    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                        CLOSING THE DATA GAP: IMPROVING
                          INTEROPERABILITY BETWEEN VA
                            AND COMMUNITY PROVIDERS

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

                                    HEARING

                                   BEFORE THE

                    SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                             MONDAY, MARCH 24, 2025

                                   __________

                               Serial No. 119-11

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                                    __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    60-672                  WASHINGTON : 2025

    -----------------------------------------------------------------------------------

                        COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,
    GREGORY F. MURPHY, North Carolina        Florida
    DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
    MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
    JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
    KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
    JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
    ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
    KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
        Mariana Islands
    TOM BARRETT, Michigan

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                    SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION

                        TOM BARRETT, Michigan, Chairman

    NANCY MACE, South Carolina           NIKKI BUDZINSKI, Illinois, Ranking
    MORGAN LUTTRELL, Texas                   Member
                                         SHEILA CHERFILUS-MCCORMICK,
                                             Florida

    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

                                  ----------

                             MONDAY, MARCH 24, 2025

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Tom Barrett, Chairman..............................     1
    The Honorable Nikki Budzinski, Ranking Member....................     3

                                   WITNESSES
                                    Panel I

    Dr. Jonathan Nebeker, M.D., Chief Medical Informatics Officer &
      Executive Director of Clinical Informatics, Veterans Health
      Administration, U.S. Department of Veterans Affairs............     6

            Accompanied by:

        Dr. Laura Prietula, Deputy Chief Information Officer,
            Electronic Health Record Modernization Integration
            Office, U.S. Department of Veterans Affairs

    Mr. Rick McGraw, Chief Growth Officer, Michigan Health
      Information Network Shared Services............................     7

    Dr. Andrew Rosenberg, M.D., Chief Information Officer, Michigan
      Medicine.......................................................     9

    Dr. Leo Greenstone, M.D., Chief Medical Officer, Signature
      Performance....................................................    11

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Jonathan Nebeker, M.D. Prepared Statement....................    33
    Mr. Rick McGraw Prepared Statement...............................    35
    Dr. Andrew Rosenberg, M.D. Prepared Statement....................    36
    Dr. Leo Greenstone, M.D. Prepared Statement......................    38

                            Statement For The Record

    DirectTrust Prepared Statement...................................    45

                        CLOSING THE DATA GAP: IMPROVING
                          INTEROPERABILITY BETWEEN VA
                            AND COMMUNITY PROVIDERS

                                  ----------

                             MONDAY, MARCH 24, 2025

      Subcommittee on Technology Modernization,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:57 p.m., in
    room 360, Cannon House Office Building, Hon. Tom Barrett
    (chairman of the subcommittee) presiding.
        Present: Representatives Barrett, and Budzinski.

               OPENING STATEMENT OF TOM BARRETT, CHAIRMAN

        Mr. Barrett. Good afternoon. The subcommittee will come to
    order.
        I want to start by saying I appreciate the effort of those
    on the panel that are here to testify today and appreciate your
    willingness to come before the committee. In the future,
    though, I would really appreciate, particularly for those here
    from the U.S. Department of Veterans Affairs (VA), if you can
    provide your testimony ahead of time. I know that a lot of work
    goes into that but, you know, the subcommittee staff here,
    myself and my staff appreciate the opportunity to review some
    of the commentary and remarks and everything ahead of these
    committees and would appreciate your willingness to provide
    that in the timelines that we have. I feel like we have been
    pretty generous with the timelines we have given, and it takes
    everybody's cooperation to make sure that we are able to do
    this in a timely and efficient way. Appreciate that.
        I asked the VA to appear today because of interoperability
    impacts and what it does to every veteran across our country.
    The Department's testimony is critical for the subcommittee's
    oversight requirements.
        Now, on to today's topic. Of course, I kind of mentioned
    briefly about interoperability, but this is important because
    all across the country right now as we are sitting here in this
    committee, a veteran somewhere is walking into a new doctor's
    office for the very first time. This veteran will not have any
    prior relationship with the provider they are encountering, and
    they may not have any of their medical records on file at that
    particular hospital or medical facility.
        This doctor's office could be at a VA medical center. It
    could be at a community care facility. No matter the location,
    the doctor will have the same question: How do I give this
    veteran the best care without knowing their medical history,
    without knowing their medication, without knowing their
    allergies, their lab results, whether or not this veteran has
    struggled with mental health challenges?
        There are several doctors on our panel today, and I am sure
    they would agree that complete and accurate information is an
    important ingredient in high-quality healthcare.
        Providers want their patients' healthcare data to be
    interoperable. They want to be able to exchange medical records
    regardless of which hospital they were created at and use that
    information to treat their patients.
        I want to be clear. VA and the entire healthcare industry
    have made enormous progress for the last two decades and
    millions of healthcare records are exchanged every single year
    all across our country in various ways.
        Even when data exchange does not happen, veterans still
    receive great healthcare every day when providers do not have
    access to their complete medical history. I know that we have
    very well-trained physicians who provide the absolute greatest
    level of care that they can. However, the best healthcare
    requires truly interoperable healthcare data that moves with
    the veteran regardless of which Electronic Health Record (EHR)
    is being used by the doctor and who is treating them.
        There are gaps that remain and opportunities for
    improvement. VA provides healthcare to millions of veterans
    every single year, including myself. However, roughly one-third
    of VA care is provided by the Community Care Network (CCN).
        Throughout their lifetime, veterans will visit an
    assortment of providers at the U.S. Department of Defense
    (DOD), the VA, and private facilities. Every appointment
    produces new information. VA has made a ton of progress
    exchanging data with larger hospital systems, but struggles to
    exchange data with many smaller hospitals and physicians'
    offices.
        In order to live up to our commitment to veterans, VA must
    be able to share and use complete and accurate healthcare
    information with each of the Community Care partners. A big
    part of that is ensuring that when healthcare data is exchanged
    between VA and Community Care providers, it is standardized.
        There is only so much a provider can do with a list of lab
    results if each hospital documents and displays the results
    differently. This is the difference between a read-only file
    and data that is searchable, sortable, and able to be organized
    and utilized. The quality of the data is just as important as
    the quantity.
        That is why this committee put a requirement in the Dole
    Act for the VA to adopt health information interoperability
    standards for the Department and its Community Care providers.
    These standards are about data quality and will improve how VA
    and Community Care providers exchange data for care and
    benefits, patient identity matching, and more, ultimately
    improving outcomes for veterans inside and outside the VA.
        During this hearing, I hope to hear some preliminary
    updates on VA's strategy. In addition, I hope to hear about
    some of VA's recent progress and their plans to bridge the
    interoperability gaps that still exist.
        VA recently created the Veterans Interoperability Pledge,
    which allows private hospitals to instantly confirm whether a
    patient is a veteran. There are many health issues that are
    assumed to be linked to military service. Simply knowing that a
    patient is a veteran allows healthcare providers outside VA's
    system to give the best care, consider service-related health
    issues, and quickly connect them to the right supports where
    necessary. This is an important leap forward for data exchange
    between VA and community partners. While it is only in its
    infancy, I am eager to hear more about its early success and
    VA's plans to expand to more Community Care providers.
        VA is currently connected to over 90 percent of hospitals
    in America through Health Information Exchanges. Ten years ago,
    though, VA exchanged less than 100,000 healthcare documents a
    year. Now they are exchanging millions.
        While VA is connected to roughly 90 percent of U.S.
    hospitals, the last 10 percent are the hardest to reach. Far
    less than 90 percent of physicians' offices are currently
    exchanging data with the VA.
        I will close by saying that many of the technical
    challenges around healthcare interoperability are no longer
    obstacles. What remains is for VA to organize and collaborate
    with its Community Care partners to make sure that the provider
    I mentioned earlier who is seeing a veteran for the first time
    today has all the information they need to provide the best
    care possible.
        Thank you again for being here. I look forward to your
    testimony.
        With that, I will yield to the Ranking Member Budzinski for
    her opening statement as well.

          OPENING STATEMENT OF NIKKI BUDZINSKI, RANKING MEMBER

        Ms. Budzinski. Thank you very much, Mr. Chairman.
        Thank you as well to the witnesses for being here to
    discuss this critical topic today.
        Interoperability is a crucial factor in ensuring safe,
    effective, and veteran-centric healthcare. It supports the care
    coordination that is a hallmark of VA healthcare.
        Unfortunately, VA's interoperability efforts have been
    hindered for decades by the decentralized nature of its
    Electronic Health Record. In fact, one of three major goals of
    the Electronic Health Record Modernization, or EHRM Program, is
    to implement an EHR that is interoperable with DOD and
    Community Care providers, creating a complete medical record
    for the life of the veteran.
        A complete medical record allows for better outcomes for
    veterans, as their providers, wherever they receive care, have
    all the information they need to make the best, most clinically
    informed decisions. I wholeheartedly support this effort.
        However, getting from where we are today to complete
    interoperability is no small undertaking. It requires a
    combination of efforts from three corners: Technology, people,
    and process. VA utilizes a multitude of platforms, systems, and
    frameworks to approach interoperability from a technology
    standpoint, from the referral of services with the Health Share
    Referral Manager, or HSRM, to the standardization of the data,
    Veterans Data Integration and Federation Enterprise Platform
    (VDIF-EP), to the information sharing itself with Veteran
    Health Information Exchange and VA's growing work with Trusted
    Exchange Framework and Federation Enterprise Platform (TEFCA).
        VA appears to be throwing everything they have at
    interoperability. VA's websites tout a seamless and secure
    interface for VA and community providers with this
    infrastructure, but from what I have heard that does not seem
    to be the case.
        Despite these systems getting us closer to our
    interoperability goals, they do not encompass the full picture.
    VA's legacy EHR does not allow for complete integration of
    medical records even when they are shared through the Health
    Information Exchange.
        This requires clerks to locate records, download them, and
    then upload them to Veterans Health Information Systems and
    Technology (VistA). Oracle Cerner's EHR has a direct link to
    the Exchange, allowing records to be pulled in and integrated
    in two to three clicks, though, again, these records can only
    be pulled through if providers are using the Veteran Health
    Information Exchange and if they know and remember to do it.
        Without standard use of the Exchange, providers continue to
    rely on sending information via fax or E--I am sorry, or HSRM,
    which inevitably results in processing delays and backlogs and
    risks incomplete records that could have disastrous clinical
    impacts, including putting patient safety at risk.
        I look forward to hearing from Dr. Greenstone, a former
    executive director of clinical operations at VA, and Mr. McGraw
    from the Michigan Health Information Network on systems that
    integrate referrals and document management into one workflow.
        Technology is great, but it is nothing without the people.
    It takes a highly skilled and impressively dedicated workforce
    to deliver the world-class healthcare and benefits the VA is
    known for.
        That is why the recent news of the Trump administration's
    personnel actions is extremely concerning. Their decisions to
    terminate over 2,400 probationary employees and its plans to
    further reduce the VA workforce by at least 15 percent, or
    80,000 positions, is abhorrent. These actions have already
    resulted in negative patient outcomes for veterans and will
    continue to do so.
        While it is great the VA purports to be exempting doctors
    and nurses from these cuts, that ignores the fact that there
    are dozens of other jobs, clinical and nonclinical, that make
    delivery of healthcare possible.
        For example, scanning and file clerks in the Health
    Information Management, or HIM service, were impacted in the
    Secretary's probationary employee purge. Without sufficient HIM
    scanning and filing clerks, medical records will continue to
    pile up, not being entered into the veterans' files and further
    risking quality of care. If we expect world-class care for
    veterans at VA, we must ensure the VA is resourced adequately
    to do so.
        Finally, VA's ongoing struggles with its processes have
    overcomplicated what was already a complicated process. Like
    most of VA's modernization efforts, the move toward
    interoperability seems to be burdened by training and change
    management challenges.
        Additionally, the variation of VA's clinical workflows
    makes the data standardization needed for interoperability
    difficult, and the agreements with Community Care providers and
    Third-Party Administrators leaves VA with little recourse for
    accountability.
        The lack of connectivity depends on the user. Some
    Community Care providers are unaware of the Health Information
    Exchanges and their practices do not possess mature enough
    systems to utilize it. Others are not trained adequately to
    just the tools, defaulting to their comfortable workflows, like
    faxes, fax machines and phone calls.
        By reverting to these antiquated workflows, providers and
    veterans may face weeks' or even months' long delays in
    accessing their records due to processing backlogs, backlogs
    that will likely only become lengthier with the Trump
    administration's cuts to the VA workforce and Information
    Technology (IT) contract support.
        I look forward to today's discussion, but also think we
    need to have a bigger conversation with Oracle and the Third-
    Party Administrators for the Community Care Network in future
    meetings on their efforts to increase awareness, training, and
    use of interoperability tools and how they are going to hold
    both VA and Community Care providers accountable.
        Ultimately, we must be realistic about what we are
    expecting VA to do and with what resources. Especially when we
    operate in an environment as we are today with an
    administration that wants VA to do more with less.
        I believe this conversation today will be enlightening, and
    I look forward to further work on this topic.
        Thank you, Mr. Chairman, and I yield back.
        Mr. Barrett. Thank you. I appreciate that.
        I will now introduce our witnesses. From the Department of
    Veterans Affairs, we have Dr. Jonathan Nebeker, chief medical
    informatics officer and executive director of clinical
    informatics. Did I say that correctly? Very good, Doctor.
        Dr. Laura Prietula--right?--deputy chief information
    officer for the Electronic Health Record Modernization
    Integration Office.
        Also joining us from the great State of Michigan, of
    course, is Mr. Rick McGraw, Chief Growth Officer for the
    University of Michigan Health Information Network Shared
    Services; and Dr. Andrew Rosenberg, chief information officer
    at Michigan Medicine. Thank you.
        Finally, we have Dr. Leo Greenstone, chief medical officer
    at Signature Performance.
        Very good. Thank you all again, each one of you, for being
    here today. I ask the witnesses to please stand and raise your
    right hand.
        [Witnesses sworn.]
        Mr. Barrett. Thank you. Let the record reflect that all
    witnesses have answered in the affirmative.
        Going in order, Dr. Nebeker, you are now recognized for 5
    minutes to deliver your opening statement on behalf of VA.

