Witness Testimony of Rear Admiral Gregory Timberlake, SHCE, USN, U.S. Department of Defense/U.S. Department of Veterans Affairs Interagency Program Office, Acting Director
Chairman Hall and distinguished members of the Committee, thank you for the opportunity to discuss the role of the DoD/VA Interagency Program Office (IPO) in the ongoing data-sharing activities of the Department of Defense (DoD) and the Department of Veterans Affairs (VA). Collaboration between the two Departments on information technology issues has grown exponentially in recent years, enabling the Departments to explore ways in which they may benefit jointly from data-sharing innovations in the private sector, as well as helping to foster bold new government-driven information-sharing capabilities, like the development of a “Virtual Lifetime Electronic Record” (VLER) for servicemembers and veterans. Working on behalf of the DoD/VA Joint Executive Council, the IPO plays a key role in facilitating these efforts, and in providing oversight of various data-sharing initiatives between the Departments. In recent months, the IPO has been focused on two central areas: (1) facilitating the efforts of the two Departments to achieve full interoperability of their electronic health records by September of this year, as defined by the VA and DoD clinicians that rely on this data to treat patients, and (2) working with the Departments to develop an effective governance and management model for the VLER project. These two areas will be the focus of my testimony today.
In April 2008, DoD and VA formed the “DoD/VA Interagency Program Office” (IPO) in response to Section 1635 of the National Defense Authorization Act for fiscal year 2008, which required the creation of an entity to serve as a single point of accountability for the rapid development and implementation of electronic health record (EHR) systems or capabilities between the Departments. Section 1635 further mandated that full interoperability of personal healthcare information between the DoD and VA be achieved by September 2009. Since its inception, the IPO has worked diligently to achieve this mandate, providing the Departments with reliable, effective management oversight of potential risks involving the identification, coordination, and review of information sharing requirements, and informing stakeholders about the impact these processes may have on DoD/VA information sharing progress.
The responsibility for developing requirements and executing technical information technology solutions remains with the respective DoD and VA organizations, using the Departments’ established statutory and regulatory processes for acquisition, funding, management control, information assurance, and other execution actions. The differences between the Departments in these areas can pose challenges to effective collaboration on joint DoD/VA information sharing projects. In order to overcome such challenges, the IPO has worked closely with the existing leadership of the Joint Executive Council to provide focused assistance and oversight to ensure the Departments achieve their goals. Our work includes facilitating discussions between DoD and VA functional business communities on areas such as supporting the definition of DoD/VA data-sharing requirements, promoting effective synchronization of DoD/VA schedules for the technical execution of joint data-sharing initiatives, assisting in the coordination of funding considerations, and assisting in obtaining the input and concurrence of stakeholders.
THE VIRTUAL LIFETIME ELECTRONIC RECORD:
THE VISION & THE BROAD CONCEPTUAL CHALLENGES
On April 9, 2009, the President, along with Secretary Gates and Secretary Shinseki, announced that DoD and VA have taken the first step in creating a joint Virtual Lifetime Electronic Record (VLER). Early in his remarks, President Obama pointed out the largest challenge that the two Departments face in their continuing efforts to modernize their electronic health and benefits records systems, declaring that “there is no comprehensive system in place that allows for a streamlined transition of healthcare records between DoD and the VA.” Creating such a capability would mark a departure from data-sharing efforts in the past, which have centered on developing an ever-proliferating array of information-sharing programs that allow one Department to access patient data that has been captured in the electronic health record system of the other Department. While this strategy has allowed DoD and VA to share unprecedented amounts of patient healthcare data, the adoption of new technologies can provide even more efficiencies in the collection, retrieval, and use of patient healthcare data across the Departments. Recognizing this, the President directed the two Departments to “work together to define and build a seamless system of integration with a simple goal: When a member of the Armed Forces separates from the military, he or she will no longer have to walk paperwork from a DoD duty station to a local VA health center; their electronic records will transition along with them and remain with them forever.”
In a press release that was issued shortly after the President’s speech, the White House highlighted the importance of creating a comprehensive virtual lifetime electronic records capability between DoD and VA, and noted some of the advantages that would likely result from the establishment of a VLER: “Access to electronic records is essential to modern healthcare delivery and the paperless administration of benefits. It provides a framework to ensure that all healthcare providers have all the information they need to deliver high-quality healthcare while reducing medical errors. The creation of this joint Virtual Lifetime Electronic Record by the two organizations would take the next leap to delivering seamless, high-quality care, and serve as a model for the nation.”
