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Sharing of Electronic Medical Records between the DoD and the VA

Sharing of Electronic Medical Records between the U.S. Department of Defense and the U.S. Department of Veterans Affairs













MAY 8, 2007

SERIAL No. 110-20

Printed for the use of the Committee on Veterans' Affairs





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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

HARRY E. MITCHELL, Arizona, Chairman

TIMOTHY J. WALZ, Minnesota
GINNY BROWN-WAITE, Florida, Ranking
BRIAN P. BILBRAY, California

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



May 8, 2007

Sharing of Electronic Medical Records Between the U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA)


Chairman Harry E. Mitchell
        Prepared statement of Chairman Mitchell
Hon. Ginny Brown-Waite, Ranking Republican Member
        Prepared statement of Congresswoman Brown-Waite
Hon. Timothy J. Walz
Hon. Ciro D. Rodriguez
Hon Cliff Stearns, prepared statement of


U.S. Government Accountability Office, Valerie C. Melvin, Director, Human Capital and Management Information Systems Issues
        Prepared statement of Ms. Melvin
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., FAAFP, Acting Principal Deputy Under Secretary for Health, Veterans Health Administration
        Prepared statement of Dr. Cross
U.S. Department of Defense, Stephen L. Jones, DHA, Principal Deputy Assistant Secretary of Defense (Health Affairs)
        Prepared statement of Dr. Jones


Tuesday, May 8, 2007
U. S. House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.

The Committee met, pursuant to notice, at 10:03 a.m., in Room 334, Cannon House Office Building, Hon. Harry E. Mitchell [Chairman of the Subcommittee] presiding.

Present: Representatives Mitchell, Space, Walz, Rodriguez, Brown-Waite, Stearns, Bilbray.


Mr. MITCHELL. Good morning and welcome to the Oversight and Investigations Subcommittee for the Committee on Veterans’ Affairs. At this particular hearing we are dealing with sharing electronic medical records between the U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA). This meeting will come to order. And let me just give my opening statement and then I will ask Ms. Brown-Waite to give hers.

One of the concerns I have heard from veterans is how difficult the process can be in the transition from their active duty status to veteran status. One of the great difficulties they experience is having their full and complete medical records from the Department of Defense available to their VA doctors. This problem isn’t new.

In 1998, President Clinton called on the VA and DoD to develop a “comprehensive, life-long medical record for each servicemember.” That was nearly ten years ago. But up to this point, progress has been painfully slow and increasingly expensive. That is why we are having this hearing today, so that this Subcommittee can continue its efforts to provide an oversight and do what we can do to speed up the process and make electronic medical records sharing a reality.

We all know that there are many benefits to this. First, we will be making sure that veterans receive better medical care by saving time and avoiding errors. And second, we will also lower costs so taxpayer dollars are more wisely spent. That is a worthy goal as well. I am glad to know that the VA and DoD are working on some demonstration projects in this area and I am eager to get an update on it.

I want to take a moment to acknowledge the VA and DoD’s progress in the long-term efforts to achieve a two-way electronic data exchange capability. They have implemented three or four earlier U.S. Government Accountability Office (GAO) recommendations, including developing an architecture for the electronic interface between DoD clinical data repository and VA’s health data repository, selecting a lead entity with final decision-making authority for the initiative and establishing a project management structure. That is a good start, but there is much more to do.

One of my greatest concerns is that the VA and DoD have not yet developed a clearly defined project management plan that provides a detailed description of the technical and managerial process necessary to satisfy project requirements as the GAO has repeatedly suggested in the past.

For example, all the way back to December 2004, the VA/DoD Joint Executive Council annual report found that the cost for government computer-based patient record Federal Health Information Exchange (FHIE) was approximately $85 million through fiscal year 2003. But here we are four years later, the cost continuing to grow and the consequences for today are growing too. We want to know why this isn’t getting done and how much longer our veterans have to wait. I believe they have already waited too long.

I look forward to today’s testimony and before I recognize the Ranking Member for her remarks, I would like to swear in our witnesses.  Would all the people who are presenting, all panelists please rise and be all sworn in at one time?

[All witnesses were sworn.]

[The statement of Chairman Mitchell appears in the Appendix.]

Mr. MITCHELL. Thank you. I will now recognize Ms. Brown-Waite for her opening remarks.


Ms. BROWN-WAITE. Thank you, Mr. Chairman. This Committee has held at least 16 hearings since 2002 to try to push the sharing of critical medical information on patients being transferred between the Department of Defense and the Department of Veterans Affairs. The movement of this information is vital to the safety and well-being of our veterans and military active duty servicemembers as they transfer between the two agencies and become finally integrated back into civilian life.

Our staff and members have visited many VA and DoD medical centers. Of particular interest are the four VA polytrauma units where servicemembers sustaining severely disabling injuries to include traumatic head, traumatic brain injury, rather, TBI, and spinal cord injuries are being cared for, while still in service as well as many after discharge in VA facilities.

We have frequently heard the concerns of VA doctors and medical personnel at these facilities that the information they are receiving isn’t timely enough or missing critical data necessary to properly treat these severely injured and disabled servicemembers.

