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Witness Testimony of Stephen L. Jones, DHA, U.S. Department of Defense, Principal Deputy Assistant Secretary of Defense (Health Affairs)

INTRODUCTION

Mr. Chairman and members of this distinguished Subcommittee, thank you for inviting me to discuss the sharing of electronic health information between the Department of Defense (DoD) and Department of Veterans Affairs (VA).   We are making great strides in sharing electronic health information, but we have more to do.

Cooperation between DoD and VA in the area of health information sharing is vital for effective management and efficient delivery of programs and benefits that our Nation’s Veterans and Service members deserve.  DoD recognizes Congressional concerns regarding the time it has taken the two Departments to establish the current level of interoperability.  Let me assure you that DoD and VA share the ultimate goals of this and other Congressional bodies seeking to address the needs of the Nation’s heroes.  We have been working together in earnest and have made significant progress in sharing electronic health information since our first efforts in 2001.  In particular, I would like to highlight current sharing activities, recent accomplishments, and some of what we hope to accomplish going forward. 

HISTORICAL OVERVIEW

DoD and VA began sharing electronic health information in 2001 and have continually enhanced and expanded the types of information we share as well as the ways in which we share the information.  At times it has not been an easy road, and there is always room for improvement in an effort as large and as crucial as this one.  Nonetheless, DoD and VA have come a long way in the areas of health information technology, interoperability standards, and health information sharing.  By working together at the top levels of DoD and VA, we have established policies that enable each Department to address its unique requirements while also addressing requirements that we share. 

CURRENT ACTIVITIES

Continuity of Care for Shared Patients.  For patients treated at both VA and DoD facilities, providers can view electronic health data from both Departments.  By the end of 2007, all essential health data will be, in the words of the President’s Commission on Care for America’s Returning Wounded Warriors, “immediately viewable by any clinician, allied health professional, or program administrator who needs it” at a DoD or VA facility.  Health data currently accessible by DoD and VA providers includes allergy information, outpatient medications, inpatient and outpatient laboratory results, radiology reports, demographic details to identify the patient, Pre- and Post Deployment Health Assessments, and Post-Deployment Health Reassessments.  To that list we can now add, as of earlier this month, vital clinical data captured in the Theater of operations, including inpatient notes, outpatient encounters, and ancillary clinical data, such as pharmacy data, allergies, laboratory results, and radiology reports.  This development is a significant accomplishment in our efforts to enhance the continuity of care for Service members returning from Iraq, Afghanistan, Kuwait, and other forward locations.  Other recent developments include expanding our efforts to share inpatient information electronically.  Specifically, over the past several months we have expanded the sharing of electronic discharge summaries to include the 13 DoD facilities with the greatest inpatient volume.  Previously only 5 DoD facilities had been capable of sharing discharge summaries.  This capability will be extended to include Landstuhl Regional Medical Center in 2008.  As the primary receiving location for patients coming out of Theater, Landstuhl is a critical link in the electronic health information chain. 

By December 2007, we will be sharing encounters and clinical notes, procedures, problem lists, inpatient consultations, and operative reports, further enhancing continuity of care for our shared patients.  In 2008, we will add vital signs, family history, social history, other history, and questionnaires and forms. 

Drug-Drug and Drug-Allergy Interaction Checking.  Outpatient pharmacy and drug allergy data are now available in a standardized format for patients receiving treatment from both DoD and VA.  This standardization enables our information systems to run vital safety checks.  Drug-drug interaction and drug-allergy checks can now be run using data from both Departments, further enhancing patient safety.  Currently, this capability is operational in the following 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; and
  • Mike O’Callaghan Federal Hospital and VA Southern Nevada Health Care System.

For this capability to work properly, the individual must have a record in the Defense Manpower Data Center/Defense Enrollment and Eligibility Reporting System (DEERS) – DoD’s “gold standard” for person identification.  More than 6 million veterans, primarily those who separated from Service prior to the establishment of DEERS, were recently added to the DEERS database.    With that completed, we are now ready for all DoD sites to implement this data sharing initiative.  Even now however, all DoD and VA facilities – not just those listed above – have access to the shared DoD and VA pharmacy and allergy data for a patient if that patient should present to their facility for care.

Continuity of Care for Polytrauma Patients (Wounded Warriors).  Earlier this year, in response to the urgent need for VA providers at Polytrauma Centers to have as much information as possible on inpatients transferring to their care, DoD began sending electronic health information directly to the Polytrauma Centers.  When providers determine that a severely wounded, injured, or ill patient should be transferred to a VA Polytrauma Center for care, DoD sends radiology images and scanned paper medical records electronically to the receiving facility.  This effort began in March 2007 with a pilot project, sharing information from one DoD facility to one VA Polytrauma Center, and quickly expanded to include the three primary DoD facilities treating incoming severely wounded warriors—Walter Reed Army Medical Center, National Naval Medical Center, and Brooke Army Medical Center—and the four level 1 VA Polytrauma Centers—Tampa, Richmond, Palo Alto, and Minneapolis. 