As the White House pointed out, the potential benefits of a VLER are indeed monumental, but so is the effort that is required in order to plan, create, and implement a VLER. The effort to create a VLER represents one of the largest single joint projects that any two federal Departments have made in recent years, and there are a number of challenges that must be overcome to achieve the President’s vision. To begin with, new IT conceptual frameworks must be invented to provide a health and benefits data-sharing architecture to which both Departments can build electronic records systems. Right now, discussions between the Departments are focused on leveraging a common services architecture framework to support modernized tools and technologies on both sides. In addition to the over-arching conceptual issues on the technical side, the Departments must reach consensus on an effective governance model for the VLER project. Each Department has unique processes for funding, management, and oversight processes for information technology projects. These processes must be brought into alignment in key areas in order for successful planning and development to occur on the VLER initiative.
IPO EFFORTS TO ADDRESS FOUNDATIONAL TECHNICAL, GOVERNANCE, & PLANNING ISSUES
The IPO is an active participant in, and contributor to, interagency efforts to develop a strategy for VLER implementation. Following the policy guidance provided by the President and the Secretaries, the IPO established a VLER working group to provide a focused requirements and management effort to accelerate the adoption of a joint DoD/VA timeline for the VLER. This timeline, when complete, will provide a roadmap of major milestones to ensure an aggressive VLER implementation schedule with evolving benefits and successes. One of the first milestones on this timeline is to reach agreement on a precise definition of the scope of the VLER. There is already consensus among senior officials from both Departments on some of the categories of health and benefits data that must be accessible through the VLER. Discussions on other issues concerning the scope of the VLER are ongoing.
In addition to discussions on the scope of VLER, the IPO also plays an active role in efforts to reach inter-Departmental consensus on broad technical requirements issues. Progress is being made on the Departments’ efforts to agree to use a nationally-recognized set of uniform and open standards for information exchange, such as those being implemented by the Department of Health and Human Services’ National Health Information Network and the Justice Department’s National Information Exchange Model. This approach could enable DoD and VA to create an architectural framework that is capable of interconnecting systems from both the private sector and the government. Ultimately, such an information-sharing architecture could serve as a model for national electronic records.
Another major focus of the IPO is to establish an effective governance model for the VLER. Under current governance processes, the IPO receives guidance from the Secretaries of DoD and VA, as well as from the Joint Executive Council (JEC) [which is co-chaired by the Departments’ Deputy Secretaries]. The IPO works collaboratively with the DoD/VA Health Executive Council (HEC) for health-related data sharing, and the DoD/VA Benefits Executive Council (BEC) for personnel and benefits data sharing. The JEC provides leadership oversight of the HEC, BEC, IPO, and other councils and work groups, as determined by the JEC co-chairs. When the IPO identifies issues that cannot be resolved at the HEC and BEC levels, we elevate those issues to the JEC for final resolution. These oversight and governing procedures ensure that information-sharing efforts move in the right direction and at a pace that meets or exceeds the expectations of our stakeholders.
The existing governance structure has been adequate to enable the Departments to improve interoperability of their electronic healthcare records and to achieve unprecedented success in sharing electronic data. As DoD and VA plan the foundations of a robust and complex VLER, the Departments need to give additional consideration to determining how they will govern and implement the VLER. The IPO is working with the Departments to analyze the current processes through which issues are filtered up and managed through the HEC, BEC and JEC governing bodies. The goal is to ensure that critical decisions can be addressed quickly and effectively, at the lowest level of authority possible. Processes for issue-resolution in other areas of collaboration between the Departments may also need to be clarified or modified in order to ensure that VLER is implemented in the most expeditious manner possible.
HEALTH DATA SHARING AND INTEROPERABILITY
Efforts related to the planning and implementation of the Virtual Lifetime Electronic Record are not intended to replace our Congressionally-mandated objective of achieving full interoperability of existing electronic health records systems by September of this year. The VLER effort and the EHR interoperability effort do not conflict with one another. In fact, the Departments’ efforts to meet Congress’ interoperability goals have resulted in a body of work and ‘lessons learned’ that will be heavily leveraged during efforts to achieve the VLER vision.