                     STATEMENT OF JONATHAN NEBEKER

        Dr. Nebeker. Good afternoon, Chairman Barrett, Ranking
    Member Budzinski, and distinguished members of the
    subcommittee.
        Joining me here today is Dr. Laura Prietula, deputy chief
    information officer of the Electronic Health Record
    Modernization Integration Office.
        Thank you for the opportunity to discuss interoperability
    between the Department of Veterans Affairs and communities
    beyond VA. Our efforts to expand veterans' access to care, both
    inside and outside VA, mean more veterans are using their
    benefits to seek care.
        Recently enacted laws like the Veterans Comprehensive
    Prevention, Access to Care, and Treatment (COMPACT) and John S.
    McCain III, Daniel K. Akaka, and Samuel R. Johnson VA
    Maintaining Internal Systems and Strengthening Integrated
    Outside Networks (MISSION) Acts empower veterans to seek care
    from the community providers when it is in the best interests
    or for--best interests for the veteran or when VA care is
    unavailable.
        As a result, the need for care coordination and exchange of
    health information among VA and community providers has surged.
    Exchange and use of healthcare data are essential for ensuring
    the veterans have better access, better health, and reduced
    out-of-pocket expenses.
        In 2009, VA and DOD began allowing clinicians to view
    shared data to reduce reliance on paper records. Launched in
    2014, the Joint Longitudinal Viewer, or JLV, provided a more
    reliable and user-friendly solution.
        In January 2025, now, over 110,000 VA employees accessed
    and opened 2.2 million Community Care documents in JLV. User
    surveys showed JLV improved patient outcomes, saved time, and
    reduced duplicative testing.
        The Joint Health Information Exchange, commonly referred to
    as JHIE, established by VA and DOD in 2020, has significantly
    improved Federal EHR interoperability. It connects well over
    100,000 provider sites through two national exchanges, eHealth
    Exchange and Commonwealth. In January 2025 alone, JHIE
    exchanged over 360 million documents for 18 million patient
    matches.
        The Trusted Exchange Framework and Common Agreement, also
    known as TEFCA, is a nationwide framework for health
    information sharing. VA aims to participate in TEFCA, contract
    with a Qualified Health Information Network (QHIN) provider,
    and be fully functional and tested for purposes of treatment by
    early December 2025. Key considerations include accurate
    patient matching and cost.
        The deployment of the Federal Electronic Health Record will
    also advance this interoperability agenda. Despite the
    significant progress, VA continues to address connectivity
    gaps, especially with small provider organizations not using a
    top five EHR system.
        While about 80 percent of veterans actively enrolled in VA
    care visit at least one--sorry. While 80 percent of veterans
    actively enrolled in VA care visit at least one provider
    connected to the national exchange, only 30 percent of
    providers billing VA for Community Care are connected to
    eHealth Exchange or Commonwealth.
        Connectivity to State or metropolitan exchanges via
    Regional Health Information Organizations, or RHIOs, may help
    close this gap. Moreover, RHIOs enhance care coordination by
    offering unique services, like longitudinal viewers and push
    notifications that national exchanges currently do not.
        VA is collaborating with industry partners to improve data
    quality gaps, which impact clinical decision support, quality
    measurement, population health and benefits adjudication.
        Examples of challenges include incorrect weights, missing
    serum sodium values, incomprehensible codes and misclassified
    allergies. Stakeholders are developing open-source technologies
    to objectively code data quality and provide improvement
    suggestions.
        The Veteran Interoperability Pledge (VIP) demonstrates a
    cost-effective approach to interoperability, yielding
    significant benefits for veterans. Launched in 2023, with 13
    high-quality healthcare systems, VIP addresses goals beyond
    TEFCA, including identifying veterans, connecting them with VA
    and community resources, and ensuring reliable care
    coordination. Our partners have already identified over 200,000
    veterans that may benefit from the COMPACT and PACT Acts.
        VA plans to expand VIP membership to more healthcare
    systems, payors, and technology companies, prioritizing
    automation in benefits determination and care coordination.
    These efforts will ensure that VA can connect veterans to
    Federal, State, and donated benefits.
        VA remains committed to putting veterans at the center of
    its operations, focusing on customer service and convenience,
    which interoperability makes easier.
        We appreciate the subcommittee's commitment and oversight
    to ensure VA serves veterans with excellence, and we look
    forward to responding to any questions you may have.

        [The Prepared Statement Of Jonathan Nebeker Appears In The
    Appendix]

        Mr. Barrett. Thank you, Doc, appreciate it.
        The written statement of Dr. Nebeker will be entered into
    the hearing record.
        I think we are moving next to Mr. McGraw. Is that correct?
    Dr. Prietula, do you have a separate--okay, very good. Then,
    Doc, I will get back to you in just a moment. I think we are
    going next to Mr. McGraw for your remarks for 5 minutes. Thank
    you.

                        STATEMENT OF RICK MCGRAW

        Mr. McGraw. Thank you. Thank you for the opportunity to
    testify today about the vital role that Health Information
    Exchanges (HIE) play in the interoperability of our overall
    healthcare infrastructure. Today, I will concentrate my
    testimony on the over 10 million residents of Michigan, with
    over 461,000 veterans of our military services.
        Michigan Health Information Network (MiHIN) is our
    statewide HIE. MiHIN was formed in 2010 as a public-private
    partnership with the Health Information Technology Commission,
    housed in the Department of Health and Human Services. MiHIN
    was designed to play a pivotal role in advancing healthcare
    interoperability by facilitating seamless information sharing
    across Michigan's healthcare ecosystem.
        Since MiHIN's inception in 2010, we have interfaced with
    nearly 80 individual Electronic Health Record systems and two
    national networks that only represent a limited number of use
    cases. A use case is a unique instance of sharing specific
    information regarding patients and their health.
        MiHIN, however, operates over 50 use cases for our clients,
    ranging from hospitals, primary care facilities, payers,
    community mental health facilities, skilled nursing facilities
    and local city and county health departments, to name a few.
        From the 5,300-plus healthcare facilities connected to
    MiHIN, we have routed over 8.3 billion messages to enhance care
    coordination and vital data delivery across the State. For
    example, 97 percent of all State admission, discharge, and
    transfer summaries pass through MiHIN today.
        MiHIN's direct interfaces with local healthcare facilities'
    EHRs provides instantaneous record submissions immediately
    following an encounter with a patient. In less than 4 minutes,
    that information is received, verified, and routed to our
    portal, where the patient's longitudinal record is updated with
    their latest information.
        Our most recent use case is collaborating with a mobile
    technology company to route realtime data from ambulances en
    route to emergency rooms (ER). Emergency medical technicians en
    route will have access to a patient's Electronic Medical
    Records (EMR) while also transmitting current vitals to the
    receiving emergency department (ED).
        Alerts sent to the ED will notify them that the patient is
    en route so they have access to the patient's longitudinal
    record from MiHIN. The best quality healthcare is not only
    local, but it is in near real time.
        For security and privacy considerations, MiHIN, as a
    business associate to the largest health and government systems
    in Michigan, provides security and privacy of healthcare data
    while ensuring it is interoperable and accessible.
        MiHIN and our major technology vendors are certified under
    Health Information Trust Alliance (HITRUST) Risk Based, 2 year
    (r2) certification. This industry-leading certification
    requires external penetration testing, security in operations,
    and security during the development of custom applications,
    ultimately ensuring best practices across all our systems and
    services.
        MiHIN designed our Active Care Relationship Service model,
    which allows realtime association of patients with their
    providers using the information found in the data ingested by
    MiHIN. This service restricts patient data access to only those
    providers that actively care for that patient.
        With all of this in mind, let us consider a veteran's
    healthcare journey. If a veteran goes to their primary care
    doctor that uses one EHR but also goes to a community mental
    health facility that uses a different EHR and also sees a
    specialist on a third EHR, without an HIE like MiHIN these
    providers would not be able to access critical patient
    information from those other encounters.
        Because of MiHIN's broad network of connectivity, MiHIN has
    all interactions from all three facilities available in that
    patient's longitudinal record to improve overall care
    coordination.
        Today, however, in Michigan, the VA and DOD are a blind
    spot to a veteran's overall healthcare. The VA does not only
    not submit data through the network but cannot access its
    patients' records from encounters outside of the VA.
        From a provider perspective, HIEs bring critical value. A
    2024 survey of primary care physicians found that 81 percent
    spend less time with their patients than they would like, 57
    percent write prescriptions or refer patients out due to time
    constraints, 46 percent report a lack of adequate time with
    patients as a top stressor and almost two-thirds feel their
    work is more transactional rather than relational.
        Accessing patient information within an HIE's longitudinal
    record has shown that a provider can save up to 15 minutes per
    patient per visit while the cost of this access is nominal.
        Today, the VA does not comprehensively see interactions
    outside of its facilities, and like the patient journey example
    I gave you, Community Care facilities cannot see veterans'
    interactions with the VA hospital either.
        There is no such thing as a lifetime record of a veteran's
    healthcare residing in one EHR system. It simply does not
    exist. There is also no such thing as a national exchange with
    a handful of EHRs that can replace the infrastructure we have
    spent the last 14 years perfecting.
        We can and we must do better to provide higher quality care
    to our veterans in Michigan. There is always potential for
    improvement, and I believe we can achieve it with the right
    strategies, support, and collaboration.
        Thank you for the time and attention to this important
    issue. Your support and understanding are greatly appreciated.

        [The Prepared Statement Of Rick McGraw Appears In The
    Appendix]

        Mr. Barrett. Thank you, Mr. McGraw.
        The written statement of Mr. McGraw will be entered into
    the hearing record.
        Dr. Rosenberg, you are now recognized for 5 minutes for
    your opening statement on behalf of Michigan Medicine. Thank
    you.

