[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]



 
               SHARING OF ELECTRONIC MEDICAL INFORMATION


                 BETWEEN THE U.S. DEPARTMENT OF DEFENSE

                       AND THE U.S. DEPARTMENT OF

                            VETERANS AFFAIRS

=======================================================================


                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 24, 2007

                               __________

                           Serial No. 110-57

                               __________

       Printed for the use of the Committee on Veterans' Affairs





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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                  HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio               GINNY BROWN-WAITE, Florida, 
TIMOTHY J. WALZ, Minnesota           Ranking
CIRO D. RODRIGUEZ, Texas             CLIFF STEARNS, Florida
                                     BRIAN P. BILBRAY, California

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                            October 24, 2007

                                                                   Page
Sharing of Electronic Medical Information Between the U.S. 
  Department of Defense and the U.S. Department of Veterans 
  Affairs........................................................     1

                           OPENING STATEMENTS

Chairman Harry E. Mitchell.......................................     1
    Prepared statement of Chairman Mitchell......................    52
Hon. Ginny Brown-Waite, Ranking Republican Member................     2
    Prepared statement of Congresswoman Brown-Waite..............    52

                               WITNESSES

U.S. Department of Defense:
  Brigadier General Douglas J. Robb, M.D., Commander, 81st 
    Medical Group, Keesler Air Force Base, Biloxi, MS, Department 
    of the Air Force.............................................     4
    Prepared statement of General Robb...........................    53
  Colonel Keith Salzman, M.D., MPH, FAAFP, FACHE, Chief of 
    Informatics, Western Region Medical Command and Madigan Army 
    Medical Center, Tacoma, WA, Department of the Army...........    19
    Prepared statement of Colonel Salzman........................    65
  Lieutenant Commander James Lawrence Martin, Regional 
    Information Systems Officer, Navy Medicine East, Medical 
    Service Corps, Department of the Navy........................    23
    Prepared statement of Commander Martin.......................    71
  Colonel Gregory Andre Marinkovich, M.D., Data Management 
    Product Line Functional Manager, Clinical Information 
    Technology Program Office, Military Health System, Medical 
    Service Corps, Department of the Army........................    25
    Prepared statement of Colonel Marinkovich....................    73
  Stephen L. Jones, DHA, Principal Deputy Assistant Secretary of 
    Defense (Health Affairs).....................................    39
    Prepared statement of Dr. Jones..............................    79

                                 ______

U.S. Government Accountability Office, Valerie C. Melvin, 
  Director, Human Capital and Management Information Systems 
  Issues.........................................................    13
    Prepared statement of Ms. Melvin.............................    54

                                 ______

U.S. Department of Veterans Affairs:
  Howard B. Green, PMP, Deputy, Operations Management, Veterans 
    Health Information Technology, Office of Enterprise 
    Development, Office of Information and Technology............    21
    Prepared statement of Mr. Green..............................    68
  Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary 
    for Health, Veterans Health Administration...................    37
    Prepared statement of Dr. Cross..............................    74

                   MATERIAL SUBMITTED FOR THE RECORD

Post Hearing Questions and Responses for the Record:
  Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, 
    Ranking Republican Member, Subcommittee on Oversight and 
    Investigations, Committee on Veterans' Affairs, to Hon. David 
    M. Walker, Comptroller General, U.S. Government 
    Accountability Office, letter dated February 5, 2008, and 
    response from Valerie C. Melvin, Director, Human Capital and 
    Management Information Systems Issues, U.S. Government 
    Accountability Office, letter dated March 7, 2008............    83
  Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, 
    Ranking Republican Member, Subcommittee on Oversight and 
    Investigations, Committee on Veterans' Affairs, to Hon. 
    Robert M. Gates, Secretary, U.S. Department of Defense, 
    letter dated February 5, 2008, and DoD responses.............    92
  Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, 
    Ranking Republican Member, Subcommittee on Oversight and 
    Investigations, Committee on Veterans' Affairs, to Hon. James 
    B. Peake, Secretary, U.S. Department of Veterans Affairs, 
    letter dated February 5, 2008, and VA responses..............    96
  The Health Executive Council Highlights, FY 2003-First Quarter 
    for FY 2008, dated June 10, 2008.............................    98


                     SHARING OF ELECTRONIC MEDICAL



                      INFORMATION BETWEEN THE U.S.



                     DEPARTMENT OF DEFENSE AND THE



                  U.S. DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                      WEDNESDAY, OCTOBER 24, 2007

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice at 10:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Mitchell, Space, Walz, Rodriguez, 
and Brown-Waite.

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. Good morning and this hearing will come to 
order. This is the Subcommittee on Oversight and 
Investigations. And today's hearing is on Sharing of Electronic 
Medical Information between the U.S. Department of Defense 
(DoD) and the U.S. Department of Veterans Affairs (VA).
    I want to thank everyone for being here today and I am very 
pleased that so many people could attend this oversight hearing 
on Sharing Electronic Medical Information between the 
Departments of Defense and Veterans Affairs.
    This is a critically important issue. Thousands of our 
service men and women require and will continue to require 
significant medical care as a result of the conflicts in Iraq 
and Afghanistan. The most seriously injured of our Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
veterans may need a lifetime of care. But even veterans 
returning with no visible injury may need assistance with Post 
Traumatic Stress Disorder (PTSD) or mild Traumatic Brain Injury 
(TBI).
    The DoD and VA are sharing more and more patients. For 
example, the patients at the VA's four polytrauma 
rehabilitation centers are almost always still on active duty. 
And active-duty servicemembers will be veterans sooner or 
later.
    A review by the VA's Inspector General shows that of the 
500,000 or so servicemembers who left active duty in fiscal 
year 2005, 92 percent had an encounter with a military health 
system while on active duty that resulted in a diagnostic code. 
In other words, nearly all of the veterans who go to the VA to 
get medical care will have military medical records that should 
be available to VA healthcare providers.
    If anyone can convince the American people of the 
importance of electronic medical records, it is our first 
panel. Specialist Channing Moss is an Army soldier who was shot 
with a rocket propelled grenade that lodged in his body. He is 
alive and walking today because the medical evacuation team and 
the combat surgeons who operated on him put their own lives in 
danger in order to remove live ordnance from Specialist Moss.
    Brigadier General Douglas Robb was Chief Surgeon of United 
States Central Command (CENTCOM) at the time. And he will 
discuss how important it was that a copy of the x-ray taken at 
the forward field hospital was available to the clinicians at 
Landstuhl before Specialist Moss arrived.
    DoD and VA have been working on electronic exchange of 
medical information for many years. For most of that time, the 
story is not a happy one. I am nevertheless pleased to be able 
to say that DoD and VA have made more progress in the past 12 
to 18 months than they have made in the preceding decade.
    But there is still much to be done. There is no reason why, 
in this day and age, that DoD and VA cannot electronically 
share the information necessary to treat our servicemembers and 
veterans. We should not have to wait any longer.
    I hope and I expect that DoD and VA will tell us today that 
by no more than a year from now clinicians at DoD and VA will 
have full electronic access to the medical information they 
need to treat their patients whether that information resides 
in computers owned by DoD or the VA.
    [The prepared statement of Chairman Mitchell appears on p. 
52.]
    Mr. Mitchell. Before I recognize the Ranking Republican 
Member for her remarks, I would like to swear in our witnesses. 
I would ask all the witnesses from all the panels to please 
rise and raise your right hand.
    [Witnesses sworn.]
    Mr. Mitchell. Thank you.
    I would now like to recognize Ms. Brown-Waite for her 
opening remarks.

          OPENING STATEMENT OF HON. GINNY BROWN-WAITE

    Ms. Brown-Waite. Thank you very much, Mr. Chairman, and I 
thank you for yielding.
    It is a good idea to hold this hearing to review the status 
of the electronic medical record sharing between DoD and VA. 
This Subcommittee has already held two hearings in the 110th 
Congress on the issue of seamless transition of our 
servicemembers. And in the 109th, various hearings were also 
held. It is a very important issue.
    The first hearing of this Committee was held in March and 
the second one in May, both of which focused primarily on the 
sharing of critical medical information of wounded 
servicemembers and the sharing of that information between DoD 
and the VA.
    I want to assure the witnesses here today this issue is of 
the utmost importance to Members of this Committee and 
certainly the full Committee and I believe every Member of 
Congress.
    I am very pleased that the Chairman requested that 
representatives from DoD testify here today. It will be 
important to hear their perspective on the timely exchange of 
critical medical information between DoD and VA for the 
seamless continuum of delivering healthcare to our 
servicemembers.
    I look forward to hearing the steps DoD has taken to allow 
critical medical information to be reviewed by VA when active-
duty servicemembers are transferred to VA facilities.
    In addition, I will be interested in hearing from VA on 
whether technological obstacles or bureaucratic intransigence 
prevent this from occurring today.
    This past week, staff members visited Keesler Air Force 
Base and the VA medical center in Biloxi, Mississippi, to see 
how the Air Force and VA are coming together in VA/DoD resource 
sharing.
    Unfortunately, the progress in this area is a result of the 
devastation of Hurricane Katrina and the dynamic personalities 
of senior leadership at these facilities and not the ``Veterans 
Administration and the Department of Defense Health Resources 
Sharing and Emergency Operations Act 1982.''
    It does appear, Mr. Chairman, I agree with you, that the 
ball has moved forward more in the last, say, 24 months than 
the last 25 years. It is a shame that it took Hurricane 
Katrina, the debacle at Walter Reed, and the devastating wounds 
of war to expedite progress between the two largest Federal 
bureaucracies.
    I am also looking forward to hearing from representatives 
of both departments about how they plan to implement the 
recommendations of the recently released Dole-Shalala 
Commission report and the Veterans Disability Benefits 
Commission report.
    Again, thank you very much, Mr. Chairman, for holding this 
hearing. The issue is very important to every Member of 
Congress and I believe every American. And with that, I yield 
back the balance of my time.
    [The prepared statement of Congresswoman Brown-Waite 
appears on p. 52.]
    Mr. Mitchell. Thank you.
    I ask unanimous consent that all Members have 5 legislative 
days to submit a statement for the record. Seeing no 
objections, so ordered.
    Before we hear from our first panel, we are going to take a 
look at a short video about Channing Moss, the soldier that I 
spoke about in my opening statement. The Subcommittee 
appreciates the cooperation of the Army Times in making this 
video available.
    If you would like to move around to see this, please do.
    [Video shown.]
    Mr. Mitchell. General Robb will speak to us in a minute 
about the importance of the electronic transmission of 
Specialist Moss' medical records.
    But before we hear from General Robb, the Subcommittee 
would like to thank the Army Times and in particular Gina 
Cavallaro, James Lee, and Chris Brass who put this video 
together.
    Ms. Cavallaro, would you please stand? We want everybody to 
know that she was the first one to report this story more than 
a year ago and I would like to thank her on behalf of the 
Subcommittee and indeed on behalf of the country for bringing 
this truly inspiring story to light. Thank you.
    At this time, we will hear from General Robb and he will 
have 5 minutes to make his presentation. Thank you.

     STATEMENT OF BRIGADIER GENERAL DOUGLAS J. ROBB, M.D., 
COMMANDER, 81ST MEDICAL GROUP, KEESLER AIR FORCE BASE, BILOXI, 
  MS, DEPARTMENT OF THE AIR FORCE, U.S. DEPARTMENT OF DEFENSE

