members of our
Armed Forces.
I am not sure if GAO read that part, and I am not sure if
they actually looked at this document. If they did, I am not
sure that there would have been a blanket implication that:
one, there was lack of clarity of a plan; or, two, that there
weren't time lines. I turn to, out of Appendix B, page 24,
where there clearly are milestones and plans. I think it is
laid out for all members to look at.
I don't disagree with you, Dr. Casscells. For a period from
2001, there was a pitiful effort put toward what I think the
private sector was still looking at trying to decide whether
they wanted to do or not. So it is not without understanding
that I look at a reluctant DOD at participation with VA. I
think had the partner been anybody, there would have been a
reluctance on the part of DOD.
But, clearly, today there is a plan. It has clarity. It has
time lines.
And then, I went not too far back in the book and I found
Appendix D. Appendix D is 21 areas: Information sharing,
inpatient electronic health information, Reserve component
access to electronic health information--I won't read them
all--personalized health care, Interagency Program Office,
interagency data sharing architecture, benefits portal,
Disability Evaluation System. That is really the meat of the
rest of the report. It is the specifics on each of those 20 or
21 areas: about how you get there, how you go from here to
there.
So, Mr. Chairman, I really don't have questions. I have a
statement, and that statement is what we have done in the last
12 months is working. What has changed in my estimation is you
have the heads who both agree where we go. What I don't think
GAO understood was, I think, there is not only an exchange of
ideas, but there is an active effort underneath those heads to
implement what the heads have agreed to. It is not limited to
the top of the chart. But, the top of the chart for the first
time is in agreement, even though from 2001 to a year ago, I
think people underneath the top were trying to figure out how
they could incrementally talk to each other and share
information. Without the buy-in at the top, it was impossible,
because you would always get caught short with the resources
needed to implement even the easy things--the things that you
were just merely replicating from the private sector.
So, this is not an endorsement that we are there. This is
an endorsement that I think we have made tremendous progress in
the last 12 months. I think the next 12 months are going to be
extremely challenging and I, for one, now know exactly which
chart I am going to look at to try to figure out, month by
month, almost, if we are hitting the time lines that are set
for us.
The demonstration we went through is impressive and the
fact is, I have sat at Womack Hospital. I have seen the troops
come in. I have seen the packet of information with their
health records. I have seen as they entered Womack the fact
that it still went--and this is over a year ago, so don't hold
me to it--that it still went into a paper form versus an
electronic form. Yet the individuals that I saw were definitely
individuals that in the near future were going to be discharged
and be the recipient of the VA system. A lack of
acknowledgement at that period that it was even important to
get the records in a form that could be defined as seamless.
I think, not only is the plan designed in a way that the
end result is seamless, I think the progress that we have made
gives me tremendous optimism that we can come extremely close,
if not across the goal line, with the target of 2009. So, I
commend you for what you have done. I encourage you to continue
to do what you are doing.
And I hope that next time we get together on this, that
truly we can hold this up as a model not just for two Federal
agencies, but actually something that I personally think the
private sector will see as an endorsement as to why the private
sector needs to have the capabilities of sharing medical data
from doctor to doctor, from facility to facility, from rural
health clinic to the hospital, because the overall result of
that is a lower cost for the delivery of health care and for a
better outcome for the patient. I have got to think that
somewhere in this packet of information, those are probably the
two things that are the foundation of why you are doing what
you are doing. Clearly, it is to make sure that the outcome is
as optimal for the patient, for the warrior, as it possibly can
be.
I thank all of you. Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Burr, for your
views here.
Before I call on Senator Murray, let me address Dr. Kussman
and Dr. Casscells. The slow progress made by VA and DOD in
fully sharing electronic medical information led Congress to
mandate the September 2009 deadline. However, in a report sent
to Congress this past April, the Departments appeared to
already be backing away from the deadline. Now, my question to
you in follow-up to this view is, is this an accurate
assessment or do you believe that you will meet the deadline?
Dr. Kussman?
Dr. Kussman. Mr. Chairman, I think that as even GAO
commented on, and what both Dr. Casscells and I have commented
on, that again, part of it is the determination and definition
of interoperability. We believe that through the Joint Clinical
Information Board that we have established, where physicians
and clinicians on both sides establish what they think they
need for interoperability to take care of patients, which is,
after all, the goal here--there are always going to be some
challenges as we move forward. But, we believe that to a large
degree, as Dr. Fletcher already showed you, there is a
tremendous amount of interoperability; and that the gaps that
still exist, we have a plan to get those done by the end of
September 2009. So, I feel very confident, as Dr. Casscells has
mentioned, that we will have clinical interoperability by the
end of September 2009.
Let me just add to that the fact that we are very
appreciative of what we have done. I always use the term
``glacial,'' as well, Mr. Chairman, on a lot of the things that
happen. But, over the last couple of years, with the commitment
of Dr. Casscells, myself, and the two Secretaries, that there
is clearly a tremendous emphasis from the leadership to get
this done and get it done right. I believe with the other
people who are sitting here with us, we have made a tectonic
shift or a quantum leap to where we are.
