VA Testimony of Michael Kussman, MD before Congress on September 24, 2008

United States Department of Veterans Affairs

STATEMENT OF
THE HONORABLE MICHAEL J. KUSSMAN, MD
UNDER SECRETARY FOR HEALTH
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
SENATE COMMITTEE ON VETERANS' AFFAIRS

September 24, 2008

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, VA Deputy Chief Information Officer for Enterprise Development, and Mr. Cliff Freeman, Acting Deputy Director of the newly formed DoD/VA Interagency Program Office (IPO).

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 believe we are taking the steps necessary to meet our goals and comply with the direction provided by the National Defense Authorization Act (NDAA), Section 1635. I will address some of the issues facing VA as we work with DoD to expand our access to shared electronic medical information.

The NDAA mandates that both Departments achieve full interoperability of electronic health record capabilities and systems by September 2009. The NDAA includes the requirement to establish a DoD/VA Interagency Program Office (IPO) to oversee the development of interoperable electronic medical record systems by September 2009.

Interagency Program Office and Information Interoperability Plan

The Government Accounting Office report GAO-08-954 recommended that VA and DoD give priority to fully establishing the IPO and finalizing the implementation plan. The IPO is operational, has developed high level milestone activities, is fully engaged with the appropriate offices in VA and DoD, and is developing a detailed implementation plan to assist the Departments in meeting the NDAA data sharing goal by September 2009.

The DoD/VA Information Interoperability Plan (IIP) was recently signed and delivered to Congress. It was also released to GAO. 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 our newly formed Joint Clinical Information Board (JCIB). The JCIB is comprised of 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 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. Once prioritized and approved by the Health Executive Council, the requirements are handed off to requirements definition teams and then to our information technology teams to develop applications and tools to put these requirements into operation.

DoD and VA have seen an increase in the types of electronic data shared and the availability of tools to view this information. Now more than ever, it is critical that we inform our clinical community of our good work in this area and the availability of this information. Recent visits to some of our local facilities have shown us we can do a better job of getting out the good news about these new capabilities and training our providers on how to access this information. Both DoD and VA providers are busy with their number one priority, taking care of patients. However, it is incumbent upon us to ensure our providers are not only aware of the health care data available to them for viewing but are skilled in using the tools to obtain this data. VA is developing comprehensive communication and training strategies to remove some of these process-based barriers to using the excellent tools available to access DoD information on our patients. I will discuss the specific types of data sharing occurring in more detail below.

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 or “FHIE” has accomplished the one-way transfer of all clinically pertinent electronic information on more than 4 million separated individuals – approximately half 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 or “BHIE” to view 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.

Most recently, at the end of 2007 and in 2008, we enhanced our bidirectional exchange by adding 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 18 of the largest military treatment facilities.

Additionally, to support our most seriously injured wounded warriors, DoD is 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 and we are continuing to work to improve the presentation of this information.

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 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.

Finally, our social workers, transition patient advocates, and other military liaison staff continue to use the Veterans Tracking Application or “VTA” successfully in order 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.

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

The DoD/VA Information Interoperability Plan was developed in response to the NDAA directing the Departments to develop a single point of accountability in the rapid development and implementation of capabilities that allow for full interoperability of personal health care information. The 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 twenty-two specific initiatives that make up the pathway to information interoperability. Eleven initiatives focus on the goal of improving continuity of patient care. Five initiatives focus on the goal of improving benefits administration. Three initiatives focus on the goal of improving the information technology infrastructure, and two initiatives focus on the goal of improving population health and research. One initiative cuts across all four goals, establishing an Interagency Program Office to help ensure our efforts remain coordinated, focused, and responsive to the direction received in the NDAA.

Each initiative has a description and high level implementation timeline. While we are moving forward to flesh out the specifics for all of the initiatives, the Interagency Program Office, as specifically mandated in the NDAA, is almost completed. As discussed earlier, the Interagency Program Office is operational, functioning within its charter, and is on target to complete the few remaining implementation action items in the next few months.

