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Hearing Transcript on Sharing of Electronic Medical Records between U.S. Department of Defense and U.S. Department of Veterans Affairs.

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SHARING OF ELECTRONIC MEDICAL INFORMATION BETWEEN THE U.S. DEPARTMENT OF DEFENSE AND THE U.S. DEPARTMENT OF VETERANS AFFAIRS

 


 HEARING

BEFORE  THE

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

OF THE

COMMITTEE ON VETERANS' AFFAIRS

U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION


OCTOBER 24, 2007


SERIAL No. 110-57


Printed for the use of the Committee on Veterans' Affairs

 

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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman

 

CORRINE BROWN, Florida
VIC SNYDER, Arkansas
MICHAEL H. MICHAUD, Maine
STEPHANIE HERSETH SANDLIN, South Dakota
HARRY E. MITCHELL, Arizona
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
SHELLEY BERKLEY, Nevada
JOHN T. SALAZAR, Colorado
CIRO D. RODRIGUEZ, Texas
JOE DONNELLY, Indiana
JERRY MCNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
CLIFF STEARNS, Florida
JERRY MORAN, Kansas
RICHARD H. BAKER, Louisiana
HENRY E. BROWN, JR., South Carolina
JEFF MILLER, Florida
JOHN BOOZMAN, Arkansas
GINNY BROWN-WAITE, Florida
MICHAEL R. TURNER, Ohio
BRIAN P. BILBRAY, California
DOUG LAMBORN, Colorado
GUS M. BILIRAKIS, Florida
VERN BUCHANAN, Florida

 

 

 

Malcom A. Shorter, Staff Director


SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
CIRO D. RODRIGUEZ, Texas
GINNY BROWN-WAITE, Florida, Ranking
CLIFF STEARNS, Florida
BRIAN P. BILBRAY, California

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
October 24, 2007


Sharing of Electronic Medical Information Between the U.S. Department of Defense and the U.S. Department of Veterans Affairs

OPENING STATEMENTS

Chairman Harry E. Mitchell
    Prepared statement of Chairman Mitchell
Hon. Ginny Brown-Waite, Ranking Republican Member
    Prepared statement of Congresswoman Brown-Waite


WITNESSES

U.S. Department of Defense:
Brigadier General Douglas J. Robb, M.D., Commander, 81st Medical Group, Keesler Air Force Base, Biloxi, MS, Department of the Air Force
    Prepared statement of General Robb
Colonel Keith Salzman, M.D., MPH, FAAFP, FACHE, Chief of Informatics, Western Region Medical Command and Madigan Army Medical Center, Tacoma, WA, Department of the Army
    Prepared statement of Colonel Salzman
Lieutenant Commander James Lawrence Martin, Regional Information Systems Officer, Navy Medicine East, Medical Service Corps, Department of the Navy
    Prepared statement of Commander Martin
Colonel Gregory Andre Marinkovich, M.D., Data Management Product Line Functional Manager, Clinical Information Technology Program Office, Military Health System, Medical Services Corps, Department of the Army
    Prepared statement of Colonel Marinkovich
Stephen L. Jones, DHA, Principal Deputy Assistant Secretary of Defense (Health Affairs)
    Prepared statement of Dr. Jones
U.S. Government Accountability Office, Valerie C. Melvin, Director, Human Capital and Management Information Systems Issues
    Prepared statement of Ms. Melvin
U.S. Department of Veterans Affairs:
Howard B. Green, PMP, Deputy, Operations Management, Veterans Health Information Technology, Office of Enterprise Development, Office of Information and Technology
    Prepared statement of Mr. Green
Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for Health, Veterans Health Administration
    Prepared statement of Dr. Cross


MATERIAL SUBMITTED FOR THE RECORD

Post Hearing Questions and Responses for the Record:

Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, to Hon. David M. Walker, Comptroller General, U.S. Government Accountability Office, letter dated February 5, 2008, and response from Valerie C. Melvin, Director, Human Capital and Management Information Systems Issues, U.S. Government Accountability Office, letter dated March 7, 2008

Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, to Hon. Robert M. Gates, Secretary, U.S. Department of Defense, letter dated February 5, 2008, and DoD responses

Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking Republican Member, Subcommittee on Oversight and Investigations, Committee on Veterans' Affairs, to Hon. James B. Peake, Secretary, U.S. Department of Veterans Affairs, letter dated February 5, 2008,  and VA responses

The Health Executive Council Highlights, FY 2003-First Quarter for FY 2008, dated June 10, 2008


SHARING OF ELECTRONIC MEDICAL INFORMATION BETWEEN THE U.S. DEPARTMENT OF DEFENSE AND THE U.S. DEPARTMENT OF VETERANS AFFAIRS


Wednesday, October 24, 2007
U. S. House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice at 10:03 a.m., in Room 334, Cannon House Office Building, Hon. Harry E. Mitchell [Chairman of the Subcommittee] presiding.

Present:  Representatives Mitchell, Space, Walz, Rodriguez, and Brown-Waite.

OPENING STATEMENT OF CHAIRMAN MITCHELL

Mr. MITCHELL.  Good morning and this hearing will come to order.  This is the Subcommittee on Oversight and Investigations.  And today's hearing is on Sharing of Electronic Medical Information between the U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA).

I want to thank everyone for being here today and I am very pleased that so many people could attend this oversight hearing on Sharing Electronic Medical Information between the Departments of Defense and Veterans Affairs.

This is a critically important issue.  Thousands of our servicemen and women require and will continue to require significant medical care as a result of the conflicts in Iraq and Afghanistan.  The most seriously injured of our Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans may need a lifetime of care.  But even veterans returning with no visible injury may need assistance with post traumatic stress disorder (PTSD) or mild traumatic brain injury (TBI).

