Prepared Statement

of

Dr. S. Ward Casscells
Assistant Secretary of Defense (Health Affairs)
and
Mr. Charles Campbell
Military Health System, Chief Information Officer

Before the

U.S. Senate Committee on Veterans Affairs

September 24, 2008
 

INTRODUCTION
 Mr. Chairman and members of this distinguished committee, thank you for this opportunity to discuss the sharing of electronic health care information between the Department of Defense (DoD) and Department of Veterans Affairs (VA).  We continue to make great strides in sharing electronic health care information - and have plans to do even more in the near future.
 Cooperation between DoD and VA in the area of health care information sharing is vital for effective management and efficient delivery of programs and benefits that our Nation's Veterans and Service members deserve.  DoD recognizes Congressional concerns regarding the time it has taken the two Departments to establish the current level of interoperability.  Let me assure you that DoD and VA share the ultimate goals of this and other Congressional bodies seeking to address the needs of the Nation's heroes.  We have been working together in earnest and have made significant progress in sharing electronic health care information since our first efforts in 2001.  Today, I would like to provide a historical overview of our joint efforts, outline some of the initiatives that form the foundation for sharing efforts moving forward, offer some details regarding the draft DoD/VA Information Interoperability Plan, and discuss some other steps we have taken to accelerate initiatives to lead us to "full interoperability of personal health care information" by September 30, 2009, as mandated in section 1635 of the National Defense Authorization Act for Fiscal Year 2008. 

HISTORICAL OVERVIEW
 DoD and VA began laying the foundation for interoperability in 2001 when our Departments first shared health care information electronically, and we have continually enhanced and expanded the types of information we share as well as the ways in which we share.  At times it has not been an easy road, and there is always room for improvement in an effort as large and as crucial as this one.  Nonetheless, DoD and VA have come a long way in the areas of health information technology, interoperability standards, and health care information sharing.  By working together at the top levels of DoD and VA, we have established policies that enable each Department to address its unique requirements while also addressing requirements that we share.  We have now taken this coordination and cooperation to new levels with oversight and governing bodies formed to ensure that our sharing efforts continue to move in the right direction at a pace that meets and, we hope, exceeds the expectations and needs of all our stakeholders. 

THE FOUNDATION FOR INTEROPERABILITY
 The foundation of current and future health care information sharing includes initiatives that have enhanced continuity of care for our patients, enabled our providers at the point of care to view health care information originating in the other Department's electronic health record, and even provided real-time safety checks and alerts at some sites.
Continuity of Care for Shared Patients.  For patients treated at both VA and DoD facilities, providers can view electronic health data from both Departments.  The Departments anticipate the addition of family history and social history by the end of fiscal year 2008, all "essential" health data, as determined by a team of DoD and VA health care providers, will be immediately viewable by clinicians, at a DoD or VA facility as called for by the President's Commission on Care for America's Returning Wounded Warriors.  Health data accessible by DoD and VA providers includes allergy information, outpatient medications, inpatient and outpatient laboratory results, radiology reports, demographic details, clinical notes, procedures, problem lists, and vital signs.  In addition to those typical bits of health care information, DoD and VA exchange Pre- and Post-Deployment Health Assessments and Post-Deployment Health Reassessments as well as vital clinical data captured in the Theater of operations.  Health care information from Theater includes inpatient notes, outpatient encounters, and ancillary clinical data, such as pharmacy data, allergies, laboratory results, and radiology reports.  Exchanging this Theater clinical information is a significant accomplishment in our efforts to enhance continuity of care for Service members returning from Iraq, Afghanistan, Kuwait, and other forward locations. 
DoD also now has an inpatient documentation system in use at 20 of its inpatient facilities, accounting for more than half of our inpatient beds, with plans to expand use of the current system to additional facilities in the next year.  This capability is now in place at Landstuhl Regional Medical Center, which, as the primary receiving location for patients coming out of Theater, is a critical link in the electronic health care information chain. 
Drug-Drug and Drug-Allergy Interaction Checking.  Beyond having viewable data available, DoD and VA are also exchanging some data at the highest, most complex level of interoperability.  Outpatient pharmacy and drug allergy data are now available in a standardized format for patients receiving treatment from both DoD and VA.  This standardization enables our information systems to run vital safety checks.  Drug-drug interaction and drug-allergy checks can now be run using data from both Departments, further enhancing patient safety.  Currently, this capability is operational in the following seven locations:

• 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; and
• Mike O'Callaghan Federal Hospital/VA Southern Nevada Health Care System.

