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    2010

                      EXAMINING THE PROGRESS OF ELECTRONIC

                     HEALTH RECORD INTEROPERABILITY BETWEEN

                    THE U.S. DEPARTMENT OF VETERANS AFFAIRS

                         AND U.S. DEPARTMENT OF DEFENSE

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

                                    HEARING

                                   before the

                  SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                     of the

                         COMMITTEE ON VETERANS' AFFAIRS
                         U.S. HOUSE OF REPRESENTATIVES

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 JULY 14, 2009

                                   __________

                               Serial No. 111-33

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                         COMMITTEE ON VETERANS' AFFAIRS

                        BOB FILNER, California, Chairman

    CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
    VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
    MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
    STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South
    Dakota                               Carolina
    HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
    JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
    DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
    THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
    HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
    CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
    JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
    JERRY McNERNEY, California
    ZACHARY T. SPACE, Ohio
    TIMOTHY J. WALZ, Minnesota
    JOHN H. ADLER, New Jersey
    ANN KIRKPATRICK, Arizona
    GLENN C. NYE, Virginia

                       Malcom A. Shorter, Staff Director

                                     ______

                  SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                      HARRY E. MITCHELL, Arizona, Chairman

    ZACHARY T. SPACE, Ohio               DAVID P. ROE, Tennessee, Ranking
    TIMOTHY J. WALZ, Minnesota           CLIFF STEARNS, Florida
    JOHN H. ADLER, New Jersey            BRIAN P. BILBRAY, California
    JOHN J. HALL, New York

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.

                                C O N T E N T S

                                   __________

                                 July 14, 2009

                                                                       Page
    Examining the Progress of Electronic Health Record
      Interoperability Between the U.S. Department of Veterans
      Affairs and U.S. Department of Defense.........................     1

                               OPENING STATEMENTS

    Chairman Harry E. Mitchell.......................................     1
        Prepared statement of Chairman Mitchell......................    40
    Hon. David P. Roe, Ranking Republican Member.....................     2
        Prepared statement of Congressman Roe........................    40
    Hon. Zachary T. Space............................................     5
    Hon. John J. Hall................................................     6

                                   WITNESSES

    U.S. Government Accountability Office, Valerie C. Melvin,
      Director, Information Management and Human Capital Issues......     4
        Prepared statement of Ms. Melvin.............................    41
    U.S. Department of Defense/U.S. Department of Veterans Affairs
      Interagency Program Office, Rear Admiral Gregory A. Timberlake,
      SHCE, USN, Acting Director.....................................    18
        Prepared statement of Rear Admiral Timberlake................    48
    U.S. Department of Defense, Mary Ann Rockey, Program Executive
      Officer/Deputy Chief Information Officer (Acquisition),
      Military Health System.........................................    20
        Prepared statement of Ms. Rockey.............................    52
    U.S. Department of Veterans Affairs, Hon. Roger W. Baker,
      Assistant Secretary for Information and Technology, Office of
      Information and Technology.....................................    22
        Prepared statement of Mr. Baker..............................    60

                           SUBMISSIONS FOR THE RECORD

    Stearns, Hon. Cliff, a Representative in Congress from the State
      of Florida, statement..........................................    63

                       MATERIAL SUBMITTED FOR THE RECORD

    Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe, Ranking
      Republican Member, Subcommittee on Oversight and
      Investigations, Committee on Veterans' Affairs, to Hon. Gene L.
      Dodaro, Acting Comptroller General, U.S. Government
      Accountability Office, letter dated August 12, 2009, and
      response from Valerie C. Melvin, Director, Information
      Management and Human Capital Issues, letter dated October 13,
      2009...........................................................    64
    Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe, Ranking
      Republican Member, Subcommittee on Oversight and
      Investigations, Committee on Veterans' Affairs, to Hon. Robert
      M. Gates, Secretary of Defense, U.S. Department of Defense,
      letter dated August 31, 2009, and DoD responses................    67
    Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe, Ranking
      Republican Member, Subcommittee on Oversight and
      Investigations, Committee on Veterans' Affairs, to Hon. Eric K.
      Shinseki, Secretary, U.S. Department of Veterans Affairs,
      letter dated August 12, 2009, and VA responses.................    72

                           EXAMINING THE PROGRESS OF

                            ELECTRONIC HEALTH RECORD

                          INTEROPERABILITY BETWEEN THE

                      U.S. DEPARTMENT OF VETERANS AFFAIRS

                         AND U.S. DEPARTMENT OF DEFENSE

                                  ----------

                             TUESDAY, JULY 14, 2009

                 U.S. House of Representatives,
                        Committee on Veterans' Affairs,
                                    Subcommittee on Oversight
                                            and Investigations,
                                                        Washington, DC.

        The Subcommittee met, pursuant to notice, at 10:00 a.m., in
    Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
    [Chairman of the Subcommittee] presiding.

        Present: Representatives Mitchell, Space, Walz, Adler,
    Hall, Roe, and Bilbray.

                 OPENING STATEMENT OF CHAIRMAN MITCHELL

        Mr. Mitchell. Good morning. This meeting is July 14th, 2009
    and this hearing will come to order. Welcome to the
    Subcommittee on Oversight and Investigations. This is a hearing
    on the Interagency Program Office (IPO) examining the progress
    of the electronic health record interoperability between the
    U.S. Department of Veterans Affairs (VA) and U.S. Department of
    Defense (DoD).
        I would like to thank everyone for attending today's
    Oversight and Investigations Subcommittee hearing entitled the
    Interagency Program Office examining the progress of electronic
    health record interoperability between the VA and DoD.
        Thank you especially to our witnesses for testifying today.
        We are here today to examine the progress being made by the
    DoD and the VA to achieve electronic health record
    interoperability.
        Currently there is no single VA/DoD electronic record that
    captures all the information needed for delivery of health care
    and benefits to servicemembers, veterans, and their
    beneficiaries.
        As many of you know, on April 9th, 2009, President Obama,
    along with Secretary of Veterans Affairs Eric Shinseki and
    Secretary of Defense Robert Gates, announced that the VA and
    DoD would create a joint lifetime electronic record that would
    contain information from the day the individual enters military
    service through their careers and for the remainder of their
    lives as veterans if they enter the VA system.
        Mandated by the ``National Defense Authorization Act (NDAA)
    of 2008,'' the Interagency Program Office was established to
    act as the single point of accountability for DoD/VA electronic
    health record interoperability.
        As the September 30th deadline for electronic health record
    interoperability approaches, it is imperative to ensure that
    both the DoD and VA are organized and working together to
    deliver a comprehensive system that will modernize and simplify
    record sharing between Departments.
        In 1982, under the VA and DoD ``Health Resources Sharing
    and Emergency Operations Act,'' both DoD and VA were first
    encouraged to find common ground to create a more efficient
    health care system that would be worthy of the sacrifices our
    men and women make every day.
        Since then, although there have been significant
    improvements in sharing patient record information, both the
    DoD and VA have yet to find the common ground to achieve full
    electronic health care interoperability.
        The U.S. Government Accountability Office's (GAO's) report
    on the state of DoD and VA's health record sharing initiatives
    is not due until the end of July, but I am grateful that they
    are here today to update us on the progress these two
    Departments have made in meeting the statute's requirement.
        As a growing number of men and women are returning from the
    battlefields in Iraq and Afghanistan with more complicated and
    more severe wounds, it is time to make their care and treatment
    easier. It is time for us to improve upon a system that will
    ensure the best and most complete care, efficient benefit
    delivery, and a seamless transition back into civilian life.
        Under the leadership of Director Rear Admiral Gregory
    Timberlake and Deputy Director Cliff Freeman of the Interagency
    Program Office, both here today, I am hopeful, I am expectant
    that we will see headway toward the vision Congress and the
    President have established for a VA of the 21st century.
        [The prepared statement of Chairman Mitchell appears on p.
    40.]
        Mr. Mitchell. Before I recognize the Ranking Republican
    Member for his remarks, I would like to swear in our witnesses.
    If all witnesses from both panels would please stand and raise
    their right hand.
        [Witnesses sworn.]
        Mr. Mitchell. Thank you.
        I would now like to recognize Dr. Roe for opening his
    remarks.

                 OPENING STATEMENT OF HON. DAVID P. ROE

        Mr. Roe. Mr. Chairman, thank you for holding this hearing.
        The issues of seamless transition and the interoperability
    of the transfer of medical records between the Department of
    Defense and Department of Veterans Affairs is one that Congress
    has been working on for a number of years.
        During the 109th Congress alone, the Committee on Veterans'
    Affairs held a total of ten hearings on the issue of seamless
    transition. Again last Congress, this Subcommittee held a
    hearing on March 8, 2007, on seamless transition; on May 8,
    2007, VA and DoD data sharing; on October 24, 2007, on the
    status of sharing electronic medical records; and on June 24,
    2008, VA and DoD cooperation in reintegrating the Guards and
    Reserves.
        Time and time again, the issue of interoperability and data
    sharing of critical medical information between the DoD and VA
    has been discussed, studied, and demoed, and the degree of
    progress is dismally glacial.
        This is one of the reasons that section 1635 was included
    in the ``2008 National Defense Authorization Act.'' This
    section revealed a plan of action for the two Departments to
    create a schedule and set a deadline of September 30, 2009, and
    issue requirements for, (1) establishment of the Interagency
    Program Office (IPO); (2) establishment of the requirements for
    electronic health records (EHR) systems or capabilities,
    including coordination with the Office of the National
    Coordinator for Health Information Technology (IT); (3) any
    acquisition and testing required in the implementation of
    electronic health record systems or capabilities that allow for
    full interoperability; and, (4) implementation of electronic
    health record systems or capabilities.
        I am interested in learning the progress that DoD and VA
    are making and moving forward with the interoperability
    transfer of medical data between the two Departments.
        In the past, this information has been held in what several
    Members have called independently stovepiped electronic medical
    record systems that had difficulty transferring data between
    the two departments.
        This issue is of great concern to me as well as other
    Members of this Committee. I hope that measurable progress has
    been made toward better communication and cooperation between
    the two Departments.
        The care of our Nation's servicemembers and veterans is of
    primary importance to everyone at this hearing today. They have
    served our country valiantly in the face of battle and should
    not have to be worried about whether or not their health
    providers have the tools and information they need to provide
    care that is timely, medically appropriate, and necessary.
        Mr. Chairman, I look forward to hearing from our witnesses
    today and yield back the balance of my time.
        [The prepared statement of Congressman Roe appears on p.
    40.]
        Mr. Mitchell. I ask unanimous consent that all Members have
    5 legislative days to submit a statement for the record.
    Hearing no objection, so ordered.
        At this time, I would like to welcome Panel One to the
    witness table. Joining us on our first panel is Valerie Melvin,
    Director for Information Management and Human Capital Issues at
    the U.S. Government Accountability Office.
        I ask that all witnesses stay within 5 minutes for their
    opening remarks. Your complete statements will be made part of
    the record.
        Thank you very much, Ms. Melvin.

         STATEMENT OF VALERIE C. MELVIN, DIRECTOR, INFORMATION
         MANAGEMENT AND HUMAN CAPITAL ISSUES, U.S. GOVERNMENT
                         ACCOUNTABILITY OFFICE

        Ms. Melvin. Thank you, Mr. Chairman, Ranking Member Roe,
    and Members of the Subcommittee. I am pleased to be here today
    to discuss the VA/DoD Interagency Program Office and efforts
    toward achieving interoperable electronic health records.
        As you know, the Departments have been working for over a
    decade to share data between their health information systems.
    Yet, while they have made progress on a number of fronts,
    questions have persisted concerning when and to what extent the
    intended sharing capabilities of the two Departments will be
    fully achieved.
        As you have stated, to expedite their efforts, the
    ``National Defense Authorization Act'' for fiscal year 2008
    directed VA and DoD to jointly develop and implement by
    September 30th fully interoperable electronic health record
    systems or capabilities and it established an Interagency
    Program Office to be a single point of accountability for the
    departments' efforts.
        Also, the Act directed GAO to semiannually report on the
    Departments' actions toward achieving interoperability.
    Accordingly, we have previously issued two reports, in July
    2008 and January 2009. We plan to issue a third report near the
    end of this month, a draft of which is currently being reviewed
    by the Departments.
        At your request, my testimony today summarizes findings
    from the draft report focusing on the Departments' progress in
    setting up the Interagency Program Office and actions taken to
    achieve fully interoperable capabilities.
        Regarding the Interagency Program Office, VA and DoD have
    taken important steps to make it operational by, for example,
    recruiting and hiring staff for government and contractor
    positions within the office.
        Further, the Office has established a charter to articulate
    its mission and functions with respect to attaining
    interoperable electronic health data and it has developed
    standard operating procedures in such areas as strategic
    communication.
        Nevertheless, key leadership positions for the Director and
    Deputy Director continue to be filled on an interim basis as
    the Departments attempt to hire permanent officials.
        In addition, the Office has not yet performed key tasks
    that are fundamental to effective IT management and that would
    be essential to effectively functioning as the point of
    accountability.
        In particular, the Office has not implemented our earlier
    recommendation that it establish results-oriented goals and
    performance measures for the objectives identified to meet the
    Departments' data sharing needs and fulfill interoperability
    requirements.
        However, early development and use of results-oriented
    metrics is essential to providing a meaningful baseline against
    which to measure the progress of the program and the outcomes
    associated with its implementation.
        Further, while the Office has begun to develop an
    integrated master schedule as required by its charter, the
    version provided for our review lacked critical information
    that would be vital to managing these complex efforts, such as
    detailed project tasks and associated start and completion
    dates, as well as relationships between tasks.
        Similarly, a project management plan is essential, but the
    Office has not yet developed one. As we have noted in prior
    work, without a plan that describes the project's scope,
    resources, and key milestones, VA and DoD lack a key tool
    needed to successfully guide their efforts.
        With regard to their ongoing efforts, the Departments have
    achieved plan capabilities for three of the six
    interoperability objectives that they identified to meet their
    data sharing needs, related to sharing social history and
    physical exam data and the operation of secure network
    gateways.
        For three other objectives, related to sharing data from
    health assessment questionnaires and self-assessment tools,
    expanding DoD's inpatient medical record system, and
    demonstrating initial document scanning, the Departments have
    partially achieved plan capabilities with additional work
    needed to fully meet clinicians' needs for health information.
        To improve the management and the success of VA's and DoD's
    efforts to achieve full interoperability, our draft report
    recommends the Interagency Program Office's establishment of a
    project plan and a complete and detailed integrated master
    schedule. This is in addition to establishing performance
    metrics as we have previously recommended.
        Without these critical tools, the Office's ability to
    effectively provide oversight and management, including
    meaningful assessment of the progress and delivery of
    interoperable capabilities, is jeopardized.
        Mr. Chairman, this concludes my statement. I would be
    pleased to respond to any questions that you or other Members
    of the Subcommittee may have.
        [The prepared statement of Ms. Melvin appears on p. 41.]
        Mr. Mitchell. Thank you very much.
        At this time, before we get to the questions, I would like
    to defer to Mr. Space and then Mr. Hall.

               OPENING STATEMENT OF HON. ZACHARY T. SPACE

        Mr. Space. Thank you, Mr. Chairman.
        And I hope you will accept my apologies for arriving late
    and my advance apologies for having to leave. I have a very
    important 10:30 meeting that I have to attend to regarding my
    Energy and Commerce Committee assignment. But I do appreciate
    the opportunity to deliver a brief statement.
        I would like to thank you, Chairman Mitchell, for calling
    this hearing and for giving me the opportunity to say a few
    words about this important issue.
        The interoperability of medical records between the VA and
    the DoD is not a technical problem or a coordination problem.
    Access to medical records is a quality of life problem for our
    veterans.
        And I did not have the benefit of hearing your statement,
    Mr. Chairman, but I suspect you may have referenced Specialist
    Travis Fugate. Okay. You will recall that Travis testified at a
    Committee hearing earlier. Like so many other veterans of the
    conflicts in Iraq and Afghanistan, he suffered a combat injury
    that left him with severely impaired vision. His doctor at the
    VA was unable to perform the necessary surgery because of the
    complicated reconstruction his facial nerves had undergone in
    prior operations under DoD care.
        I believe that the U.S. Government failed Mr. Fugate by
    effectively losing the records of his prior surgeries, leaving
    him completely blind. This is just an example of the
    significant quality of life issues faced by veterans because we
    have not yet met this goal of fully sharing medical records.
        I am frustrated at the lack of progress over the past
    decade and even more frustrated that no law or directive seems
    to have any impact on the speed of implementation.
        I understand that there are significant financial,
    technological, and logistical barriers to progress into the
    completion of an entirely interoperable electronic medical
    record. I also understand that there are multiple levels of
    interoperability and that the office must balance competing
    demands for both quality record sharing and faster
    implementation.
        However, I feel compelled to remind those responsible for
    this project that every day that we do not overcome the
    challenges to implementing this system is a day that we pass on
    the hardship to our veterans. Their sacrifices and their
    challenges are much greater and much more personal and heart
    breaking than our challenges in establishing this system.
        I look forward to hearing from the witnesses here today and
    I hope that their testimony will illuminate a clear and
    achievable path to success on this initiative.
        And I yield back. Thank you, Mr. Chairman.
        Mr. Mitchell. Thank you.
        Mr. Hall.

