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Witness Testimony of Howard B. Green, PMP, Veterans Health Information Technology, Deputy, Operations Management, Office of Enterprise Development, Office of Information and Technology, U.S. Department of Veterans Affairs

Thank you, Mr. Chairman.  I would like to thank you for the opportunity to testify on the Sharing of Electronic Medical Information between the Department of Defense and the Department of Veterans Affairs, what is being done to accomplish the objectives, and the viability of the approach. 

I have been a member of the Department of Veterans Affairs Health IT community for over 19 years serving in multiple capacities at the local, regional (VISN) and national level.  Prior to joining the Office of Information and Technology in 2004, I was the Chief Information Officer for the Heartland Network (VISN 15) and  was responsible for the introduction of VA’s VistA system at all facilities and clinics in the region.  Most recently, as Deputy for Operations Management within the Veterans Health IT Portfolio, I participated as a staff member on the President’s Commission for America’s Returning Wounded Warriors, and with my DoD counterpart was responsible for the creation of the information technology chapter and final report recommendations.  Following that assignment, I have been given the responsibility for coordinating many of the recommendations from the President’s Commission report.

Systems Supporting the Exchange of Clinical Information

Formal activities related to the sharing of clinical information between the Department of Veterans Affairs (VA) and the Department of Defense (DoD) have been ongoing since 2001.  Though there are a number of systems that have been developed to support this function, for all intents and purposes the overarching goal is to bi-directionally exchange computable information between VA and DoD in real-time. The following systems are in place to support this exchange of clinical information.

  • Federal Health Information Exchange (FHIE): is the one-way transfer of separated service member health data from DoD to VA.  
  • Bi-Directional Health Information Exchange (BHIE): supports functional interoperability between VA and DoD through the exchange of textual patient health information such as provider notes, non-computable test results, discharge summaries for all service member/veterans known as active dual consumers.
  • Clinical Health Data Repository (CHDR):  utilizes established data standards, and terminology services to enable exchange of standardized and computable health record data between VA and DoD.
  • Laboratory Data Systems Interchange (LDSI): supports the lab reference model by providing an interoperable interagency application for lab order entry and results reporting. 
  • Imaging Pilots and Demonstrations:  demonstrate the most efficient approaches to the transmission of medical images and clinically relevant documentation. 

Effectiveness of Selected Clinical Information Exchange Systems:

The FHIE system has supported the transfer of more than 187 million pieces of discharge related health information on over 3.8 million patients who have separated from the military.  FHIE continues to exchange health record data for separated service members.

BHIE is currently the bi-directional medical exchange interface having transferred information for over 2.3million unique patients who are active dual consumers of both healthcare systems.  Currently, VA and DOD are bi-directionally sharing viewable outpatient pharmacy data, anatomic pathology/surgical reports, cytology results, microbiology results, chemistry and hematology laboratory results, laboratory order information, radiology text reports, food and drug allergy information, and discharge summaries from several DoD sites running CIS.  The Information through the BHIE interface flows to and from the following systems:  VA’s 128 VistA Systems and DoD’s Composite Health Care System (CHCS), Clinical Data Record (CDR),  AHLTA Share, CIS, and Theater Medical Data Store systems.  There are plans to expand the amount of clinical data exchanged through BHIE.  Encounter notes, patient focused problem lists such as on going treatment for diabetes or hypertension, procedures, and theater level inpatient & outpatient notes will be available by December 2007.  By September 2008, VA and DoD improvements will include the addition of a PolyTrauma Marker and OEF/OIF Combat Veterans Identifier, Electronic Patient Handoff indicators, a DoD Scanning Interface, the Interagency Sharing of Essential Health Images, Provider Notes, Theater Data, Vital Signs, and Patient Histories. Site specific information regarding the volume of data passed through BHIE through September 2007 can be found at the end of this testimony.

CHDR is the clinical data exchange interface that supports the exchange of standardized and computable data that can be used to support automated clinical decision support tools such as drug/drug and drug/allergy order checking.  Currently CHDR data is viewable at all VA sites and several DoD sites.  In addition, VA drug-drug and drug-allergy order checks are performed based on data from all VA systems and data from CHDR.  User interface applications leveraging the BHIE interface often require the clinicians to look in several locations to retrieve health record information from other points of care.  This often requires the clinician to interpolate based on approximation  when comparing data elements due to the use of different terminologies.  By comparison clinical information obtained through the CHDR interface can be incorporated into the same clinical view, automated computations, and edits allowing the user to readily compare like data.  The CHDR interface currently supports the movement of pharmacy and medication allergy data and will be upgraded to include laboratory Chemistry and Hematology data in the fourth quarter of FY 2008. 

The Veterans Tracking Application (VTA) is the VA’s interface to DoD’s Joint Patient Tracking Application (JPTA) and supports the passage of information related to the location of wounded, injured or ill service members being transferred from theater to Military Treatment Facilities in the Continental United States (CONUS), who may be transitioning to the VA.  VTA is a critical tool used to support the benefit claims and seamless transition processes. 