    General Robb. Mr. Chairman and Members of the distinguished 
Subcommittee, thank you for inviting me here today. I am 
Brigadier General Douglas J. Robb and I served as the Command 
Surgeon, United States Central Command from 2004 to 2007.
    Currently, I am serving as the Keesler Medical Center 
Commander and as the Senior Market Manager for the Gulf Coast 
Multi-Service Market Office, Keesler Air Force Base, Biloxi, 
Mississippi.
    Thank you for the opportunity to express my advocacy for a 
healthcare information systems platform and an electronic 
medical record that supports the world-class quality healthcare 
that our military and Veterans Administration healthcare 
facilities provide to our DoD and VA beneficiaries.
    In my previous assignment as the CENTCOM surgeon, I had the 
opportunity to witness the evolution of our deployed healthcare 
information systems platforms that support access to patient 
care data as our wounded warriors move through the continuum of 
care from our combat casualty care lifesavers to our forward 
surgical teams, to our theater hospitals, and then on to our 
definitive care facilities at hospitals such as Landstuhl, 
Walter Reed, Bethesda, Wilford Hall, and our VA polytrauma 
centers.
    As you saw in the video, on March 16, 2006, Specialist 
Channing Moss was severely injured in an attack in southeastern 
Afghanistan. The lifesaving care performed by the combat 
lifesavers in his unit and the subsequent and surgical 
stabilization by the forward surgical team and the Bagram 
Theater Hospital saved his life.
    What was also lifesaving was the ability of the surgeons at 
Landstuhl Hospital in Germany who would receive Moss less than 
24 hours after his initial injury and the surgeons at Walter 
Reed to be able to view his operative notes and his x-rays 
before the patient arrived at their hospitals. This was 
accomplished via the Joint Patient Tracking Application (JPTA), 
which is part of the DoD's deployed healthcare information 
systems platform.
    As an aside here, and you noticed in the video, that Moss 
said he was going to fight to live. And it is our task as 
medics in the combat environment to give him that opportunity 
to fight to live. And I was privileged to serve with those men 
and women, our medics in the Area of Rescue (AOR) who saved 
Moss' life, and especially to Dr. Oh did a great job there with 
the forward surgical teams.
    Earlier that year, and again in Afghanistan, a general 
surgeon and the Commander of one of our other forward surgical 
teams commented on his excitement when he was able to send 
completely digital trauma resuscitation and operative reports 
to the Bagram Combat Support Hospital, again before the patient 
arrived.
    This is something that had been his vision for our forward 
surgical teams for a long time. During his previous assignment, 
he had been a surgeon at Landstuhl, Germany, and was frustrated 
by the lack of medical data from the forward surgical teams' 
initial surgical resuscitation. He was happy that this had been 
corrected.
    Now, currently in my position as the Senior Market Manager 
for the Gulf Coast Multi-Service Market through the 
collaborative and joint DoD and VA initiatives, we are 
entrusted with the in-garrison care of our DoD and VA 
beneficiaries. In this capacity, we also require a healthcare 
information system platform that supports access to real-time 
patient data for our shared population.
    Our patients are from the Gulf Coast and are treated in the 
DoD and VA hospitals and clinics that are often located in 
proximity from Biloxi to Panama City. Our goal is to provide 
quality services in a seamless manner. This requires an 
integrated healthcare information systems platform that is user 
friendly for our jointly operating DoD and VA healthcare 
facilities.
    Significant progress has been made in the past few years to 
bridge this gap of electronic information flow. Just last 
month, our staffs were excited when the Bidirectional Health 
Information System (BDHI) became available at some of our 
facilities. Although not at its full capability yet, it is a 
very positive step in the right direction in our ability to 
view patient care data from both VA and DoD facilities.
    In conclusion, as a former Combatant Command Surgeon and 
currently as the Multi-Service Market Manager, I continue to be 
a strong advocate for healthcare information systems. We need 
to support heroes like Channing Moss as they move through our 
deployed and garrison-based continuum of care from the combat 
casualty to the forward surgical resuscitation, to theater 
hospitalization, and finally our DoD and medical centers and 
clinics.
    The current capability has proven itself in contributing to 
the quality of care for our beneficiaries and with your 
support, I believe we can continue to improve upon our already 
existing and evolving capability and further share and make 
available the full spectrum of electronic health information 
between our Department of Defense and Department of Veterans 
Affairs.
    Mr. Chairman, Committee Members, thank you again for 
allowing me this opportunity to appear before you.
    [The prepared statement of General Robb appears on p. 53.]
    Mr. Mitchell. Thank you, General Robb.
    I have just got a couple questions and I am not sure I 
understand all the acronyms or all the----
    General Robb. Yes, sir.
    Mr. Mitchell [continuing]. Things that I am going to throw 
out and ask you about, but I am sure you do. It is our 
understanding that the Joint Patient Tracking Application is 
currently used to get inpatient information from the theater 
but that some in DoD are trying to require clinicians in the 
theater to use an application called Tactical Command and 
Control (TC2).
    In your expert opinion, will doctors in the theater 
actually use this application, TC2, for inpatient documentation 
of clinical notes? That is one question.
    And if use of the JPTA for documenting encounters in 
theater is stopped, could this negatively impact delivery of 
healthcare for our most seriously injured as they travel 
through the continuum of the VA?
    General Robb. Well, sir, as far as the TC2, which is the 
current inpatient platform documentation system, that was 
implemented and introduced into the theater of operations after 
I left as the Combatant Surgeon. And as a result, in my current 
capacity, I have not been keeping up as much as I maybe should 
with my previous job, but my views on it in general are this.
    The initial inpatient module that was introduced into the 
theater did not accomplish what it was intended to do for a 
couple of reasons. Primarily it was because it was not user 
friendly for the providers. So if something is not user 
friendly by the providers and also providing a useful note to 
convey patient care information and data from one provider to 
another provider, then the providers are probably not going to 
accept that as a platform to use to take care of, remember, 
their patients.
    Number two, another reason was I believe at the time that 
was a stand-alone system and it did not allow information to 
flow. And as a result, when the Joint Patient Tracking 
Application was introduced into the theater to track patients 
from level two, level three, all the way back to the United 
States, the clinicians, the providers themselves figured out 
that they can put patient care data on that platform that, as 
we described in Moss' case, we are able to move patient care 
data along the continuum before and during and after the 
patient moved through the system.
    So that is the system that needs to be in place. The 
current inpatient module, if it is user friendly, and the 
providers decide that it is a useful note, okay, and it is 
real-time accessible, then it will be successful, yes, sir.
    Your second question about JPTA if it stopped right now, I 
think, again, my direction when I was the Command Surgeon was 
when the inpatient module is user friendly, provides a useful 
note, and provides real-time patient care data, and we can view 
inpatient data from real-time, before, after, and during their 
movement, then we can switch from the Joint Patient Tracking 
Application over to whatever system is going to work for us on 
the Armed Forces Health Longitudinal Technology Application 
(AHLTA) deployed platforms.
    But until then, I think we need to allow the providers the 
opportunity to move the patient care data that is useful to 
them.
    Mr. Mitchell. Thank you.
    After seeing this video about Specialist Moss, I can 
imagine that great things are happening like that all over 
today.
    General Robb. Yes, sir.
    Mr. Mitchell. However, I understand that there still may be 
some problems getting information from the field medics to 
hospitals and to the VA.
    What more can be done to ensure that this process goes 
smoothly?
    General Robb. Well, again, as I described in my testimony, 
we have some monumental, I think, steps that have occurred, 
nothing occurs as fast as we want it to, but that have 
occurred. One of them is the Bidirectional Health Information 
System.
    And, again, when we demonstrated that, I mean, we received 
it the day before and the next day, we flicked the switch and 
we got everybody together. But the opportunity for us through a 
bridge portal to view AHLTA data in VistA, which is the DoD 
system, view it in the Veterans Administration system, and then 
look from the Veterans Administration system into the DoD 
system to be able to see outpatient notes, lab, x-rays, 
pharmacy, allergies, we are there.
    The inpatient piece of it, that is going to be fielded 
here. At some places, it is already fielded. But the ability to 
field it at my particular location will be by next summer. That 
will be a tremendous milestone for us to accomplish. And for us 
in the Gulf Coast region and the patients that we share with 
our veterans to be able to look at each other's healthcare 
data, I am excited about that.
    The opportunity that we have had for the connections 
between the outpatient modules and then as we watch the 
evolution of the inpatient module, if that becomes connected, I 
know the outpatient is, we can view outpatient data from the 
field from any of our DoD locations and now through BDHI into 
the VA system.
    And once the inpatient module becomes successful, then the 
ability to view that again will advance again and contribute to 
the healthcare of our veterans.
    Mr. Mitchell. Thank you.
    Ms. Brown-Waite?
    Ms. Brown-Waite. Thank you, Mr. Chairman.
    By the way, congratulations on your recent promotion to 
Brigadier General. It certainly is refreshing to see that the 
military still rewards leaders for their candor and their 
refreshing approach to real-life problems.
    Let me ask you, if JPTA did not exist in the combat 
theater, how would, for example, the operative notes and x-rays 
be sent with the patient within 24 hours from, for example, in 
the video that we saw from Afghanistan to Landstuhl, Germany to 
be used by the accepting surgeon there, whether it is a 
situation like we just saw or whether it is TBI? How would that 
information be transmitted?
    General Robb. Well, under the old paradigm and the paradigm 
that I lived in when I first came to U.S. Central Command was 
we were moving paper records. In other words, if you had the 
opportunity to--I will regress a little bit. The patients move 
so fast through our system today. From the time of wounding on 
the battlefield to the time you are under the knife, it is 
sometimes as little as 20 minutes to your forward surgical 
team.
    And then you are usually in a combat theater hospital 
within an hour, sometimes two or three. And then you are at 
Landstuhl usually under 24 hours and sometimes you are at 
Walter Reed in 24 hours.
    And so you can imagine that under the old paradigm with the 
paper record, that may not keep up with the patient. And so, 
you know, a lot of times, physicians are moving, especially in 
the mass casualty situation, are moving so fast through the 
system that you complete the paperwork after the patient 
leaves. And so then it is hard to give the hard copy to move 
with the patient.
    So that was a dilemma we faced. And that is why it is 
important that we have a deployed healthcare information system 
platform that allows it so that you can enter the data. It is 
okay to enter the data after the patient leaves, but then it 
needs to be able to be viewed.
    So, you know, hypothetically you could put the data in or 
do the op note or whatever while the patient is being shipped 
to the next level. And so by the time they get to the next 
level, whether it is the theater hospital or to Walter Reed or 
to Landstuhl, it is in the system for the receiving physicians 
to see. And, again, that prepares that team for what is coming 
with them. They can anticipate the specialties.
    And so the clinicians, actually specifically the joint 
theater trauma system team, and the directors embraced this 
platform, the Joint Patient Tracking Application platform to be 
able to hang that type of data so that they could inform their 
colleagues along the continuum of care what was coming to them 
so they could better prepare for the care when they received 
them.
    Ms. Brown-Waite. Obviously that is a giant step forward.
    We have heard from providers in the combat theater that the 
current effort to document inpatient medical notes useable or 
very difficult at best that these actually were discouraged. 
This was after two failed implementations of the Composite 
Healthcare System (CHCS) legacy system.
    To the best of your recollection from your time in theater, 
was JPTA discouraged and, if so, by whom? And I guess we hope 
that candor is still there.
    General Robb. Well, I am a physician by trade. And so I 
understand how physicians talk to each other and I understand 
what needs to be passed from one physician to another.
    My staff, myself, and then the joint theater trauma system 
embraced the capability that the joint theater tracking 
application brought to us besides just the patient tracking 
application piece of it.
    And as a result, we made a decision that this was the way 
that we were going to support the movement of data for en route 
patient care because it was the right thing to do. And so we 
supported it from my staff and then subsequently through the 
component surgeons and then down to the different levels. That 
was the direction that we gave them for inpatient 
documentation. And that is what we executed.
    Did everybody accept it? It was something different. And 
change is always difficult.
    Ms. Brown-Waite. But was it actually discouraged?
    General Robb. Was it actually discouraged? There were some 
locations that did not embrace it as much as others, yes, 
ma'am.
    Ms. Brown-Waite. If you are not comfortable saying it now, 
I would like to know those locations so that we can make sure 
that regardless of where the injury takes place that we have 
the best records being transferred. It is not about the staff.
    General Robb. Right.
    Ms. Brown-Waite. With all due respect, it is not about the 
doctors who do wonderful work. It is about making sure that it 
is a system----
    General Robb. Yes, ma'am.
    Ms. Brown-Waite [continuing]. That works well on behalf of 
the patient.
    General Robb. Yes, ma'am.
    Ms. Brown-Waite. Thank you very much, General.
    General Robb. Yes, ma'am.
    Ms. Brown-Waite. I yield back.
    Mr. Mitchell. Thank you.
    Congressman Walz?
    Mr. Walz. Thank you, Chairman.
    And thank you, General. A special thank you for your 
service in where you are at in providing medical care which I 
think is without a doubt the best surgical and the best medical 
care ever given to warriors in the history of mankind. And that 
has been an amazing success story.
    And this issue and this topic of medical records is 
critically important. I understand, and many of us, I think, 
oversimplify what goes into this, what data needs to be on 
there. And I represent the part of Minnesota that has the Mayo 
Clinic and this is a conversation I have had many, many times 
on this, on a broader area of healthcare in general, and what 
is going to be done.
    Now, it looks like and what I am hearing is I am very 
optimistic, too, that massive progress has been made. I think 
for our perspective here in Congress, the end result, the 
progress, the improved medical records, it is going to help in 
terms of patient care, cost, research, all of those things that 
go with medical records.
    My question to you is, and I know again some of these have 
to be subjective, what do you attribute what appears to be an 
increased pace of change, an increased pace of trying or a 
sense of urgency to implement this idea of data sharing and 
electronic medical records, or do you think it has just been on 
a continuum and it is finally reaching fruition where it has 
gotten to where we can get the types of things you are talking 
about?
    General Robb. Well, I think, of course, you know it was the 
President's vision that we go this direction as a Nation. And 
as I spend time also in my professional capacity with my state 
organizations and associations from the State of Florida, they 
are wrestling again with how are they as a state going to come 
up with an electronic medical record or healthcare information 
systems platform to support that vision.
    If it were easy, I think one of the states would have 
figured this out already. And so I applaud the Department of 
Defense again for leading the charge. You know, sometimes we 
make some of our best advances in crisis and I think that has 
probably been part of the addition to the momentum of where we 
are going, the sense or urgency, because there is a lot of 
competing priorities out there.
    I believe, as we all believe, that we have the interest of 
our patients, whether they are civilian, whether they are 
veterans, or whether they are active duty, at heart. And I 
believe as a Nation and with the Department of Defense and with 
the Department of Veterans Affairs and the Federal Government 
in the lead on this, I think we have the opportunity to set the 
standard for what is an electronic health record or, even 
bigger, what I call a health information systems platform to 
support patient care as we want it to be in the future.
    Mr. Walz. One of the questions that always comes up here is 
the Congress' role in providing not only oversight but 
resources. In your experience now, are the resources there to 
make this transition because many of us up here understand it 
is a scarce amount of resources and what we are getting out of 
it?
    But this issue is so broad and so important and especially 
in the care of our veterans and seamless transition. I kind of 
ask the question, the last question with a little bit of 
leaning toward, did Walter Reed wake us all up and those types 
of things? Was this one part of it?
    And I guess my question to you is, do you feel that the 
resources are there, the commitment is there to get this right 
this time?
    General Robb. I think the oversight and the emphasis is 
there, absolutely. This is a tremendous monumental paradigm 
shift from where we were and to where we are going. And it is 
taking a lot of resources, probably more than we maybe had 
anticipated.
    I think we have the brain power to do it. I think we have 
some of the solutions. In fact, I think we have most of the 
solutions, at least to get us through the interim. The next 
generation of platform is something that we need to work on. 
But for the interim, for the next 12 to 18 to 24 months, I 
believe we have some solutions in place.
    Could we accelerate that with resources? The answer is 
potentially. But I am not in that business, so I do not know if 
we can go any faster if, let us say, either more manpower or 
money was thrown at it. Sir, I do not know that.
    But I know that they have a road map way ahead which you 
will hear later that I am very optimistic about in making this 
happen. And if they can have the opportunity to answer that 
question later, then they can probably tell you whether or not 
the resourcing piece of it is something that could either 
accelerate this or slow it down, yes, sir.
    Mr. Walz [presiding]. Very good. Thank you, General.
    Mr. Rodriguez?
    Mr. Rodriguez. Thank you very much. And I apologize for not 
being here, although I hear my colleague is very optimistic.
    This is my ninth year on this Committee with the absence of 
2 years, and about 5 or 8 years prior to me getting on here, we 
had been talking about this process. And so I am pleased and 
glad that we are finally making some inroads, although it has 
taken a long time.
    And we talk about it is monumental, but it is monumental 
from our part when we have been talking about this for a 
significant amount of time. And, you know, until I see it, in 
all honesty, I will not believe it. I can only react based on 
the fact that we know the Department of Defense has been 
stonewalling us on a couple of items on this area and not you 
personally, General.
    And I want to personally thank you for your efforts. But, 
you know, we have to get this straight because there are a lot 
of other things that took us 20 years to finally tell some of 
our veterans from Project 112 that when they told us there was 
no experimental, you know, exercises being done on our own 
soldiers then we found out that was the case.
    So I would like to be able to get that documentation and 
also go back and addressing some of the needs of those soldiers 
in the sixties and seventies that we did some of those things 
and experimented with some of those gases and other things with 
them that the Department of Defense failed to--not failed--
actually denied us that information for over 20 years. And, you 
know, I experienced that on this Committee.
    Now, I have also witnessed that the process to get there 
is, you know, because one after another have shown us some 
models of how we can do that and make that happen, and I want 
to throw a question to you in terms of--because at one point, I 
was just, you know--well, I am frustrated with both and that we 
need almost an external group to come in here and take care of 
it for you guys, both the Department of Defense and the VA when 
it comes to our computers, especially in terms of what happened 
with the loss of the information in the VA.
    And so I was wondering if in terms of expediting this, 
would it help to get some external groups to come in and take 
care of it in terms of the high tech stuff that is required?
    General Robb. That is kind of out of my area of expertise. 
I am an operator and an executor. And I am the one that 
executes what you all give me. And I am not in what I will call 
the developmental arena. So, sir, I have to pass that question 
on to----
    Mr. Rodriguez. The second question, as we speak now, we 
hear the Department of Defense doing some diagnosing already on 
some 20 something thousand personality disorders which 
automatically identifies preexisting condition.
    Are we having any other of those kind of things occurring 
at the present time, that we are going to have some additional 
problems in the future? Are there some problems specifically 
with some of that might be occurring at the Department of 
Defense?
    General Robb. Sir, I do not think I understand your 
question.
    Mr. Rodriguez. There was a group of some 20,000 soldiers 
that were identified with personality disorders. And when that 
occurs, when that soldier leaves, and I had a couple of them 
come and visit me, that presupposes a preexisting condition 
which means they do not qualify for any kind of benefits or 
anything when they try to go if that is their diagnosis. And so 
the Department of Defense, it is my understanding, did these 
diagnoses.
    Where are we at on that kind of stuff?
    General Robb. Sir, that is again probably out of my area of 
expertise because you are talking about accession standards in 
the way we access our individuals' preexisting conditions, of 
course, or conditions that the medical profession and through 
the administrative channels also believe existed prior to 
service. And then that particular condition arises or surfaces 
when they are in the military.
    But as far as what we are doing to better pick up on some 
of those preexisting conditions, that, sir, again, is out of my 
area of expertise.
    Mr. Rodriguez. Okay. And I would also want to go back as we 
move on this to some of our previous veterans. We want to do 
the right thing now, but we also want to go back to Vietnam and 
some of those areas where we did have and at one point had 
identified some 5,600, maybe even more, because I was gone for 
a couple of years, so close to 6,000 soldiers that we used, you 
know, nerve gas and other things on our own soldiers, and 
wanted to see from the Department of Defense, you know, later 
on, maybe we can get, Mr. Chairman, a little status report on 
those assessments that were done in the 1960s and 1970s on our 
soldiers because I know they first said that they only 
identified some 30 projects and then it went to 40 and the last 
I heard, it was close to 50-something projects where we had 
done experimental stuff with our own soldiers, and I want to 
just get, you know, and that is with the Department of Defense, 
I just want to get some feedback on that.
    General Robb. Sir, again, that is again out of my area of 
expertise and I am not aware of that.
    Mr. Rodriguez. Thank you very much for what you are doing, 
sir. A lot of the Members feel optimistic, so you must have 
said some good things.
    General Robb. Well, I will tell you, the group of folks 
that I had a chance to work with and work for are medical 
professionals not only in the CENTCOM area of responsibility 
but also back here at our, again, our major hospitals and our 
clinics, and then my opportunity in my current capacity to work 
with the Veterans Administration. You know, we have all heard 
the expression from Secretary Nicholson this is not your 
father's VA. There are a group of dedicated professionals out 
there in the Veterans Administration that care for our 
soldiers, sailors, airmen, Marines, coalition forces and they 
are second to none. And I am proud to be part of that team, 
yes, sir.
    Mr. Rodriguez. And I hope the Department of Defense takes 
it from the perspective that file belongs to that soldier.
    General Robb. Yes, sir.
    Mr. Rodriguez. And they be able to get a grasp of it and be 
able to have it so that when they move into the VA, and it 
would be more cost effective for us as a whole, and not to 
mention in terms of that particular soldier. Thank you.
    General Robb. Yes, sir.
    Mr. Walz. Ranking Member Brown-Waite?
    Ms. Brown-Waite. General, I just wanted to thank you very 
much for being here, for your candor, and also for your ability 
to accept and promote the kind of technology that will 
certainly help the patient a whole lot more than the past. Lord 
only knows where the paper trail system is that was there.
    Thank you so much.
    General Robb. Yes, ma'am.
    Ms. Brown-Waite. And please encourage others to follow 
suit.
    General Robb. Yes, ma'am.
    Mr. Walz. I would echo and associate myself with the 
Ranking Member's comments generally. It is refreshing to hear 
this. We have a lot of work to do. Please know that we sit up 
here as representatives of the American people and we want 
nothing more than to provide the highest quality care to our 
soldiers and our warriors that are out there and as they become 
veterans.
    So you simply need to see us as partners in this. We are 
glad to have you out there. And I thank you for your time.
    General Robb. Thank you.
    Mr. Walz. We will go ahead and seat the second panel, 
please. Welcome to our witnesses. Our witness today, Ms. 
Valerie Melvin, is Director of Human Capital and Management 
Information Systems Issues for the U.S. Government 
Accountability Office, the GAO. She will be accompanied by her 
Assistant Director, Ms. Barbara Oliver. We look forward to her 
unbiased view on this situation.
    And, Ms. Melvin, you are recognized for 5 minutes.