Throughout the past 20 years, the VA and DoD have spent billions of dollars working on independently stove-piped electronic medical record systems that would provide better care to those serving on the front line of our Nation’s efforts to freedom. Yet to date, neither seems to work together in a coordinated effort of care.

On April 10th, 2007, an article appeared in the Washington Post which touted the VA’s VistA System as a means to lower cost and provide better treatment to our Nation’s veterans. Can the VistA System receive information from the Department of Defense?

We have also heard about the joint patient tracking system which permits the transmission of patient care notes from the battleground up the line to the patient’s final destination, whether for continued care at a VA facility or to prepare for redeployment. However, in January, the Department of Defense temporarily cut off access of this critical data to the VA.

Today we have sitting before us both departments. It is my sincere hope that after two decades, that finally there is good news on the horizon and we will see a system that will permit the exchange of critical medical information that is interoperable, bidirectional and occurs in real time. The care for those who serve our country does not stop at the exit door of the Department of Defense, but continues through the doors of the VA. And the hand-off between the two medical systems should be seamless, not a fumble. Our Nation’s heroes deserve no less.

Mr. Chairman, I yield back the balance of my time.

[The statement of Congresswoman Brown-Waite appears in the Appendix.]

Mr. MITCHELL. Thank you. Mr. Walz?


Mr. WALZ. Well, thank you, Mr. Chairman, and in the sake of time, I will make this brief and submit my written opening statement. But I wanted to thank the witnesses for coming today. I thank each and every one of you for being here. Our job up here and Congress’ job is to provide oversight and we share in the teamwork between what you are trying to do and what we are trying to do, is to care for our veterans in the best possible way.

So I thank you for that ahead of time. But as it was stated, and I would associate my comments with the Ranking Member, of the time that it has taken and the cost, and yet, still not being at the point where we need to be. My concern from this comes from—I represent the district that is home to the Mayo Clinic—and I have had many, many conversations on this issue of medical records and have been given some great advice on this. And I want to hear today in what direction we are moving and what are the lessons learned with the private sector, because trust me on that, I know they are not infallible too. And one of the complaints I hear from the VA is sometimes it is more difficult to get records from the private sector than it is from DoD. So that is a fact too.

We are here today to try and solve this problem, to try and do whatever we can. As the Ranking Member said, we have been at this for nearly two decades and 16 hearings. At some point, the group that is in this room has to decide that maybe it is time to move forward and maybe we can get some things done. So I look forward to your testimony. I look forward to whatever we can do to help assist you to get that done. We are in this together. And the bottom line is, if we get this done, we will get it done right, and all of our veterans benefit. And that is a positive.

I yield back, Mr. Chairman.

[No statement was submitted.]

Mr. MITCHELL. Thank you.

Mr. Bilbray?

Mr. Rodriguez?


Mr. RODRIGUEZ. Let me just thank you, Mr. Chairman, for holding this hearing. And I also want to emphasize the importance of moving as quickly as we can and of doing a good job in the process. I know that technology exists out there that can actually check all those that are in the Department of Defense and follow up and anticipate what is going to be needed medically.  We can be on top of it, especially for proposals in terms of what is needed, in terms of resources to be able to meet those gaps for those soldiers that will become veterans in the future.

So we are ready to work with you. I do feel that because I had spent eight years on this Committee before. I was gone for two years. I am back and we are still not where we want to be. And so, I would hope that we would move as quickly as possible on some of the information.

I know that it also deals with the whole issue of the new technology that is out there that we can make it happen, which is the same area that we have had difficulty with the VA in terms of using some of that technology and not coming to grips with that in terms of those records of some of those soldiers. And so, somehow, we need to come to grips with that and also make sure that whatever information we do have, that it is available, but that it is also secure and hopefully strike that balance.

Thank you very much and I yield back the balance of my time.

Mr. MITCHELL. Thank you, Mr. Rodriguez.

We will now proceed to panel one. Ms. Valerie Melvin is the Director of Human Capital and Management Information Systems Issues for the U.S. Government Accountability Office. She will be accompanied by her Assistant Director, Ms. Barbara Oliver. We look forward to hearing your unbiased view of this situation. Thank you.


Ms. MELVIN. Thank you. Mr. Chairman and members of the Subcommittee, I am pleased to be here to discuss VA’s and DoD’s efforts to share electronic medical records. Sharing medical information can help ensure that active duty military personnel and veterans receive high quality healthcare and assistance with disability claims, goals that are more essential than ever in the face of current demands on our military.

For almost a decade, VA and DoD have been pursuing ways to share medical information. These includes efforts focused on the long-term vision a single, comprehensive, life-long medical record for each servicemember to allow a seamless transition between the departments, and more near-term efforts to meet immediate needs to exchange health information. Since undertaking these efforts, however, the departments have faced considerable challenges leading to repeated changes in the focus of and target dates of their initiatives, and in our recommending greater project management and accountability.

Currently, each department is developing its own modern health information system to replace existing systems and they are now collaborating on the development of an interface to enable these systems to have interoperable electronic medical records. The modernized systems are based on using computable data; that is, data in a format that a computer application can act on, for example, to alert clinicians of a drug allergy or of significant changes in vital signs such as blood pressure.

