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Mr. Chairman and Members of the Committee, I am pleased to appear before you today to give testimony regarding the progress being made by the Department of Defense (DoD) and the Department of Veterans Affairs (VA) to share health information and to develop a veteran-centric, seamless electronic health record.
One of the most important lessons learned from the 1st Gulf War is the need for interagency collaboration on deployment health issues, and the need for health data regarding a service member’s deployment, occupational exposures and health conditions that will allow VA to provide the best possible health care and benefits for veterans. VA applauds the efforts of DoD to prevent health problems among deployed troops. Furthermore DoD is providing cutting edge care in-theater for combat casualties. However, the wounds of war are not always obvious, and we appreciate today that military service may have enduring health consequences long after the actual war has ended.
Improved medical record keeping and data from environmental surveillance during deployments can be invaluable for addressing the short and long-term health care and benefits needs of America’s veterans. In the short-term, VA needs information that may be relevant to recently deployed service members’ or veterans’ immediate health care needs, looking for any unusual health problems among newly separated veterans from a specific deployment, and to establish special health care eligibility for returning combat theatre veterans. In the long term, VA needs clinical and administrative data to evaluate the long-term health of veterans from a specific deployment – to be able to answer key questions and concerns from veterans and their families about important matters like reproductive health issues or cancer rates among veterans in comparison with their non-deployed peers.
To this end, the “President’s Taskforce to Improve Health Care Delivery For Our Nation’s Veterans” (PTF) focused upon the importance of providing for a seamless transition from military to veteran status, including the coordination and sharing of electronic health information between VA and DoD. VA is working with DoD through the VA/DoD Health Executive Council and Joint Executive Council and in other venues to keep the focus upon this critical goal of information sharing.

Create a Seamless Transition
The President’s Task Force recommended that the two departments use standardized electronic health-related information nationwide to help ensure a seamless transition from military to veteran status. As the Task Force has noted, information systems coordination is a critical link between the two Departments.
DoD and VA are moving forward jointly to improve the efficiency and accuracy of enrollment information through the creation of integration points that will permit VA to access the Defense Enrollment and Eligibility Reporting System (DEERS) in real time by the end of 2005, a key objective in the President’s Management Agenda. The Veterans Health Administration (VHA) has identified a need for service indicators (such as contingency locations and dates of service, receipt of imminent danger and hazardous duty pay, etc) from DoD that will support VA’s delivery of special health care benefits to Combat Veterans. As this information sharing becomes a reality, we expect that a service member’s transition from active duty to veteran status will be simplified significantly while improving the process of accurately informing the veteran of all potential benefits for which s/he may be eligible.
Another key information technology initiative in the President’s Management Agenda addresses the sharing of individual health care information between the two systems. We believe that VA and DoD are making progress towards deployment of electronic medical records that are interoperable, bi-directional, and standards-based by the end of 2005. Our Departments have formed a close collaborative partnership, to include the development of a joint business case for electronic health records, under the Federal Health Information Exchange (FHIE) and HealthePeople (Federal) projects. In addition, we have signed formal Memoranda of Understanding on development of additional joint activities under both FHIE and HealthePeople (Federal).
As a result of the implementation of FHIE, VA clinical staff have access to information that was collected in DoD's Composite Health Care System (CHCS) on veterans who have been discharged since that system was implemented in 1989. Information available up to the time of their separation includes laboratory results, radiology reports, outpatient pharmacy prescription information, admission/disposition/transfer records, discharge summaries, and in the near future information on allergies, consult reports, and summary outpatient appointment information. The Veterans Benefit Administration (VBA) staff use this information to fulfill the evidentiary requirements for processing disability compensation claims as well as in determining eligibility for Vocational Rehabilitation and Employment benefits.
The joint VA/DoD Interoperable Electronic Health Record Plan (HealthePeople (Federal)) goes much further by committing our two Departments to implementing compatible IT enterprise architectures and adopting common standards, both of which serve as the essential technical foundation to achieve interoperable electronic health record systems. The end result will be interoperable electronic health record systems that will serve the needs of our nation’s veterans and service members and that could potentially serve as a model for a national health information infrastructure.
Mr. Chairman, we testified before the subcommittee on July 9, 2003 and before the full committee on October 16, 2003 on current efforts to assure a seamless transition for veterans returning from Operations Iraqi Freedom and Enduring Freedom. I would first like to update the committee on the efforts of our Seamless Transition Taskforce and then discuss our plan and progress toward improving electronic transmission of health information.