  STATEMENT OF VALERIE C. MELVIN, DIRECTOR, HUMAN CAPITAL AND 
    MANAGEMENT INFORMATION SYSTEMS ISSUES, U.S. GOVERNMENT 
ACCOUNTABILITY OFFICE; ACCOMPANIED BY BARBARA OLIVER, ASSISTANT 
  DIRECTOR, HUMAN CAPITAL AND MANAGEMENT INFORMATION SYSTEMS 
         ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Melvin. Thank you. Members of the Subcommittee, I am 
pleased to be here today to continue the dialog on VA's and 
DoD's efforts to share electronic medical information and 
attempts to ensure that active-duty military personnel and 
veterans receive high-quality healthcare.
    As you have mentioned, accompanying me today is Ms. Barbara 
Oliver, Assistant Director.
    As you know, VA and DoD have been pursuing ways to share 
medical information for nearly a decade. And since 2001, GAO 
has reported numerous times on their initiatives.
    Our last testimony before you on May 8th highlighted the 
key projects that the two departments have pursued and the 
substantial work that remained to achieve comprehensive 
electronic medical records.
    At your request, my statement today further discusses the 
history and status of these efforts.
    In this regard, since 1998, VA and DoD have focused on the 
long-term vision of a single comprehensive lifelong medical 
record for each servicemember to achieve a seamless transition 
between the departments.
    However, they have faced considerable challenges in their 
efforts to reach this goal, leading to repeated changes in the 
focus of and target dates for their initiatives.
    Our prior reviews noted weaknesses in project management, 
oversight, and accountability, and we recommended that the 
departments develop a comprehensive and coordinated project 
management plan to guide their efforts.
    Since we last testified, each Department has continued 
developing its own modern health information system to replace 
existing systems. The modernized systems are based on using 
computable data, that is data in a format that a computer 
application can act on, for example, to alert clinicians of a 
drug allergy.
    The departments have begun to implement the first release 
of an interface between their modernized data repositories and 
are currently exchanging computable outpatient pharmacy and 
drug allergy data at seven VA and DoD sites.
    At the same time, the departments have made progress on 
short-term projects to share health information using their 
existing systems. Of these, the Laboratory Data Sharing 
Interface Application is currently implemented at nine sites, 
allowing the departments to share medical laboratory results.
    In addition, the Bidirectional Health Information Exchange 
or BHIE interface is allowing a two-way view of selected 
categories of health data on shared patients from VA's and 
DoD's existing health information systems.
    Because BHIE provides access to up-to-date information, the 
departments' clinicians have expressed interest in its further 
use. Accordingly, since May, the departments have been 
expanding BHIE's capabilities and implementation using the 
interface to connect not only VA and DoD but also DoD's 
multiple legacy systems which were not previously linked. In 
this way, the departments have begun sharing more of their 
current information more quickly.
    Beyond these two efforts, various ad-hoc processes that the 
departments established to provide data on severely wounded 
servicemembers to VA's polytrauma centers are being used. These 
processes include manual work-arounds such as scanning paper 
records for transfer to incompatible systems.
    While particularly significant to the treatment of 
servicemembers who sustain traumatic injuries, as we have 
testified previously, such laborious processes are generally 
feasible only because the number of polytrauma patients is 
small.
    Overall, through all of these initiatives, VA and DoD are 
exchanging health information which is an important 
accomplishment. However, these exchanges are limited and 
significant work still remains to achieve the long-term goal of 
a comprehensive electronic medical record.
    Moreover, it remains unclear how all of the initiatives 
that VA and DoD have undertaken are to be incorporated into an 
overall strategy for a seamless exchange of health information.
    The multiple projects and ad-hoc processes being discussed 
today highlight the need for further efforts to integrate 
information systems and automate information exchanges. Yet, VA 
and DoD are continuing to proceed without a comprehensive 
project plan and overall strategy to effectively guide their 
efforts.
    As we have previously recommended, the departments need 
such a plan to help ensure success in reaching their goals.
    This concludes my prepared statement. I would be pleased to 
respond to any questions that you may have.
    [The prepared statement of Ms. Melvin appears on p. 54.]
    Mr. Walz. Thank you, Ms. Melvin.
    In listening, and I think you heard on the last panel as we 
were trying to assess where we are at on this progress, what is 
GAO's assessment as far as a timeline of a real-time viewable, 
useable platform for these medical records? Do you think it is 
reasonable or are we a year, are we 2 years, or where are we at 
from this being in place?
    We saw, and heard General Robb talk about, that there has 
been a momentum. There has been the resources necessary. We 
have been moving toward it. We are seeing successes.
    In your opinion, where are we at in terms of before this is 
going to be up and running?
    Ms. Melvin. We have seen definite progress in terms of the 
short-term initiatives that were mentioned today relative to 
the Bidirectional Health Information Exchange. There are other 
initiatives related to the laboratory data sharing interface as 
well as a number of ad-hoc processes that have been put in 
place, in particular to serve the polytrauma patients who are 
coming back into the country.
    From our assessment, these initiatives definitely bring 
additional capabilities and services to the clinicians by 
providing them with more information. However, I am not able to 
say when the departments would be at a point of having the goal 
of a longitudinal, comprehensive electronic medical record, 
which they have indicated was their long-term goal or mission 
to have, because we have not yet seen their final plans for 
actually doing that.
    As of now, we cannot state when they would have those 
systems in place. Both departments at this point have told us 
that they do not have a date for their final modernized systems 
which are key components of putting in place the overall 
sharing capability that they have talked about having.
    Mr. Walz. So no data has been expressed? It is just a goal 
out there to try and get it done?
    The reason I ask this is I am optimistic on this. The need 
to get this done is very apparent, but I do not want to find 
myself in the position of my colleague from Texas of being here 
for 9 years and saying I can remember that conversation we had 
back in October of 2007 and here we are in 2016.
    Do you have that fear or do you think that there is a 
difference now?
    Ms. Melvin. There is a concern that we still have from two 
perspectives. First of all, as I mentioned in my last response, 
both departments are still in the process of developing their 
modernized health information systems. Those are the two 
systems that we no longer see specific completion dates for.
    Beyond that, one of the concerns that we have repeatedly 
raised in our work is that the departments did not articulate a 
defined strategy for getting to this final mission. And within 
that strategy, we would certainly hope that there would be 
interim milestones as well as a final timeframe for 
accomplishing this.
    Mr. Walz. Thank you, Ms. Melvin.
    Ms. Brown-Waite, the Ranking Member, is recognized.
    Ms. Brown-Waite. Thank you very much.
    I have been here. This is my fifth year here, not fifth 
term, but fifth year, and served on the Veterans' Affairs 
Committee. And this has been an ongoing issue and it is almost 
to the point where it is like deja vu all over again because 
the same issue has not yet fully been resolved.
    I think we have come a long way. Of course, part of the 
problem is we do not have any authority over DoD in this 
Committee. But I think that there finally seems to be a working 
relationship there and the belief that Congress is not going to 
just drop this issue.
    In your testimony, you stated that although there are 
multiple initiatives between the VA and the DoD, there is an 
important requirement to integrate and automate information 
exchange. I think you further stated that there is not a clear 
overall strategy to incorporate this in a seamless exchange of 
information.
    I have been here 5 years. Mr. Rodriguez has been here ten 
total, nine total. How many times have you stated this same 
finding?
    Ms. Melvin. Well, we have been reporting on this issue 
since 2001 and across the multiple reports that we have issued, 
we have, in fact, made the recommendation and reemphasized that 
recommendation a number of times.
    Ms. Brown-Waite. Do you know offhand how many?
    Ms. Melvin. I can provide you that for the record. I do not 
know offhand at this moment, but we can certainly tell you 
after this hearing.
    [The response was provided in the Post Hearing Questions 
and Responses for the Record, which appear on p. 83.]
    Ms. Brown-Waite. Okay. Are you encouraged that there seems 
to finally be the realization by DoD that this has to happen?
    Ms. Melvin. We are encouraged in seeing the different 
initiatives, the short-term initiatives that are being put in 
place. We do see them as an opportunity to provide more 
information to the clinicians in the immediate.
    What we have not seen is the actual plan that VA or DoD 
would be using to do this. So I hesitate to say that or to 
speak or render a view of the plan that DoD has at this time 
because we have not actually seen that plan. I am not familiar 
with the road map that they have indicated that they have.
    Ms. Brown-Waite. Have you asked to see it?
    Ms. Melvin. We have asked for their strategies relative to 
what they are doing. We have not been informed prior to today 
that there was an actual road map.
    Ms. Brown-Waite. Okay. With that, I yield back the balance 
of my time.
    Mr. Walz. Mr. Rodriguez is recognized.
    Mr. Rodriguez. Let me ask you in terms of trying to get 
this accomplished and get it done, do we need to give you any 
additional leeway or any guidance, you know, or any additional 
authority to go in? Are you going to be going in again and 
reassessing where they are at or do you need that additional 
guidance from us?
    Ms. Melvin. We have previously responded to your request 
for oversight in this particular area. So certainly to the 
extent that you would want to have additional oversight, we 
would certainly be willing to follow through with that.
    Mr. Rodriguez. Because it has been an issue that I think we 
have dealt with. I think they dealt with it for 4 or 5 years 
prior to even going to GAO. And I am convinced that there is 
some movement now, but I am concerned that you mentioned just 
short term, I think mainly because our troops are coming in and 
it is embarrassing to leave some of these seriously injured 
troops out there and just transfer them out and fall through 
the cracks the way they have been falling through the cracks. 
And that is obvious now. But we have to come to grips and try 
to come up with and require them to come up with a long-term 
strategy.
    So I would encourage the Chairman to look in terms of what 
we might have to do in asking the GAO to continue on this issue 
for further implementation of that and requiring the DoD to do 
that and maybe getting the Armed Services Committee, getting 
Chairman Skelton also aware of our concerns as it deals with 
our servicemember.
    And I am concerned not only with the existing one, but, you 
know, we are not going back. I am just going back on my own 
personal experience with them in terms of health. It is kind of 
like they drop them and then they do not particularly care 
anymore, you know, and they expect the VA to handle them. And 
for good reason, you know, if we had that information and 
follow the soldier, it would help us tremendously, not to 
mention what it would do to the soldier.
    So I would ask the Chairman to see if we can keep on this 
track and hopefully 10 years from now, we will not be talking 
about this, but maybe going after some of those other pockets 
of concerns that I had with those other studies.
    While I am here, and maybe you are not the one, we had 
asked for studies on Project 112. I do not know if you heard me 
talk about our soldiers that the Department of Defense had used 
studies on, health studies, you know, where they used nerve gas 
and other things on ship.
    And maybe later on, I would like to see if, you know, we 
can get a report as to where we are at on that because I have 
not heard anything. And once again, it is my fault because I 
have not been here. I was gone for 2 years. But I wanted to get 
an assessment of that and if you get me that information as to 
where we are at. And back then, we had identified, as I recall, 
some 5,600 soldiers, but we were concerned that there might 
have been more and maybe other projects that were not disclosed 
where we could ID additional soldiers that might have been 
impacted with certain forms of studies that were done with 
plombage and other things because we knew that there were some 
other exercises that took place that were not part of the 56 
projects that were out there.
    Ms. Melvin. Sir, I am not familiar with those studies, but 
we would be glad to go back and share your concerns and 
interest with others in our healthcare area who might be more 
familiar and have them to be in touch with you on that matter.
    Mr. Rodriguez. Okay. And also if you have done any studies 
on the recent diagnosing of soldiers with personality disorders 
because the other question that would come into play if they 
did come in with preexisting condition, personality disorders, 
you know, schizophrenia can have an onset around that age, but 
those onsets are much earlier.
    So the question would be, why did we allow them to get into 
the military in the first place if that was the case? If you 
have anything on that, I would appreciate it.
    Ms. Melvin. Okay. Will do.
    Mr. Rodriguez. Thank you.
    Mr. Walz. The gentleman from Ohio, Mr. Space, is 
recognized.
    Mr. Space. I have no questions, Mr. Chairman. Thank you.
    Mr. Walz. Ranking Member Brown-Waite?
    Ms. Brown-Waite. Mr. Chairman, I have just one other 
question for Ms. Melvin.
    Have you, in pursuing this issue, had any indication that 
perhaps part of DoD's reluctance to proceed with the 
information sharing may be because of a concern with the 
security of VA's system?
    Ms. Melvin. We have not heard that concern expressed. I 
would say that most of our studies have focused on the VA/DoD 
sharing effort from looking within the Department of Veterans 
Affairs and the relationships that it is having with DoD.
    However, I would say that because we are talking about 
sharing data across networks in particular and a number of 
multiple systems involved, certainly the security aspect is 
very critical to what they are doing.
    However, we have not gotten specific statements rendered to 
us relative to concerns with that at the moment.
    Ms. Brown-Waite. Thank you very much.
    And with that, I yield back.
    Mr. Mitchell [presiding]. Thank you.
    Mr. Rodriguez?
    Mr. Rodriguez. Yes. One last question since the issue of 
the VA and the documentation and security of that documentation 
was raised, maybe later on, Mr. Chairman, not so much for the 
GAO, but for the Chairman to see later on in the next coming 
year, we get an assessment of where the VA is in terms of that 
documentation because even then, I think we have talked about 
trying to get external groups to come in and take care of the 
computer stuff for them or try to correct that. But unless the 
GAO has something that is more recent from the last testimony 
we received, I would like to get some feedback on that.
    Ms. Melvin. We have, if you are talking about their 
computer security, in particular, we have issued a report. I 
believe it was on September 19th. What I would like to do is 
again have our Director who has the expertise relative to 
security issues to contact you and provide you specific 
information.
    But we have identified some problems and concerns along 
with progress relative to their overall information security 
management program that we would be glad to share with you in 
detail.
    Mr. Mitchell. Thank you. All right. Thank you very much.
    Ms. Melvin. You are very welcome.
    Mr. Mitchell. I would like to welcome Panel Number Three to 
the witness table. Colonel Keith Salzman is the Chief of 
Informatics from Madigan Army Medical Center and the Western 
Region Medical Command. He has been taking the lead with his 
counterparts at the VA Puget Sound Healthcare System on 
creating a pilot program for sharing electronic medical 
information.
    Lieutenant Commander James Martin fulfills a similar 
function at the new truly Federal facility being created by the 
U.S. Navy and VA out of the Great Lakes and North Chicago 
Hospitals. Lieutenant Commander Martin has been instrumental in 
helping create a way for DoD and VA to treat patients at the 
same facility while fulfilling their missions.
    Mr. Howard Green, the Deputy for the Operations Management 
for Veterans Health Information Technology, Office of 
Enterprise Development at the VA is here to discuss where the 
VA stands in making sure all facilities can access medical 
information from the DoD as needed.
    Finally, Colonel Greg Andre Marinkovich is here 
representing DoD's Clinical Information Technology Program 
Office or CITPO which is the DoD organization responsible for 
implementing sharing agreements throughout the service and 
theater.
    And I would like to thank each of these gentlemen for the 
work they do on behalf of our veterans and Nation and will 
recognize Colonel Salzman and all four panelists for 5 minutes. 
Thank you.