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 committed to working 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. Prior to the passage of the NDAA, the Dole-Shalala Presidential Commission on Care for America’s Returning Wounded Warriors recommended the VA and DoD accelerate efforts to share data by ensuring all essential health information is viewable, bidirectional, between our providers. The departments anticipate that by the end of Fiscal Year 2008, we will meet this goal 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 JCIB 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 JCIB recommends to the DoD/VA Health Executive Council 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/disapproves the JCIB recommendations.

To attain full interoperability of electronic health record capabilities and systems by September 2009, the HEC approved the JCIB recommendation to add to the list of essential data requirements, family and social history data, and expanded types of patient questionnaires and forms. DoD has undertaken plans to pilot test a capability to scan paper documents and associate them with a specific patient so that providers are aware that the documents are available. In addition, DoD intends to implement their inpatient clinical documentation system at additional military treatment facilities in fiscal year 2009, enabling VA providers to view inpatient clinical documentation on a greater number of patients. Additional inpatient documentation such as operative notes, inpatient consultations, transfer summary notes, and inpatient history and physical reports, currently piloted in the Puget Sound area, will also be viewable by VA sites.

Under the purview of the Senior Oversight Committee or “SOC,” and in conjunction with the ongoing efforts of the DoD/VA Joint Executive Council, we are continuing to accelerate efforts to meet the immediate needs of the seriously injured transitioning to VA as a result of the current operations in theater settings. All transitioning service members will benefit from this work. Line of Action 4 under the SOC continues to focus on data sharing needs in the areas of disability evaluation, traumatic brain injury and post-traumatic stress disorder, case management, and reserve component records. 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 have expanded a pilot program to share digital radiology images bidirectionally, beyond the initial test site in El Paso, Texas, to Evans Army Community Hospital and VA Eastern Colorado Health Care System and Naval Health Clinic Great Lakes and North Chicago VA Medical Center where images are key to critical medical sharing programs. Over the next several months, we will expand this capability to additional sites including Washington D.C. VA Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center where VA providers will use DoD radiology images to conduct service disability rating examinations.

Additional work is being done to expand the excellent work done in the Puget Sound area to develop the capability to share key inpatient documentation. Another example of our ongoing efforts is the expansion of the ability to share computable health data beyond the initial seven locations listed below. 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.

William Beaumont Army Medical Center/El Paso VA Health Care System
Eisenhower Army Medical Center/Augusta VA Medical Center
Naval Hospital Pensacola/VA Gulf Coast Health Care System
Madigan Army Medical Center/VA Puget Sound Health Care System
Naval Health Clinic Great Lakes/North Chicago VA Medical Center
Naval Hospital San Diego/VA San Diego Health Care System
Mike O’Callaghan Federal Hospital/VA Southern Nevada Health Care System

VA and DoD will enhance this capability by adding computable laboratory (chemistry and hematology) results in 2009.

I am pleased to inform you that VA and DoD have received the 3^rd party study that evaluated our options for developing joint electronic inpatient capability and provided the complete report to this committee on September 19^th, 2008. As we consider the report’s recommendations for approval by the DoD/VA Joint Executive Council, we are simultaneously exploring a forward moving strategy.

Meeting the NDAA requirements

VA and DoD’s current plan to meet NDAA requirements includes leveraging existing data exchanges to support the expansion of additional data sharing capabilities. Most importantly, VA appreciates the continued support of this Committee and those at the national level, including the National Coordinator for Health Information Technology, as we work to ensure VA health care remains state of the art and that our IT tools are capable of supporting our workflow.

HealtheVet will be the foundational tool allowing us to not only deliver top quality care to our patients, but to support data sharing capabilities with DoD and eventually other health care partners that treat our veterans. A significant number of our veterans receive care from not only VA and DoD, but private providers as well. Our vision is to ensure their medical information is available wherever and whenever it is needed. To achieve this goal, we must continue developing HealtheVet and therefore, continued funding and support of this comprehensive initiative is needed.

Thank you once again for the opportunity to address this Committee and provide you with an update on the important work we are doing to improve medical record sharing with DoD. I and my colleagues will attempt to address any additional questions you might have.