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

Mr. Chairman, Madame Ranking Member Brown-Waite and Members of the Subcommittee, thank you for providing the opportunity to report the progress made by the Department of Veterans Affairs (VA) to share electronic medical records with the Department of Defense (DOD).  We have made progress toward developing secure, interoperable electronic medical record systems and I am here today to discuss the current status of our efforts and the work that is underway to achieve electronic health record interoperability.

Overview

Today, VA and DOD are sharing electronic health data bidirectionally to support the care of shared patients.  Additionally, VA and DOD are sharing more data than ever before on our seriously wounded service members and veterans who are transitioning from military facilities to VA facilities and polytrauma centers.   The availability of these data to VA and DOD providers enhances our ability to provide world class care to veterans, active duty service members receiving care from both systems, and to our wounded warriors returning from theaters of operation in Iraq and Afghanistan.  Ensuring that we have accurate, comprehensive and timely medical data to treat our Nation’s heroes remains a top priority of this department. 

In recent months, we have built upon our earlier successful development of one-way and bidirectional exchanges of text and computable data.  Today, VA providers are able to access more electronic inpatient data from DOD than ever before.  DoD also has a study underway, funded by VA and DoD, to examine our development of a joint inpatient electronic health record with DOD.  Additionally, for the first time, VA has access to critical medical electronic data from current theater of operations, to treat wounded warriors coming to our facilities.  The challenges of sharing large amounts of data from disparate electronic systems remain complex.  Our processes are not perfect, and I will discuss that below.  However, we are working to provide as much electronic data as possible as quickly as possible in support of our returning warriors and shared patient populations.  We are now sharing data from multiple settings, including outpatient, inpatient, and theater, as well as tracking information to improve our case management and coordination.  These accomplishments reaffirm our commitment to develop interoperable electronic health records with DOD.  Moreover, we believe our current capabilities to share electronic medical data demonstrate progress toward our goal.    

Active Joint Governance

VA and DOD efforts to achieve interoperability are jointly governed at the highest levels of our departments.  Our VA Acting Secretary and the Under Secretary of Defense for Personnel and Readiness continue to co-chair the DOD/VA Joint Executive Council (JEC).  The JEC provides executive and overarching leadership of all VA/DOD collaborative activities, including the development of interoperable electronic medical records.  Since 2003, VA and DOD have documented these activities in the DOD/VA Joint Strategic Plan (JSP) that is maintained by the JEC. The JSP contains measurable strategic goals, objectives and milestones for our collaborative work with DOD, including electronic medical data sharing.  VA and DOD work to update the JSP each year and progress under the JSP is reported to the JEC on a monthly basis.  Under the leadership of the JEC and the clear goals contained in the JSP, VA and DOD realized success in meeting JSP health data sharing milestones.

VA's Under Secretary for Health and the DOD Assistant Secretary of Defense for Health Affairs co-chair the VA/DOD Health Executive Council (HEC), a subcommittee of the JEC.  The HEC is responsible for coordination of those joint activities related to health care and is committed to ensuring that our ongoing partnership optimizes health delivery to veterans and military beneficiaries. The HEC Information Management and Information Technology Work Group, co-chaired by the VHA Chief Information Officer for Health Information Technology Systems and the Military Health System Chief Information Officer, maintains day to day  responsibility for health information technology work and, most importantly, for the implementation of our joint electronic health record and data sharing initiatives.

Theater and Inpatient Data Supporting the Seriously Ill and Wounded 

At no other time has it been more important for VA and DOD to overcome some of the ongoing complexities of sharing disparate electronic health data.  VA and DOD are firmly committed to supporting the seamless care of our injured men and women returning from the battlefield to military facilities and eventually to VA facilities for longer term care and rehabilitation.  Our Nation’s heroes deserve nothing less.  In cooperation with our sharing partner, our most recent accomplishments to report have focused on the development of electronic solutions to support these seriously ill and wounded patients. 