 STATEMENTS OF COLONEL KEITH SALZMAN, M.D., MPH, FAAFP, FACHE, 
   CHIEF OF INFORMATICS, WESTERN REGION MEDICAL COMMAND AND 
  MADIGAN ARMY MEDICAL CENTER, TACOMA, WA, DEPARTMENT OF THE 
ARMY, U.S. DEPARTMENT OF DEFENSE; HOWARD B. GREEN, PMP, DEPUTY, 
OPERATIONS MANAGEMENT, VETERANS HEALTH INFORMATION TECHNOLOGY, 
  OFFICE OF ENTERPRISE DEVELOPMENT, OFFICE OF INFORMATION AND 
  TECHNOLOGY, U.S. DEPARTMENT OF VETERANS AFFAIRS; LIEUTENANT 
 COMMANDER JAMES LAWRENCE MARTIN, REGIONAL INFORMATION SYSTEMS 
OFFICER, NAVY MEDICINE EAST, MEDICAL SERVICES CORPS, DEPARTMENT 
 OF THE NAVY, U.S. DEPARTMENT OF DEFENSE; AND COLONEL GREGORY 
     ANDRE MARINKOVICH, M.D., DATA MANAGEMENT PRODUCT LINE 
  FUNCTIONAL MANAGER, CLINICAL INFORMATION TECHNOLOGY PROGRAM 
    OFFICE, MILITARY HEALTH SYSTEM, MEDICAL SERVICE CORPS, 
       DEPARTMENT OF THE ARMY, U.S. DEPARTMENT OF DEFENSE

               STATEMENT OF COLONEL KEITH SALZMAN

    Colonel Salzman. Thank you very much, Mr. Chairman, 
Congressman Brown-Waite, and the distinguished Members of the 
Subcommittee, for inviting me to testify.
    I am, as said, Colonel Salzman from Madigan Army Medical 
Center and have the privilege of leading in the newly emerging 
discipline of informatics.
    We have had a long history of command support at Madigan 
for doing projects that are often funded out of hide. So having 
the National Defense Authorization (NDA) funds to supplement 
our efforts has propelled us down the path in sharing 
information technology.
    In the 3 years that we have had to complete the 4-year 
project, we have delivered all the deliverables that we were 
chartered to do in our business plan and all of those 
deliverables are in use in the enterprise system. So it shows 
the benefit of merging local development with enterprise 
architecture to deliver rapid turnaround products that can be 
used in the information systems.
    In addition, we have added information requirements to 
cater to polytrauma information needs as well as additional 
requests from VA providers and DoD providers as we have 
prioritized from critical information needs to less critical 
but important needs.
    At the outset of this testimony, I would underscore our 
assessment that the choice on many levels that we face if it is 
couched in an either/or strategy is misinformed, but we need to 
look at both strategies in approaching the problems that we 
face starting with having the local and the enterprise teams 
meet together and work together so that both are working 
together on the solution and not the local project as an 
isolated project directing things or an enterprise solution 
directing things that does not meet local needs.
    The initial challenges surrounded learning required to 
overcome the first either/or proposition of who drove the 
project, enterprise or the local site. A critical lesson 
learned was both. The local site had access to the clinical end 
user community and the requirements necessary to improve the 
flow of information while the enterprise had ownership of the 
architecture and systems and which requirements would be built 
and deployed.
    At the outset, it is important to state that while this 
project is a demonstration project, all of the deliverables are 
being used by the enterprise systems of both the DoD and VA in 
production in near real time and that is meaning in seconds, 
not days, weeks, or months.
    The strategy of development based on the priority of 
information delivery shaped our work and the work cycles for 
this project were generally in six- to nine-month increments.
    The critical dialog between clinical end user and the 
development team at the local level combined with an active 
dialog between local and enterprise team members ensured that a 
principle of software development, namely to correct functional 
problems as they are identified in the design phase, proceeds 
iteratively and cost effectively.
    The savings can be significant over allowing major design 
problems to persist into production. This exemplifies another 
both solution to an either/or proposition.
    As far as AHLTA or VistA, there are strengths and 
weaknesses in both systems. That is another either/or 
proposition, I think, that is better answered with both.
    AHLTA is integrated worldwide and available 24/7. There are 
functional problems that are being worked on to improve use at 
the clinical and at the business level.
    VistA shows the benefits of local design and its adoption 
by end users who are more inclined to buy into products they 
create.
    The downside for the VA is the historic lack of 
configuration management. I use management intentionally as 
against configuration control. The VA faces big challenges in 
reorganization and must be careful not to destroy the strategy 
that delivered its success while addressing its Achilles heel 
of decentralized, unmanaged growth.
    The cost of imposing one system on both organizations now 
would be prohibitive. Establishing interoperability and 
designing a strategy of convergence over the next 10 to 20 
years will allow both a solution and capitalize on best 
practices and less disruptive to changes to either system.
    These comments summarize what I would offer as a Steering 
Committee Member engaged in this project from the start.
    I would also encourage Congress to continue its support of 
the VistA program and the agencies involved. Sustaining this 
and other successful projects will enable the DoD and VA to 
maintain forward momentum rather than losing the intellectual 
capital that brought these results about.
    And in addition to General Robb's testimony, I think 
financial resources to maintain the intellectual momentum we 
have gained are necessary. And I would say that we need those 
to continue. Otherwise, we will get this far and then put on 
hold until another round of money comes through and you have to 
reassemble a team and start basically, go a few steps backward 
before you can go forwards again.
    I would like to thank the Committee for inviting me to 
testify and welcome questions.
    [The prepared statement of Colonel Salzman appears on p. 
64.]
    Mr. Mitchell. Thank you.
    Mr. Green, you have 5 minutes.

                  TESTIMONY OF HOWARD B. GREEN

    Mr. Green. Thank you, Mr. Chairman. I would like to thank 
you for the opportunity to testify on sharing of electronic 
medical information between the Department of Defense and 
Department of Veterans Affairs, what is being done to 
accomplish the objectives and the viability of the approach.
    I have been a member of the Department of Veterans Affairs 
Health Information Technology (IT) community for over 19 years, 
serving in multiple capacities at the local, regional, and 
national level.
    Prior to joining the Office of Information and Technology 
in 2004, I was the Chief Information Officer (CIO) for the VA 
Heartland Network, Veterans Integrated Systems Network 15, and 
was responsible for the introduction of VA's VistA system at 
all facilities and clinics in the region.
    Most recently, as Deputy for Operations Management within 
the Veterans Health IT portfolio, I participated as a staff 
member on the President's Commission for America's Returning 
Wounded Warrior and was co-author of the Information Technology 
chapter and final report recommendations.
    Following that assignment, I have been given the 
responsibility for coordinating many of the recommendations 
from the President's Commission report.
    Formal activities related to the sharing of clinical 
information between VA and DoD have been ongoing since 2001. 
Although there are a number of systems that have been developed 
to support this function, for all intents and purposes, the 
overarching goal is the bidirectional exchange of computable 
information between VA and DoD in real time.
    The following are a selection of the systems that are in 
place to support the exchange of clinical information: 
Bidirectional Health Information Exchange or BHIE supports the 
functional interoperability between VA and DoD through the 
exchange of textual patient health information. Through BHIE, 
the two departments have transferred information for over 2.3 
million unique patients who are active dual consumers. The 
information is viewable through BHIE. The BHIE interface flows 
to and from the following systems:
    On the VA side, we pull data from 128 VistA systems and the 
data is viewable through Computerized Patient Record System 
(CPRS) and VistA web. On the DoD side, data is pulled from the 
composite healthcare system, clinical data record, the clinical 
information system (CIS), and theater medical data store. Data 
is then viewable through the AHLTA share application.
    Currently VA and DoD are bidirectionally sharing viewable 
information supporting ten categories of clinically relevant 
data including outpatient pharmacy data and anatomic 
pathologies, surgical reports, radiology text reports, and 
discharge summaries from several DoD sites running CIS.
    By December 2007, the goal is to expand the amount of 
clinical data exchange through BHIE to include encounter notes, 
patient focus problems list, and theater level inpatient and 
outpatient notes.
    By September 2008, VA and DoD improvements will include the 
addition of a polytrauma marker, an OIF combat veterans 
identifier, electronic patient handoff indicators, DoD scanning 
interface, the interagency sharing of essential health images, 
and much more.
    The clinical health data repository or CHDR is the clinical 
data interface that supports the exchange of standardized and 
computable data. This data can be used to support the automated 
clinical decision support tools such as drug/drug and drug/
allergy order checking.
    Currently data from the CHDR system interface is being used 
at seven VA and DoD sites. The interface currently supports the 
movement of pharmacy and medication allergy data and will be 
upgraded to include chemistries and hematologies in the fourth 
quarter of fiscal year 2008.
    The key distinction between BHIE and CHDR is that the 
applications leveraging the BHIE interface often require the 
clinicians to look in several locations to retrieve health 
record information from other points of care. This often 
requires the clinician to interpellate based on approximation 
when comparing data elements due to the different 
terminologies.
    By comparison, clinical information obtained through CHDR 
can be incorporated into the same clinical view allowing for 
automated computation and thus allowing the users to readily 
compare like data.
    Collaborations such as the one between the VA Puget Sound 
Healthcare System and Madigan Army Medical Center focuses on 
specific functionality and support of limited sharing 
agreements and are vital partners in the process of 
demonstrating new capabilities and functions.
    By comparison, the Great Lakes Federal Healthcare Center 
will eventually push the concepts of medical and administrative 
data sharing to its limits. The goal at the Federal Healthcare 
Center is to fully integrate the clinical and administrative 
functions between the two healthcare systems.
    Planning activities are underway to develop the local 
project team to support this activity and, additionally, an 
enterprise level of team resources is being assembled to 
resolve technical and operational issues that are beyond the 
local team's ability to address.
    There are certainly advances in the application of 
information technology that can be applied. However, the 
process is complex and must be driven by key business decisions 
and not by IT.
    Mr. Mitchell. Could you----
    Mr. Green. Mr. Chairman, this----
    Mr. Mitchell. Okay.
    Mr. Green [continuing]. Does conclude my opening remarks.
    [The prepared statement of Mr. Green appears on p. 68.]
    Mr. Mitchell. Thank you.
    Lieutenant Commander Martin?

    STATEMENT OF LIEUTENANT COMMANDER JAMES LAWRENCE MARTIN

    Commander Martin. Mr. Chairman and Members of this 
distinguished Subcommittee, thank you for inviting me to be 
here today. I am Lieutenant Commander James L. Martin and I 
serve as the Regional Information Systems Officer, Navy 
Medicine East.
    Thank you for this opportunity to talk about my personal 
involvement in design and implementation of the composite 
healthcare system, CHCS2, AHLTA, and the electronic medical 
record sharing between the Department of Defense and the 
Department of Veterans Affairs.
    The present method of sharing electronic medical 
information at Naval Health Clinic, Great Lakes is through the 
Bidirectional Health Information Exchange, BHIE, and the 
clinical health data repository, CHDR.
    The Veterans Affairs' providers are granted read-only 
access to the Department of Defense composite healthcare system 
and AHLTA. The Department of Defense providers are granted read 
and write privileges to the Veterans Affairs' computerized 
patient record system which resides on the Veterans Health 
Information System and Technology Architecture, VistA.
    Specifically, access to the composite healthcare system, 
AHLTA, and the computerized patient record system in North 
Chicago is achieved through a single end user device with icons 
on the desktop representing each of these applications. This 
allows for seamless patient flow from the recruit processing 
center clinic at recruit training center, Great Lakes, to the 
emergency room and inpatient facility at the North Chicago 
Veterans Affairs Medical Center.
    Laboratory data sharing interoperability, LDSI, is used to 
share laboratory information between these two systems. The 
combination of these methods listed above allows complete 
sharing of all clinical information between the Veterans 
Affairs and the Department of Defense providers.
    My personal involvement in this process dates back to 1992 
when I assisted in the design and implementation of the 
infrastructure and end user device placement and support, a 
Composite Healthcare System, CHCS Legacy.
    While serving as Assistant Department Head in Naval Medical 
Information Management Center, Bethesda, my involvement 
included personally visiting each naval healthcare treatment 
facility prior to and during the system implementation.
    Thereafter, my role expanded in 1994 as Head Management 
Information Department Naval Hospital, Pensacola, where I 
managed the composite healthcare system host site for the 
hospital and its remote facilities.
    In 1997, while serving as the TRICARE Region 2 Regional 
Information Systems Officer, Naval Medical Center, Portsmouth, 
one of our commands was selected to be the test site for the 
composite healthcare system 2, the predecessor to AHLTA.
    From 2000 to 2004, I was the Information Systems Officer at 
Navy Medical Center, Portsmouth overseeing the test and 
implementation of the composite healthcare system 2 system, 
AHLTA.
    It was during this tour that Naval Medical Center, 
Portsmouth first populated the clinical data repository with a 
25-month data pool from the CHCS Legacy system, placing 
demographic information and laboratory, pharmacy, and radiology 
results in the clinical data repository.
    From 2004 until 2006, I served as the Medical Liaison 
Officer, Space and Naval Warfare System Center, Norfolk, where 
I was in charge of design and testing of the theater medical 
information program maritime, TMIPM, the Navy operational 
version of the composite healthcare system 2 and AHLTA, 
designated at the time CHCS2 and AHLTA-T.
    Currently as the Regional Information Systems Officer for 
Navy Medicine East, I oversee all the information management 
and technology for the Navy military healthcare facilities that 
fall under Navy Medicine East. Naval Healthcare Clinic, Great 
Lakes is one of these commands.
    I have made five site visits in direct support of the DoD/
VA initiative at Great Lakes. During these visits, I have 
surveyed the existing facilities and assisted in the planning 
and relocation of the Information Management/Information 
Technology (IM/IT) equipment to its new location at the Federal 
Healthcare Center.
    I attend biweekly conference calls and engineering support 
meetings where the design and layout of the actual IM/IT spaces 
is discussed.
    The other commands under Navy Medicine East that I am 
presently assisting with DoD/VA IM/IT initiatives include Naval 
Health Clinic, Charleston, Naval Hospital, Pensacola, Navy 
Hospital, Jacksonville, and Naval Medical Center, Portsmouth.
    I am also a member of the National Information Management 
and Technology Task Group for the Department of Defense and 
Department of Veterans Affairs Electronic Health Information 
Sharing Initiative.
    My responsibility as a member of this task force is to plan 
and oversee the acquisition and implementation of information 
systems that integrate VA and DoD healthcare processes at the 
North Chicago Federal Healthcare Center.
    Our goal is to have an interoperable information system 
that supports clinical and business operations by June 2010. We 
plan to create a single main computer room and a single main 
telecommunications room.
    Additionally, an information management and information 
technology network trust between DoD and VA must be established 
along with domain ownership and single electronic mail system.
    We are presently gathering requirements in the functional 
use so that a determination can be made on whether a 
combination of the information systems or a new information 
system is required to meet the functional user requirements.
    The ultimate goal is to have a single point of entry to 
support the missions of both DoD and VA patient populations. At 
present, this goal is met by providing access to CHCS, AHLTA, 
and CPRS using multiple icons on a single end user device.
    Mr. Mitchell. Could you wrap up your testimony, please?
    Commander Martin. Yes, sir.
    In addition to the goal of the single point of entry, we 
are also working on the consolidation of IM/IT systems of all 
the functional areas in the Federal Healthcare Center. This 
involves the management of development of functional 
requirements, assisting with local site integration efforts, 
assisting enterprise solutions, and communicating the status.
    I would like to conclude by saying that one of our top 
priorities is to continue finding ways for electronic medical 
data sharing between DoD and VA.
    Mr. Chairman, Committee Members, thank you again for this 
opportunity to speak about our efforts. At this time, I would 
be pleased to answer any questions you may have.
    [The prepared statement of Commander Martin appears on p. 
71.]
    Mr. Mitchell. Thank you.
    Colonel Marinkovich, you have 5 minutes.