The DoD and VA are sharing more and more patients.  For example, the patients at the VA's four polytrauma rehabilitation centers are almost always still on active duty.  And active-duty servicemembers will be veterans sooner or later.

A review by the VA's Inspector General shows that of the 500,000 or so servicemembers who left active duty in fiscal year 2005, 92 percent had an encounter with a military health system while on active duty that resulted in a diagnostic code.  In other words, nearly all of the veterans who go to the VA to get medical care will have military medical records that should be available to VA healthcare providers.

If anyone can convince the American people of the importance of electronic medical records, it is our first panel.  Specialist Channing Moss is an Army soldier who was shot with a rocket propelled grenade that lodged in his body.  He is alive and walking today because the medical evacuation team and the combat surgeons who operated on him put their own lives in danger in order to remove live ordnance from Specialist Moss.

Brigadier General Douglas Robb was Chief Surgeon of United States Central Command (CENTCOM) at the time.  And he will discuss how important it was that a copy of the x-ray taken at the forward field hospital was available to the clinicians at Landstuhl before Specialist Moss arrived.

DoD and VA have been working on electronic exchange of medical information for many years.  For most of that time, the story is not a happy one.  I am nevertheless pleased to be able to say that DoD and VA have made more progress in the past 12 to 18 months than they have made in the preceding decade.

But there is still much to be done.  There is no reason why, in this day and age, that DoD and VA cannot electronically share the information necessary to treat our servicemembers and veterans.  We should not have to wait any longer.

I hope and I expect that DoD and VA will tell us today that by no more than a year from now clinicians at DoD and VA will have full electronic access to the medical information they need to treat their patients whether that information resides in computers owned by DoD or the VA.

[The statement of Chairman Mitchell appears in the Appendix.]

Mr. MITCHELL.  Before I recognize the Ranking Republican Member for her remarks, I would like to swear in our witnesses.  I would ask all the witnesses from all the panels to please rise and raise your right hand.

[Witnesses sworn.]

Mr. MITCHELL.  Thank you.

I would now like to recognize Ms. Brown-Waite for her opening remarks.

OPENING STATEMENT OF HON. GINNY BROWN-WAITE

Ms. BROWN-WAITE.  Thank you very much, Mr. Chairman, and I thank you for yielding.

It is a good idea to hold this hearing to review the status of the electronic medical record sharing between DoD and VA.  This Subcommittee has already held two hearings in the 110th Congress on the issue of seamless transition of our servicemembers.  And in the 109th, various hearings were also held.  It is a very important issue.

The first hearing of this Committee was held in March and the second one in May, both of which focused primarily on the sharing of critical medical information of wounded servicemembers and the sharing of that information between DoD and the VA.

I want to assure the witnesses here today this issue is of the utmost importance to Members of this Committee and certainly the full Committee and I believe every Member of Congress.

I am very pleased that the Chairman requested that representatives from DoD testify here today.  It will be important to hear their perspective on the timely exchange of critical medical information between DoD and VA for the seamless continuum of delivering healthcare to our servicemembers.

I look forward to hearing the steps DoD has taken to allow critical medical information to be reviewed by VA when active-duty servicemembers are transferred to VA facilities.

In addition, I will be interested in hearing from VA on whether technological obstacles or bureaucratic intransigence prevent this from occurring today.

This past week, staff members visited Keesler Air Force Base and the VA medical center in Biloxi, Mississippi, to see how the Air Force and VA are coming together in VA/DoD resource sharing.

Unfortunately, the progress in this area is a result of the devastation of Hurricane Katrina and the dynamic personalities of senior leadership at these facilities and not the "Veterans Administration and the Department of Defense Health Resources Sharing and Emergency Operations Act of 1982."

It does appear, Mr. Chairman, I agree with you, that the ball has moved forward more in the last, say, 24 months than the last 25 years.  It is a shame that it took Hurricane Katrina, the debacle at Walter Reed, and the devastating wounds of war to expedite progress between the two largest Federal bureaucracies.

I am also looking forward to hearing from representatives of both departments about how they plan to implement the recommendations of the recently released Dole-Shalala Commission report and the Veterans Disability Benefits Commission report.

Again, thank you very much, Mr. Chairman, for holding this hearing.  The issue is very important to every Member of Congress and I believe every American.  And with that, I yield back the balance of my time.

[The prepared statement of Congresswoman Brown-Waite appears in the Appendix.]

Mr. MITCHELL.  Thank you. 

I ask unanimous consent that all Members have five legislative days to submit a statement for the record.  Seeing no objections, so ordered.

Before we hear from our first panel, we are going to take a look at a short video about Channing Moss, the soldier that I spoke about in my opening statement.  The Subcommittee appreciates the cooperation of the Army Times in making this video available.

If you would like to move around to see this, please do.

[Video shown.]

Mr. MITCHELL.  General Robb will speak to us in a minute about the importance of the electronic transmission of Specialist Moss' medical records.

But before we hear from General Robb, the Subcommittee would like to thank the Army Times and in particular Gina Cavallaro, James Lee, and Chris Brass who put this video together. 

Ms. Cavallaro, would you please stand?  We want everybody to know that she was the first one to report this story more than a year ago and I would like to thank her on behalf of the Subcommittee and indeed on behalf of the country for bringing this truly inspiring story to light.  Thank you.

At this time, we will hear from General Robb and he will have five minutes to make his presentation.  Thank you.

