VA Testimony of Roger Baker before Congress on July 14, 2009

United States Department of Veterans Affairs

STATEMENT OF
THE HONORABLE ROGER W. BAKER
ASSISTANT SECRETARY FOR INFORMATION AND TECHNOLOGY
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
HOUSE COMMITTEE ON VETERANS’ AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

July 14, 2009

Mr. Chairman, thank you for the opportunity to update you on the status of our efforts to exchange electronic medical information with our partners at the Department of Defense (DoD). This Committee has always been supportive of our efforts and I look forward to providing you the information you need. Accompanying me today are Dr. Paul Tibbits and Mr. Scott Cragg.

VA and DoD continue to work toward improving the exchange of medical information to best serve our active duty service members and Veterans who come to us for medical care. Today, we are sharing more information than ever before. Although our data exchanges are unprecedented in the scope and amount of data we share, we realize there is more work to be done and are taking the steps necessary to meet our goals and comply with Section 1635 of the National Defense Authorization Act (NDAA). I will address some of our recent successes, as well as some of the issues facing VA, as we work with DoD to expand our access to shared electronic medical information.

I think you will agree that the current level of data sharing between VA facilities and between VA and DoD facilities is without equal anywhere else in the country. VA’s award-winning electronic medical record system, VistA, is recognized world-wide as a model for integrated health information technology systems. Developed by VA from a clinical perspective, VistA is successfully deployed and used by administrative and clinical staff working in more than 1,200 VA medical centers, clinics, and nursing homes across the country. VA hospitals using VistA are one of only three hospital systems that have achieved the qualifications for the Healthcare Information and Management Systems Society (HIMSS) stage 7, the highest level of electronic health record integration, while a non-VA hospital using VistA – the Midland Memorial Hospital in Midland, TX – is one of only 42 U.S. hospitals that have achieved HIMSS stage 6. VistA was awarded the prestigious Innovations in American Government Award by Harvard University’s Ash Institute for its estimated annual efficiency improvement rate of 6 percent. One of the key modules facilitating VistA’s information availability,

My HealtheVet, is the recipient of numerous government and industry accolades, including the CIO 100 award and first place in the 2009 TEPR (Towards the Electronic Patient Record) personal health record competition. Open-source versions of VistA are widely deployed in private health systems, public hospitals, and medical offices in the US and overseas.

The NDAA mandates that both Departments achieve full interoperability of electronic health record capabilities and systems by September 2009. The NDAA also includes the requirement to establish the DoD/VA Interagency Program Office (IPO), which today provides vital coordinating linkages as envisioned by the NDAA legislation.

Information Interoperability Plan

The DoD/VA information interoperability plan (IIP) continues to serve as our interoperability roadmap. The IIP describes the current state of electronic data sharing between the Departments and identifies the gaps that must be addressed to achieve the level of information interoperability necessary to support the clinical and benefits needs of our Veterans and members of the Armed Forces. The IIP provides the strategic organizing framework for current and future work and establishes the scope and milestones necessary to measure progress toward intermediate and long term goals.

The IIP also emphasizes leveraging our existing data exchanges through which we already share almost all essential health information in viewable format. By September 2009 we will enhance the existing data exchanges to share those additional types of information identified and prioritized by the Interagency Clinical Information Board (ICIB). The ICIB comprises clinicians from both DoD and VA. It is responsible for identifying and prioritizing the types and format of electronic medical information that needs to be shared by DoD and VA, to care for our patients. This group ensures that our data sharing is focused on needs identified and prioritized by clinicians for clinicians. Thus, we have used our clinician community to define for us those high priority items that must be shared by September 2009.

I will now discuss the specific types of data sharing occurring in more detail.