                 OPENING STATEMENT OF HON. JOHN J. HALL

        Mr. Hall. Thank you, Mr. Chairman and Ranking Member Roe,
    for holding this hearing.
        Ms. Melvin, Admiral Timberlake, and Assistant Secretary
    Baker, thank you for being here today to testify.
        One of the largest impediments facing the VA and the
    veterans it serves is the handoff from DoD. In my conversations
    with veterans, I have heard stories that simply astound me.
    Veterans walking paper files from one office to another banded
    together with rubber bands and covered in sticky notes.
        It is hard to believe that in 2009 veterans must still
    shlep their materials from a DoD doctor to a VA doctor as paper
    files, costing time, money, and meaning that, as was mentioned
    by Mr. Space, the quality of care is not what it should be.
        I have been working on trying to fix this issue as have
    many of us on the full Committee and the Subcommittee since I
    was first elected to Congress and last year sponsored
    legislation to require the VA to convert to electronic records
    and modern information technology. I was proud to see it signed
    into law, a good first step toward bringing the VA into the
    21st century.
        For more than a decade, Congress, the VA, and the DoD have
    been trying to move this interoperability initiative forward.
    We have finally made some progress on this common-sense, good
    government initiative.
        In January of last year, for instance, Congress established
    the Interagency Program Office to allow the DoD and the
    Department of Veterans Affairs to fully share personal health
    information between the two agencies. It seems like the VA and
    the DoD are making progress, but, unfortunately, things are not
    moving as quickly as they should.
        We laid down a deadline of September 30th, 2009, which is
    less than 80 days away. And I hope that in the course of this
    hearing, we will hear some good news about the progress being
    made, learn about ways we can help to fix any problems that
    have arisen, and work together to take steps to move the
    process along.
        I thank you and I yield back.
        Mr. Mitchell. Thank you.
        Ms. Melvin, I have a couple questions. In your testimony,
    you state that though DoD and VA have generally made progress
    toward making the IPO operational, the absence of performance
    metrics and absence of a complete integrated master schedule
    and an absence of a project plan limits the IPO's ability to
    effectively report on the delivery of interoperability
    capabilities.
        Since the IPO was created, what actual and tangible
    benefits has the Office brought to improve the quality of life
    to our Nation's veterans?
        Ms. Melvin. I would start by saying that it appears that
    setting up and bringing the Office into operation has been the
    main accomplishment of the Office thus far. It is important to
    note that they have been recruiting staff for that Office. They
    have been hiring staff and they have developed standard
    operating procedures and an initial version of their master
    schedule.
        However, what we have seen beyond that has been primarily,
    I think, focused on reporting to Congress in terms of meeting
    the requirements of the Act for reporting out on what the
    Office is doing.
        We have not yet seen the evidence of any real linkage
    between what they are doing and how this is really translating
    into measurable progress as well as in terms of improvements in
    quality of health.
        I think it is important to note that in looking at
    improvements in quality of health, that is probably something
    that will require a while to get to because you have to have
    the means in place to really start serving the clients in terms
    of what they are giving them in capabilities.
        However, it is important that they establish their
    milestones and measures to make sure that they can look forward
    to specifically what they are providing and serving the
    clinicians' needs as well as the patients' needs and in terms
    of the capabilities that they are offering to them.
        So we have not seen the quality of care improvements yet.
        Mr. Mitchell. Maybe this second question is not appropriate
    then. According to your testimony, since the IPO has yet to
    fully meet clinicians' needs for health information, has the
    limited accomplishments, that is DoD and VA mainly meeting
    three of the six interoperability objectives, given clinicians
    everything they need to provide complete health care to our
    Nation's veterans?
        Ms. Melvin. I think it is important to point to and ask VA
    and DoD relative to the clinicians' needs. They have been
    relying on the Interagency Clinical Informatics Board to define
    the patients' needs and, as I understand it, that is still an
    ongoing process.
        However, they have put some capabilities in place and VA
    and DoD do maintain that relative to the capabilities that they
    are providing to meet the interoperability objectives that they
    have defined for September 2009, coupled with the initiatives
    that they have put in place, the Federal Health Information
    Exchange (FHIE), the Bidirectional Health Information Exchange
    (BHIE), that, in fact, those will give them the capabilities
    that they are looking to have in place by September 2009.
        However, from our perspective, we cannot really tell
    whether, in fact, that will truly meet their needs because we
    have not seen the mechanisms in place yet for them to truly
    measure performance against these particular goals.
        It is only with understanding specifically what it is that
    they are trying to achieve quantitatively and measurably will
    we be able to assess that.
        I would add, however, that both VA and DoD have
    acknowledged that there is additional work that will need to be
    undertaken after September 2009 to continue to provide
    additional capabilities.
        And across our work, we have seen instances or indications
    that there are significant areas of work needed. For example,
    the Essentris System, while that is one place that they, in
    fact, did establish a measurable goal, they have also indicated
    that a significant portion of that goal will have to be
    accomplished after 2009, specifically, I think we include in
    our testimony, 92 percent of the inpatient beds served by
    September 2010.
        Beyond that, we also know that a laboratory data sharing
    capability that was supposed to be a computable capability by,
    shortly after September 2009, it is our understanding that that
    also has been pushed out to a later date.
        So while they are making incremental increases in their
    sharing of data, as far as how that collectively will meet
    clinicians' needs, that is still in our view a bit uncertain.
        Mr. Mitchell. Thank you.
        I will defer to Dr. Roe.
        Mr. Roe. Thank you, Mr. Chairman.
        A couple things. This interoperability is not going to
    happen by September 30th obviously. And let me just make a
    couple of quick points.
        Of the three things that you said you could get now, as a
    physician, if I walk in to see a patient, I can pull up their
    allergies. I can do that in 2 seconds. Are you allergic to
    anything?
        Number two, your social history. Do you smoke, drink? Do
    you take prescription drugs? I can do that in 5 seconds.
        And how much money have we spent? And what else can I find
    when I pull this up because as a physician, when I see a
    patient, and a very good point was made by Mr. Space, there are
    some critical bits of information that you do need.
        When I am in there and someone else has had three or four
    previous surgeries or whatever that they may have had, that is
    very critical to know what was done during those surgeries. It
    is very critical to know their lab data, to know their X-rays,
    those types of things. That is very critical.
        Is that available when you walk in to see a patient? When
    you walk in, I walk in as a doctor, sit down to talk to a
    patient, some of these things you mentioned, I can get the
    history in literally less than 15 seconds? I do not need a
    record for that.
        Ms. Melvin. I do not want to paint the picture that they do
    not have any sharing capabilities. As I mentioned earlier, they
    have had a number of initiatives that they put in place over
    time, their Bidirectional Health Information Exchange, their
    Federal Health Information Exchange, which allows information
    from DoD to go to VA when a servicemember separates. They do
    have a number of capabilities.
        We have reported previously on, for example, them having
    pharmacy and drug allergy, computable data which is what is
    considered the highest level of interoperability. There are a
    number of capabilities that they currently have in place.
        One of the difficulties that we have, however, is in terms
    of finding a place that we can truly look across both VA and
    DoD and see how all of these various efforts are being put
    together to work toward this----
        Mr. Roe. Not to interrupt, but when a patient comes to see
    me, if they bring a stack this big, at least I have something
    to look at.
        Ms. Melvin. Yes.
        Mr. Roe. And when a patient gets out of the military and
    they are severely injured as we have seen, all of us here have
    seen the terrible injuries a lot of these soldiers have seen,
    that information, I do not see how it can be all that hard to
    get that information from Walter Reed if somebody ETSs
    (expiration term of service) from the military to the VA at
    Mountain Home in Johnson City, Tennessee.
        How can it be that hard?
        Ms. Melvin. It is hard if you have not established
    specifically how you are going to go about doing that from the
    standpoint of having specific plans for how the
    interoperability will be achieved. We do know that they have
    some sharing capability, as I was saying earlier.
        You are right. We do understand that some patients come
    into, for example, Walter Reed with their paper folders
    attached to them. And VA and DoD have been working toward some
    scanning capabilities to try to make that information
    electronically available, but there is not a comprehensive
    record at this point.
        Mr. Roe. Well, here is the problem I have with this. And I
    put an electronic medical record system into operation, our
    group had done it for 70 providers. And I realize this is a
    huge system. I understand, believe me, the stumbles and bumbles
    that you go through in implementing. This is an incredibly
    complex system.
        But it really all comes down to taking care of a patient.
    So when a soldier leaves, I do not know--I cannot understand up
    here yet after all this. I have read all this testimony. I
    still cannot understand when a soldier leaves the military why
    that soldier could not leave with a memory stick or a DVD or
    whatever and have all that information right there. You can
    walk in my office. I can plug a DVD in, a memory stick or
    whatever you want to and you can walk out with your complete
    medical record in your hand.
        Now, why can we not do that?
        Ms. Melvin. Mr. Roe, that is a very good question. I think
    it is one that has to be directed to VA and DoD.
        Again, I would go back to they have not set the basic
    mechanisms in place to make sure that they have a program that
    looks across all of the different initiatives that they have
    and that builds them collectively to make sure that they have
    the capability that you are asking for.
        They have made steps in that direction. But, again, we have
    not seen the progress that we feel is necessary for them to
    really have one collective record across VA and DoD to
    accomplish just what you are saying.
        Mr. Roe. I think, and I will not take much more time, but I
    think in Great Lakes Naval and VA venture had a joint venture
    in 2002.
        Are they are able to do that where there was a joint
    venture?
        Ms. Melvin. We have not looked specifically at them, but I
    do understand that they are taking some initiatives toward
    creating that type of capability.
        However, within the documentation that we have reviewed so
    far, we have not seen specifically how they are doing that. We
    have not seen the evidence of how that is being achieved or
    what they have actually accomplished.
        It is my understanding that a lot of the milestones that
    are necessary for accomplishing that are still due sometime
    maybe next year.
        So we understand that maybe they have done some project
    initiation and some business requirements, but I am not certain
    at this point as to exactly what they have achieved in that
    capability and it is not specified in the documents that we
    have seen thus far.
        Mr. Roe. Thank you.
        Mr. Chairman, I will need to leave early to go to another
    meeting and I ask unanimous consent in absence of a Member of
    the Minority Party, Counsel be permitted to ask questions of
    the witnesses.
        Mr. Mitchell. Mr. Space.
        Mr. Space. Thank you, Mr. Chairman.
        The goal in creating the IPO was to create this single
    point of accountability for achieving the interoperable health
    care data. And it strikes me as a bit ironic that with that as
    its main goal, to this date as of right now, there are still
    some serious concerns about its leadership and management.
        And I cannot help but be stricken by the fact that if this
    were a private company, and I know it is not and I know its
    intents and purposes are much different, but if this were a
    large corporation and 10 years ago their IT Director were
    dispatched to achieve interoperability, I am wondering how many
    IT directors in that 10-year period would have been fired for
    failing to get this job done.
        To this day, it is my understanding that the IPO does not
    have a Director and it does not have a Deputy Director.
        Ms. Melvin. That is correct, sir.
        Mr. Space. Can you give us, and I know your report touches
    on it, but can you give us some idea as to why they have waited
    so long to engage in this process of assigning permanent
    leadership as opposed to interim directors, number one?
        And, number two, what kind of time table we can expect for
    the appointment of a Director and a Deputy Director under the
    IPO?
        Ms. Melvin. It is our understanding that there were a
    couple of factors in play. I would actually go back to about
    December, which is December of 2008, which is when we
    understand that the office finally got an approved delegation
    of authority to be able to operationalize itself. So I would
    say that that is one factor.
        We do understand that they have been trying to hire. And in
    speaking with them, what we understand is that they have had a
    number of candidates come across and it seems that in some
    cases, they have withdrawn their nomination, at least in one
    instance that I know of.
        It is my understanding that currently, however, they do
    have a candidate whose name has been sent forward and an
    application has been sent forward to OPM and that they are
    awaiting a decision from the Office of Personnel Management
    (OPM) on that.
        In the interim, they have an interim Director whose
    appointment has been extended through at least the time of
    hiring or September 30th. I am not sure whether it is one or
    the other, but at least at that point.
        With regard to the Deputy Director, it is our understanding
    from VA that they are also in the process of selecting someone
    for that position. And we have been told that they intend to
    have someone in place by the end of July.
        However, I have no more specifics relative to whether that
    is going to actually occur as intended at this point.
        Mr. Space. Do you believe that they are exercising proper
    diligence in the creation of a leadership team and a management
    team in this process or have they been lax or failed to
    properly prioritize this issue?
        Ms. Melvin. It appears that they have given priority to it.
    However, I would say that it has been a very slow process in
    terms of what they have done and the appointments that they
    have tried to make to the positions so far.
        If you separate it from the staff positions, they have put
    those positions in place, the hires for those positions or at
    least selected them, but for the leadership positions, I would
    say that we do question how long it is taking them to get them
    in place. I do not think that it has been a particularly
    expeditious process.
        Mr. Space. Right. I think that is pretty obvious from the
    face of things.
        And has the VA or the DoD given you any specific reasons as
    to why they have failed to appoint permanent leadership at the
    very top of this program that is supposed to achieve
    interoperability within 80 days? It just seems to me to be a
    complete lack of responsibility and prioritization.
        Ms. Melvin. No other than indicating that they were trying
    to hire individuals, that they had selected individuals who
    subsequently withdrew their application and that they had to go
    back out through the recruiting and rehiring process
    subsequently to find a person for that position.
        Mr. Space. Thank you.
        Ms. Melvin. You are welcome.
        Mr. Space. I yield back the balance of my time.
        Mr. Mitchell. Mr. Bilbray.
        Mr. Bilbray. Thank you, Mr. Chairman.
        Since 1992, the Departments had latitude to be able to
    address this issue. How long have you been working on this
    project?
        Ms. Melvin. We have been looking at VA----
        Mr. Bilbray. You personally.
        Ms. Melvin. How long have I personally? Since about 2001, I
    think.
        Mr. Bilbray. Two thousand one?
        Ms. Melvin. Yes.
        Mr. Bilbray. How long has the Department been into it?
        Ms. Melvin. Since 1998, they have been working on
    electronic sharing capabilities.
        Mr. Bilbray. And are we going to reach our September 30th
    goal?
        Ms. Melvin. It depends on how that is defined. We have
    concerns about the clarity of the definition for fully
    interoperable and what it means at September 30th to say that
    they have full interoperability.
        They will achieve something. It will likely be perhaps a
    measure more than what they have had in the past relative to
    incremental increases in sharing in terms of increased
    scanning, for example, increased sharing of social history
    data, and the like.
        What we have not been able to get from VA and DoD to date
    has been a clear quantitative and measurable definition of what
    it is that they will have at that point.
        If you look at the interoperability objectives that are in
    place right now, they talk about establishing an initial
    scanning capability or expanding a capability. For us, that
    does not convey in terms of what you will actually have as far
    as a measurable capability.
        Mr. Bilbray. Now, you are talking about over the Internet,
    not this issue that the client has to bring in a package,
    basically the ability to access a system over the Internet no
    matter where you are and be able to access this?
        Ms. Melvin. They have varying initiatives. We have not seen
    yet that big picture relative to how all of these projects are
    going to come together to create that one----
        Mr. Bilbray. Well, before we go on, let me just really lay
    down a marker. If you do not have this data available on the
    Internet to where anybody anywhere basically if they have the
    right access systems can access this because, frankly, I just
    think that, you know, I would love to talk about details,
    things like the biometrics. Any patient comes in, you know, and
    we can biometrically read them. We can get to their CO. We can
    find out if they want to be a donor, this, this, and this.
        Ms. Melvin. Yes.
        Mr. Bilbray. Those are all issues. What scares me is that
    we are not even getting around to that modem. Is this a
    technical problem or is this a bureaucratic problem to reaching
    our goals?
        Ms. Melvin. I think it is largely a bureaucratic problem
    from the standpoint of managing the overall initiatives. They
    have a number of initiatives that allow them to share data.
    Again, I do not want to paint the impression that they are not
    sharing. They are sharing data. But from the standpoint of
    having one longitudinal, if you will, electronic health record
    across these two Departments, that does not currently exist in
    the form that I believe perhaps was intended or was thought
    about in terms of the legislation.
        Underlying all of that is the fact that the Departments do
    not have the necessary planning in place to explain how they
    will take all of the multiple projects that they have that
    allow them to share capabilities on some level at this point,
    bring them all together into one package that enables them to
    share in the way that you are describing.
        Mr. Bilbray. Ms. Melvin, do you understand that, though,
    for 20 years, Congress has been looking for this, the new
    President, this is one of his top priorities he talks about.
    When he talks about all this other, with health care, he starts
    off with this. And, you know, this is the vanguard for the
    national data system.
        If we cannot make it work here, how in the world is the new
    President going to make it work with 350 million people?
        Ms. Melvin. I understand exactly where you are coming from
    in terms of that. At this point, though, I do not believe that
    they will be able to produce the type of system that is
    intended unless they have done more in terms of looking across
    what they have and they have established more of a convincing
    approach to how they are going to bring all of these
    initiatives together.
        Mr. Bilbray. Do we have a prototype that we see over the
    horizon? We see somebody that seems to have a system that will
    work. Do we have a prototype that we can build our assumptions
    around?
        Ms. Melvin. There are systems. VA actually has a great
    system in terms of what it provides. The difficulty is in terms
    of looking for examples of interoperability from the standpoint
    of bringing together different systems and making them work and
    deciding how you are going to do that from a technical
    standpoint. And that is the part that VA and DoD have not done.
        I cannot point to a specific example of one that has worked
    successfully, but I do not believe that technically--technology
    is the problem with their ability to do this. I do believe that
    it is a management problem.
        Mr. Bilbray. Thank you.
        Let me just say to my colleagues as we design the system,
    you know, I operated a supervised health care system for 3
    million people, and if I can leave you with one thing, if we do
    not have a system that allows a veteran to go into an emergency
    room and for us to biometrically be able to pull up his files,
    be able to know what their health is, know little things like
    do they want to be a donor, all those things need to be in the
    system. If you do not have a system to where you can
    automatically, a physician in an emergency can pull up these
    files, then the system is deficient.
        And I just ask you to keep an eye on that as we come and go
    as policymakers, but this is one of the goals, sort of a
    minimum goal. We want to make sure that every veteran, thus in
    the long run every citizen, will be able to have their files
    drawn up by a physician in an emergency room just because they
    are able to pull the biometrics and pull those files. And I
    hope that we keep that as a goal.
        Thank you very much, Mr. Chairman.
        Mr. Mitchell. Mr. Hall.
        Mr. Hall. Thank you, Mr. Chairman.
        And thank you, Ms. Melvin.
        And I would just comment on Mr. Bilbray's remarks. I agree.
        And, you know, my family who are and friends who are in
    TRICARE because they are either in service or working still for
    DoD are quite happy with the care they receive there and the
    ability, in fact, to go to any DoD medical facility and have
    their record pulled up.
        And as you said, Ms. Melvin, once they are in the Veterans
    Health Administration (VHA) system and have their veterans'
    health card can go to any VA facility in the country and have
    their electronic record pulled up. The problem as I see it is
    the handoff from DoD to VA.
        And, you know, I have the honor of chairing a Subcommittee
    on Disability Assistance and Memorial Affairs as well as the
    honor of serving on this Committee. And one of the things that
    we are most concerned about is this interoperability and the
    electronic handoff because it is the beginning of being able to
    establish whether there should be a claim granted or not,
    especially with our new veterans.
        Our Operation Enduring Freedom/Operation Iraqi Freedom
    (OEF/OIF) vets who are emerging now into civilian or VA world
    and leaving active duty, they really need, especially facing
    the injuries that the Chairman referred to, you know, some
    severe injuries, they need to be able to have hopefully at the
    speed of light their electronic medical record transferred to
    the VA so that we can go ahead and process their claims
    expeditiously.
        In your testimony, you stated that the Interoperability
    Office still has not established quantifiable and measurable
    goals and performance measures and that the office has cited a
    number of different reasons for the delay.
        As of today, less than 80 days from the deadline, there are
    still 4 vacant positions. That means it has taken more than a
    year and a half for the Office to get staffed up. This does run
    back into the previous Administration and when the ``Claims
    Modernization Act'' was passed as part of our veterans omnibus
    bill in the last term.
        So, in fact, it seems that the Office is likely not to be
    fully staffed up until after September 30th.
        So my question, I guess, to you is, the unemployment rate
    in this country is teetering close to 10 percent. I have
    personally spoken to dozens of veterans who are looking for
    work, including some who are quite qualified in engineering,
    computer technology, et cetera.
        Can we not find qualified people, even qualified veterans
    to fill these jobs? And what do you believe is causing the
    delay in hiring staff? Is there something we in Congress can do
    to speed up that process?
        Ms. Melvin. One of the points I would like to make about
    hiring the staff, it is very important that they get those in
    place, and you are right that it has taken a while to do that.
        I think it is important, though, to also recognize that as
    they put staff in place and define what exactly it is that they
    are going to do, it is important for them to have put the other
    basics in place as far as what this office is going to be doing
    relative to achieving interoperability.
        Right now without having the basics relative to a project
    plan to really define their resource needs, the timelines,
    their financial needs, it is very difficult to say whether they
    are choosing the right people for the right jobs. So there is
    probably a need for an element of caution in what they are
    doing.
        Having said that, since they have moved ahead, it does
    appear that there has been an effort on their part to try to be
    careful about who they are hiring. However, it is not very
    clear yet as to why they really--it is not clear to us as to
    why they have not been able to secure all the positions. I
    believe it is four positions within the government type
    positions that they have.
        It is our understanding they have all of the contractor
    positions. But, again, I would ask the question more
    importantly do they know what these individuals are going to be
    doing that they are putting in place.
        Mr. Hall. Last year, VA commissioned a study by IBM to look
    into the electronic handoff and the compatibility of different
    systems. Apparently they were dissatisfied with that and toward
    the end of last year, before our new Secretary was sworn in, I
    believe, contracted with Booz Allen Hamilton to do another
    study of how the systems should be structured.
        Have you seen that study? Are you aware of it? I think it
    was commissioned by Veterans Benefits Administration (VBA), but
    it has a bearing on VHA as well.
        Ms. Melvin. I am vaguely familiar, but I do not feel that I
    am informed enough today about the details on it to speak to it
    very effectively.
        Mr. Hall. We are waiting to see it and hopefully will soon.
    And it is, I understand, an attempt to come up with the correct
    or the most expeditious approach to this compatibility problem.
        Any more suggestions you can make to speed the process
    along? In terms of hiring, for instance, you said a number of
    candidates have withdrawn. Is that because of issues that they
    did not want aired in confirmation or is it because of other
    factors? Do you know what the reasons are?
        Ms. Melvin. I do not know the reasons for that. I would
    say, however, that it is very important that the leadership be
    put in place for this Office. The tone from the top is all
    important for setting the stage for how effective any
    organization is going to operate.
        I think it is very important that the IPO, the Interagency
    Program Office, be not just another layer in the process of
    what they have already had, but that it be an effective office
    and that it have an established and defined definition of what
    it really is going to be as far as achieving interoperability
    and its role from an accountability standpoint.
        Mr. Hall. Thank you very much.
        Thank you, Mr. Chairman.
        Mr. Mitchell. Mr. Walz.
        Mr. Walz. Well, thank you, Mr. Chairman, again for a long
    line of very pertinent and important oversight responsibilities
    here.
        And, Ms. Melvin, thank you again. In my short time here, I
    found your reports to be very helpful, very informative, and
    helping us move us in the right direction. So thank you for
    that.
        I do want to note that on the positive side of things
    today, we have both VA and DoD setting in the same room. That
    is positive for around here. But you do not see Members of the
    Armed Services Committee here with us.
        So this issue of seamless transition for many of us, and I
    see many folks setting out there, have worked on this thing for
    decades. There is a cynicism that pervades this issue because
    we all know that the fundamental reason for wanting to get
    seamless transition is better care for our veterans, more
    accountability over the system, and cost savings in the long
    run. So it is in everybody's best interest to get there.
        So I do want to make note that under the Chairman's
    leadership and Chairman Filner and the Ranking Member, I think
    you are right. We are making some progress.
        I wanted to note one thing. You did talk about in here we
    are starting to share on allergy data that is going back and
    forth. The one thing I did note, though, is you said between
    June 2008 and January 2009, we got 9,000 more patients on that.
        Ms. Melvin. Yes.
        Mr. Walz. At that rate, the current military will be
    enrolled in 78 years.
        Ms. Melvin. My understanding is that they are at about
    33,000 or 34,000 now. It is a slow process, yes.
        Mr. Walz. That might be an understatement. The point of
    that hearing is, is that the best we can do is where I am
    trying to get at. If that is the best we can do, when I think
    of the President's declaration in April of this year when he
    talked about the virtual lifetime electronic record (VLER) that
    many of us see as the holy grail of fixing the backlog in
    claims that Mr. Hall's Subcommittee deals with on a daily
    basis, the care that veterans get, the timely delivery of not
    only medical services but medals that were deserved and all of
    that, was he just making a pie-in-the-sky suggestion or the way
    I am treating it is, is this was a Presidential Directive that
    needs to be done? And are we moving toward that in a fashion
    that is attainable?
        Ms. Melvin. I think that obviously there are a lot of
    questions about where they are going to be by any particular
    date and especially the September 30th date.
        VA and DoD have a lot of experience. I mean, we talked
    earlier about the fact that, you know, they have been at this
    data sharing, since about 1998. And from that standpoint, there
    should be a lot of lessons and experiences learned that they
    can bring to bear in terms of how they move forward.
        Having said that, I think again it is important that you
    have the necessary foundation in place to guide your efforts.
    And until the two Departments really can come together very
    convincingly to show how they are working together differently
    and better than they did on previous initiatives to achieve
    this, advance achieving the interoperability, the questions
    will remain in terms of----
        Mr. Walz. And I think both organizations know the
    skepticism that is out there amongst the veteran's community.
    As you said, you have been tracking progress on this yourself
    for 8 years. You will do this long enough to retire and the
    next person will track progress.
        And at the point right now I think many of us are saying we
    are willing to draw the line in the sand.
        I do have a question. The staff, we were just discussing
    this, the interesting part of this. Mr. Space brought up a good
    part about the staffing and staffing up. We do not have all of
    the staff positions filled. We do not have all the government
    positions filled.
        All 16 private contractors already hired, what are they
    doing if we do not even have the vision?
        Ms. Melvin. That is the question and that is a concern for
    us in terms of who they have brought in to work right now and
    really not having the overall project planning in place to
    really guide that effort.
        It is a very valid question. It is a question of concern
    relative to how you use these individuals effectively to
    accomplish the goal that you have and that you do so in a cost-
    efficient way.
        Mr. Walz. Okay. I am old schoolteacher, so that is called a
    preparatory set for the next panel.
        Ms. Melvin. Okay.
        Mr. Walz. So thank you.
        Ms. Melvin. You are welcome.
        Mr. Mitchell. Thank you.
        And thank you, Ms. Melvin, for your work and we appreciate
    very much your testimony.
        Mr. Bilbray. Mr. Chairman.
        Ms. Melvin. Thank you very much.
        Mr. Mitchell. Yes.
        Mr. Bilbray. Can I just ask one last question, one
    statement?
        Mr. Mitchell. Yes.
        Mr. Bilbray. How many times have you testified before this
    Committee, ma'am?
        Ms. Melvin. You know, I have to provide you a number for
    the record, but it has been numerous.
        Mr. Bilbray. Is that numerous or countless?
        Ms. Melvin. No, I would not say countless.
        Mr. Bilbray. Okay. Close to it, though, huh? Thank you.
        Ms. Melvin. But a number of times, yeah.
        Mr. Mitchell. Thank you very much.
        Ms. Melvin. You are welcome.
        Mr. Bilbray. Thank you, Mr. Chairman.
        Mr. Mitchell. At this time, I would like to welcome Panel
    Two to the witness table.
        For our second panel, we will hear from Rear Admiral
    Gregory Timberlake, Acting Director of the Interagency Program
    Office. Rear Admiral Timberlake is accompanied by Cliff
    Freeman, Deputy Director of the Interagency Program Office.
        Also joining us is Mary Ann Rockey, Deputy Chief
    Information Officer, Military Health System, U.S. Department of
    Defense. She is accompanied by Captain Michael Weiner, Chief
    Medical Officer, Defense Health Information Management System.
        Also with us is the Honorable Roger Baker, Assistant
    Secretary for Information and Technology, U.S. Department of
    Veterans Affairs. Assistant Secretary Baker is accompanied by
    Dr. Paul Tibbits, Deputy Chief Information Officer, Office of
    Enterprise Development; Scott Cragg, Executive Director and
    Program Manager for the Virtual Lifetime Electronic Record
    Program, U.S. Department of Veterans Affairs; Dr. Douglas
    Rosendale, Enterprise System Manager for Joint Interoperability
    Ventures in the Office of Health Information, Veterans Health
    Administration; and Dr. Ross Fletcher, Chief of Staff of the
    Washington, DC, VA Medical Center.
        Please be seated.
        At this time, I would like to recognize Admiral Timberlake,
    Ms. Rockey, and Assistant Secretary Baker for up to 5 minutes
    each. And I just want you to know that your testimony will be
    as submitted in the record.
        Thank you.

     STATEMENTS OF REAR ADMIRAL GREGORY A. TIMBERLAKE, SHCE, USN,
    ACTING DIRECTOR, U.S. DEPARTMENT OF DEFENSE/U.S. DEPARTMENT OF
      VETERANS AFFAIRS INTERAGENCY PROGRAM OFFICE; ACCOMPANIED BY
    CLIFF FREEMAN, DEPUTY DIRECTOR, U.S. DEPARTMENT OF DEFENSE/U.S.
    DEPARTMENT OF VETERANS AFFAIRS INTERAGENCY PROGRAM OFFICE; MARY
    ANN ROCKEY, PROGRAM EXECUTIVE OFFICER/DEPUTY CHIEF INFORMATION
    OFFICER (ACQUISITION), MILITARY HEALTH SYSTEM, U.S. DEPARTMENT
    OF DEFENSE; ACCOMPANIED BY CAPTAIN (SELECT) MICHAEL WEINER, MC,
        USN, CHIEF MEDICAL OFFICER, DEFENSE HEALTH INFORMATION
     MANAGEMENT SYSTEM, U.S. DEPARTMENT OF DEFENSE; HON. ROGER W.
      BAKER, ASSISTANT SECRETARY FOR INFORMATION AND TECHNOLOGY,
       OFFICE OF INFORMATION AND TECHNOLOGY, U.S. DEPARTMENT OF
    VETERANS AFFAIRS; ACCOMPANIED BY PAUL A. TIBBITS, M.D., DEPUTY
    CHIEF INFORMATION, OFFICE OF ENTERPRISE DEVELOPMENT, OFFICE OF
        INFORMATION AND TECHNOLOGY, U.S. DEPARTMENT OF VETERANS
     AFFAIRS; SCOTT CRAGG, EXECUTIVE DIRECTOR AND PROGRAM MANAGER,
    VIRTUAL LIFETIME ELECTRONIC RECORD PROGRAM, U.S. DEPARTMENT OF
     VETERANS AFFAIRS; DOUGLAS E. ROSENDALE, DO, FACOS, ENTERPRISE
    SYSTEM MANAGER FOR JOINT INTEROPERABILITY VENTURES, OFFFICE OF
       HEALTH INFORMATION, VETERANS HEALTH ADMINISTRATION, U.S.
      DEPARTMENT OF VETERANS AFFAIRS; AND ROSS D. FLETCHER, M.D.,
       CHIEF OF STAFF, WASHINGTON, DC, VETERANS AFFAIRS MEDICAL
      CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
                            VETERANS AFFAIRS

                       STATEMENT OF REAR ADMIRAL
                    GREGORY A. TIMBERLAKE, SHCE, USN

        Admiral Timberlake. Thank you very much, Chairman Mitchell,
    Ranking Member Roe, and distinguished Members of the
    Subcommittee. I appreciate this opportunity to discuss the role
    of the IPO in the ongoing data sharing activities of the
    Department of Defense and the Department of Veteran Affairs.
        As has been previously mentioned in recent months, the IPO
    has been focused on two central areas, first facilitating the
    efforts of the two Departments to develop capabilities that
    will allow for full interoperability of their electronic health
    records by the end of September of this year and, two, working
    with the Departments to develop an effective governance and
    management model for the new virtual lifetime electronic record
    project announced by the President. These two areas will be the
    focus of my testimony today.
        Let me begin by providing you with a very brief overview of
    the DoD/VA Interagency Program Office or the IPO. Since its
    inception in 2008, the main objective of the IPO has been to
    provide management oversight of joint DoD/VA information
    sharing efforts.
        Specifically the IPO works with the DoD and VA to ensure
    that by September of this year, as previously mentioned,
    electronic health record systems or capabilities have been
    developed that allow for full interoperability of personal
    health care information between the Departments.
        DoD and VA began laying the foundation for this full
    interoperability in 2001 when the first patient health
    information was shared electronically using the Federal Health
    Information Exchange or FHIE.
        Since that time, both Departments have continued to enhance
    and expand the types of information that is shared as well as
    the manner in which it is shared. By building upon the prior
    accomplishments of the Departments to develop interoperable,
    bidirectional electronic health records, the IPO and the
    Departments have been successful in formulating a plan to meet
    the requirements of section 1635 of the FY 2008 ``National
    Defense Authorization Act.''
        As part of this plan, VA's and DoD's ability to utilize
    well-known interoperability capabilities like the FHIE and the
    Bidirectional Health Information Exchange have been greatly
    expanded. At the same time, new capabilities like the clinical
    data repository, health data repository or CHDR have been
    added, allowing even more medical data to be transferred
    between DoD and VA. These systems are enabling unprecedented
    amounts of medical data to be transferred between DoD and VA.
        My colleagues on the panel have included detailed
    information about these and other interoperability capabilities
    in their written testimony.
        Today I am pleased to report that we are on target to
    achieve the capabilities that allow for full interoperability
    of personal health care information for the delivery of
    clinical care by September 2009 as defined by our DoD/VA
    Interagency Clinical Informatics Board.
        The future promises even greater possibilities for data
    sharing as we work to fulfill the President's vision to develop
    a virtual lifetime electronic record or VLER. The VLER will
    serve as a single source of health care, benefits, and
    personnel information on the servicemember and veteran from the
    time of accession through the entire military career and the
    veteran continuum up to and including burial.
        The effort to create a VLER is a monumental undertaking
    representing one of the largest projects that any two Federal
    departments have collaborated on in recent years. As with any
    undertaking of this magnitude, proper planning and governance
    is absolutely critical to success.
        To begin, new IT conceptual frameworks must be established
    to provide health and benefits data sharing architecture to
    which both Departments can connect their electronic health
    record.
        To date, discussions between the Departments have focused
    on leveraging common services architecture framework to support
    modernized tools. The strategy for VLER implementation has been
    agreed upon by DoD and VA at a Joint Executive Council meeting
    on the 26th of June. This plan will allow expansion beyond the
    current level of interoperability to bring it in line with the
    President's direction in his speech of April 9th.
        In addition to discussions on the scope of VLER, the IPO
    also plays an active role in efforts to reach interdepartmental
    consensus on broad technical requirements issues. In this area,
    progress is being made on the Departments' efforts to agree to
    use a nationally recognized set of uniform and open standards
    for information exchange.
        This approach would enable DoD and VA to create an
    architectural framework capable of interconnecting systems from
    both the private sector and the government.
        Thank you very much for the opportunity to address the
    Committee and to provide you with an update on the important
    work that is being done by both Departments to advance
    electronic data sharing between the DoD and VA. I look forward
    to answering any questions you may have.
        [The prepared statement of Admiral Timberlake appears on p.
    48.]
        Mr. Mitchell. Thank you.
        Ms. Rockey.