The Departments began laying the foundation for interoperability in 2001, when the first patient health information was transferred electronically from DoD to VA using the Federal Health Information Exchange (FHIE). Since that time, both Departments have continued to enhance the exchange to support bidirectional data sharing, and to expand the types of information that is shared, as well as the manner in which information is shared. By leveraging the prior accomplishments of the Departments, the IPO and the Departments have been successful in formulating a plan to achieve full interoperability that will meet the needs our treating clinicians by the September 2009 target date. As part of this plan, VA and DoD will continue to improve upon the successes of existing data exchange initiatives, like the FHIE and the Bidirectional Health Information Exchange (BHIE), and expand the type of data shared through the already interoperable Clinical Data Repository/Health Data Repository (CHDR interface). To add further capability, new pilot programs such as the BHIE Imaging Pilot were developed. This pilot is now deployed and operational at major military and VA medical centers across the country.
The following examples provide greater detail of some of the successes of the Departments’ ongoing data-sharing initiatives (figures are current as of April 29, 2009):
- The Federal Health Information Exchange (FHIE) data repository allows VA to access electronic health information from DoD on over 4.8 million separated servicemembers. The FHIE allows VA providers to access and view 71 million laboratory results, 11.7 million radiology reports, 73.8 million pharmacy records, 78.8 million standard ambulatory records, 3.1 million consultation reports, and 2.5 million deployment health assessments for shared patients.
- The Bidirectional Health Information Exchange (BHIE) enables bidirectional real-time sharing of readable electronic health information between DoD and VA for shared patients. Since July 2007, BHIE data from all DoD and VA medical facilities are available to VA and DoD providers. As of February 2009, health data is available through BHIE for more than 3.3 million shared patients, including over 117,980 Theater patients.
- BHIE also allows VA and DoD to share inpatient information, and provides VA with the ability to access to inpatient discharge summaries from DoD’s inpatient documentation system. This capability is operational at some of DoD’s largest inpatient facilities, representing approximately 55 percent of total DoD inpatient beds. DoD will increase the number of sites with electronic inpatient documentation system in FY 2009.
- In addition to sharing viewable text data, DoD and VA are sharing digital radiology images at key locations.
- Since 2006, DoD and VA have been sharing computable outpatient pharmacy and allergy data through the interface between the Clinical Data Repository (CDR) of AHLTA and VA’s Health Data Repository (HDR) of HealtheVet VistA. This initiative, known as the Clinical Health Data Repository (CHDR), integrates outpatient pharmacy and medication allergy data for shared patients, and supports automatic check for drug-drug and drug-allergy interactions by using data from both Departments. In December 2007, all DoD facilities received the capability to initiate the exchange of this data on shared patients.
While much progress has been made toward our current interoperability goals, some challenges still remain. The key challenges include the following:
- Developing, adopting, and maturing standards at the national level to ensure efficient operational use.
- Updating capabilities, systems, infrastructure, and technology consistent with emerging standards.
- Identifying and prioritizing information requirements for sequential upgrade to new technologies and common services, as defined by the business process owners and the functional community.
In addition to this list of challenges, the Departments must continually work together to overcome difficulties created by different acquisition and funding cycles, different contracting processes, and differences in information assurance certification processes. The Departments and the IPO continue to engage in collaborative efforts to ensure that any impediment that may arise from these differences is resolved in an efficient manner. In spite of these challenges, the IPO and the two Departments are on track to achieve full interoperability for the provision of clinical care by September 30, 2009, as defined by the Interagency Clinical Informatics Board (ICIB).
The IPO and the Departments are engaged in many efforts to ensure that full interoperability for the provision of clinical care is achieved by September of this year. We recognize that interoperability does not have a discrete end point, as technologies and standards continue to evolve. Our efforts in the future will continue to build upon our past successes, allowing the Departments’ to maintain their standard of providing the highest quality care for our servicemembers, veterans and their beneficiaries.
That future is beginning to come into focus as we make progress on joint efforts to plan the Virtual Lifetime Electronic Record. Creating and implementing the VLER will require an unprecedented amount of effort, coordination, and interagency cooperation. The IPO is committed to this work, and looks forward to continuing to facilitate the efforts of the Departments on the VLER. When operational, the VLER will provide our servicemembers, veterans, and service providers with the health and benefits data they need, when and where they need it, thereby ultimately improving the quality of both healthcare and benefits services.
Thank you for the opportunity to address the Committee, and to provide you with an update on the important work that we are doing to advance electronic data-sharing between the DoD and VA. I look forward to keeping you apprised of our progress toward our shared goal of improving the quality of services for our servicemembers, veterans and their families.