It is not perfect yet. We have things that we need to do
and will continue to do them. Because a lot of the strategic
plan is a work in progress, we will learn more things and we
will evolve what we are doing. But, I believe we--practically,
from day to day--have made huge strides in making sure that the
most deserving patients in the world--people who are hurt in
defense of their country--do not suffer in any way by a lack of
information flow.
Chairman Akaka. Dr. Casscells?
Dr. Casscells. Mr. Chairman, Senator Murray, by the end of
September next year, we will add to the current bidirectional
health information exchange the remaining major pieces--family
history, social history, and so forth--because we already are
exchanging the problem lists, the clinical notes, the radiology
reports, the lab reports, the pharmacy data, the allergies, the
operative notes. So, we will have all the basic clinical
information that the doctors and the patients want.
In parallel to this, of course, we have some other things
going on. We are rolling out the inpatient record, which is, in
our case, a commercial off-the-shelf product, as at least an
interim step so that we, too, have an inpatient electronic
record. This one is called Essentris. We are also rolling out
AHLTA Version 3.3 and we will be offering at the end of this
calendar year web-based personal health records, which patients
can use in a secure and confidential private way as their own
backup.
So, we are doing several things at the same time, and yet I
am confident that we will--one year from today plus a week--
have all the real-time exchange that any clinical doctor or
patient would want. So, they could say, it doesn't matter
whether I am seen today at the VA or at Walter Reed or Brooke
Army Medical Center. Some patients do go back and forth.
I can not promise yet that we will have interoperability a
year from now with the average civilian hospital. I would say
that yesterday's demonstration at HHS was very, very
successful, and that is coming along faster than I had hoped.
We will, I think, have interoperability with many of the
major civilian hospitals, as well, over the next year. But the
key one is the DOD/VA transition and bidirectional. That, we
will have a year from now.
Chairman Akaka. I have questions to ask, but let me pass it
on to Senator Murray and ask for her statement and questions.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Thank you very much, Mr. Chairman. I
apologize for being late. There is a lot going on. We are
working our way through here.
I was interested because I did see the discrepancy between
the Defense Authorization Bill time line of a year from now and
several of the time lines that were included in the DOD/VA
Information Interoperability Plan that were confusing to me
because they were different. So, I think what you are saying,
if I heard you correctly, is that you do expect the major parts
of this to be done by next September, but as far as the
civilian exchange, that will extend beyond next year?
Dr. Casscells. Yes, ma'am.
Senator Murray. OK, and that is achievable?
Dr. Casscells. Yes.
Senator Murray. OK, because I know that you don't expect to
have the Interagency Program Office that is tasked with
overseeing this in place until the end of this year, so it just
gives you 9 months, and that time line is workable?
Dr. Kussman. Can I jump in here?
Senator Murray. Sure.
Dr. Kussman. Sorry. Thank you, Senator Murray. The office
has already been established and set up. We have acting people
in those positions. Mr. Freeman here is the Acting Deputy of
that. So, it is not that the office hasn't been established and
nobody is doing anything, but we have been developing position
descriptions and hiring people, and we believe that will be
completed by the end of the calendar year. But the office is
already up. Cliff, would you like to say something?
Mr. Freeman. We have actually been doing this work for 4 or
5 years, just out of different offices. So, from where I was
detailed--the DOD/VA Health IT Sharing Office--much of the work
that the IPO will do at a higher level was already being done.
So, as we move forward and put the permanent staff in place--we
have military staff in uniform detailed to us, we have contract
staff accessible to us, and then a lot of the staff that were
doing the work previously are still moving this forward. So, we
do have in process reviews with some of the DOD/VA projects to
make sure that they are making adequate progress as we move
forward.
Obviously, once we are fully stood up, it will be very
powerful. We will have everybody we need at that point. We are
making progress. We are moving forward.
Senator Murray. OK. And the GAO testified that the
definition of full interoperability is unclear. Can you comment
on what that means for your efforts and how we should interpret
that?
Dr. Kussman. As the GAO representative testified, is that
it is partly a definitional term.
Senator Murray. Right.
Dr. Kussman. If one looks at interoperability as a single
system, you know, that is not practical and is not going to be
achievable over this short period of time, if ever. We are
talking about clinical interoperability that allows the
important information flow to be sure that the patients get
what they need as they transition; and we believe, and even the
GAO person acknowledged, that we already have a tremendous
amount of interoperability. And the question was, where will we
be a year from now? And as you have heard, we are going to fill
in the gaps about the social histories, the other things that
we believe are valuable to the clinicians.
What we have tried to do is have this interoperability
driven by the people who are taking care of patients to
determine what information really needs to be transferred. And
we believe that we have already achieved a great deal, as the
demonstration showed, but also have some ways to go. We expect
by the end of September 2009 we will have filled in those gaps.
Senator Murray. Is anything being done to put in place a
definition so we all are on the same page and know where we are
going?