For this capability to work properly, the individual must have a record in the Defense Manpower Data Center/Defense Enrollment and Eligibility Reporting System (DEERS).  More than 6 million veterans, primarily those who separated from Service prior to the establishment of DEERS, were added to the DEERS database this year.  With that completed, DoD sent instructions that allow any DoD site to now utilize this capability of dug-drug and drug-allergy interaction checking.  In addition, all DoD and VA facilities - not just those listed above - have access to the shared DoD and VA pharmacy and allergy data for a patient if that patient should present to their facility for care.  To further expand the use of this functionality, DoD will begin implementation of an automated process for identifying patients receiving care at both DoD and VA so manual intervention for this level of data exchange is no longer necessary.
Continuity of Care for Polytrauma Patients (Wounded Warriors).  In response to the urgent need for VA providers at Polytrauma Centers to have as much information as possible on inpatients transferring to their care, DoD sends electronic health care information directly to the Polytrauma Centers.  When providers determine that a severely wounded, injured, or ill patient should be transferred to a VA Polytrauma Center for care, DoD sends radiology images and scanned paper medical records electronically to the receiving facility.  This effort began in March 2007 with a pilot project, sharing information from one DoD facility to one VA Polytrauma Center, and quickly expanded to include the three primary DoD facilities treating incoming severely wounded warriors-Walter Reed Army Medical Center, National Naval Medical Center, and Brooke Army Medical Center-and the four level 1 VA Polytrauma Centers-Tampa, Richmond, Palo Alto, and Minneapolis. 
Separated Service Members (Potential VA Patients).  More than 4 million former Service members eligible for VA health care now have electronic health care information accessible to their new provider should they seek care at a VA facility.  In 2001, DoD transmitted electronic health care information for Service members who had separated since 1989.  Monthly transfers of health care information for newly separated Service members began in 2002 and continue today.  Historical electronic health care information available to VA providers includes the following data elements:

• Outpatient pharmacy data, laboratory and radiology results;
• Inpatient laboratory and radiology results;
• Allergy data;
• Consult reports;
• Admission, disposition, transfer data;
• Standard ambulatory data record elements (including diagnosis and treating physician);
• Pre- and post-deployment health assessments; and
• Post-deployment health reassessments.

When the former Service member presents to VA for care or evaluation, the VA provider  can access this information from within the VA electronic health record.
NATIONAL DEFENSE AUTHORIZATION ACT FOR FISCAL YEAR 2008
 DoD and VA have worked hard to implement, enhance, and expand health care information sharing initiatives to support all of our beneficiaries since we first started sharing data in 2001.  In the past couple of years, with evolving needs and technological advances, we have accelerated our collaborative efforts.  Although DoD and VA both want to do whatever necessary to provide our beneficiaries with the best possible care, our Departments and our beneficiaries have benefited from much-needed Congressional guidance and direction.  We are grateful for your devotion to our beneficiaries, the Nation's heroes, and your assistance in helping us find ways to enhance the care we can offer them.  To that end, the National Defense Authorization Act for Fiscal Year 2008 has set a timeframe for reaching the goal of full information interoperability.  The Act specifically calls for the establishment of a DoD/VA Interagency Program Office whose function "shall be to implement, by not later than September 30, 2009, electronic health record systems or capabilities that allow for full interoperability of personal health care information."  To meet this deadline, DoD and VA have taken a number of key steps that will help us further accelerate our efforts to achieve interoperability, including drafting an Information Interoperability Plan. 

 

DOD/VA INFORMATION INTEROPERABILITY PLAN
 The DoD/VA Information Interoperability Plan serves as the strategic organizing framework for current and future information technology projects and information needs.  The purpose of the Information Interoperability Plan is to guide DoD and VA leadership, policy makers, and information management and technology personnel in achieving the shared vision for DoD and VA health, personnel, and benefits information interoperability.  The Plan discusses issues and opportunities for interoperability: what it involves, why we should care about it, and how it can be achieved.  It explains the benefits for stakeholders; identifies the main issues that lie on the road to achievement; and provides an initiative-focused, problem-oriented, phased implementation schedule, though not all initiatives described in the Plan are funded.  The Information Interoperability Plan specifically seeks to accomplish the following objectives:

• Define VA and DoD strategic interoperability maturation and organizing framework;
• Map the current and future health, administrative, and benefit information sharing through a problem-oriented approach to establish an interoperability roadmap;
• Identify information capability gaps to guide future investment portfolio decisions and prioritization of initiatives and influence information technology design solutions;
• Set milestones to measure progress of near-, mid-, and long-term interoperability goals; and
• Leverage the national standardization activities led by the Department of Health and Human Services to foster health care information sharing with the private sector.

To realize our shared vision of information interoperability, the two Departments will leverage our current, robust information sharing programs and infrastructure to close remaining gaps in information coverage.  We will expand upon existing initiatives and incrementally implement greater capabilities as determined by the health, benefits, and personnel communities and as technology advances.  Wherever possible, our solutions will leverage harmonized interoperability standards recognized by the Secretary of Health and Human Services in an effort to ensure we do not create a sharing solution that will work between the DoD and VA but not with our private sector partners and other federal agencies.  The initiatives outlined in the Plan address the following constraints relating to the implementation of interoperable systems between DoD and VA:

• Incompatible legacy computing and communications infrastructure;
• Lack of a robust, joint architecture facilitating interagency data sharing;
• Existing data in unstructured formats difficult to discover and access;
• Undefined standards and maturing standards that are neither implemented nor robust;
• Large amounts of existing data with limited documentation and non-standardized access mechanisms;
• Workforce insufficiently trained regarding available information;
• Shared information often not effectively integrated into the workflow of clinicians and administrators;
• Different levels of policy and governance that vary based on organizational culture;
• Resource availability, both manpower and dollars;
• Contracting and acquisition policies and vehicles; and
• Industry and market place divergence.

