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Witness Testimony of The Honorable Roger W. Baker, Assistant Secretary for Information and Technology and Chief Information Officer U.S. Department of Veterans Affairs

Good morning Chairman Miller, Ranking Member Michaud, and members of the committee.  We appreciate the opportunity to appear before you today to discuss the Department of Veterans Affairs’ (VA) efforts to develop an integrated Electronic Health Record (iEHR) with the Department of Defense (DoD).  Our testimony will address the current and future state of iEHR.   We will also address the decision to utilize the Veterans Health Information Systems and Technology Architecture (VistA) as VA’s core for iEHR.
First, we would like to dispel any notion that VA and DoD are moving away from a single, joint, electronic health record—both Secretary Shinseki and Secretary Panetta reaffirmed our commitment to this in public statements on February 5th.  What has changed is the strategy that we will use to accomplish that goal.

Initiation of the iEHR
In April of 2009, President Obama charged the Departments of Defense and Veterans Affairs to make Servicemember and Veteran health record information seamlessly available so that all information about a Servicemember or Veteran is available when they seek service from VA or DoD.  In May of 2009, as VA and DoD established the Virtual Lifetime Electronic Record (VLER) program to provide portability and accessibility of health, benefits, and administrative data for every Servicemember and Veteran, regardless of status, for the remainder of their lives, addressing the challenges many Veterans experience transitioning to VA service.
In addition to the exchange of information facilitated by VLER, in March of 2011, Secretaries Shinseki and Gates agreed that VA and DoD would work together to establish a joint plan to create a single, joint electronic health record (iEHR). Key to the decision to work together was the fact that both VA and DoD were pursuing paths to modernize their existing EHR platforms.  DoD was planning to replace its current EHR, the Armed Forces Health Longitudinal Technology Application (AHLTA), with a new electronic health record, and VA was planning to improve VistA by establishing an Open Source consortium and gradually replacing parts of the system with packages acquired from private sector developers.  In June of 2011, the Secretaries accepted the plan put forth by the Departments, which included the fundamental architecture, governance, and approach that would deliver an iEHR.

iEHR Governance
To address the challenges in achieving a large-scale, joint DoD-VA initiative, the iEHR program established a governance structure designed to support interagency decision-making.  The Interagency Program Office (IPO), established under PL 110-181, serves as the single point of accountability for the joint development and implementation of iEHR.  The IPO receives direction, supervision, and control from the Department Secretaries and guidance from the IPO Advisory Board and Joint Executive Committee (JEC).  The IPO receives requirements from and collaborates with DoD / VA Health and Benefits Executive Councils (HEC and BEC) and the JEC reviews the implementation of iEHR activities.
The governance structure was established to ensure decisions are made and executed at the appropriate level in the organization.  The IPO Advisory Board co-chairs are the DoD Deputy Chief Management Officer (DCMO) and the VA Assistant Secretary for Information and Technology.  In 2013, an Executive Committee of the IPO Advisory Board was established to oversee the execution of the iEHR program and the IPO.  In the event the Executive Committee cannot reach a consensus, issues are addressed by the JEC, and then to the two Secretaries, if necessary.

iEHR Cost Estimates

The IPO has approximately 135 federal employees, several hundred contractor employees, and approximately $758 million in planned spending for FY 2013. Despite these resources, the IPO has been challenged to meet its program deadlines. The initial estimate of the cost for the iEHR presented to the Secretaries in 2011 projected the cost to develop the iEHR at between $4 and $6 billion.  VA and DoD agreed to split the costs of iEHR development equally, and a cost sharing memorandum of understanding was completed in 2012.  In September of 2012, the IPO produced a new estimate of the cost of the iEHR that doubled the estimated cost of development of the system. While no missed milestone has yet caused a change in the “critical path” toward Initial Operating Capability (IOC) in 2014, the program has met very few of the milestones it has set.  

Revised iEHR Plan

In December of 2012, when presented with the revised cost and schedule information, the Secretaries directed that the Interagency Program Office (IPO) Advisory Board Co-Chairs and the Health Executive Committee (HEC) Co-Chairs prepare and provide a report within 30 days that would assess the current program strategy, provide “quick win” recommendations to accelerate interoperability and recommend changes to the governance structure and budget impacts.  As a result, the IPO Advisory Board Co-Chairs and HEC Co-Chairs provided a plan which the Secretaries approved that included:
•    Program Strategy:  Adjusted the iEHR acquisition business rules agreed to in March 2011 from “buy” commercially available solutions for joint use, “adopt” a Department-developed application if a modular commercial solution is not available and one Department has a solution, “create” a joint application on a case by case basis if neither a modular commercial or Department-developed solution are available, to “adopt, buy, create” to leverage existing capabilities for joint use.  The Departments will also define a “core” set of iEHR capabilities that would allow us to evaluate the selection of existing EHR products to reduce program risks and costs while accelerating implementation.