VA and DOD have charted the Senior Oversight Committee (SOC) for the Wounded, and Injured.  Co-chaired by the Acting VA Secretary and the DOD Deputy Secretary, the SOC works in conjunction with the JEC to ensure targeted focus on the population of men and women injured in OEF and OIF and now returning for treatment.  Underneath the SOC, VA and DOD have organized several Lines of Actions (LOAs), with one LOA specifically focused on data sharing.  The purpose of the data sharing LOA is to ensure that appropriate beneficiary and medical information is visible, accessible and understandable by each departments and that available electronic information is shared.  Since the formation of the SOC and LOAs, the President’s Commission on Care for America’s Returning Wounded Warriors (President’s Commission) has recommended that VA and DOD share all essential health, administrative and benefit data in viewable format initially, within twelve months.  Heeding this recommendation, we have worked with DOD to accelerate and enhance our existing data exchanging to meet this target.  Today, VA and DOD are on target to ensure that these essential data which are available electronically will be viewable between the departments by October 2008.  Additionally, VA and DOD are now actively developing a plan to establish technology support for the newly formed position of Federal Recovery Coordinator.  This Recovery Coordinator will support seriously ill and wounded patients by maintaining on the ground oversight and coordination for all essential clinical and non-clinical aspects of the recovery care plan.  We anticipate documenting an information technology plan to support this position by November of this year. 

Our most notable achievements demonstrating our commitment to wounded warriors is the sharing of theater and inpatient data.  For the first time, DOD medical data captured electronically in the theater of operations are now viewable in text format to any VA provider treating these wounded warriors.  We accomplished this in September of 2007 by leveraging an existing bidirectional data exchange.  Subsequently, we are implementing a plan that will permit us to share unprecedented amounts of the available inpatient electronic data from DOD.  Currently, VA providers are able to view electronic discharge summaries, emergency department notes, and other narrative documents captured during inpatient encounters at 13 major DOD facilities that use the Essentris Clinical Information System (CIS) ™.  These 13 facilities include the Military Treatment Facilities that are key to supporting returning combat veterans, such as Walter Reed Army Medical Center (Walter Reed) and Bethesda National Naval Medical Center (Bethesda), and have greatly contributed to our ability to provide seamless care to these wounded warriors.   This work was accomplished, due in large part, to the innovation of our local clinicians and informatics professionals in the field, at locations such as the Puget Sound VA Healthcare System and Madigan Army Medical Center.  Cooperative efforts between VA and DOD are systemic, reaching all the way down to our facilities.  

In addition to sharing available electronic documentation, DOD is sending digital radiology images and scanned inpatient paper records that do not originate in electronic format.  These capabilities are in place between the key military treatment facilities that receive these patients in the Continental United States (CONUS), (Walter Reed, Bethesda, and Brooke Army Medical Center), and VA polytrauma centers located in Tampa, Richmond, Minneapolis and Palo Alto. 

VA and DOD continue to maintain the highly secure and audited direct connection allowing viewing access to the data in the inpatient electronic data systems at Walter Reed and Bethesda by clinicians at the four polytrauma centers.   Using these connections allows authorized VA clinicians to view real-time DOD data on wounded service members and combat veterans who are coming to or have transferred to the VA from these DOD facilities.  VA and DOD are working to expand our electronic capabilities enterprise wide.  We have already successfully demonstrated our capability to leverage bidirectional data exchange to support image sharing with the El Paso pilot.  We are now working to expand this pilot to other active sharing locations and are on target to document a plan to share images enterprise wide by March 2008.  As is commonly understood, much of the DOD inpatient data is not available electronically.  Despite this ongoing challenge, VA and DOD quickly developed these capabilities as interim solutions to support these patients while we work to expand our electronic capabilities.  To ensure that we provide full support in the face of these ongoing challenges, VA continues to embed Transition Patient Advocates and social workers at key facilities.  At minimum, all pertinent medical records not available electronically are at least copied and transferred with the patient.  Our enhanced inpatient capabilities support and bolster the seamless transition of these patients.  It is our goal that no patient will fall through the cracks.    

In January of 2007, VA and DOD announced a study to explore the development of a joint inpatient electronic health record system.  Since that time, VA and DOD have actively pursued this initiative.  We are now under contract with a prominent and independent third party firm that is conducting the analysis of alternatives.  To date, we have made progress by documenting the scope and elements of those joint inpatient data elements that would need electronic support.  This work includes conducting comprehensive surveys of industry best practices in this area.  We anticipate  we will have a final report by July 2008.  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.