                     STATEMENT OF ANDREW ROSENBERG

        Dr. Rosenberg. Good afternoon. I want to use my time to
    emphasize three areas in my statement. I want to take the
    perspective of a provider in particular, but also with an
    organization that is providing the care in the communities that
    we have discussed.
        Exchanging the information that we are talking about is not
    controversial. This is common sense. It is a common expectation
    that we as providers have, our nurses, our doctors, our
    administrators. It is a common expectation of patients and
    their families. This is a good discussion for us to be having.
    I would also say it is really an ethical responsibility. The
    providers feel very, very strongly to do this and to do it
    well, as you have already mentioned.
        The reality is when I think about some of us, Dr. Nebeker
    or Dr. Greenstone and I, when we were training, we did Health
    Information Exchange a few times a day, at best. Usually it was
    a packet of papers in an envelope and occasionally later on a
    CD that we would hand walk down and try to get the images
    loaded. The reality is these were at very, very good places
    really only 10 years ago.
        Now, as you have already mentioned, we are doing a lot of
    Health Information Exchange. At Michigan Medicine alone, across
    our large health system in our somewhat unique role in the
    State, within our electronic medical record we are exchanging
    over 220,000 records a day. With our excellent State HIE, we
    are exchanging tens of thousands of records and results,
    particularly admission, discharge, and transfer notices, that
    are critical in that infrastructure to make this work, for a
    community doctor or others to know when a veteran has been seen
    or not.
        Within our VA itself, although somewhat new, we are
    exchanging almost 3,000 records a day. Especially as we,
    Michigan Medicine, sign onto the QHIN VR EHR and with the VA
    already involved in eHealth Exchange, those numbers are going
    to go up more and more and more.
        From where we were to where we are now is a very good news
    story. Obviously, we want to do better. Why is that happening?
    I was recently in the U.K. I was lecturing at some very good
    health systems, and they were challenged exchanging information
    even within their own health system; whereas, for us, because
    of the networks we have, Commonwealth, Care quality, and
    especially now TEFCA, the frameworks and the networks
    themselves, eHealth Exchange--and I would argue that the direct
    EHR to EHR and EHR into these nodes is the way that we are
    expanding the use of this.
        We have good to very good government regulations. We have
    agreed-upon open standards, Health Level Seven (HL7),
    Consolidated Clinical Document Architecture (C-CDA), the Fast
    Healthcare Interoperability Resources (FHIR) standard. We have
    a very good set of agreed-upon data elements and categories
    with United States Core Data for Interoperability (USCDI). We
    have a number of tools that are currently working to give us
    those numbers that I have just mentioned and even more that are
    in my statement that we can focus on.
        Then the third element of--this has been one of our
    challenges. Within Health Information Exchange, one of the
    challenges that all providers right now are having as we get
    more digital are the digital systems themselves. We have an
    enormous amount of data that we can look up whereas before we
    could not. We have an enormous need to document these, not just
    for patient care but for quality care and efficiency and
    improvements.
        Health Information Exchange is no different from that. We
    want to do it, and yet at the same time we are also overwhelmed
    with all of the other work that our doctors, nurses, and others
    have to do.
        Also, we know that with all these options we have to
    choose. Which do we use? How do we sign up? How long does it
    take to sign up for one versus another? These are things that
    we can continue to improve upon because, as I said, in the end
    we are so much better now but the reality is we know that we
    can still do better.
        I will yield the rest of my time but, hopefully, that
    helps.

        [The Prepared Statement Of Andrew Rosenberg Appears In The
    Appendix]

        Mr. Barrett. Thank you, Doc. I appreciate your testimony.
    We will enter that. Your written statement will be entered into
    the hearing record.
        Dr. Greenstone, you are now recognized for 5 minutes to
    deliver your opening statement on behalf of Signature
    Performance. Thank you as well for being here today.

                      STATEMENT OF LEO GREENSTONE

        Dr. Greenstone. Thank you, Chairman Barrett, Ranking Member
    Budzinski. It is a pleasure to be here to talk to you about
    interoperability between the VA and the community.
        I come to you as a former VA physician for over 18 years,
    primary care doctor; as well as an executive at the local Ann
    Arbor VA for 11 years; and a senior executive in the Office of
    Community Care for 6 and a half years; and now working in the
    private sector for Signature Performance, where we are focused
    on decreasing administrative cost burden within the industry.
        There is no question that we absolutely agree that
    interoperability is so important and so necessary and as also
    we have to recognize it has been really, really hard. People
    have been working at this for a couple decades now, and you can
    hear the incredible progress that has, in fact, been made over
    the years.
        One of the things that I think is critically important to
    recognize is that--I am going to give you a perspective from
    the Veteran Community Care Program that I care deeply about--is
    that we absolutely have to, as the ranking member mentioned,
    focus not just on technology but on people and processes,
    because the technology will not be fully adopted unless we have
    pretty much ubiquitous and reliable tools.
        That is why within healthcare today, we still have a lot of
    use of those tools, telephones and fax machines. A lot of that
    is used today within VA to actually get records back and forth,
    and we want to get rid of that. I would love to sunset fax
    machines but, boy, are they still, you know, pretty active
    today.
        You know, one of the things that I think is critical as
    well is that VA really needs to stay--and they have been really
    good at doing this, but staying in lockstep with U.S.
    Department of Health and Human Services (HHS), in lockstep with
    industry, understanding what is happening with the EHR vendors,
    what is happening with--in the community, and staying very
    close with their colleagues at the Integrated Veteran Care
    Office within VA so that we can ensure that VA staff as well as
    the Community Care Network providers are working very closely
    together to try and ensure that there are work flows that
    utilize a lot of the technologies that we have been hearing
    about and work flows that really support the work that
    individual folks are doing. We have to have thoughtful change
    management for the implementation of these great technologies
    that we have been talking about.
        Within the Veteran Community Care Program, we not only have
    to make sure that providers in the community are receiving
    appropriate clinical information about the veterans that have
    been referred to them, but those providers also need an
    authorization.
        The way things stand now within the Veteran Community Care
    Program, it requires an authorization. That means that the
    provider in the community needs to know what the VA is
    authorizing, what the VA will be paying for, what VA--how long
    is that referral for, and for some services how many visits are
    available. That referral and authorization is not available in
    the Exchange today, but perhaps it could be and that may be a
    future.
        When we look at the solutions going forward, there are a
    couple of things that I think will be valuable to think about
    in the short term and perhaps even a little longer.
        One is, let the VA take advantage of the Dole Act, where
    there is incentive to actually have Third Party Administrators
    (TPA) in the Community Care Network and their providers work
    together, because all of the TPAs, Optum Serve, TriWest, they
    have Veterans Integrated Service Network (VISN)-based provider
    groups that go out and can, in fact, work with providers in the
    CCN network and those providers who get a fair number of
    referrals.
        They can ensure that those providers are connected to an
    Exchange that is connected to a QHIN, that that information
    will be available for VA providers to be able to see and best
    care for veterans, and that that information can be made
    available to VA providers and other staff within the PPMS. This
    is the Provider Profile Management System. It is the directory
    for the Veteran Community Care Program of all its providers.
        Then VA has an opportunity to send referrals to those
    providers who actually are connected to an Exchange. That means
    I may want to do that because I know I can actually get access
    to the data that I need to care for veterans.
        The other thing to consider is, you know, they have this
    closed-loop referral data transfer process that is something
    that is worth further investigating. What I mean is this: Is
    that when a VA provider writes an order and that veteran opts
    to go to the community, the authorization and associated
    medical documentation is passed through the infrastructure of
    the Exchange into the EHR of the receiving provider. Then when
    that veteran is seen, that provider's information that they
    generate is passed on into VA's EHR.
        Therefore, you have this closed-loop referral and medical
    documentation system that is in play today in some places, and
    it is something that the VA may want to consider.
        Thank you for your time, and I look forward to further
    questions.

        [The Prepared Statement Of Leo Greenstone Appears In The
    Appendix]