Seamless Transition Taskforce
In August of this year, VA’s Under Secretary for Benefits and the Under Secretary for Health charged a new VA Taskforce for the Seamless Transition of Returning Service Members to intensify and continue efforts to assure world class services are provided to our military and veterans. This taskforce focused initially on internal coordination, communication and staff training efforts to ensure that VA approaches this mission in a comprehensive manner. Also, efforts are targeted on improving dialogue and collaboration with DoD at all levels between our two Departments, including the Military Services, Personnel and Readiness, Health Affairs, and Reserve Affairs. We have been working closely with DoD to enhance our ability to identify and serve all returning service members that sustained injuries or illnesses while serving our country.
Thanks to the leadership of Dr. David Chu and Dr. Bill Winkenwerder, I am pleased to report that DoD transferred to VHA a list of military personnel who recently served in theaters of combat in Afghanistan and Iraq and subsequently separated from active duty. Our records indicate that of the approximate 17,000 veterans on this initial list, as of September 30, 2003, about 2,000 (12%) had sought health care from VA for a wide variety of health problems. Of this group, most have been seen as outpatients. VA looks forward to timely updates of this list and to the sharing of a complete roster of deployed troops, as was provided after the Gulf war in 1991. With a complete roster, VA can ensure that combat veterans receive new health care benefits and that emerging health problems are rapidly identified. VA also looks forward to receiving DoD pre- and post-deployment screening data, which will assist VA in the clinical evaluation of returning war veterans.
To ensure that our commitment is understood and shared at every level of the Department of Veterans Affairs, the Seamless Transition Taskforce has developed training materials for staff including a script and video for front line staff to ensure that they can reliably identify veterans who have served in a theater of combat operations and take the steps necessary to ensure they receive appropriate care. A software package was recently released to identify these combat veterans and a video for staff training has been finalized and will be provided to every VHA and VBA field site.
As discussed during the October 16 full Committee hearing, we have taken a number of additional steps including assignment of points of contact at each facility; issuance of case management guidance; assignment of VA staff to Military Treatment Facilities to provide information and assistance concerning VA benefits and to arrange for transfer of patients to VA health care facilities; and expanded outreach efforts to assure a seamless transition. We are working to expand these efforts and have partnered with the Army Disabled Solder Liaison Team. An MOU is being worked on which will help to standardize information transfer processes to sustain our progress.
Mr. Chairman, we testified before the Oversight and Investigations Subcommittee in early July of this year on the long - term outreach strategies that VA is pursuing to assure the best possible care is provided to returning Iraqi Freedom and Afghanistan Enduring Freedom service members. Many of these efforts are coordinated with DoD under the umbrella of the Health Executive Council.
All health or exposure data that DoD collects during deployment will be useful to VA. Through the Deployment Health Work Group, we are actively engaged with DoD in obtaining as much deployment health and exposure information as is available. Members of the Work Group are also charged with reviewing eventual sharing of data on troop locations, deployment health risks, and pre- and post-deployment health screening. Further, we are actively working with DoD to develop separation physical examinations that thoroughly document a veteran’s health status at the time of separation from military service and that also meet the requirements of the physical examination needed by VA in connection with a veteran’s claim for compensation benefits. We are optimistic that as a result of the improved collaboration between VA and DoD in these programs, we will be better positioned to evaluate health problems among service members and veterans after they leave military service, to address short and long-term post-deployment health questions, and to document any changes in health status that may be relevant for determining disability.
VA understands that veterans and their families will have questions and concerns about any special health problems that may be associated with a particular deployment, including infectious diseases and other deployment hazards. To respond to those concerns, VHA has produced and widely distributed a brochure addressing the main health concerns for military service in Iraq today, and a similar brochure for veterans serving in Afghanistan. Recently VHA distributed another brochure on health care for women veterans returning from the Gulf region. These brochures answer health-related questions that veterans, their families, and health care providers may have about these hazardous military deployments. They also describe relevant medical care programs that VA has developed in anticipation of the health needs of veterans returning from combat and peacekeeping missions abroad. These are also widely distributed to military contacts, veterans service representatives and are on VA’s website.