         STATEMENT OF COLONEL GREGORY ANDRE MARINKOVICH

    Colonel Marinkovich. Mr. Chairman, Members of this 
distinguished Subcommittee, thank you for inviting me here 
today. I am Colonel Andre Marinkovich and I serve as the Data 
Architect in the Clinical Information Technology Program 
Office, that is CITPO, with the MHS, Military Health System.
    Thank you for this opportunity to talk about the military's 
electronic health record, AHLTA, and the strides we are making 
in sharing information between the Department of Defense and 
the Department of Veterans Affairs.
    AHLTA is an enterprise-wide medical and dental outpatient 
clinical information system. It currently is the military's 
outpatient EHR or electronic health record that generates, 
stores, and provides secure online access to longitudinal, 
lifelong patient healthcare records for the more than 9.1 
million MHS beneficiaries seen in our military treatment 
facilities.
    AHLTA ensures the continuity of the Department's health 
information and patient centered healthcare delivery worldwide 
with accessibility anywhere, any time. Worldwide deployment of 
AHLTA which began in 2004 was successfully completed in 
November of 2006. Implementation support activities span 11 
time zones and trained over 55,000 users with more than 18,000 
healthcare providers.
    The current AHLTA functionality includes encounter 
documentation, orders, results, retrievable coding, and alerts, 
reminders, role-based security, master patient index, the 
ability to do ad-hoc queries.
    AHLTA use continues to grow at a significant pace. To date, 
we have had 45 million outpatient encounters recorded. It is 
growing approximately 120,000 to 112,000 per day, per workday.
    DoD and VA are also taking the first steps toward a joint 
electronic health system. There has recently been a contract to 
assess the DoD and VA's business and clinical processes, design 
features, and system constraints relative to the inpatient 
component of an EHR.
    This assessment will determine and describe in narrative 
and graphic format the scope and elements of the joint 
inpatient electronic health record and identify those clinical 
and business capabilities and applications that interact with 
the joint inpatient electronic health record.
    An analysis of alternatives will then be conducted to 
develop a recommendation for the best technical approach. We 
will then implement that solution.
    Based on feedback from several AHLTA user conferences, we 
are making significant changes to the next version of AHLTA 
that will be released in December 2007. Better performance and 
better user friendliness are a couple of the things that we are 
going to be providing. There will also be other enhancements 
with the ability of people to use the system from multiple 
sites and enable mobile providers to continue to use the system 
seamlessly.
    Looking ahead into 2008, we plan to begin worldwide 
deployment of dental charting and eyeglass ordering.
    I would like to conclude by saying that one of our top 
priorities is to continue finding ways for AHLTA to seamlessly 
transfer information between the DoD and the VA, ensuring 
continuity of quality care for returning wounded warriors.
    With your support, we will continue building on our 
achievements and sharing electronic health information in 
support of the men and women who serve and have served this 
country.
    Mr. Chairman, Committee Members, thank you again for this 
opportunity to speak about our efforts. And at this time, I 
would be pleased to answer any questions you may have.
    [The prepared statement of Colonel Marinkovich appears on 
p. 73.]
    Mr. Mitchell. I want to thank all of you. And I wanted to 
apologize before the bell rings that we are about to be called 
for a vote which means we will take a vote and I am not sure 
how many votes there will be. Okay. So it will be about a half 
hour in between. But we can get started with some of the 
questions anyway until the bell rings, but I wanted to 
apologize. We will take a break and recess and come back.
    The last two panels explained the importance and necessity 
for electronically sharing medical records. You are all on the 
ground doing it. And the question is for the DoD folks.
    In your opinion, what obstacle is most responsible for 
getting in the way of sharing electronic medical records with 
the VA? Anyone?
    Colonel Marinkovich. I think the biggest obstacle has been 
that the DoD has been working to develop and deploy a system 
that has only recently been finished. And I think since that 
time, since basically December of 2006, we have made really 
significant strides in terms of being able to share 
information.
    Our systems simply did not have all of the electronic 
information that we wanted to share and I think now we are 
beginning to have all that and have those capabilities. So I 
think once things become electronic, the sharing becomes easier 
and all the work that we have been doing with BHIE and with 
CHDR are going to bear fruits.
    Mr. Mitchell. Mr. Green, first of all, do you agree with 
the assessment of what has been holding us up?
    And, secondly, I know the VA has been actively researching 
and implementing electronic medical records. I am also aware 
that integrating these systems with DoD records has been 
challenging.
    What is standing in the way of getting all of this medical 
information into a readable and computable format and how long 
will that take to do that?
    Mr. Green. Well, I would certainly agree with the 
statements of Colonel Marinkovich.
    The question is somewhat complex. As far as how long it 
will take, we do have plans to complete delivery of the medical 
record through the end of fiscal year 2008. However, and what 
you have seen is, you know, a slow progression from 2001 
forward.
    Some of the issues are as Colonel Marinkovich stated, but 
you also have to understand that the state of the industry is 
not exactly rushing ahead of us to say this is how we should do 
it. A lot of the territory that we are stepping into is new 
ground.
    There are no standards in certain spaces that we are 
working with and we are having to derive those standards in 
advance of, say, what the national interests may come to 
conclude.
    So there are a lot of technical challenges. I have seen a 
lot of activity in the past 24 months which is extremely 
pleasing and great to see. We have a long road to go. and we 
are working as collaboratively as we have ever worked in the 
past.
    Mr. Mitchell. Thank you.
    And one last question for anyone on the panel. Are there 
any possible Health Insurance Portability and Accountability 
Act (HIPAA) restraints or constraints that are standing in the 
way?
    Colonel Salzman. Well, I think both agencies probably need 
to answer independently, but I know on our side, we follow all 
the HIPAA requirements as everyone should. So I do not think 
there are constraints. There are simply things we have to do to 
make sure we cover those bases.
    Mr. Mitchell. And the reason I ask that is because we have 
heard before that the reason there is no sharing of these 
records from DoD to VA is because of HIPAA and that it takes a 
long time. I am just wanting to make sure that, if that is a 
problem and that has held up any transfer of records that we 
take care of that as quickly as we can.
    Colonel Marinkovich. I think you are asking a question that 
really should not be addressed necessarily to technical people. 
We all believe, I think, and I think we would all agree that 
there should be role-based security down to the level of an 
individual patient.
    And so our systems should be able to accommodate whatever 
HIPAA tells us to do. And I think, historically, we have had 
some issues with that because we have needed to get that kind 
of ironed out.
    Mr. Green. I would agree. Certainly we are progressing very 
sensitively through this area. As a member of Dole-Shalala 
Commission, we actually looked into that and did not see any 
overwhelming HIPAA constraints that would preclude the sharing 
of data. In fact, there are sharing agreements that support it.
    But it is something that we do not take lightly. We do not 
want to end up in a situation where we are jeopardizing the 
privacy of either personal health or identifier information.
    Mr. Mitchell. Thank you.
    Would you like to ask some before we--as soon as Ms. Brown-
Waite gets through, we are going to take our recess and go 
vote.
    Ms. Brown-Waite. Just a couple of things. I believe that we 
have held hearings in the past where it was absolutely 
clarified that there are no HIPAA problems. So please, 
gentlemen, do not use that as an excuse. That issue is off the 
table. There are not any HIPAA problems.
    Do you all agree?
    Colonel Marinkovich. Absolutely, ma'am.
    Ms. Brown-Waite. I think in the past, it was a great thing 
to use as an excuse, but it should not be. That show is over.
    Let me ask a question. I have been told this and I would 
like a response. Do the various branches of the military use, 
for example, the same kind of x-ray, magnetic resonance imaging 
(MRI) equipment so that it can be even within the branches 
shared? So if you all use separate systems, is that part of the 
complicated problem here?
    And, you know, there is certainly an ability to save money 
by bulk purchasing. Why is this not done? I mean, why are all 
these separate systems out there? And any one of you all can 
just jump right in here.
    Colonel Marinkovich. I think that is for me to answer. The 
MHS, Military Health System, has not had an overarching 
radiology PACS approach. And so it has been left up to the 
responsibility of the services and the sites themselves to 
procure those kinds of systems.
    Now, part of the reason for that is that those systems are 
medical devices and so they fall under a different set of rules 
and regulations relative to electronic health records.
    And so I think you are absolutely correct. If we had enough 
money to go in and tear out everything we had and put in 
something new, that would be a positive thing. But because 
things have been bought over various periods of time, the life 
cycles are completely out of step.
    Ms. Brown-Waite. So the health system in DoD has been there 
for----
    Colonel Marinkovich. I am talking about PACS, ma'am.
    Ms. Brown-Waite. I beg your pardon?
    Colonel Marinkovich. I apologize. I am talking about the 
radiology systems, what are called picture archiving----
    Ms. Brown-Waite. Correct. It has been there. This is not 
new technology, guys. Okay? It is not new. Why not consolidate? 
Why suddenly say, gee, we have disparate systems?
    Colonel Marinkovich. I think that is going to have to be 
something I will have to leave to Mr.----
    Ms. Brown-Waite. And, you know, this is not something that 
today we should immediately change. It has been coming. You 
know that the sharing issue, it is not new. It has been here 
for a very long time.
    And to have even this complicated system, these systems out 
there that are not even--would it be accurate to say that, you 
know, every time that it is transferred over to a hospital that 
there is a problem? Would that be an accurate thing to say if 
the receiving entity does not have the same ability?
    Colonel Marinkovich. Well, once again, you are asking a 
question that is a little bit outside of my expertise. I can 
tell you that if you are talking about the access to these 
kinds of radiology images for certain kinds of uses that we are 
in the process of putting together an integration effort that 
has made significant strides. We have also worked with the 
folks down in El Paso who----
    Ms. Brown-Waite. Colonel, I do not mean to be rude. I 
really do want to hear your answer. We do have to go to vote.
    Colonel Marinkovich. Not a problem, ma'am.
    Ms. Brown-Waite. Mr. Chairman, if I am unable to come back 
after the vote, I would ask that Art Wu, Minority Subcommittee 
Counsel, take my place instead.
    As you know, Mr. Bilbray is from California and he 
rightfully went to be home with his constituents during the 
tragic fires that are taking place.
    Mr. Mitchell. So without objection.
    Ms. Brown-Waite. Thank you.
    Mr. Mitchell. Thank you.
    This hearing is recessed.
    [Recess.]
    Mr. Rodriguez [presiding]. Thank you very much. I know the 
Chairman hopefully will be making it pretty soon. Let me once 
again just thank you not only for your service but for your 
testimony.
    Some of you, I gather, had the opportunity to listen to the 
testimony of the GAO report. Do you all have any comments in 
terms of their findings and the problems that were identified 
from their findings?
    Mr. Green. Having reviewed those findings in the past and, 
you know, through many efforts, you know, we have made a lot of 
progress. I have to agree. And we continue making progress.
    Is there a need to focus our energy, create a strategic 
direction between the two departments that is tangible, that we 
can build to? I think that is the opportunity that exists.
    And that is one of the points that I clearly take away from 
the GAO report, that a combined plan is necessary that is 
tangible, sets expectations, objectives, and that we can build 
to. So I would be remiss if I said I did not agree.
    Mr. Rodriguez. But the GAO has indicated that you have not 
come up with a long-term plan. And I know the military. If they 
are good for something, they are really good for planning. I 
know you have them all over and I am sure you have some on the 
shelf. So what is the problem?
    Mr. Green. We have plans to deliver, and I invite my other 
colleagues here to comment, but we have plans to deliver 
specific functionality. How that equates into the long-term 
strategy is somewhat vague.
    But we are not doing the wrong things. There is absolutely 
no question in my mind that the things that we do are the right 
things. It is just how do they fit into the overall strategy of 
how VA and DoD need to support our population into the future.
    Mr. Rodriguez. Colonel, anyone else?
    Colonel Marinkovich. Well, I was going to start by just 
apologizing that I do not have full visibility to be able to 
answer the question completely. But I know the 2 years that I 
have spent at CITPO and the Military Health System has 
demonstrated to me that there is just an increasing commitment 
to share.
    And I know that just in this last year, we have been 
working to share electronic documents and radiology images for 
regular providers between the DoD and the VA in a way that, you 
know, is just very encouraging to me. I spent a lot of time 
working with the VA people and our DoD colleagues to achieve 
that. The visibility again is just not----
    Mr. Rodriguez. And, by the way, I was glad that Colonel is 
it Salzman?
    Colonel Salzman. Salzman.
    Mr. Rodriguez [continuing]. That you indicated the need for 
resources in order to make that happen. Although, as I recall, 
we have pumped a good amount of--I cannot quote you the amount 
in the past--whether it has gone for that purpose, I do not 
know--but we have kicked in some resources in the past.
    But you need to let us know the amount of resources that 
are needed in order to make this happen because I think it can 
be more cost effective in the long term, not to mention that it 
would be much better for our soldiers for them to be able to 
have that folder and make better decisions when it comes to 
benefits and other types of treatment.
    Yes, sir. Go ahead, Colonel.
    Colonel Salzman. Thanks for that support. The problem is 
that where the money is allocated makes a difference in what 
programs get supported and how it goes forward. There are so 
many requirements out there that are dedicated and focus on one 
area. To sustain, that requires some intention, you know, from 
Congress through DoD and VA to the specific projects.
    Mr. Rodriguez. And it is my understanding that your program 
is running out of money. Is it because it was not allocated 
sufficient resources or what?
    Colonel Salzman. No, no. It is not that. It is ending as 
far as fiscally. That is the end of that project. And therein 
lies the problem that if you identify toward the end of a 
project something that has been successful, the lag time in 
getting legislation to support that in the future----
    Mr. Rodriguez. That is why the GAO has indicated that you 
have not come up with a plan, a long-term plan that would go 
beyond a year, 2 years, 3 years, whatever. And that is why that 
is essential so that those resources can continue to flow.
    Colonel Salzman. And part of it is the lessons learned that 
you gain as you go through the process. The feedback loop to 
