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Witness Testimony of Gerald M. Cross, M.D., FAAFP, Veterans Health Administration, Acting Principal Deputy Under Secretary of Health, U.S. Department of Veteran Affairs

 

Good morning Mr. Chairman and Members of the Subcommittee.  I am pleased to discuss sharing electronic medical records between the Department of Defense (DoD) and the Department of Veterans Affairs (VA) and the significant progress VA has made toward the development of a secure, interoperable and bidirectional electronic health data sharing with DoD.

Overview

This progress includes the development of one way and bidirectional data exchanges to support service members who are separated and retired from active duty service. In addition, the data exchanges support active duty service members and veterans who receive care from both VA and DoD health care facilities. VA’s achievements in the area of electronic health data sharing with DoD directly support the efforts to seamlessly transition our service men and women as they move from DoD facilities to VA facilities and Centers of Excellence to continue their care and rehabilitation. Striving to provide world class health care to the wounded warriors returning from Iraq and Afghanistan remains one of VA’s top priorities. 

In March 2007, VA added a personal touch to seamless transition by creating 100 new Transition Patient Advocates (TPA). They are dedicated to assisting our most severely injured veterans and their families. The TPA’s job is to ensure a smooth transition to VA health care facilities throughout the nation and cut through red tape for other VA benefits. Recruitment to fill the TPA positions began in March, and to date VA medical centers have hired 46 TPAs.  Interviews are being conducted to fill the remaining 54 positions.  Until these positions are filled, each medical center with a vacant TPA position has detailed an employee to perform that function.  We believe these new patient advocates will help VA assure that no severely-injured Iraq or Afghanistan veteran falls through the cracks.  VA will continue to adapt its health care system to meet the unique medical issues facing our newest generation of combat veterans while locating services closer to their homes.  DoD and VA sharing electronic medical records facilitate this process.

It should be noted that sharing electronic medical records between DoD and VA is a longstanding issue, which has been the subject of several GAO reviews.  Developing an electronic interface to exchange computable data between disparate systems is a highly complex undertaking.  Let me assure the Committee that VA is fully committed to ongoing collaboration with DoD and the development of interoperable electronic health records.  While significant and demonstrable progress has been made in our pilots with DoD, work remains to bring this commitment to system-wide fruition.  VA is always mindful of the debt our Nation owes to its veterans, and our health care system is designed to fulfill that debt.  To that end VA is committed to seeing through the successful development of interoperable electronic health records. 

As part of our commitment to being veteran centric, we recently deployed the Veterans Tracking Application (VTA). It brings data from three sources, DoD, the Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA) together for display on one platform creating the beginning of a truly veteran-centric patient tracking record.

Active Joint Governance

VA and DoD maintain an active joint governance structure at the highest levels of each department.  This joint governance ensures ongoing collaboration and commitment to advance the further development of interoperable electronic health records.  The records will be bidirectional, seamless, and available to support the care of our beneficiaries wherever and whenever treatment is sought. 

The DoD/VA Joint Executive Council (JEC), co-chaired by the VA Deputy Secretary and the DoD Under Secretary of Defense for Personnel and Readiness, continues its ongoing active executive oversight of collaborative activities, including health data sharing initiatives. VA and DoD have documented a Joint Strategic Plan (JSP) that is maintained by the JEC.  The JSP contains the strategic goals, objectives and milestones for VA/DoD collaboration, including VA and DoD health data sharing activities.  Under the leadership of the JEC, VA and DoD realized significant success in meeting JSP health data sharing milestones.  

VA and DoD also chartered the DoD/VA Health Executive Council (HEC), co-chaired by VA’s Under Secretary for Health and the DoD Assistant Secretary of Defense for Health Affairs.  The HEC serves to ensure full cooperation and coordination for optimal health delivery to our veterans and military beneficiaries.  Through the HEC Information Management and Information Technology Work Group, co-chaired by the VHA Chief Officer, Health Information Technology Systems and the MHS Chief Information Officer HEC maintain management responsibility for the implementation of electronic health data sharing activities.  These data sharing activities are largely governed by the DoD/VA Joint Electronic Health Records Interoperability (JEHRI) Plan, approved in 2002, which serves as the overarching strategy around which these data sharing activities are managed.