STATEMENT OF BRIGADIER GENERAL DOUGLAS J. ROBB, M.D., COMMANDER, 81ST MEDICAL GROUP, KEESLER AIR FORCE BASE, BILOXI, MS, DEPARTMENT OF THE AIR FORCE, U.S. DEPARTMENT OF DEFENSE

General ROBB.  Mr. Chairman and Members of the distinguished Subcommittee, thank you for inviting me here today.  I am Brigadier General Douglas J. Robb and I served as the Command Surgeon, United States Central Command from 2004 to 2007.

Currently, I am serving as the Keesler Medical Center Commander and as the Senior Market Manager for the Gulf Coast Multi-Service Market Office, Keesler Air Force Base, Biloxi, Mississippi.

Thank you for the opportunity to express my advocacy for a healthcare information systems platform and an electronic medical record that supports the world-class quality healthcare that our military and Veterans Administration healthcare facilities provide to our DoD and VA beneficiaries.

In my previous assignment as the CENTCOM surgeon, I had the opportunity to witness the evolution of our deployed healthcare information systems platforms that support access to patient care data as our wounded warriors move through the continuum of care from our combat casualty care lifesavers to our forward surgical teams, to our theater hospitals, and then on to our definitive care facilities at hospitals such as Landstuhl, Walter Reed, Bethesda, Wilford Hall, and our VA polytrauma centers.

As you saw in the video, on March 16, 2006, Specialist Channing Moss was severely injured in an attack in southeastern Afghanistan.  The lifesaving care performed by the combat lifesavers in his unit and the subsequent and surgical stabilization by the forward surgical team and the Bagram Theater Hospital saved his life.

What was also lifesaving was the ability of the surgeons at Landstuhl Hospital in Germany who would receive Moss less than 24 hours after his initial injury and the surgeons at Walter Reed to be able to view his operative notes and his x-rays before the patient arrived at their hospitals.  This was accomplished via the Joint Patient Tracking Application (JPTA), which is part of the DoD's deployed healthcare information systems platform.

As an aside here, and you noticed in the video, that Moss said he was going to fight to live.  And it is our task as medics in the combat environment to give him that opportunity to fight to live.  And I was privileged to serve with those men and women, our medics in the Area of Rescue (AOR) who saved Moss' life, and especially to Dr. Oh did a great job there with the forward surgical teams.

Earlier that year, and again in Afghanistan, a general surgeon and the Commander of one of our other forward surgical teams commented on his excitement when he was able to send completely digital trauma resuscitation and operative reports to the Bagram Combat Support Hospital, again before the patient arrived.

This is something that had been his vision for our forward surgical teams for a long time.  During his previous assignment, he had been a surgeon at Landstuhl, Germany, and was frustrated by the lack of medical data from the forward surgical teams' initial surgical resuscitation.  He was happy that this had been corrected.

Now, currently in my position as the Senior Market Manager for the Gulf Coast Multi-Service Market through the collaborative and joint DoD and VA initiatives, we are entrusted with the in-garrison care of our DoD and VA beneficiaries.  In this capacity, we also require a healthcare information system platform that supports access to real-time patient data for our shared population.

Our patients are from the Gulf Coast and are treated in the DoD and VA hospitals and clinics that are often located in proximity from Biloxi to Panama City.  Our goal is to provide quality services in a seamless manner.  This requires an integrated healthcare information systems platform that is user friendly for our jointly-operating DoD and VA healthcare facilities.

Significant progress has been made in the past few years to bridge this gap of electronic information flow.  Just last month, our staffs were excited when the Bidirectional Health Information System (BDHI) became available at some of our facilities.  Although not at its full capability yet, it is a very positive step in the right direction in our ability to view patient care data from both VA and DoD facilities.

In conclusion, as a former Combatant Command Surgeon and currently as the Multi-Service Market Manager, I continue to be a strong advocate for healthcare information systems.  We need to support heroes like Channing Moss as they move through our deployed and garrison-based continuum of care from the combat casualty to the forward surgical resuscitation, to theater hospitalization, and finally our DoD and medical centers and clinics.

The current capability has proven itself in contributing to the quality of care for our beneficiaries and with your support, I believe we can continue to improve upon our already existing and evolving capability and further share and make available the full spectrum of electronic health information between our Department of Defense and Department of Veterans Affairs.

Mr. Chairman, Committee Members, thank you again for allowing me this opportunity to appear before you.

[The statement of General Robb appears in the Appendix.]

Mr. MITCHELL.  Thank you, General Robb.

I have just got a couple questions and I am not sure I understand all the acronyms or all the—

General ROBB.  Yes, sir.

Mr. MITCHELL.  —things that I am going to throw out and ask you about, but I am sure you do.  It is our understanding that the Joint Patient Tracking Application is currently used to get inpatient information from the theater but that some in DoD are trying to require clinicians in the theater to use an application called Tactical Command and Control (TC2 )

In your expert opinion, will doctors in the theater actually use this application, TC2, for inpatient documentation of clinical notes?  That is one question.

And if use of the JPTA for documenting encounters in theater is stopped, could this negatively impact delivery of healthcare for our most seriously injured as they travel through the continuum of the VA?

General ROBB.  Well, sir, as far as the TC2, which is the current inpatient platform documentation system, that was implemented and introduced into the theater of operations after I left as the Combatant Surgeon.  And as a result, in my current capacity, I have not been keeping up as much as I maybe should with my previous job, but my views on it in general are this.

The initial inpatient module that was introduced into the theater did not accomplish what it was intended to do for a couple of reasons.  Primarily it was because it was not user friendly for the providers.  So if something is not user friendly by the providers and also providing a useful note to convey patient care information and data from one provider to another provider, then the providers are probably not going to accept that as a platform to use to take care of, remember, their patients.