Other Long-Term Strategies
Since the 1991 Gulf War, VA has developed a broad array of programs and policies to assist veterans returning from combat missions abroad. These were discussed during the subcommittee’s July 9, 2003 hearing and the full committee’s October 16, 2003 hearings. Two initiatives are particularly important to assuring recognition of service related health problems:
• Implementation of a screening instrument in the form of a clinical reminder triggered by the veteran's separation date to assist our health care providers to properly identify and treat returning Iraqi Freedom and Afghanistan veterans that present for care in VA. This assessment tool will prompt the provider with specific data requirements to assure that veterans are screened for medical and psychological conditions that may be related to recent combat deployment. This clinical reminder is in final pilot testing at several VAMCs.
• VA has developed evidence based clinical approaches for treating veterans following hazardous deployments. These clinical practice guidelines (CPGs) give health care providers the needed structure, clinical tools, and educational resources that allow them to diagnose and manage patients with deployment-related health concerns. Two post-deployment CPGs have been developed in collaboration with DoD, a general purpose post-deployment CPG and a CPG for chronic fatigue and pain. These CPGs will substantially aid VA and DoD efforts to care for veterans with unexplained illnesses, which are found among veterans following all wars.
• VA and DoD will soon release a new CPG on the management of traumatic stress. This guideline pools DoD and VA expertise to help build a joint assessment and treatment infrastructure between the two systems in order to coordinate primary care and mental health care for the purpose of managing, and, if possible, preventing acute and chronic Post Traumatic Stress Disorder (PTSD).

The Electronic Health Record Systems Plan – HealthePeople (Federal)
Having documented many lessons from treating returning veterans after the 1991 Gulf War, VA implemented a number of initiatives to better support sharing medical information with DoD. In addition, it became quite evident that the Departments needed a workable strategy whereby they could effectively transmit health information between Departments for the purpose of providing high-quality, effective, safe healthcare for beneficiaries of both Departments. Also, the electronic transfer of medical information will improve the quality of care to the over 700,000 individuals who receive care from both DoD and VA annually.
During this past year the Departments developed and received approval for a strategy to achieve interoperability of health information systems for the purpose of sharing health data. The plan documents the roadmap for VA and DoD to demonstrate interoperability in 2004 and to achieve initial interoperability between health information systems in DoD and VA by 2005. The plan provides for the exchange of health data by the Departments and development of a health information infrastructure and architecture supported by common data, communications, security and software standards and high performance health information systems.
The Joint Plan will support HealthePeople (Federal), a long-term strategy to achieve full interoperability among Federal health information systems starting with the ability to provide a two-way exchange of health related information between VA and DoD. Providers of care in both Departments will be able to access relevant medical information to aid them in patient care. HealthePeople (Federal) was initiated to:
• Improve sharing of information
• Adopt common standards for architecture, security, communications, data, technology, and software
• Seek joint procurements and/or building of applications where appropriate
• Seek opportunities for sharing existing systems and technology
• Explore convergence of VA and DoD health information technology applications where feasible and within mission requirements
• Develop interoperable health records and data repositories

The standards and processes developed in this VA – DoD initiative will be beneficial to the private sector effort to transmit medical information electronically. Full interoperability is dependent upon both Departments deploying their next-generation health information systems, the DoD Composite Healthcare System II (CHCS II) and the VA HealtheVet-VistA system.

Plan Initiatives
There are several major initiatives that form the Electronic Health Record Systems Plan – HealthePeople (Federal). The Departments are presently collaborating on the development of interoperable data repositories that will form the backbone for all sharing of electronic health information; joint or interoperable software applications; and the adoption and identification of common data, architecture, communications, security and software standards.
The backbone of the Electronic Health Records Plan is the co-development and acquisition of interoperable data repositories by the Departments. By linking the DoD Clinical Data Repository (CDR) to the VA Health Data Repository (HDR), the Departments will achieve full interoperability of health information between DoD's CHCS II and VA's HealtheVet-VistA. Using clinical decision support applications, providers of care in both Departments will be able to access and use the relevant health information to aid them in making medication decisions for their patients regardless of whether that information resides in VA's or DoD's information systems.
The Departments are on track to demonstrate bi-directional health information using interoperable data repositories beginning with pharmacy data this fiscal year. VA and DoD have formed an active working integrated product team to lead this effort and development efforts are underway to deploy a working prototype in a lab environment.

