Witness Testimony of Mr. Stephen L. Jones, U.S. Department of Defense, Principal Assistant Defense Secretary of Defense (Health Affairs)
Mr. Chairman and members of this distinguished Subcommittee, thank you for inviting me to be here today to discuss the sharing of electronic medical records between the Department of Defense (DoD) and Department of Veterans Affairs (VA).
DoD recognizes that the programs and benefits earned by veterans and Service members could not be delivered without the cooperation between DoD and the VA in the area of information sharing. While we are aware of the concerns regarding the time it has taken to establish the desired level of interoperability, I am pleased to tell you today of the many positive achievements we have made in sharing a significant amount of electronic health information between DoD and VA. I am also pleased to discuss with you the efforts we are taking to share more data.
TOP DoD AND VA PRIORITIES
Dr. Chu, Undersecretary of Defense for Personnel and Readiness, and Dr. Mansfield, Deputy Secretary for Veterans Affairs, recently identified the continuity of care for returning wounded warriors and the inpatient electronic health record project as two of their top priorities for DoD and VA sharing.
DoD and VA have been sharing electronic health information since 2001 and we continue to enhance and expand our efforts. We recognize room for improvement remains. Nonetheless, we are leading the nation in health information technology, implementation of interoperability standards, and electronic health information sharing. By working together at the top levels of each Department, we have established effective policies for sharing. Under our joint governance process and VA/DoD Joint Strategic Plan (JSP) goals (which I will discuss later in my statement), we are collaborating in ways that enable each Department to address unique requirements as well as common requirements.
Continuity of Care for Shared Patients. Today for our shared patients, those treated at both VA and DoD facilities, VA and DoD providers are able to view data from the other Department. By the end of 2007, DoD and VA will share electronically many health record data elements identified in our VA/DoD Joint Strategic Plan for health information transfer. This means we will have largely established VA and DoD health record interoperability as agreed to in the JSP by the Departments’ leadership. Specifically, at our fixed facilities we now share electronic health data elements for outpatient pharmacy data, laboratory and radiology results, allergy data, Pre- and Post Deployment Health Assessments and Post-Deployment Health Reassessments for individuals referred to VA for care or evaluation. We also share electronically discharge summaries at 5 sites currently, but will expand to 13 DoD facilities with the greatest inpatient volume. Additionally, we have planned near-term enhancements to add encounters/clinical notes and problem lists, inpatient consultations and operative reports. In June, all DoD medical facilities will share electronic health information on shared patients with all VA facilities. In 2008, we will be sharing the remaining health record data elements identified in the VA/DoD Joint Strategic Plan including family history, social history, other history, and questionnaires/forms. At this point we will have achieved our current health information interoperability goals as defined in our JSP.
Continuity of Care for Shared Patients: Drug-drug and drug-allergy interaction checking
For our shared patients we also make outpatient pharmacy and drug allergy data available in real-time to allow drug-drug and drug-allergy interaction checking using data from both departments. This capability is operational in seven locations:
- William Beaumont Army Medical Center/El Paso VA Health Care System
- Eisenhower Army Medical Center/Augusta VA Medical Center
- Naval Hospital Pensacola/VA Gulf Coast Health Care System
- Madigan Army Medical Center/VA Puget Sound Health Care System
- Naval Health Clinic Great Lakes/North Chicago VA Medical Center
- Naval Hospital San Diego/VA San Diego Health Care System
- Mike O’Callaghan Federal Hospital and VA Southern Nevada Health Care System
All 65 DoD hospitals and 412 DoD medical clinics and all VA sites have access to this data for patients presenting to them for care. This capability will be deployed DoD-wide this fiscal year.
Continuity of Care for Polytrauma Patients (Wounded Warriors). For severely wounded or injured patients transferred to VA polytrauma centers, we begin sending information upon the decision to transfer a patient to the VA. We already transmit digital radiology images and scanned medical records between Walter Reed Army Medical Center and each of the four VA Polytrauma Centers, and have partially implemented this solution for the National Naval Medical Center, Brooke Army Medical Centerand the four VA Polytrauma Centers. All three of our DoD major trauma centers and the VA Polytrauma Centers will have this capability to transfer images and scanned medical records this year.
Separated Service Members (Potential VA Patients). For more than 3.8 million former Service members eligible for care from VA, we have made electronic health information available to VA. In 2001, we began sharing historical information dating from as early as 1989. Monthly transfers of electronic health information from DoD to VA began in 2002. The data elements transferred include:
- Outpatient pharmacy data, laboratory and radiology results
- Inpatient laboratory and radiology results
- Allergy data
- Consult reports
- Admission, disposition, transfer data
- Standard ambulatory data record elements (including diagnosis and treating physician)
- Pre- and post-deployment health assessments
- Post-deployment health reassessments
Business Practice Coordination. Where it makes sense or will enhance quality of care, DoD and VA have collaborated on additional sharing initiatives. For example, the Laboratory Data Sharing Initiative established the bidirectional electronic exchange of laboratory chemistry orders and results when one Department’s lab acts as a reference lab for the other. This means expedited lab testing and results that enhance the quality of care for our patients. We are exploring other opportunities such as charge master billing, eHealth portals, and expanded image sharing, to expand our business practice coordination.
A Health Information System Tailored to Meet the Needs of the Warfighter and Military Families (Outpatient Medical Record System). The question often asked is why do DoD and VA have separate electronic health record systems. Simply put, DoD and VA have different requirements.