Mr. Freeman. We used the Joint Clinical Information Board,
which is a board composed of both VA and DOD clinicians, and
for this milestone, we went through an inventory with them to
review what was already available; and the question they were
asked was, what, in addition to what you get now, do you need
to provide quality care to patients across the VA/DOD continuum
of care? They came back with five or six additional pieces of
either data or interoperability that they needed to meet that
definition of quality care. So, that was really the definition
we have used to this point.
Dr. Tibbits. Maybe it would be useful to just interject
here that the definition we are aiming for is a clinical
definition. It is not a technical or a computer definition. So,
it is not all data or all real time or any of those technical
terms. It is a clinical definition that we are after, which I
think is what you are hearing described here.
Senator Murray. OK. All right. And finally, just quickly,
on the security issue, what are we doing to ensure that this
information is secure? Is it encrypted? What are we--can you
just give me a quick glimpse of that?
Dr. Tibbits. Well, let me--I am going to have to answer you
in general terms. We are working very closely on both sides
with our respective security experts. We are very aggressive in
both Departments in enforcing security provisions.
These information exchanges are no exception to any of
those provisions, so on our side, for example, we have our
points of contact that work very closely with DISA to make sure
we meet the gateway specifications and all of those things to
exchange the information. Where encryption is necessary, we
either do it or will do it, if that turns out to be a
necessity. We have certain monitoring devices on our laptops
and what not to make sure inappropriate information is not sent
inadvertently.
There are a variety of things, initiatives we have
underway. There is no end run around all of that. We are
working very closely with our respective security communities
to make sure that we do that. In the Department of Veterans
Affairs OI&T, we have an entire division under an SES to lead
information protection initiatives in the Department and we
follow all the standards and rules that they set, provide the
systems capabilities to achieve the necessary Authority to
Operate, and so forth.
Senator Murray. OK. All right. Yes, sir?
Mr. Campbell. Just to follow on to that, on the DOD side,
we have to take our plans of how we are going to share that
information and the architecture of how we are going to do that
and we have to run those through the DOD security folks. They
review all that and approve it before we can go ahead, and they
have done that.
Senator Murray. OK. I just wanted to clarify it. So, thank
you very much. I really appreciate all of your work on this.
Thank you, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
Dr. Kussman and Dr. Casscells, let us move fast forward to
January and let us assume that neither of you will be in your
current positions. [Laughter.]
Well, I am saying that because I don't want the progress to
stop. We want to move as close as we can. Let me ask you this.
What can you leave behind in terms of resources and more
information to ensure that your good work to date is not lost?
I was thinking in terms of something you mentioned, Dr.
Kussman--you said, position description. I was thinking of a
job description that can help whoever comes on so that there is
no loss and that there would be a benefit from what you have
gained and what you think will be coming. Dr. Kussman?
Dr. Kussman. Yes. Mr. Chairman, obviously, people sometimes
get concerned about this. I think if you look at the people who
are sitting here, there is no accident why we have been
successful. Chuck was on active duty, came over to the VA, he
is now back in DOD. Paul is former Navy--I won't hold that
against him--and Cliff was former Army. I believe that the
commitment and the inculcation into the culture is now beyond
Trip or myself. It is not a personality-driven thing and that
work will go on because it is the right thing to do.
We have now got the momentum going forward and I believe
there is great enthusiasm up and down, for lack of a better
term, the bureaucracy on both sides that want to make this
happen. So, whoever comes in in the leadership positions would
find it extremely difficult to change any of it because it is
moving forward in the right way.
Chairman Akaka. Dr. Casscells?
Dr. Casscells. Sir, I would just add that the two
Secretaries have made this a priority and both the Secretary of
the VA and the Secretary of Defense are people who mean
business. Their reminders plus the Congressional requirements
have really kept this issue on the front burner for Dr. Kussman
and myself.
So, I think I would just add that it would be great if the
succeeding Secretaries recognized that electronic health
records are critical to providing quality and reliable, secure,
cost-effective care, because there are people who doubt this.
But, as you mentioned in your opening statement, this is really
proven and it just needs to be made a priority. It is now. We
hope it is maintained as a priority.
Chairman Akaka. Well, I thank you very much. As Chairman of
the Subcommittee on Federal Workforce and Government
Management, I have been spending time on transition and this is
part of the transition, because I feel it is so important to
whoever is going to be the next President to have this kind of
information so that he can move forward.
I thank you for what you folks are doing. It is really
tremendous--the progress that you have made; however, we are
still looking at the deadlines.
In closing, I again thank all of our witnesses for
appearing today. And by the way, I have other questions that I
will submit. Your input on these issues is valuable to the
Committee as we work to ensure that veterans and servicemembers
receive the best health care possible. I believe that effective
data sharing between the Departments is really a key component
toward reaching that goal.
As the session winds down, so does this administration, and
I do not know where all of our department witnesses will be
come January. For those who will be moving on, I urge you to
leave behind good people, and you have mentioned that, Dr.
Kussman and Dr. Casscells--good people and a road map for
success. So, that is what we are looking at for the future of
our great country and for our troops as well as our veterans.
So, thank you again very much, and this hearing is
adjourned.
[Whereupon, at 10:55 a.m., the Committee was adjourned.]