Mr. James Neighbors
Chairman Runyan, Ranking Member McNerney, and Members of the Subcommittee, thank you for the opportunity to appear before you today to discuss Department of Defense (DoD) efforts to ensure military health, personnel, and other records are properly and efficiently maintained and shared with the Department of Veterans Affairs (VA) in a timely and effective manner. In this testimony, I will cover how DoD captures and transfers to the VA, Medical and Personnel records for Active and Reserve Component Service members while in deployed or in garrison status. DoD leadership is keenly aware of the importance of military records as they pertain to the VA disability claims process. Improving the system for which our Service members and Veterans receive their well-deserved and earned benefits is a top priority of both departments.
Overview of Policy and Procedures Governing the Life Cycle of Medical Records
Medical and dental records of all Service members, Active Duty, Reserve, and National Guard, are created when a person enters military service at the Military Services’ Reception/Training Centers using the Applicant’s Record Packets. An Applicant Record Packet contains an entrance physical examination, vaccination records, adult preventive and chronic care flow-sheet, and associated chronological medical and dental care documentation. The information is then transferred to the Medical Treatment Facilities (MTF) and Dental Treatment Facilities (DTF) at the Service member’s first Permanent Duty Station. If the Service member is affiliated with a Reserve or National Guard unit, the records are transferred to the applicable Reserve or Guard units.
Maintenance of DoD Service Member Medical and Dental Records
Medical and dental records are maintained at the MTF and DTF at the Active Duty Service member’s base location, and consistently transferred with the Service member as he or she moves to a new military installation throughout his or her career. All Reserve and National Guard members’ applicable medical and dental records are maintained at their assigned unit location and will remain there until the member transfers to a different unit.
When Service members are deployed in combat supporting contingency operations overseas, medical and dental records are additionally maintained at the forward operating base aid station or clinic. When the Service member’s deployment has completed, all records transfer back to the home station MTF and DTF, or to the servicing Reserve/Guard units for members of the Reserve and National Guard.
As Service members out-process for transition or retirement, the MTF and DTF where the Service member is stationed conducts a review that includes known combat records and outpatient records, for completeness.
Capturing Care Delivered in Garrison and Theater
Implemented worldwide in 2006, the Armed Forces Health Longitudinal Technology Application (AHLTA) is the current DoD electronic Health Record system. This electronic health record captures and stores structured data in the AHLTA Central Data Repository (CDR), giving health care providers worldwide, secure, around-the-clock access to electronic health information to support DoD’s highly mobile Service members and beneficiaries. Records in the AHLTA CDR are retrievable at nearly 900 fixed and deployed medical and dental treatment facilities. The Theater Medical Information Program-Joint (TMIP-J) is an integrated suite of software solutions that includes AHLTA-Theater (AHLTA-T) and supports military readiness and health care quality with a modular, scalable version of AHLTA to operate in low to no communications environments such as in theater and aboard ship. AHLTA-T captures outpatient encounter records in theater and transfers them to the CDR. The information in the AHLTA CDR is available to VA immediately through a data feed known as the Bi-directional Health Information Exchange (BHIE).
Active Component Personnel Records
Active Component Service members’ official personnel records are managed separately from medical and dental records. Personnel data VA requires to adjudicate benefits claims, with some exceptions, is contained on the paper DD Form 214 (Certificate of Release or Discharge from Active Duty), which the Service member receives upon separation from the Service. The Military Departments routinely provide this same personnel data to the Defense Manpower Data Center (DMDC). DoD also provides this information electronically to a VA repository known as the VA DoD Identity Repository, commonly referred to as VADIR.
Prior to the mid-1990s, a Service member’s Official Military Personnel File (OMPF) was mailed to the National Personnel Records Center (NPRC) in St. Louis, Missouri when he or she left military service. These OMPF records are still maintained by the National Archives and Records Administration (NARA) and are currently available for VA through the NPRC. VA routinely accesses these records, and DoD maintains financial responsibility for servicing and storing them.
Since the mid-1990s, the Services have scanned paper records of the OMPF and store them as images in Service-specific digital record management systems. Since 2002, DoD has provided VA with access to Service-specific personnel records using the Defense Personnel Records Information Retrieval System (DPRIS). Starting in 2007, DPRIS has been available to VA claims adjudicators in a secure, web-based application.