                      STATEMENT OF MARY ANN ROCKEY

        Ms. Rockey. Thank you, Chairman Mitchell, Ranking Member
    Roe, and Members of the distinguished Subcommittee. Thank you
    for inviting me to discuss the substantial progress made to
    date with VA/DoD electronic health record interoperability. I
    am pleased to join my dedicated colleagues from the VA and IPO.
        Our electronic data sharing efforts have gained undeniable
    momentum since we first began sharing data in 2001. The scope
    of these efforts has increased steadily, improving the delivery
    of health care and administration of benefits to our Nation's
    servicemembers and veterans.
        Right now electronic health data is accessible to VA for
    more than 4.8 million separated servicemembers. Each day,
    health care providers and benefits specialists access
    electronic data on patients as they deliver care and resolve
    claims.
        We also share real-time data on 3.3 million shared patients
    and made it possible for DoD and VA providers to view real-time
    electronic data from each Department's electronic health record
    system.
        Sharing data on care delivered in deployed settings is
    critical to improve continuity of care for our wounded, ill,
    and injured servicemembers.
        Since 2007, we have shared data for care delivered in Iraq,
    Afghanistan, and Kuwait. This theater outpatient and inpatient
    data is accessed using the Departments' existing EHRs. Today
    more than 2.4 million theater outpatient clinical encounters
    are available to DoD and VA providers who treat these
    servicemembers and veterans.
        We have also made great strides in sharing servicemembers'
    inpatient care records. As the Committee knows, Landstuhl
    Regional Medical Center is the first stop for many wounded,
    ill, and injured servicemembers. Interagency access to
    inpatient discharge summaries from Landstuhl and other large
    hospitals is a tremendous aid to the continuity of care.
    Records are available from 21 military sites that account for
    55 percent of our inpatient beds. We expect to share inpatient
    records for 90 percent of our inpatient beds by 2010.
        Today the Bidirectional Health Information Exchange
    provides two-way, on-demand, viewable data exchanged between
    all DoD and VA facilities in real time. This live data flow
    became available enterprise-wide in July 2007 and includes data
    from 1989 forward.
        The data exchange includes allergy information, outpatient
    pharmacy data, demographic data, inpatient and outpatient lab
    results and radiology reports, procedures, vital sign data,
    patient histories, questionnaires, and theater clinical data.
        We are also transferring health data on separating
    servicemembers to the VA through the Federal Health Information
    Exchange. This comprehensive data flow began in 2002 and
    includes data from 1989 forward.
        The transferred data includes inpatient and outpatient lab
    and radiology results, outpatient pharmacy data, allergy
    information, discharge summaries, admission disposition and
    transfer information, consultation reports and pre- and post-
    deployment health assessments and health reassessments (PDHRA).
        In September 2006, the Department established
    interoperability between the data repositories used by the
    respective EHR systems. This DoD/VA interface enables the
    exchange of interoperable and computable outpatient pharmacy
    and medication allergy data between the Departments on patients
    who receive care from both health care systems. Information is
    included from DoD pharmacies, retail pharmacies, and mail order
    pharmacies. This functionality is available to all DoD
    facilities enabling drug-drug interaction checking and drug
    allergy checking using data from both Departments.
        To ensure continuity of care for our polytrauma patients,
    we are also exchanging radiology images and digital and scanned
    medical records between Walter Reed Army Medical Center,
    National Naval Medical Center, and Brooke Army Medical Center
    to the four VA polytrauma centers. This capability began in
    March 2007.
        We are moving swiftly and surely toward full health care
    information interoperability to support the provision of
    clinical care by 30 September 2009. With the two Departments,
    we look to a group of clinicians called the Interagency
    Clinical Informatics Boards to identify specific mutual data
    needs supporting care, continuity, and health-related benefits
    administration.
        Moving forward, we will build on this foundation to enhance
    future electronic health care information sharing. We will
    collaborate with the U.S. Department of Health and Human
    Services (HHS) on national standards. These standards are
    necessary for broader exchange of health information to realize
    the President's vision of the virtual lifetime electronic
    record and the Nationwide Health Information Network.
        Clearly we have made much progress in enhancing and
    expanding VA/DoD sharing and plan to continue these efforts.
    Our interagency collaboration continues to support the
    provision of the highest quality care for our Nation's heroes,
    past, present, and future.
        Thank you again for inviting me today. I am accompanied by
    my Chief Medical Information Officer, Dr. Michael Weiner, who
    is here to show you how our clinicians can access theater and
    BA data within our EHR system. I will be happy to answer any
    questions. Thank you.
        [The prepared statement of Ms. Rockey appears on p. 52.]
        Mr. Mitchell. Thank you.
        Assistant Secretary Baker.

                    STATEMENT OF HON. ROGER W. BAKER

        Mr. Baker. Thank you, Mr. Chairman. Thank you for the
    opportunity to update you on the status of our efforts to
    exchange electronic medical information with our partners at
    the Department of Defense.
        This Committee has always been supportive of our efforts
    and I look forward to providing you the information you need.
    And I would note that as this is the first time that I have
    appeared before the Committee, I appreciate the opportunity to
    come and testify and I look forward to seeing the Committee
    numerous more times in my tenure. So thank you.
        As you noted, I am accompanied by Dr. Paul Tibbits, Mr.
    Scott Cragg, and Dr. Doug Rosendale, senior members of the team
    working on this. And I would note that after my remarks, Dr.
    Ross Fletcher, who is one of the fathers of the VistA system,
    will demonstrate how DoD information is accessed and used by a
    clinician from within VistA.
        VA and DoD have made great progress in the exchange of
    information necessary to provide services to our Nation's
    veterans. For servicemembers who separate from the service,
    electronic medical records are delivered to VA and incorporated
    into VistA via a one-way transmission.
        For servicemembers who are being seen at both DoD and VA
    facilities, a bidirectional system makes their information
    available to both services. And for our most seriously wounded
    warriors, an exchange of information directly between the
    polytrauma care facilities ensures that all necessary
    information is available at the point of care.
        As impressive as this interoperability is, our work cannot
    stop. First, the current systems have shortfalls. VA clinicians
    need further training to ensure they know when DoD information
    is available and how to access it.
        Second, performance for BHIE, the Bidirectional Health
    Information Exchange, which is the system that accomplishes the
    two-way transmissions, can be very slow and is sensitive to how
    local computers are configured or how they are set up.
        Some information that is available today in a viewable form
    could also be made searchable and we recognize the need to do
    that from our clinicians.
        And while we are able to exchange information in electronic
    forms, information that is not currently made electronic is
    substantially less efficient for clinicians even if made
    available later via scanning.
        An example of further progress being made is our joint work
    on the Captain James A. Lovell Federal health care Center.
        The BHIE system that I mentioned earlier was designed to
    share data collected between episodes of care for patients
    receiving care in both VA and DoD systems. But a patient in the
    collocated environment of North Chicago may see either or both
    a DoD and VA clinician during a single episode of care.
        We have determined that additional functionality is
    required to ensure that data is exchanged seamlessly, including
    a single patient registration for both VistA and Armed Forces
    Health Longitudinal Technology Application (AHLTA), a single
    sign-on to both systems for our clinician, and the ability to
    easily move orders between the two systems.
        VA and DoD information interoperability successes to date
    have focused on applications that facilitate exchanging patient
    information between the departments to individual electronic
    medical record systems.
        On April 9, 2009, the President along with Secretary
    Shinseki and Secretary Gates announced that VA and DoD would
    create a joint virtual lifetime electronic record or VLER. The
    VLER will permit information vital to health care and other
    benefits and services to be available seamlessly to both
    Departments from the moment a servicemember enters the
    military. I would say, gentlemen, I believe that means getting
    beyond interoperability and into common use.
        The potential benefits of the VLER are many and planning
    and creating and implementing the VLER will be a challenging
    endeavor. VA and DoD are working jointly together on an overall
    strategy to achieve the President's vision and developing an
    effective governance model to implement that strategy.
        In closing, I would like to thank you again for your
    continued support and the opportunity to testify before the
    Subcommittee on the accomplishments and the important future
    work of VA and DoD to improve medical record sharing between
    us. I look forward to your questions. Thank you.
        [The prepared statement of Mr. Baker appears on p. 60.]
        Mr. Mitchell. Thank you.
        The questions I have first are for both DoD and VA. For
    both Departments, what obstacles or difficulties have you
    encountered while working to increase electronic health care
    interoperability? And what actions have the Departments taken
    to address these obstacles? Again, what are the difficulties or
    obstacles you face, and obviously you have some, and what have
    you done to address them?
        Admiral Timberlake. Sir, I may start just from my
    observations. I was asked to come back on active duty in
    January to be the interim Director and so I have had some
    observations.
        Some of them are just simply due to the fact that we are
    trying to work between two separate Departments and those
    Departments have different budgeting cycles and processes. They
    have different contracting processes. They have different ways
    by which they develop and define their requirements.
        And in my personal opinion, some of the difficulty has been
    in trying to find the ways to move smoothly when you have rules
    and regulations set up for two different Departments, but you
    are trying to bring them together.
        I will now turn to my counterparts and see if they have
    specific issues that they wish to share.
        Mr. Baker. Certainly I would look to some of the experts
    that came with me on this, but two things that I would observe
    for you.
        These are two huge, separately developed medical systems
    that we are looking to bring together. And a key issue is that
    representations of information in one system are not
    necessarily the same as they are in the other system.
        And so the Departments have created information exchange
    systems to pull information out of one, translate it, and put
    it into the other. What that means is while the maintenance and
    development of the two main missions go forward, we also now
    have the responsibility for bringing along those interchange
    systems in between them.
        It is not an easy process. Technically it is not simple and
    requires an awful lot of work to bring forward. And as you look
    at the individual types of information that need to come
    forward, whether it be pharmacy records, whether it be viewable
    information or computable information, determining what the
    data standards are and how those will be represented as they
    are exchanged from system A to system B is fairly complex.
        And while I agree that the main issues facing us may well
    be on the, you know, how do we continue to get along and define
    things, you know, from a cooperative standpoint, technically
    this is also a very challenging problem. And I do not think we
    can lose sight of the fact that it is not an easy question that
    is being asked here.
        Mr. Mitchell. You suggested there are two large
    bureaucratic organizations, two systems, but I think instead of
    trying to defend and protect the particular base, if they look
    at the ultimate goal, which should be the case, and that is
    looking after the veteran, you should be able to overcome the
    difference in cultures, the difference in systems, the
    different things that have happened over time. And I would hope
    that that would happen.
        One other question for both DoD and the VA. Why have the
    Departments not addressed the GAO's recommendations from the
    January 2009 report to develop results-oriented performance
    goals and measures for the achievement of full
    interoperability?
        Ms. Rockey. Currently we have an information
    interoperability plan and a joint strategic plan. And the
    Interagency Clinical Informatics Board (ICIB) sets the
    priorities for the items in the IIP and JSP and those, the ICIB
    requirements, I believe in the updates for the Information
    Interoperability Plan (IIP) and Joint Strategic Plan (JSP), and
    Rear Admiral Timberlake can confirm this for me, the updates of
    those plans will have those measures in them for the next
    version.
        Admiral Timberlake. Yes. The JSP is actually a product of
    the Joint Executive Council and it is the projects that have
    been agreed upon between the two departments. And with the
    revision that is going on now, we will have measurable goals,
    all the things that were talked about by the GAO in their
    report going forward.
        And the IIP is actually, if you will, almost a look ahead,
    the strategic goal. It is what we should be asking the ICIB or
    the other work groups to I come up with next to be done by the
    Departments. And obviously as those then roll, if and when they
    roll into the JSP, they will be assigned measurable outcomes
    and program guidance will occur. Yes, sir.
        Sir, could I ask might it be appropriate at this time to
    have the demonstration of what information we can share?
        Mr. Mitchell. Sure.
        Admiral Timberlake. Captain Weiner, if you would go first,
    please.
        Captain Weiner. Chairman Mitchell, Ranking Member Roe, and
    Members of the distinguished Committee, thank you for allowing
    us the opportunity to demonstrate the military health system
    electronic health system.
        What I would like to just spend 1 second is sort of showing
    you what our clinicians see throughout our enterprise and then
    the shared information in context for today that we are able to
    view from our VA colleagues.
        So we have been able to select a patient, a real-time
    patient back in April that was ultimately seen in theater. That
    data was captured back in Kuwait. He was then medevacked, air
    evacked up into Balad in Iraq and then moved to Landstuhl where
    he received further care. He came back to the States and then
    was ultimately seen by the VA in Palo Alto.
        [Slide.]
        Captain Weiner. This first view is the view that a
    clinician when they log on to our system and pull up a
    particular patient, this is what they see. So just to sort of
    orient everyone, up on the left is tabular bars and icons that
    help navigate throughout the system.
        Up on the top, we have selected previous encounters and you
    can either select it on the left or up on the top for ease. And
    it is a chronological order of care that has been delivered to
    this patient in an outpatient setting.
        You will see some other tabs up above, allergy, meds, DoD,
    VA, theater which we will discuss in a bit.
        And the other thing I would like to point out is just for
    this particular patient, there is a T up in the upper right-
    hand corner and then there are also Ts next to two different
    encounters of care, demonstrating that this patient was seen in
    a theater setting, so automatically letting the clinician, if
    he is coming to see us, if we take a second and think that we
    are seeing him, we are logging on, and he is coming to us for
    follow on care, what previous care has he seen.
        And then just as a separate note, you can see up here,
    there is a little nose that demonstrates he has allergies and
    then there is a little red flag that demonstrates he has
    command interest and meaning that he is a wounded warrior and
    that we want to ensure that we are able to review his entire
    record.
        So this particular gentleman, a 40-year-old, was seen in
    Kuwait. You see in the big frame down below is actually the
    care that was documented and the incident that was documented.
        Looking up just a little above where we saw the T, the
    theater notes, we also see that he was ultimately seen at
    Landstuhl Regional Medical Center. He had an ophthalmology
    appointment for some follow-up care and that care is all
    documented down in the large pane.
        But as we see this patient, he describes to us that he was
    also air evacked. He was also seen by the VA. And we know by
    the theater encounter that there is more data that can be seen.
        So we click over to DoD/VA theater history, which is also
    above and on the left. And you cannot really see right--well,
    right there, the pointer, this entire column on the right helps
    us demonstrate the chronologic order that the patient was seen
    in.
        So up at the top, if we slide this to the top, we are at
    current care. This is care that was delivered back in April. So
    we know that he was seen on April 24th and then we realize that
    there is a discharge summary done on April 27th, but there are
    also some ICU nursing notes from when he was seen. There is an
    operative note and then there is his surgical note.
        So all care that was seen and documented in theater is
    here; we can click here to view note details of his discharge
    summary. And what we see is the record, the discharge summary.
    And, again, we are seeing him now as an outpatient, say at
    Bethesda Naval Hospital, and we want a summary of what care
    occurred in theater while he was an inpatient. And we see that
    he was seen at Balad Air Base and we see what his admission
    diagnosis is and we see what his discharge diagnosis is.
        He also lets us know that he was seen just a few weeks ago
    by our colleagues at the VA at Palo Alto. So we slide our bar
    all the way up and in chronologic order with the top being the
    most recent, we see he was seen at the prosthetics clinic. He
    was seen by the speech pathology clinic and then also some
    physical rehabilitation.
        But we are interested in his neuropsychiatric assessment.
    We click on to view details and here we see the entire
    assessment conducted in the VA at Palo Alto.
        So prior to leaving, though, we like to discuss with him
    some new medications for the cause of his follow-up visit. We
    can go up above and we can click medications and we want to
    ensure that there will be no drug-drug interaction of any
    medications that we give and to also know what current
    medications he is taking.
        And prior to closing out, we also want to make sure he does
    not have any allergies with any of the medications that he has
    been given or as we see down in other any medications he has
    received in civilian pharmacies. So we click on the allergy tab
    and as a final, we are able to see allergies that were
    collected in both the DoD and in the VA.
        And with that, we are able to get a full view from the
    time, the point of injury from Kuwait to each movement
    throughout the system to his final appointment within the VA.
        Thank you for your time and we will be happy to entertain
    any questions.
        Mr. Mitchell. Thank you.
        My understanding is the VA also has a presentation?
        Admiral Timberlake. Yes. Dr. Fletcher would show you the
    VistA system. Minor technical adjustment here.
        Dr. Fletcher. It is my pleasure to be here to show the
    system that we are using at the current moment. We obviously
    are covering a lot of VA hospitals at one time, but also are
    increasingly able to see a good deal of the information coming
    over from DoD.
        You have already been told about the FHIE, the BHIE, the
    bidirectional view, the computable data, and the sharing of
    data for severely wounded warriors, so I will not go into that
    except to show you how it works in actual patients.
        [Slide.]
        Dr. Fletcher. The first patient is a dual user for VA and
    DoD. He served in Bosnia, Iraq, and Afghanistan. It actually
    says he was exposed to blasts at least 11 times, the last one
    in Afghanistan, rupturing his tympanic membrane and probably
    causing some TBI.
        When he comes to our institution, the cover sheet looks
    like this. If I click on remote data available, I will see that
    there is Defense Department data as well as Baltimore data. And
    simply clicking on that and I get a look-up of that
    information. It will start out with new and then become done,
    at which point I can click on the discharge summary and see
    that.
        If I click on other pieces of information, I will see the
    progress notes. And you can see in this instance that the
    progress note comes from the field hospital. As described
    earlier, this is a note from Afghanistan at the time that he
    had a shrapnel wound to his head which also caused the tympanic
    membrane to be ruptured as we saw later. Even at this time, he
    could still hear a whisper, however. But the exact details of
    what was done is in this format.
        If I clicked on viewable information, I could see it in a
    Web-based site that was talked about earlier. We do have a Web-
    based site that will show us all the information of the
    patient, whether he has been seen in any other VA sites, but
    also wherever there is a cruciform with the arrow, this
    information is available for the DoD as well and this is the
    DoD note you just saw pulled up in this Web-based viewable
    form.
        I can click on the pharmacy outpatient and, again, it will
    be new for a while, but then as it is done I can see the whole
    medication list from Bethesda, Walter Reed, and many other
    sites if I go down the list. These are very important because
    at the time we were seeing him, even after he left the service,
    we were having to follow him on a daily basis with his
    medications largely being given to him from Bethesda Navy. So
    we needed to know exactly what he was on when we would see him
    in our hospital. But simply using this Bidirectional Health
    Information Exchange, we could see that updated real time
    whenever we are seeing the patient.
        Notice that if I go into older areas of his medication, we
    see that I can view what was given to him in Landstuhl,
    Germany, Walter Reed, Eisenhower, Camp Shelby, and even CVS
    Pharmacy. So the TRICARE information that is coming over is
    seen by us as well all in one site.
        This is a different patient, but it also shows information
    from the TRICARE health clinic, DeLorenzo Health Clinic at the
    Pentagon. I like to show this because while I was in the Army,
    I served in that health care clinic under Dr. DeLorenzo. It was
    not called that at that time. He was well known in this city
    because he had accompanied many people through the Bataan Death
    March and helped a lot of people out at that time.
        If we look at the laboratory data, we can simply by
    clicking flag isolate all the abnormal lab data, so we do not
    have to look at the whole list. We can look at the combined
    data from the DoD sites and VA at the same time.
        Second patient is a severely wounded warrior who went to
    DoD polytrauma and then to our polytrauma sites and then to the
    VA. This particular patient had an improvised explosive device
    (IED) blast and suffered a fractured spine and had traumatic
    brain injury as well.
        When I go to remote data and find out if it is available, I
    can initialize the Defense Department data and click on
    allergies. The patient had not been seen in Washington, so it
    was not assessed. But as the information became more available,
    penicillin allergy was seen at every DoD site the patient was
    seen, so Brooke, Martin, Bethesda, Navy all had that allergy
    listed.
        And as a matter of fact, if I tried to give penicillin to
    the patient, which I simulate here, it would tell me that we
    had not assessed the allergy as he walks in the emergency room
    but that he has had adverse reactions to penicillin reported
    over from the DoD sites. So this is computable data allowing me
    to cancel that order and move on.
        This is the same patient whose image has been shipped over
    in the severely Wounded Warrior Program. All the images and all
    the files in a PDF format have been sent over to the polytrauma
    sites. The beauty of that is that in the VA, if it is in the
    imaging system, I in Washington can easily see the records that
    have been sent to Richmond or sent to Tampa. They are all
    interchangeable and whenever I pick up images, all of these
    images are available to me.
        If I click on the zoom feature, you can see that in this
    instance, he has screws into his spine. And at this point,
    there is a fracture of the spine. The screws are not at that
    level, but they are above and below that level. And this is
    very helpful for me to see the image as well as the description
    of the image.
        I also can pull a PDF document up. In this instance, it was
    about 1,600 pages, but it was well indexed and I can search
    through that and see all the information that was available not
    only at Walter Reed but all the sites prior to that, in
    Landstuhl, Germany, as well.
        If I go to the third patient, this is one that was dual
    care initially, now with the VA. The patient was hit by a
    truck, had severe traumatic brain injury and that the patient
    was in coma when she came to our hospital. And we thought she
    might well not live much less achieve any reasonable activity
    in the future.
        This is the way the record appears. And, again, I can pick
    up the remote data and see that she has chemistries listed.
    These are Palo Alto, Bethesda Navy, Richmond. I can also pull
    up the consults which are seen in both places. And I can see
    the discharge summaries. Again clicked on the discharge
    summaries to see the discharge summaries from the DoD as well
    as VA.
        Here is a radiology report. Radiology reports have been
    shared on the bidirectional health information system for quite
    some time, but more recently the actual X-rays are now being
    shared between our place and Walter Reed and between our place
    and Beaumont and the North Chicago. We can see them so that if
    this comes up, I can simply click on the image and now I can
    see these two images.
        This is the first one. These are some months apart. This
    one is in March and the follow-up is in October of the same
    year. Notice they are very different. And I can cycle through
    these in a comparison mode. I see very large vacuous holes
    inside the brain, which are the ventricles, which are quite
    swollen, not swollen at the same level several months later.
        I can go through them together and notice how much bigger
    these are and how much the brain has been pushed up against the
    skull. And the fact that she was not able to wake up was easily
    judged by this problem.
        Mr. Mitchell. Dr. Fletcher, can we wind this up?
        Dr. Fletcher. Yes, I will.
        Mr. Mitchell. I think we get the gist of this.
        Dr. Fletcher. I will.
        Mr. Mitchell. We are way over time.
        Dr. Fletcher. Yes, I will.
        We put a catheter inside the ventricle and decompress that.
    And now you can see that she can wake up.
        This is another example of sharing of the X-rays which I
    will quickly click through and summarize by saying that I have
    shown you some examples of the Federal Health Information
    Exchange, the Bidirectional Health Information Exchange, the
    CHDR Program which is computable data, the Wounded Warrior
    Program, and the VIX Image Sharing Program.
        Thank you very much.
        Mr. Mitchell. Thank you.
        Admiral Timberlake. Mr. Chairman, thank you very much for
    your indulgence in allowing us to demonstrate this because one
    thing I noticed when I came to the office was that there was a
    lot more sharing going on than I had ever as a veteran before I
    came back on active service ever understood.
        I am not going to stand here and tell you it is perfect and
    there is not more to do and this is not VLER, but certainly I
    think there is more going on than many of us out in my
    veterans' community ever understood.
        Thank you.
        Mr. Mitchell. Thank you.
        Mr. Bilbray.
        Mr. Bilbray. Thank you, Mr. Chairman.
        You know, I want to just open up for discussion and I just
    got to tell you looking at the task in front of us, I do not
    see any way we are going to reach the threshold mandated in
    2010. In fact, we have a new joint facility opening up in 2010.
        Is that facility going to be able to share data files from
    the two agencies, two Departments?
        Mr. Baker. Sir, that facility will utilize the
    Bidirectional Health Information Exchange, what we have right
    now, and several new features that pull AHLTA and VistA more
    closely together to allow exchange of orders, allow single
    sign-on for doctors, and a single registration for patients.
        So enhance interoperability at the facility from what we
    currently have right now between AHLTA and VistA.
        Mr. Bilbray. Well, the question is enhanced from what we
    have now seems to be short of what we hope to have or thought
    we were going to have as dictated by Congress.
        Let me just tell DoD up front that if I was the manager and
    I looked at this issue, I have to figure that not only is the
    client going to be with the VA 20 to 30 years where you are
    maybe 5 to 10, but that because Veterans is going to inherit
    the client, any good manager would reverse engineer it from
    where the files are going and then modify the source to reflect
    that long term.
        I just got to say right up front, and I want DoD to defend
    yourself on this issue, a reasonable manager would say the lead
    agency should be VA because they are the recipient and they are
    going to be the custodians longer than DoD.
        DoD, what is your argument to defend your turf here over
    the fact that VA ought to be setting the standards and only if
    you can show where it is not compatible with your active duty
    should you be able to modify it?
        Ms. Rockey. The Interagency Clinical Informatics Board sets
    the priorities for sharing, on what information we are going to
    share and that is based on clinical priorities. We are making
    changes in our architecture to enable sharing not just with VA
    but sharing also with private sector, which is a big component
    of the lifetime electronic record that we discussed earlier.
        I think it is critical the sharing not just with VA but
    that we are able to use standards so that we can connect to the
    Nationwide Health Information Network and be able to share
    information with the private sector as well.
        Between VA and DoD, over 50 percent of our care is in the
    private sector and it is critical that we are able to share
    information and get information from the private sector as well
    as between VA and DoD.
        Mr. Bilbray. When we right now have problems with Bethesda
    talking to Walter Reed, I mean, it pretty well tells me that we
    need some adult supervision here and that we need to set a
    standard, somebody needs to set a standard. And right now you
    are talking about the Committee setting a standard that
    everybody lives with without one agency having the lead and the
    other one basically being a support system.
        You have a major problem with the Veterans Affairs
    Department being the lead agency with this data system?
        Ms. Rockey. The requirements for interagency sharing are
    set by the Clinical Informatics Board, which has VA and DoD on
    the Board. The IIP and the Joint Strategic Plan are developed
    by both DoD and VA.
        Mr. Bilbray. Ma'am, in all fairness, the system may sound
    good on paper, but the results that we are seeing is not a
    result that, you know, I do not think this Committee wants to
    accept and I do not think the public will accept. The fact is
    everybody seems to be basically passing around the process but
    not getting to an outcome that reflects reality. And the issue
    is somebody needs to be in command here to dictate it and at
    least then set a standard that everybody else can work around
    or ask for modification, a mainframe to build around.
        You are saying the Committee is doing that. I have not seen
    and I do not think this Committee has seen that as being an
    outcome that is timely and appropriate.
        Ms. Rockey. I think the establishment of the IPO in April
    of 2008 is a big step forward and putting the leadership in
    place at the IPO as was discussed with the GAO testimony is a
    critical next step for moving that forward. But I think the IPO
    will provide that leadership and is providing that leadership
    now under the interim guidance of Admiral Timberlake.
        And I see us continuing to move forward on interoperability
    and, again, not just with VA, which is critical for our
    servicemembers, but also with the private sector as the private
    sector begins the sharing process and moves forward with the
    sharing process as well.
        Mr. Bilbray. Thank you very much.
        And, Admiral, thank you for coming back. I mean, what a
    thankless job. And hopefully we will when your successor will
    be a permanent appointment, at least in the foreseeable future.
        I yield back, Mr. Chairman.
        Mr. Mitchell. Mr. Hall.
        Mr. Hall. Thank you, Mr. Chairman.
        Admiral, am I correct in surmising that the samples that we
    just looked at of different servicemembers' records were
    selected from the many others which may or may not be as
    complete or be as interconnected? And, if so, what percentage
    of those who have been separated from service in the last year
    had this degree of interoperability and depth so that the
    physician from VA or DoD or private sector, but especially VA,
    can access all that information going back to when the injury
    may have occurred?
        Admiral Timberlake. I will take for the record the
    percentage. But what I wanted to say was, you know, going back,
    and it was mentioned earlier about Specialist Fugate, we have,
    we, these two Departments have worked madly over the last few
    years to be sure that more and more of the patient encounters
    are recorded electronically. And the electronic patient
    encounters that are recorded are now available between the two
    Departments.
        [The DoD subsequently provided the following information:]