In establishing this first version of the Information Interoperability Plan, the two Departments agreed to goals that fall in four main categories:  continuity of care, benefits, infrastructure, and population health and research.  Each of the 23 interoperability initiatives detailed in the Plan aligns with one of these four categories as shown in the following table.
Initiatives to Achieve Our Shared Vision
Image Sharing
Inpatient Electronic Health Information
Reserve Component Access to Electronic Health Information
Enhancements to Health Information Exchange between Clinical Information Systems
Clinical Case Management
Psychological Health Treatment and Care Records
Immunizations Records and History
Integrated Personal Health Data with Patient Self-Assessment
Nationwide Health Information Network
Personalized Healthcare (Family History)
Interagency Program Office
Integration of Interagency Data Sharing into DoD and VA architectures
Trusted Partnership and Communication Infrastructure
Exposure History (Environmental and Occupational Hazards)
Data marts to support Clinical Research, Quality, and Population Health Management
Knowledge sharing for Psychological Health and Traumatic Brain Injury
e-Benefits Portal
Disability Evaluation System
Non-Clinical Case Management
Pay Systems Enhancements
Identity Management
Federal Health Center Information Technology Support
The DoD/VA Information Interoperability Plan is an implementation roadmap of potential phased initiatives that will help the Departments achieve a shared vision.  The success of this roadmap will depend on many factors and will require collaboration at all levels of both Departments.  The Plan is only the first step in the process.  As we move forward, the continuing diligence of governing bodies and the functional and technical communities will be vital to identifying and bridging all information gaps. 
MEETING THE INTEROPERABILITY DEADLINE
 Drafting the DoD/VA Information Interoperability Plan is one of several recent steps the Departments have taken to meet the deadline set forth in the National Defense Authorization Act for Fiscal Year 2008.  Other steps designed to accelerate sharing efforts include establishing the DoD/VA Interagency Program Office and the DoD/VA Joint Clinical Information Board. 
Interagency Program Office.  The Interagency Program Office was established in April 2008 to "act as a single point of accountability" for cross-organizational coordination and collaboration to support health, personnel, and benefits data sharing.  This office will report progress to the DoD/VA Joint Executive Council and incorporate key milestones into the DoD/VA Joint Strategic Plan.  The Interagency Program Office will be responsible for management and oversight but will not be the technical execution organization.  It will help resolve conflicts in the DoD and VA sharing requirements for health, personnel, and benefits functional communities; ensure DoD and VA schedules are coordinated for technical execution of initiatives; assist in coordinating funding considerations; obtain input and concurrence of other DoD and VA stakeholders; and report to Congress on progress and plans.  Technical execution remains in the appropriate DoD and VA offices using the established Departmental statutory and regulatory processes for acquisition, funding, management control, information assurance, and other execution actions, which are significantly different for each Department.
Joint Clinical Information Board.  The Joint Clinical Information Board enables clinicians to have a direct voice in the prioritization of recommendations for DoD/VA interoperability initiatives.  The Deputy Assistant Secretary of Defense for Clinical and Program Policy and the Chief Patient Care Services Officer, Veterans Health Administration, serve as the lead functional proponents.  The Board guides clinical priorities for what electronic health care information the Departments should share next and reviews planned clinical information system solutions for DoD/VA sharing to ensure alignment to clinical sharing priorities as defined by the Board.  To support efforts to meet the September 2009 deadline, the Joint Clinical Information Board submitted recommendations to the Interagency Program Office and DoD/VA Health Executive Council Information Management/Information Technology Work Group in July 2008.  The Board will refine and prioritize new requirements to ensure continued improvements in DoD/VA electronic health data sharing in a manner that supports clinicians in health care delivery.
CONCLUSION
 The initial movement toward interoperability was a struggle.  In the past several years, however, the efforts of DoD and VA to share health care information have gained undeniable momentum.  We continue to build on this momentum and a solid foundation of sharing initiatives as we move toward next September and the goal of full interoperability of health care information and beyond.  The journey has been long and arduous and will not end when we achieve interoperability.  Rather, our journey will continue as DoD and VA strive to enhance the care we provide for all of our beneficiaries. 
 As always, we appreciate the insights, recommendations, and guidance of this Congressional committee.  We are all working toward the same end-to provide the highest quality care for our Nation's heroes, past and present-and we need to work together to achieve our goals as efficiently and effectively as possible.  Thank you again for allowing us the opportunity to appear before you and testify about DoD/VA electronic health care information sharing achievements, goals, and plans.