Number two, another reason was I believe at the time that that was a stand-alone system and it did not allow information to flow.  And as a result, when the Joint Patient Tracking Application was introduced into the theater to track patients from level two, level three, all the way back to the United States, the clinicians, the providers themselves figured out that they can put patient care data on that platform that, as we described in Moss' case, we are able to move patient care data along the continuum before and during and after the patient moved through the system.

So that is the system that needs to be in place.  The current inpatient module, if it is user friendly, and the providers decide that it is a useful note, okay, and it is real-time accessible, then it will be successful, yes, sir.

Your second question about JPTA if it stopped right now, I think, again, my direction when I was the Command Surgeon was when the inpatient module is user friendly, provides a useful note, and provides real-time patient care data, and we can view inpatient data from real-time, before, after, and during their movement, then we can switch from the Joint Patient Tracking Application over to whatever system is going to work for us on the Armed Forces Health Longitudinal Technology Application (AHLTA) deployed platforms.

But until then, I think we need to allow the providers the opportunity to move the patient care data that is useful to them.

Mr. MITCHELL.  Thank you.

After seeing this video about Specialist Moss, I can imagine that great things are happening like that all over today.

General ROBB.  Yes, sir.

Mr. MITCHELL.  However, I understand that there still may be some problems getting information from the field medics to hospitals and to the VA.

What more can be done to ensure that this process goes smoothly?

General ROBB.  Well, again, as I described in my testimony, we have some monumental, I think, steps that have occurred, nothing occurs as fast as we want it to, but that have occurred.  One of them is the Bidirectional Health Information System. 

And, again, when we demonstrated that, I mean, we received it the day before and the next day, we flicked the switch and we got everybody together.  But the opportunity for us through a bridge portal to view AHLTA data in VistA, which is the DoD system, view it in the Veterans Administration system, and then look from the Veterans Administration system into the DoD system to be able to see outpatient notes, lab, x-rays, pharmacy, allergies, we are there.

The inpatient piece of it, that is going to be fielded here.  At some places, it is already fielded.  But the ability to field it at my particular location will be by next summer.  That will be a tremendous milestone for us to accomplish.  And for us in the Gulf Coast region and the patients that we share with our veterans to be able to look at each other's healthcare data, I am excited about that.

The opportunity that we have had for the connections between the outpatient modules and then as we watch the evolution of the inpatient module, if that becomes connected, I know the outpatient is, we can view outpatient data from the field from any of our DoD locations and now through BDHI into the VA system.

And once the inpatient module becomes successful, then the ability to view that again will advance again and contribute to the healthcare of our veterans.

Mr. MITCHELL.  Thank you.

Ms. Brown-Waite?

Ms. BROWN-WAITE.  Thank you, Mr. Chairman. 

By the way, congratulations on your recent promotion to Brigadier General.  It certainly is refreshing to see that the military still rewards leaders for their candor and their refreshing approach to real-life problems.

Let me ask you, if JPTA did not exist in the combat theater, how would, for example, the operative notes and x-rays be sent with the patient within 24 hours from, for example, in the video that we saw from Afghanistan to Landstuhl, Germany to be used by the accepting surgeon there, whether it is a situation like we just saw or whether it is TBI?  How would that information be transmitted?

General ROBB.  Well, under the old paradigm and the paradigm that I lived in when I first came to U.S. Central Command was we were moving paper records.  In other words, if you had the opportunity to—I will regress a little bit.  The patients move so fast through our system today.  From the time of wounding on the battlefield to the time you are under the knife, it is sometimes as little as 20 minutes to your forward surgical team.

And then you are usually in a combat theater hospital within an hour, sometimes two or three.  And then you are at Landstuhl usually under 24 hours and sometimes you are at Walter Reed in 24 hours.

And so you can imagine that under the old paradigm with the paper record, that may not keep up with the patient.  And so, you know, a lot of times, physicians are moving, especially in the mass casualty situation, are moving so fast through the system that you complete the paperwork after the patient leaves.  And so then it is hard to give the hard copy to move with the patient. 

So that was a dilemma we faced.  And that is why it is important that we have a deployed healthcare information system platform that allows it so that you can enter the data.  It is okay to enter the data after the patient leaves, but then it needs to be able to be viewed. 

So, you know, hypothetically you could put the data in or do the op note or whatever while the patient is being shipped to the next level.  And so by the time they get to the next level, whether it is the theater hospital or to Walter Reed or to Landstuhl, it is in the system for the receiving physicians to see.  And, again, that prepares that team for what is coming with them.  They can anticipate the specialties.

And so the clinicians, actually specifically the joint theater trauma system team, and the directors embraced this platform, the Joint Patient Tracking Application platform to be able to hang that type of data so that they could inform their colleagues along the continuum of care what was coming to them so they could better prepare for the care when they received them.

Ms. BROWN-WAITE.  Obviously that is a giant step forward.

We have heard from providers in the combat theater that the current effort to document inpatient medical notes useable or very difficult at best that these actually were discouraged.  This was after two failed implementations of the Composite Health Care System (CHCS) legacy system. 

To the best of your recollection from your time in theater, was JPTA discouraged and, if so, by whom?  And I guess we hope that candor is still there.

General ROBB.  Well, I am a physician by trade.  And so I understand how physicians talk to each other and I understand what needs to be passed from one physician to another.

My staff, myself, and then the joint theater trauma system embraced the capability that the joint theater tracking application brought to us besides just the patient tracking application piece of it.