The departments have made some progress toward their long-term objectives. They have begun implementing the first release of an interface between their modernized data repositories. Now at seven DoD sites, the interface allows the departments to exchange computable outpatient pharmacy and drug allergy data. Although the data being exchanged are limited, this interface is an important milestone. Nonetheless, the departments still need a project management plan that is sufficiently detailed to effectively guide this effort and ensure its full implementation as we have previously recommended and as you have noted here today.

In parallel with their long-term objective, VA and DoD are also pursuing short-term initiatives to share information in their existing health information systems. One of these, the laboratory data sharing interface project, has developed an application that allows the departments to share medical laboratory resources. This application is currently implemented at nine sites. The other, the bidirectional health information exchange, or BHIE, has developed an interface that provides a two-way, almost instantaneous view of selected categories of health data on shared patients from VA’s existing systems, and from those DoD sites where the interface is implemented.

Current BHIE capabilities are available throughout VA and DoD plans to make these capabilities available throughout its department by next month. Further, responding to a demand for more access to health data, the departments have begun expanding BHIE’s capabilities and implementation, in effect using the interface to connect not only VA and DoD, but also DoD’s multiple legacy systems which were not previously linked. In this way, the departments plan to share more of their current information more quickly.

Beyond these two efforts, the departments have also established various ad hoc processes to provide data on severely wounded servicemembers to VA’s polytrauma centers which specialize in treating such patients. These processes included manual work-around such as scanning paper records to transfer records to incompatible systems. While particularly significant to the treatment of servicemembers who sustain traumatic injuries, such laborious processes are generally feasible only because the number of polytrauma patients is small.

Mr. Chairman, although the departments are sharing some health information, including certain computable data, they still face considerable work and challenges to achieve this long-term goal. Their multiple initiates and ad hoc processes, while significant, highlight the need for continued efforts to integrate information systems and automatic information exchange. However, it is not yet clear how all the initiatives that VA and DoD have undertaken are to be incorporated into an overall strategy focused on achieving the ultimate goal of a comprehensive, seamless exchange of health information.

This concludes my prepared statement. I would be happy to respond to any questions that you might have.

[The statement of Ms. Melvin appears in the Appendix.]

Mr. MITCHELL. Thank you very much. Do you have any idea, Ms. Melvin, why there has not been a clearly defined project management plan? What do they tell you?

Ms. MELVIN. Throughout our reviews over the years— and we have been reviewing this since approximately 2001 in detail—one of the concerns that we have noted, as you have said, is the project management plan and what we learned is that VA and DoD do, in fact, recognize the need for such project management. However, the actions relative to actually putting those plans in place and specifying in detail, the level of detail, what is necessary is where they tend to fall short.

We have seen efforts on their part to, in fact, indicate or develop project plans in some respects for some of the systems. However, as they move forward, we don’t see the detail that would show how these plans would move beyond perhaps the immediate systems that they are looking at, or certainly to show how they would integrate future systems and how they would then manage and ensure the outcomes of those initiatives.

Mr. MITCHELL. Do they give you any reasons why they are not doing what they should be doing? Do they say they don’t have money, they don’t have staff? What are the reasons they give you for not moving ahead and doing this? You know, this is a long time coming.

Ms. MELVIN. Yes. It is a long time project. In our discussions with VA and DoD, there is continual recognition that there is a need to move forward on these systems. We have not gotten explanations from VA or DoD that suggest that they don’t feel that they can move forward. However, what we do not see in the work that we have conducted has been the—I guess the overall recognition of the specific requirements that it would take to have the project planning in place for these systems.

Mr. MITCHELL. Do you think they are making any progress toward this? And if they are—I don’t want to hold these hearings just to hear everybody talk and then we leave and nothing happens. Is there some type of a time line or something you might be able to suggest that we ought to have another hearing say,  six months from now or a year from now, or whatever it may be, and ask what has happened? Do they not recognize the importance of what you are suggesting?

Ms. MELVIN. I believe they do recognize the importance. However, through the work that we have conducted over the years, one of the things that we found is that your continued oversight has been critical to making sure that both departments move forward on this effort. We don’t see that the departments don’t have a common understanding of the goal that they are trying to achieve. However, we do feel that they fall short relative to the particular actions that they take relative to planning for this initiative, the particular strategies that they identify.

One of the key things in the work that we have noted is that VA and DoD have—their systems development efforts toward the modernized systems that they are trying to put in place are initiatives that have always been on separate tracks. So it is very critical for those departments to be able to develop the type of collaboration, or have the type of collaboration that will be geared toward making sure that the strategy that is put in place identifies clearly and acknowledges the steps and the time frames that are necessary to get them to a shared type of capability.

We have seen action on their part relative to the Clinical Data Repository/Health Data Repository (CHDR) interface that the departments are putting in place. However, as our work has shown, we do still feel that there is a need for a more defined time line or more specific risk management and certainly for more performance-based measures to guide their efforts.

Mr. MITCHELL. One last question on my part. As I noted in my statement, President Clinton called for VA and DoD to develop “a comprehensive life-long medical record for each servicemember.” Do you think that these two branches, the DoD and VA, believe in this mission? Because I think that is what we are all here trying to do. A life-long medical record for each servicemember that follows them through, that is what we are trying to accomplish.