        Mr. Barrett. Thank you, Doctor.
        The written statement of Dr. Greenstone will be entered
    into the hearing record.
        With the opening statements complete, we will now proceed
    to questioning. I will now recognize myself for 5 minutes.
        Again, thank you all for being here and for the time and
    attention you put toward this.
        A few questions I had just jotted down, based on some of
    your opening statements.
        Dr. Rosenberg, maybe you can answer this and Dr. Greenstone
    too: Do you know of examples where we have duplicated
    procedures, whether it is testing or other, you know,
    procedures, diagnoses, tools that you have, things like that,
    where we have duplicated that because of a lack of
    transferability of medical records or the cumbersome nature of
    it or the lack of interoperability that would apply? I will let
    both of you answer that question separately.
        Dr. Greenstone. Sure. I can certainly start with that,
    Chairman Barrett. I can give an example. I was in a clinic at
    the VA last summer and I saw a veteran who said, hey, Doc, I
    passed out about 2 weeks ago and went to an outside hospital. I
    am like, oh my goodness.
        I looked to see if that was care that was actually
    authorized by VA, and it was. I went into our systems to look
    to see whether a fax had come in, and it had not. I then went
    to the Joint Longitudinal Viewer to ping the Exchange. Look, I
    saw a record from the ER from where he was. When I opened it, I
    was excited because I thought I was going to see everything I
    needed, and all I saw was a problem list, meds and allergies.
    At the top of the problem list, it said syncope, which means he
    passed out. That is what he already told me.
        Then I had asked my clerk to try and call over to get the
    information faxed. Then I have this veteran in front of me who
    I have to start from square one to order tests to figure out
    what the heck was going on with him, do his exam, his history.
        I probably was ordering things that may have already been
    done, right? I had to do all that I had--what I had available,
    as you mentioned before, hey, good docs, we do what we have to
    do, but I will bet you that I ended up doing things that may
    have already been done. I did not have access to do that, but I
    had to come up with a treatment plan.
        Mr. Barrett. Thank you. Do you think the--and that to me is
    not based upon the ability to send data back and forth. It is
    based on the perhaps data protocols of how we organize these
    things so that you are able to access it and read what it says
    and interface with it in a usable way.
        Is that--am I understanding that correctly?
        Dr. Greenstone. Yes. Even when providers within my great
    State of Michigan are connected, not all the information is
    readily available, right? We talked about quality of data and
    we talked about all the data, like notes. Very often office
    notes are not there. Procedure notes may not be available.
        The question is: Why are not all those things available
    when folks have connections and, therefore, some information is
    available? We need better information to be able to make
    clinical decisions.
        Mr. Barrett. Sure. Okay. Dr. Rosenberg.
        Dr. Rosenberg. Quantifying your excellent question is a bit
    difficult, but I will give you my impression. It is probably
    somewhere in the thirds. It depends on the situation. A patient
    arriving in an emergency department where you know nothing
    about them, we are going to be repeating--or we are going to be
    drawing and sending labs and imaging no matter what we find.
        Sometimes it would be helpful to know what preexisting
    conditions or data, labs, imaging existed before, but it is
    usually not that we are going to either rely on those data,
    rely on what might be old data for the situation.
        Another third would be where we have some data but we need
    more complete data or different. It will depend on if we are
    primary care or we are quaternary care itself.
        I think the area that you are focusing on that is
    especially important is when the data are more expensive and
    difficult to get, a biopsy, for example, an expensive or
    difficult radiologic study that we would normally not get or
    that we would want to compare to. Those are still elements
    where, depending on the system, the proximity, the closeness,
    we will either have those data or we will not.
        I think where efficiency would be gained is that, as I have
    mentioned before, the common elements of medications, of basic
    labs, of conditions and documentation where you can frequently
    find the results of data, even if it is not a discrete
    variable, will help some of that gap.
        I would argue that for those things that really are
    difficult to get and expensive, those would be interesting and
    good targets. For example, MiHIN fits into that in the ability
    to act as a broker where a biopsy result is from another
    element that we can commonly get to where we sometimes close
    those gaps, but to quantify that I think would be difficult.
        Mr. Barrett. Sure. Thank you. I do appreciate that. I know
    my first round of questions just run out of time.
        I want to recognize the ranking member for your questions.
        Ms. Budzinski. Sure. Thank you, Chairman.
        Actually, to kind of build on your initial question, I
    wanted to ask Dr. Nebeker from the VA, because in your
    testimony you talked about how the Federal system is 90 percent
    interoperable with hospitals today.
        I think the question, after we have heard from, you know,
    both Dr. Greenstone and Dr. Rosenberg and those experiences,
    you know, how are you measuring interoperability and how are
    you certifying that?
        I just--I find it hard to believe that--where that 90
    percent is coming from, based on at least Dr. Greenstone's
    story.
        Dr. Nebeker. Yes. Thanks for the question. That number
    comes from eHealth Exchange that has looked at who are
    connected to and knows a number of hospitals that are in each
    healthcare organization that we are connecting to. That is
    where that 90 percent comes from.
        Ms. Budzinski. Do you know how they gauge that?
        Dr. Nebeker. I could speculate, but I am not sure. I mean,
    each organization has a website that has--you know, it usually
    states the number of hospitals that they have. The American
    Hospital Association also has similar information on it. I
    imagine--it is, again, speculation, but I imagine that is how
    they arrived at that number.
        Ms. Budzinski. Okay. Can I ask you, continuing just about
    Community Care providers, what is the requirement for Community
    Care providers to return records to the VA?
        Dr. Nebeker. I might want to ask you to clarify the
    question. For my practice, for example, most of the documents
    that I am looking for are actually not paid for by VA. It just
    happens to be the way my patients are and the Salt Lake City
    area is.
        There are no requirements, you know, obviously for those
    people when they go out and use their own health insurance to
    get a specialty appointment or they are seeing sometimes a
    primary care physician. I practice primary care geriatrics.
        Then there is the Community Care documents that--that there
    is a requirement to return documentation on. That is as far as
    I can go, because I am not, you know, overseeing the Integrated
    Veteran Care (IVC) Community Care Network contract.
        Ms. Budzinski. It is possible, basically, you are seeing a
    veteran and that their complete record might not be completely
    captured is what you are saying, because it is not all required
    to be passed back to the VA.
        Dr. Nebeker. Yes. As Dr. Greenstone was stating, the--so, I
    mean, I saw a guy who had--a really healthy 88-year-old guy
    last Friday, I said, how is everything going? No problems at
    all, Doc, I am doing great.
        Then I open up JLV and, click on the button. Up comes these
    records. I say, oh, well, you were in the hospital 2 months ago
    for a urinary tract infection. That actually prevented me from
    ordering a whole raft of lab tests and everything that I was
    thinking about ordering at the time. This was an emergency room
    visit.
        More often than not we do not see notes in the national
    exchanges. It is kind of a mystery to us as to why. You know,
    we deal with--primarily with Hospital Corporations of America
    (HCA), with Intermountain Healthcare, you know, that currently
    has Oracle, and University of Utah that has Epic. From all
    those institutions I am often missing inexplicably data that I
    would expect from a hospitalization and emergency room visits.
    Also, doctors' office visits are rarely there.
        The--you know, what Dr. Greenstone was talking about of
    getting--and also Mr. McCormick, about using--getting the
    office notes, that is kind of really valuable data. Missing
    office-visit notes sometimes results from the way that people
    craft their continuity of care documents. It is often not
    driven by office visits but more by emergency room visits and
    hospitalizations.
        There is a bit of a gap in recent ambulatory-care visits.
    Sometimes, if there is an emergency room visit or
    hospitalization after a consult, a specialty care visit, then
    we will see those notes, but not for recent specialty care
    visits, again, whether paid by VA Community Care network or
    not.
        We can take for the record and get back to you what the--
    what the requirement is on the VA contract.
        Ms. Budzinski. That would be--I would be very interested in
    that and like what the timeliness is of Community Care
    providers as well to provide that information back to the VA,
    you know, and then what recourse the VA has if you are running
    into Community Care providers that just are not providing that
    type of timely information, because, to me, interoperability
    would be if it is successful it is capturing the full picture
    for the veteran patient, not just some, and we are eliminating
    those gaps.
        I will yield back to the chairman.
        Mr. Barrett. Sure. Thank you very much.
        Just following up on that, Dr. Nebeker, is that missing
    data that you are talking about, is the reason for that because
    that record does not exist or because it is not being
    displayed, because you cannot access it because it is not, you
    know, sent through the system? What do you attribute most of
    that to?
        Dr. Nebeker. We are not getting those records because they
    are not being sent from the exchange system. Remember, it is a
    query system that we use typically from these exchanges. We
    send the query out, say, hey, give us your documents. They say,
    okay, here are the documents. Then the excellent portal, the
    gateway that Dr. Prietula and Oracle and others have worked on
    to provide for us collates all those documents and gives them
    to us. A lot of those data just are not getting there in the
    first place.
        Mr. Barrett. That is--where is the pinch point in that?
    Like, what--is it the system that collates it, the system that
    you are querying? I mean, if you were to look up my name and my
    date of birth and Social Security number, it would probably
    give you all my medical records is my assumption. It sounds
    like what you are saying is some of that might be missing.
        Dr. Nebeker. Yes, yes. The EHRs do really well what the
    EHRs were designed for, which is, you know, storing records and
    transactions for a lab test and radiology test and that sort of
    thing.
        They could use some work on getting those data into their
    external gateway and then pushing those out in response to a
    query.
        Mr. Barrett. Okay. I might need some more guidance around
    if they have the information and they are sending some of it,
    why are not they sending all of it? Like, it seems to me like
    it would be an equal amount of work to send all and maybe even
    harder to only send some of it, because you are stopping part
    of that.
        Dr. Nebeker. We do not think it is intentional.
        Mr. Barrett. Right.
        Dr. Nebeker [continuing]. that they are leaving out
    information. I think that would be a nice experiment to, you
    know, talk with some of our partners in the VIP Pledge, for
    example, why are you getting everything there consistently?
        Mr. Barrett. Okay. Then the--that Veteran Information
    Pledge--am I saying that correctly? Is that the name of that
    program?
        Dr. Nebeker. The Veteran Interoperability Pledge, yes.
        Mr. Barrett. Yes. One question I had about that is, I know
    some veterans are not eligible for VA care because of the
    status of their discharge. Does that account for that in that
    system or not?
        Dr. Nebeker. The first piece of work we did was around the
    Veteran Confirmation Application Programming Interface (API).
    This is also known as the Dick's Sporting Good API.
        What this does is use--draws on DOD and VA records and uses
    the Title 38 definition of a veteran whatever that definition
    is at the time. Demographic information are sent to our API,
    the Application Program Interface, on our side, and we send
    back a simple confirmed or not confirmed answer.
        Mr. Barrett. Okay. That would be determined by the
    definition within that, not necessarily all of the protocols,
    like a general discharge, dishonorable.
        Dr. Nebeker. That goes into that Title 38, but it is a
    legal definition created by Congress.
        Mr. Barrett. Okay. All right. Okay, thank you.
        Mr. McGraw, I know that MiHIN has quite a bit of market
    share throughout Michigan. Most network or most systems,
    providers, and other things through Michigan are included
    within that.
        Can you I guess explain if you have records outside of
    Michigan or we have, you know, snowbirds who go down to
    Florida, for example, then come back to Michigan and spend a
    predominant share of their time outside the State, are you--
    what is the process by which their records would be able to
    transfer back and forth or is that still a coverage gap that
    exists?
        Mr. McGraw. We do have--we pay a certain amount of money,
    several hundred thousand dollars a year for access to the three
    national exchanges. We do not just keep the records within the
    State of Michigan. If they do snowbird down to Florida and we
    know that they snowbird down to Florida and they come back, we
    will ping those exchanges to get that data from the national
    exchanges.
        All of our clients can access those national networks
    through an aggregated volume that we have purchased from those
    exchanges. They do not have to go one-on-one. The whole State
    of Michigan can come through us. We connect to those exchanges
    to fill in those gaps.
        Mr. Barrett. Okay. Are the VA facilities in Michigan part
    of MiHIN?
        Mr. McGraw. Today, they are not.
        Mr. Barrett. Okay. Dr. Rosenberg, with the amount of time I
    have left, if you can tell us, I know that Michigan Medicine
    and the Ann Arbor VA, just as an anecdotal example, have quite
    an arrangement between the two of them together.
        How is that information shared without using MiHIN? Like,
    what is the functional way in which that patient information is
    shared across both sides?
        Dr. Rosenberg. Our method of exchanging is fairly typical
    for geographically nearly collocated and very tightly managed
    academic Veteran Affairs where, if not all, most of the faculty
    who work at the Veterans Affairs Hospital are less than a mile
    away from the campus, as you saw recently.
        Right now, I would say more of the exchange is from
    interpersonal discussions with each other and the fact that the
    care delivery are frequently similar teams. That, of course,
    does not scale rural America or even within the State of
    Michigan.
        The more contemporary digital methods, as I have mentioned
    now, are the beginning of our use of Carequality and then TEFCA
    to start exchanging those core records.
        One thing I wanted to mention from the previous
    conversation, I think it is helpful for us to talk about core
    records, medications, allergies, problems. For more complex--a
    primary care visit would be part of a core record, basic labs.
        For example, as a cardiac anesthesiologist/intensivist, the
    kind of data that I need to do very special critical care or
    even anesthesiology are not typically in core medical records.
    That is where the expanded use of the data, the data elements
    within TEFCA will improve the further exchange of those kinds
    of records.
        Then a final point: There is, very importantly, very
    privileged, very confidential data that we want to be careful
    about that we make sure that the patient and their consent is
    allowing that data to be sent very, very specifically, mental
    health, substance use and things like that.
        When we talk about the records that we are sharing, I do
    think it will be helpful for us to stage out what we mean by
    those specific elements.
        Mr. Barrett. Thank you, Doctor.
        Ranking Member Budzinski, do you have further questions?
        Ms. Budzinski. I do. I actually just kind of wanted to go
    back to what Dr. Rosenberg brought us back to, which is this
    bidirectional Community Care VA complete interoperability
    record. I wanted to ask both Dr. Greenstone, Mr. McGraw, and
    Dr. Rosenberg a little bit more about where you believe that
    disconnect is. If you could speak, I guess the three of you
    could each speak to where you think that disconnect could be.
        I think from Dr. Rosenberg, what you were saying, though,
    is you are not suggesting, though, that like a complete--like
    the mental health record or substance--that should all still be
    encompassed within a record of a veteran.
        Dr. Rosenberg. Absolutely. It is I think appropriate, like
    some other confidential data, frequently behind extra levels of
    protection, but it is absolutely part of the medical record.
        What I would say, I would say there is not so much a
    disconnect right now. My opening statements, I really mean
    that. I think it is an evolution and maturity.
        For us, for example, and I will use Michigan Medicine, it
