STATEMENT OF THE HONORABLE ROBERT N. MCFARLAND
ASSISTANT SECRETARY FOR INFORMATION AND TECHNOLOGY
U.S. DEPARTMENT OF VETERANS AFFAIRS BEFORE THE
HOUSE COMMITTEE ON APPROPRIATIONS
SUBCOMMITEE ON MILITARY QUALITY OF LIFE
AND VETERANS AFFAIRS AND RELATED AGENCIES

March 29, 2006

      Mr. Chairman and members of the Committee, good morning. Thank you for giving me the opportunity to discuss the importance of electronic health records and the tremendous progress made by the Department of Veterans Affairs (VA) toward the development of these technologies and the sharing of information with our close partner, the Department of Defense (DoD). I am pleased to appear before the Subcommittee to discuss how VA is working closely with DoD to meet the needs of returning Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans as well as the needs of the many veterans already benefiting from VA services. Our joint work to achieve electronic sharing of data goes to the core of our mission to ensure that the best medical care is available for those who have served their country. I also am pleased to have with me Mr. Cliff Freeman, Director, VA/DoD Health IT Sharing Program; Mr. Robert Reynolds, Assistant Chief, Information Technology and Program Analysis, Veterans Benefits Administration; and, Mr. Scott Cragg, VA's Chief Enterprise Architect.

      VA and DoD together have made substantial progress toward achieving interoperability of electronic health information as well as establishing key data sharing strategies essential to demographic data exchange and data synchronization. Additionally, we continue to make progress toward simplifying registration and enrollment of veterans as well as the ways we manage contact with veterans throughout their continuum of care. I'd like to begin by telling you about our efforts in health information and then follow with what we're doing in the area of demographic data sharing.

      Much of our success is due to the successful implementation of our joint strategy, the DoD/VA Joint Electronic Health Records Interoperability (JEHRI) Plan. This plan consists of a series of separate data exchange initiatives that, when taken together, provide DoD and VA with a roadmap for comprehensive health data sharing that is further enhanced with progressive movement toward interoperability as the technology and standards mature. Importantly, this plan provides the strategic planning component that ensures that VA and DoD will meet these targets in a systematic, prioritized fashion. The plan was signed at the high levels of both organizations, by the Joint Executive Council which is co-chaired by the VA Deputy Secretary and the DoD Under Secretary of Defense for Personnel and Readiness. The plan is overseen by the Health Executive Council, which is co-chaired by the VA's Under Secretary for Health and the DoD Assistant Secretary of Defense for Health Affairs.

      Since 2002 and implementation of this plan, we have successfully developed the capability to share medical records one way, from DoD to VA, and bidirectionally, between DoD and VA. VA and DoD began implementation of Phase I of the plan in 2002 with the Federal Health Information Exchange, known as FHIE. This exchange delivers the one-way transfer of electronic military health data on separated service members to the VA Computerized Patient Record System for viewing by VA clinicians treating veterans. Since implementation of this exchange in 2002, DoD has transferred records for more than 3.2 million unique patients to the joint secure repository set up for this exchange. Of these 3.2 million patients, we know that over 2 million have actually received care or treatment from VA. These same records also are available for viewing by the Veterans Benefits Administration (VBA) claims examiners accessing FHIE data through an interface with the VBA Compensation and Pension Records Interchange. FHIE allows our clinicians and claims examiners to view all pertinent historical electronic information from DoD's legacy system, the Composite Health Care System. These data include outpatient pharmacy data, allergy information, laboratory results, consults, admission, disposition and transfer information, and medical diagnostic coding data.

      Following the success of FHIE, and again working jointly with DoD, we leveraged FHIE investments to quickly and inexpensively implement the Bidirectional Health Information Exchange in October 2004. This initiative, known as BHIE, builds upon the success of FHIE and delivers real-time, bidirectional exchange of readable text data between VA and DoD medical facilities where shared patients receive care. Whereas FHIE allows VA to access historical data on any separated or retired service member who comes to us for care, BHIE expands our access and includes Patient Identification Management, which allows VA and DoD to automatically match patient identities for active DoD military service members and their dependents with their electronic health records at VA facilities, when needed. BHIE also supports the real-time bidirectional exchange of outpatient pharmacy data, anatomic pathology/surgical reports, cytology results, microbiology results, chemistry and hematology laboratory results, laboratory order information, radiology text reports and food and drug allergy information.