And as a result, we made a decision that this was the way that we were going to support the movement of data for en route patient care because it was the right thing to do.  And so we supported it from my staff and then subsequently through the component surgeons and then down to the different levels.  That was the direction that we gave them for inpatient documentation.  And that is what we executed.

Did everybody accept it?  It was something different.  And change is always difficult. 

Ms. BROWN-WAITE.  But was it actually discouraged?

General ROBB.  Was it actually discouraged?  There were some locations that did not embrace it as much as others, yes, ma'am.

Ms. BROWN-WAITE.  If you are not comfortable saying it now, I would like to know those locations so that we can make sure that regardless of where the injury takes place that we have the best records being transferred.  It is not about the staff.

General ROBB.  Right.

Ms. BROWN-WAITE.  With all due respect, it is not about the doctors who do wonderful work.  It is about making sure that it is a system—

General ROBB.  Yes, ma'am.

Ms. BROWN-WAITE.  —that works well on behalf of the patient.

General ROBB.  Yes, ma'am.

Ms. BROWN-WAITE.  Thank you very much, General.

General ROBB.  Yes, ma'am.

Ms. BROWN-WAITE.  I yield back.

Mr. MITCHELL.  Thank you.

Congressman Walz?

Mr. WALZ.  Thank you, Chairman. 

And thank you, General.  A special thank you for your service in where you are at in providing medical care which I think is without a doubt the best surgical and the best medical care ever given to warriors in the history of mankind.  And that has been an amazing success story.

And this issue and this topic of medical records is critically important.  I understand, and many of us, I think, oversimplify what goes into this, what data needs to be on there.  And I represent the part of Minnesota that has the Mayo Clinic and this is a conversation I have had many, many times on this, on a broader area of healthcare in general, and what is going to be done.

Now, it looks like and what I am hearing is I am very optimistic, too, that massive progress has been made.  I think for our perspective here in Congress, the end result, the progress, the improved medical records, it is going to help in terms of patient care, cost, research, all of those things that go with medical records.

My question to you is, and I know again some of these have to be subjective, what do you attribute what appears to be an increased pace of change, an increased pace of trying or a sense of urgency to implement this idea of data sharing and electronic medical records, or do you think it has just been on a continuum and it is finally reaching fruition where it has gotten to where we can get the types of things you are talking about?

General ROBB.  Well, I think, of course, you know it was the President's vision that we go this direction as a Nation.  And as I spend time also in my professional capacity with my State organizations and associations from the State of Florida, they are wrestling again with how are they as a State going to come up with an electronic medical record or healthcare information systems platform to support that vision.

If it were easy, I think one of the States would have figured this out already.  And so I applaud the Department of Defense again for leading the charge.  You know, sometimes we make some of our best advances in crisis and I think that has probably been part of the addition to the momentum of where we are going, the sense or urgency, because there is a lot of competing priorities out there.

I believe, as we all believe, that we have the interest of our patients, whether they are civilian, whether they are veterans, or whether they are active duty, at heart.  And I believe as a Nation and with the Department of Defense and with the Department of Veterans Affairs and the Federal Government in the lead on this, I think we have the opportunity to set the standard for what is an electronic health record or, even bigger, what I call a health information systems platform to support patient care as we want it to be in the future.

Mr. WALZ.  One of the questions that always comes up here is the Congress' role in providing not only oversight but resources.  In your experience now, are the resources there to make this transition because many of us up here understand it is a scarce amount of resources and what we are getting out of it?  

But this issue is so broad and so important and especially in the care of our veterans and seamless transition.  I kind of ask the question, the last question with a little bit of leaning towards, did Walter Reed wake us all up and those types of things?  Was this one part of it?

And I guess my question to you is, do you feel that the resources are there, the commitment is there to get this right this time?

General ROBB.  I think the oversight and the emphasis is there, absolutely.  This is a tremendous monumental paradigm shift from where we were and to where we are going.  And it is taking a lot of resources, probably more than we maybe had anticipated. 

I think we have the brain power to do it.  I think we have some of the solutions.  In fact, I think we have most of the solutions, at least to get us through the interim.  The next generation of platform is something that we need to work on.  But for the interim, for the next 12 to 18 to 24 months, I believe we have some solutions in place. 

Could we accelerate that with resources?  The answer is potentially.  But I am not in that business, so I do not know if we can go any faster if, let us say, either more manpower or money was thrown at it.  Sir, I do not know that.

But I know that they have a road map way ahead which you will hear later that I am very optimistic about in making this happen.  And if they can have the opportunity to answer that question later, then they can probably tell you whether or not the resourcing piece of it is something that could either accelerate this or slow it down, yes, sir. 

Mr. WALZ.  [Presiding]  Very good.  Thank you, General.

Mr. Rodriguez?

Mr. RODRIGUEZ.  Thank you very much.  And I apologize for not being here, although I hear my colleague is very optimistic.

This is my ninth year on this Committee with the absence of two years, and about five or eight years prior to me getting on here, we had been talking about this process.  And so I am pleased and glad that we are finally making some inroads, although it has taken a long time.

And we talk about it is monumental, but it is monumental from our part when we have been talking about this for a significant amount of time.  And, you know, until I see it, in all honesty, I will not believe it.  I can only react based on the fact that we know the Department of Defense has been stonewalling us on a couple of items on this area and not you personally, General.

And I want to personally thank you for your efforts.  But, you know, we have got to get this straight because there are a lot of other things that took us 20 years to finally tell some of our veterans from Project 112 that when they told us there was no experimental, you know, exercises being done on our own soldiers then we found out that that was the case. 