    might not be as indicative of across the country, but it
    probably is. It takes a certain administrative workload to
    procure, contract, and administratively set up these systems.
    That is not a--that is not a criticism of the network or the
    exchanges or the frameworks, but it is a reality.
        For us, Epic to Epic works extremely well, and that is one
    reason why Epic has such a large exchange of information among
    itself. I suspect as Oracle Cerner continues to roll out, we
    will enjoy those benefits of contemporary EHRs connecting to
    each other as well and/or I should say probably through the
    QHINs as part of TEFCA.
        I also think that while query-based, as Dr. Nebeker pointed
    out, is still perhaps the predominant method of getting that
    data, there are also mechanisms now for push, as Dr. Nebeker
    mentioned.
        As push starts to occur and as expanded data within this
    framework occurs, those disconnects, which are really not
    disconnects, but those gaps will narrow from the common data to
    the more sophisticated to the more nuanced data.
        Ms. Budzinski. Mr. McGraw, would you be willing to add
    anything?
        Mr. McGraw. Yes. A lot of the disconnects we see in the
    State of Michigan is around connectivity, the local facilities'
    EHR systems.
        The two impediments that we see the most is really a time
    constraint. Sometimes the implementation of that connectivity
    could be up to 6 months. Sometimes it is a fiscal constraint.
        The EHR companies, you know, they are not charity
    organizations, they are for-profit companies, so they will
    charge thousands of dollars to just connect and then an annual
    maintenance fee.
        You know, as the facilities will ask, you know, is the
    juice worth the squeeze? The juice in the State of Michigan is
    we really work well with our payer partners, and they put
    incentives together. Those incentives incentivize facilities to
    submit data.
        What MiHIN does is we get that data that comes in. It is a
    push. The second that record is saved, as I mention in my
    testimony, it is pushed to us. Within 4 minutes, it is
    available in the longitudinal record.
        That push comes to us. The incentives are there is a lot of
    information in an admission, discharge, and transfer document.
    Today, 27 of those elements are incentivized. We have physician
    organizations that do transition of care that say, this is not
    enough for us to do transition of care, can you go back to the
    payers and can they incent the facilities to provide more.
        Those incentives are financial incentives. The conformance
    comes through us. We look if 95 percent of what they submit to
    us has all columns filled in, and then we check the box and we
    tell the payer they are eligible for the incentive program.
        I think the mention before was someone mentioned something
    about quality. Today it is a quantity thing. At MiHIN, we are
    really ahead of other HIEs in the country, and our next phase
    is the data that you are coming in meets the quality
    standpoint, but is the data quality, is it usable or is there
    just stuff in a particular area of the data or is it--can we
    use it for gaps in care, population health management.
        We are moving away from quantity and getting into the
    quality. That is how we incent people, and those are the
    impediments I see today. It is not enough incentives. There is
    no interoperability issue. There is an incentive misalignment.
        Dr. Rosenberg. May I add something about the incentive? It
    is not so much for us to do the work, as I mentioned before,
    but, as Mr. McGraw said, it is around the quality.
        It is expensive. It takes people with expertise and the
    time explicitly to make sure the data quality, the data entry,
    the data mapping work, and we audit to make sure it works well.
        MiHIN, our HIE, our EHR provider and I would argue really
    as a broader TEFCA goal is to incentivize organizations to be
    able to have the resources to do that quality and that ongoing
    quality check, because if we get some of those data wrong, it
    is amplified, it is copied, and it could be very difficult.
        Ms. Budzinski. Dr. Greenstone, do you want to add anything
    on this as well, please?
        Dr. Greenstone. Well, I will say that everything you have
    heard is things that we have absolutely seen and experienced.
    In my organization, we work very closely with numerous critical
    access hospitals where they do not have big IT departments.
        Some of them have the ability to connect, but there may not
    be knowledge of how to do it. They may not have the funding to
    be able to do it. They do not fully understand it.
        I was talking to Mr. McGraw, and until 2 years ago he was
    unfamiliar with the Exchanges, right? It is like--and he was
    not alone. Still, you know, when I look at where veterans are
    seen in a lot of these rural places, these small hospitals and
    health systems, you know, are not sort of connected. They do
    not know. They do not understand.
        That is where this opportunity for our TPAs to go out
    there. If they are seeing veterans, let us go out there and
    help them actually get connected and find ways to do that and
    use incentives to help them in that way.
        I would also say that it is been wonderful in the last sort
    of year that in practicing when I have veterans who go to
    Michigan Medicine, I can find almost everything I need when I
    actually ping an Exchange for queries.
        I think that, you know, before that I would be so
    frustrated. They are across the street. They are our friends. I
    have to call somebody as opposed to in my workflow being able
    to find it. Now we can. I think that is what we want to see
    everywhere in all States and territories where veterans are.
        When they are traveling, like the chairman mentioned, they
    go down, you know, to Florida and out to Arizona, we need to be
    able to ping the Exchange and be able to see the records where
    those veterans are in the community out there and then be able
    to use JLV to see when they are seen at another VA medical
    center.
        Ms. Budzinski. Thank you. That is very helpful.
        Thank you. I yield back.
        Mr. Barrett. Thank you. The more discussion we have the
    more questions I end up writing down. I will start just from
    ones I have not written down so I do not forget them first.
        Mr. McGraw, you were mentioning that for those people that
    are not within your network of--you know, within Michigan, for
    example, and transferring data back and forth, that you are
    part of a broader, bigger network to, you know, switch to other
    regional areas, things like that.
        Does that then--is that part of the service that you offer
    to the subscribers within your network so that they are not
    having to subscribe to a separate network in order to do that?
        Mr. McGraw. Correct.
        We have, obviously, all the information in the State of
    Michigan, and then we work with those national exchanges. We
    buy in bulk the ability to ping those national exchanges
    several million pings a month for our clients, and then they
    can all go through us to those national exchanges----
        Mr. Barrett. Okay.
        Mr. McGraw [continuing]. so that they do not have to work
    directly with thousands of individual clients.
        Mr. Barrett. Sure. Then you were saying the whole
    longitudinal record and pushing the record forward and a few
    minutes only to kind of update that record.
        Forgive my ignorance, but MiHIN, you are not storing the
    actual patient information, right, you are merely transferring
    it to the EHR that is actually storing that record, so----
        Mr. McGraw. All that data in the State of Michigan is
    stored in our cloud-based servers.
        Mr. Barrett. Okay.
        Mr. McGraw. We do store all that information. The
    longitudinal record that we are talking about as access is
    MiHIN's portal. We do store for Health Insurance Portability
    and Accountability Act (HIPAA) rules all that----
        Mr. Barrett. Okay. An individual with their principal
    record through their network that they are a part of--Oracle,
    Epic, whichever it is--they are not actually storing that
    information. They are logging into your server, they are
    bouncing a signal to your server that has that patient's
    records stored there.
        That way, if they go somewhere else, the idea being that it
    would automatically update so the next time they go to their
    local doctor's office it already has the urgent care, emergency
    care visit that they had 6 weeks ago or something like that.
        Mr. McGraw. Yes. It is in both. As soon as they save that
    record, it is always going to be in the EHR system for 7 years
    or more.
        The second that they save it, then a copy of that is sent
    to us within seconds. Then, within 4 minutes, it is on our
    longitudinal record.
        Mr. Barrett. Okay. Then if they go across town to somewhere
    else, that provider should be able to see it in there as well.
        Mr. McGraw. If they are attached to our network. Even if
    they are not attached to the network, let us say they are not
    submitting data to us, they still have access through our
    portal to see that patient's interaction everywhere outside of
    them.
        There are people that use our portal to see the
    longitudinal record of a patient for all their interactions.
    They may not have started submitting data to us yet. They can
    see that.
        As I mentioned in my testimony, we have connected I say
    nearly 80 for dramatic effect, but it is 79 EHR systems that
    we've connected to in our 14-year history.
        Mr. Barrett. Okay.
        Dr. Rosenberg, I think it was you that mentioned the
    sensitive nature of some records that we want to make sure we
    are keeping as secured and stored as safely as possible.
        Some number of years ago, I worked for the State treasurer.
    This was an issue we had with people's tax information. We did
    not want people browsing the Governor's tax returns or
    something like that.
        Is there a similar mechanism through MiHIN to make sure
    that somebody--like, would it--is there a mechanism by which
    you could tell if somebody was trying to open a patient's
    record when they did not need access to it for that nefarious
    purpose?
        Mr. McGraw. Yes.
        Mr. Barrett. Like, even if they are a licensed provider,
    right? Like, you hear about this occasionally with law
    enforcement officers looking up somebody's record who they do
    not actually have a reason to, and then that violates the
    protocol for the record management.
        Mr. McGraw. Yes. That is our Active Care Relationship
    Service, ACRS, and that means that you have to have an
    interaction with that patient in order to view their record.
        One of the things we also have is what we call common key
    services. Sometimes a patient might have their name spelled
    different ways in different EHR systems, and then we commonize
    that and give them one unique identifier--think of it as a
    Social Security number for your medical history in the State of
    Michigan--and then only providers that have interactions with
    that patient in their EMRs are allowed to see that patient's
    record.
        You could not just log into our system and look up
    anybody's healthcare information. It is extremely restricted.
        Mr. Barrett. Just because you have access, you do not
    have--like, it is not just once you are in the door you can
    just go start perusing around or something like that?
        Mr. McGraw. Correct.
        Dr. Rosenberg. There are several avenues to do this.
        One, as you have mentioned, is to assure that the people
    asking for the data are appropriate. That changes, again to the
    previous comment of the expense it takes to maintain those
    records and make sure that they are up to date.
        Epic has a concept of ``break the glass'' either for
    accessing data or accessing data within the record itself. If I
    remember, when I was doing TeleCritical Care for the VA, there
    was within VistA a similar way to identify when some data you
    may be wanting to look at was a bit more privileged, a bit more
    protected.
        Then there are also indirect methods. The reality is, if I
    look at a medication list and I see an antidepressant on the
    medication list, I do not have to have access to the problem
    list to potentially see that a patient may have a mental health
    condition that is important for all of us to know.
        There are layers and then there are matrices, almost, of
    where these data come together. I think part of the complexity,
    part of those gaps, as we mentioned, is to try to do it
    properly. If anything, we are probably a bit conservative to
    start with, and that is one reason of many why we might not be
    as fast in some areas.
        Mr. Barrett. All right. Thank you.
        Ranking Member Budzinski.
        Ms. Budzinski. Thank you, Chairman.
        I know we have talked a lot about--or somewhat about--
    people and the importance of people as it relates to
    interoperability. We also can acknowledge that a lot of the
    functionality is still happening manually through fax or HSRM.
        With these systems, clerks and Health Information
    Management, or HIM, staff must manually upload documents to the
    VA's EHRs.
        Dr. Nebeker, I would like to know how many individuals in
    this workforce have been impacted by the mass terminations
    carried out since January 20th of 2025.
        Dr. Nebeker. Thanks for that question. I just do not have
    the answer for that. Sorry.
        Ms. Budzinski. Would you be able to get us the answer?
        Dr. Nebeker. We will take it back. Yes, ma'am.
        Ms. Budzinski. Okay. We will be able to. Okay.
        I was obviously very relieved when Judge Alsup came back
    and said that those probationary employees that were terminated
    need to be rehired, but then the administration immediately put
    those same 2,400 employees on administrative leave.
        Do you know why the VA decided to put those 2,400 employees
    on administrative leave?
        Dr. Nebeker. I am sorry. I really do not know.
        Ms. Budzinski. Would you be able to follow up with the
    committee on the rationale behind that?
        Dr. Nebeker. Sure.
        Ms. Budzinski. Okay.
        Dr. Nebeker. I mean, my esteemed colleagues will help with
    that, yes.
        Ms. Budzinski. Okay. Thank you.
        Are individuals in this workforce--well, let me say this.
        Have any of the HIM staff, do you know, taken the ``Fork in
    the Road''?
        Dr. Nebeker. Again, I do not have that information, but we
    can take it back.
        Ms. Budzinski. Okay. Great.
        What are VA's plans to make VA fully operational with QHIN
    participation by December 2025 without many of these critical
    skilled staff that are needed to carry out this work? How are
    you looking at that with these folks off?
        Dr. Nebeker. I think I can answer that one.
        Ms. Budzinski. Okay.
        Dr. Nebeker. Really, the people that do that work are in
    central office for connecting the QHIN, and I am not aware that
    we have any problem with the current Federal staff to meet the
    needs of connecting to the QHIN and rolling that out to the
    local facilities.
        Ms. Budzinski. Okay.
        My next question is for Dr. Prietula.
        The subcommittee has heard reports of several canceled
    contracts that support the EHRM project. How many contracts or
    other support services have been cut by Department of
    Government Efficiency (DOGE) since January 20th of 2025?
        Dr. Prietula. We have received the requests for information
    for all those contracts, and the office is currently reviewing
    those, and I am sure that as soon as that is completed we will
    be providing it to this committee.
        Ms. Budzinski. Okay. At least one of these terminated
    contracts we know focuses on supporting interoperability across
    VA, DOD, and community providers. While some of these have been
    reinstated, the contractor stated that the smaller workload,
    quote, ``probably is not enough for them to keep doing business
    with the VA in the long term,'' end quote.
        What would be the impact of losing such a contractor's
    support for the EHRM program?
        Dr. Prietula. I am not aware of the contract that you are
    talking about. We can take it back for the record and see what
    the impact would be on that one.
        Ms. Budzinski. Okay.
        I just want to say I think it is extremely concerning that
    the VA's witnesses today do not have answers to these important
    questions around staffing and contract support. Without this
    information, the committee is significantly inhibited in its
    requirement to perform oversight of the Department's
    activities.
        I look forward to receiving this information from VA in a
    timely manner and working with Chairman Barrett to continue
    oversight of this program.
        I have another question for Dr. Nebeker.
        Has VA performed any audits of providers where veterans may
    seek care in the community to see if they are connected to the
    exchange?
        Dr. Nebeker. Yes. We are right now, as I mentioned earlier,
    going through all of the academic affiliates to make sure that
    they are connected. The University of Michigan just recently
    connected with us. Now we are going to go systemically through
    all the academic affiliates.
        In addition to people that are not yet connected, we have a
    data quality monitoring program by which we look at all the
    messages that are coming across. Those are saved in an Oracle
    location. Right now we have a bit of a contract gap to get
    those data back to the VA, but we expect that to be resolved
    shortly. Dr. Prietula's team is doing a great job with that.
        Then we actually sample the data to look for data quality
    problems. We do it based on various scenarios for care
    coordination of what is quality sufficient. Then we go back to
    the healthcare systems and help them improve the quality of
    data that they are sending us.
        Ms. Budzinski. Okay. Thank you.
        I yield back to Chairman Barrett.
        Mr. Barrett. Thank you.
        Dr. Nebeker, just briefly, I know that in Michigan we
    learned that VA is not part of the local or regional Health