              For recently separating servicemembers, with the exception of
            shared images, the samples shown are representative of the
            electronic health data available to VA. Servicemembers who
            separated several years ago may still have a significant
            portion of their medical data that were not captured
            electronically. While we are unable to provide a percentage of
            separated servicemembers that would have the degree of
            interoperability demonstrated, we can say the majority of
            servicemembers separating in the last few years will have a
            significant amount of health data available to VA.
              Not all prior servicemembers will have Theater data available
            electronically to VA. The ability for VA to access Theater data
            became operational in October 2007. VA would not be able to
            access Theater data on individuals in Theater prior to October
            2007. Likewise, not all former servicemembers would have
            digital radiology images available to VA at this time, since
            that capability is operational at a limited number of pilot
            sites.
              VA has access to electronic health information on more than
            4.8 million individuals. The earliest data, starting with
            ancillary data, are from 1989. Since 2001, more and more data
            have been made available electronically. At this time,
            electronic health data are not available to private physicians.
              In general, VA has access to:

                Since 2001, for separated servicemembers, DoD has
            provided VA with one-way historic information through the
            Federal Health Information Exchange. On a monthly basis, DoD
            sends laboratory results; radiology reports; outpatient
            pharmacy data; allergy data; discharge summaries; consult
            reports; admission, discharge, transfer information; standard
            ambulatory data records; demographic data; Pre- and Post-
            deployment Health Assessments; and Post-deployment Health
            Reassessments.
                For shared patients being treated by both DoD and
            VA, the Departments continue to maintain the jointly developed
            Bidirectional Health Information Exchange (BHIE) system, which
            was implemented in 2004. Using BHIE, DoD and VA clinicians are
            able to access each other's health data in real-time, including
            the following types of information: allergy; outpatient
            pharmacy; inpatient and outpatient laboratory and radiology
            reports; demographic data; diagnoses; vital signs; family
            history, social history, other history; questionnaires; and
            Theater clinical data, including inpatient notes, outpatient
            encounters, and ancillary clinical data such as pharmacy data,
            allergies, laboratory results and radiology reports.

        Admiral Timberlake. Now, having said that, you know, I
    personally, this is my 36th year of Naval service, active and
    Reserve, I think I have 8 years of electronic data, so I have
    about 28 years of carrying around a big, thick record.
        But if we are talking about what we are doing now, you
    know, then I think in most instances, I am not going to tell
    you it is a hundred percent because somebody is always going to
    find the, you know, the----
        Mr. Hall. Exception.
        Admiral Timberlake. Yeah, that proves the thing. But if it
    is entered electronically, then they can see it between. Now,
    you know, there are some issues. I think it was brought up
    earlier by Mr. Baker. Sometimes you go to a facility and
    somebody does not understand how to do it.
        DoD had an issue where if you do not get the functionals,
    the business community, the physicians to tell you what, really
    tell you what the requirements are, you know, they had a thing
    for a while where the DoD people could not get to the VA data
    because instead of a button that would be--you know, they just
    said build us a button, so they built a button that said BHIE.
        Well, techies did that. That is what the IT people are
    supposed to do. But the functionals did not then teach the
    clinicians that that is what that button meant. And so for a
    long time you could go to somewhere like Walter Reed and a lot
    of physicians would not know how to see the data. It was
    available to exchange, but they did not understand how to do
    it.
        And let me turn to Mary Ann or----
        Ms. Rockey. I do want to point out that that button is no
    longer labeled BHIE, that that was what you saw in the
    demonstration. It is VA information and theater information is
    what it is labeled, now which is a better descriptor.
        Also, a little different architecture for our electronic
    health record system in which we have a central data
    repository. So the capabilities you saw are accessible across
    the DoD.
        Mr. Hall. I do not want to minimize the progress that you
    have shown us because this is the first time in my recollection
    that we have seen this kind of electronically accessible record
    for a servicemember, that is accessible from both Departments.
        But I just wonder if anybody here at the table can tell me
    what percentage, let us just say today, what percentage of
    servicemembers leaving active duty today and being separated
    and joining the Veterans Corps have records that look like that
    and that have that degree of detail and accessibility and
    interoperability?
        Admiral Timberlake. You know, my understanding, sir, is
    that when the serviceman separates, every bit of DoD electronic
    information is transferred via the BHIE to the Veterans
    Administration.
        Now, the Veterans Administration does not access that until
    a member comes in for care or treatment because of privacy
    issues and Health Insurance Portability and Accountability Act
    (HIPAA) and all, but it is transferred.
        Mr. Baker. Sir, I think we would agree with that. Maybe a
    statistic for you. May help or may not. The statistic I have is
    that in April of 2009, there were 295,000 accesses of the BHIE,
    of the bidirectional system.
        The other statistic is that there are about 4.8 million
    unique patients that have been transferred from the DoD to the
    VA via the FHIE, the Federal Health Information Exchange.
        I do not have the percentages for that. I just have the
    statistics. We can certainly, I believe, come back to you with
    what we believe the actual percentage is of DoD patients. We
    believe it is a hundred percent, but we would like to make
    certain that we do a little bit of analysis from the folks here
    at the table and come back to you with the actual answer.
        But of the people leaving service today, if they have any
    electronic records from the DoD being seen, that information is
    transferred into the VA.
        Mr. Hall. Thank you very much.
        Thank you, Mr. Chairman.
        Mr. Mitchell. Thank you.
        Mr. Walz.
        Mr. Walz. Thank you, Mr. Chairman.
        First of all, I would like to thank every one of you for
    your service. I think all too often we get into the heart of
    these and we forget the incredible work you are doing, the
    incredible selfless service to the public sector, when all of
    you could be in the private sector. I understand that.
        And, Admiral, you came back out of that. So I think we want
    to be very clear and also to be very clear that we are absolute
    partners with you in this endeavor because you can be certain
    when we go home, we set on the other side of the table and our
    veterans set up here and grill us on everything that is there.
    And that is the way a system is supposed to work.
        But I do want to be very clear that we are all in this
    together. It is absolutely understood that everyone in this
    room wants the quality care for our veterans, timely manner, do
    it in the most efficient and cost-effective manner. So I know
    sometimes we lose that and we get lost in a little bit what
    goes on.
        A couple of question on this and I am impressed that we are
    making progress on that. I think Mr. Hall asked some good
    questions.
        I as a 24-year veteran that retired in 2006, if I went to
    the VA, what would my record look like?
        Mr. Baker. Gentlemen, somebody who knows VistA----
        Mr. Walz. Where would they get it? How would I find out
    about it? I went in there. I was a 24-year artilleryman. I
    cannot hear very well. What is going to happen?
        Mr. Baker. I would ask Dr. Fletcher to address that one.
        Dr. Fletcher. You would see a button that says remote data.
    They would see a button and it is labeled remote data. And if
    they clicked on that or went in VistA Web, it would
    automatically come up if you had been seen in DoD and VA. And
    all of that data in terms of radiology reports, all the labs,
    all the medicines, most of the electronic notes would be
    available to the doctor.
        Mr. Walz. And I say this, I just have to say when we
    deployed in 2006, I will be damned if I did not have to get
    every shot again. No record, nothing. Nine of them. Oh, First
    Sergeant, you do not have any records. How can I not have any
    records?
        So my question is still, and I know it has been maybe--
    maybe 3 years ago is a lifetime, but I still just know from
    personal experience that that 201 file that is this thick that
    is in the safe in the bottom of my house, I am convinced that
    is the only one at this point. And that makes me a little
    nervous.
        And I say this because I am passing on, yes, maybe
    anecdotal from I see Vietnam veterans out there, I see Iraq
    veterans out there. Our question is, is that I absolutely, I am
    trying to get to where we are going and where this is
    happening.
        I want to come back to where the GAO was on this. And they
    came to a different conclusion than I am hearing from you.
        Now, the one thing was, as many of you--do not think I do
    not underestimate the technical side of this. It is massive.
    And I agree with, I think, Admiral, you said this or maybe it
    was Mr. Baker, you are shooting for a hundred percent. And I
    think, you know, we have to. This is a zero sum game. I do not
    know if we will ever get there. The Secretary says that, but
    anything less than that attempt is probably not right for our
    veterans.
        What I am trying to figure out is, is that they were very
    clear. They stated three things. They think it is taking you
    too long to hire staff. They think we forced you to come up
    here and testify here where you should all be out doing your
    job right now basically is what it said, and that you are
    trying to align yourself with a time table.
        And I agree, Admiral. You said our time tables are
    different, our funding is different, and it would be easier if
    we could just get those into alignment. Our job is to try and
    help you get there.
        So I want to see if maybe, Admiral, this might be for you
    to respond first. The GAO wrong about that on why we are not
    getting there?
        Admiral Timberlake. I think that many of the things that
    they have said are absolutely right on. Let me address your
    first issue.
        I tried to be specific that we can only transfer electronic
    information that we have. If you are like me, you know, there
    is a lot of your information that is on paper.
        Mr. Walz. That is right.
        Admiral Timberlake. We cannot transfer paper
    electronically. That is a whole other discussion, but it is
    outside of the electronic health record.
        So your information may be limited depending upon how long
    you were in the service after we started the transfer.
        Mr. Walz. Right.
        Admiral Timberlake. As far as the other, yes, it is taking
    both Departments a long time in my opinion to bring personnel
    on board. I am not sure why.
        On the DoD side, part of it was that although the office
    was stood up, and I would almost call it a virtual office, in
    April with a couple of--Cliff was one and another, and a DoD
    person that tried to start getting some of the program
    descriptions written and the people hired. And they had a
    couple of loaned military officers for a few months.
        But on the DoD, they could not begin to officially hire
    until this delegation of authority memo was signed which was
    not done until December 30th. Once that happened, then the DoD
    position descriptions could go out and we could start the
    process of trying to hire. And we are continuing to do that.
        The VA, they went out earlier, but with the change of
    Administration relooking at what their--because each Department
    hires the people and then gives them to me or my hopefully
    successor soon. They had to look at their priorities.
        And I might let--do you have something, Cliff? Let me let
    Cliff----
        Mr. Freeman. Yeah. It is not for lack of effort. The
    position descriptions were written for the, what used to eight
    positions, were written in May of 2008. That was a month after
    we stood up the office. And then the seventh position was
    written the next month when the Senior Oversight Committee
    (SOC) decided that we would also oversee benefits and
    personnel.
        It has been a challenging experience and very frustrating.
    We have had certs that came back with only one name on them.
    Very nice people, but they were not the skill set that we
    needed. We have offered jobs to people and they have turned
    them down, either stay in the private sector or take other
    government jobs. So I do not think it is for lack of effort.
        And the one thing I would like to say is that although all
    the positions have not been filled, what we have done is we
    have borrowed very qualified folks from the two Departments to
    come in and make sure that those skill sets we needed did not
    go unfilled.
        So DoD brought on people in uniform to help us. The VA
    provided folks, some project managers and folks to help fill
    those specific spots.
        So I do not want to leave the Committee with the impression
    that the work went undone because we did not fill the permanent
    positions.
        Mr. Walz. No. And I very much appreciate that.
        And I would say, if the Chairman indulges me for an extra
    minute, to just let you know these hearings are meant to be
    bidirectional also. Our job is if these are things we can cut
    through, and I am absolutely committed to this seamless
    transition, we are starting to send out overtures and it is
    difficult here to try and get Armed Services to work with VA,
    but we are making that attempt and talking to members over
    there of ways that we can make this happen.
        So these are the things that need to be brought to our
    attention, to the staff's attention if there are things that we
    can help speed that up because I think any of us who have
    worked in this environment know that what you are saying is
    absolutely true. We just cannot allow those hurdles to get in
    the way of making this happen, if there is anything we can do
    to break them down.
        I yield back. Thank you, Mr. Chairman.
        Mr. Mitchell. Thank you.
        Just indulge me, if the Committee would for just a second.
        I heard Mr. Walz say that when he went back to be deployed
    that there is no record of any of his shots. And I was just
    talking to our counsel here. When he was first deployed in
    1991, he had 25 shots. When he was redeployed in 2002 through
    2004, there was no record of them again.
        The problem with this, of course, is when a veteran tries
    to apply for benefits, and I think that I heard, Ms. Rockey say
    that every electronic record that DoD has is transferred to the
    VA, but it looks to me like a lot of the problem is that DoD
    does not have all this stuff on electronic records.
        Our counsel here says that he had to carry them around with
    a rubber band around them and he carried them around himself.
    The real problem then occurs when they try to apply for
    benefits. So it is just an observation.
        If the Committee will indulge me, I want to ask two quick
    questions of the Admiral.
        First, will the Interagency Program Office meet its
    statutory deadline on September 30th, 2009, to have an
    interoperable electronic health record system?
        Admiral Timberlake. Thank you, sir. I will take the first
    crack at perhaps answering that.
        My understanding in reading of H.R. 4986, the ``NDAA
    2008,'' Public Law 110-181, section 1635 required, and I quote,
    ``By no later than September 30th, 2009, electronic health
    record systems or capabilities that allow for full
    interoperability of personal health care information between
    the Department of Defense and the Department of Veterans
    Affairs.''
        The two Departments and then again the IPO when it was
    subsequently set up turned to that expert working group we have
    mentioned in the Health Executive Council called the Joint
    Clinical Informatics Board at that time, subsequently called
    ICIB, to define what these capabilities should be.
        Those members examined the information sharing capabilities
    currently extant between the Departments of Defense and
    Veterans Affairs and identified a path toward reaching the next
    level of integration, which they said would support this
    interoperability for the provision of clinical care.
        They used five criteria established by the Institute of
    Medicine (IOM) that defined the core functionalities of an EHR.
    The five criteria from the Institute of Medicine are improve
    patient safety, support the delivery of effective patient care,
    facilitate management of chronic conditions, improve efficiency
    and feasibility of implementation.
        Using the IOM model and prioritizing provider access to
    clinically relevant information, the JSP now called ICIB
    members made the determination that the sharing of this
    additional set of capabilities, which have been talked about
    between the VA and DoD in addition to currently shared
    information would provide a level of clinical care sufficient
    to reach the desired level of interoperability.
        Adding these new capabilities to the already robust
    information sharing occurring between the two Departments
    provides a level of integration that far surpasses the level
    generally observed between health care systems and the private
    sector.
        It should be noted that the Departments were looking at and
    the ICIB were looking at interoperability from a functional
    perspective. In other words, what is needed for the provision
    of clinical care. They had not and I believe still have not
    spent a lot of time and energy trying to define the term
    interoperability from an academic perspective. As to whether
    something is fully interoperable depends on the use case or
    what the functional business community or medical community
    says it needs to do with the data.
        So the Departments considered the provision of clinical
    care to be their first priority since that is in essence the
    use case at a high level. And that is the priority they are
    addressing now. And, thus, in addition to the current and
    ongoing information exchange, they identified six additional
    capabilities that they believed needed to be developed by
    September 30, 2009, to meet the requirement for EHRs or
    additional capabilities.
        And those six by expansion of Essentris or provision of an
    inpatient record component to AHLTA, demonstration of trusted
    gateways so you can share the information, the social history
    refined, as we talked about, demonstrate a capability to do
    document scanning and expansion of the questionnaires that were
    already mentioned and then showing the separation physical
    exams are going back and forth.
        As of today, three of those objectives have been met and
    the other three appear to be en route to being achieved by
    September 30th. So it is my opinion that we will meet that
    deadline based upon these definitions which the departments
    have come up with working together.
        Mr. Mitchell. So the answer is yes?
        Admiral Timberlake. My answer is at this time, it seems to
    me we will.
        Mr. Mitchell. I understand about the six interoperability
    objectives. I thought the GAO said there was only one that was
    met. You say there is three?
        Admiral Timberlake. According to my most recent update
    which is right here, we have three that seemed to have been met
    and there are three that are still in process, but I believe
    will be met.
        Ms. Rockey. I can confirm it is the three. Social history,
    separation physical exams, and the expanded gateways have been
    completed.
        Mr. Mitchell. One last question, if the Subcommittee will
    indulge me.
        According to the GAO, in early July, DoD and VA reported
    they had selected 10 of 14 government positions. However, all
    16, and this kind of goes back to what Mr. Walz said, all 16
    designated contractor positions have been filled.
        If there has not been established results-oriented goals
    and performance measures for all six objectives yet, how does
    the IPO measure whether the contractors are meeting their
    requirements? What is the scope of work of the contractors and
    what positions do they fill?
        Admiral Timberlake. The contractors range from support
    staff such as secretaries to specialists in program management
    who work with our program manager to begin to gather the data
    that was talked about.
        Now, I will be the first to admit we are not fully where we
    want to be. But, for example, in looking at and following the
    status of the Essentris implementation, which is just one of
    the six which is not complete, we were following what was the
    contract, was the contract let, and then what were the outcomes
    that the Departments had agreed upon would define success.
        In that case, success was defined by selecting an inpatient
    module, which ended up being Essentris, having the contract
    let, and then deploying that contract, that capability at three
    additional sites in DoD facilities, one from each service.
        As of today, I believe two Army? I will ask Ms. Rockey.
        Ms. Rockey. Yes, that is correct. We have two Army sites
    complete and we are on track for at least one Air Force and one
    Navy site by September.
        Admiral Timberlake. And so at that level and that sort of a
    rudimentary level of program management, I would be the first
    to admit we have goals, we have objectives, and we are tracking
    to see that the DoD and VA are meeting them.
        Mr. Mitchell. Mr. Wu.
        Mr. Wu. Thank you for your indulgence, Chairman Mitchell. A
    couple questions.
        Admiral Timberlake or the collective group, as a staff
    member and as a Staff Director, it has been painful to listen
    to this testimony.
        The NDAA requirement on interoperable systems in our
    opinion was not to identify the six objectives. It was to have
    the system in place.
        In looking back in former PowerPoint presentations, this
    thing was supposed to have been in effect 2005. And if you will
    indulge me, I will read you the quote from the press release
    when this agreement came in place.
        ``In October of 2002, this joint initiative marks the
    beginning of an era of renewed and I believe unprecedented
    collaboration between the health care resources of VA and DoD.
    This partnership is critical to our ability to continue to
    deliver high quality care in our respective beneficiaries
    across the country,'' quote, unquote.
        Now it is 7 years later and we are just beginning to
    identify what those objectives are to get there.
        When you opened the doors in October of 2010 and you are
    seeing DoD beneficiaries and veterans affairs' beneficiaries,
    what are you going to be able to do?
        I understand. I heard the testimonies saying you will have
    joint sign-off. You will have this sharing. I personally do not
    believe that you will be able to see the patients in the
    seamless manner that the NDAA 2008, the spirit of what you were
    supposed to do and where you are at right now. I hear a lot of
    excuses. I do not think that is right.
        I see in the NDAA language that the House Armed Services
    Committee (HASC) put out after the joint hearing that they
    recommended that all the money from DoD and from MHS be
    stripped because there was no adult supervision.
        Would you like to comment on that because we have not moved
    forward in the manner that I think was in the spirit of what
    the Members of Congress wanted?
        Admiral Timberlake. I am going to allow my two colleagues
    to comment on that because I think you have switched over to
    talking about the North Chicago Federal Health Care----
        Mr. Wu. Well, I think North Chicago has been touted to be
    the poster child of interoperability and I see that it is
    silent in the testimony of VA and DoD. Not silent. One line in
    the testimony. And this was supposed to be the joint venture,
    the demonstration of interoperability. I do not see that
    happening.
        Ms. Rockey. For North Chicago, the requirements for the six
    baseline functional requirements for opening day, and this is
    in addition to the current sharing we are already doing, of
    that, we have completed one so far. We have the requirements
    defined for the other five in detail. Those were delivered in
    June.
        We have a Joint Incentive Fund (JIF) package that we have
    pending to work on single patient registration process, single
    sign-on, phase one of single order entry, address rapid dental,
    and work on outpatient appointment scheduling as well. Those
    are the items that were identified as baseline functional
    requirements for North Chicago and those are the ones we are
    targeting for completion by October 2010.
        Mr. Wu. Thank you, Chairman Mitchell, but I understand that
    that JIF money is going to be VA money, not DoD money. That is
    my last question. Thank you very much, Chairman Mitchell.
        Mr. Mitchell. Thank you.
        I want to thank all of you for appearing today. And I think
    you realize how seriously we take this. And we understand you
    are trying to work for this. It is very vital because many
    people's lives and quality of life are dependent on these
    records.
        So, again, thank you very much, and this concludes the
    hearing. It is adjourned.
        [Whereupon, at 11:57 a.m., the Subcommittee was adjourned.]

                                A P P E N D I X

                                  ----------

            Prepared Statement of Hon. Harry E. Mitchell, Chairman,
                  Subcommittee on Oversight and Investigations
        I would like to thank everyone for attending today's Oversight and
    Investigations Subcommittee hearing entitled, the Interagency Program
    Office: Examining the Progress of Electronic Health Record
    Interoperability Between VA and DoD. Thank you especially to our
    witnesses for testifying today.
        We are here today to examine the progress being made by the
    Department of Defense and Department of Veterans Affairs to achieve
    electronic health record interoperability. Currently, there is no
    single VA/DoD electronic record that captures all information needed
    for delivery of health care and benefits to servicemembers, veterans
    and their beneficiaries. As many of you know, on April 9, 2009,
    President Obama, along with Secretary of Veterans Affairs Eric Shinseki
    and Secretary of Defense Robert Gates, announced that the VA and DoD
    would create a Joint Lifetime Electronic Record that would contain
    information from the day individuals enter military service, through
    their careers, and for the remainder of their lives as veterans if they
    enter the VA system.
        Mandated by the National Defense Authorization Act of 2008, the
    Interagency Program Office was established to act as the ``single point
    of accountability'' for DoD/VA electronic health record
    interoperability. As the September 30 deadline for electronic health
    record interoperability approaches, it is imperative to ensure that
    both the DoD and VA are organized and working together to deliver a
    comprehensive system that will modernize and simplify record sharing
    between Departments.
        In 1982, under the VA and DoD Health Resources Sharing and
    Emergency Operations Act, both DoD and VA were first encouraged to find
    common ground to create a more efficient health care system that would
    be worthy of the sacrifices our men and women make every day. Since
    then, although they have made significant improvements in sharing
    patient record information, both the DoD and VA have yet to find the
    common ground to achieve full electronic health record
    interoperability. The GAO's report on the state of DoD and VA's health
    record sharing initiatives is not due until the end of July, but I'm
    grateful that they are here today to update us on the progress these
    two Departments have made in meeting the statute's requirements.
        As a growing number of men and women return from the battlefields
    in Iraq and Afghanistan with more complicated and more severe wounds,
    it is time to make their care and treatment easier. It is time for us
    to improve upon a system that will ensure the best and most complete
    care, efficient benefits delivery, and a seamless transition back into
    civilian life. Under the leadership of Director Rear Admiral Gregory
    Timberlake and Deputy Director Cliff Freeman of the Interagency Program
    Office, both here today, I am hopeful--I am expectant--that we will see
    headway toward the vision Congress and the President have established
    for a VA of the 21st century.

      Prepared Statement of Hon. David P. Roe, Ranking Republican Member,
                  Subcommittee on Oversight and Investigations
        Mr. Chairman, thank you for holding this hearing.
        The issue of Seamless Transition and the interoperability of the
    transfer of medical records between the Department of Defense and the
    Department of Veterans Affairs is one that Congress has been working on
    for a number of years. During the 109th Congress alone, the Committee
    on Veterans Affairs held a total of 10 hearings on the issue of
    Seamless Transition. Again, last Congress, this Subcommittee held a
    hearing on March 8, 2007 on Seamless Transition, on May 8, 2007 on VA/
    DoD Data Sharing, on October 24, 2007 on the status of sharing
    electronic medical records and on June 24, 2008 on VA and DoD
    Cooperation in Reintegrating the Guards and Reserves.
        Time and again, the issue of interoperability and data sharing of
    critical medical information between the DoD and the VA is discussed,
    studied and demo'ed and the degree of progress is dismally glacial.
    This is one of the reasons that section 1635(e) was included in the
    2008 National Defense Authorization Act.
        This section revealed a plan of action for the two departments to
    create a schedule and set a deadline of September 30, 2009, and issued
    requirements for (1) the establishment of the Interagency Program
    Office (IPO); (2) the establishment of the requirements for electronic
    health records (EHR) systems or capabilities, including coordination
    with the Office of the National Coordinator for Health Information
    Technology; (3) any acquisition and testing required in the
    implementation of electronic health record systems or capabilities that
    allow for full interoperability; and (4) the implementation of
    electronic health record systems or capabilities.
        I am interested in learning the progress that DoD and VA are making
    in moving forward with the interoperable transfer of medical data
    between the two departments. In the past, this information has been
    held in what several members have called ``independently stove-piped
    electronic medical records systems'' that had difficulty transferring
    data between the two departments. This issue is of great concern to me
    as well as other members of the Committee. I hope that measurable
    progress has been made toward better communication and cooperation
    between the two departments.
        The care of our Nation's servicemembers and veterans is of primary
    importance to everyone at this hearing today. They have served our
    country valiantly in the face of battle, and should not have to be
    worried about whether or not their health care providers have the tools
    and information they need to provide care that is timely, medically
    appropriate, and necessary.
        Mr. Chairman, I look forward to hearing from our witnesses today,
    and yield back the balance of my time.