So I would like to be able to get that documentation and also go back and addressing some of the needs of those soldiers in the 1960s and 1970s that we did some of those things and experimented with some of those gases and other things with them that the Department of Defense failed to—not failed—actually denied us that information for over 20 years.  And, you know, I experienced that on this Committee.

Now, I have also witnessed that the process to get there is, you know, because one after another have shown us some models of how we can do that and make that happen, and I want to throw a question to you in terms of—because at one point, I was just, you know—well, I am frustrated with both and that we need almost an external group to come in here and take care of it for you guys, both the Department of Defense and the VA when it comes to our computers, especially in terms of what happened with the loss of the information in the VA.

And so I was wondering if in terms of expediting this, would it help to get some external groups to come in and take care of it in terms of the high tech stuff that is required?

General ROBB.  That is kind of out of my area of expertise.  I am an operator and an executor.  And I am the one that executes what you all give me.  And I am not in what I will call the developmental arena.  So, sir, I have to pass that question on to—

Mr. RODRIGUEZ.  The second question, as we speak now, we hear the Department of Defense doing some diagnosing already on some 20 something thousand personality disorders which automatically identifies preexisting condition.

Are we having any other of those kind of things occurring at the present time, that we are going to have some additional problems in the future?  Are there some problems specifically with some of that that might be occurring at the Department of Defense?

General ROBB.  Sir, I do not think I understand your question.

Mr. RODRIGUEZ.  There was a group of some 20,000 soldiers that were identified with personality disorders.  And when that occurs, when that soldier leaves, and I had a couple of them come and visit me, that presupposes a preexisting condition which means they do not qualify for any kind of benefits or anything when they try to go if that is their diagnosis.  And so the Department of Defense, it is my understanding, did these diagnoses.

Where are we at on that kind of stuff?

General ROBB.  Sir, that is again probably out of my area of expertise because you are talking about accession standards in the way we access our individuals' preexisting conditions, of course, or conditions that the medical profession and through the administrative channels also believe existed prior to service.  And then that particular condition arises or surfaces when they are in the military.

But as far as what we are doing to better pick up on some of those preexisting conditions, that, sir, again, is out of my area of expertise.

Mr. RODRIGUEZ.  Okay.  And I would also want to go back as we move on this to some of our previous veterans.  We want to do the right thing now, but we also want to go back to Vietnam and some of those areas where we did have and at one point had identified some 5,600, maybe even more, because I was gone for a couple of years, so close to 6,000 soldiers that we used, you know, nerve gas and other things on on our own soldiers, and wanted to see from the Department of Defense, you know, later on, maybe we can get, Mr. Chairman, a little status report on those assessments that were done in the 1960s and 1970s on our soldiers because I know they first said that they only identified some 30 projects and then it went to 40 and the last I heard, it was close to 50-something projects where we had done experimental stuff with our own soldiers, and I want to just get, you know, and that is with the Department of Defense, I just want to get some feedback on that.

General ROBB.  Sir, again, that is again out of my area of expertise and I am not aware of that.

Mr. RODRIGUEZ.  Thank you very much for what you are doing, sir.  A lot of the Members feel optimistic, so you must have said some good things.

General ROBB.  Well, I will tell you, the group of folks that I had a chance to work with and work for are medical professionals not only in the CENTCOM area of responsibility but also back here at our, again, our major hospitals and our clinics, and then my opportunity in my current capacity to work with the Veterans Administration.  You know, we have all heard the expression from Secretary Nicholson this is not your father's VA.  There are a group of dedicated professionals out there in the Veterans Administration that care for our soldiers, sailors, airmen, Marines, coalition forces and they are second to none.  And I am proud to be part of that team, yes, sir.

Mr. RODRIGUEZ.  And I hope the Department of Defense takes it from the perspective that that file belongs to that soldier.

General ROBB.  Yes, sir.

Mr. RODRIGUEZ.  And they be able to get a grasp of it and be able to have it so that when they move into the VA, and it would be more cost effective for us as a whole, and not to mention in terms of that particular soldier.  Thank you.

General ROBB.  Yes, sir.

Mr. WALZ.  Ranking Member Brown-Waite?

Ms. BROWN-WAITE.  General, I just wanted to thank you very much for being here, for your candor, and also for your ability to accept and promote the kind of technology that will certainly help the patient a whole lot more than the past.  Lord only knows where the paper trail system is that was there.

Thank you so much.

General ROBB.  Yes, ma'am.

Ms. BROWN-WAITE.  And please encourage others to follow suit.

General ROBB.  Yes, ma'am.

Mr. WALZ.  I would echo and associate myself with the Ranking Member's comments generally.  It is refreshing to hear this.  We have got a lot of work to do.  Please know that we sit up here as representatives of the American people and we want nothing more than to provide the highest quality care to our soldiers and our warriors that are out there and as they become veterans. 

So you simply need to see us as partners in this.  We are glad to have you out there.  And I thank you for your time.

General ROBB.  Thank you.

Mr. WALZ.  We will go ahead and seat the second panel, please.  Welcome to our witnesses.  Our witness today, Ms. Valerie Melvin, is Director of Human Capital and Management Information Systems Issues for the U.S. Government Accountability Office, the GAO.  She will be accompanied by her Assistant Director, Ms. Barbara Oliver.  We look forward to her unbiased view on this situation.

And, Ms. Melvin, you are recognized for five minutes.

STATEMENT OF VALERIE C. MELVIN, DIRECTOR, HUMAN CAPITAL AND MANAGEMENT INFORMATION SYSTEMS ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; ACCOMPANIED BY BARBARA OLIVER, ASSISTANT DIRECTOR, HUMAN CAPITAL AND MANAGEMENT INFORMATION SYSTEMS ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

Ms. MELVIN.  Thank you.  Members of the Subcommittee, I am pleased to be here today to continue the dialogue on VA's and DoD's efforts to share electronic medical information and attempts to ensure that active-duty military personnel and veterans receive high-quality healthcare.