      BHIE data from seven DoD medical treatment facilities (MTFs) are available at every VA site of care, subject to applicable privacy and security restrictions. Staff at those DoD MTFs have full access to this information from every VA facility. BHIE is currently available at seven DoD hosts sites, which combined have 7 medical centers, 5 hospitals, and over 50 clinics from Army, Navy and Air Force locations. These DoD host sites include locations that receive large numbers of Operation Enduring Freedom and Operation Iraqi Freedom combat veterans, including the National Capital Area with Walter Reed Army Medical Center and Bethesda National Naval Medical Center. VA is working closely with DoD to expand the number of DoD military treatment facilities where BHIE is implemented and to increase the scope of data available between DoD and VA.

      In addition to BHIE, these same FHIE technical investments now support the transfer of military pre- and post-deployment health assessment data from DoD Forms 2795 and 2796. In July 2005, DoD completed a one-time historical extraction of approximately 400,000 pre- and post-deployment health assessments from the Defense Medical Surveillance System and sent the data to the FHIE data repository.

      In September 2005, DoD began the monthly transmission of these electronic data to the FHIE data repository and has continued each month since then. In December 2005, VA completed the work necessary to allow its clinicians to view these data as progress notes in the VA Computerized Patient Record System. To date, DoD has transmitted to VA more than 515,000 pre- and post-deployment health assessments on over 266,900 separated service members.

      Whereas FHIE and BHIE provide the means for VA to access clinically pertinent data from DoD's legacy system, the Departments also have devised an initiative that will permit VA and DoD to share data as we both move forward and deploy our future information systems. As you are aware, DoD is currently deploying its next-generation system, and VA is moving toward HealtheVet. Both the DoD and VA systems rely on data repositories that will ensure that standardized data is delivered across each enterprise, where and when it is needed.

      Phase II of the JEHRI Plan will provide VA and DoD the ability to share data between these data repositories. Phase II will support the bidirectional exchange of select types of computable electronic health information through the VA and DoD interoperable data repositories. The first release of this interface, known as the Clinical Data Repository/Health Data Repository (CHDR), allows VA and DoD to conduct drug-drug and drug-allergy interaction checking between VA and DoD pharmacy systems through the Clinical Data Repository of DoD's AHLTA system and the Health Data Repository that VA is implementing as part of its activities to update and replace VistA. A successful demonstration of this capability in September 2004 using a pharmacy prototype confirmed that a more robust solution could be developed.

      Since that time, VA and DoD have worked to develop the capability to support the exchange of computable allergy and pharmacy data in a live production environment. In January 2006, the Departments completed formalized interagency testing and conducted a second successful demonstration using the production version of CHDR for VHA and Military Health System IT leadership. The Departments are now working closely with an interagency staff in El Paso, Texas, where the goal is to implement CHDR between the William Beaumont Army Medical Center and the VA El Paso Healthcare System no later than July 2006.

      CHDR is groundbreaking work. The exchange of computable health information necessarily relies on the ability to exchange standardized data and the implementation of data standards, such as those jointly adopted by the Departments as part of the Consolidated Health Informatics (CHI) initiative. This work is extremely challenging, and VA and DoD are at the forefront in determining how to accurately standardize the vast amounts of data that are available in a manner that does not compromise patient care and safety.

      VA and DoD also are examining how CHDR and other solutions, such as BHIE, can be used together to support an even greater exchange of electronic health information and to provide a seamless view of electronic data to VA and DoD providers. Presently, we are working to plan for the next release of CHDR that will exchange standardized, computable laboratory data between the Departments' data repositories. The exchange of such computable pharmacy, allergy, and laboratory data between two separate systems has never been done on the scale that VA and DoD are working to accomplish.

      Laboratory Data Sharing and Interoperability (LDSI) is another example where future work will leverage our ability to implement standards. VA and DoD jointly developed LDSI software to support the bidirectional electronic ordering and results retrieval of chemistry laboratory tests from each other's facilities. The software is operational at five locations where DoD and VA provide laboratory support to one another, and it is available to all sites where VA and DoD serve as reference lab facilities for one another and where the business case justifies its use. The next phase of this work involves using the Logical Observation Identifiers Names and Codes (LOINC) and Systemized Nomenclature of Medicine (SNOMED) standards that have been jointly adopted as part of the CHI initiative to support the ordering and results retrieval of electronic anatomic pathology and microbiology labs at test sites in San Antonio and El Paso, Texas. Upon completion of development and testing, the Departments will determine future timelines for implementation at other locations.

      Our data exchange efforts are closely tied to the work that we are doing as lead partners on the Federal Health Architecture (FHA) and CHI eGOV initiatives sponsored by the Department of Health and Human Services with participation from other federal partners. The FHA initiative defines the overarching framework and methodology used to establish targets and standards for interoperability and communication among the federal health community. The CHI initiative is establishing a portfolio of existing clinical vocabularies and messaging standards. The standards that are ultimately identified, adopted and implemented will enable federal agencies to build interoperable federal health data systems that comply with all applicable requirements for information privacy.