               Prepared Statement of Valerie C. Melvin, Director,
                Information Management and Human Capital Issues,
                     U.S. Government Accountability Office
                           ELECTRONIC HEALTH RECORDS
         Program Office Improvements Needed to Strengthen Management of
              VA and DoD Efforts to Achieve Full Interoperability
                                 GAO Highlights
    Why GAO Did This Study
        For over a decade, the Department of Veterans Affairs (VA) and the
    Department of Defense (DoD) have been working on initiatives to share
    electronic health information. To expedite their efforts, Congress
    mandated in the National Defense Authorization Act for Fiscal Year 2008
    that VA and DoD establish a joint interagency program office to act as
    a single point of accountability in the development of electronic
    health records systems or capabilities that allow for full
    interoperability (generally, the ability of systems to exchange data)
    by September 30, 2009.
        In this statement, GAO summarizes findings from its upcoming
    report, focusing on progress in setting up the interagency program
    office and the departments' actions to achieve fully interoperable
    capabilities by September 30, 2009. To do so, GAO analyzed agency
    documentation on project status and conducted interviews with agency
    officials.
    What GAO Recommends
        GAO's draft report recommends that the Secretaries of Defense and
    Veterans Affairs emphasize the interagency program office's
    establishment of a project plan and integrated master schedule to guide
    their interoperability activities.
    What GAO Found
        VA and DoD have made progress in setting up the interagency program
    office; however, the office is not yet effectively positioned to be
    accountable for the departments' efforts to achieve fully interoperable
    electronic health record systems or capabilities. The departments have
    taken the important steps of completing personnel descriptions and
    hiring necessary staff to perform the office's functions, but key
    leadership positions (for the Director and Deputy Director) continue to
    be filled on an interim basis. In addition, the office has established
    a charter and begun to demonstrate responsibilities outlined within
    this document. Nonetheless, the office is not yet fulfilling key
    information technology management responsibilities in the areas of
    performance measurement, project planning, and scheduling--all of which
    are essential to establishing the office as a single point of
    accountability for the departments' interoperability efforts.
        VA and DoD continue to take steps toward achieving full
    interoperability by the September deadline. In this regard, the
    departments have achieved planned capabilities for three of six
    interoperability objectives (see table) that they identified to meet
    their data sharing needs--refine social history data, share physical
    exam data, and demonstrate initial network gateway operation. For the
    remaining three objectives--expand questionnaires and self assessment
    tools, expand DoD inpatient medical records system, and demonstrate
    initial document scanning--the departments have partially achieved
    planned capabilities, with additional work needed to fully meet
    clinicians' needs for health information.

              Description of VA and DoD Interoperability Objectives
    ------------------------------------------------------------------------
                   Objective                           Description
    ------------------------------------------------------------------------
    Refine social history data              DoD will begin sharing with VA
                                             social history data currently
                                             captured in the DoD electronic
                                             health record. Such data
                                             describe, for example,
                                             patients' involvement in
                                             hazardous activities and
                                             tobacco and alcohol use.
    ------------------------------------------------------------------------
    Share physical exam data                DoD will provide an initial
                                             capability to share with VA its
                                             electronic health record
                                             information that supports the
                                             physical exam process when a
                                             servicemember separates from
                                             active military duty.
    ------------------------------------------------------------------------
    Demonstrate initial network gateway     DoD and VA will demonstrate the
     operation                               operation of secure network
                                             gateways that provide expanded
                                             bandwidth to support
                                             information sharing between DoD
                                             and VA health care facilities.
    ------------------------------------------------------------------------
    Expand questionnaires and self          DoD will provide all periodic
     assessment tools                        health assessment data stored
                                             in its electronic health record
                                             to the VA such that
                                             questionnaire responses are
                                             viewable with the questions
                                             that elicited them.
    ------------------------------------------------------------------------
    Expand DoD inpatient medical records    DoD will expand its inpatient
     system                                  medical records system to at
                                             least one additional site in
                                             each military medical
                                             department (one Army, one Air
                                             Force, and one Navy for a total
                                             of three sites).
    ------------------------------------------------------------------------
    Demonstrate initial document scanning   DoD will demonstrate an initial
                                             capability for scanning
                                             servicemembers' medical
                                             documents into its electronic
                                             health record and sharing the
                                             documents electronically with
                                             the VA.
    ------------------------------------------------------------------------
    Source: GAO based on VA and DoD data.

        View GAO-09-895T or key components. For more information, contact
    Valerie Melvin at (202) 512-6304 or melvinv@gao.gov.

                                   __________
    Mr. Chairman and Members of the Subcommittee:

        I am pleased to be here today to discuss the Departments of
    Veterans Affairs' (VA) and Defense's (DoD) interagency program office
    and efforts toward advancing the use of health information technology
    to achieve interoperable electronic health records. As you know, VA and
    DoD have been working for over a decade on initiatives to share data
    between their health information systems; yet, while they have made
    progress in a number of areas, questions have persisted concerning when
    and to what extent the intended electronic sharing capabilities of the
    two departments will be fully achieved. To expedite their efforts, the
    National Defense Authorization Act for Fiscal Year 2008 \1\ included
    provisions directing VA and DoD to jointly develop and implement, by
    September 30, 2009, fully interoperable electronic health record
    systems or capabilities that are compliant with applicable Federal
    interoperability \2\ standards. It further established an interagency
    program office to be a single point of accountability for the
    departments' efforts.
    ---------------------------------------------------------------------------
        \1\ Pub. L. No. 110-181, Sec. 1635 (2008).
        \2\ Interoperability is the ability of two or more systems or
    components to exchange information and to use the information that has
    been exchanged. Further discussion of levels of interoperability is
    provided later in this testimony.
    ---------------------------------------------------------------------------
        Also, the act directed us to report semiannually on VA's and DoD's
    progress in implementing their electronic health record systems. In
    this regard, we have previously issued two reports (in July 2008 and
    January 2009). We plan to issue a third report near the end of this
    month--a draft of which is currently with the departments for their
    review and comments. At your request, my testimony today summarizes
    findings from this latest draft report, focusing on the departments'
    progress in setting up the interagency program office as a point of
    accountability for the implementation of interoperable electronic
    health records, and actions being taken to achieve these capabilities
    by September 30, 2009.
        In developing this testimony, we relied on our previous work
    supporting the draft report. We conducted our work from April 2009
    through July 2009, in the Washington, D.C. metropolitan area. All work
    on which this testimony is based was performed in accordance with
    generally accepted government auditing standards. Those standards
    require that we plan and perform the audit to obtain sufficient,
    appropriate evidence to provide a reasonable basis for our findings and
    conclusions based on our audit objectives. We believe that the evidence
    obtained provides a reasonable basis for our findings and conclusions
    based on our audit objectives.
    Background
        The use of information technology (IT) to electronically collect,
    store, retrieve, and transfer clinical, administrative, and financial
    health information has great potential to help improve the quality and
    efficiency of health care and is important to improving the performance
    of the U.S. health care system. Historically, patient health
    information has been scattered across paper records kept by many
    different caregivers in many different locations, making it difficult
    for a clinician to access all of a patient's health information at the
    time of care. Lacking access to these critical data, a clinician may be
    challenged to make the most informed decisions on treatment options,
    potentially putting the patient's health at greater risk. The use of
    electronic health records can help provide this access and improve
    clinical decisions.\3\
    ---------------------------------------------------------------------------
        \3\ An electronic health record is a collection of information
    about the health of an individual or the care provided, including
    patient demographics, progress notes, problems, medications, vital
    signs, past medical history, immunizations, laboratory data, and
    radiology reports.
    ---------------------------------------------------------------------------
        Key to making health care information electronically available is
    interoperability--that is, the ability to share data among health care
    providers. Interoperability enables different information systems or
    components to exchange information and to use the information that has
    been exchanged. This capability is important because it allows
    patients' electronic health information to move with them from provider
    to provider, regardless of where the information originated. If
    electronic health records conform to interoperability standards, they
    can be created, managed, and consulted by authorized clinicians and
    staff across more than one health care organization, thus providing
    patients and their caregivers the necessary information required for
    optimal care. In the health IT field, standards may govern areas
    ranging from technical issues, such as file types and interchange
    systems, to content issues, such as medical terminology. Unlike paper-
    based documents, electronic health records can also provide automatic
    alerts about a particular patient's health, or other advantages of
    automation.
        In prior reports, we have discussed the different levels of
    interoperability that agencies can achieve.\4\ At the highest level,
    electronic data are computable (that is, in a format that a computer
    can understand and act on to, for example, provide alerts to clinicians
    on drug allergies). At a lower level, electronic data are structured
    and viewable, but not computable. At still a lower level, electronic
    data are unstructured and viewable, but not computable. With
    unstructured electronic data, a user would have to find needed or
    relevant information by searching uncategorized data. Beyond these,
    paper records also can be considered interoperable (at the lowest
    level) because they allow data to be shared, read, and interpreted by
    human beings. According to VA and DoD officials, not all data require
    the same level of interoperability, nor is interoperability at the
    highest level achievable in all cases. For example, unstructured,
    viewable data may be sufficient for such narrative information as
    clinical notes.
    ---------------------------------------------------------------------------
        \4\ These levels were identified by the Center for Information
    Technology Leadership, which was chartered in 2002 as a research
    organization to help guide the health care community in making more
    informed strategic IT investment decisions. According to VA and DoD,
    the different levels of interoperability have been accepted for use by
    the Office of the National Coordinator for Health Information
    Technology.
    ---------------------------------------------------------------------------
    VA and DoD Are Required by Law to Establish an Interagency Program
            Office and Achieve Full Interoperability
        As previously noted, the National Defense Authorization Act for
    Fiscal Year 2008 \5\ called for VA and DoD to jointly develop and
    implement fully interoperable electronic health record systems or
    capabilities by September 30, 2009, and established an interagency
    program office to be accountable for the departments' efforts in this
    regard. The departments have been working to set up this office since
    April 2008. In January 2009, the office completed its charter,
    articulating, among other things, its mission and functions with
    respect to attaining interoperable electronic health data. The charter
    further identified the office's responsibilities in carrying out its
    mission, in areas such as oversight and management, stakeholder
    communication, and decision-making.
    ---------------------------------------------------------------------------
        \5\ Pub. L. No. 110-181, Sec. 1635 (2008).
    ---------------------------------------------------------------------------
        Further, to help meet the intent of the act, the Interagency
    Clinical Informatics Board,\6\ made up of senior clinical leaders from
    both departments who represent the user community, began establishing
    priorities for health data sharing between VA and DoD. The board
    subsequently identified six interoperability objectives for meeting the
    departments' data sharing needs, as reflected in table 1.
    ---------------------------------------------------------------------------
        \6\ This board was originally named the Joint Clinical Information
    Board.

         Table 1: Description of VA and DoD Interoperability Objectives
    ------------------------------------------------------------------------
                                                              Associated
               Objective                 Description       interoperability
                                                                 level
    ------------------------------------------------------------------------
    Refine social history data       DoD will begin       Structured,
                                      sharing with VA      viewable
                                      the social history   electronic data
                                      data that is
                                      currently captured
                                      in the DoD
                                      electronic health
                                      record. Such data
                                      describe, for
                                      example, patients'
                                      involvement in
                                      hazardous
                                      activities and
                                      tobacco and
                                      alcohol use.
    ------------------------------------------------------------------------
    Share physical exam data         DoD will provide an  Structured,
                                      initial capability   viewable
                                      to share with VA     electronic data
                                      its electronic
                                      health record
                                      information that
                                      supports the
                                      physical exam
                                      process when a
                                      servicemember
                                      separates from
                                      active military
                                      duty.
    ------------------------------------------------------------------------
    Demonstrate initial network      VA and DoD will      There is no
     gateway operation                demonstrate the      interoperability
                                      operation of the     level associated
                                      secure network       with this
                                      gateways a to        objective.
                                      support joint DoD-
                                      VA health
                                      information
                                      sharing.
    ------------------------------------------------------------------------
    Expand questionnaires and self   DoD will provide     Structured,
     assessment tools                 all periodic         viewable
                                      health assessment    electronic data
                                      data stored in its
                                      electronic health
                                      record to the VA
                                      in such a fashion
                                      that questionnaire
                                      responses are
                                      viewable with the
                                      questions that
                                      elicited them.
    ------------------------------------------------------------------------
    Expand DoD inpatient medical     DoD will expand its  Unstructured,
     records system                   inpatient medical    viewable
                                      records system       electronic data
                                      (CliniComp's
                                      Essentris b
                                      product suite),
                                      also called the
                                      clinical
                                      information
                                      system, to at
                                      least one
                                      additional site in
                                      each military
                                      medical department
                                      (one Army, one Air
                                      Force, and one
                                      Navy for a total
                                      of three sites).
    ------------------------------------------------------------------------
    Demonstrate initial document     DoD will             Unstructured,
     scanning                         demonstrate an       viewable
                                      initial capability   electronic data
                                      for scanning
                                      servicemembers'
                                      medical documents
                                      into its
                                      electronic health
                                      record and sharing
                                      the documents
                                      electronically
                                      with the VA.
    ------------------------------------------------------------------------
    Source: GAO Analysis of VA and DoD data.

    a Secure network gateways provide expanded bandwidth to support
      information sharing and ensure secure and reliable data communications
      between VA and DoD health care facilities.
    b Essentris is a commercial health information system customized to
      support inpatient treatment at military medical facilities.

        According to the former acting director of the interagency program
    office, VA and DoD consider achievement of these six objectives, in
    conjunction with data sharing capabilities previously achieved (e.g.,
    the Federal Health Information Exchange (FHIE),\7\ the Bidirectional
    Health Information Exchange (BHIE),\8\ and the interface between DoD's
    Clinical Data Repository (CDR) and VA's Health Data Repository (HDR),
    known as CHDR),\9\ to be sufficient to satisfy the requirement for full
    interoperability by September 2009.
    ---------------------------------------------------------------------------
        \7\ FHIE, enhanced through its completion in 2004, provides a one-
    way transfer of data that enables DoD to electronically transfer
    servicemembers' electronic health information to VA when the members
    leave active duty.
        \8\ BHIE, established in 2004, was aimed at allowing clinicians at
    both departments viewable access to records on shared patients--that
    is, those who receive care from both departments. For example, veterans
    may receive outpatient care from VA clinicians and be hospitalized at a
    military treatment facility. To create BHIE, the departments drew on
    the architecture and framework of the information transfer system
    established by the FHIE project. Unlike FHIE, BHIE is a two-way
    interface that allows clinicians in both departments to view, in real
    time, limited health data (in text form) from the departments' existing
    health information systems. The interface also allows DoD sites to see
    previously inaccessible data at other DoD sites.
        \9\ Combining the names of the two repositories, the Clinical Data
    Repository/Health Data Repository (CHDR) interface, pronounced
    ``cheddar,'' implemented in September 2006, linked the department's
    separate repositories of standardized data to enable a two-way exchange
    of computable health information. These repositories are a part of the
    modernized health information systems that the departments have been
    developing--DoD's AHLTA and VA's HealtheVet.
    ---------------------------------------------------------------------------
    DoD/VA Interagency Program Office Has Made Progress in Becoming
            Operational, but Is Not Fully Functioning as a Single Point of
            Accountability
        As our report later this month will note, VA and DoD have taken
    important steps to make the interagency program office operational.
    However, more work is needed to solidify its leadership and management
    capabilities if the office is to effectively function as a single point
    of accountability for achieving interoperable electronic health data.
        In particular, the departments have completed personnel
    descriptions and recruited and hired staff for government positions and
    obtained necessary contractor staff to perform the office's functions.
    As of early July, the departments reported that they had selected staff
    members for 10 of 14 government positions and that recruitment efforts
    were underway to fill the remaining 4 positions by late September 2009.
    Further, all of the 16 designated contractor positions had been filled.
        Nonetheless, VA and DoD continue to fill the office's key
    leadership positions--that of director and deputy director--on an
    interim basis. To their credit, the departments have taken steps to
    hire a full-time permanent director and a deputy director to lead the
    office. Earlier this month, DoD selected a candidate for the director
    position, VA concurred with the selection, and the candidate's
    application was sent to the Office of Personnel Management for
    approval. In the meantime, the departments requested and received an
    extension of the interim director's appointment until September 30,
    2009, or until a permanent official is hired. Further, as of late June,
    interagency program officials stated that actions were underway to fill
    the deputy director position and that VA was interviewing candidates
    for this position. The interim director stated that the departments
    anticipate making a selection for the deputy director position by the
    end of this month.
        Beyond the need to appoint these key permanent leaders, the office
    needs to fulfill a number of responsibilities identified in its January
    2009 charter that are critical to its effectiveness. To this end, the
    office has taken several steps. For example, it submitted its first
    annual report to Congress that summarized the departments' efforts
    toward achieving full interoperability and the status of key activities
    completed to set up the office. Further, the office developed 11
    standard operating procedures in areas such as program management
    oversight, strategic communications, and process improvement.
        However, the office has not yet carried out other key
    responsibilities identified in its charter that are fundamental to
    effective IT program management and that would be essential to
    effectively serving as the single point of accountability. For example,
    the office has not yet established results-oriented (i.e., objective,
    quantifiable, and measurable) goals and performance measures for all
    six of the interoperability objectives discussed previously.
        In particular, early development and use of results-oriented
    metrics is an important IT program management activity. Performance
    goals and measures, if effectively implemented, can provide a
    meaningful baseline against which to measure the progress of a program
    and the outcomes associated with its implementation. VA and DoD agreed
    with our previous recommendation calling for the development of such
    goals and measures.\10\ Further, the interagency program office charter
    identified the development of metrics to monitor the departments'
    performance against interoperability objectives as a responsibility of
    the office. Nevertheless, the office has developed performance goals
    for only one of the six identified interoperability objectives--the
    expansion of DoD's medical records system (Essentris) to share
    inpatient discharge summaries with VA. Department officials have stated
    that results-oriented goals and measures for the other five
    interoperability objectives will be included in the next version of the
    DoD/VA Joint Executive Council Joint Strategic Plan, expected to be
    completed by December 2009. To the extent that the departments
    establish and effectively use results-oriented goals and measures for
    their interoperability objectives, they will be better positioned to
    gauge their progress toward achieving fully interoperable capabilities
    and improving veterans' health care.
    ---------------------------------------------------------------------------
        \10\ GAO, Electronic Health Records: DoD's and VA's Sharing of
    Information Could Benefit from Improved Management, GAO-09-268
    (Washington, D.C.: Jan. 28, 2009).
    ---------------------------------------------------------------------------
        Further, development of an integrated master schedule is a key IT
    program management activity, especially given the magnitude and
    complexity of the departments' efforts to achieve full
    interoperability. According to DoD guidance,\11\ an integrated master
    schedule should identify detailed project tasks and the associated
    start, completion, and interim milestone dates; resource needs; and
    relationships (e.g., sequence and dependencies) between tasks.
    ---------------------------------------------------------------------------
        \11\ DoD Integrated Master Plan and Integrated Master Schedule
    Preparation and Use Guide, Version 0.9, October 21, 2005.
    ---------------------------------------------------------------------------
        While the program office has begun to develop an integrated master
    schedule as required by its charter, the current version does not
    include the attributes of an effective schedule. For example, the
    schedule included limited information--only the name of the objective
    and a completion date of September 30, 2009--for three of the six
    interoperability objectives (i.e., refine social history data, share
    physical exam data, and expand questionnaires and self assessment
    tools). The schedule did not include information on tasks to be
    performed to meet the objectives, nor start dates, resource needs, or
    relationships between tasks for any of the six objectives. Without a
    complete and detailed integrated master schedule, the departments are
    devoid of critical information that could be vital to their ability to
    appropriately respond to project needs and guide project efforts.
        Similarly, development of a project plan is an important activity
    for IT program management. Industry best practices and IT program
    management principles stress the importance of sound planning for any
    project. Inherent in such planning is the development and use of a
    project management plan that describes, among other things, the
    project's scope, resource needs, and key milestones. The interagency
    program office charter identified the need to develop a project plan
    but, as of late June, the office had not yet done so. As we have noted
    in our prior work,\12\ without a project plan, the departments lack a
    key tool that could be used to guide their efforts in achieving full
    interoperability.
    ---------------------------------------------------------------------------
        \12\ GAO, Computer-Based Patient Records: VA and DoD Efforts to
    Exchange Health Data Could Benefit from Improved Planning and Project
    Management, GAO-04-687 (Washington, D.C.: June 7, 2004).
    ---------------------------------------------------------------------------
        In discussing these activities, the interagency program office's
    interim director and former acting director cited three reasons for why
    performance measurement, scheduling, and project planning
    responsibilities had not been accomplished. First, they stated that
    because it has taken longer than anticipated to hire staff, the office
    has not been able to perform all of its responsibilities. Second, the
    office's interim leadership and staff have focused their efforts on
    providing interested parties (e.g., Federal agencies and military
    organizations) with briefings, presentations, and status information on
    activities the office is undertaking to achieve interoperability, in
    addition to participating in efforts to develop a strategy for
    implementation of the Virtual Lifetime Electronic Record, which the
    President announced in April 2009. Finally, according to the officials,
    the office waited until June to begin the process of developing
    performance metrics so that it could do so in conjunction with the
    departments' annual update to the Joint Strategic Plan that is
    scheduled for completion in December 2009.
        In the absence of sufficient metrics to monitor progress, a
    complete integrated master schedule, and a project plan, the
    interagency program office's ability to effectively provide oversight
    and management, including meaningful reporting on the progress and
    delivery of interoperable capabilities, is jeopardized. As importantly,
    the absence of these critical management tools calls into question the
    effectiveness of this office in functioning as the single point of
    accountability for achieving full interoperability, and the
    departments' overall success in meeting this goal.
    VA and DoD Are Taking Steps To Meet Their Objectives, but Activities To
            Meet Clinicians' Needs Are Expected To Remain After the
            Deadline for Achieving Full Interoperability
        VA and DoD continue to take steps toward achieving full
    interoperability by September 30, 2009. In this regard, the departments
    have achieved planned capabilities for three of the objectives--refine
    social history data, share physical exam data, and demonstrate initial
    network gateway operation. Specifically, with regard to these
    objectives, the departments have accomplished the following
    capabilities:

          The sharing of viewable social history data captured in
    DoD's electronic health record, thus providing VA with additional
    clinical information on shared patients that clinicians could not
    previously view. These data describe, for example, patients'
    involvement in hazardous activities and tobacco and alcohol use.
          The sharing of physical exam data, allowing VA to view
    DoD's medical exam data through the BHIE interface, which supports the
    physical exam process when a servicemember separates from active
    military duty. VA clinicians are able to view outpatient treatment
    records, pre- and post-deployment health assessments, and post-
    deployment health reassessments.
          The operation of secure network gateways to support
    health information sharing between the departments, thus facilitating
    future growth in data sharing. As of early July, the departments
    reported that five network gateways were operational and that data
    migration to two of the operational gateways had begun.\13\ The
    departments believed these five gateways satisfy the intent of the
    objective and will provide sufficient capacity to support health
    information sharing between VA and DoD as of September 2009.
    ---------------------------------------------------------------------------
        \13\ The five operational gateways are located in Dallas, Texas;
    Reston, Virginia; Kansas City, Missouri; North Chicago, Illinois; and
    Santa Clara, California.

        For the remaining three objectives--expand questionnaires and self
    assessment tools, expand Essentris in DoD, and demonstrate initial
    document scanning--the departments have partially achieved planned
    capabilities, with additional work needed to fully meet clinicians'
    needs.
        Specifically, for the objective to expand questionnaires and self
    assessment tools, the departments intend to provide all periodic health
    assessment data stored in the DoD electronic health record to VA in a
    format that associates questions with responses. Health assessment data
    is collected from two sources: questionnaires administered at military
    treatment facilities and a DoD health assessment reporting tool that
    enables patients to answer questions about their health upon entry into
    the military. Questions relate to a wide range of personal health
    information, such as dietary habits, physical exercise, and tobacco and
    alcohol use. While the departments have established the capability for
    VA to view questions and answers from the questionnaires collected by
    DoD at military treatment facilities, they have not yet established the
    additional capability for VA to view information from DoD's health
    assessment reporting tool. Department officials stated that they intend
    to provide this capability by September 2009.
        However, the other two objectives--expand Essentris in DoD and
    demonstrate initial document scanning--are expected to require
    substantial additional work beyond September to meet clinicians' needs.
    By September 30, DoD intends to expand its Essentris system to at least
    one additional site for each military medical service and to increase
    the percentage of inpatient discharge summaries that it shares
    electronically with VA to 70 percent. According to the interim director
    of the interagency program office, as of late June 2009, the
    departments had expanded the system to two Army sites (but not yet to
    an Air Force or Navy site) and were sharing 58 percent of inpatient
    discharge summaries. The interim director stated that the departments
    expect to share 70 percent of inpatient discharge summaries and expand
    the system to an Air Force and a Navy site by the September deadline.
    Nevertheless, the official added that to better meet clinicians' needs,
    DoD will need to further expand the inpatient medical records system.
    In this regard, the department has established a future goal of making
    the inpatient system operational for 92 percent of DoD's inpatient beds
    by September 2010.
        The departments also expect to demonstrate an initial capability to
    scan servicemembers' medical documents into the DoD electronic health
    record and share the documents electronically with VA by September
    2009. According to the program office interim director, the departments
    were in the process of setting up an interagency test environment to
    test the initial capability to query medical documents associated with
    specific patients as of late June 2009. He stated that the departments
    expect to begin user testing at up to nine sites by September 2009.
    According to this official, these activities are expected to
    demonstrate an initial document scanning capability. However, after
    September 2009, the departments anticipate needing to perform
    additional work to expand their initial document scanning capability
    (e.g., completion of user testing and establishment of the scanning
    capability at all DoD sites).
        In conclusion, VA and DoD have continued to increase electronic
    health information interoperability, and have taken steps to meet the
    six objectives that they identified as necessary to achieve full
    interoperability by September 30, 2009. However, for two of the six
    interoperability objectives, the departments subsequently plan to
    perform significant additional activities that are necessary to meet
    clinicians' needs. Further, the departments' lack of progress in
    establishing fundamental IT management capabilities that are the
    specific responsibilities of the interagency program office contributes
    to uncertainty about the extent to which they will achieve full
    interoperability by the deadline. Although the departments have
    generally made progress toward making the program office operational,
    the absence of performance metrics, and a complete integrated master
    schedule and a project plan, limits the office's ability to effectively
    manage and provide meaningful progress reporting on the delivery of
    interoperable capabilities that are deemed critical to improving the
    quality of health care for our Nation's veterans.
        To better improve the management of VA's and DoD's efforts to
    achieve fully interoperable electronic health record systems, our draft
    report recommends that the Secretaries of Defense and Veterans Affairs
    emphasize the interagency program office's establishment of a project
    plan and a complete and detailed integrated master schedule.
        Mr. Chairman, this concludes my prepared statement. I would be
    pleased to respond to any questions that you or other Members of the
    Subcommittee may have.
    Contact and Acknowledgments
        If you have any questions on matters discussed in this testimony,
    please contact Valerie C. Melvin, Director, Information Management and
    Human Capital Issues, at (202) 512-6304 or melvinv@gao.gov. Other
    individuals who made key contributions to this testimony are Mark Bird,
    Assistant Director; Rebecca Eyler; Michael Redfern; J. Michael Resser;
    Kelly Shaw; Eric Trout; and Merry Woo.