Exchange of electronic medical information

VA and DoD are successfully sharing electronic medical information on separated service members and shared patients, who come to both VA and DoD for care and benefits. Since 2001, the Federal Health Information Exchange (FHIE) has accomplished the one-way transfer of all clinically pertinent electronic information on more than 4.8 million separated individuals – approximately 3.3 million of these individuals have come to VA for health care or benefits as Veterans. In addition to FHIE, VA and DoD clinicians are using the Bidirectional Health Information Exchange (BHIE) to view current medical data on shared patients, including Veterans, active duty personnel, and their dependents from every VA and DoD facility. Today, VA and DoD continue to share bidirectional viewable outpatient pharmacy data, allergy information, inpatient and outpatient laboratory results (including chemistry, hematology, microbiology, surgical pathology, and cytology), inpatient and outpatient radiology reports, ambulatory progress notes, procedures, and problem lists.

Our most recent enhancements in bidirectional exchange added vital sign data (including blood pressure, heart rate, respiratory rate, temperature, height, weight, oxygen saturation, pain severity, and head circumference) from all VA and DoD facilities, DoD Theater clinical data (including inpatient notes, outpatient encounters, and ancillary clinical data such as pharmacy data, allergies, laboratory results, and radiology reports), and inpatient discharge summaries from DoD’s largest military treatment facilities, representing more than 55 percent of total DoD inpatient beds.

DoD and VA continue to improve our efficiency in transferring digital radiological images and scanned inpatient information for every patient being transferred from Walter Reed and Brooke Army Medical Centers and Bethesda National Naval Medical Center, to one of our four polytrauma centers in Richmond, Tampa, Palo Alto, and Minneapolis. Our polytrauma doctors find this information invaluable for treating our most seriously injured patients.

In addition to the viewable text and scanned information we receive and share with DoD, VA and DoD are sharing computable allergy and pharmacy information on patients who use both health care systems. The benefit of sharing computable data is that each system can use information from the other system to conduct automatic checks for drug interactions and allergies. In VA, we have implemented this capability at seven of our most active locations where patients simultaneously receive care from both VA and DoD facilities. Once a patient is “turned on” with this capability, his or her pharmacy and allergy information is computable enterprise-wide in DoD and VA and available for this automatic clinical decision support.

Our social workers, transition patient advocates, and other military liaison staff continue to successfully use the Veterans Tracking Application (VTA) to improve the coordination of care for patients transitioning from DoD to VA. VTA provides our staff with key patient tracking and patient coordination information on a near real-time basis.

Finally, VA and DoD are dedicated to ensuring that transitioning service members receive the benefits they have earned in a timely manner. The information critical to the provision of benefits is obtained through the one VA/DoD data sharing initiative, which consolidates the transfer of data between DoD and VA and will eventually eliminate the need for paper copies of DD-214s. The Defense Enrollment Eligibility Reporting System (DEERS) supports that transfer, and the VA Defense Information Repository (VADIR), serves as the secure and authoritative database for a service member’s demographic, personal identity information, and military history. This longitudinal electronic eligibility record can be used by all VA entities to administer benefits and care for a transitioning service member.

Details of the DoD/VA Information Interoperability Plan (IIP)

The DoD/VA IIP provides a roadmap to guide our Departments’ information technology investment decisions and establish a shared understanding of interoperability principles, practices, enablers, and barriers.

The IIP is a living document whose ultimate purpose is to identify and address the information needed by the Departments to improve continuity of care and benefits administration for our nation’s service members, Veterans, and their beneficiaries. To that end, the plan aligns our goals with 22 specific initiatives that make up the pathway to information interoperability.

In addition to identifying those actions necessary to achieve inter-Departmental interoperability, the IIP also identifies the barriers to success that need to be overcome. These barriers include concerns about data standardization and quality, information privacy and confidentiality, the investment cost to implement the initiatives, and the investment cost to upgrade legacy systems and infrastructure.

Interoperability by September 30, 2009

VA is working closely with our DoD partners to implement the provisions of the NDAA requiring interoperability by September 2009. Our main commitment is to ensure doctors and health care staff from both Departments have the information they need from each other to treat our common patients. This is not to say all electronic medical data will be shared; only to emphasize that everything deemed essential by our clinicians will be shared.