Supporting Separated Service Members and Shared Patients

VA and DoD began JEHRI implementation by developing the capability to support the one-way and bidirectional transmission of all clinically pertinent electronic health data between DoD’s system, the Composite Health Information System (CHCS) and VA’s medical record, VistA Computerized Patient Record System.  These initial data exchanges permitted VA clinicians and claims staff to access data on separated and retired service members coming to VA for medical care and disability benefits.  This exchange allows VA and DoD clinicians to share data on patients who receive care from both systems.  These initial data exchange initiatives remain an integral component of the ongoing partnership with DoD to share health data. 

To date, DoD transferred electronic health data on almost 3.8 million unique separated service members to VA.  Of these individuals, VA provided care or benefits to more than 2.2 million veterans.  On separated service members, DoD is providing VA with outpatient pharmacy data, allergy information, laboratory results, consults, admission, disposition and transfer information, medical diagnostic coding data, and military pre- and post-deployment health assessment and reassessment data.  Since mid 2006, when DoD first began transferring pre- and post- deployment health assessment and post deployment health reassessment data to VA, DoD made  approximately l.6 million of these forms available for viewing by VHA clinicians and VBA staff.  

VA and DoD are bidirectionally exchanging electronic medical data that are viewable and computable on shared patients.  In 2004, VA achieved the ability to match patient identities for active DoD military service members and their dependents with their electronic medical records at VA facilities, and deliver care to these patients whether they present for care at VA or DoD facilities.  Currently, VA and DoD are bidirectionally sharing viewable outpatient pharmacy data, anatomic pathology/surgical reports, cytology results, microbiology results, chemistry and hematology laboratory results, laboratory order information, radiology text reports and food and drug allergy information. 

There are a number of ongoing pilot programs that have developed into operational capabilities to share increased amounts and types of viewable data being exchanged between VA and DoD. After a successful pilot in El Paso, Texas, VA and DoD are now sharing digital images at this location.  The same is true in the Puget Sound area, Hawaii and San Antonio, Texas where VA and DoD can now share narrative text documents, such as inpatient discharge summaries.  VA successfully implemented bidirectional capability at every VA medical facility. Bidirectional Health Information Exchange data is now available to DoD from all of these facilities.  DoD implemented the capability at 25 DoD host locations.  This means VA is receiving these data from 15 DoD Medical Centers, 18 DoD Hospitals and over 190 DoD outpatient clinics.   These sites include the Walter Reed Army Medical Center and the Bethesda National Naval Medical Center, the Landstuhl Regional Medical Center in Germany and the Naval Medical Center, San Diego.   VA is working closely with DoD to increase the scope of data available between DoD and VA and to ensure the data are available from all DoD medical facilities.  By June 2007, VA and DoD will be sharing data bidirectionally between all facilities.  Throughout the remainder of the year and into 2008, the types of data shared bidirectionally will increase by adding domains such as progress notes and problem lists. 

In 2006, VA and DoD began sharing bidirectional computable data on our active dual consumers of both health care systems.  This capability is now deployed to seven locations where patients receive care from both VA and DoD facilities and allows the sharing of computable pharmacy and allergy data.  As a result of this capability, VA providers benefit by having DoD prescription and allergy data instantly available to check for medication interactions or medication allergies on patients who are active dual consumers of both health care systems. VA is also working with DoD to share standardized computable laboratory data.

In addition to the one way and bidirectional exchange of electronic medical information, VA and DoD successfully developed a number of other applications that support information sharing and improve the way both Departments care for beneficiaries.  For example, one of the joint software initiatives permits VA and DoD to serve as reference laboratories for one another at locations where VA and DoD use each other’s facilities to order and conduct chemistry laboratory tests and results reporting.  The software is operational at nine locations where VA and DoD provide laboratory support to one another 

Sharing Inpatient Data and Support for the Seriously Wounded

VA and DoD’s earliest efforts focused on the sharing of outpatient data in support of transitioning service members and shared beneficiaries receiving care from both systems.  VA and DoD are now making significant progress toward the sharing of inpatient data and data from the theater of operations to support the wounded warriors coming to us for care.  As is commonly understood, much of the DoD inpatient data exists on paper and is not available electronically.  To ensure VA is fully supporting the most seriously ill and wounded service members transferred to VA polytrauma facilities, VA social workers are embedded in designated military treatment facilities to ensure all pertinent inpatient records are copied and transferred with the patient. 