Congress to legislate specifically, that lag time does not 
inform the legislative process, I think.
    Mr. Rodriguez. And, Lieutenant Commander Martin, did you 
want to make any comments on the GAO and the fact that I know 
you have been engaged for a good 15 years? You know, what has 
been the problem?
    Commander Martin. Well, sir, it is my opinion that we do 
have a schedule. It depends on what we are working specifically 
on. If you take North Chicago for an example, you know, our 
timeline is 2010. So we have built a schedule to have your 
facility operational in 2010 with the systems that the 
functional users are identifying.
    Mr. Rodriguez. Okay. Let me go ahead and get, Mr. Wu, do 
you have any questions?
    Mr. Wu. Yes, I do, Mr. Rodriguez. Thank you very much.
    Commander Martin, looking at your testimony--and, Mr. 
Rodriguez and Chairman Mitchell, appreciate the opportunity for 
the Ranking Member to have the questions asked through her 
Counsel--you have been working at this since 1992. Can you tell 
me what the original deployment date was for CHCS1 and 2?
    Commander Martin. The original deployment date for CHCS1?
    Mr. Wu. Its implementation.
    Commander Martin. I do not know that off the top of my 
head, sir. I know what my schedule was in the Navy and we had 
CHCS1 implemented on the Navy side on schedule. I mean, we 
followed it. I did that for 24 months between 1992 and 1994.
    Mr. Wu. Don't you think the original, or maybe someone else 
out there may know, don't you think that implementation date 
was supposed to have been probably a decade ago? Anyone?
    Colonel Marinkovich. I think the answer to that question 
may be able to come more easily from the next panel. But are 
you asking CHS1, sir, or CHS2?
    Mr. Wu. When do you think CHS1 started?
    Colonel Marinkovich. I know when I was in Tripler, it was 
one of the beta sites and that was 1989.
    Mr. Wu. Right. It originally started in 1987. We are in 
2007. We are talking about 2010. And VA has got to follow the 
lead of DoD in order to get that integrated system, correct?
    Mr. Green. Sir, if you are asking that VA has plans to 
create an integrated system that go out several years, I think 
the current year target is 2014 or so and that we have been in 
the process of doing this for several years. That is correct.
    Mr. Wu. All right. Commander Martin, I have another 
question for you if you do not mind. You stated in your 
testimony that your mutual goals with VA is to have an 
interoperable information system that supports joint clinical 
and business operations at the joint venture at Great Lakes 
Naval Training Center in North Chicago by June 2010.
    And I think we all look forward to that happening. I think 
that will be the model on a lot of the governance issues 
between VA and DoD that can be ironed out, at least at that 
test site, maybe not uniquely, geographically unique to that.
    My question to you is, right now does DoD trust VA's IT 
security measures?
    Commander Martin. In my opinion, sir, they trust them. The 
issue is whether or not the VA is recognized as a trusted agent 
with DoD which is separate.
    Mr. Wu. Okay. Are they a trusted agent?
    Commander Martin. As of today, sir, in my opinion, no.
    Mr. Wu. And I also understand the DoD's distrust of VA's IT 
issues and vulnerabilities has resulted in DoD placing its own 
servers in VA's four polytrauma centers. Is this true?
    Commander Martin. I am not an expert in that area, sir. I 
could not answer that one.
    Mr. Wu. Mr. Green?
    Mr. Green. I am not an expert either. There may be somebody 
in the panel behind me that can address that.
    Mr. Wu. So you are punting?
    Mr. Green. I am punting, yes, sir.
    Mr. Wu. Let us say that it is true. What does that indicate 
to you?
    Mr. Green. The placement of servers in the VA application 
in order to support or VA environment in order to support DoD 
applications, it would indicate that we are adding layers of 
complexity in order to achieve the end goal.
    Mr. Wu. Okay. A question collectively for the panel, not to 
put any of you on the spot. This whole issue of 
interoperability exchange and timely exchange of information, 
do you think this is a technological barrier that is taking 
this 20-year tango down this path or is there a cultural will 
issue?
    Colonel Marinkovich. I would have to say from my vantage 
point, it is a little bit of a combination of both because the 
question is what data do you want to share. And if the answer 
is, well, what you put in CHCS, then I agree completely. It 
should not have taken us 20 years to share what is in CHCS with 
what is in VistA, basically being very similar systems.
    But if you are talking about the rest of the EHR, I think 
that has only begun in the last 5 or 6 years to be truly an 
industry in itself and I think we are pretty close to being 
able to deploy that kind of capability between the two agencies 
or the readability, the readable electronic health record.
    Mr. Wu. Anyone else? Colonel Salzman.
    Colonel Salzman. Yes, sir. As far as interoperability, and 
I did not get to those comments in my testimony, but I think 
that that is where we are now capable of doing that 
technologically.
    But if you look at the private healthcare sector, they are 
facing the same problem. And I think by breaking ground, the 
DoD and VA are leading in the efforts to demonstrate 
interoperability and that the private sector will follow that 
path as we extend it into Regional Health Information 
Organizations (RHIOs) and into the national health information 
network. So I do not see us in looking at private healthcare 
sector as being behind. I think we are in the lead. And that--
--
    Mr. Wu. I do not think there is an argument there even 
though I have seen a couple meltdowns on the RHIO attempts.
    Colonel Salzman. Right.
    Mr. Wu. Is that not correct? San Diego melted. I mean, as 
the private sector, public sector initiatives and DoD and VA 
are leading the way.
    I am just asking after 15, 20, however many years you want 
to call it, the GAO says a decade, we say two decades, some say 
25 years, is why have we not moved, or as the opening statement 
of Ms. Brown-Waite is we have seen probably more movement and 
in Chairman Mitchell's statement as citing more movement in the 
last 24 to 18 months than we have in the last 20 years? What do 
you attribute that to?
    Mr. Green. Well, the standards are being developed kind of 
by Health Level 7 and different organizations, so there is, I 
think somebody mentioned it before, we are kind of charting 
uncharted territory, and so there is a learning curve that has 
to happen in doing that.
    Colonel Marinkovich. I would say, too, I mean, from my 
vantage point, it is because we are being pushed to do that. I 
mean, I appreciate visionary leaders like General Dunn, who 
used to lead us at Madigan, who would set the bar way out in 
front and say make it happen. And I think it is leadership that 
makes these things happen. So we appreciate it.
    Commander Martin. Yes, sir. I have to agree. I think in my 
opinion, anything is technically possible. Now it is defining, 
meeting the mission of the VA and meeting the mission of DoD 
and deciding what are those data fields and elements that we 
absolutely have to share and now we are finally at the point 
where those are being defined by the functional providers. And 
once we have that information, the technology will follow, 
giving them the information they need as the functional 
experts.
    Mr. Wu. Thank you. And I appreciate the latitude that the 
Chair has offered us.
    And piggybacking on Ms. Brown-Waite's questioning of you, 
Colonel Marinkovich, you know, talking about the PACS system, 
talking about the multiple MRI, ophthalmoradiography 
capabilities we have within the services and even within the 
VA, multiple, multiple systems that do not communicate with 
each other, what would be your reaction, and I am not asking 
you to speak for the Department, about an interoperable clause 
in the procurement of major medical IT or medical devices with 
an IT component of both DoD and VA purchases where there is a 
standard utilized where there has to be a sign-off that there 
is an interoperability issue or possibility that that is 
addressed during the procurement phase?
    Colonel Marinkovich. I am strongly in favor of such a 
thing. I have to tell you. I devoted much of the last maybe 6 
or 7 years to standards organizations and the reason we do not 
follow standards is we do not have discipline. I mean, that is 
what you need to have to follow standards.
    But I think that is only part of it. Once we have done 
that, we then still need to have an overarching governance and 
an overarching management structure to make the systems that 
could talk to each other actually connect. So I agree with you. 
You are absolutely----
    Mr. Wu. I appreciate that.
    Your indulgence one more time, Mr. Rodriguez. I have a 
question for this panel and the next panel is an issue that you 
see in the press quite a bit now as we talk about our wounded 
warriors come back from OIF and OEF is TBI, mental health 
component, PTSD, and how they are related perhaps sometimes, 
many times.
    What are we doing about capturing that information and 
sharing that information? I do not see any of that in anyone's 
testimony, in any of the briefings we have had on what we are 
doing as these soldiers and servicemembers transition to the 
VA.
    How do they get treated if there is no PTSD record or 
record of medical annotation or any other mental health issue 
or what you need to capture on the requirements under TBI if 
you are going to screen? How is the VA going to do that or how 
does VA work a compensation and pension claim for those 
diagnoses if that information is not being transferred in some 
format? I am not even talking electronically to the VA. How 
does the VA do their job if they do not get the information?
    I know that mental health records are held separately. I 
used to be in the Army, an inpatient admin, and those mental 
health records are kept separately or retired separately. I do 
not see where they are merged. So if they are not merged, where 
do they go to and how does VA get access to them?
    Colonel Salzman. If I could answer from how we do that 
locally and we are trying to design a model for expanding to 
the enterprises, which we always keep in sight, we have a swap 
process. I do not know if you were able to see that when you 
were out there, but that interview process captures all the 
survey information.
    Mr. Wu. Actually, we did see that, Colonel Salzman. Is that 
Madigan specific?
    Colonel Salzman. Yes, sir. And that----
    Mr. Wu. And what about the other 65 facilities?
    Colonel Salzman. Well, the DoD is looking at that. What 
happened was there was a mandate to come up with a solution but 
no overarching process to do that. And so of necessity, which 
is what usually happens, and particularly with TBI, you have a 
new requirement and you have to address it. And there is not an 
enterprise process that addresses it effectively to deliver a 
solution that handles the soldier in front of you.
    Mr. Wu. It was pretty impressive what you did at Madigan on 
that issue, but what you are saying, I do not know, Mr. 
Rodriguez, is if you have PTSD or TBI, then we should send you 
to Madigan then because no other place can screen you well?
    Colonel Salzman. Well, the benefit of doing it there is 
that you can develop a model, test it, see how it works, and 
then you can share it enterprise-wide. And so the TBI question 
is not a simple question. It is complicated for the 
neuropsychologist to answer.
    So thinking that we can diagnose and have a treatment plan 
that is cookie cutter and you can spread across the enterprise 
at this point, I think, oversimplifies the problem. And so what 
we are doing is going through the steps to validate like the 
screening process. If you take the two screening questions that 
were supposed to be put into the post-deployment interview----
    Mr. Wu. Right. Are there any other military treatment 
facilities (MTFs) that are doing this or just----
    Colonel Salzman. Yes, sir.
    Mr. Wu [continuing]. Madigan?
    Colonel Salzman. No. There are other MTFs.
    Mr. Wu. How many?
    Colonel Salzman. Colorado kind of had the lead because they 
had done it before we did it and they used the Air Force 
Academy, the psychiatrists there as their referral. So they had 
one provider to refer to.
    But the problem is if your filter is too open, you would 
get 80 percent of people coming through. If you refine that 
filter with background questions, you can cut it down to 16 to 
20 percent which we did in our pilot program. So----
    Mr. Wu. I appreciate that. We are looking to see exactly 
what the requirement is and how you implement that or address 
that enterprise-wide though.
    Thank you very much, Mr. Rodriguez.
    Mr. Rodriguez. Okay. Thank you very much.
    And let me, one quick question or maybe two, yes or no on 
the part of each of you.
    In your opinion, could the Department of Defense and the VA 
start to share all the noncomputable data that exists right now 
on our soldiers' healthcare and pull that off within 12 months? 
Yes or no? All the data that is not in the computers, 
paperwork, information.
    Colonel Marinkovich. Yes.
    Mr. Rodriguez. Okay.
    Colonel Marinkovich. It is currently in our EHR systems, 
yes.
    Mr. Rodriguez. Within 12 months, you say yes. Thank you.
    Mr. Green. The electronic data, the plans are to share 
that, yes.
    Mr. Rodriguez. Within 12 months, you think you can pull it 
off?
    Mr. Green. That is the plan, yes.
    Commander Martin. In my opinion, yes, sir.
    Mr. Rodriguez. The question is, can you do it, can you pull 
it off within 12 months?
    Mr. Green. Yes.
    Commander Martin. In my opinion, yes, sir.
    Colonel Salzman. I will agree, yes, sir.
    Mr. Rodriguez. Okay. We will probably have a hearing in 12 
months and see where we are at, in 6 months.
    Let me ask you one additional. And, Colonel Marinkovich----
    Colonel Marinkovich. Marinkovich, yes, sir.
    Mr. Rodriguez. Yeah. Sorry about pronunciation. You 
indicated that leadership was one of the obstacles in putting 
the document files and the imaging and the progress or the lack 
of progress in development of the Department of Defense 
electronic medical record systems and being able to get that 
through.
    Any other obstacles there besides leadership?
    Colonel Marinkovich. If I could be so bold as to correct a 
little bit. What I said was that leadership is what makes us 
move forward. And I do not think it is an obstacle. It is just 
a requirement. You cannot work in an organization like ours or 
the VA, I would think, without the leaders agreeing and the 
leaders having a vision.
    And I think the point I was trying to make is that over the 
last maybe 3 years, I have just seen an enormous amount of 
leadership and vision from the leaders that I have had to work 
for. And I think that is why we have made a lot of progress to 
this point.
    Mr. Rodriguez. Is it safe to say it just has not been a 
priority on the part of the Defense, DoD?
    Colonel Marinkovich. If you are asking prior to that, sir, 
I just cannot answer. It is outside of my experience. But I 
know now the people that I work with within my experience, 
there is no doubt it is the highest priority.
    Mr. Rodriguez. Any of you want to comment? Have you all 
seen the reports of the GAO on your lack of performance in that 
area? Have you all seen it? Say yes or no.
    Colonel Marinkovich. Yes, I have seen it, sir.
    Colonel Salzman. Yes.
    Mr. Green. Yes.
    Commander Martin. Yes, sir.
    Mr. Rodriguez. So all of you have seen that lack of 
performance in that area? Okay. And so we are saying that 
within 12 months, we can try to pull off some major things and 
that you are going to let us know if you need additional 
resources.
    Colonel Salzman. Yes, sir.
    Colonel Marinkovich. Yes, sir.
    Commander Martin. Yes, sir.
    Mr. Green. Yes.
    Mr. Rodriguez. Mr. Wu, any last questions?
    Mr. Wu. No, sir.
    Mr. Rodriguez. Thank you very much. Thank you for being 
here. Thank you.
    Let me welcome panel four to the witness table. Dr. Gerald 
Cross is the Principal Deputy Under Secretary for Health at the 
Department of Veterans Affairs. Dr. Stephen Jones is the 
Principal Deputy Assistant Secretary of Defense for Health 
Affairs at the Department of Defense.
    Gentlemen, we welcome you for your insight and I would ask 
for each of you to introduce yourselves when you make your 
comments. I want to recognize Dr. Cross.