Requirement to Share Psychological Health Data and TBI Data

In order to ensure comprehensive continuation of services, and to better leverage the world-class care that is already available to patients at VA’s centers of excellence for Post-traumatic Stress Disorders (PTSD), Traumatic Brain Injuries, and other diagnoses impacting psychological health, it is necessary for VA and DOD to improve routine and appropriate sharing of mental health data.  VA has a need to receive these data from DOD.

Sharing of information on mental health conditions and other sensitive matters is important in a number of different contexts.  Most simply, they can be divided into areas where the sharing of information is needed to facilitate clinical care of veterans or servicemembers who receive care in both systems, either sequentially or in parallel, and information used for administrative or command purposes.

For clinical purposes, our systems should work toward minimizing barriers for transmittal to the greatest extent possible.  Examples of mental health information that would support the VA in serving veterans include records of acute stress disorders, other mental health conditions, and suicidal behaviors, as well as head trauma.  Having this information on returning veterans would be important to guide treatment and monitoring plans.

For other purposes, VA, as an agency that functions in the community in parallel to civilian providers of health care, the issues may be more complex.  For example, in developing principles about disclosure of information about mental health conditions from VA to DoD, VA must balance its responsibilities as a civilian community health care provider with those as part of a DoD/VA system.    Viewed from community standards, it is important to honor patient privacy values, while from the VA/DoD perspective, it is important to provide relevant information to DoD that may have an impact on the efficiency of the fighting force.  This issue is being addressed in ongoing discussion within VA.      

Ongoing Support for Separated Service Members and Shared Patients

In addition to our accelerated efforts to support our most seriously injured patients, VA and DOD continue the ongoing implementation of our Joint Electronic Health Records Interoperability (JEHRI) plan.  The HEC IM/IT Work Group continues to manage the implementation of JEHRI and the maintenance and enhancement of our one-way and bidirectional data exchanges.  Today, VA continues to receive all clinically relevant data that are available in DOD's legacy system, the Composite Health Information System (CHCS), on service members separated from active military service.  These data are viewable through our shared Federal Health Information Exchange repository by VA clinicians and disability claims staff using VA health and administrative information systems.  To date, DOD has transferred electronic health data on over 4 million unique separated service members to VA.  Of these individuals, VA has provided care or benefits to the more than 2 million veterans who have sought care or benefits from VA.  The data transferred for viewing includes 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 (PPDHA) and reassessment (PDHRA) data on separated and demobilized National Guard and Reserve members.  DOD has made almost 2 million of these PPDHA and PDHRA forms available for viewing by VHA clinicians and VBA staff.

In addition to ongoing maintenance of our one-way data exchange, VA and DOD continue to bidirectionally exchange viewable and computable electronic data on shared patients.  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. We also are maintaining our ongoing exchange of computable allergy and pharmacy data supporting automatic drug-drug and drug-allergy interaction checks at seven locations.  The development of this joint capability is complete.  The departments are now working together to expand implementation across both enterprises by addressing issues such as user training, site specific issues related to identification and flagging of active dual consumers for whom this capability is in place, and ongoing deployment of department system dependencies related to HealtheVet. 

As mentioned above, and in keeping with the recommendation of the Presidential Commission, VA and DOD are leveraging our bidirectional exchanges to expand the types of data shared and to share all essential information by October 2008.  By December of this year, our providers will have access to viewable encounter notes, problem lists, and procedures from DOD’s modern system, AHLTA.  By June 2008, we will add vital signs and by October 2008 enterprise wide capability to view scanned documents, such as paper inpatient records.  By March 2008, VA and DOD will document a plan to support the enterprise wide bidirectional sharing of digital images.   This work will leverage the successful imaging pilot in El Paso and incorporate the work that will soon get underway at expanded pilot locations.   By the fourth quarter of 2008, VA and DOD will deploy our computable laboratory capability to support automatic decision support using electronic laboratory result data transferred bidirectionally.   

Enhanced Tracking Capability (Veterans Tracking Application)

This month, VA achieved the ability to access patient tracking data enterprise wide using the Veterans Tracking Application (VTA).  As reported previously, VTA is a modified version of the DOD developed Joint Patient Tracking Application (JPTA).  Our facility based liaisons, such as case managers, can now access VTA from VistA Web to assist with the coordination of care for patients treated at both VHA and DOD.  This coordination includes the tracking of these patients as service members move from the battlefield through Landstuhl, Germany, to stateside military treatment facilities and into our VA polytrauma and medical centers.  VTA is completely compatible with JPTA allowing overnight electronic transfer of critical tracking data on medically evacuated patients. 