        Prepared Statement of Rear Admiral Gregory A. Timberlake, SHCE,
             USN, Acting Director, U.S. Department of Defense/U.S.
           Department of Veterans Affairs Interagency Program Office
                                  INTRODUCTION
        Chairman Mitchell and distinguished Members of the Committee, thank
    you for the opportunity to discuss the role of the DoD/VA Interagency
    Program Office (IPO) in the ongoing data-sharing activities of the
    Department of Defense (DoD) and the Department of Veterans Affairs
    (VA). Collaboration between the two Departments on information
    technology issues has grown exponentially in recent years, enabling the
    Departments to explore ways in which they may benefit jointly from
    data-sharing innovations in the private sector, as well as helping to
    foster bold new government-driven information-sharing capabilities,
    like the development of a ``Virtual Lifetime Electronic Record'' (VLER)
    for servicemembers and veterans. Working on behalf of the DoD/VA Joint
    Executive Council, the IPO plays a key role in facilitating these
    efforts, and in providing oversight of various data-sharing initiatives
    between the Departments. In recent months, the IPO has been focused on
    two central areas: (1) facilitating the efforts of the two Departments
    to achieve full interoperability of their electronic health records by
    September of this year, as defined by the VA and DoD clinicians that
    rely on this data to treat patients, and (2) working with the
    Departments to develop an effective governance and management model for
    VLER. These two areas will be the focus of my testimony today.
                                 IPO BACKGROUND
        In April 2008, DoD and VA formed the ``DoD/VA Interagency Program
    Office'' (IPO) in response to section 1635 of the National Defense
    Authorization Act for fiscal year 2008, which required the creation of
    an entity to serve as a single point of accountability for the rapid
    development and implementation of electronic health record (EHR)
    systems or capabilities between the Departments. Section 1635 further
    mandated that full interoperability of personal health care information
    between the DoD and VA be achieved by September 2009. Since its
    inception, the IPO has worked diligently to achieve this mandate,
    providing the Departments with reliable, effective management oversight
    of potential risks involving the identification, coordination, and
    review of information sharing requirements, and informing stakeholders
    about the impact these processes may have on DoD/VA information sharing
    progress.
        The responsibility for developing requirements and executing
    technical information technology solutions remains with the respective
    DoD and VA organizations, using the Departments' established statutory
    and regulatory processes for acquisition, funding, management control,
    information assurance, and other execution actions. The differences
    between the Departments in these areas can pose challenges to effective
    collaboration on joint DoD/VA information sharing projects. In order to
    overcome such challenges, the IPO has worked closely with the existing
    leadership of the Joint Executive Council to provide focused assistance
    and oversight to ensure the Departments achieve their goals. Our work
    includes facilitating discussions between DoD and VA functional
    business communities on areas such as supporting the definition of DoD/
    VA data-sharing requirements, promoting effective synchronization of
    DoD/VA schedules for the technical execution of joint data-sharing
    initiatives, assisting in the coordination of funding considerations,
    and assisting in obtaining the input and concurrence of stakeholders.
        The nature of the IPO's work requires a professional staff that
    possesses a wide scope of varied, but complementary, skills and
    knowledge. The initial staff of the IPO consisted of an Acting Director
    from the DoD, an Acting Deputy Director from the VA, and four military
    personnel that were briefly detailed to the IPO as a final assignment
    before retirement. In the early stages of the IPO's formal existence,
    this small staff focused most of their energies on acquiring office
    space and equipment, determining permanent staffing requirements and an
    office governance structure, advertising for and recruiting permanent
    staff, drafting the IPO charter, writing the first IPO report to
    Congress, and setting in place procedures to gather information that
    would enable the IPO to provide informed oversight of the
    interoperability efforts of the two Departments.
        The staffing model that the IPO developed consists of two Senior
    Executive Service positions, fourteen DoD and VA civilian government
    positions, and a small contingent of contracted employees (up to
    sixteen). Filling these positions with the most highly qualified
    personnel possible has been challenging and time-consuming, because all
    of the government employees had to go through an extensive formal
    hiring process. This process includes the development of detailed
    position descriptions; advertising the positions on USA Jobs;
    processing applications based on relevant knowledge, skills, and
    abilities; selection of candidates for interviews; formal job offers;
    and security clearance vetting. The hiring process was the same for all
    job applicants regardless of whether the applicant was already a
    Federal employee or was hired from the private sector. Approximately
    half of the candidates that were selected came from the private sector;
    the remaining candidates were already Federal employees, but not all of
    them were executive branch Federal employees.
        The hiring process is now nearing completion. The current status of
    our staffing posture is as follows: Ten of the fourteen government
    positions are now hired and on staff. This includes the Chief of Staff,
    two Audit Analysts (DoD & VA), one Senior Program Analyst for Health
    (DoD), a Configuration Management expert (VA), a Public Affairs
    Specialist (DoD), a Budget Analyst (VA), a Portfolio Analyst (DoD), and
    two Senior Financial Program Analysts (DoD & VA). In addition, three
    civilian government positions have accepted job offers, but are not yet
    on staff. These include a Senior Program Analyst for Benefits (DoD), a
    Senior Program Analyst for Health (VA), and a Senior Management Analyst
    (VA). The only position that remains unfilled is a Senior Program
    Analyst for Benefits (VA). The IPO is currently evaluating candidates
    for this position. The anticipated target date for filling this
    position is late summer of this year.
        Advertising for the Senior Executive Service (SES) Director
    position closed on March 17, 2009. The SES screening board convened on
    April 16, 2009, to rank the candidates and select those to be
    interviewed. The process for selection is on-going.
        The SES Deputy Director's position announcement closed April 17,
    2009. Initial interviews have occurred, with additional interviews of
    the top one or two candidates to follow. After a selection is made, the
    candidate will be referred to DoD for concurrence. Upon concurrence
    from DoD, a formal offer will be made, contingent on a security
    background check. The anticipated start date for the new Deputy
    Director is late summer 2009.
                    HEALTH DATA SHARING AND INTEROPERABILITY
        The Departments began laying the foundation for interoperability in
    2001, when the first patient health information was transferred
    electronically from DoD to VA using the Federal Health Information
    Exchange (FHIE). Since that time, both Departments have continued to
    expand the types of information that is shared, as well as the manner
    in which information is shared. By leveraging the prior accomplishments
    of VA and DoD, the IPO and the Departments have been successful in
    formulating a plan to achieve full interoperability for the provision
    of clinical care by the September 2009 target date. This plan centers
    on meeting the data-sharing requirements of treating clinicians in the
    two Departments as defined by the DoD/VA Interagency Clinical
    Informatics Board (ICIB).
        From an early point in the planning process, the IPO and the
    Departments agreed to turn to the ICIB to assist in the prioritization
    of DoD/VA health data interoperability initiatives. The ICIB is an
    organization comprised of clinicians from both DoD and VA. The Deputy
    Assistant Secretary of Defense for Clinical and Program Policy and the
    Chief Patient Care Services Officer, Veterans Health Administration,
    serve as its lead functional proponents. Through the ICIB, we enabled
    the clinical community to define the items that must be shared by
    September 2009 in order to achieve full interoperability. Once the ICIB
    identified and prioritized its needs for electronic data-sharing, their
    recommendations were forwarded to the Health Executive Committee (HEC)
    for review and approval. Upon approval by the HEC, the list of
    priorities was handed off to requirements and definition teams, and
    then to our information technology teams to develop applications and
    tools to put them into operation.
        Detailed information about the Departments' ongoing data-sharing
    initiatives appears in the prepared testimony of Mr. Charles ``Chuck''
    Campbell, Chief Information Officer, Military Health System (MHS) and
    Mr. Roger Baker, VA Assistant Secretary for Information and Technology.
    As a general overview, however, VA and DoD have continued to improve
    upon the successes of existing data exchange initiatives like the
    Federal Health Information Exchange (FIDE) and the Bidirectional Health
    Information Exchange (BHIE), and have expanded the type of data that is
    available through the Clinical Data Repository/Health Data Repository
    (CHDR interface). To add further capability, new pilot programs such as
    the BHIE Imaging Pilot have been developed. This pilot is now deployed
    and operational at several major military and VA medical centers across
    the country.
        While much progress has been made toward our current
    interoperability goals, some challenges still remain. The key
    challenges include the following:

          Developing, adopting, and maturing standards at the
    national level to ensure efficient operational use.
          Updating capabilities, systems, infrastructure, and
    technology consistent with emerging standards.
          Identifying and prioritizing information requirements for
    sequential upgrade to new technologies and common services, as defined
    by the business process owners and the functional community.

        In addition to this list of challenges, the Departments must
    continually work together to overcome difficulties created by different
    acquisition and funding cycles, different contracting processes, and
    differences in information assurance certification processes. The
    Departments and the IPO continue to engage in collaborative efforts to
    ensure that any impediment that may arise from these differences is
    resolved in an efficient manner. In spite of these challenges, the IPO
    and the two Departments are on track to achieve full interoperability
    for the provision of clinical care by September 30, 2009, as defined by
    the Interagency Clinical Informatics Board.
                    THE VIRTUAL LIFETIME ELECTRONIC RECORD:
                 THE VISION AND THE BROAD CONCEPTUAL CHALLENGES
        On April 9, 2009, the President, along with Secretary Gates and
    Secretary Shinseki, announced that DoD and VA have taken the first step
    in creating a joint Virtual Lifetime Electronic Record (VLER).
    President Obama pointed out the largest challenge that the two
    Departments face in their continuing efforts to modernize their
    electronic health and benefits records systems, declaring that ``there
    is no comprehensive system in place that allows for a streamlined
    transition of health care records between DoD and the VA.'' Creating
    such a capability would mark a departure from data-sharing efforts in
    the past, which have centered on developing an ever-proliferating array
    of information-sharing programs that allow one Department to access
    patient data captured in the electronic health record system of the
    other Department. While this strategy has allowed DoD and VA to share
    unprecedented amounts of patient health care data, the adoption of new
    technologies can provide even more efficiencies in the collection,
    retrieval, and use of patient health care data across the Departments.
    Recognizing this, the President directed the two Departments to ``work
    together to define and build a seamless system of integration with a
    simple goal: When a member of the Armed Forces separates from the
    military, he or she will no longer have to walk paperwork from a DoD
    duty station to a local VA health center; their electronic records will
    transition along with them and remain with them forever.'' These
    activities will be carried out in coordination with the health IT
    implementation going on nationwide and headed by the Department of
    Health and Human Services.
        In a press release that was issued shortly after the President's
    speech, the White House highlighted the importance of creating a
    comprehensive virtual lifetime electronic records capability between
    DoD and VA, and noted some of the advantages that would likely result
    from the establishment of a VLER: ``Access to electronic records is
    essential to modern health care delivery and the paperless
    administration of benefits. It provides a framework to ensure that all
    health care providers have all the information they need to deliver
    high-quality health care while reducing medical errors. The creation of
    this joint Virtual Lifetime Electronic Record by the two organizations
    would take the next leap to delivering seamless, high-quality care, and
    serve as a model for the Nation.''
        As the White House pointed out, the potential benefits of a VLER
    are indeed monumental, but so is the effort required in order to plan,
    create, and implement a VLER. This effort represents one of the largest
    projects that any two Federal Departments have made in recent years,
    and there are a number of challenges that must be overcome to achieve
    the President's vision. To begin, new IT conceptual frameworks must be
    established to provide a health and benefits data-sharing architecture
    to which both Departments can connect their electronic records systems.
    To date, discussions between the Departments have been focused on
    leveraging a common services architecture framework to support
    modernized tools and technologies on both sides.
        In addition to the over-arching conceptual issues on the technical
    side, the Departments must establish an effective governance model and
    collaborative strategy for the VLER. Each Department has unique
    processes for funding, management, and oversight for information
    technology projects. These processes must be brought into alignment in
    key areas in order for successful planning and development to occur on
    the VLER initiative.
        The IPO also plays an active role in efforts to reach inter-
    Departmental consensus on broad technical requirements issues. Progress
    is being made on the Departments' efforts to agree to use a nationally
    recognized set of uniform and open standards for information exchange,
    such as those being implemented by the Department of Health and Human
    Services' Nationwide Health Information Network. This approach will
    enable DoD and VA to create an architectural framework that is capable
    of sharing electronic health data from both the private sector and the
    government. Ultimately, such an information-sharing architecture may
    serve as a model for national electronic records data sharing.
                                   CONCLUSION
        The IPO and the Departments are engaged in many efforts to ensure
    that full interoperability for the provision of clinical care is
    achieved by September of this year. We recognize that interoperability
    does not have a discrete end point, as technologies and standards
    continue to evolve. Our efforts in the future will continue to build
    upon our past successes, allowing the Departments' to maintain their
    standard of providing the highest quality care for our servicemembers,
    veterans and their beneficiaries.
        That future is beginning to come into focus as we make progress on
    joint efforts to plan the Virtual Lifetime Electronic Record. Creating
    and implementing the VLER will require an unprecedented amount of
    effort, coordination, and interagency cooperation. The IPO is committed
    to this work, and looks forward to continuing to facilitate the efforts
    of the Departments on the VLER. When operational, the VLER will provide
    our servicemembers, veterans, and service providers with the health and
    benefits data they need, when and where they need it, thereby
    ultimately improving the quality of both health care and benefits
    services.
        Thank you for the opportunity to address the Committee, and to
    provide you with an update on the important work that we are doing to
    advance electronic data-sharing between the DoD and VA. I look forward
    to keeping you apprised of our progress toward our shared goal of
    improving the quality of services for our servicemembers, veterans and
    their families.

            Prepared Statement of Mary Ann Rockey, Program Executive
            Officer/Deputy Chief Information Officer (Acquisition),
               Military Health System, U.S. Department of Defense
                                  INTRODUCTION
        Chairman Mitchell, Ranking Member Roe, and Members of this
    distinguished Committee, thank you for the opportunity to discuss with
    you the progress that is being made toward creating an interoperable
    electronic health record (EHR) for the provision of clinical care
    between the Department of Defense (DoD) and Department of Veterans
    Affairs (VA).
        Great strides forward have been made in electronic data sharing
    between the Departments during the past few years. The Departments
    currently experience a level of interoperability unsurpassed by other
    health care delivery partners. This shared information supports the
    delivery of high-quality health care and the administration of benefits
    to our Nation's servicemembers and Veterans. The EHR interoperability
    achieved by the Departments is a showcase and a precursor for U.S.
    electronic health data sharing and interoperability initiatives such as
    the Nationwide Health Information Network (NHIN). This network of
    networks is being developed to provide a secure, nationwide,
    interoperable health information infrastructure that will connect
    providers, consumers, and others involved in supporting health and
    health care. Like our DoD/VA sharing solutions, the NHIN will enable
    health information to follow the patient, ensuring it is available for
    clinical decision-making, and supporting appropriate use of health care
    information beyond direct patient care.
        The Departments are committed to evolving and expanding the
    appropriate sharing of health information to enhance care delivery and
    continuity of care for our patients. Efforts are underway to deliver
    full interoperability, as defined by DoD and VA clinicians who rely on
    data to treat patients, for the provision of clinical care by September
    2009, and to provide expanded interoperability capabilities beyond
    September 2009. As with any large information technology initiative,
    the Departments have met and resolved challenges and will continue to
    do so in the future.
        Today, I will discuss our joint efforts, highlighting the level of
    data sharing achieved through the data sharing solutions that form the
    foundation for EHR interoperability.
                       OVERVIEW--ELECTRONIC DATA SHARING
        DoD and VA began laying the foundation for interoperability in 2001
    when our Departments first shared health care information
    electronically. Since that time, we have enhanced and expanded the
    types of information we share, as well as the ways in which we share;
    created increased organizational transparency; and formed oversight and
    governing bodies to ensure our sharing efforts progress at a pace
    meeting or exceeding the needs and expectations of our stakeholders.
        The foundation of current and future health care information
    sharing includes data sharing initiatives that have enhanced continuity
    of care for separated servicemembers and shared patients; enabled our
    providers to view health care information originating in the other
    Department's EHR; and alerted providers to the potential for severe
    allergic reactions or drug interactions before an electronic
    prescription was issued.
        Continuity of Care for Separated Servicemembers (Potential VA
    Patients). Since 2001, DoD has transferred electronic health
    information on separated servicemembers to a jointly developed data
    repository known as the Federal Health Information Exchange (FHIE). VA
    providers and benefits specialists access the data in FHIE daily for
    use in the delivery of health care and resolution of claims.
        As of May 2009, DoD has transferred health information for over 4.8
    million patients to the FHIE data repository. Of these 4.8 million
    patients, approximately 3.3 million patients have presented to VA for
    care, treatment, or claim determination. The amount of data available
    to VA continues to grow as health information on recently separated
    servicemembers is extracted and transferred to VA. Transfer of data to
    VA is executed in a manner that is compliant with Health Insurance
    Portability and Accountability Act (HIPAA) privacy regulations.
        The transferred data includes: inpatient and outpatient laboratory
    results and radiology reports; outpatient pharmacy data from military
    treatment facilities (MTFs), retail network pharmacies, and DoD mail-
    order pharmacy; allergy information; discharge summaries; admission,
    disposition, and transfer information; consultation reports; standard
    ambulatory data record information such as diagnostic codes, primary
    care physician, treating physician; patient demographic information;
    and Pre/Post-Deployment Health Assessment (PPDHA) and Post-Deployment
    Health Reassessment (PDHRA) forms. As of May 2009, over 2.5 million
    PPDHA and PDHRA forms on more than 1.0 million individuals have been
    sent from DoD to VA.
        DoD also transfers data to FHIE for VA patients treated in DoD
    facilities under local sharing agreements, making that data accessible
    to VA providers. As of May 2009, over 4 million cumulative patient
    messages containing laboratory, radiology, pharmacy, and consult
    information have been transmitted on VA patients treated in DoD
    facilities.
        Continuity of Care for Shared Patients. For shared patients being
    treated by both DoD and VA, the Departments continue to use the
    Bidirectional Health Information Exchange (BHIE) which enables real-
    time bidirectional sharing of allergy information; outpatient pharmacy
    data; demographic data; inpatient and outpatient laboratory results and
    radiology reports; ambulatory encounters/clinical notes; procedures;
    vital sign data; patient histories; questionnaires; and theater
    clinical data including inpatient notes, outpatient encounters, and
    ancillary clinical data, such as pharmacy data, allergies, laboratory
    results, and radiology reports.
        AHLTA, the DoD's EHR, serves as the enterprise foundation for
    information interoperability with VA. Access to BHIE data is available
    through AHLTA and through VistA, VA's EHR, for patients treated by both
    Departments. As of May 2009, information on more than 3.3 million
    shared patients, including over 117,980 theater patients, is available
    through BHIE.
        To increase the availability of clinical information on a shared
    patient population, VA and DoD leveraged BHIE functionality to allow
    bidirectional access to inpatient documentation from DoD's inpatient
    documentation system. This capability is operational at some of DoD's
    largest inpatient facilities, representing more than 55 percent of
    total DoD inpatient beds. By the end of Fiscal Year (FY) 2010, this
    capability will be operational for approximately 90 percent of total
    DoD inpatient beds.
        In addition to sharing viewable text data, VA and DoD are
    leveraging the BHIE infrastructure to support the exchange of digital
    radiology images to support continuity of care. The Departments will
    continue to monitor and evaluate this capability.
        For our most seriously wounded, ill, and injured servicemembers
    transferring to VA Polytrauma Rehabilitation Centers (PRCs) for care,
    the Departments continue to send radiology images and scanned medical
    records electronically from three major DoD trauma centers at Walter
    Reed Army Medical Center, Brooke Army Medical Center, and Bethesda
    National Naval Medical Center to VA PRCs located in Tampa, Florida,
    Richmond, Virginia, Minneapolis, Minnesota, and Palo Alto, California.
    To date, scanned medical records for 230 patients and digital images
    for 167 patients have been sent.
        Computable Data for Shared Patients. In September 2006, the
    Departments established interoperability between AHLTA's Clinical Data
    Repository (CDR) and VA's Health Data Repository (HDR). The DoD/VA
    Clinical Data Repository/Health Data Repository (CHDR) interface
    enables the first exchange of interoperable and computable outpatient
    pharmacy and medication allergy data between the Departments on
    patients who receive care from both health care systems. DoD's
    outpatient pharmacy data exchange includes information from MTF
    pharmacies, retail pharmacies, and mail order pharmacies. This
    functionality is available to all DoD facilities.
        For patients with pharmacy and allergy data exchanged through CHDR,
    DoD providers view a combined medication and allergy list without
    having to access a separate application or making any changes to how
    they typically view medication or allergy data within AHLTA. The
    exchange of computable outpatient pharmacy and medication allergy data
    enables drug-drug interaction checking and drug allergy checking using
    data from both Departments. In FY 2008 alone, DoD providers were
    presented with more than 19,600 Level 1 and Level 2 drug-drug alerts;
    these are the most severe potential drug alerts provided to clinicians
    for decision support. This capability significantly enhances patient
    safety and quality of care.
        Clinicians are actively using CHDR and we are currently exchanging
    outpatient pharmacy and medication allergy data on more than 34,000
    patients who receive health care from both DoD and VA. These patients
    are referred to as Active Dual Consumers (ADCs). In September 2008, DoD
    implemented a process to automatically identify patients being treated
    in both Departments and began setting the ADC flag on approximately 50
    patients per day. When the ADC flag is activated, medication and drug
    allergy data is exchanged between the repositories. Subsequently, when
    a new medication or drug allergy is recorded by a provider in either
    Department, the new data is sent to the other Department's repository.
    This capability is being implemented in a phased approach to enable the
    Departments to monitor the impact on system performance and perform
    capacity planning.
        Virtual Lifetime Electronic Record. On April 9, 2009, the
    President, along with Secretary Shinseki and Secretary Gates, announced
    that VA and DoD have taken steps toward creating a joint Virtual
    Lifetime Electronic Record (VLER). VA and DoD are working together on
    an overall strategy to achieve the President's VLER vision and jointly
    developing an effective governance model. The VLER will permit
    information vital to health care, benefits, and services, to be
    available seamlessly to both Departments from the moment a
    servicemember enters into the military until the servicemember's or
    Veteran's death. The testimony by the Acting Director of the
    Interagency Program Office will address the Departments' collaborative
    work on this important interagency effort.
        It is important to note that the DoD EHR ``way ahead'' dovetails
    with the plans being discussed for the virtual lifetime electronic
    record, which will leverage the investments made in the Departments'
    existing electronic record systems. DoD is making a number of
    improvements to our EHR to enhance its performance, reliability, and
    usability. Those improvements include an improved flexible graphical
    user interface and architecture that uses a common services approach.
                     MEETING THE INTEROPERABILITY DEADLINE
        The Departments expect to achieve by no later than September 30,
    2009, electronic health record systems or capabilities that allow for
    full interoperability of personal health care information between the
    Department of Defense and the Department of Veterans Affairs to support
    the provision of clinical care. The DoD/VA Interagency Clinical
    Informatics Board (ICIB) has played a critical role in defining the
    priorities for the Departments in meeting the September 2009
    interoperability deadline and will guide our continued progress in
    electronic data sharing after the initial interoperability goals are
    achieved.
        DoD Coordination with the Interagency Program Office. Achieving our
    electronic data sharing goals requires increased agency transparency.
    To increase DoD's organizational transparency, the DoD/VA Interagency
    Program Office is involved in internal DoD and cross-organizational
    DoD/VA meetings hosted by the Military Health System Office of the
    Chief Information Officer (CIO) focused on DoD/VA electronic data
    sharing initiatives. This level of involvement and access to DoD
    information ensures the Interagency Program Office is able to provide
    management oversight of potential risks involving the identification,
    coordination, and execution of information sharing requirements.
        Further, to ensure open lines of communication are maintained, I
    have designated an Interagency Program Office liaison within the Office
    of the CIO. This knowledgeable senior staff member has access to the
    Department resources necessary to ensure the Interagency Program Office
    receives timely responses to requests for information and assistance.
        DoD/VA ICIB. To ensure clinically relevant information is shared
    electronically between the Departments, the ICIB was formed. The ICIB
    is an organization comprised of clinicians from both DoD and VA.
    Through the ICIB, we enabled the clinical community to define the items
    that must be shared by September 2009 in order to achieve full
    interoperability. The Deputy Assistant Secretary of Defense for
    Clinical and Program Policy and the Chief Patient Care Services
    Officer, Veterans Health Administration, serve as the lead functional
    proponents. The ICIB guides clinical priorities for what electronic
    health care information the Departments should share next and reviews
    planned clinical information system solutions for DoD/VA sharing to
    ensure alignment to clinical sharing priorities as defined by the ICIB.
        To support efforts to meet the September 2009 deadline, the ICIB
    submitted clinical priorities to the Interagency Program Office and
    DoD/VA Health Executive Council. For future years, the ICIB will
    prioritize additional health related sharing requirements to
    continually advance DoD/VA interoperability in a manner that supports
    clinicians in health care delivery.
        As the Departments work together to enhance data sharing by
    September 2009 and to achieve the vision for the virtual lifetime
    electronic record agreed to by the Secretaries, there will be key
    interoperability challenges, including:

        1.  Developing and adopting standards at the national level and the
    maturing of those standards for operational use;
        2.  Updating systems, infrastructure, and technology consistent
    with emerging standards;
        3.  Identifying and prioritizing information sharing requirements;
    and
        4.  Making the business process changes necessary to support
    increased electronic data sharing.