    Information Exchange. Is it common or unusual for VA facilities
    to be members of their regional HIEs?
        Dr. Nebeker. We are not members of any of the regional
    HIEs. We have been in discussions on this topic for, I do not
    know, 10 years about how do we participate or not. I was not
    involved in most of those discussions previously.
        Mr. Barrett. Neither was I. I have only been here 2 months.
        Dr. Nebeker. Well, what we are looking for now--so right
    now there are 50--over 50 Regional Health Information Networks
    that are connected to eHealth Exchange. Eight of those are
    connected to a QHIN, to the eHealth Exchange QHIN. The rest are
    in the traditional network.
        Our strategy is that we will join a QHIN, and many of the
    RHIOs--and we are in discussions with some of those, all those
    that we have talked to are planning on joining the QHIN. We
    will then get connectivity to those Regional Health Information
    Organizations through TEFCA.
        Mr. Barrett. Okay.
        Then I know the Indian Health Service currently is the only
    Federal agency that is connected to a QHIN right now. Is that
    the case?
        Dr. Nebeker. Given that the other of the Federal on our
    gateway----
        Mr. Barrett. Right. There are only two, correct?
        Dr. Nebeker. To my knowledge, yes.
        Mr. Barrett. Okay. Do you know which EHR they use?
        Dr. Nebeker. Indian Health Service uses a variant of VistA.
    A lot of it is based on VistA. They have what is called
    Resource and Patient Management System (RPMS), Computerized
    Patient Record System (CPRS) is equivalent to RPMS. It is a
    similar shared technology but a little bit different.
        Mr. Barrett. Okay. They do not have one of, I guess, the
    more mainline modernized EHRs that VA is currently going
    through the process of upgrading?
        Dr. Nebeker. Correct. They have contracted with Oracle to
    provide that but not joining----
        Mr. Barrett. Tell them to get ready.
        Dr. Nebeker. I mean, I have, of course, a lot of friends in
    that organization. They are just starting their journey toward
    their implementation.
        Mr. Barrett. Okay.
        Then VA is not sure yet which of the QHINs--now, is it true
    that Oracle is trying to create their own QHIN? Is that also
    accurate?
        Dr. Nebeker. Yes.
        Mr. Barrett. Okay.
        Dr. Nebeker. Right now the reason we have to do this, it
    takes a little bit of time, is we have to do it with DOD. The
    Federal Electronic Health Record Modernization (FEHRM) is
    hosting some of those discussions. Dr. Prietula's team is
    really doing a lot of the heavy lifting as far as the technical
    approach, and we should have a decision on that fairly soon.
        Sorry, the second part of your question?
        Mr. Barrett. Oracle is creating their own. Then would it be
    natural to assume that that will follow--that VA and DOD will
    follow into that?
        Dr. Nebeker. I would not make any assumptions. I do not
    make assumptions on this category. It is logical that that
    might happen.
        There are testing and certification requirements that take
    about a year to get through after there is an establishment of
    technology for QHIN. You will have to talk to Oracle about how
    they are meeting those timelines.
        I would add that the barriers for switching--for entry and
    switching among QHINs--are extremely low. If Oracle comes up
    with a great product and it is better than what else we are
    seeing, the price is right, it would be logical for us to
    switch to an Oracle solution.
        Mr. Barrett. Okay. Thank you.
        Then could you explain also, through TEFCA--which will
    establish these, the kind of framework for these QHINs with
    quality of information and everything else--how is that--or how
    can that address VA's interoperability gaps that exist in some
    of the examples we heard about today?
        Dr. Nebeker. TEFCA is primarily about the trust framework,
    about what can we exchange, the legal framework for trusting
    each other to exchange information. Then about the pipes, that
    is the QHIN part, the Qualified Health Information Network. We
    are using the same technology to exchange the data.
        QHINs, with active RHIO help we really need the help from
    the RHIOs--will solve a lot of the connectivity problem, but
    there is still the data quality program that this does not--it
    is pretty much silent on data quality.
        Mr. Barrett. Okay. Are there discussions in place around
    that standardization, if you will, and where do those go in
    this process?
        Dr. Nebeker. Yes. I have got to say I really appreciate
    your interest in these questions. It is such a nerdy topic.
        Right now Leavitt Partners is leading a coalition around
    data quality. It involves Centers for Medicare and Medicaid
    Services (CMS). It used to involve Centers for Disease Control
    and Prevention (CDC). They are replacing a member there. Then
    payers some of the Blues are participating. Also other data
    exchange and quality organizations. National Committee for
    Quality Assurance (NCQA) is participating.
        The goal of this collaborative is to address exactly the
    data quality problem, because all of us want to be able to
    provide better decision support, better quality management of
    the care, better population health, et cetera, and we need data
    we can compute on.
        For example, our studies have shown that only in 35 percent
    of our patients can we tell from the information exchange
    whether they need a colonoscopy for screening or not.
        It is very poor data that we are currently getting. It is
    not 100 percent bad, but has gaps.
        There is a lot of progress on this. I see that we are over
    time a little bit. There is a vendor that stepped up to donate
    and will provide through open source some of their technology
    that allows objective scoring of data, and the score is also
    accompanied with, ``Hey, this is what you might be doing wrong
    because the data came out this way.''
        It is going to be a really powerful initiative. We are
    hoping that insurance companies more powerfully participate. -
    like how MiHIN has a tight partnership with their payers. They
    recognize the value of this interoperability, not only the
    connectivity, but also the quality of the data. We hope that
    they will be writing in their contracts data quality provisions
    to really incentivize for us this exchange of high-quality
    data, not just data.
        Mr. Barrett. Thank you.
        Ranking Member Budzinski.
        Ms. Budzinski. Thank you, Chairman.
        Dr. Greenstone, can you share what is the utilization rate
    of these tools that VA utilizes, like HSRM, JLV, and the
    Veterans Health Information Exchange, among community care
    providers?
        Dr. Greenstone. Sure. I can clearly speak to HSRM, which I
    was a product owner for many years.
        HSRM is the referral and authorization system for VA, and
    what it creates is the true authorization that providers in the
    community need to have so they know what VA is authorizing, and
    there is a referral number that has to be associated with the
    claims that are actually submitted.
        There are approximately 130,000 providers in the community,
    in this Community Care Network, who are provisioned to use HSRM
    as the means by which they receive their referrals as well as
    having access in one click to the entire veteran medical record
    in an organized way.
        The challenge, however, is that it is only for veterans who
    are seen in that 165 sort of medical centers that are still on
    our legacy VistA CPRS system.
        Those five facilities that are on Oracle Cerner have not
    had that data in Oracle moved over to our Middleware VDIF that
    actually--HSRM actually uses to show the data.
        We know that--let us say if you receive as a provider in
    the community more than two referrals a day, about 75 percent
    of those providers are using HSRM to receive their referrals
    and to upload medical documents. If you receive more than 10,
    we are talking 95 percent to 100 percent of providers.
        Those providers who get a lot of referrals want to organize
    their data and their referrals, and they do that within HSRM.
    That is why they log in. That is why they see the entire
    veteran medical record. That is why many of them will then
    upload data.
        Some of them are being challenged because some VA medical
    centers are like, ``Hey, our back-end people are using faxes
    and phone calls and scanning all day long. We do not want to
    use HSRM. Send us faxes.''
        That is a problem that still exists today, when VA medical
    centers are telling folks to fax and not utilize the system
    that providers want to use because it makes it easier for them
    to actually do their work.
        Ms. Budzinski. That is a great point. Fax machines have
    come up a few times, I think, today.
        I would like to ask Dr. Nebeker, when we are talking about
    interoperability and things like fax machines are coming up,
    what is the VA's plan to address this reliance and push people
    to utilize more interoperable tools like HSRM or the exchange?
        Dr. Nebeker. Thanks for that question.
        Back when I was starting out as a young faculty member at
    the University of Utah, I had what then seemed to be a very
    large contract with Medicaid, and we were providing really
    great decision support on drugs when people were prescribing
    drugs together that they should never prescribe together, like
    Viagra and nitrates, for example.
        The providers loved it. When we went out and we asked them,
    ``What do you think about these forms we are mailing to you?''
    (We mailed back in those days) They said, ``They are great. We
    love them. I just take them and I throw them in the garbage.''
    I said, ``Why?'' 3 percent of their patient volume is Medicaid,
    and they cannot create workflows in their office to deal with 3
    percent of their volume.
        My answer is we have got to join the rest of the community.
    Dr. Greenstone was really emphasizing this in his opening
    comments. We have got to do things the same way as the rest of
    the community.
        Then, thankfully, the Elizabeth Dole Act Section 108 was a
    gift in this matter because it directs the Secretary of VA to
    work with the Secretary of HHS. We need that teamwork.
        Here we are as the largest integrated healthcare provider
    in the country, and we are not part of that health community
    oversight process. To have a more cohesive policymaking, I
    think, is really going to be important to address that
    disconnect in oversight.
        If you have any further technical questions about that, Dr.
    Prietula could cover those.
        Ms. Budzinski. Would you like to add anything, Dr.
    Prietula?
        Dr. Prietula. Yes. We have been working on
    interoperability, as you all said, probably about 20 years,
    whether it is healthcare or otherwise, and we will continue to
    do that, consistently improving, whether it is e-faxing and
    turning them into something else.
        We have plans as well for bringing some of that
    interoperability more to rural communities and helping them. We
    have secure messaging as well that they can use so that,
    instead of faxing they can, well, email, if they have that
    ability, so that then we start having also some more computable
    information.
        As Dr. Nebeker and the rest of the panel here have said, we
    really need to get into everybody really working toward
    semantic interoperability, making sure that our data models are
    similar, if not the same.
        Open source is a great way for us to start really looking
    into what do others do that can help us so that it is not a
    closed-door or behind-the-door kind of discussion around
    interoperability.
        Ms. Budzinski. Thank you.
        I yield back.
        Mr. Barrett. Thank you.
        I know I have got to go to closing remarks because,
    unfortunately, we have to move on to other activities.
        Dr. Nebeker, just--and I can follow up with you later--but
    when you talked about quality of record and everything else, I
    do not know if that means the data itself through the system
    or, like, how a physician describes a certain thing.
        I will give you an example.
        When I was in Ann Arbor last week, a few days ago, they
    said that the carpal tunnel condition procedure could be
    categorized one of several different ways by the physician, and
    the next physician looking it up may not look at it through the
    same lens perhaps.
        I just would be curious. I mean, we spent a lot of time
    making sure we had standardized language in the Army for the
    things that we did there. I assume that is probably a goal in
    medicine as well.
        I am happy to ask you some of those follow ups offline
    unless you have got some brief comments you want to make.
        Dr. Nebeker. Yes. Very briefly.
        The kind of nuanced classification of diseases is what we
    think about more for internal interoperability when we are
    generating the data.
        The kinds of quality that I was talking about before is
    about getting those data that are in the EHR and that are great
    in the EHR across that divide to where they are actually going
    out in a way that can be read. And so that is----
        Mr. Barrett. You are talking ones and zeroes, not human
    interfacing?
        Dr. Nebeker. More are they getting the right information in
    the right slot? Are the units for blood pressure millimoles per
    liter instead of millimeters of mercury, which is very
    different.
        Mr. Barrett. Sure.
        Dr. Nebeker. Are they plausible values? Is the blood
    pressure 500? We are seeing these data quality problems, when
    they are going from the EHR, being pushed out to the exchanges,
    the data is getting scrambled.
        Mr. Barrett. Okay. You crash a lunar module when you have
    one guy measuring meters and the other guy measuring feet.
    Okay. All right.
        Thank you. I really appreciate all of your testimony, each
    of you for being here today. Definitely learned quite a bit
    from your testimony. I am only slightly more confused than when
    I started, so that shows that we are making progress.
        VA is the largest healthcare system in the Nation, but it
    only represents--oh, I am sorry.
        Ranking Member Budzinski, go ahead. You can do your
    statement first.
        Ms. Budzinski. Sure. Thank you, Mr. Chairman.
        Mr. Barrett. I will get this right over the next----
        Ms. Budzinski. It is Okay. We are in it together.
        I appreciate the testimony and answers from our witnesses
    this afternoon. Having a truly seamless and secure
    interoperability program is crucial for our veterans to be able
    to seek the care they need.
        There has been a series of active interoperability efforts,
    but there are still major issues that need to be addressed
    about the sharing of information between the VA and the non-VA
    providers. I am glad to see that the VA is actively taking
    steps to figure out how to securely exchange information so
    veterans can continue to receive care inside and outside of the
    VA.
        While these efforts are on the right track, I would be
    remiss to not acknowledge the impact of the recent personnel
    actions on VA's ability to ensure that veterans have a complete
    medical record.
        It is critical that VA have sufficient staffing in Office
    of Information and Technology (OIT) and EHRM, as well as the
    clinical settings, to ensure that VA can participate in the
    information exchange processes. Otherwise, our veterans are the
    ones that will suffer.
        Relying on only technology alone is not going to work for a
    seamless exchange of information. We need to work together to
    figure out how to produce complete medical records for our
    veterans so they can receive the care that they so rightfully
    deserve.
        Thank you so much, Mr. Chairman, and I yield back.
        Mr. Barrett. Thank you.
        I want to thank the ranking member for participating and
    being here for the entire committee hearing today.
        Thank you.
        I want to thank our witnesses.
        As I was beginning to say, the VA is the largest healthcare
    system in the Nation, of course has more medical records
    perhaps than any other system out there, but still only
    represents about 3 percent of all U.S. hospitals. While it is
    the largest, it is still not the majority by any stretch.
        Veterans are people at the end of the day and the other 97
    percent of hospitals will always play a role in veterans'
    healthcare.
        As I said in my opening remarks, roughly one-third of VA
    care has currently gone through the community. The healthcare
    data in the Community Care Network will always form a large
    part of the complete picture of a veteran's medical history.
        Republicans on this committee are prioritizing making sure
    that veterans have access to community care when they are
    eligible for it and are given the opportunity to choose what is
    best for them and placing them in the driver's seat.
        Part of how we make VA stronger and deliver better outcomes
    for veterans is to continue moving the ball forward on
    interoperability so there is that seamless ability and no
    coverage gap exists.
        This includes VA producing a thorough, actionable plan on
    healthcare information interoperability standards, expanding
    the Veterans Interoperability Pledge and fostering more direct
    information exchange with community partners, building stronger
    partnerships for providers like Michigan Medicine as well as
    Health Information Exchanges like MiHIN that we learned a lot
    from today and appreciate that, participating in TEFCA to
    bridge the data exchange gaps with community care providers
    that still exist.
        I urge the VA to be a leader in interoperability and build
    on the progress of recent years. America's veterans have much
    to gain from your work.
        I thank you all again for participating in today's hearing.
        I ask unanimous consent that all members have 5 legislative
    days to revise and extend their remarks and include extraneous
    material.
        Without objection, so ordered.
        With that, we are adjourned.
        [Whereupon, at 4:26 p.m., the subcommittee was adjourned.]