Reserve Components Personnel Records
DoD maintains, for the most part, separate personnel data systems for our Reserve Components, but with the same goals – to leverage electronic data capabilities and afford access to VA. The Reserve Components Common Personnel Data System (RCCPDS) forms the basis for official strength accounting, an authoritative source of identity information for identification card issuance, and personnel information for the identification of eligibility for federal benefits and entitlements. Each Reserve Component (RC) reports personnel data for a specific purpose in a licensed DoD reporting requirement. DMDC specifies procedures to collect, manage, and maintain this personnel data and in addition maintains a bi-directional interface with the VA for the management of this data.
The personnel systems of the Military Services remain the systems of record, and the Services have responsibility to maintain the complete military record for each Service member. RCCPDS is an information source, through electronic reporting, to satisfy VA’s information needs. The RC Active Service Transaction File, for example, provides a key source for the electronic information contained on the DD Form 214 for RC Service members, such as periods of active duty, and the characterization of service.
Other Personnel Administrative data
DoD captures other personnel administrative data which VA requires to adjudicate benefits for Active, Reserve and Guard Service members in the Defense Enrollment Eligibility Reporting System (DEERS). DEERS is a series of databases that provide timely and accurate information on benefits and entitlements prescribed in DoD policy and published instructions. DEERS serves as the definitive centralized source of identity, enrollment into TRICARE, and eligibility verification for members of the Uniformed Services, other designated personnel, and their eligible family members. In addition, DEERS provides statistical and demographic information to support the DoD Components and serves as the National Enrollment Database for the Military Health System (MHS) benefits eligibility and TRICARE enrollments for medical care services. DMDC has shared DEERS data electronically with VA since November 2000. It is currently transmitted to VA’s VADIR system mentioned earlier.
Deployed unit location accountability
With respect to the Department’s ability to identify and account for locations and records of units deployed to Iraq and Afghanistan, we have applied lessons learned from previous conflicts and have greatly enhanced our capability in this area to include the following:
The Joint Services Records Research Center (JSRRC) provides unit information/deck logs to VA for Post-Traumatic Stress Disorder (PTSD) via DPRIS. JSRRC has responded to Veterans’ claims and initiatives since 1980 and conducts PTSD claims research. The DoD Persian Gulf Registry, for which the Army is the Executive Agent, is a database that contains the names of 758,000 personnel and more than 900,000 daily locations of units to which these personnel were assigned while in the Persian Gulf.
Unit Location and Environmental Hazards
DoD recognizes the importance of linking environmental hazard data and unit locations and works closely with the VA to provide exposure data to adjudicate disability claims as required. Since the 1991 Gulf War DoD has implemented programs and policies to better address the health protection of deployed Services members for both acute and latent/chronic health conditions that may result from environmental health hazard exposures. Occupational and environmental health assessments are conducted at deployed camps soon after they are established to document baseline monitoring of the air, water, and soil for hazardous agents. In addition, annual occupational and environmental monitoring summaries are completed at major deployment locations to identify any changes in occupational and environmental health exposure risks and associated health implications. Exposures of concern are promptly investigated and if there is a likelihood of latent/chronic health effects, special medical surveillance programs are established, such as in response to the chromium exposures at the Qarmat Ali Industrial Water Treatment Plant in Iraq. When appropriate, exposure registries are created for a specific event, as we did in response to the Operation Tomodachi Fukushima Nuclear Power Station accident in Spring 2011.
DoD continues to improve systems and processes that document exposures during deployments and we are working on an Individual Longitudinal Exposure Record (ILER) concept, a joint DoD/VA initiative to create a complete record of Service members’ exposures over the course of their careers. ILER will create exposure registries based on location, date, time, and exposure agent, which will support contemporary benefits claims as well as retrospective studies. This concept will assist Service members and veterans in showing that their disabilities were caused by their service. Exposure alone does not always lead to illness or injury; VA relies on scientific evidence to determine when there is a link between exposure to environmental hazards and specific illnesses or injuries that would make Service members or veterans eligible for VA disability benefits.
Transfer of Records to VA
It is DoD policy to transfer medical and dental records to VA when a Service member leaves Active Duty due to retirement or discharge. We currently transfer personnel and medical records data to VA for over 300,000 Service members annually both in paper and the majority via electronic interface.