Do you think that they view this as one of their goals, one of the things that they are trying to accomplish? And if so, why are they taking so long? In the meantime, there are many, many veterans and servicemembers who are falling through the cracks because of the lack of a life-long medical record that follows each person.

Ms. MELVIN. Each of these organizations certainly have had its own objectives relative to creating its systems. We have not heard anything from VA or DoD to suggest that they don’t believe in this mission. However, I think that there are organizational cultures that do have to be overcome on the part of VA and DoD relative to achieving the particular capability that they desire as far as a life-long medical record.

VA certainly has developed a comprehensive record that includes inpatient and outpatient data. DoD’s systems are set up much different in the way that they currently exist. There are a number of multiple systems that are not integrated in the same capacity. So for each of these agencies to move forward, there has to—first of all, the Department of Defense, for example, has to deal with its own internal issues of how it will manage and address the multiple systems that it has in place. And then beyond that, both of these departments must have a dedicated collaboration on how they will either develop one common record or at least have systems that are interoperable and can exchange data in the way that would be needed to develop a seamless transition in the exchange of records.

Mr. MITCHELL. Thank you. It seems to me that they are really more concerned about defending their own system instead of the ultimate goal of taking care of these veterans.

Ms. MELVIN. Organizational culture of each department must be considered, yes.

Mr. MITCHELL. Thank you.

Ms. Brown-Waite?

Ms. BROWN-WAITE. I thank the Chairman.

And I thank the witnesses for being here. You know, I think this gives new meaning to Yogi Berra’s “this is déjà vu all over again.” There is a report that was dated the first year I came to Congress, and this is my fifth year here. And that report is dated November of 2003.

It was also from the Subcommittee on Oversight and the response from the DoD from your predecessor was that they were still working on it. Then there was an Executive Order, Executive Order 13410, which gave a deadline for implementation of a joint system of January 1, 2007. This tells me that not only are the agencies dragging their feet, they are ignoring Congress, they are ignoring the President. And in the meantime, people at the polytrauma unit down in Tampa and other polytrauma units, the spinal cord injury units, those injured warriors who are coming back are suffering.

The foot-dragging is inexcusable. It absolutely is. It is like—it is déjà vu all over again. Tell me why I shouldn’t be cynical that you are just giving Congress lip service and ignoring an Executive Order.

Ms. MELVIN. Through the work that we have conducted, certainly one of the critical issues that we have emphasized has been the repeated change in strategy, the repeated change in milestones of the initials that VA and DoD have undertaken to get their systems in place. I think that over the years, because you do see the multiple changes, the multiple projects, first of all, that have come into play, as well as the strategies and the lack of clarity relative to how they plan to get to the end results of the record, does in fact raise skepticism in the minds of those who look at the actions being taken on these systems.

Ms. BROWN-WAITE. Ma’am, let me point out that the title of this is VA/DoD shared medical records, 20 years and waiting. This report was November of 2003.

Ms. MELVIN. Mm-hmm.

Ms. BROWN-WAITE. It was 20 years then. This is 2007. You missed the deadline. Could we have from you a precise date when these records are going to be easily transferable? Do you have a date in mind? Do you have a contract out there? Is there a system that is going to work? You know, this isn’t rocket science. Help me out here.

Ms. MELVIN. I can’t speak for DoD and VA. The work that GAO has done does support the concerns that you raise about the fact that these systems have been in play for a long time, that the agencies are, in fact, pursuing a strategy or a series of strategies that have been changed along the way, and that the milestones accompanying those strategies have certainly changed also.

We have not gotten specific reasons from VA and DoD to suggest why, in fact, their strategies are different. We do know, however, that again, each of these departments is working on their separate systems and they are also working on multiple systems in the short-term to address these initiatives, or at least to address the immediate needs for data, which have to be weighed against the overall long-term objective of a comprehensive, life-long medical record.

Ms. BROWN-WAITE. Is it your opinion that this will happen in the next three years, five years, one year? You know, you have looked at both systems, correct?

Ms. MELVIN. We have not looked at DoD’s system in detail. We have only looked at DoD’s system as it pertains to the interface with VA systems. The majority of the work that we have done has been for the Veterans’ Affairs Committee examining the VA system so far.

What I can tell you, though, in response to the early part of your question about the time frame, we don’t feel positioned to give you a time frame for when VA and DoD can have this in place. We have looked over the years at what they are doing to develop these systems and we have seen multiple changes. And I think by the very nature of the fact that we do not see an integrated strategy or a defined project plan for the systems at this point, we are not in a position to be able to say when they would have these systems developed.

Ms. BROWN-WAITE. Thank you. I will ask that question of others also in the future. Thank you.

Mr. MITCHELL. Thank you.

Mr. Walz?

Mr. WALZ. Well, thank you, Mr. Chairman.

And I too think that many of these questions will cut between the two panels. But I do want to make it clear that in my speaking with and having people come in and brief me, specifically from the Mayo Clinic, I understand this was a difficult prospect. I understand it is much more difficult than a common software issue, that there are many things that have to take place.

But I, too, share the concern of this Subcommittee that this is a long time coming, especially when we have focused and tried to put our emphasis on doing this. It is a very important project. It is important for our veterans. It is important for their care. But I think it is important also in that we can prove that this can work on a scale that is large enough to get the rest of the country moving in this direction.