The Readiness Requirement. DoD must track care in theater using information systems that operate on desktop computers at a fixed hospital, laptops at a deployed Combat Support Hospital in Theater, or handheld devices on the battlefield. In addition, we must have an electronic health record system that supports continuity of care through availability in no- and low-communications environments. Importantly, our medical systems must operate on the command and control information technology infrastructure. Our requirement is to use a single system at both fixed facilities and our deployed units so our Service members will not have to learn a new system when they deploy. Our guiding principle is that we “train as we fight.” In addition, DoD requires highly structured medical data, enabling us to conduct medical surveillance to identify potential natural disease outbreaks and/or biological attacks in theater.
Our Beneficiary Population. Finally, the high mobility of both our patient and provider populations led us to establish a centralized clinical data repository.
JOINT INPATIENT ELECTRONIC HEALTH RECORD
Recently, we announced that DoD and VA will modernize our inpatient systems together through a joint acquisition/development effort over the next several years. Because we have similar inpatient requirements there is a unique opportunity to explore a coordinated approach with seamless transition built in. Both Departments believe the timing is right for this initiative. VA is planning to modernize the inpatient portion of its electronic medical record, and with the full deployment of DoD’s electronic health record – AHLTA – across the Military Health System, DoD is poised to incorporate documentation of inpatient care into AHLTA. Done right, this will support the needs of both Departments and help ensure the continuity of care, better meet requirements for joint facilities, and leverage economies of scale in terms of development and/or integration costs, license fees, and hardware purchases. To get it right, our approach is to document and assess DoD and VA inpatient clinical processes, workflows, and requirements; identify and analyze alternatives for acquisition or development approaches; and determine benefits and impacts on each Department’s timelines and costs for deploying a common inpatient electronic health record solution. I also would like to point out that the solution is not yet defined, and that we should expect one system, not necessarily one database. Regardless of the solution, we will implement in a way to ensure data interoperability is built in. Once the requirements analysis is completed in 2008, we will establish the acquisition/development timeline based on our assessment of the alternatives.
Our DoD-VA electronic health information collaboration efforts I’ve described are a major component of the VA/DoD Joint Strategic Plan. The goals of the DoD/VA Joint Executive Council (JEC) are described in the VA/DoD Joint Strategic Plan for Fiscal Years 2007 through 2009 and cover a full spectrum of DoD/VA health related sharing. The JECwas established in January 2002 and co-chaired by Under Secretary of Defense for Personnel and Readiness and the VA Deputy Secretary. It includes senior DoD and VA health managers involved in sharing initiatives and meets quarterly. The JEC provides leadership oversight of interdepartmental cooperation at all levels and to oversee the efforts of the Health Executive Council and Benefits Executive Council. The Health Executive Council (HEC) is co-chaired by the Assistant Secretary of Defense (Health Affairs) and VA Under Secretary for Health. It was formed to establish a high-level program of DoD/VA cooperation and coordination in a joint effort to reduce costs and improve health care for VA and DoD beneficiaries. The HEC Information Management/Information Technology (IM/IT) workgroup is co-chaired by health Chief Information Officers (CIOs) of the MHS and Veterans Health Administration. The HEC IM/IT workgroup ensures that appropriate beneficiary and medical data is visible, accessible and understandable through secure and interoperable information management systems.
NATIONAL STANDARDS ADOPTION AND IMPLEMENTATION
As I mentioned earlier, we believe we are leading the nation in health information technology, implementation of interoperability standards, and electronic health information sharing. As an example of our efforts to conform to national standards, the Certification Commission for Healthcare Information Technology (CCHIT) announced on April 30th that they awarded pre-market, conditional certification of AHLTA version 3.3 (DoD’s electronic health record system). CCHIT is an independent, non-profit organization that sets the benchmark for electronic health record systems. AHLTA 3.3 passed a rigorous inspection process and met 100% of their criteria and we are very proud of this accomplishment. DoD and VA have been and will continue to be driving forces supporting the American Health Information Community (AHIC), the Health IT Policy Council (HITPC), and the Health IT Standards Panel (HITSP). Our efforts participating in these national level activities support Executive Order 13410, issued August 2006, which requires Federal agencies to use recognized health interoperability standards to promote the direct exchange of health information between agencies and with non-federal entities. We know that together the Medicare beneficiaries, DoD beneficiaries, VA beneficiaries, and Federal employees represents a significant percentage of insured Americans. This means our efforts can have a potentially dramatic effect on the private sector adoption of health IT and will ultimately impact our ability to exchange electronic health information with private sector providers.
I would like to reiterate that the continuity of care for returning wounded warriors and the inpatient electronic health record project are our top priorities for DoD and VA electronic health information sharing. In the last several years, DoD and VA have made significant progress and are leading the nation in many ways in the sharing of electronic health information, but there is room for improvement. We are accelerating our efforts to achieve a greater degree of health information sharing to support our top priorities. 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. DoD and VA are already working together to accomplish the recommendations made in the area of electronic health information sharing. In addition, we have jointly briefed the President’s Commission on Care for America’s Returning Wounded Warriors on the current status of DoD/VA electronic health information sharing and future plans. We look forward to receiving their recommendations as well. With your support, we will continue building on our achievements in sharing electronic health information in support of the men and women who serve and have served this country.