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                             A  P  P  E  N  D  I  X

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                        Prepared Statements of Witnesses

                                  ----------

                     Prepared Statement of Jonathan Nebeker

        Good morning, Chairman Barrett, Ranking Member Budzinski, and
    distinguished Members of the Subcommittee. Joining me today is Dr.
    Laura Prietula, Deputy Chief Information Officer, Electronic Health
    Record Modernization Integration Office. Thank you for the opportunity
    to testify about the interoperability between the VA electronic health
    record (EHR) system and the systems that facilitate care for Veterans
    in their communities beyond VA.
        Efforts to expand Veterans' access to care have led to
    unprecedented utilization of their earned benefits. the Veterans
    COMPACT Act of 2020 (``the COMPACT Act,'' P.L. 116-214) and VA MISSION
    ACT of 2018 (P.L. 115-182) empower Veterans to seek care from community
    providers when it's in the best medical interest for the Veteran or
    when VA care is unavailable. As a result, health information exchange
    between VA and community providers has reached an all-time high,
    enhancing care coordination and accessibility.
        The exchange and use of health care data are essential for ensuring
    that Veterans have better access, better health, and reduced out-of-
    pocket expenses. VA is working to improve how different health care
    systems talk to each other, or enhance interoperability, by using a
    common set of rules called Fast Healthcare Interoperability Resources.
    Achieving more benefits for treatment, quality improvement, population
    health, and benefits adjudication requires more functionality and
    higher quality data than what traditional health information exchanges
    (HIE) or current Qualified Health Information Networks (QHIN) offer.
        Since 2009, clinicians have been able to view all VA and Department
    of Defense (DoD) data, reducing the need for paper records. The 2009
    product, VistaWeb, had some challenges. In 2014, VA and DoD released
    the Joint Legacy Viewer, now known as Joint Longitudinal Viewer (JLV)
    which is more reliable and user-friendly. JLV now contains nearly all
    necessary VA and DoD data and can display community care documents. To
    illustrate its widespread use and utility, in January 2025 alone, about
    110,000 VA employees used JLV over 7.4 million times, opening over 2.2
    million community care documents. A survey last year showed that 48
    percent of users reported that the JLV system improved patient
    outcomes, 70 percent reported time savings, and 23 percent reported
    reductions in duplicative testing.
        Since VA and DoD launched the Joint Health Information Exchange
    (JHIE) in 2020, Federal EHR interoperability has increased
    significantly, with data exchange partners reaching more than 90
    percent of U.S. hospitals in 2024. Through two national exchanges-
    electronic health exchange (eHX) and CommonWell (CW)-JHIE connects to
    over 100,000 provider sites. In January 2025, JHIE exchanged over 360
    million documents for over 18 million patient matches.
        As the demand for interoperability with community care provider
    increases, VA continues to work to address interoperability gaps in
    collaboration with multiple communities. One issue is connectivity to
    small provider organizations that do not use a ``top-five'' EHR, such
    as Epic, Allscripts, Meditech, and Athena Health. Many of these smaller
    organizations connect to State or metropolitan exchanges provided by
    regional health information organizations (RHIOs). A 2024 study by one
    of VA's third-party administrators showed that approximately 80 percent
    of Veterans enrolled in or otherwise receiving care from VHA, also
    receive care from at least one provider connected to national health
    information exchanges. At the same time, only 830 percent of providers
    billing VA for community care are connected to eHX or CW.
        RHIOs offer services not available through eHX and CW, such as
    longitudinal viewers and push notifications for hospital admissions,
    transfers, and discharges. VA providers often receive notifications by
    word of mouth, impairing care coordination.
        VA is also working with community partners to improve data quality
    that impacts clinical decision support, quality measurement, population
    health, and benefits adjudication. Examples of data quality challenges
    include incorrect weights, empty serum sodium values, incomprehensible
    codes, and misclassified allergies. Stakeholders are collaborating to
    create open-source technologies to objectively code data quality and
    offer suggestions for improvement.
        The Trusted Exchange Framework and Common Agreement (TEFCA) is a
    nationwide framework for health information sharing. The goal is to
    remove barriers for sharing health records electronically among health
    care providers, patients, public health agencies, and payers. VA aims
    to participate in TEFCA, contract with a QHIN provider and be fully
    functional and tested for the purpose of treatment by early December
    2025. The Federal Electronic Health Record Modernization (FEHRM)
    office, which is charged with coordinating EHR implementation across
    the Federal Government, VA, and DoD are working together toward this
    aim. VA obtained an independent and comprehensive assessment by the
    Institute for Defense Analysis Systems and Analysis Center - a DoD
    sponsored federally Funded Research and Development Center-relative to
    QHIN candidates that can support VA and DoD health data exchange across
    different health information networks in accordance with TEFCA. The key
    decision points are the accuracy of patient match and cost.
        QHIN participation will increase our connectivity but impose a
    practical deadline for participation of December 2025. A prominent
    feature of a QHIN is that once connected to one, a health care
    participant is connected to all QHINs. However, QHINs do not exchange
    data with traditional HIEs. Our JHIE gateway is currently connected to
    traditional national HIEs (e.g., eHX and CW). After December 2025,
    health care systems that use Epic, and the Epic QHIN, will start
    disconnecting from traditional HIEs because of the extra costs
    associated with the continued connection to traditional HIEs. Epic
    tells us that their partners will accelerate disconnecting over the
    first quarter of calendar year 2026. Epic systems originate 60 percent
    of community documents that VA providers read. If VA is not fully
    operational with QHIN participation by the December 2025 deadline, we
    could lose access to these records, thus reducing care coordination.
        The Veteran Interoperability Pledge (VIP) and associated activity
    is an example of a creative approach to interoperability that is
    yielding a significant benefit to Veterans at a low cost to VA. In
    2023, VA met with 13 high-quality health care systems. Together, we
    created the VIP, which addresses interoperability goals beyond TEFCA
    and other U.S. Department of Health and Human Services (HHS)
    initiatives. The major goals are:

        1. Accurately identify Veterans when they seek care from providers
    in our communities.

        2. Connect Veterans with VA and community resources that promote
    health and health care--especially VA services that lower Veterans'
    out-of-pocket expenses.

        3. Responsively and reliably coordinate care for shared patients-
    including exchange of information about care requested and provided.