But the one thing I want to make note of—and I am going to ask a couple of specific questions. I am much more concerned with quantifiable data, but I think this anecdotal evidence is pretty telling.

I had the opportunity, about a month ago, to meet with a high ranking General Officer in the Medical Corp of the Army and had mentioned that that week I had just sat down for a two-hour briefing on electronic medical records. And this was again with the Mayo Clinic and their top experts on this. They are convinced that the VA has this figured out in a very, very good way, and that it is very cost effective and it should be adapted, that that is the starting point on this.

Now, I don’t know that to be a fact and I didn’t have anything other than the two-hour briefing on this, but I started to mention this to this officer and was cut short and it became apparent that this person, without mentioning names and they may be up here soon enough, had totally disregarded anything that I had to share on that, that the official didn’t want to hear about that. And that made me very, very concerned. And my civilian career before Congress was as a cultural studies teacher. So I appreciate, Ms. Melvin, your bringing up on cultural side of this, because this deeply concerns me.

A couple of questions for you. Obviously, we have to have ad hoc solutions, in the short-term for the polytrauma centers. Are those setting us back in the long-term goal of integration here, in your opinion?

Ms. MELVIN. The short-term initiatives are very critical to helping the immediate needs of the servicemembers who are severely wounded. So from the standpoint of setting us back, I can’t really say. What I do say, however, is that it is important to examine what VA and DoD are doing relative to implementing the short-term initiatives and how—what bearing this does have on their plans and their strategies and approaches for leading to the longer term goals.

What I would be concerned about seeing is the long-term initiative of the comprehensive life-long record being, for lack of a better word, short-changed at the expense of immediate needs. There is a need to balance on both of those areas. It is important to serve the critical needs of the returning soldiers now. At that same time, there needs to be continued effort, continued dialogue and collaboration relative to making sure that they continue to move toward the longer term objective.

Mr. WALZ. The last question I would have. Our job is obviously oversight and guidance. We don’t want to tell either one of these agencies specifically how to do things. But in your opinion, are we reaching a point on this where—I am quoting outside experts on this, people who have no financial gain in this, but have expertise, like the Mayo Clinic in this record. Are we at the point now, in your opinion, where DoD needs to start thinking about adapting the way the VA is doing this? And is that where we need to give the guidance to start moving in that direction? Would you be comfortable in saying that that looks like it has the strongest possibility to get this done?

Ms. MELVIN. Because of the nature of the work, I wouldn’t say that it is definitely the way to go. But I would say, however, that it is certainly an option that should be considered by the agency as it proceeds with determining on how it is going to integrate its systems, achieve the modernized health system that it has been trying to develop, and work toward the longer term goal with VA.

Mr. WALZ. Thank you. I yield back.

Mr. MITCHELL. Thank you.

Mr. Bilbray?

Mr. BILBRAY. For the record, how long have we been working on this project?

Ms. MELVIN. How long have we been working on this project?

Mr. BILBRAY. How long have the DoD and Veterans been working at trying to have a consolidated record system?

Ms. MELVIN. The start date that we have been using in our work is 1998, and that was at the point in which the President called for the comprehensive record. However, there were efforts on the part of VA and DoD prior to that in the way of developing modernized systems.

Mr. BILBRAY. You know, my 18 years before coming to Congress I was in local government and watched this type of bureaucratic run around. Everybody wants to control their record system and wants it to be their little possession because it has traditionally been their possession. And to try to break down the barriers of bureaucracy set-up is a major challenge.

And, you know, when you are talking about—how long would you predict it is going to take now to finally get the system consolidated?

Ms. MELVIN. How long would I predict that it is—

Mr. BILBRAY. Yeah.

Ms. MELVIN. —going to take?  I really cannot—

Mr. BILBRAY. Working at the present pace.

Ms. MELVIN. VA and DoD have indicated that they would have their modernized health systems developed by, I believe, 2012 and 2011, respectively. However, in the work that we have done, we have seen delays in their efforts, at least in the efforts of VA—I am sorry, DoD to get its modernized system and all of its systems put together.

And also, VA and DoD, I believe, recently have indicated that they have now changed those milestones and don’t have a specific date for when those systems would be completed. Lacking that and lacking more specifics relative to the strategy that they are actually taking, I am not sure that anyone could say at this point how long it is going to take them to get there. We certainly are not in a position to do so at GAO.

Mr. BILBRAY. Okay. Let me shift around now. Were you including—seeing what technology you are looking at, there is not that many Bilbrays running around America right now. But Mr. Rodriguez would agree that there is a whole lot of Rodriguezes and that right now working with just a number and a name, the potential that hospitals in the private sector run into of mixing names and numbers up and going to biometric confirmation. Are they including the concept of biometric confirmation in the recordkeeping capability?

Ms. MELVIN. We have not gotten any information on that concept in the work that we have done.

Mr. BILBRAY. Okay. And in the private sector more and more is really looking at this as not only being a recordkeeping, but an absolute lifesaver in a critical time to be able to identify somebody when they are unconscious and to make sure that you are not triaging the wrong person for a procedure. And what I am worried about is we will get all the way down this line and then all of the sudden someone says oops, we didn’t consider the cutting edge.