        The Departments and the Interagency Program Office will continue to
    collaborate with the Department of Health and Human Services, and
    others, on the development and adoption of the national standards
    required to enable health information to follow the patient regardless
    of the point of care. Our beneficiaries receive health care from the
    private sector so the ability to exchange health information between
    the public and private sectors is critical to both Departments. In
    addition, fulfillment of our goal of the virtual lifetime electronic
    record requires that it include complete administrative and medical
    information from all points of care. We look forward to future
    opportunities to present this Committee with our progress toward
    increased health data sharing and interoperability.
                                   CONCLUSION
        Mr. Chairman and distinguished Members of the Committee, the
    efforts of DoD and VA to share health care information have gained
    undeniable momentum. We continue to build on this momentum, leveraging
    our EHR and our solid foundation of electronic data sharing initiatives
    as we move toward this September and the goal of full interoperability
    for the provision of clinical care and beyond. Further, our EHR way
    ahead will rapidly increase our data sharing capabilities with VA as
    well as our private sector care delivery partners through both the
    virtual lifetime electronic record and NHIN.
        I value your insight, recommendations, and guidance. We are all
    working toward the same end--to provide the highest quality care for
    our Nation's heroes, past and present--and we must continue to work
    together to achieve our goals as efficiently and effectively as
    possible. Thank you again for the opportunity to discuss the
    significant progress achieved toward DoD/VA interoperable electronic
    health record.

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                   Prepared Statement of Hon. Roger W. Baker,
              Assistant Secretary for Information and Technology,
       Office of Information and Technology, U.S. Department of Veterans
                                    Affairs
        Mr. Chairman, thank you for the opportunity to update you on the
    status of our efforts to exchange electronic medical information with
    our partners at the Department of Defense (DoD). This Committee has
    always been supportive of our efforts and I look forward to providing
    you the information you need. Accompanying me today are Dr. Paul
    Tibbits and Mr. Scott Cragg.
        VA and DoD continue to work toward improving the exchange of
    medical information to best serve our active duty servicemembers and
    Veterans who come to us for medical care. Today, we are sharing more
    information than ever before. Although our data exchanges are
    unprecedented in the scope and amount of data we share, we realize
    there is more work to be done and are taking the steps necessary to
    meet our goals and comply with section 1635 of the National Defense
    Authorization Act (NDAA). I will address some of our recent successes,
    as well as some of the issues facing VA, as we work with DoD to expand
    our access to shared electronic medical information.
        I think you will agree that the current level of data sharing
    between VA facilities and between VA and DoD facilities is without
    equal anywhere else in the country. VA's award-winning electronic
    medical record system, VistA, is recognized world-wide as a model for
    integrated health information technology systems. Developed by VA from
    a clinical perspective, VistA is successfully deployed and used by
    administrative and clinical staff working in more than 1,200 VA medical
    centers, clinics, and nursing homes across the country. VA hospitals
    using VistA are one of only three hospital systems that have achieved
    the qualifications for the Healthcare Information and Management
    Systems Society (HIMSS) stage 7, the highest level of electronic health
    record integration, while a non-VA hospital using VistA--the Midland
    Memorial Hospital in Midland, TX--is one of only 42 U.S. hospitals that
    have achieved HIMSS stage 6. VistA was awarded the prestigious
    Innovations in American Government Award by Harvard University's Ash
    Institute for its estimated annual efficiency improvement rate of 6
    percent. One of the key modules facilitating VistA's information
    availability,
        My HealtheVet, is the recipient of numerous government and industry
    accolades, including the CIO 100 award and first place in the 2009 TEPR
    (Toward the Electronic Patient Record) personal health record
    competition. Open-source versions of VistA are widely deployed in
    private health systems, public hospitals, and medical offices in the
    U.S. and overseas.
        The NDAA mandates that both Departments achieve full
    interoperability of electronic health record capabilities and systems
    by September 2009. The NDAA also includes the requirement to establish
    the DoD/VA Interagency Program Office (IPO), which today provides vital
    coordinating linkages as envisioned by the NDAA legislation.
    Information Interoperability Plan
        The DoD/VA information interoperability plan (IIP) continues to
    serve as our interoperability roadmap. The IIP describes the current
    state of electronic data sharing between the Departments and identifies
    the gaps that must be addressed to achieve the level of information
    interoperability necessary to support the clinical and benefits needs
    of our Veterans and members of the Armed Forces. The IIP provides the
    strategic organizing framework for current and future work and
    establishes the scope and milestones necessary to measure progress
    toward intermediate and long term goals.
        The IIP also emphasizes leveraging our existing data exchanges
    through which we already share almost all essential health information
    in viewable format. By September 2009 we will enhance the existing data
    exchanges to share those additional types of information identified and
    prioritized by the Interagency Clinical Information Board (ICIB). The
    ICIB comprises clinicians from both DoD and VA. It is responsible for
    identifying and prioritizing the types and format of electronic medical
    information that needs to be shared by DoD and VA, to care for our
    patients. This group ensures that our data sharing is focused on needs
    identified and prioritized by clinicians for clinicians. Thus, we have
    used our clinician community to define for us those high priority items
    that must be shared by September 2009.
        I will now discuss the specific types of data sharing occurring in
    more detail.
    Exchange of electronic medical information
        VA and DoD are successfully sharing electronic medical information
    on separated servicemembers and shared patients, who come to both VA
    and DoD for care and benefits. Since 2001, the Federal Health
    Information Exchange (FHIE) has accomplished the one-way transfer of
    all clinically pertinent electronic information on more than 4.8
    million separated individuals--approximately 3.3 million of these
    individuals have come to VA for health care or benefits as Veterans. In
    addition to FHIE, VA and DoD clinicians are using the Bidirectional
    Health Information Exchange (BHIE) to view current medical data on
    shared patients, including Veterans, active duty personnel, and their
    dependents from every VA and DoD facility. Today, VA and DoD continue
    to share bidirectional viewable outpatient pharmacy data, allergy
    information, inpatient and outpatient laboratory results (including
    chemistry, hematology, microbiology, surgical pathology, and cytology),
    inpatient and outpatient radiology reports, ambulatory progress notes,
    procedures, and problem lists.
        Our most recent enhancements in bidirectional exchange added vital
    sign data (including blood pressure, heart rate, respiratory rate,
    temperature, height, weight, oxygen saturation, pain severity, and head
    circumference) from all VA and DoD facilities, DoD Theater clinical
    data (including inpatient notes, outpatient encounters, and ancillary
    clinical data such as pharmacy data, allergies, laboratory results, and
    radiology reports), and inpatient discharge summaries from DoD's
    largest military treatment facilities, representing more than 55
    percent of total DoD inpatient beds.
        DoD and VA continue to improve our efficiency in transferring
    digital radiological images and scanned inpatient information for every
    patient being transferred from Walter Reed and Brooke Army Medical
    Centers and Bethesda National Naval Medical Center, to one of our four
    polytrauma centers in Richmond, Tampa, Palo Alto, and Minneapolis. Our
    polytrauma doctors find this information invaluable for treating our
    most seriously injured patients.
        In addition to the viewable text and scanned information we receive
    and share with DoD, VA and DoD are sharing computable allergy and
    pharmacy information on patients who use both health care systems. The
    benefit of sharing computable data is that each system can use
    information from the other system to conduct automatic checks for drug
    interactions and allergies. In VA, we have implemented this capability
    at seven of our most active locations where patients simultaneously
    receive care from both VA and DoD facilities. Once a patient is
    ``turned on'' with this capability, his or her pharmacy and allergy
    information is computable enterprise-wide in DoD and VA and available
    for this automatic clinical decision support.
        Our social workers, transition patient advocates, and other
    military liaison staff continue to successfully use the Veterans
    Tracking Application (VTA) to improve the coordination of care for
    patients transitioning from DoD to VA. VTA provides our staff with key
    patient tracking and patient coordination information on a near real-
    time basis.
        Finally, VA and DoD are dedicated to ensuring that transitioning
    servicemembers receive the benefits they have earned in a timely
    manner. The information critical to the provision of benefits is
    obtained through the One VA/DoD data sharing initiative, which
    consolidates the transfer of data between DoD and VA and will
    eventually eliminate the need for paper copies of DD-214s. The Defense
    Enrollment Eligibility Reporting System (DEERS) supports that transfer,
    and the VA Defense Information Repository (VADIR), serves as the secure
    and authoritative database for a servicemember's demographic, personal
    identity information, and military history. This longitudinal
    electronic eligibility record can be used by all VA entities to
    administer benefits and care for a transitioning servicemember.
    Details of the DoD/VA Information Interoperability Plan (IIP)
        The DoD/VA IIP provides a roadmap to guide our Departments'
    information technology investment decisions and establish a shared
    understanding of interoperability principles, practices, enablers, and
    barriers.
        The IIP is a living document whose ultimate purpose is to identify
    and address the information needed by the Departments to improve
    continuity of care and benefits administration for our Nation's
    servicemembers, Veterans, and their beneficiaries. To that end, the
    plan aligns our goals with 22 specific initiatives that make up the
    pathway to information interoperability.
        In addition to identifying those actions necessary to achieve
    inter-Departmental interoperability, the IIP also identifies the
    barriers to success that need to be overcome. These barriers include
    concerns about data standardization and quality, information privacy
    and confidentiality, the investment cost to implement the initiatives,
    and the investment cost to upgrade legacy systems and infrastructure.
    Interoperability by September 30, 2009
        VA is working closely with our DoD partners to implement the
    provisions of the NDAA requiring interoperability by September 2009.
    Our main commitment is to ensure doctors and health care staff from
    both Departments have the information they need from each other to
    treat our common patients. This is not to say all electronic medical
    data will be shared; only to emphasize that everything deemed essential
    by our clinicians will be shared.
        With respect to the September 2009 target, the ICIB plays a key
    role by determining, from a clinical perspective, the categories and
    priorities of clinical information that must be shared to most
    effectively treat our beneficiaries and meet the NDAA requirements. The
    ICIB recommends to the DoD/VA Health Executive Council (HEC) the types
    and format of health information that is necessary to provide top
    quality, effective care to shared patients, wounded warriors coming to
    us for treatment and rehabilitation, and Veterans transitioning to VA
    for care and benefits. The HEC approves or disapproves the ICIB
    recommendations.
        To attain the interoperability of electronic health record
    capabilities and systems recommended by the ICIB by September 2009, the
    HEC approved six ICIB recommendations. Working collaboratively with
    DoD, three of these recommendations are already complete (share refined
    social history data, expand sharing of questionnaires/self assessment
    tools, and share information to support separation physical exams). A
    fourth recommendation to establish trusted network gateways is well
    underway. DoD and VA have approved implementing four enterprise
    gateways and up to five Federal health care center (FHCC) gateways. The
    focus of these gateways is to support VA/DoD general purpose health
    data traffic (i.e., CHDR, LDSI, FHIE/BHIE, imaging). All four
    enterprise gateways are operational, as is the FHCC gateway supporting
    the Captain James A. Lovell FHCC (North Chicago).
        A fifth recommendation, document scanning, is also well underway.
    DoD has piloted the capability to scan paper documents and associate
    them with a specific patient so that providers are aware that the
    documents are available. Interagency testing of this pilot capability
    is on schedule for September 2009. The sixth initiative focuses on
    DoD's expansion of their inpatient electronic medical record system.
        Under the purview of the Senior Oversight Committee (SOC) and in
    conjunction with the ongoing efforts of the DoD/VA Joint Executive
    Council (JEC), we are continuing our efforts to meet the immediate
    needs of seriously injured servicemembers transitioning to VA as a
    result of the current operations in theater settings. All transitioning
    servicemembers will benefit from this work. Toward this end, VA and
    DoD, working with the IPO, are continuing to define information and
    technology requirements to support disability evaluation, assessment,
    and documentation of traumatic brain injury and Post-traumatic stress
    disorders, case management tools, and automated solutions for reserve
    component records. Additionally, work continues on development of the
    eBenefits portal that will support unified and secure Web access to
    benefits and services that support wounded warriors. The SOC has been
    instrumental in defining requirements and implementing acquisition
    activities to support these key critical business needs.
        Despite these accomplishments, we realize our work is not done and
    continue to expand the types of electronic medical data we share. For
    example, we are now sharing digital radiology images bidirectionally
    beyond the initial test site in El Paso, Texas. This capability is now
    available at several sites, including the Washington, DC, VA Medical
    Center, Walter Reed Army Medical Center, and National Naval Medical
    Center, where VA providers now use DoD radiology images to conduct
    service disability rating examinations.
        Another example of our ongoing efforts is the enhancement of our
    ability to share computable health information. The capability enabling
    the exchange of computable outpatient pharmacy and medication allergy
    data for shared patients was made available to all DoD sites in
    December 2007.
        VA and DoD will enhance this capability by adding computable
    laboratory (chemistry and hematology) results in the summer of 2010.
    The Path to Information Interoperability in the Future
        To date, VA and DoD information interoperability successes have
    focused on developing a suite of applications that facilitate
    exchanging patient information between the two Department's individual
    electronic medical record systems. However, on April 9, 2009, the
    President, along with Secretary Shinseki and Secretary Gates, announced
    that VA and DoD have taken steps toward creating a joint Virtual
    Lifetime Electronic Record (VLER). The VLER will permit information
    vital to health care, benefits, and services, to be available
    seamlessly to both Departments from the moment a servicemember enters
    into the military until the servicemember's or Veteran's death. The
    potential benefits of the VLER are many and planning, creating, and
    implementing the VLER will be a challenging endeavor. VA and DoD are
    working together on an overall strategy to achieve the President's VLER
    vision and jointly developing an effective governance model.
        Concurrent with the VLER effort, VA continues to develop HealtheVet
    as our foundational tool, to deliver top quality health care to our
    patients and share important medical information with DoD and
    eventually, other health care partners that treat our Veterans. VA
    appreciates this Committee's past support of this project and its
    continued funding, which is vital to our success.
        In closing, I would like to thank you again for your continued
    support and the opportunity to testify before this Subcommittee on the
    important work we are undertaking to improve medical record sharing
    between the VA and DoD. I would now like to address any questions you
    might have.

                        Statement of Hon. Cliff Stearns,
             a Representative in Congress from the State of Florida
        Thank you, Mr. Chairman.
        Thank you for holding this very important hearing. As a
    Representative from the State of Florida, which is home to the second
    largest veterans population in the country, this is an issue I have
    been particularly concerned about, and I am glad to be here this
    morning to receive the latest updates from the VA and DoD on their
    efforts to achieve full interoperability of their electronic health
    records.
        September 30, 2009, as we all know, is the deadline set for VA and
    DoD to achieve interoperability of personal health care information.
    Achieving this interoperability is essential to ensuring our returning
    servicemen and women receive the care they need and the seamless
    transition they deserve.
        Many of my own constituents have had to suffer through the frenetic
    and often frustrating transition from DoD to VA, and I commend the
    progress that has been made thus far to achieve interoperability.
    However, we are just three short months away and we are not at a point
    where all electronic health information is being shared, and it appears
    that we won't have full and complete interoperability by the September
    30th deadline.
        One important component of achieving interoperability is the
    ability of DoD to scan medical documents of servicemembers into its
    Electronic Health Record (EHR) and then share these important documents
    electronically with the VA. This document scanning and sharing
    initiative is reported to be ``on schedule'' and I sincerely hope this
    component of interoperability is deliverable by the deadline.
        Additionally, I am concerned about reports of incomplete staffing
    at the Interagency Program Office for key information technology
    management positions and the management challenges reported by the GAO.
    Any potential problems must be identified and addressed immediately.
    Our veterans have waited long enough, we can't afford significant
    delays--our veterans' quality of life depends upon it.
                       MATERIAL SUBMITTED FOR THE RECORD

                                         Committee on Veterans' Affairs
                            Subcommittee on Oversight and Investigation
                                                        Washington, DC.
                                                        August 12, 2009

    Honorable Gene L. Dodaro
    Acting Comptroller General
    U.S. Government Accountability Office
    441 G Street, NW
    Washington, DC 20548

    Dear Comptroller General Dodaro:

        Thank you for the testimony of Valerie C. Melvin, Director of
    Information Management and Human Capital Issues, U.S. Government
    Accountability Office at the U.S. House of Representatives Committee on
    Veterans' Affairs Subcommittee on Oversight and Investigations hearing
    that took place on July 14, 2009 on ``Examining the Progress of
    Electronic Health Record Interoperability Between the U.S. Department
    of Veterans Affairs and U.S. Department of Defense.''
        Please provide answers to the following questions by COB on
    Wednesday, September 16, 2009 to Todd Chambers, Legislative Assistant
    to the Subcommittee on Oversight and Investigations.

        1.  How would the GAO grade the efforts of both the Department of
    Defense (DoD) and the Department of Veterans Affairs (VA) on their
    efforts toward interoperability of systems?
        2.  VA and DoD have been meeting for decades on interoperability
    and resource sharing. The law permitting them to address this issue
    goes as far back as 1982. Why are we just now seeing a description of
    VA and DoD interoperability objectives? Is this a technology or a
    bureaucratic cultural issue?
        3.  In your testimony, you state the progress is being made, but do
    you feel that under the circumstances, IPO, VA and DoD are maximizing
    their time and effort in moving forward as expeditiously as possible?
    If not, how do you propose they make changes to fulfill the intent of
    the NDAA and maximize production?
        4.  What plans do DoD and VA have for continuity as key leadership
    positions are permanently filled? What challenges to do you foresee?

        Thank you again for taking the time to answer these questions. The
    Committee looks forward to receiving your answers. If you have any
    questions concerning these questions, please contact Subcommittee on
    Oversight and Investigations Majority Staff Director, Martin Herbert,
    at (202) 225-3569 or the Subcommittee Minority Staff Director, Arthur
    Wu, at (202) 225-3527.

                Sincerely,

    Harry E. Mitchell
    Chairman

                                                    David P. Roe

                                                    Ranking Republican
                                                    Member

    MH/tc

                                   __________
                                  U.S. Government Accountability Office
                                                        Washington, DC.
                                                       October 13, 2009

    The Honorable Harry Mitchell
    Chairman
    Subcommittee on Oversight and
      Investigations
    House Veterans' Affairs Committee
    335 Cannon House Office Building
    Washington, D.C. 20515

                                                    The Honorable David Roe

                                                    Ranking Member

                                                    Subcommittee on
                                                    Oversight and

                                                    Investigations

                                                    House Veterans' Affairs
                                                    Committee

                                                    335 Cannon House Office
                                                    Building

                                                    Washington, D.C. 20515

    Subject: Program Office Improvements Needed to Strengthen Management of
            VA and DoD Efforts to Achieve Fully Interoperable Electronic
            Health Records: Responses to Post-Hearing Questions

        This letter responds to your August 12, 2009, request that we
    answer questions relating to our testimony on July 14, 2009.\1\ During
    that hearing, we discussed the Departments of Veterans Affairs' (VA)
    and Defense's (DoD) interagency program office and efforts toward
    achieving fully interoperable electronic health record capabilities.
    Your questions, along with our responses, follow.
    ---------------------------------------------------------------------------
        \1\ GAO, Electronic Health Records: Program Office Improvements
    Needed to Strengthen Management of VA and DoD Efforts to Achieve Full
    Interoperability, GAO-09-895T (Washington, D.C.: July 14, 2009).
    ---------------------------------------------------------------------------
    1.  How would the GAO grade the efforts of both the Department of
            Defense (DoD) and the Department of Veterans Affairs (VA) on
            their efforts toward interoperability of systems?
        Based on their accomplishments as of late July 2009,\2\ we would
    grade the departments' efforts toward achieving fully interoperable
    electronic health record systems as incomplete. As noted in the
    testimony, DoD and VA identified six objectives for achieving full
    interoperability in compliance with applicable standards by September
    30, 2009. When we last reported on their efforts in late July, the
    departments had achieved planned capabilities for three of the
    objectives--refine social history data, share physical exam data, and
    demonstrate initial network gateway operation. For the remaining three
    objectives, the departments had partially achieved planned
    capabilities, with additional work needed to fully meet the objectives.
    Regarding an objective to expand questionnaires and self-assessment
    tools to provide VA all periodic health assessment data stored in DoD's
    electronic health record, department officials stated that they
    intended to complete the additional work by September 2009. The
    officials stated that they also intended to meet objectives to expand
    DoD's inpatient medical records system for each military medical
    service and to demonstrate an initial capability to scan
    servicemembers' medical documents; however, they noted that additional
    work related to these objectives would be required beyond September to
    achieve the fully interoperable capabilities necessary to meet
    clinicians' needs for health information.
    ---------------------------------------------------------------------------
        \2\ GAO, Electronic Health Records: DoD and VA Efforts to Achieve
    Full Interoperability Are Ongoing; Program Office Management Needs
    Improvement, GAO-09-775 (Washington, D.C.: July 28, 2009).
    ---------------------------------------------------------------------------
        Further, we reported in late July that the DoD/VA Interagency
    Program Office had not yet been effectively positioned to serve as the
    single point of accountability for the implementation of fully
    interoperable electronic health records. While the departments had made
    progress in setting up the office by recruiting and hiring staff to
    fill government and contractor positions, they lacked full-time
    permanent leadership for the office and had not fulfilled key
    information technology management responsibilities in the areas of
    performance measurement, project planning, and scheduling. Thus, the
    office was limited in its ability to effectively manage and provide
    meaningful progress reporting on the delivery of interoperable
    capabilities that are intended to improve the quality of health care
    provided to our Nation's veterans.
    2.  VA and DoD have been meeting for decades on interoperability and
            resource sharing. The law permitting them to address this issue
            goes as far back as 1982. Why are we just now seeing a
            description of VA and DoD interoperability objectives? Is this
            a technology or a bureaucratic cultural issue?
        While VA and DoD have been working to exchange patient health
    information electronically since 1998, the departments undertook key
    steps to define their interoperability objectives only within the last
    2 years. Specifically, it was not until December 2007 that the
    departments established the Interagency Clinical Informatics Board \3\
    (made up of senior clinical leaders from both departments who represent
    the user community) to be responsible for determining clinical
    priorities for electronic data sharing between VA and DoD. The
    departments included the six interoperability objectives identified by
    the board in the September 2008 DoD/VA Information Interoperability
    Plan (Version 1.0), which was developed to address the requirements for
    interoperable electronic health records set forth in the National
    Defense Authorization Act for Fiscal Year 2008 (NDAA). The departments
    produced a draft of the plan in March 2008, completed their reviews of
    the plan approximately 6 months later, and issued the plan in September
    2008.
    ---------------------------------------------------------------------------
        \3\ This board was originally named the Joint Clinical Information
    Board.
    ---------------------------------------------------------------------------
        Our reviews of VA's and DoD's efforts to electronically share
    health data have generally identified managerial, rather than
    technical, deficiencies as a key factor hindering the departments'
    progress toward achieving interoperability. For example, in reporting
    on the departments' initial efforts to ``share clinical information via
    a comprehensive, lifelong medical record'' in 2001, we noted that
    accountability for the initiative \4\ was blurred across several
    management entities, and that basic principles of sound information
    technology (IT) project planning, development, and oversight had not
    been followed, creating barriers to progress. In June 2004, we reported
    that the two departments lacked an established project management
    structure and a lead entity with final decision-making authority to
    guide the investment in and implementation of this capability, and a
    project management plan that defined the technical and managerial
    processes necessary to satisfy project requirements.\5\ Also, in June
    2006, we noted that although VA and DoD had developed an interagency
    project management plan, this plan had not specified the authority and
    responsibility of organizational units for particular tasks, and the
    work breakdown structure was at a high level and lacked detail on
    specific tasks and time frames.\6\ Further, with regard to their more
    recent efforts to meet the NDAA's requirement for full
    interoperability, we reported in July 2008 that the departments lacked
    a fully established program office and a finalized implementation plan
    with milestones for setting up the office and for carrying out
    activities, such as validating and establishing requirements for
    interoperable health capabilities.\7\ In January 2009, we reported that
    the departments had not established results-oriented (i.e., objective,
    quantifiable, and measurable) performance goals and measures to be used
    as a basis for reporting interoperability progress.\8\ In July of this
    year, we noted that the departments' lack of progress in establishing
    fundamental IT management capabilities that are specific
    responsibilities of the interagency program office had contributed to
    uncertainty about the extent to which the departments would progress
    toward achieving full interoperability.\9\ We recommended actions to
    address these deficiencies and improve the departments' efforts to
    electronically share health data.
    ---------------------------------------------------------------------------
        \4\ This initiative was called the Government Computer-Based
    Patient Record. See GAO, Computer-Based Patient Records: Better
    Planning and Oversight by VA, DoD, and IHS Would Enhance Health Data
    Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001).
        \5\ GAO, Computer-Based Patient Records: VA and DoD Efforts to
    Exchange Health Data Could Benefit from Improved Planning and Project
    Management, GAO-04-687 (Washington, D.C.: June 7, 2004).
        \6\ GAO, Information Technology: VA and DoD Face Challenges in
    Completing Key Efforts, GAO-06-905T (Washington, D.C.: June 22, 2006).
        \7\ GAO, Electronic Health Records: DoD and VA Have Increased Their
    Sharing of Health Information, but More Work Remains, GAO-08-954
    (Washington, D.C.: July 28, 2008).
        \8\ GAO, Electronic Health Records: DoD's and VA's Sharing of
    Information Could Benefit from Improved Management, GAO-09-268
    (Washington, D.C.: January 28, 2009).
        \9\ GAO-09-775.
    ---------------------------------------------------------------------------
    3.  In your testimony, you state that progress is being made, but do
            you feel that under the circumstances, IPO, VA, and DoD are
            maximizing their time and effort in moving forward as
            expeditiously as possible? If not, how do you propose they make
            changes to fulfill the intent of the NDAA and maximize
            production?
        Our studies suggest that neither VA and DoD, nor the interagency
    program office have effectively maximized their time and effort to
    expeditiously achieve interoperable electronic health records. Although
    we have noted progress in the departments' sharing of patient health
    data, we have also pointed out their need to address important
    weaknesses in their data sharing efforts. This need is highlighted in
    the history of management weaknesses (previously discussed) that have
    persisted since our earliest reporting on the departments' efforts in
    2001.
        The reports that we have issued in response to the NDAA have
    included recommendations to VA and DoD that are relevant to fulfilling
    the intent of the act. For example, in our reports since July 2008, we
    have recommended that the departments expedite efforts to put in place
    permanent leadership, staff, and facilities for the interagency program
    office. We have also recommended that they develop results-oriented
    goals and associated performance measures for their interoperability
    objectives, document these goals and measures in the department's
    interoperability plans, and use the goals and measures as the basis for
    future assessments and reporting of interoperability progress.
    Similarly, we have recommended that the departments direct the
    interagency program office to establish a project plan and a complete
    and detailed integrated master schedule to guide their efforts to
    achieve fully interoperable electronic health record systems. In the
    absence of these important mechanisms, VA, DoD, and the interagency
    program office are limited in their ability to effectively manage and
    successfully deliver the intended interoperable capabilities.
    4.  What plans do DoD and VA have for continuity as key leadership
            positions are permanently filled? What challenges do you
            foresee?
        At the time of our studies, VA and DoD planned to have acting
    officials serve in key leadership positions (i.e., as director and
    deputy director) until permanent officials could be hired. In this
    regard, the departments had taken action toward hiring a full-time
    permanent director and a deputy director to lead the office. However,
    our July testimony and report noted that these positions continued to
    be filled on an interim basis.\10\ As of early July, DoD had selected a
    candidate for the director position, VA had concurred with the
    selection, and the candidate's application had been sent to the Office
    of Personnel Management for approval. In the meantime, the departments
    requested and received an extension of the current acting director's
    appointment until September 30, 2009, or until a permanent official was
    hired. Additionally, the acting director had stated that the
    departments anticipated making a selection for the deputy director
    position. As we have previously noted, until the departments appoint
    these key permanent leaders, the interagency program office will be
    challenged to fulfill all of the responsibilities that are fundamental
    to effective program management and that are essential to effectively
    serving as the single point of accountability for achieving fully
    interoperable capabilities.
    ---------------------------------------------------------------------------
        \10\ GAO-09-895T and GAO-09-775.