As you have mentioned, accompanying me today is Ms. Barbara Oliver, Assistant Director.

As you know, VA and DoD have been pursuing ways to share medical information for nearly a decade.  And since 2001, GAO has reported numerous times on their initiatives.

Our last testimony before you on May 8th highlighted the key projects that the two departments have pursued and the substantial work that remained to achieve comprehensive electronic medical records.

At your request, my statement today further discusses the history and status of these efforts.

In this regard, since 1998, VA and DoD have focused on the long-term vision of a single comprehensive life-long medical record for each servicemember to achieve a seamless transition between the departments.

However, they have faced considerable challenges in their efforts to reach this goal, leading to repeated changes in the focus of and target dates for their initiatives.

Our prior reviews noted weaknesses in project management, oversight, and accountability, and we recommended that the departments develop a comprehensive and coordinated project management plan to guide their efforts.

Since we last testified, each Department has continued developing its own modern health information system to replace existing systems.  The modernized systems are based on using computable data, that is data in a format that a computer application can act on, for example, to alert clinicians of a drug allergy.

The departments have begun to implement the first release of an interface between their modernized data repositories and are currently exchanging computable outpatient pharmacy and drug allergy data at seven VA and DoD sites.

At the same time, the departments have made progress on short-term projects to share health information using their existing systems.  Of these, the Laboratory Data Sharing Interface Application is currently implemented at nine sites, allowing the departments to share medical laboratory results.

In addition, the Bidirectional Health Information Exchange or BHIE interface is allowing a two-way view of selected categories of health data on shared patients from VA's and DoD's existing health information systems.

Because BHIE provides access to up-to-date information, the departments' clinicians have expressed interest in its further use.  Accordingly, since May, the departments have been expanding BHIE's capabilities and implementation using the interface to connect not only VA and DoD but also DoD's multiple legacy systems which were not previously linked.  In this way, the departments have begun sharing more of their current information more quickly.

Beyond these two efforts, various ad-hoc processes that the departments established to provide data on severely wounded servicemembers to VA's polytrauma centers are being used.  These processes include manual work-arounds such as scanning paper records for transfer to incompatible systems.

While particularly significant to the treatment of servicemembers who sustain traumatic injuries, as we have testified previously, such laborious processes are generally feasible only because the number of polytrauma patients is small.

Overall, through all of these initiatives, VA and DoD are exchanging health information which is an important accomplishment.  However, these exchanges are limited and significant work still remains to achieve the long-term goal of a comprehensive electronic medical record.

Moreover, it remains unclear how all of the initiatives that VA and DoD have undertaken are to be incorporated into an overall strategy for a seamless exchange of health information.

The multiple projects and ad-hoc processes being discussed today highlight the need for further efforts to integrate information systems and automate information exchanges.  Yet, VA and DoD are continuing to proceed without a comprehensive project plan and overall strategy to effectively guide their efforts.

As we have previously recommended, the departments need such a plan to help ensure success in reaching their goals.

This concludes my prepared statement.  I would be pleased to respond to any questions that you may have.

[The statement of Ms. Melvin appears in the Appendix.]

Mr. WALZ.  Thank you, Ms. Melvin.

In listening, and I think you heard on the last panel as we were trying to assess where we are at on this progress, what is GAO's assessment as far as a time line of a real-time viewable, useable platform for these medical records?  Do you think it is reasonable or are we a year, are we two years, or where are we at from this being in place? 

We saw, and heard General Robb talk about, that there has been a momentum.  There has been the resources necessary.  We have been moving towards it.  We are seeing successes. 

In your opinion, where are we at in terms of before this is going to be up and running?

Ms. MELVIN.  We have seen definite progress in terms of the short-term initiatives that were mentioned today relative to the Bidirectional Health Information Exchange.  There are other initiatives related to the laboratory data sharing interface as well as a number of ad-hoc processes that have been put in place, in particular to serve the polytrauma patients who are coming back into the country.

From our assessment, these initiatives definitely bring additional capabilities and services to the clinicians by providing them with more information.  However, I am not able to say when the departments would be at a point of having the goal of a longitudinal, comprehensive electronic medical record, which they have indicated was their long-term goal or mission to have, because we have not yet seen their final plans for actually doing that.

As of now, we cannot state when they would have those systems in place.  Both departments at this point have told us that they do not have a date for their final modernized systems which are key components of putting in place the overall sharing capability that they have talked about having.

Mr. WALZ.  So no data has been expressed?  It is just a goal out there to try and get it done? 

The reason I ask this is I am optimistic on this.  The need to get this done is very apparent, but I do not want to find myself in the position of my colleague from Texas of being here for nine years and saying I can remember that conversation we had back in October of 2007 and here we are in 2016.

Do you have that fear or do you think that there is a difference now?

Ms. MELVIN.  There is a concern that we still have from two perspectives.  First of all, as I mentioned in my last response, both departments are still in the process of developing their modernized health information systems.  Those are the two systems that we no longer see specific completion dates for.

Beyond that, one of the concerns that we have repeatedly raised in our work is that the departments did not articulate a defined strategy for getting to this final mission.  And within that strategy, we would certainly hope that there would be interim milestones as well as a final time frame for accomplishing this.

Mr. WALZ.  Thank you, Ms. Melvin.

Ms. Brown-Waite, the Ranking Member, is recognized.

Ms. BROWN-WAITE.  Thank you very much.