You know, Mr. Chairman, I really would suggest that we take a look at the fact that if we continue to go the way we are going, we are all going to be retired and gone by the time somebody goes the promise. I am not one for commissions. But I would strongly believe that we are probably looking at needing direct oversight, a taskmaster here. And if I would—let me just say flat out.

I would say that a five-member commission not made up of veterans, but made up of three members of high tech information specialists, one member from military hospital capabilities and another member from a civilian hospital capability so we can sort of intermix. But not being the focus of just complaining about the system, but bringing people in with the expertise to drive the system towards cutting edge approaches to recordkeeping rather than always the defensive.

And I just think what we are looking at is, we need a taskmaster that we can empower with the ability to hang over them and say we want to see this report in six months. We want to have another report and we want to see this product ready to go in two years and somebody hounding over them to where they have one and one purpose only, and that is to make sure the bureaucracy works.

I only throw this out with no research on it, but I just think that when I am told that a responsibility that has been dragged on this long does not have a foreseeable sunset, it tells me that we need to modify our approach to it and be a little more hands-on to it and I just think it is something that we may want to discuss as a Subcommittee and talk to the Ranking Member and the Chairman about getting somebody to look over the shoulder of these guys every week to finally get them moving in the right direction.

And with that good information and that cheery news, I will yield back to my Chair.

Mr. MITCHELL. Thank you. You know, it is one thing to be concerned about a bureaucracy and the cost. But what we are really dealing with here are people’s lives and bureaucracies can go on and on and waste lots of money. The very fact that we have got people’s lives involved here I think is very important.

Mr. BILBRAY. Mr. Chairman, would you yield just on that point?


Mr. BILBRAY. I think too often the cost is an issue because it costs money to do things and if you waste money, that is money you can’t use for other work. But you have got the private sector, you got local governments that are looking at the same crisis. They all—this happens in government and business all over America. And I assure you that there is a privacy issue here, but that applies in private and public sector. This challenge is not unique and we ought to be looking around at all the things that are being done by everyone else and finding ways to get over the barriers of privacy, funding and other related—and getting the job done. And right now, we just don’t see that happening and I yield back. Thank you.

Mr. MITCHELL. Thank you.

Mr. Rodriguez?

Mr. RODRIGUEZ. Thank you very much for the testimony. And I had indicated to you that I had been eight years on this Committee before and then gone for two years and then came back and we are still talking about the same thing. And I remember getting up here in 1997 and we were talking about this.

Would it help—and I am just throwing this out—if we did a pilot program and included just the Marines or maybe just the Air Force where we got someone to basically get that data and transfer it over after they become veterans? Would it help in any way that maybe—or an external group did that, because you seem not to indicate that they still need a lot of communicating among themselves because I know that technology is there.

I have seen the technology there that can even get different languages to be able to put it together and come up with one system. And I have seen where you can get a soldier, and even with a thousand soldiers, and know exactly what you are going to be needing in terms of the access to the healthcare that is there.

And so can you provide me feedback on that, please?

Ms. MELVIN. I think that VA and DoD have a lot of initiatives underway and they have already accomplished a lot relative to the actions that they have taken. VA has an integrated system which I believe there are a lot of lessons that can be learned from relative to how to put together a comprehensive medical record.

These agencies have also engaged in a previous effort to—that has resulted in the one-way transfer of data from DoD’s computerized system into VA’s to give VA the capability to see critical data elements related to patients. So I would hesitate to say that a pilot project necessarily would be the answer, but I would say that I believe it is very important that these two departments borrow on the experiences that they have already undertaken.

They have a—DoD in particular is engaged in a number of short-term initiatives to provide critical health information on servicemembers at this time.  And I think coupled with what VA has already accomplished in its way, there should be room for very serious and very productive dialogue on how to take the lessons learned from what they have already accomplished and what they have learned about their needs and capabilities and to allow that to move them forward in deciding what strategy—

Mr. RODRIGUEZ. But apparently the will has not been there. So do you have any suggestions? There were suggestions that maybe we have an external group come in and force them to do that. Do you have any other recommendations?

Ms. MELVIN. I think there is certainly room for continued oversight and for holding VA and DoD accountable for making, for coming to a point where they have a definite strategy on this. I believe that there is certainly room for continued oversight. Perhaps there is room for lessons learned from other bodies, private entities that have been involved in looking at the development of electronic medical records. But again, I would stress that these agencies have a wealth of information, or should have a wealth of information.

I believe, though, that they have to held accountable for—

Mr. RODRIGUEZ.  But you don’t—

Ms. MELVIN. —deciding how to move forward—

Mr. RODRIGUEZ. Yes, because it is extremely costly for them to—when the Department of Defense has done some work already with the soldiers and you have all these documents that are already on the soldiers, a packet, and then you have to start from scratch in the VA to redo some of the stuff because of the fact that they don’t communicate and they don’t pass that information on.

It not only hurts the soldier in terms of the access to quality care, but it also costs the taxpayer money in terms of having to redo a lot of the stuff that maybe has already been done. From your perspective, what can you do or what kind of direction can we give you that would help in this process to force them to communicate and force them to come up with an approach?