With respect to the September 2009 target, the ICIB plays a key role by determining, from a clinical perspective, the categories and priorities of clinical information that must be shared to most effectively treat our beneficiaries and meet the NDAA requirements. The ICIB recommends to the DoD/VA Health Executive Council (HEC) the types and format of health information that is necessary to provide top quality, effective care to shared patients, wounded warriors coming to us for treatment and rehabilitation, and Veterans transitioning to VA for care and benefits. The HEC approves or disapproves the ICIB recommendations.

To attain the interoperability of electronic health record capabilities and systems recommended by the ICIB by September 2009, the HEC approved six ICIB recommendations. Working collaboratively with DoD, three of these recommendations are already complete (share refined social history data, expand sharing of questionnaires/self assessment tools, and share information to support separation physical exams). A fourth recommendation to establish trusted network gateways is well underway. DoD and VA have approved implementing four enterprise gateways and up to five Federal health care center (FHCC) gateways. The focus of these gateways is to support VA/DoD general purpose health data traffic (i.e., CHDR, LDSI, FHIE/BHIE, imaging). All four enterprise gateways are operational, as is the FHCC gateway supporting the Captain James A. Lovell FHCC (North Chicago).

A fifth recommendation, document scanning, is also well underway. DoD has piloted the capability to scan paper documents and associate them with a specific patient so that providers are aware that the documents are available. Interagency testing of this pilot capability is on schedule for September 2009. The sixth initiative focuses on DoD’s expansion of their inpatient electronic medical record system.

Under the purview of the Senior Oversight Committee (SOC) and in conjunction with the ongoing efforts of the DoD/VA Joint Executive Council (JEC), we are continuing our efforts to meet the immediate needs of seriously injured service members transitioning to VA as a result of the current operations in theater settings. All transitioning service members will benefit from this work. Toward this end, VA and DoD, working with the IPO, are continuing to define information and technology requirements to support disability evaluation, assessment, and documentation of traumatic brain injury and post-traumatic stress disorders, case management tools, and automated solutions for reserve component records. Additionally, work continues on development of the eBenefits portal that will support unified and secure Web access to benefits and services that support wounded warriors. The SOC has been instrumental in defining requirements and implementing acquisition activities to support these key critical business needs.

Despite these accomplishments, we realize our work is not done and continue to expand the types of electronic medical data we share. For example, we are now sharing digital radiology images bidirectionally beyond the initial test site in El Paso, Texas. This capability is now available at several sites, including the Washington, DC, VA Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center, where VA providers now use DoD radiology images to conduct service disability rating examinations.

Another example of our ongoing efforts is the enhancement of our ability to share computable health information. The capability enabling the exchange of computable outpatient pharmacy and medication allergy data for shared patients was made available to all DoD sites in December 2007.

VA and DoD will enhance this capability by adding computable laboratory (chemistry and hematology) results in the summer of 2010.

The Path to Information Interoperability in the Future

To date, VA and DoD information interoperability successes have focused on developing a suite of applications that facilitate exchanging patient information between the two Department’s individual electronic medical record systems. However, on April 9, 2009, the President, along with Secretary Shineski and Secretary Gates, announced that VA and DoD have taken steps towards creating a joint Virtual Lifetime Electronic Record (VLER). The VLER will permit information vital to health care, benefits, and services, to be available seamlessly to both Departments from the moment a service member enters into the military until the service member’s or Veteran’s death. The potential benefits of the VLER are many and planning, creating, and implementing the VLER will be a challenging endeavor. VA and DoD are working together on an overall strategy to achieve the President’s VLER vision and jointly developing an effective governance model.

Concurrent with the VLER effort, VA continues to develop HealtheVet as our foundational tool, to deliver top quality health care to our patients and share important medical information with DoD and eventually, other health care partners that treat our Veterans. VA appreciates this Committee‘s past support of this project and its continued funding, which is vital to our success.

In closing, I would like to thank you again for your continued support and the opportunity to testify before this Subcommittee on the important work we are undertaking to improve medical record sharing between the VA and DoD. I would now like to address any questions you might have.