MTFs and DTFs provide the Service member’s complete dental records to the appropriate Military Service Personnel Out-Processing Centers within 30 business days of member’s retirement or discharge. TRICARE (i.e. military) and civilian doctors’ consultation results documentation are included in the Service member’s medical record jacket. The Military Service Personnel Out-Processing Centers (or a designated equivalent entity by the Service) then transfers the medical and dental records and a paper copy of the DD Form 214 to VA.
DoD provides the data contained on the DD Form 214 electronically to VA within 7 days of the Service member’s retirement or discharge to use in the benefits adjudication process. The DD Form 214 is an official source of information needed to demonstrate eligibility for Veterans benefits administered by VA, state and local governments. The “remarks” section contains a number of additional entries, such as confirmation that a first term of enlistment had been completed, whether the Veteran is subject to recall or annual screening, and dates of contingency operation participation. DoD policy requires two paper copies of the DD Form 214 to be physically delivered to the separating Service member upon transition from the Service. If the Service member is not available at separation, these copies are mailed to him or her. The separating member may also elect to have a copy mailed to the state office of Veterans Affairs where he or she will reside.
Sharing Health Data to Ensure Continuity of Care
Current exchanges of health care information support continuity of care for wounded and injured Service members by enabling:
· Transmission of electronic historical information at the time of separation;
· Access to electronic health information for both VA and MHS patients by both DoD and VA;
· Sharing of computable outpatient pharmacy and medication allergy data on shared patients; and the
· Availability of radiology images and scanned medical records at VA Polytrauma Rehabilitation Centers to support continuity of care for our most severely wounded and injured Service members.
The DoD/VA Bidirectional Health Information Exchange (BHIE) initiative is an inpatient and outpatient health data sharing capability. DoD affords VA clinicians and benefits claims specialists with access to health data on more than 4.6 million patients. DoD and VA clinicians currently access each other’s health data in real time, for information pertaining to: allergy, outpatient pharmacy, inpatient and outpatient laboratory and radiology reports, demographic data, diagnoses, procedures, vital signs, problem lists, family history, social history, other history, questionnaires, outpatient encounters, periodic health assessments, and theater clinical data, including inpatient notes, outpatient encounters, and ancillary clinical data (such as pharmacy data, allergies, laboratory results, and radiology reports). BHIE also provides bi-directional access to inpatient notes (including discharge summaries, inpatient consultations, operative reports, history and physical reports, transfer summary notes, initial evaluation notes, procedure notes, evaluation and management notes, pre-operative evaluation notes, and post-operative evaluation and management notes) from DoD’s inpatient documentation system.
Moving Toward a Joint Integrated Electronic Health Record
DoD and VA recognize access to the other Departments’ health records is a necessary capability to provide a “single system experience of lifetime services”. As we move forward in this effort, we are also continuing to improve the current systems and processes serving our transitioning Service members and Veterans. We are working collaboratively with VA to develop and implement an interim electronic data sharing solution that will feature shared access to electronic medical records. In January 2011, the VA-DoD Benefits Executive Committee approved a recommendation from the Medical Records Working Group to leverage ongoing work in the Military Health System in conjunction with the Veterans Health Administration to develop and deploy a scanning solution known as the Health Artifacts and Image Management Solution (HAIMS), a secure web-based technology solution. DoD has incorporated Veterans Benefits Administration’s (VBA) known Information Technology requirements into the current version of HAIMS, which is in testing and on track for accelerated deployment by September 2013. All loose paper medical documentation will be scanned into HAIMS allowing VBA claims adjudicators direct access to scanned medical data in the HAIMS repository or access to the information via an interface between VBA’s internal systems. Although DoD Service Treatment Records remain a hybrid of paper and electronic records, approximately 60 percent of the DoD health information is available electronically and only 40 percent paper bound, HAIMs will greatly increase the percentage of electronically available health information. Currently VBA personnel can access DoD health data electronically through an electronic data exchange.