I have been here.  This is my fifth year here, not fifth term, but fifth year, and served on the Veterans' Affairs Committee.  And this has been an ongoing issue and it is almost to the point where it is like déjà vu all over again because the same issue has not yet fully been resolved.

I think we have come a long way.  Of course, part of the problem is we do not have any authority over DoD in this Committee.  But I think that there finally seems to be a working relationship there and the belief that Congress is not going to just drop this issue.

In your testimony, you stated that although there are multiple initiatives between the VA and the DoD, there is an important requirement to integrate and automate information exchange.  I think you further stated that there is not a clear overall strategy to incorporate this in a seamless exchange of information.

I have been here five years.  Mr. Rodriguez has been here ten total, nine total.  How many times have you stated this same finding?

Ms. MELVIN.  Well, we have been reporting on this issue since 2001 and across the multiple reports that we have issued, we have, in fact, made the recommendation and reemphasized that recommendation a number of times.

Ms. BROWN-WAITE.  Do you know offhand how many?

Ms. MELVIN.  I can provide you that for the record.  I do not know offhand at this moment, but we can certainly tell you after this hearing.

[The response was provided in the Post Hearing Questions and Responses for the Record, which appear in the Appendix.]

Ms. BROWN-WAITE.  Okay.  Are you encouraged that there seems to finally be the realization by DoD that this has to happen?

Ms. MELVIN.  We are encouraged in seeing the different initiatives, the short-term initiatives that are being put in place.  We do see them as an opportunity to provide more information to the clinicians in the immediate.

What we have not seen is the actual plan that VA or DoD would be using to do this.  So I hesitate to say that or to speak or render a view of the plan that DoD has at this time because we have not actually seen that plan.  I am not familiar with the road map that they have indicated that they have.

Ms. BROWN-WAITE.  Have you asked to see it?

Ms. MELVIN.  We have asked for their strategies relative to what they are doing.  We have not been informed prior to today that there was an actual road map.

Ms. BROWN-WAITE.  Okay.  With that, I yield back the balance of my time.

Mr. WALZ.  Mr. Rodriguez is recognized.

Mr. RODRIGUEZ.  Let me ask you in terms of trying to get this accomplished and get it done, do we need to give you any additional leeway or any guidance, you know, or any additional authority to go in?  Are you going to be going in again and reassessing where they are at or do you need that additional guidance from us?

Ms. MELVIN.  We have previously responded to your request for oversight in this particular area.  So certainly to the extent that you would want to have additional oversight, we would certainly be willing to follow through with that.

Mr. RODRIGUEZ.  Because it has been an issue that I think we have dealt with.  I think they dealt with it for four or five years prior to even going to GAO.  And I am convinced that there is some movement now, but I am concerned that you mentioned just short term, I think mainly because our troops are coming in and it is embarrassing to leave some of these seriously injured troops out there and just transfer them out and fall through the cracks the way they have been falling through the cracks.  And that is obvious now.  But we have got to come to grips and try to come up with and require them to come up with a long-term strategy.     

So I would encourage the Chairman to look in terms of what we might have to do in asking the GAO to continue on this issue for further implementation of that and requiring the DoD to do that and maybe getting the Armed Services Committee, getting Chairman Skelton also aware of our concerns as it deals with our servicemember. 

And I am concerned not only with the existing one, but, you know, we are not going back.  I am just going back on my own personal experience with them in terms of health.  It is kind of like they drop them and then they do not particularly care anymore, you know, and they expect the VA to handle them.  And for good reason, you know, if we had that information and follow the soldier, it would help us tremendously, not to mention what it would do to the soldier. 

So I would ask the Chairman to see if we can keep on this track and hopefully ten years from now, we will not be talking about this, but maybe going after some of those other pockets of concerns that I had with those other studies.

While I am here, and maybe you are not the one, we had asked for studies on Project 112.  I do not know if you heard me talk about our soldiers that the Department of Defense had used studies on, health studies, you know, where they used nerve gas and other things on ship. 

And maybe later on, I would like to see if, you know, we can get a report as to where we are at on that because I have not heard anything.  And once again, it is my fault because I have not been here.  I was gone for two years.  But I wanted to get an assessment of that and if you get me that information as to where we are at.  And back then, we had identified, as I recall, some 5,600 soldiers, but we were concerned that there might have been more and maybe other projects that were not disclosed where we could ID additional soldiers that might have been impacted with certain forms of studies that were done with plombage and other things because we knew that there were some other exercises that took place that were not part of the 56 projects that were out there.

Ms. MELVIN.  Sir, I am not familiar with those studies, but we would be glad to go back and share your concerns and interest with others in our healthcare area who might be more familiar and have them to be in touch with you on that matter.

Mr. RODRIGUEZ.  Okay.  And also if you have done any studies on the recent diagnosing of soldiers with personality disorders because the other question that would come into play if they did come in with preexisting condition, personality disorders, you know, schizophrenia can have an onset around that age, but those onsets are much earlier. 

So the question would be, why did we allow them to get into the military in the first place if that was the case?  If you have got anything on that, I would appreciate it.

Ms. MELVIN.  Okay.  Will do.

Mr. RODRIGUEZ.  Thank you.

Mr. WALZ.  The gentleman from Ohio, Mr. Space, is recognized.

Mr. SPACE.  I have no questions, Mr. Chairman.  Thank you.

Mr. WALZ.  Ranking Member Brown-Waite?

Ms. BROWN-WAITE.  Mr. Chairman, I have just one other question for Ms. Melvin.

Have you, in pursuing this issue, had any indication that perhaps part of DoD's reluctance to proceed with the information sharing may be because of a c