Ms. MELVIN. What we have seen in the past is where we have been asked to conduct continued oversight and comprehensive oversight relative to the actions that VA and DoD have taken.  We have seen some progress relative to their identifying the lead entities for their efforts and trying to clarify strategies.  At least on some of the prior initiatives that have been undertaken from our role as an oversight body, I would suggest that continued oversight on our part—

Mr. RODRIGUEZ. Let me ask you, if it is okay with the Chairman, to submit to the Chairman those guidelines that would allow you that opportunity to have that oversight that would force them to move quicker in coming together to make this happen, because then maybe they might have it by 2011, 2012 when they started and, you know—but they started before 1998.  You started to look at it in 1998—

Ms. MELVIN. That is correct.

Mr. RODRIGUEZ. —but they started before then. So it is going to be, what, 14, 15 years, and maybe we might have something by 2011, 2012. That is not satisfactory. It has been 15 years or more, and I would ask that you submit some specific recommendations to the Chairman and we will see if we can help in this process, to expedite that, and see what other things we can come up with in addition to the possibility of a Committee that can do the oversight and ask them to come up with additional recommendations.

Ms. MELVIN. We would be happy to respond to any requests that you have for additional work on our part to support you in that effort.

Mr. RODRIGUEZ. Thank you very much.

Mr. MITCHELL. Thank you. Thank you.

Mr. Space, would you like to—

Mr. SPACE.  I don’t have any—

Mr. MITCHELL. Okay. Thank you.

Thank you very much. We appreciate your testimony and hopefully you do keep on this and help us out.

Ms. MELVIN. We look forward to working with you.

Mr. MITCHELL. Thank you.

At this time we will have the second panel. And I want to welcome the second panel to the witness table. Dr. Gerald Cross is here to represent the viewpoints of the VA. Dr. Stephen Jones is here on behalf of the Department of Defense. And I welcome the opportunity to hear both sides of this issue in this setting.

Dr. Cross and Dr. Jones are accompanied by key IT and transition officers from their central offices, as well as Dr. Gordon Starkebaum and Dr. Glenn Zwinger from the Seattle VA Medical Center and Puget Sound VA Health Care System, and Lieutenant Colonel Keith Salzman from the Madigan Army Medical Center in Seattle, Washington.

There is an interesting electronic sharing process taking place in Seattle and I am eager to learn more about this program.

I would also like to welcome Lieutenant Colonel Michael Fravell. He is not representing either the views of the VA or the Department of Defense, but is here at the request of the Subcommittee to answer questions about the Joint Patient Tracking Application (JPTA). I welcome his views on this issue.

Dr. Cross, if you would. You are recognized for five minutes.



Dr. CROSS. Well, good morning, Mr. Chairman and members of the Subcommittee. Accompanying me are Charles Campbell, VHA’s Assistant Chief Officer for Health Information, Cliff Freeman, VHA’s Director of VA/DoD Health Information Technology Sharing, and behind me I have Gordon Starkebaum, Chief of Staff at the VA Puget Sound and Glenn Zwinger, Chief Officer of Information at the Puget Sound VA Medical Center.

The VA is fully committed to ongoing collaboration with DoD in the development of interoperable electronic health records. Until that is achieved, we are using technology and processes to exchange information. We, VA and DoD, share patients and we must effectively share the clinical information necessary for their care.

Now, relevant to injured service members, the starting point for the electronic transfer of clinical information from DoD to VA is in Iraq and Afghanistan. Information from that point on is entered in the Joint Patient Tracking Application, JPTA. When the patient is ready to be transferred to a VA medical center, VA staff working at the military hospital copy the record and fax it to the VA facility which prepares to receive the patient.

VA now has a version of JPTA called Veterans Tracking Application. This contains all of the information in JPTA except that information deemed sensitive to military activities. Also, DoD has begun to transform other key portions of their medical records into electronic documents that are accessible to us in our program called VistA. This reduces the number of documents that must be copied and faxed back and forth.

The patient may ultimately be cared for at several VA military facilities. The VA is increasingly using VTA, Veterans Tracking Application, to track patients through each of these steps. Let me emphasize that we do not exclusively rely on any electronic system to ensure the transfer of information. We have VA staff at military facilities working with their DoD counterparts to assist the patient and family during the transfer and to ensure the information we need is sent.

The development of information exchange systems like JPTA and VTA for tracking, the Federal Health Information Exchange, called FHIE, which is for separating servicemembers, and the Bidirectional Health Information Exchange, BHIE, for two-way exchange of information represents significant milestones VA and DoD have accomplished together. However, none of these systems by themselves are sufficient. Neither JPTA, nor FHIE, nor BHIE contain the complete set of clinical information. Work is continuing to expand the reach of these systems.

An example of this cooperation is the work done at VA’s Puget Sound Regional Center and the Madigan Army Medical Center. Once the veteran is enrolled in the VA healthcare system, all clinical information related to VA care is available at every VA medical facility. Using a secure virtual private network called VPN and a web browser, our doctors can assess a patient’s record on the Internet from anywhere. VA, through its affiliation with 107 medical schools, has already trained many of the Nation’s doctors and other providers on VA’s electronic health record system.