Previously, we testified that our JPTA/VTA interface would support the transfer of medical data from the theater.  DOD’s recent successful efforts to consolidate theater clinical data and to make it viewable to VA through our bidirectional data exchange overcame that effort.  As mentioned above, VA clinicians access clinical data, including theater clinical data, through the Bidirectional Health Information Exchange.  Our JPTA/VTA interface now supports the provision of viewable tracking data.  The VTA database of seriously injured OEF/OIF service members and veterans is used as the authoritative source for the movement of theater patients and supports and documents contacts with veterans and service members.  VTA is now a critical tool in the support of our seamless case management of patients.  VTA also continues to support the benefit claims process and consolidates data from across all major components, DOD, VHA and VBA into a veteran centric record enhancing our case management capabilities.

Ongoing Collaboration and Dependence on Standards

VA and DOD' continue to work closely with the Department of Health and Human Services (HHS) and other partners on national efforts to align our groundbreaking work on data exchanges with the nationwide effort to support health interoperability.  These efforts are led by the HHS National Coordinator for Health Information Technology and will include ongoing efforts to identify mature standards, study infrastructure interoperability, and work closely with commercial healthcare providers to foster a global interoperability infrastructure. 

The President’s Commission recognized the complexity of achieving full data interoperability and tailored its recommendation to initially share data in viewable format versus computable format.  Mature standards are necessary and evolved technologies are critical dependencies to the seamless exchange of all data.   As these health data and communication standards mature and are identified, we will adopt and implement the standards into the systems we are modernizing.  VA and DOD continue to play a leadership role in these efforts.  Our VA/DOD Health Architecture Interagency Group continues to participate in and contribute to standards related organizations such as Healthcare Information Technology Standards Panel (HITSP) and Health Level 7(HL7) to improve the availability of shared health information.  Current efforts are focused on areas such as case management and disability evaluation.  

Conclusion

VA and DOD have achieved progress toward sharing all available electronic data and remain committed to efforts that will help us to reach our final goal.  Under the leadership of the JEC and the HEC, we are marching forward to implement enhancements to existing data exchanges while identifying attainable opportunities to support our most seriously ill and wounded warriors and combat veterans.  We assure you that we continue to work toward a long-term strategy that will support full enterprise wide electronic data interoperability.  Never before have we been able to access data from the theater and provide care to our veterans and rehabilitating service members using the amount of inpatient data currently available from DOD.  Our efforts are subject to tremendous interest by the President and Congress, and we are working hard to ensure that recommendations coming from bodies such as the President’s Commission, the Task Force on the Returning Global War on Terror Heroes, chaired by our own Acting Secretary, and the Veterans Disability Benefits Commission, are evaluated and incorporated, where feasible, to ensure we form a complete and comprehensive approach to sharing health data in support of our veterans and service members

To continue our successes, we ask for your continued support as we each work to modernize and update our existing technologies.  VA has been recognized many times over for the world-class care it provides to veterans.  Our electronic health record is second to none in its fully integrated electronic capabilities across all settings of care.  More work is needed to update our world-class system and to ensure that it uses state of the art technologies and tools that will better support data interoperability.  Thank you for the opportunity to appear before you and provide you the status of our ongoing efforts.  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's 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

TMDS - DoD's Theater Medical Data Store

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)

Groups /Organizations /Plans

AHIC - American Health Information Community

CHI - Consolidated Health Informatics

BEC - DoD/VA Benefits Executive Council

HEC – DoD/VA Health Executive Council

JEC - DoD/VA Joint Executive Council

JEHRI- DoD/VA Joint Electronic Health Records Interoperability

JSP - Joint Strategic Plan

LOA - Line of Action

MTF - Military Treatment Facilities

ONCHIT - Office of the National Coordinator for Health Information Technology

SOC -Senior Oversight Committee

Click on Chart for Larger View--DoD/VA Data Sharing - Milestones & Plans (Health) Flow Chart