[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]


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51-872

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 [email protected].

                               __________
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 [email protected]. 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 [email protected].

                                                  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.