Separated Service Members (Potential VA Patients).  More than 4 million former Service members eligible for VA health care now have electronic health information accessible to their new provider should they seek care at a VA facility.  In 2001, DoD transmitted electronic health information for Service members who had separated since 1989.  Monthly transfers of health information for newly separated Service members began in 2002 and continue today.  Electronic health information available to VA providers includes the following data elements:

  • 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; and
  • Post-deployment health reassessments.

When the former Service member presents to VA for care or evaluation, the VA provider can access this information from within the VA electronic medical record.

Business Practice Coordination.  DoD and VA have extended the sharing concept to include coordination of business practices.  For example, the Laboratory Data Sharing Initiative (LDSI) established bidirectional electronic exchange of laboratory chemistry orders and results when one Department’s lab acts as a reference lab for the other.  In other words, when it will speed the process of getting a lab result, DoD can send a test to a VA lab for processing or VA can send a test to a DoD lab.  The end result is expedited testing and results, enhancing the quality of care for our patients.  Expanding the LDSI capability, DoD and VA have added laboratory anatomic pathology and microbiology orders and results retrieval.  This enhanced functionality became operational at Brooke Army Medical Center and VA South Texas Health Care System in May 2007.  The LDSI capability can be expanded to include other sites should they demonstrate that the capability would enhance quality of care and make sense from a business perspective. 

DoD and VA are also exploring other opportunities for coordinating business practices to support Veterans and Service members and their families.  These opportunities include an eHealth portal to improve accessibility of information for patients and expanded image sharing.  In both cases, DoD and VA will explore opportunities in search of the best ways to coordinate business practices to achieve the greatest benefit for the patients we serve.

DoD’s Electronic Health Record Meets Unique Needs.  Sharing electronic health information with VA is just one function of the DoD electronic health record.  DoD has many unique requirements that have shaped the development of its electronic health record system. 

Theater.  To track health care most effectively in Theater, a flexible, mobile, and highly scalable electronic information system is necessary.  DoD’s electronic health record operates on the full spectrum of hardware, according to what is available or practical in a given location or situation.  DoD providers at fixed facilities—what most of us think of as hospitals—can use desktop computers.  Providers at Combat Support Hospitals—sometimes nothing more than tents in the desert—use laptops that can operate in a standalone mode or as part of a small network.  Medics in the field can use handheld devices that are later synched with a laptop or desktop to add valuable information to the patient’s electronic health record.  DoD’s electronic health record, on all platforms, is designed to collect highly structured medical data, enabling us to identify potential natural disease outbreaks and chemical or biological attacks much faster than ever before in Theater.  DoD’s Theater health care mission also necessitates that an electronic health record system be operational in situations and places where external communications are often sporadic or unreliable.  Additionally, because health care information from Theater supports command and control efforts, our electronic health record system needs to fit within the greater DoD information technology infrastructure. 

One System in Garrison and Theater.  When our providers deploy, they must be provided with familiar tools to maximize their readiness. Therefore, we need to use one electronic health record system in garrison and in Theater.  Multiple systems could delay deployment of health care providers as they learn the “Theater” system or could negatively affect the quality of care in Theater as providers use a system with which they are either unfamiliar or less familiar. 

Our Beneficiary Population.  DoD’s beneficiaries include millions of people who relocate every few years.  To maintain accurate and complete electronic health records for such a mobile population requires a centralized clinical data repository.  As DoD providers and patients alike move from one part of the country to another, or from one end of the world to another, they benefit from a system that maintains complete records with information from more than 60 major hospitals and medical centers and more than 400 clinics in a single, electronic health record – accessible from DoD facilities around the globe. 

JOINT INPATIENT ELECTRONIC HEALTH RECORD

DoD and VA have developed or acquired separate outpatient electronic health record systems to meet unique needs.  For inpatient care, however, the Departments are exploring the possibility of a joint electronic health record solution.  The timing for examining this potentially ground-breaking effort is right, as both Departments currently plan to modernize, upgrade, or integrate inpatient records with their outpatient electronic health records and must find an interoperable solution.  A joint inpatient solution that meets the needs of both Departments could further enhance continuity of care, better meet requirements for joint facilities, and leverage economies of scale in terms of development and integration costs, license fees, and hardware purchases.  

We have taken the first steps in this effort to examine the potential for a joint system by working closely to award a contract to assess VA’s and DoD’s business and clinical processes, design features, and system constraints relevant to the inpatient component of an electronic health record.  This assessment will determine and describe, in narrative and graphic format, the scope and elements of a joint inpatient electronic health record and identify those clinical and business capabilities and applications that interact with the joint inpatient electronic health record.  An analysis of alternatives will then be conducted to develop a recommendation for the best technical approach.  We will implement the solution in a manner that builds data interoperability in as a fundamental precept.  Our goal is for a solution to address the information needs of the end users in all inpatient care venues from the forward surgical units in Theater to the domiciliary care facilities in VA.  A joint solution could provide users with all essential inpatient data—regardless of where in DoD or VA that data was acquired—as the patient moves through the continuum of care from Theater to home again.  The requirements analysis will be complete in 2008, after which we will establish an acquisition or development timeline based on the assessment of alternatives.