        The first phase of VIP involved getting health care providers to
    connect to VA's Veteran Confirmation application programming interface
    (API). Given demographic information, this API returns a simple
    ``confirmed'' or ``unconfirmed'' as meeting the title 38 definition for
    Veteran. Tufts University and Sanford/Marshfield Clinic worked with
    Epic and Oracle, their respective vendors, to develop functionality so
    that all users of their EHRs can access the API. This work was done at
    no cost to VA or vendor partners. Several partners are now using the
    API at check-in and once a year thereafter. On average, partners are
    identifying 20 percent more Veterans than by self-reported status.
        Community partners are now using the Veteran Status API to provide
    crucial benefits to Veterans. Some are sending Veteran status to their
    financial department, which prevents initiation of collection
    activities on a Veteran's health care debt. Some provide Veterans with
    VA information about VA benefits at check-in. Some trigger workflows
    for social workers, so Veterans in suicidal crisis can receive full
    benefits provided by the COMPACT Act. Some trigger workflows for
    clinicians to identify patients with conditions related to toxic
    exposure who may be eligible under the Honoring our PACT Act of 2022
    (``the PACT Act'' P.L. 117-168). By the end of last calendar year,
    providers had identified over 200,000 Veterans that can benefit from
    either the COMPACT Act or the PACT Act and helped connect those
    Veterans to these benefits.
        Next, VA will work to expand membership to more health care
    systems, payors, community organizations, and vendors that help
    coordinate health care benefits. Health care systems and organizations
    have asked VA to work with the industry to automate benefits
    determination. We also expect this collaboration to result in improved
    Veteran access to many Federal, State, and donated benefits.
        VA's interoperability goals demonstrate our commitment to put
    Veterans at the center of everything VA does, focusing relentlessly on
    customer service and convenience. In addition to the interoperability
    efforts cited above, VA is continuing to move forward with a modern,
    commercial EHR solution in close coordination with our Federal
    partners, including DoD and the FEHRM. This new Federal EHR system and
    the interoperability it provides will, improve the Veteran experience,
    allow care teams to understand patient medical history more
    holistically, and ultimately ensure Veterans receive care that is more
    seamlessly coordinated across the enterprise. VA's interoperability
    efforts and deployment of the Federal EHR will remain a key enabler of
    VA's ability to deliver the comprehensive health care Veterans deserve.
        We appreciate the Subcommittee's commitment and oversight to ensure
    VA serves Veterans with excellence. We look forward to responding to
    any questions that you may have.

                       Prepared Statement of Rick McGraw

        Thank you for the opportunity to testify today about the vital role
    that Health Information Exchanges (HIEs) play in the interoperability
    of our overall healthcare infrastructure. Today, I will concentrate my
    testimony on the over 10 million residents of Michigan, with over
    461,000 veterans of our military services.
        Michigan Health Information Network (MiHIN) is our statewide HIE.
    MiHIN was formed in 2010 as a public/private partnership with the
    Health Information Technology Commission housed in the Department of
    Health and Human Services. MiHIN was designed to play a pivotal role in
    advancing healthcare interoperability by facilitating seamless
    information sharing across Michigan's healthcare ecosystem.
        Since MiHIN's inception in 2010, we have interfaced with nearly
    eighty individual Electronic Health Record systems (EHRs) and two
    national networks that only represent a limited number of use cases. A
    use case is a unique instance of sharing specific information regarding
    patients and their health. MiHIN, however, operates over fifty use
    cases for our clients, ranging from hospitals, primary care facilities,
    payors, community mental health facilities, skilled nursing facilities,
    and local city and county health departments, to name a few. From the
    5,300+ healthcare facilities connected to MiHIN, we have routed over
    8.3 billion messages to enhance care coordination and vital data
    delivery across the State. For example, ninety-seven percent of all
    State admission, discharge, and transfer summaries pass through MiHIN
    today.
        MiHIN's direct interfaces with local healthcare facilities' EHRs
    provide instantaneous record submissions immediately following an
    encounter with a patient. In less than 4 minutes, that information is
    received, verified, and routed to our portal, where the patient's
    longitudinal record is updated with their latest information. Our most
    recent use case is collaborating with a mobile technology company to
    route real-time data from ambulances en route to emergency rooms.
    Emergency Medical Technicians en route will have access to a patient's
    electronic medical records while also transmitting current vitals to
    the receiving emergency department. Alerts sent to the ED will notify
    them of the patient en route so they can access that patient's
    longitudinal record from MiHIN. The best quality healthcare is not only
    local, but it is in near real-time.
        For security and privacy considerations, MiHIN, as a business
    associate to the largest health and government systems in Michigan,
    provides security and privacy of healthcare data while ensuring it is
    interoperable and accessible. MiHIN and our major technology vendors
    are certified under HITRUST's r2 certification. This industry-leading
    certification requires external penetration testing, security in
    operations, and security during the development of custom applications,
    ultimately ensuring best practices across all our systems and services.
    MiHIN designed our Active Care Relationship Service (ACRS) model, which
    allows the real-time association of patients with their providers using
    the information found in the data ingested by MiHIN. This service
    restricts patient data access to only those providers that actively
    care for that patient.
        With all this in mind, let's consider a veteran's healthcare
    journey. If a veteran goes to their primary care doctor who uses one
    EHR but also goes to a community mental health facility that uses a
    different EHR and also sees a specialist on a third EHR, without an HIE
    like MiHIN, these providers wouldn't be able to access critical patient
    information from those other encounters. Because of MiHIN's broad
    network of connectivity, MiHIN has all interactions from all three
    facilities available in that patient's longitudinal record to improve
    overall care coordination. Today, however, in Michigan, the VA and DOD
    are a blind spot to a veteran's overall healthcare. The Michigan VA
    does not only not submit data through the network but cannot access its
    patients' records from encounters outside the VA.
        From a provider perspective, HIEs bring critical value. A 2024
    Survey of Primary Care Physicians found that:

        -81 percent spend less time with their patients than they'd like.

        -57 percent write prescriptions or refer patients out due to time
    constraints.

        -46 percent report a lack of adequate time with patients as a top
    stressor, and

        -Almost two-thirds feel their work is more transactional than
    relational.

        Accessing patient information within an HIE's longitudinal record
    has shown that a provider can save up to 15 minutes per patient per
    visit, while the cost of this access is nominal.
        Today, the VA does not comprehensively see interactions outside of
    its facilities. And--like the patient journey example I gave you--
    community care facilities cannot see veterans' interactions with the VA
    hospital either. There is no such thing as a lifetime record of a
    veteran's healthcare residing in one EHR system. It simply does not
    exist. There's also no such thing as a national exchange with a handful
    of EHRs that can replace the infrastructure we have spent the last 14
    years perfecting.
        We can--and must--do better to provide higher-quality care to our
    veterans in Michigan. There is always potential for improvement, and I
    believe we can achieve it with the right strategies, support, and
    collaboration.
        Thank you for your time and attention to this important issue. Your
    support and understanding are greatly appreciated.

                     Prepared Statement of Andrew Rosenberg

        Good afternoon. Chairman Barrett, Ranking Member Budzinski and
    distinguished members of the Subcommittee, I would like to add my
    appreciation that you have convened this panel to discuss the important
    details and issues related to how we exchange health care data and
    coordinate care between the Department of Veterans Affairs (VA) and
    health care organizations such as Michigan Medicine (Mich.Med). As a
    physician, and Chief Information Officer, I would like to further
    explain how we currently exchange information and the opportunities
    available to improve this soon. Michigan Medicine is neither the best
    nor worst at HIE and our examples may be representative of US health
    organizations. I will begin by briefly summarizing how we do health
    information exchange (HIE) at a large, statewide health system and then
    several challenges we face and how we are working to address these.
        Health providers such as Mich.Med. benefits from the excellent
    national interoperability frameworks as well as distinct data sharing
    networks across, and within, the states themselves that guide and
    facilitate HIE. The US frameworks and networks have improved how we are
    sharing data than earlier methods that included sending stacks of
    paper, CDs or worse, faxing random bits of information (something still
    occurring today). Notable examples you are aware of include the
    Carequality, CommonWell Health Alliance, eHealth Exchange (eHX), and
    most recently, the Trusted Exchange Framework and Common Agreement
    (TEFCA). Our peers in global health care do not have these national
    standards. We should not take these resources for granted.
        Details for Michigan Medicine's health information exchange
    practices may be of interest and are representative of large,
    quaternary health systems across the United States. Regardless of the
    various network and frameworks, the most detailed, secure, and
    efficient exchange of health information for us at Michigan Medicine is
    through our primary electronic health record (EHR) system, Epic. I am
    not here to extol the virtues of any one contemporary EHR, however you
    all are aware of the dominant position Epic and Oracle/Cerner have in
    the US EMR market, and Michigan Medicine is no exception. Since
    beginning EPIC's Care Everywhere HIE, in 2014, Michigan Medicine's
    health system (including UMH West and UMH Sparrow) has exchanged over
    361M records, including 83M records this year to date. The EPIC
    organization itself reports exchanging over six billion records a year
    at this point.
        Specifically for VA patients, since August 2023, we estimate that
    the combined record exchanges within The University of Michigan Health
    System were 77k records per month. This practice will only increase as
    we join the TEFCA trust framework through the Epic Nexus QHIN in the
    fall and more robustly take part with other organizations exchanging
    data through Carequality, eHX and our State HIE, MiHIN. We expect
    significant increase in the amount and quality of data exchanged for
    both acute and ambulatory/outpatient care.
        Similarly, Michigan Medicine providers connected to the MiHIN State
    HIE over 38k/month to query data on 600k actively seen Michigan
    patients for such things as ADT messages (800k/mo.) lab results (560k/
    mo.) and radiology results (100k/mo.). These data cover the 148
    hospital, 665 outpatient facilities, 298 skilled nursing facilities and
    all forty-four provider organizations in the State of Michigan. Taken
    in total, we estimate exchanging over 275k records per day across
    Michigan Medicine alone.
        While the variety of available HIE methods offers advantages, it
    also presents the challenge of deciding which systems to use and
    integrate into routine practice. Each needs specific expertise,
    different technical support, and cost. Diverse options can lead to
    fragmentation of which network to use and the design, configuration,
    and data mapping practices inherent to one method of HIE compared to
    another.
        What can we do to continue to improve our interoperability and
    exchange of health information? The single most important step is to
    encourage, advance and accelerate the adoption of the TEFCA framework
    to health care organizations. This and the continued progress to adopt
    and upgrade contemporary EHRS will only improve the data sharing I have
    previously mentioned. The second is to seek specific areas of
    improvement within these frameworks, evaluate them for benefit and
    priority of adoption and seek methods to accelerate this process.
    Examples within the TEFCA framework we and our colleagues discuss
    frequently include methods to improve data segmentation, encourage
    adopting current UCSDI versions, widen the use of FHIR to include more
    public health reporting, controlled prescription, patient outcomes and
    other determinants of health in the interfaces (APIs), broaden the data
    shared for benefits, and improve the precise and strict onboarding and
    organization validation for those who can participate in these
    networks. Use case, auditing, and individual access are also important
    considerations.
        Additionally, where they exist, strong State health information
    organizations such as Michigan's MiHIN, the Indiana Health Information
    Exchange (IHIE), the Maryland CRISP, Colorado CORHIO, Utah's UHIN and
    others provide added value. Local and regional data sharing often
    includes care coordination among competing health providers, public
    health and quality improvement initiatives population and chronic
    disease management and managing other determinants of health. These are
    often `value added' capabilities that State HIEs and third-party
    companies provide better than a given health organization can do on its
    own. I believe if these firms are rigorously following the rules of the
    road established by the broader ecosystem and trust frameworks
    previously mentioned, there is enormous value from these more nimble
    and focused organizations to also participate in the collective health
    information exchange and interoperability work we have briefly
    discussed here today.
        Thank you once again for the opportunity to address this
    subcommittee. I am eager to work collaboratively to ensure that our
    Nation's health IT infrastructure supports the exceptional care
    Americans expect and uphold the ethical standards to which we are all
    committed. I am happy to answer any questions you may have.

                      Prepared Statement of Leo Greenstone
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                            Statement for the Record

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                       Prepared Statement of DirectTrust
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