[Senate Hearing 110-714]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-714
 
       HEARING ON SHARING OF VA/DOD ELECTRONIC HEALTH INFORMATION

=======================================================================


                                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

                              ----------                              

                           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

                              ----------                              


                     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.]