The El Paso Clinical Imaging Demonstration leverages the existing BHIE framework to exchange clinical images, descriptive data and reports between the VA and DoD facilities.  As a result of this demonstration, six sites have been selected for installation and testing of the El Paso Imaging prototype are (in order of installation):  Great Lakes/North Chicago, Evans Army Community Hospital/Eastern Colorado Health Care System, Landstuhl Regional Medical Center, National Capital Area (Walter Reed Army Medical Center, National Naval Medical Center, Washington DC VA), VA Polytrauma Centers at Richmond and Tampa, Keesler Medical Center/VA Gulf Coast Health Care System.

In general, the volume of medical information that is being exchanged is growing at a substantial rate.  Every effort is being made to meet the standard of “essential” data referenced in the report of the President’s Commission on America’s Returning Wounded Warriors.

As it relates to achieving the stated objectives of the projects referenced above, the impact of senior leadership in driving the two organizations in the right direction can not be understated.  The Joint Executive Committee (JEC) has been a driving force in setting the long term direction toward true electronic health record and veteran benefits data interoperability.  The addition of the Senior Oversight Committee (SOC), the Overarching Integrated Project Team (OIPT) and Lines of Action (LOA) sub-committees have sharpened the focus and intensity of leadership engagement, expanded leadership engagement to include Under Secretaries and top-level General and Flag Officers, and elevated the topic to the level of the Deputy Secretaries of both Departments, intended to achieve results by addressing cross-organizational issues and dependencies related to returning wounded service members and veterans. 

The Role of Puget Sound Health Care System and Madigan Army Medical Center, the Great Lakes Federal Health Care System,  and other sites in testing and supporting critical data exchange:

Sharing agreements such as the one developed in Tacoma, Washington, between the Puget Sound Health Care System and Madigan Army Medical Center (aka Team Puget Sound) demonstrate new capabilities and functions within products such as BHIE and CHDR.  In the Seattle/Tacoma region the two sites are leveraging the BHIE interface in support of inpatient services provided to VA at Madigan Army Medical Center.  The primary focus is the exchange of discharge summaries and other clinically relevant inpatient notes.  Through these efforts new functionality can be fully tested and incorporated into future national releases. 

While collaborations such as the one in the northwest tend to focus on specific functionality in support of limited sharing agreements, the Great Lakes Federal Health Care Center will eventually push the concepts of medical and administrative data sharing too its limits.  The goal in Federal Health Care Center is to fully integrate the clinical and administrative functions between two health care systems.  Planning activities are underway to develop the local project team required to manage the information technology requirements needed to support the new organization.  Initial activities include the preparation of an integrated project schedule reflecting the expected delivery of local and national capabilities so that the gaps can be evaluated and resolved.  Additionally, an enterprise-level team of resources is being assembled to resolve technical and operational issues that are beyond the local team’s ability to address.  The new Great Lakes System will exercise every element of both clinical and administrative operations; a planned and deliberate approach must be taken to ensure that the business goals are met.  There are certainly advances in the application of information technology that can be applied, however, the process is complex and must be driven by key business decisions and not by IT. 

I would like to thank you Mr. Chairman for giving me the opportunity to testify about the progress being made in clinical information sharing between VA and DoD and I will gladly take any questions at this point.

BHIE Statistics (as of 25 September 07)

MTF Number of correlated Patients Number of new patients * MTF Number of correlated Patients Number of new patients *
Tripler AMC 179,304 52,064 NACC Groton 78,321 33,833
Womack AMC 129,737 41,541 MacDill 70,025 40,028
Leonard Wood ACH 112,676 31,876 NCA 316,981 121,345
Irwin ACH 42,079 13,543 NH Camp Lejeune 136,008 40,672
Eisenhower AMC 246,781 96,654 Wright-Patterson 101,188 47,201
Martin ACH 139,410 39,402 Wm Beaumont AMC 124,275 6,199
Fox AHC 25,061 10,753 NH Corpus Christi 39,399 19,202
Wilford Hall MC 601,170 227,103 Madigan AMC 201,519 63,392
Darnall ACH 135,239 40,465 Landstuhl RMC 436,716 100,922
Elmendorf 40,717 13,153 NMC Portsmouth 303,976 97,422
Keesler 171,436 70,101 NH Pensacola 112,551 40,413
O'Callaghan FH 75,777 22,619 NH Great Lakes 134,931 36,955
Kirtland 77,066 55,796 NH Jacksonville 135,111 54,682
Lyster AHC 30,868 12,355 NMC San Diego 243,934 60,644
Bassett ACH 22,357 5,711 NH Lemoore 23,752 8,711
David Grant MC 150,067 68,902 NH Charleston 119,450 36,356
Evans ACH 107,596 40,602 NH Camp Pendleton 165,589 49,444
Total # of Unique Patients**

2,386,625

1,033,658

*Patients not in the FHIE Domain

**Columns do not add tot he total, since patients have been seen at multiple facilities.