•    Quick Wins:  Accelerate the federation of VA and DoD clinical health data, to include VA’s mapping of the Health Data Dictionary (HDD) to their Corporate Data Warehouse (CDW) and update the CDW to provide near real-time patient data access.  This data interoperability work will be completed by January 2014. The VA will also rapidly adopt the common DoD-VA identity management solution and create the VA-DoD Medical Community of Interest network and security infrastructure. VA and DoD will continue to expand and accelerate patient access to data through the “Blue Button” initiatives.

•    Governance: Established an Executive Committee of the IPO Advisory board consisting of the DoD Deputy Chief Management Officer, the DoD Assistant Secretary for Health Affairs, the VA Under Secretary for Health, and the VA Assistant Secretary for Information and Technology.

Additionally the Secretaries approved deployment of the JANUS Graphical User Interface (GUI) to five VA polytrauma rehabilitation centers and two associated Military Treatment Facilities.

Under this plan, VA has committed to use the “core” technology of VistA, while DoD will evaluate available alternatives in order to make a “core” technology selection that will best fit its needs.  In order to achieve the desired data interoperability between both Departments, both “cores” will conform to an agreed-upon set of standards that enable the secure and interoperable exchange of information.

While the immediate focus is on accelerating data interoperability between the two Departments, our end goal remains the same – to make certain that we are creating a single, joint electronic health record for each Servicemember and Veteran.

VA Selection of VistA

VA chose the “core” technology of VistA to reduce the costs and risks associated with the selection and implementation of a different technology.  Most importantly, while we are engaged in continuously improving VistA, it is still one of the best EHR systems available worldwide.  And, because the source code to VistA is available via Open Source, we know that we will always be able to achieve competitive pricing for any changes we need to make.
VistA’s current Graphic User Interface known as the Computerized Patient Record System (CPRS), allows providers to update a patient’s medical history, place a variety of orders, and review test results and drug prescriptions.  Its tabbed chart interface organizes problem lists, pharmacy data, orders, lab results, progress notes, vital signs, radiology results, transcribed documents, and reports from various studies such as echocardiograms in a clinically relevant manner.  CPRS enables clinicians to enter, review, and continuously update all order-related information connected with any patient.  With CPRS, a clinician can order lab tests, medications, diets, radiology tests and procedures, record a patient’s allergies or adverse reactions to medications, request and track consults, and enter progress notes, diagnoses, and treatments for each encounter, and enter discharge summaries.  Close integration with the Clinical Reminders and Text Integration packages allows better record keeping and compliance with Clinical Guidelines and medical record requirements.  
The system has been implemented at all VA medical centers and at VA outpatient clinics, long-term care facilities, and domiciliaries – 1,300 sites of care throughout the Veterans Health Administration.  VA is the largest installation of VistA, with over 250,000 daily users at 152 of the nation's largest hospitals and over 800 community-based outpatient clinics nationwide.  VA serves over 6 million unique Veterans each year, and every visit is tracked and supported through the VistA EHR.  The largest individual VistA "sites" each have more than 80 million orders in their individual databases and each of these sites creates and handles an average of 22-28 thousand new orders per weekday.
VistA consists of approximately 160 applications (modules) which cover all aspects of health care and health care delivery (i.e. hospital operations).  More than half are clinically focused; the rest are supportive/administrative applications that are integral to delivering efficient, comprehensive, and safe patient care for the largest medical system in the US.  VistA functionality reaches far beyond the general hospital/health care EHR requirements.  Highly complex, government-specific regulations related to health care coordination, reporting, compliance, billing, and countless other functions.  VistA represents a deep and comprehensive integration of services.
In 2012, the VA health care system was honored to have 16 of its health care entities named to the 2012 “Most Wired” hospitals list.  The list that is released by Hospitals & Health Networks annually, in partnership with McKesson, the College of Healthcare Information Management Executives (CHIME), and the American Hospital Association (AHA), is a result of a national assessment aimed at ranking hospitals which are leveraging health information technology in new and innovative ways.

Conclusion
Mr. Chairman, the iEHR has proven to be a very challenging program, but both DoD and VA are committed to achieving the President’s goal of making Servicemember and Veteran information seamlessly available across the two Departments. As part of our efforts to make rapid progress on data interoperability, we are pleased to announce that in the coming months VA will be deploying the Janus Graphic User Interface to five VA polytrauma rehabilitation centers and two associated Military Treatment Facilities; standardizing health care data to facilitate interoperability;  upgrading the Corporate Data Warehouse to enable the near real-time exchange of data between Departments; and enabling patients in both Departments to download and transmit their medical records using national standards in with what is known as the Blue Button.
We appreciate the opportunity to appear before you today, and we are prepared to respond to any questions you may have