 STATEMENTS OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY 
  UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, 
   U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY PAUL 
  TIBBITS, M.D., DEPUTY CHIEF INFORMATION OFFICER, OFFICE OF 
 ENTERPRISE DEVELOPMENT, OFFICE OF INFORMATION AND TECHNOLOGY, 
    U.S. DEPARTMENT OF VETERANS AFFAIRS, AND CLIFF FREEMAN, 
    DIRECTOR, VA/DOD INTERAGENCY PROGRAMS, VETERANS HEALTH 
   ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 
STEPHEN L. JONES, DHA, PRINCIPAL DEPUTY ASSISTANT SECRETARY OF 
     DEFENSE (HEALTH AFFAIRS) U.S. DEPARTMENT OF DEFENSE; 
   ACCOMPANIED BY CHARLES CAMPBELL, ACTING CHIEF INFORMATION 
   OFFICER, TRICARE MANAGEMENT ACTIVITY, U.S. DEPARTMENT OF 
   DEFENSE, AND DAVID GILBERTSON, PROGRAM MANAGER, CLINICAL 
   INFORMATION TECHNOLOGY PROGRAM OFFICE, U.S. DEPARTMENT OF 
                            DEFENSE

           STATEMENT OF GERALD M. CROSS, M.D., FAAFP

    Dr. Cross. Sir, I am pleased to be here today.
    And I wanted to point out that we have given you some 
handouts. We have two that we provided to the Members and I 
believe we have a poster for the audience over here behind us 
that reflects our timelines.
    Good morning, Mr. Chairman and Members of the Subcommittee. 
Accompanying me are Dr. Paul Tibbits to my right, Mr. Cliff 
Freeman farther to the right.
    VA is working with DoD to move efficiently to exchange 
medical information to better serve our clinicians caring for 
servicemembers and veterans. And although we have recently made 
significant progress in sharing health data, we realize that we 
still have more work to do together.
    Today my comments will focus on five components of data 
exchange, video teleconferencing, scanned information, 
bidirectional exchange of text, and the exchange of computable 
data, and case tracking using a veterans tracking application 
called VTA.
    First, my staff report that video teleconferences for 
physicians and nurses at VA polytrauma centers with their 
colleagues at Walter Reed and periodically those at Bethesda 
are very effective, offering a format where the clinicians can 
directly exchange information and ask questions. These 
conferences also enhance collaborative relationships.
    VA level one polytrauma centers now receive digital 
radiographic images and scanned inpatient information for all 
patients transferred from several military treatment 
facilities. These facilities include Walter Reed and Bethesda. 
The inpatient information arrives at our polytrauma centers 
level one in the form of nonsearchable PDF files.
    The bidirectional health information exchange supports the 
real-time bidirectional exchange of current medical----
    [Bells ring for votes in the House.]
    Mr. Rodriguez. It reminds you that you still might be in 
school.
    Dr. Cross. Yes, sir. It is interesting to compete with 
that.
    The Bidirectional Health Information Exchange supports the 
real-time bidirectional exchange of current medical data in the 
form of noncomputable text between VA and DoD treatment 
facilities for all of our shared patients. These data include, 
here is what it includes, discharge summaries, emergency room 
reports, theater data, inpatient and outpatient laboratory 
data, pharmacy data, radiological text reports.
    In addition, BHIE functionality is being expanded, and here 
is a key point, to facilitate the sharing of additional key 
data to include clinical encounter notes, problem list, and 
vital signs.
    In 2008, we plan to have more viewable data. Viewable data 
will include vital signs, scanned documents, and family and 
social history reports.
    The interface between the DoD clinical data repository and 
VA health data repository known as CHDR permits us to share 
computable allergy and pharmacy data between the departments.
    By computable, we mean these data augment automatic 
decision support capability so that VA and DoD providers 
treating the same patients see automatic alerts when a 
prescription order would result in adverse drug or allergy 
interaction.
    This interface is being used by DoD and VA providers at 
seven locations where large populations of patients receive 
care from both VA and DoD healthcare systems.
    The work to make data computable between two different 
healthcare systems is very complex and requires complete 
standardization of data. VA and DoD with the U.S. Department of 
Health and Human Services and others are leading the national 
effort to identify standards that are robust and mature enough 
to support full interoperability between computer systems. This 
work is also dependent upon the prioritization of these data by 
our clinical communities within VA and DoD and the ability of 
each department to get these data into our data repositories in 
a standardized format.
    Despite these complexities, the IT staff has informed me 
that jointly we are doing the work to begin sharing laboratory 
data in computable format by the end of 2008. Beyond 
laboratory, we are analyzing the feasibility of sharing vital 
signs, orders, radiology reports, encounters, immunizations, 
and problem list in computable format. The order in which these 
domains are standardized and shared in computable format will 
be prioritized by both VA and DoD clinicians.
    As you aware, sharing inpatient data is a particular 
challenge since most of the historical data is not in 
computable standardized electronic format. VA and DoD now have 
a study underway that will address sharing inpatient data. VA 
and DoD have agreed that any joint inpatient record will 
utilize the look and feel of VA's award-winning VistA records 
as a benchmark or target system.
    I want to emphasize that in my view, it is important to 
build on VA's electronic health record that has clinical 
functionality, highly praised by doctors and nurses, and is 
credited with helping VA achieve national benchmarks for 
quality as well as national award recognition.
    VA has achieved the ability to assess patient tracking data 
enterprise-wide using Veterans Tracking Application. VTA is a 
modified version of DoD's Joint Patient Tracking Application. 
Our case managers can now access VTA to assist with tracking 
patients treated at both VHA and DoD facilities. VTA is 
compatible with DoD's JPTA allowing overnight electronic 
transfer of clinical data on medically evacuated patients.
    Finally, our departments are collaborating in the 
development of an information interoperability plan. The IT 
staff expect this to be drafted as early as 2008 and proceed 
toward the concurrence and clearance for a final plan later in 
2008. This plan will be recommended to the deputy secretaries 
of both departments and subsequently overseen by the Joint 
Executive Council (JEC), Health Executive Council (HEC), and 
the Benefits Executive Council (BEC).
    This plan will serve as the strategic organizing framework 
for current and future work to set the scope and milestones 
necessary to measure progress toward the intermediate goals and 
an end state needed to continuously improve service to veterans 
and members of the Armed Forces.
    Sir, my colleagues and I stand ready to answer your 
questions.
    [The prepared statement of Dr. Cross appears on p. 74.]
    Mr. Rodriguez. Dr. Jones?

               STATEMENT OF STEPHEN L. JONES, DHA

    Dr. Jones. Thank you, Mr. Chairman.
    It is a pleasure to be here and I would like to go on 
record and join your comments and that of the Chairman as to 
thanking those great men and women who serve in the Military 
Health System and serve our folks in harm's way and also for 
the veterans healthcare workers that do such a great job in 
treating wounded warriors. So thank you, sir.
    Joining me today is Chuck Campbell, the MHS CIO, and 
Colonel Gilbertson, who is a technical individual, particularly 
in theater programs.
    Thank you for inviting me to update you on activities to 
improve sharing of electronic health information between the 
Department of Defense and Department of Veterans Affairs.
    Since I last spoke to you in May of this year, we have made 
substantial progress in sharing information and it is 
gratifying to know that even the GAO recognize that progress is 
being made. Yet, we know that much work lies ahead.
    Today across town, our military medical leaders are meeting 
with former Senator Dole, with each other, and with VA 
participation to help move organizations to the next level of 
service coordination and systems integration on behalf of our 
veterans, particularly our wounded warriors returning from Iraq 
and Afghanistan.
    We know we need to cut through the bureaucratic barriers 
and that has become quite evident to all of us in this room. 
Today I will let you know about the aggressive actions underway 
to do exactly that.
    DoD recently directed a significant change. As you have 
heard, as of October 6, VA providers now can access theater 
clinical data for patients who transfer to the VA for care or 
evaluation. The theater clinical data includes inpatient notes 
and outpatient encounters, as well as pharmacy, laboratory, 
radiology, and other important clinical information. This means 
that VA doctors are able to see clinical information on and 
better prepare for treating severely injured patients before 
they arrive in VA facilities.
    We have also taken steps to better integrate and understand 
our two cultures. In addition to sharing information, we are 
sharing people.
    Just a few weeks ago, we exchanged our most senior 
Information Technical Officer. Chuck Hume, our former Deputy 
CIO for the Military Health System, moved over to the VA. And 
Chuck Campbell, the former Deputy CIO for Health for the 
Veterans Health Administration, joined us as our new Chief 
Information Officer.
    This exchange is about more than two people. It signals a 
new level of trust, respect, and commitment for change that is 
evident in DoD and VA staff alike and provides an intensified 
focus on improving our service to wounded warriors.
    Here are the major points of progress we have achieved or 
will achieve this year. One, continuity of care. For patients 
treated at both VA and DoD facilities, providers can view 
electronic health data from both departments.
    By the end of 2007 calendar year, all essential health data 
will be, in the words of the President's Commission on Care for 
America's Returning Wounded Warriors, ``Immediately viewable by 
any clinician, allied health professional, or program 
administrator who needs that at a VA or DoD facility.''
    Two, continuity of care for polytrauma patients. In 
response to the urgent need for VA providers at polytrauma 
centers to have as much information as possible on inpatients 
transferring for their care, DoD began sending electronic 
health information such as----
    Mr. Rodriguez. Dr. Jones, I apologize. I have less than 4 
minutes to go vote. Let me recess and I will be right back.
    Dr. Jones. All right, sir. Thank you, sir.
    Mr. Rodriguez. Thank you. I apologize.
    [Recess.]
    Mr. Rodriguez. Would you like to continue with your 
testimony? Do you want to continue with your testimony?
    Dr. Jones. Thank you, sir. And thank you for your quickness 
in getting over and getting back.
    Mr. Rodriguez. There were two votes.
    Dr. Jones. Sir, we were talking about the polytrauma 
centers and I would just like to echo Dr. Cross' comments.
    Having visited each of the polytrauma centers, it has been 
operational and working well. And one of the reasons is because 
they do include VTC conferences between the sending and 
receiving hospitals which enhance communication between the 
caregivers and the family members and patients.
    Three, medical services coordination. DoD and VA have 
extended the sharing concept to include coordination of our 
other medical services. For example, when a DoD and VA medical 
facility does not have the equipment or personnel needed to 
process certain types of lab tests, DoD can send the test to a 
VA lab for processing or VA can send the test to a DoD lab. The 
end result is expedited testing and results shared 
electronically enhancing the quality of care for our patients.
    Four, a joint inpatient electronic health record. Since our 
announcement in March to assess the feasibility of DoD and VA 
developing a joint electronic inpatient health record, we have 
awarded a joint contract to conduct a study and we will see 
those findings in the next several months.
    We know that DoD medical staff require a flexible, mobile, 
and highly scalable electronic information system in the combat 
theater that we describe as one system in garrison and one in 
theater.
    We will also ensure our unique theater medical systems work 
with the VA to support continuity of care for our veterans. It 
is the agency's goal to take the best from the DoD and VA 
systems in designing this joint inpatient system.
    Five, joint governance. VA and DoD electronic health 
information collaboration is a major component of the 
Department's joint strategic plan. The Under Secretary of 
Defense for Personnel and Readiness and the VA Deputy 
Secretary, Co-Chair the Joint Executive Council. Supporting the 
JEC is the Health Executive Council Co-Chaired by the Assistant 
Secretary for Defense of Health Affairs and the VA Under 
Secretary for Health.
    In addition, the Chief Information Officers of the Military 
Health System and the VHA Co-Chair the Health Executive 
Council's Information Management/Information Technology Work 
Group.
    Through these joint governance efforts, an unprecedented 
degree of collaboration between VA and DoD is occurring. We 
understand each other's mission and we are ensuring change 
occurs at the right levels.
    Six, standards adoption. According to many experts, 
together DoD and VA lead the Nation in health information 
technology, implementation of interoperable standards, and 
electronic health information sharing.
    The Certification Commission of the Healthcare Information 
Technology, an independent, nonprofit organization, that serves 
as the Department of Health and Human Services certification 
entity for electronic health records systems recently certified 
AHLTA, our electronic health system, assuring our users, 
partners and patients that our information system meets all 
basic criteria for functionality, interoperability, and 
security.
    In conclusion, as always, we appreciate the insights and 
recommendations and guidance of this 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 
recognize that we need to work together to achieve our goals as 
efficiently and effectively as possible.
    Thank you for allowing me the opportunity to appear before 
you and to testify about DoD/VA electronic health information 
sharing achievements, goals, and plans. Thank you.
    [The prepared statement of Dr. Jones appears on p. 79.]
    Mr. Rodriguez. Thank you, Dr. Jones.
    And both, Dr. Jones and Dr. Cross, do you want any of the 
individuals that are with you to make any comments or 
testimony?
    Dr. Jones. No, sir.
    Dr. Cross. No, sir.
    Mr. Rodriguez. Okay. Thank you.
    Good to see, David, Colonel Gilbertson. I know that we have 
a good friend in common back in San Antonio, so good seeing 
you. Okay? And thank you for being here with us.
    And all of you, thank you for your service and what you 
have done for us.
    Let me quickly ask: The Chairman of the Committee, full 
Committee and the Ranking Member also of the full Committee 
requested that I ask you this question and it is in reference 
to, I think, Lieutenant Colonel Mike Fravell that we ask to 
stay in Washington and remain engaged in the development of the 
JPTA and VTA.
    And it is our understanding that the VA wants Mr. Fravell 
to continue to consult on the VTA, but that he has been shut 
out of the future efforts with JPTA. And the question would be 
that some of us felt that, in fact the Chairman and others, 
that would not be advantageous to keeping him managing the 
program since he contributed to much of the success. Do you 
want to comment on that?
    Dr. Jones. Sir, the individual you speak of did a great job 
in helping develop JPTA. But as you know, decisions as to 
assignments are made by the services. So I will be glad to get 
back on the record to you and pass your question to the service 
if that is appropriate, sir.
    [The following was subsequently received:]

        Lieutenant Colonel (LTC) Michael Fravell will remain assigned 
        in Washington in a position where he can make an impact to the 
        information technology enterprise as the Director of 
        Engineering for AHLTA. In his role, he is not only assisting 
        with Joint Patient Tracking Application (JPTA), but he is 
        contributing to the entire Department of Defense (DoD) 
        electronic health record. Since the Assistant Secretary for 
        Health Affairs oversees the DoD component of the joint venture 
        with the Department of Veterans Affairs (VA), LTC Fravell is 
        involved in projects with the VA. LTC Fravell has also been 
        made available to the VA as a consultant on the Veterans 
        Tracking Application, and he is involved with developing 
        additional functionality in the JPTA.