                                   __________
        In responding to these questions, we relied on previously reported
    information that was compiled in support of our July 14, 2009,
    testimony and our July 28, 2009, report. Our work in support of those
    products was performed in accordance with generally accepted government
    auditing standards. Should you or your staffs have any questions on
    matters discussed in this letter, please contact me at (202) 512-6304
    or melvinv@gao.gov.

                                                      Valerie C. Melvin
              Director, Information Management and Human Capital Issues

                                         Committee on Veterans' Affairs
                            Subcommittee on Oversight and Investigation
                                                        Washington, DC.
                                                        August 31, 2009

    Honorable Robert M. Gates
    Secretary of Defense
    U.S. Department of Defense
    1000 Defense Pentagon
    Washington, D.C. 20301

    Dear Secretary Gates:

        Thank you for the testimony of Rear Admiral Gregory Timberlake,
    SCHE, USN, Acting Director of the Interagency Program Office and Mary
    Ann Rockey, Deputy Chief Information Officer, Military Health System,
    U.S. Department of Defense at the U.S. House of Representatives
    Committee on Veterans' Affairs Subcommittee on Oversight and
    Investigations hearing that took place on July 14, 2009 on ``Examining
    the Progress of Electronic Health Record Interoperability Between the
    U.S. Department of Veterans Affairs and U.S. Department of Defense.''
        Please provide answers to the following questions by COB on
    Tuesday, October 29, 2009 to Todd Chambers, Legislative Assistant to
    the Subcommittee on Oversight and Investigations.

        1.  Who is the reporting authority for Admiral Timberlake? How long
    has Admiral Timberlake been Acting Director of the IPO program?
        2.  When was the IPO charter finally approved by the Department of
    Defense?
        3.  Should the Great Lakes Naval/North Chicago VA joint venture,
    scheduled for opening in 2010 be considered the poster child for VA/DoD
    interoperability?
        4.  Though only 10 out of 14 government positions have been filled,
    how much have the 16 contractors cost the U.S. taxpayers? Since there
    is no meaningful baseline to measure performance, how can you tell
    whether the contractors are adding any value to the IPO?
        5.  What are DoD's plans, including a schedule, for expanding the
    capability for scanning DoD documents into AHLTA?
        6.  What percentage of DoD's medical records is still in paper
    format? What are the department's plans, including a schedule, for
    transitioning medical records from paper to an electronic form?
        7.  What is the plan and timeline for DoD to expand Essentris to
    100 percent of its sites and account for every inpatient bed in the DoD
    system? What challenges does this create for clinicians and medical
    providers between both DoD and VA medical systems?
        8.  Are we correct in surmising that the samples that the Committee
    viewed during the hearing of different servicemembers' records were
    selected from the many others in which may or may not be as complete or
    be as interconnected? If so, what percentage of those who have been
    separated from service in the last year had this degree of
    interoperability and depth so that the physician from VA or DoD or
    private sector, but especially VA, can access all that information
    going back to when the injury may have occurred.

        Thank you again for taking the time to answer these questions. The
    Committee looks forward to receiving your answers. If you have any
    questions concerning these questions, please contact Subcommittee on
    Oversight and Investigations Majority Staff Director, Martin Herbert,
    at (202) 225-3569 or the Subcommittee Minority Staff Director, Arthur
    Wu, at (202) 225-3527.

                Sincerely,

    Harry E. Mitchell
    Chairman

                                                    David P. Roe

                                                    Ranking Republican
                                                    Member

    MH/tc

                                   __________
                            Questions for the Record
                     The Honorable Harry Mitchell, Chairman
                  Subcommittee on Oversight and Investigations
                      House Committee on Veterans' Affairs
                                 July 14, 2009

        Question #1: Who is the reporting authority for Admiral Timberlake?
    How long has Admiral Timberlake been Acting Director of the IPO
    program?

        Answer: For purposes of executing the IPO mission, the IPO Director
    is subject to the authority, direction and control of the Under
    Secretary of Defense (Personnel and Readiness)(USD(P&R)) in the
    USD(P&R)'s dual position as the Director, Defense Human Resources
    Activity.
        In performing IPO's oversight role, the IPO Director reports to the
    Department of Veterans Affairs/Department of Defense Joint Executive
    Council cochairs; namely, the USD(P&R) and Deputy Secretary of Veterans
    Affairs.
        Due to RADM Timberlake's active military status, his official
    reporting chain follows Navy policy and includes the Chief of Naval
    Operations.
        RADM Timberlake's initial set of orders covered January 5, through
    July 2, and the second set cover July 3, through August 29. We
    anticipate orders will need to be extended through September 30.

        Question #2: When was the IPO charter finally approved by the
    Department of Defense?

        Answer: The IPO charter was executed on January 16, by Deputy
    Secretary of Veterans Affairs (VA), Gordon H. Mansfield, and Under
    Secretary of Defense for Personnel and Readiness, Dr. David S. C. Chu.
    On June 26, the VA/DoD Joint Executive Council directed IPO to revise
    the statement of responsibilities and authority in its charter. A
    revised and restated IPO charter is anticipated by September 30,
    subject to review and approval by Deputy Secretary of VA, W. Scott
    Gould, and Deputy Secretary of Defense, William J. Lynn III.

        Question #3: Should the Great Lakes Naval/North Chicago VA joint
    venture, scheduled for opening in 2010 be considered the poster child
    for VA/DoD interoperability?

        Answer: Member of Congress, VA, and DoD sought to address the need
    to replace Naval Hospital Great Lakes (NHGL) and utilize excess patient
    care capacity at nearby North Chicago Veterans Affairs Medical Center
    (NCVAMC). In 2002, the decision was reached to create the first Federal
    Health Care Center (FHCC), a fully integrated partnership between NHGL
    and NCVAMC. Developing the first FHCC is a major initiative. A single
    chain of command will manage inpatient and outpatient medical and
    dental care at the new Captain James A. Lovell Federal Health Care
    Center (JALFHCC); the new Federal ambulatory care clinic co-located on
    the JALFHCC campus; DoD clinics at recruit and student training
    centers; and VA Community-Based Outpatient Clinics. The Departments
    expect to realize benefits in the simultaneous, non-duplicative
    provision of accessible, high-quality health care for recruit, Active
    Duty, dependent, retiree, and Veteran beneficiary populations.
        JALFHCC has many unique business needs that require alternate
    technology solutions. Future FHCCs also will have unique business
    needs, which may or may not require development of alternate technology
    solutions. For example, beneficiary population and catchment area,
    local facility organizational structure, resources, funding, networks,
    and specific Service requirements may all influence DoD/VA business
    needs. Using a common services approach with service oriented
    architecture establishes an environment in which functions can be
    standardized and used across systems and processes, enabling the
    Departments to develop common business and data services to utilize
    across the DoD/VA continuum of care. Enterprise solutions developed for
    JALFHCC will be exported to other joint ventures, whenever appropriate.
        By October 2010, the Departments seek to achieve the following key
    capabilities at JALFHCC:

          building a single patient registration process that
    unifies patient registration, so that registering a patient in either
    system will begin the registration process in both systems;
          creating a clinical single sign-on capability that
    enables a clinical user to log securely into multiple clinical
    applications with a single user name and password, and maintains the
    patient context across applications;
          developing the first phase of orders management/order
    portability for:
              laboratory
              radiology
              pharmacy and
              consultations/referrals; and,
          beginning the development of applications to support Navy
    operational readiness requirements, such as mass rapid dental exams.

        The Departments will also gather requirements and work flow data
    for financial, quality, performance, and workload metrics processes,
    and, explore cross agency outpatient appointment scheduling.

        Question #4: Though only 10 out of 14 government positions have
    been filled, how much have the 16 contractors cost the United States
    taxpayers? Since there is no meaningful baseline to measure
    performance, how can you tell whether the contractors are adding any
    value to the Interagency Program Office (IPO)?

        Answer: The IPO has filled 10 of 14 government positions with
    personnel on staff. The status of the four remaining positions follows:

          Senior Program Analyst--Benefits (DoD): Selection made;
    anticipate security clearance process to be completed in August 2009;
    anticipate report date to be September 28, 2009
          Program Analyst (VA): Selection made; anticipate report
    date to be August 20, 2009
          Senior Program Analyst--Health (VA): Anticipate internal
    and external advertisement to close by the end of Fiscal Year 2009
          Senior Program Analyst--Benefits (VA): Anticipate
    candidate selection by the end of Fiscal Year 2009

        The work of the IPO spans a variety of skill sets and functional
    areas, and relies on a team-like atmosphere to accomplish its mission.
    Contractors provide critical support in each functional area.
    Contractors at the IPO bring skill sets that augment work done by
    government personnel. Skills provided by contractors at the IPO
    include:
    Subject Matter Expertise in Service Oriented Architecture
        This contract support role has specific application to the VA/DoD
    and Nationwide Health Information Network data sharing environments,
    which have been described in documentation related to the Virtual
    Lifetime Electronic Record (VLER). In this role, contractors at the IPO
    provide experience and expertise that is scarce in both Departments.
    The contractors also contribute to IPO with their understanding of
    common services architecture, business users, client users, and use
    cases, as applicable, in VA or DoD.
    Quality Assurance and Risk Management
        This role ensures an effective program operations management
    process exists at the IPO. The purpose of such a process is to
    adequately and quantitatively evaluate and identify risk. The
    contractors also provide support to ensure that quality assurance
    programs at the IPO are adequate. This is fundamental, foundational
    work needed to build and implement standards specifications for VLER.
    The work of this subject matter expert, coordinating with subject
    matter experts from each Department, is critical.
    Congressional Relations
        The IPO is frequently asked to provide information about data
    interoperability and the progress being made toward VLER. Contract
    support staff in this role provide advice to IPO leadership and
    government leads regarding audit and external oversight activities.
    This position requires superior written and oral communications skills,
    as well as knowledge of information technology and health program
    delivery that contract staff is able to provide.
        These positions, as well as other contract support at the IPO,
    bridge gaps in existing resources to complete the IPO team quickly and
    effectively. As of July 14, 2009, about $2.0 million has been spent on
    16 contract support staff. The value of the contract for IPO contract
    support is $4.9 million.

        Question #5: What are DoD's plans, including a schedule, for
    expanding the capability for scanning DoD documents into AHLTA?

        Answer: The DoD Healthcare Artifact and Image Management Solution
    (HAIMS) will enable DoD users to scan or import documents and
    artifacts, associate those documents and artifacts with a patient's
    record, and make them globally accessible to authorized DoD and
    Department of Veterans Affairs users.
        The initial evaluation of HAIMS, in a test environment, will be
    completed by the end of September 2009. The first phase of HAIMS
    implementation activities will begin at the end of Fiscal Year (FY)
    2009 and will involve software systems integration testing and
    deploying capabilities for limited user testing. Nine sites (three
    Navy, three Army, and three Air Force) will be selected for limited
    user testing, which is planned to run from December 2009 through March
    2010. Based on the results of the limited user testing, enterprise-wide
    deployment of HAIMS is anticipated to begin in FY 2010.

        Question #6: What percentage of DoD's medical records is still in
    paper format? What are the department's plans, including a schedule,
    for transitioning medical records from paper to an electronic form?

        Answer: In accordance with Strategy 3.5 of the VA/DoD Joint
    Strategic Plan, signed January 2009, a Medical Records Working Group
    (MRWG) has been established under the Benefits Executive Council. The
    MRWG is involved in the systematic examination of all phases of the
    Military paper service treatment record (STR) lifecycle management
    process, with an emphasis on promptly providing accurate and complete
    STR related information for all Servicemembers in all components and
    veterans to DoD and VA designated benefits determination decision-
    makers.
        Analysis of the entire STR lifecycle conducted by the MRWG this
    year generated more than 50 recommendations. Next steps include
    implementing low cost/high impact recommendations and developing
    business cases for other recommendations. Key recommendations included
    interim means of eliminating costly and problematic paper-based
    business processes associated with STR maintenance and transfer until
    the Virtual Lifetime Electronic Record (VLER) is developed and
    implemented. The interim solution must bridge the gap until VLER is in
    place by leveraging existing records management system capabilities to
    support the scanning of paper-generated documentation into a repository
    that would either exist parallel to the AHLTA record or enable scanning
    directly into the AHLTA record. DoD would then expand the use of its
    Defense Personnel Records Information System to provide Veterans
    Benefits Administration regional offices with ready access to this
    medical documentation on a Servicemember.
        It is important to consider, while DoD has achieved an increase in
    the number of outpatient clinical encounters being documented in AHLTA
    in recent years, some care continues to be documented on paper.
    Additionally, even if today we capture 100 percent of data
    electronically, for those personnel who were in the military prior to
    full implementation of AHLTA, at least a portion of their records will
    be paper-based. Further, at the time of a Servicemember's separation or
    release from Active Duty, a hard copy of the STR (which includes the
    outpatient medical record) must be sent to the VA Records Management
    Center in St. Louis. This process involves manually printing any
    encounters that were captured in AHLTA and reconciling them with the
    hard copy outpatient medical records folder.

        Question #7: What is the plan and timeline for DoD to expand
    Essentris to 100 percent of its sites and account for every inpatient
    bed in the DoD system? What challenges does this create for clinicians
    and medical providers between both DoD and VA medical systems?

        Answer: The DoD Military Health System continues to expand its use
    of Essentris, an inpatient clinical documentation product. On March 26,
    DoD awarded a contract for centrally funded implementation and
    sustainment of Essentris to vendor, CliniComp International. DoD
    anticipates that by the end of Fiscal Year 2009, DoD will be sharing
    discharge summaries with VA from 24 Essentris sites which cover 59
    percent of DoD's total inpatient beds. DoD plans to deploy Essentris to
    cover more than 90 percent of its total inpatient beds by January 2011.
        To realize the full value of Essentris, DoD and VA clinicians and
    medical providers must be aware that information exists, must know how
    to access it, and must actually access it. To facilitate access to
    Essentris data, the DoD desktop icon through which DoD clinicians and
    providers access the data has been relabeled to read VA information and
    Theater information to be more intuitive.

        Question #8: Are we correct in surmising that the samples that the
    Committee viewed during the hearing of different servicemembers'
    records were selected from the many others in which may or may not be
    as complete or be as interconnected? If so, what percentage of those
    who have been separated from service in the last year had this degree
    of interoperability and depth so that the physician from VA or DoD or
    private sector, but especially VA, can access all that information
    going back to when the injury may have occurred.

        Answer: VA has access to electronic health information on more than
    4.8 million individuals. The earliest data, starting with ancillary
    data, are from 1989. Since 2001, increasingly more data have been made
    available electronically.
        Not all prior Servicemembers will have Theater data available
    electronically to VA. The ability for VA to access Theater data became
    operational in October 2007. VA would not be able to access Theater
    data on individuals in Theater prior to October 2007. Likewise, not all
    former Servicemembers would have digital radiology images available to
    VA at this time, since that capability is operational at a limited
    number of pilot sites.
        Additionally, VA and DoD are working to upgrade and enhance the
    technical framework that supports data sharing and improve the
    framework's capability to handle increasing amounts of shared data.
    Contract awards for beginning these upgrades and enhancements are
    expected in the next 2 months.
        In general, VA has access to:

          Since 2001, for separated Servicemembers, DoD has
    provided VA with one-way historic information through the Federal
    Health Information Exchange. On a monthly basis DoD sends laboratory
    results; radiology reports; outpatient pharmacy data; allergy data;
    discharge summaries; consult reports; admission, discharge, transfer
    information; standard ambulatory data records; demographic data; pre-
    and post-deployment health assessments; and post-deployment health
    reassessments.

        For shared patients being treated by both DoD and VA, DoD continues
    to maintain the jointly developed Bidirectional Health Information
    Exchange (BHIE) system, which was implemented in 2004. Using BHIE, DoD
    and VA clinicians are able to access each other's health data in real-
    time, including the following types of information: allergy; outpatient
    pharmacy; inpatient and outpatient laboratory and radiology reports;
    demographic data; diagnoses; vital signs; family history, social
    history, other history; questionnaires; and Theater clinical data,
    including inpatient notes, outpatient encounters, and ancillary
    clinical data such as pharmacy data, allergies, laboratory results and
    radiology reports.

                                         Committee on Veterans' Affairs
                            Subcommittee on Oversight and Investigation
                                                        Washington, DC.
                                                        August 12, 2009

    Honorable Eric K. Shinseki
    Secretary
    U.S. Department of Veterans Affairs
    810 Vermont Avenue, NW
    Washington, DC 20420

    Dear Secretary Shinseki:

        Thank you for the testimony of the Honorable Roger W. Baker,
    Assistant Secretary for Information Technology, U.S. Department of
    Veterans Affairs, accompanied by Paul Tibbits, M.D., Deputy Chief
    Information Officer, Office of Enterprise and Development, U.S.
    Department of Veterans Affairs, Scott Cragg, Executive Director and
    Program Manager, Virtual Lifetime Electronic Record Program, U.S.
    Department of Veterans Affairs, Douglas E. Rosendale, DO, FACOS,
    Enterprise System Manager for Joint Interoperability Ventures, Office
    of Health Information, Veterans Health Administration, U.S. Department
    of Veterans Affairs, and Ross D. Fletcher, M.D., Chief of Staff,
    Washington, DC Veterans Affairs Medical Center, Veterans Health
    Administration, U.S. Department of Veterans Affairs at the U.S. House
    of Representatives Committee on Veterans' Affairs Subcommittee on
    Oversight and Investigations hearing that took place on July 14, 2009
    on ``Examining the Progress of Electronic Health Record
    Interoperability Between the U.S. Department of Veterans Affairs and
    U.S. Department of Defense.''
        Please provide answers to the following questions by COB on
    Wednesday, September 16, 2009 to Todd Chambers, Legislative Assistant
    to the Subcommittee on Oversight and Investigations.

        1.  You stated that DoD and VA have come a long way in sharing
    electronic medical records to serve our veterans, but please discuss
    the challenges you see with fee-basis documents, test results, imaging,
    etc. for our veterans that are referred out to civilian physicians. How
    does this affect our Reserve/Guard forces, as well as our rural
    veterans in need of medical care?
        2.  Please tell us how many patients get transferred to a
    polytrauma center each year and what is the percentage of those
    patients that are referred with their digital radiological images and
    scanned inpatient information? Are any being transferred without these
    electronic medical records at this point in time?
        3.  It is stated in testimony that the DoD and VA Information
    Interoperability Plan (IIP) is a living document and that it has 22
    initiatives that make up the pathway to information interoperability.
    Would you define this document as fluid or certain? What challenges
    exist with working on this ``living'' document? If the IIP is always
    evolving, do you believe that you will ever reach a fully interoperable
    state?

        Thank you again for taking the time to answer these questions. The
    Committee looks forward to receiving your answers. If you have any
    questions concerning these questions, please contact Subcommittee on
    Oversight and Investigations Majority Staff Director, Martin Herbert,
    at (202) 225-3569 or the Subcommittee Minority Staff Director, Arthur
    Wu, at (202) 225-3527.

                Sincerely,

    Harry E. Mitchell
    Chairman

                                                    David P. Roe

                                                    Ranking Republican
                                                    Member

    MH/tc

                                   __________
                            Questions for the Record
                     The Honorable Harry Mitchell, Chairman
                  Subcommittee on Oversight and Investigations
                      House Committee on Veterans' Affairs
                                 July 14, 2009
               Examining the Progress of Electronic Health Record
                Interoperability Between the U.S. Department of
                Veterans Affairs and U.S. Department of Defense

        Question 1: You stated that DoD and VA have come a long way in
    sharing electronic medical records to serve our veterans, but please
    discuss the challenges you see with fee-basis documents, test results,
    imaging, etc. for our veterans that are referred out to civilian
    physicians. How does this affect our Reserve/Guard forces, as well as
    our rural veterans in need of medical care?

        Response: Using the bidirectional health information exchange
    (BHIE), the Department of Veterans Affairs (VA) and the Department of
    Defense (DoD) currently share almost all pertinent clinical information
    that is available electronically on shared patients. This includes
    Veterans residing in rural areas since BHIE is available at every VA
    medical center. Patient clinical test results, such as laboratory and
    radiology reports, are included in this information and are available
    in readable text format. Additionally, VA and DoD have made some
    progress sharing images at select locations, and are working on the
    capability to support image sharing enterprise-wide. Patients for whom
    records are shared between VA and DoD include those Reserve and
    National Guard forces who are serving on active duty and have military
    health data available in DoD systems. It also includes those who are
    fully separated or demobilized from service and who are referred to VA
    for care or treatment.
        With respect to sharing fee basis documents, test results and
    images with private civilian clinicians, VA is working with DoD and
    other civilian participants at a national level to develop the
    Nationwide Health Information Network (NHIN) sponsored by the
    Department of Health and Human Services (HHS). NHIN will leverage
    recognized interoperability standards to support information sharing
    among both government and private health care organizations. Within the
    context of NHIN, VA and DoD will apply lessons learned from its data
    sharing efforts to ensure that information is available to support
    Veteran care where and when it is needed. The data sharing capabilities
    using NHIN will be contingent on whether private sector providers
    choose to use NHIN. When VA and DoD exchange data through NHIN it will
    include all Veterans and servicemembers, including those in rural
    areas.

        Question 2: Please tell us how many patients get transferred to a
    polytrauma center each year and what is the percentage of those
    patients that are referred with their digital radiological images and
    scanned inpatient information? Are any being transferred without these
    electronic medical records at this point in time?

        Response: On average, 100-125 active duty patients are referred
    annually to a VA polytrauma rehabilitation center (PRC) from military
    treatment facilities. From April 2008 to present, 103 active duty
    patients were referred to a PRC from National Naval Medical Center
    (NNMC), Walter Reed Army Medical Center (WRAMC) and Brooke Army Medical
    Center (BAMC). All 97 of the patients referred from NNMC and WRAMC were
    sent with both digital radiological images and scanned patient
    information. The six patients referred from BAMC during this period
    provided only digital radiological images (not scanned patient
    information).
        Additionally, for fiscal 2008 through June 30, 2009, 92 active duty
    patients were referred to a PRC from other DoD military treatment
    facilities and warrior transition units which are not yet sending
    digital radiological images or scanned patient information.

        Question 3: It is stated in testimony that the DoD and VA
    Information Interoperability Plan (IIP) is a living document and that
    it has 22 initiatives that make up the pathway to information
    interoperability. Would you define this document as fluid or certain?
    What challenges exist with working on this ``living'' document? If the
    IIP is always evolving, do you believe that you will ever reach a fully
    interoperable state?

        Response: The information interoperability plan (IIP) is a fluid
    living document intended to guide the interoperability efforts between
    VA and DoD. The IIP does not represent ``funded'' or ``programmed''
    projects but provides a necessary strategic blueprint VA and DoD can
    work toward. VA and DoD define ``interoperability'' based on the
    business needs to share information. For example, health data
    interoperability is determined by the clinical priorities established
    by VA and DoD clinicians on the Interagency Clinical Informatics Board
    (ICIB). With respect to challenges, VA and DoD must work to achieve
    interoperability while facing disparate funding cycles for information
    technology development. The Departments are also faced with fulfilling
    shared business requirements for information while simultaneously
    meeting the unique mission needs of each organization (i.e., support
    for DoD warriors and support for VA long term care facilities).
    Additionally, achieving interoperability depends not only on technical
    progress made by the Departments, but also on the availability of data
    standards to support information exchange. The Departments must remain
    aligned with national standards identification and development efforts
    led by HHS while at the same time making progress to share data between
    VA and DoD. To address challenges related to standards, VA and DoD
    continue to participate on national standards development organizations
    and have closely partnered with HHS and industry leaders for health
    technology.
        While the IIP evolves, so does the availability of data standards
    and modern technologies that will continue to improve data sharing
    between the Departments. In this regard, the Departments anticipate
    that the level of interoperability will continue to evolve. The focus
    of sharing information is on supporting the level of interoperability
    that meets the information requirements identified by those who need
    the information, such as clinicians treating Veterans and staff
    adjudicating claims benefits. In this regard, VA and DoD believe the
    goals of the IIP will be met.