In addition to the electronic pathways I discussed, we are taking additional steps, including stationing VA staff at the military hospitals to ensure we have redundant capabilities. And we are adding 100 transition patient advocates and placing them across the country at VA medical centers. When seriously injured servicemembers arrive at military hospitals, the advocate closest to the patient’s home will fly to the military hospital to meet the patient and the patient’s family. The advocate will stay in contact with the patient as he or she seeks additional care and the advocate will enter information about the care received into VTA. Ultimately, the advocate will greet the patient upon arrival at their hometown VA medical center.

VA and DoD are collaborating at the highest levels to determine that progress is made toward our ultimate goal, fully interoperable electronic health records. Together, VA and DoD can lead the way toward the adoption of electronic health records throughout the Nation’s healthcare system. Indeed, VA’s VistA System was awarded the Innovations in American Government Award in July 2006 by Harvard University.

I would like to submit my written statement for the record. My colleagues and I look forward to your questions.

And, sir, we have given you two documents in addition for each of the members. One is a list of acronyms. I note we use a lot of acronyms and I apologize for that. But there are lots of acronyms. And then a simple diagram that shows how information is exchanged. And it also has some dates and numbers on there.

[The statement of Dr. Cross, along with the attachments, appears in the Appendix.]

Mr. MITCHELL. Thank you.

Dr. Jones?


Dr. JONES. Mr. Chairman, thank you very much. Members of the distinguished Subcommittee, I appreciate your inviting us here today to discuss the sharing of electronic health records between the Department of Defense and the Veterans Administration.

DoD and VA currently share a significant amount of health information data. I know you are frustrated and we are frustrated also. But we are making progress. And I guess you have heard that before, but I think in this case it is correct.

I am aware, however, of your concerns regarding the time it has taken to establish this level of sharing and recognize there is room for continued improvement. By 2008, DoD and VA will achieve all of our current health information exchange goals.

Mr. MITCHELL. Excuse me, Dr. Jones. Could you move the microphone closer—is it on? Do you see a green light there?

Dr. JONES. Yeah, I am sorry.

Mr. MITCHELL. Okay. Thank you.

Dr. JONES. No one recognizes the need for information sharing more than DoD and VA. Our ability to share information affects the quality of healthcare delivery and sometimes determines the benefits earned by veterans and servicemembers. We have to get it right. DoD and VA have the ability to enhance clinical processes and workflow through technology, and to collaborate on better processes for our deserving beneficiaries.

But digitization and automation are only the first part of the solution. DoD and VA are also prepared to collaborate on a new level for our shared patients, to create a better paradigm for care. No single organization has all the answers to these technological challenges and at DoD we are melding our expertise with the VA and other experts, both in the private and public sector.

This collaboration will continue to ensure that our systems and our partner’s systems support the continuum of care and stay ahead of the technological curve.

Dr. Chu, our Under Secretary for Personnel and Readiness and Mr. Mansfield with the VA have two top priorities; first addressing the continuity of care for returning wounded warriors, and second, modernizing our inpatient systems together through a joint acquisition development effort over the next several years.

As one who has spent many months traveling and visiting VA and DoD medical centers, including the VA’s polytrauma center, I know from personal experience that our wounded warriors are best served by our specialized care. As you know, our shared patients sometimes begin treatment at a DoD facility and transferred to a VA polytrauma center and sometimes returned to a DoD facility for necessary medical procedures. Recently, to better support the transition of care, we began sending radiology images and scanned medical records to the four VA polytrauma centers.

Today, DoD and VA providers are able to view data from each of those departments for their shared patients. The health data elements we currently share include outpatient pharmacy data, inpatient and outpatient laboratory and radiological results, allergy data, pre and post-deployment health assessments and post-deployment health reassessment.

If you have ever spent time in a hospital, you know how important a discharge summary is to your personal physician. Today, five DoD sites share electronic discharge summaries with VA and we will soon expand this capability to 13 of our largest DoD inpatient facilities.

As I said earlier, collaboration is the right thing to do and it is the only way that organizations can ensure that they take advantage of the expertise necessary to be leaders. In this spirit, we recently announced that DoD and VA will modernize our inpatient systems together through a joint acquisition development effort over the next several years.

Both departments believe the timing is right for this initiative. VA is planning to modernize the inpatient portion of its electronic health record and DoD is poised to incorporate documentation of inpatient care into a fully deployed Armed Forces Health Longitudinal Technology Application (AHLTA) electronic health record. Over the next year, DoD and VA will analyze the requirements of this convergence. Our goal is to concurrently support the needs of the clinicians of both departments and enhance continuity of care for our patients.

In addition, DoD and VA are driving forces in the national level activities to support the President’s Executive Order to require Federal agencies to use recognized health exchange standards to promote the direct exchange of health information between agencies with non-Federal entities.

Before I close, I will mention that the certification commission for health care information technology recently awarded premarket conditional certification of a version of AHLTA that will be released this fall. This certification of quality and safety is a giant step and shows that our electronic health records meet expected industry standards.

Thank you for the opportunity to appear before you today and we look forward to your questions, Mr. Chairman.

[The statement of Dr. Jones appears in the Appendix.]

Mr. MITCHELL. Thank you. I would