DoD and VA are currently planning the development and acquisition of a joint integrated Electronic Health Record (iEHR) to replace legacy DoD and VA EHRs. The iEHR will unify the two Departments’ EHR systems into a common system that will ensure DoD and VA health facilities have Service members’ and Veterans’ health information available throughout their lifetime. By implementing a single, common health record for DoD and VA medical facilities, the iEHR will ensure information about injuries and illnesses incurred during military service remain available for health and benefits purposes throughout a person’s lifetime, supporting patient safety and continuity of care and facilitating access to and delivery of benefits. Seamless information sharing is expected to support the expedient processing of disability claims in the future.
The joint iEHR will be deployed in increments based on prioritized functional community needs, technical feasibility, and financial viability. The initial iEHR capabilities, laboratory and immunizations, will be delivered to two sites (San Antonio, Texas and Hampton Roads, Virginia) by the end of 2014. The capabilities of the iEHR will be increased incrementally through the end of 2017.
Virtual Lifetime Electronic Record (VLER)
Virtual Lifetime Electronic Record (VLER) is a joint initiative which will ultimately allow Service members’ and Veterans’ electronic administrative and personnel information to be shared seamlessly among DoD, VA, and other appropriate federal and private sector healthcare providers. VLER is a broad, multifaceted, business and technology initiative that leverages existing DoD and VA investments by synchronizing information sharing across multiple agencies. It includes a portfolio of health, benefits, personnel and administrative sharing capabilities. When fully implemented, it will establish a relationship with Service members and Veterans that begins the day they enter Military service, and maintains that relationship throughout their lifetime, proactively providing them with benefits and services. The VLER Health Initiative supports the portability and accessibility of Service members’ and Veterans’ electronic health information between VA, DoD, and other federal and non-federal exchange partners for the purpose of health care delivery. To date, the VLER Health initiative has focused on the exchange of medical information for health care services among DoD, VA, and private sector providers at joint pilot site locations. Through these VLER Health pilots, DoD, VA, and private partners successfully leveraged the Nationwide Health Information Network to exchange an initial set of clinical information needed for health care delivery through four initial pilots in the San Diego, California; Tidewater, Virginia; Spokane, Washington; and Puget Sound, Washington regions.
VLER Health is exploring additional innovative technology, such as the Office of the National Coordinator for Health Information Technology Direct Project, a Health Information Portability and Accountability Act-compliant electronic health information exchange over the Internet through secure email. Direct Project provides an affordable approach to health information-sharing among DoD, VA, and private sector providers, which is intended to increase adoption of EHRs throughout the health industry. Specifically, it will provide a mechanism for including private provider medical reports into the DoD and VA EHRs or the joint DoD/VA integrated EHR (iEHR).
TheVLER Benefits initiative supports the portability and accessibility of Service members’ and veterans’ electronic health and administrative information among DoD, VA, and other appropriate federal exchange partners for the purpose of benefits determination and delivery. This will ultimately result in standardized delivery of health information to VA benefits adjudicators, decreasing processing time and more efficiently supporting our Nation’s wounded warriors and other transitioning Service members.
A key feature of VLER Benefits is the development of a DoD Self-Service (DS) Logon. To date, DS Logon has provided more than 2 million Service members and veterans with a log-on ID which allows them access to the eBenefits portal to view their personal data. The eBenefits portal provides Service members and veterans with more than 40 self-service features, such as the ability to apply and track application for Loan Guaranty Certificate of Eligibility and Veterans Retraining Assistance Program.
To further understand the issue surrounding our journey to a paperless future, we are conducting monthly DoD/VA Data Sharing Summits to bring Senior Executive-level DoD and VA stakeholders together to one forum to discuss the health and administrative information sharing processes and obtain resolution to known issues. This forum establishes DoD/VA information sharing priorities and tracks progress against identified activities. There are also regular meetings with interagency partners and internal DoD agencies, such as Social Security Administration and the Office of the Assistant Secretary of Defense for Health Affairs, to collaborate on information exchange efforts and resolve identified obstacles.
The Department of Defense is committed to a future that eliminates reliance on paper-based record keeping and the warehouses that support it. DoD is also committed to developing the capability to provide VA with requisite information to facilitate a single system experience of lifetime services. As we move toward electronic exchange of information in real time, it is giving DoD and VA the added benefit of improving inter-agency processes based on information requirements, unencumbered by legacy forms or manual, paper-based exchange of information.