      VA and DoD are presently co-chairing the New Standards Work Group development effort for CHI, the purpose of which is to help identify standards to support additional data exchange in areas where there are no existing standards known. To date, we have adopted standards in approximately 20 clinical domain areas. It is not enough just to adopt the standards; standards must be subsequently implemented in new systems to be useful and to support data interoperability. To this end, VA and DoD are leading the development of CHI Implementation Guidelines for Digital Imaging and Communications in Medicine and Health Level 7 Clinical Documentation Architecture standards.

      The standards and health architecture work that VA and DoD are conducting is closely tied to that being done by the Office of the National Coordinator for Health Information Technology (ONCHIT), created by an Executive Order from President Bush. The purpose of ONCHIT is to facilitate the development of a national infrastructure for health information sharing. VA and DoD subject matter experts are active participants in every level of ONCHIT activity, including advisory councils, work groups and ongoing liaison activities. Our work with ONCHIT is especially important to our veterans, where up to as many as 40% of our veterans receive health care from additional private and public health care providers. VA strongly believes that every veteran's health information should be available in a secure manner, wherever it is needed to provide seamless high quality health care to that veteran.

      In conjunction with commitments made to the JEC in November 2004, we've moved forward to streamline demographic data we receive from the Defense Manpower Data Center (DMDC) and have characterized 31 data feeds from DoD as well as the 11 feeds we provide DoD in return. Doing so has effectively demonstrated that we're capable of implementing a joint demographic data structure between agencies that is critical to synchronizing veteran administrative and benefits data. Following through will also mean that the VA will eventually be able to minimize the number of exchanges and interfaces currently in operation. We expect to reduce outlays in operations and maintenance as well as sunset systems that are single use and perform one function instead of sharing services as part of a Service Oriented Architecture. Currently we are in the demonstration phase with the repository and joint data schema and are developing a systems sequencing and migration plan.

      The end result goal is to streamline data exchange, reduce outlays for operations and maintenance, sunset and shut down redundant systems, converge data into a consolidated repository, link to DMDC managed identity numbers and establish an internal VA capability to merge veteran data housed in numerous databases. This effort is not related to veteran owned business, but rather is data specific to demographics that will enable VA to align each veteran's data in a simple way. Eventually this strategy will also provide for web enabled self service to veterans.

      Critical to this effort is our developing identity management strategy. In parallel with registration and enrollment initiatives underway at VA, CIO staff along with administration representatives from VA's three administrations are collaboratively working toward an agency level identity management strategy that will allow us to uniformly link managed identities for service members, coordinated by DMDC, with veteran files and records held by VA. Agreements are being negotiated with DoD that recognize their Electronic Data Interface Personnel Identification Numbering (EDIPIN) system practices such that VA will be able to correlate benefits and health information about active duty, and separated service members in transition to veteran status. When we have completed this work we will be able to align an individual veteran's health information with their benefits information. EDIPIN is the DoD method for assigning numerical identification numbers. VA will leverage their practices to establish an internal VA ID number that will enable us to merge multiple VA data sources and present a single view to veteran's data as opposed to multiple views as may be experienced today.

      In addition, VA has a priority to identify veteran-owned businesses to provide post-active duty opportunities for veterans. This is being accomplished through VETBIZ.GOV and through the Central Contractor Registry housed at DoD.

      VA and DoD are now conducting the initial planning for several projects to increase the amount of health data that can be shared. Both Departments have great interest in sharing images, such as radiological studies, and believe it could add value to the delivery of healthcare to service members and veterans. VA and DoD have agreed to work together as VA updates and replaces its current system, VistA Imaging. The Departments anticipate that this work will provide an effective imaging solution for both Departments and increase shared access to health data images.

      We also are planning to make scanned DoD paper health records available to VA clinicians. Much of the historical DoD health record exists in paper format. Developing a method whereby VA clinicians could access the information contained in these records, including inpatient files, would greatly enhance our total access to DoD data. We are forming an interagency working group and pilot study to explore the feasibility of scanning, storing and viewing DoD paper health records across VA in an electronic format. The effort is centered on the records of OEF and OIF veterans with severe injuries, but the concept could apply to other patient categories if the initial efforts to capture and view these records are successful and cost effective.

      VA is fully committed to supporting the uninterrupted delivery of care to those who are returning or have returned from the battlefield and are transitioning into our VA healthcare system. We recognize the importance of sharing health information with our DoD partners and are working hard toward that end. My colleagues and I are happy to answer any questions that you or other members of the Committee might have.