In addition to ensuring the manual transfer of these inpatient and paper-based records, we are now able to support the automatic electronic transfer of inpatient data to VA clinicians who will treat these patients upon their arrival at VA facilities.   VA successfully achieved the capability to electronically transfer DoD medical digital images and electronically scanned inpatient health records to the VA.  This effort has been successfully piloted, between the Walter Reed Army Medical Center and three of the four Level 1 VA Polytrauma Centers located in Tampa, Richmond, and Palo Alto, California.  We are working now to add the polytrauma center at Minneapolis to this pilot project, and anticipate this will be accomplished soon.   VA is also working to add this capability from Bethesda National Naval Medical Center and Brooke Army Medical Center to the four VA polytrauma centers.  The pilot project currently provides VA clinicians, who receive these combat veterans, with immediate access to critical components of their inpatient care at DoD military treatment facilities.  In the future, VA hopes to add the capability to provide this data bidirectionally to support any patients returning to DoD for further care.  VA and DoD also established direct connectivity between the inpatient electronic data systems at Walter Reed Army Medical Center and Bethesda National Naval Medical Center and clinicians at the four Level 1 VA Polytrauma Centers.  These direct connections are secure and closely audited to ensure only authorized personnel at the VA facilities access the electronic military data on the Operation Enduring Freedom and Operation Iraqi Freedom service members who are coming to or have transferred to the VA Polytrauma centers.  VA and DoD are finalizing a long term strategy that will facilitate the expansion of this work across the enterprise in both departments.  

Finally, VA and DoD have undertaken a groundbreaking challenge to collaborate on a common inpatient electronic health record.  On January 24, 2007, the Secretaries of VA and DoD agreed to study the feasibility of a common inpatient electronic health record system. The initial phase of this work is expected to last between six and twelve months. VA and DoD are working to identify the requirements that will define the common VA/DoD inpatient electronic health record.  The Departments are working closely to conduct the joint study and report findings.  The analysis is currently scheduled to be completed in mid FY 2008.  At the conclusion of the study, work to develop the common solution will immediately begin.  A common inpatient electronic health record will support the transfer of our most seriously injured patients between DoD facilities and VA facilities as well as broad enterprise-level data sharing between VA and DoD clinicians for all shared patients.

Veterans Tracking Application

VA also recently deployed a new application with the ability to track servicemembers from the battlefield through Landstuhl, Germany, to Military Treatment Facilities (MTFs) in the states, and on to VA medical facilities. The new application, known as the Veterans Tracking Application (VTA), is a modified version of DoD's Joint Patient Tracking Application (JPTA) - a web-based patient tracking and management tool that collects, manages, and reports on patients arriving at MTFs from forward-deployed locations.   VTA is completely compatible with JPTA allowing the electronic transfer of DoD tracking and medical data in JPTA on medically evacuated patients to VA on a daily basis. 

The VTA, also a web-based system, allows approved VA users access to this near real-time case management information about service members and the ability to track injured active duty service members as they move through the medical evacuation and care system and transition to veteran status. This additional information directly from the battlefield assists VA in coordinating the transition of healthcare to VA facilities and in providing high quality healthcare in those VA facilities after the transfer has been completed.   The application is also designed to track the benefit claims process and greatly enhances our benefits counselors’ ability to assist the service member or veteran with his or her benefit claims.  VHA implemented the new system on April 23, 2007 and deployment across VBA is underway.  Our VA Liaisons stationed at ten MTFs now use this new tracking system to communicate transfers of care to the OEF and OIF points of contact and case managers at each VA Medical Center.  In addition the system provides electronic access to clinical information from the point of injury in the combat theater assisting VA medical providers in providing ongoing healthcare services.  VTA brings data from three sources, DoD, VHA and VBA together for display on one platform creating the beginning of a truly veteran centric record.