Collaborative Software Applications
Since June 2002, phase I of the Electronic Health Record Systems Plan, the Federal Health Information Exchange (FHIE) (Its predecessor was the government computer based patient record (GCPR)) has provided all medical centers the capability to access historical data on separated and retired military personnel from the DoD’s Composite Health Care System (CHCS I). Current patient data that are being sent from DoD to VA via secure messaging include laboratory results, radiology reports, outpatient pharmacy information, patient demographics, admission discharge transfer (ADT) data, discharge summaries and allergies. This includes (a) providing such information at the time of the service member’s separation from military service, and (b) gathering and transmitting, under a set schedule, the same protected electronic health information on previously separated veterans. The original requirements for FHIE were revised to make them HIPAA compliant. The current phase of FHIE work continues in operational status and adds three more data categories as part of the enhancement work or planned product improvements. All of the initial requirements for FHIE have now been met through the implementation of Version 4 in September 2003. Additional capabilities have been added to the original project to transmit data from the DoD Pharmacy Data Transaction Service (PDTS) and the DoD Standard Ambulatory Data Record (SADR).
Beyond FHIE and as part of the joint plan, VA is working closely with DoD to jointly develop or acquire other software applications that will support the delivery of health care by enabling the sharing of health information. The Departments have made significant progress toward development of interoperable software applications to include credentialing, scheduling laboratory and electronic portal systems for beneficiaries. The Departments are presently enhancing the Laboratory Data Sharing and Interoperability software application to permit bi-directional support of lab requests and results between VA and DoD reference labs.

Additional VA Work on the Electronic Health Record
A significant, supportive component of our better serving veterans is VA’s new web application, “My HealtheVet”. My HealtheVet creates an Internet environment where veterans, family, and clinicians may come together to optimize veterans’ health care. An early release of this application on Veterans Day 2003 provides powerful health education information and health self-assessment tools. In the future, veterans will be able to reorder medications, view appointments and review copies of their health records online. In addition, My HealtheVet will allow each Veteran to share important military service history that can be utilized for evaluating health and disability status with the veteran’s permission. Nationwide implementation will occur through three phases, each with increasingly complex functionality and security. Project implementation is targeted for completion by October 2005. VA is closely working with DoD on its portal application, TRICARE Online. The Departments presently share the same health and wellness content and are exploring additional collaboration.

VA/DoD Medical Demonstration Sites
The FY 2003 Defense Authorization Act mandated eight medical sites for joint demonstrations between VA and DoD medical facilities. VA and DoD recently announced the demonstration sites – three of which are pilot efforts to enhance medical information and information technology systems sharing between the two systems:
• Madigan Army Medical Center and Puget Sound VA Health Care System are to be part of the piloting for a joint VA/DoD Electronic Health Record Systems Interoperability Plan;
• El Paso VA Health Care System and William Beaumont Army Medical System will conduct a Laboratory Data Sharing Initiative (LDSI); and
• South Texas Veterans Health Care System and Wilford Hall Medical Center and Brooke Army Medical Center will develop and test a Laboratory Data Sharing Initiative (LDSI) and test an integrated credentialing system.

These demonstration projects will run through FY 2007.

Summary
A service member separating from military service and seeking health care through VA today will have the benefit of VA’s more than decade-long experience with Gulf War health issues as well as the President’s commitment to improving VA/DoD collaboration. VA has successfully adapted many existing programs, and created new programs as necessary, that have improved outreach, improved clinical care through practice guidelines and educational efforts, and improved VA health providers access to DoD medical records. VA is actively working with DoD to attain the maximum level of sharing of information on injured combat veterans and recently discharged veterans. As a first step in creating a lifelong electronic health record for veterans, VA and DoD have developed a plan to share available electronic medical records by FY 2005.
A key component of optimal health care and assistance will be the development with DoD of a veteran-centric, life-long health record. Because this record has to begin at the start of military service, VA has been actively engaged with DoD in the development of the Recruit Assessment Program (RAP), which will collect comprehensive health data from all service personnel at entry into the military. A life-long health record will then be updated with clinical and exposure data during military service, pre- and post-deployment health screening data, discharge health data, and then clinical data from health care within VA. This information will enable VA to provide the best health care possible for our Nation’s veterans.
I note finally that the collection and sharing of medical information by and between the Departments of Veterans Affairs and Defense is subject to all privacy safeguards afforded by the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996.
This concludes my statement. My colleague and I will be happy to respond to any questions that you or other members of the Subcommittee might have.