INTENSIFIED FOCUS ON WOUNDED WARRIORS

In the words of Secretary Gates, “Apart from the war itself, this department and I have no higher priority” than taking care of those who have “stepped forward to serve.”  Over the last several months DoD and VA have accelerated our electronic health information sharing initiatives to support America’s heroes.  We have received and are responding to the recommendations of various commissions and task forces, including the Independent Review Group, the Department of Veterans Affairs Interagency Task Force on Returning Global War on Terror Heroes, , and most recently, the Veterans Disability Benefits Commission.  Under the auspices of a Senior Oversight Committee and Overarching Integrated Product Team, I along with Dr. Paul Tibbits have had the privilege of co-chairing the team for DoD/VA Data Sharing.  Not only are we focusing on sharing health, personnel, and administrative data electronically between DoD and VA, but we are also working with other teams to determine the information technology needed to support reengineered business processes that better support our wounded warriors.

In addition, we are working to implement the recommendations of the President’s Commission on Care for America’s Returning Wounded Warriors.  We will: 

  • By next July, in order to implement our new Recovery Plans for wounded, make patient data much more accessible—to begin with, in viewable form. All essential health, administrative, and benefits data must be immediately viewable by any clinician, allied health professional, or program administrator who needs it.
  • Continue the work under way at present to create a fully interoperable information system that will meet the long-term administrative and clinical needs of all military personnel over time.
  • Develop a plan for a user-friendly, tailored, and specific services and benefits portal for service members, veterans, and family members.

Over the next several months, DoD/VA teams will define information technology requirements, enabling the two Departments to begin the work necessary to make all appropriate demographic, personnel, and medical information on Service members, Veterans, and their beneficiaries visible, accessible, and understandable through secure and interoperable information management systems.  We will work to provide the information technology needed to care for and track the status of our wounded warriors through their transition to Veteran status.  DoD and VA are now working more collaboratively across health and personnel organizational lines than ever before.  Our overall goal is to ensure appropriate beneficiary and medical information is visible, accessible, and understandable through secure and interoperable information management systems.

JOINT GOVERNANCE

VA/DoD electronic health information collaboration is a major component of the Departments’ Joint Strategic Plan.  The goals of the Joint Executive Council are described in the Joint Strategic Plan for Fiscal Years 2007 through 2009 and cover a full spectrum of VA/DoD health-related sharing.  The Under Secretary of Defense for Personnel and Readiness and the VA Deputy Secretary co-chair the Joint Executive Council, whose members include senior DoD and VA health managers involved in sharing initiatives.  This Council was established in 2002 and now meets quarterly to provide leadership oversight of interdepartmental cooperation at all levels and to oversee the efforts of the Health Executive Council and Benefits Executive Council.  The Assistant Secretary of Defense (Health Affairs) and VA Under Secretary for Health co-chair the Health Executive Council, which was formed to establish a high-level program of cooperation and coordination in a joint effort to reduce costs and improve health care for all our beneficiaries.  The Chief Information Officers of the Military Health System and the VA co-chair the Health Executive Council’s Information Management/Information Technology workgroup.   

NATIONAL STANDARDS ADOPTION AND IMPLEMENTATION 

DoD and VA lead the nation in health information technology, implementation of interoperability standards, and electronic health information sharing.  DoD’s electronic health record system has been awarded pre-market, conditional certification by the Certification Commission for Healthcare Information Technology, an independent, non-profit organization that sets the benchmark for electronic health record systems.  Full certification for DoD’s electronic health record system is expected in December 2007 when we begin deploying the next major enhancement.  As we implement, acquire, or upgrade health information technology systems used for the direct exchange of health information between agencies and with non-Federal entities, we shall utilize, where available, health information technology systems and products that meet recognized interoperability standards.

DoD and VA will continue to be driving forces in National initiatives such as the American Health Information Community, the Health Information Technology Standards Panel, the Health Information Technology Policy Council, and the Federal Health Architecture.  DoD and VA support Executive Order 13410, issued in 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.  Because such a significant portion of the American population is eligible for health care through Medicare, DoD, VA, and Federal employee health programs, our efforts can have a dramatic effect on private sector adoption of health information technology and will ultimately affect our ability to exchange electronic health information with private sector providers.

CONCLUSION

Providing the best possible care for America’s returning wounded warriors is a top priority for DoD and VA.  Electronic health information sharing is unquestionably a key component of enhancing the quality and continuity of the care both Departments deliver.  We have made great strides since our initial sharing efforts, building on the foundation established beginning in 2001.  We have accelerated our expansion of the types of data shared and methods of sharing in recent months to support urgent needs.  In the coming months, we will continue to explore additional projects such as a joint inpatient electronic health record and expanded image sharing. 

As always, we appreciate the insights, recommendations, and guidance of this and other Congressional and federal bodies.  We are all working toward the same end—to provide the highest quality care for our Nation’s heroes, past and present—and we need to work together to achieve our goals as efficiently and effectively as possible.  Thank you for allowing me the opportunity to appear before you and to testify about DoD/VA electronic health information sharing achievements, goals, and plans.