Collaboration on Standards

VA and DoD’s work to develop interoperable data exchanges are closely aligned and dependent upon parallel developments in health data standards.  These efforts are led by the Department of Health and Human Services ‘ (HHS) Office of the National Coordinator for Health Information Technology (ONC) through which VA and DoD are closely partnered.  As standards and technologies mature, interoperability will increase.  Efforts to ensure the seamless exchange of data between departments and eventually as part of a national infrastructure, is dependent upon the adoption and implementation of health data and communication standards. 

VA and DoD played a significant leadership role in the work done pursuant to the Consolidated Health Informatics (CHI) initiative, one of the 24 e-gov initiatives that were previously identified on the President’s Management Agenda.  Our successful efforts on CHI, under the guidance of HHS, facilitated the informed and collaborative federal identification and adoption of health information standards across the government.  Some of these CHI standards have since been incorporated into our data exchanges.   These standards adoption activities, including CHI, have since been referred to the Health Information Technology Standards Panel for inclusion in the standards harmonization process, an activity informed by ONC and the American Health Information Community (AHIC).   VA is an active AHIC participant and will continue to play a leading role in the national-level discussions on health data standards adoption and implementation. 

VA previously gave Congressional testimony about our close collaboration with DoD and other partners on the Federal Health Architecture initiative, known as “FHA.”  FHA provides VA with a framework in which we can operate to support the President’s goal to promote interoperable health technology to improve access to information and efficiency of care across settings.  VA remains actively engaged in FHA activities and appreciates the opportunity to rally around a unified strategy that ultimately will support provision of care for all of our veterans, regardless of the private or public setting.  VA strongly believes every veteran’s health information should be available in a secure manner, with the veteran’s permission, wherever that information is needed to provide seamless high quality health care to that veteran. 

Conclusion

VA is fully committed to ongoing collaboration with DoD and the development of bidirectional interoperable electronic health records.  VA also will continue to promote world-class health technologies to improve health care for veterans.  As an example, VistA, the VA’s electronic health record was awarded the Harvard University Innovations in American Government Award in July 2006.  VistA was the only electronic health record to receive this award and was singled out for its innovation and contribution to provision of high quality care.  The President is monitoring our progress in this area.  The Task Force on Returning Global War on Terror Heroes has made specific recommendations to the President that DoD and VA continue to improve and ensure timely electronic access by VA to DoD paper and electronic health records for service members treated in VA facilities.  The President has accepted these recommendations and directed Secretary Nicholson to report back to him on how these measures are being implemented. My colleagues and I are happy to answer any questions you or other members of the Subcommittee might have. 


VA/DoD Interoperability Acronyms

Health Care Delivery Systems

AHLTA - Armed Forces Health Longitudinal Technology Application -- DoD Next generation Electronic Record System - formerly CHCS II

CHCS - Composite Health Care System (DoD legacy system housing order entry/labs/radiology/allergy/meds, largely used for ambulatory care

CIS - Clinical Information System (new name is Essentris Clinicomp -- DoD's stand­alone inpatient system installed in most major military treatment facilities

CPRS - Computerized Patient Record System

HealtheVet - Next generation of VistA based on computable data

JPTA - DoD's Joint Patient Tracking Application

VistA - Veterans Health Information Systems and Technology Architecture

VistA Web - The VistA web-based application for viewing remote data (VA and DoD)

VTA - Veterans Tracking Application

Other

TPA - Transition Patient Advocates

Health Care Exchange Systems

BHIE - Bidirectional Health Information Exchange

CHDR - Clinical Data Repository/Health Data Repository (Interoperability Project)

FHIE - Federal Health Information Exchange (formerly GCPR)

LDSI - Laboratory Data Sharing & Interoperability

VPN - Virtual Private Network

Groups/Organizations/Plans

AHIC - American Health Information Community

CHI - Consolidated Health Informatics

HEC – DoD/VA Health Executive Council

JEC – DoD/VA Joint Executive Council

JEHRI- DoD/VA Joint Electronic Health Records Interoperability

JSP - Joint Strategic Plan

MTF - Military Treatment Facilities

ONCHIT - Office of the National Coordinator for Health Information Technology


DoD-VA Health Information Sharing Flow Chart