    Mr. Rodriguez. Okay. And then let me also, Dr. Jones, 
compared to other Department of Defense and VA applications, 
the JPTA and VTA are relatively inexpensive, almost no new 
development has been done since the JPTA, in the 18 months, 
even though the user community is asking for new 
functionalities.
    So why hasn't the Department of Defense medical health 
systems embraced this technology and expanded its capabilities?
    Dr. Jones. Let me ask Colonel Gilbertson if he would 
address that question, please.
    Colonel Gilbertson. Sir, on the development of JPTA, the 
continued efforts from theater in terms of growing the JPTA 
application are indeed continuing. JPTA is part of the DoD 
family of systems or is now part of the enterprise solution.
    In fact, we are now building out the functionality of JPTA 
so that all of the information that is in JPTA becomes part of 
the medical record. That was the primary challenge with JPTA is 
it was its own system, a separate stovepipe system. So that 
information never made it into that longitudinal health record.
    So by keeping the functionality of JPTA is really what the 
providers wanted and making it part of the enterprise system, 
we are now able to make sure that all of that information is 
captured in the electronic health record so that it can be 
shared to all DoD and VA providers. So that is really where our 
effort is at.
    So we are definitely still developing against JPTA, the 
current application, and we are trying to enhance it based on 
the feedback that we got from Landstuhl and other providers. We 
were just out there last week and we are very much engaged with 
the actual users to make sure that what we are building 
continues to meet their needs.
    Mr. Rodriguez. Thank you.
    Mr. Wu?
    Mr. Wu. Thank you, Mr. Rodriguez.
    Dr. Jones, piggybacking on Mr. Rodriguez's question here on 
Lieutenant Colonel Fravell, and not to beat a dead horse to 
death here, is if my memory serves me correctly, I have a copy 
of a letter from Dr. Kussman, our now Under Secretary of 
Health, and Admiral Cooper, our Under Secretary of Benefits, 
letter that went to DoD asking for an extension on Lieutenant 
Colonel Fravell.
    And there is a subsequent letter signed by Chairman Filner 
and Mr. Buyer to then acting Secretary Garens saying that they 
would like an extension of Lieutenant Colonel Fravell, I am not 
sure if we ever got a response to that or not, to continue the 
work of JPTA and VTA.
    I do not know if you would like to comment on that at all.
    Colonel Gilbertson. As I was saying, the JPTA is part of 
our enterprise solution. And as you know, AHLTA ultimately, 
because AHLTA is going to collect the whole patient record, is 
a critical part of what we are doing throughout the entire MHS.
    Lieutenant Colonel Mike Fravell is assigned in a position 
where he can make the greatest impact to the enterprise over 
the long run as the Director of Engineering for AHLTA. So in 
his role, he is not only affecting the future evolution of 
JPTA, he is now affecting the entire product, the entire DoD 
electronic health record.
    And because we also oversee the DoD component of the joint 
venture with the VA, the DoD/VA sharing, he is intimately 
involved in all sharing information projects with the VA to 
include VTA.
    And I have made him available to the VA as a consultant on 
future developments of the Veterans Tracking Application and he 
is intimately involved with the developer of the additional 
functionality in JPTA which is Colonel Hines, who is also in 
this room.
    So in his current role, he is positioned to go beyond what 
he has been able to do before and actually make a huge impact 
on the entire DoD and the entire VA as the Director of 
Engineering for our electronic health record.
    Mr. Wu. Is he working on VTA, JPTA interface right now?
    Colonel Gilbertson. Yes, he is. Well, he is working as a 
consultant. The VA has their own program office and their own 
way of developing. And he is intimately involved in identifying 
the requirements for not only VTA, but also he was with us last 
week when we went to Landstuhl and he helped understand what 
our future is for JPTA and its integration into AHLTA.
    Mr. Wu. Well, maybe you can shed some light. We have been 
looking at this issue for some time, especially when it came to 
light, and there was a Washington Post article where JPTA was 
abruptly cut off from the polytrauma center in Richmond while 
the doctor was on--I think that has been resolved. I think they 
all said it was a security issue. It was just shut off in the 
middle of a program.
    JPTA, actually I saw JPTA being demonstrated by Colonel Dr. 
Rhonda Cornum probably 2 years ago at a conference. She was at 
a Commanders' conference. Said you want to see medical 
information being transferred, I will show you. It is not a 
medical record, but it is a tracking application, but essential 
medical information tracked on that is attached to it as a PDF.
    Now, Dr. Jones, AHLTA, AHLTA-T, this year, how much has DoD 
TRICARE Management Activity going to spend on AHLTA and the 
deployment? Three hundred million dollars plus, I think; is it 
not?
    Dr. Jones. The program manager should have it.
    Mr. Wu. The program manager should have it right down to 
the penny, right?
    Colonel Gilbertson. The life cycle cost for AHLTA right now 
is at $5 billion, but that also is going to include the 
inpatient and the ancillary replacements for the Legacy. So to 
date, we have spent just over $1 billion on AHLTA and the 
sustainment of CHCS which is now part of AHLTA.
    Mr. Wu. CHCS1, 2, AHLTA, AHLTA-T, the rebranding. Is there 
any difference between AHLTA and CHCS2?
    Colonel Gilbertson. Yes. They are totally different 
applications. AHLTA is an enhancement upon CHCS. So it sits on 
top of CHCS. It does not survive without CHCS. So the Legacy 
CHCS is part of AHLTA. You cannot have one without the other.
    Mr. Wu. Okay. Then someone needs to correct what we were 
hearing as that there is no difference. It is just a 
rebranding.
    Colonel Gilbertson. No. There is a significant difference. 
What AHLTA does is it now documents the clinical encounter. 
CHCS was primarily an ancillary system that supported our labs, 
pharmacy, radiology, admissions, discharge, transfers, billing. 
Now we have a tool that took it from 101 different locations 
and brought all that data together and made it semantically 
interoperable across the entire enterprise.
    It used to be when I moved from one station, when I left 
San Antonio and went to Hawaii, I had a blank record in Hawaii. 
There was no electronic information available in Hawaii because 
all of our systems were disconnected. AHLTA brought those all 
together. So now when I moved here from San Antonio, my entire 
medical record moved with me. And that is what AHLTA did.
    Mr. Wu. All right. Would you describe AHLTA as in Dr. 
Jones' words, to track healthcare most effectively in theater, 
a flexible, mobile, and highly scalable electronic information 
system is necessary? Does that describe AHLTA?
    Colonel Gilbertson. Can you repeat the question, sir?
    Mr. Wu. I am taking the text right out of Dr. Jones' 
testimony. I am just asking if that is AHLTA where he says to 
track healthcare most effectively in theater, a flexible, 
mobile, and highly scalable electronic information system is 
necessary? Is that AHLTA?
    Colonel Gilbertson. I think today that it is becoming more 
AHLTA than it was 2 years ago. AHLTA was----
    Mr. Wu. Does JPTA do that?
    Colonel Gilbertson. Say again, sir.
    Mr. Wu. Does the medical attachments, the PDFs to JPTA, 
would that describe Dr. Jones' statement there?
    Colonel Gilbertson. JPTA, if you have the infrastructure. 
When JPTA was implemented in theater, the theater had matured 
to a point where they had the bandwidth and it provided a 
connectivity all the way back to the United States.
    What Dr. Jones was talking about is a system that can work 
on a ship, it can work on initial deployments when you have no 
communications, and it can work far forward on the battlefield 
in the hands of a medic. JPTA is not that system. AHLTA is that 
system.
    Mr. Wu. If we had the Channing Moss issue today with the 
surgical team forward Afghanistan and Dr. Oh, that information 
and what was captured there, could that be captured under AHLTA 
today? Since it came under JPTA, I am just wondering what the 
evolution is here.
    Colonel Gilbertson. Today without JPTA, that information 
can be captured. It would be captured through the current TMIP 
suite and the radiology images would be captured and moved as 
they are today from a PACS server in theater, that is called 
Med Web, to Landstuhl. So, yes, today without JPTA, all that 
information could have been captured and moved. At the time, 
the answer is no.
    Mr. Wu. Okay. Thank you very much.
    Now, under the current system that you are describing, if a 
Channing Moss situation happened again today, are you saying 
that Landstuhl's accepting physician as that patient is 
arriving from the mobile air staging facility out of theater 
would have all that information that you just described?
    Colonel Gilbertson. If the systems were used as designed, 
in other words, if the system that was used to enter that 
information was the AHLTA solution in theater, that information 
would have been available to the Landstuhl provider today.
    Mr. Wu. If that situation happened today, would the current 
system be able to capture that information as depicted in that 
video clip?
    Colonel Gilbertson. The current systems in place would 
capture that information and move it back.
    Mr. Wu. Thank you.
    I think we heard you talk about taking JPTA data and 
populating AHLTA. Are we saying, and I think that Ms. Embry may 
have said this to Mr. Buyer last year, is that there is no 
further money and further development of any other applications 
under JPTA? Is that true or false?
    Colonel Gilbertson. That is not true. We just invested in 
JPTA integration into the electronic health record. So----
    Mr. Wu. I understand that. But besides the integration 
effort, any other applications?
    Colonel Gilbertson. Additional dollars specifically to 
JPTA?
    Mr. Wu. Right. Correct.
    Colonel Gilbertson. Well, once it is part of the 
enterprise, the dollars that are spent on JPTA modifications 
will come out as modifications to the DoD TMIP suite. So there 
could be depending on the requirement. And JPTA brings 
functionality that will be used and if that functionality needs 
to be expanded, then investment will be made in that 
functionality. So----
    Mr. Wu. To the best of your knowledge, there is no new 
money earmarked to new JPTA applications as of today, is there?
    Colonel Gilbertson. Well, JPTA will cease to be its own 
application. So as we invest in AHLTA and AHLTA-T, we will 
invest in enhancing JPTA along with the rest of the AHLTA 
suite.
    Mr. Wu. Okay. Thank you very much.
    Dr. Cross, in your testimony, you stated that DoD and VA 
have funded a study to study the mutual development of a joint 
inpatient electronic health record. I understand that 
initiative took place this year.
    Dr. Cross. Correct.
    Mr. Wu. Can you tell why it has taken 15, 20 years to get 
to this point?
    Dr. Cross. I think this is a point in time where the 
situation was right to do this. I think you can certainly argue 
that it should have been looked at before.
    I will ask my colleagues here to comment on that as well.
    Mr. Wu. I mean, I could go back and look at the 
congressional intent, the legislation, all the way back to 
1982, the various legislative initiatives we had.
    I have asked GAO to go back on our recess break to look at 
how many studies they have done and maybe a GAO study of all 
the GAO studies to see how many recommendations on this issue 
have been issued in the last decade where the recommendations 
have not been implemented.
    I am just wondering. What was the impetus to all of a 
sudden January 2007 to do this?
    Dr. Cross. Actually, there was a good meeting between Dr. 
Jones and myself in my office where we discussed what we could 
do next and we moved that forward.
    Mr. Wu. Okay.
    Dr. Jones. I think it is a number of factors. One is, as 
Dr. Cross said, we are working more closely together than we 
ever had before. I mean, we switched. You know, we have Chuck 
Campbell, who was working over at the VA, and Chuck Hume was 
working over. So we are working more closely together.
    We realized the need, as somebody mentioned earlier, 
because of the Walter Reed issues and all the various task 
forces and committees puts additional impetus on making it 
happen and making it happen faster and making it happen right.
    And then thirdly, I think with us, we were getting ready to 
invest more heavily into our inpatient record. We now, as you 
heard by an earlier person that testified, the AHLTA which was 
started as an outpatient record was only implemented into each 
of our medical centers last December, so we are the next phase 
was to move more aggressively into the inpatient.
    And it is my understanding that the VA was looking at VistA 
to upgrade because it was time that they needed to refresh 
because of the Legacy system they have. So all those factors, I 
think, came together to, you know, make this time is right.
    And this is not just a study to inform us. This is a study 
to inform us so that we can take action. And I would be 
surprised if we do not take the information from that study and 
make it happen.
    Mr. Wu. I have one question and one more than that. I think 
that Mr. Rodriguez asked the question. Do you think you will be 
able to implement Dole-Shalala within the timeframe?
    Dr. Jones. Well, again, I think it depends on, you know, 
all of the issues of Dole-Shalala I cannot speak of. The thrust 
of both agencies and Secretary England, Secretary Gates, and I 
know on our VA counterparts is to implement as much as we can 
between the two agencies under existing law.
    Of course, those things that we cannot implement because of 
law or because of legislative packages will be considered by 
this body and the Senate. But we are----
    Mr. Wu. Sir, do you see those legislative initiatives 
coming up any time soon?
    Dr. Jones. It is my understanding that those packages have 
been delivered last week or the week before, I am not certain 
of the time, by the two secretaries.
    Mr. Wu. Thank you, sir.
    Dr. Cross. May I echo that we take that very seriously. 
Great emphasis and importance is given to that project. Some of 
the testimony that I included in my oral statement today 
related to time factors and so forth of what we are doing, I 
think, relate to that. And on many issues outside of the IT 
world, which is probably mostly outside of the IT world, we are 
moving forward aggressively as we can to implement those 
things.
    Dr. Tibbits. Let me add to that since I am the Co-Chair of 
Lines of Action 4 (LOA4) (eBenefits portal) which is the IT 
portion of this senior Oversight Committee process with Dr. 
Jones. And for just the IT slice of your question, yes, we are 
very committed to it.
    We have a very aggressive series of meetings going on right 
now this month to gather requirements from all the other lines 
of action. We are now deeply engaged in costing out those 
requirements from an IT perspective, the IT support to all 
those other lines of action.
    We will be presenting that IT plan sometime in the month of 
November whenever we are told to go present it to both deputy 
secretaries and that will subsequently result in certain 
decisions and actions with respect to funding and monitoring 
with a scoreboard-like approach of our progress.
    So the Administration is very committed to that and we, I 
think, have everybody engaged as much as we possibly could in 
trying to make that happen at all levels of both the 
departments.
    Mr. Wu. Dr. Tibbits, would it be safe to assume that in the 
requirements identification that you would have a TBI component 
there, a mental health, and a PTSD component there?
    Dr. Tibbits. That is correct. There is a line of action, 
too, which is specifically focused on that.
    Mr. Wu. Okay. Dr. Cross, one last question.
    Thank you for indulging me, Mr. Rodriguez.
    Dr. Cross, you also stated VA and DoD are committed to 
ensuring an ongoing partnership to optimize health delivery to 
veterans and military beneficiaries. Probably for the record, I 
would say here, it be a little onerous to do that now.
    Could you highlight since 2003 when we created the HEC and 
the JEC all initiatives emanating from DoD, VA's Health 
Executive Committee, direct cost of these initiatives, specific 
measurable outcomes, everything that has been accomplished?
    Dr. Cross. Certainly I think we could do that for the 
record.
    [The Health Executive Council Highlights, FY 2003-First 
Quarter for FY 2008, dated June 10, 2008, appears on p. 98.]
    Mr. Wu. Thank you very much.
    Thank you, Mr. Rodriguez.
    Mr. Rodriguez. Thank you very much.
    And both, Dr. Jones and Dr. Cross, thank you very much for 
your testimony.
    Let me, as you have indicated, that we seem to have made 
some significant progress with your dialog. I would just 
encourage you to keep dialoguing with each other. This is 
really essential for our soldiers and our veterans to try to 
make this happen as smoothly as possible and as quickly as 
possible.
    And so that it just makes sense for anyone who is providing 
access to healthcare to our soldiers that data and that folder 
or whatever the documentation is with that soldier that they 
have access after they leave the military and become veterans 
so that we can best not only treat them but see what we can do 
in terms of meeting their needs. And I think it would behoove 
us to try to move as quickly as possible.
    And I would ask you once again, I guess, Dr. Jones and Dr. 
Cross, are there any other obstacles out there that we as a 
Congress can look at to try to make that happen as quickly as 
possible?
    Dr. Cross. Let me say very clearly that we support the 
generosity that Congress has shown with us. The cooperation 
that we have had, there is a new atmosphere, I think, between 
DoD and VA. We meet very frequently. We know each other on a 
first name basis. We are taking all of these initiatives very 
seriously and in many ways, it is a new world.
    Mr. Rodriguez. Thank you.
    Dr. Jones. And I would just echo that, Mr. Chairman. I 
believe that Congress has been more than adequate and has 
already given us some funding in DoD to address TBI, PTSD, and 
mental health, and we are aggressively moving forward in those 
areas.
    Mr. Rodriguez. Because I would think that hopefully our 
next step, I know in some of the areas already, I know in El 
Paso, both the VA and the DoD, they are in the same facility. 
They might not communicate as much, but at some point, 
hopefully they will start communicating when they are providing 
access to healthcare.
    And I have other communities and there are some throughout 
the country where it would be ideal for both, you know, the 
Department of Defense and the VA to get together in providing 
access to healthcare not only to our soldiers but also to our 
veterans. And where they could do that together, it just makes 
all the sense in the world in terms of being cost effective, 
not to mention in terms of getting access to our soldiers.
    And so are there any now in terms of, I asked you what we 
could do, are there any obstacles there that both the 
Department of Defense and the Department of Veterans Affairs 
have that you still feel that you need to overcome?
    Dr. Jones?
    Dr. Jones. I think our main areas that we need to continue 
to pursue aggressively, which we are, the challenges that are 
before us are to ensure that we have funding at the same time 
that the VA has funding so that we can move forward with the 
various projects in tandem.
    Secondly, on our side, it is helpful for us to--as you 
know, we have different color money in Washington and we have 
to have research and development money, sustained money, 
implementation funds, so there is different funds.
    So we just need to make sure that we have adequate funding 
in the appropriate categories that can allow us to rapidly move 
forward as we come forward with our plans that Dr. Tibbits 
mentioned to ensure that we are meeting the needs, to implement 
Dole-Shalala. That is going to take funding. Congress, we hope 
you will consider that.
    And, secondly, once we get the plan to have the joint 
inpatient record, that is going to take funding. So, again, we 
will be able to provide you the necessary justifications so 
that you will see fit to make that funding available. Those 
would be my comments, sir.
    Mr. Rodriguez. Thank you.
    Dr. Cross?
    Dr. Cross. I will ask my IT colleagues, Dr. Tibbits, and 
others to comment as well.
    But this is plowing new ground. We are out in front of our 
many civilian healthcare systems where they are still using 
paper records, where they are still transferring information by 
mail. And we are way out in advance of that. We are pioneering 
for the country, I think, on how to do this.
    And I just hope that we can have the understanding that we 
are on, I think, the cutting edge of learning how to do this.
    I will ask my IT colleagues to comment as well.
    Dr. Tibbits. Well, thank you, Dr. Cross, and thank you for 
the question. The learning is a key piece of this.
    [The chart is attached to Dr. Cross' statement, which 
appears on p. 79.]
    Dr. Tibbits. Dr. Cross pointed out that as you look at the 
chart there on the easel, the dots get closer together as you 
go from left to right. The activity is becoming much more 
intense.
    But the learning also has to happen and learning at all 
levels anywhere from setting requirements all the way down to 
deep in the bows of how a server is configured and not so much 
HIPAA, but more so the information security policies of both 
departments. A lot of exploration and learning has to happen 
there.
    There is, however, a great interest, a great commitment on 
the part of the Administration to do so. The need could not be 
greater to serve our Nation's heroes which would bring me to my 
sort of last point here while I have the microphone for this 
time, this question.
    And that is taking the need of our Nation's heroes, taking 
the need and formulating that into a plan. I think you have 
heard a lot of conversation, particularly from the GAO, but 
others also, about the importance of such a plan. If we were 
and which we are doing now, by the way, once we have properly 
depicted that need, the high priority needs for information 
exchange to best serve our active-duty members and veterans, 
then we will have a framework to better explain how all this 
activity that you see here fits together, how the remaining 
activity that is already scheduled that you see there fits 
together, and what is the gap with respect to the need and what 
you do not see on that chart. That plan we will have together 
probably, let us say, by spring of next year. I would call that 
an information interoperability plan.
    I want to be very careful to emphasize that information 
interoperability, the sharing of data, can jumpstart, as you 
see there on that board, can jumpstart the service to the way 
we treat, care for servicemembers and veterans before we ever 
decide to jointly develop software.
    So while this study is going on and we are trying to figure 
out from a cost perspective will it save money and can it move 
the departments forward to jointly develop software, the data 
plan can help us now in the short term, in the medium term, and 
in the long term to meet veterans' needs and servicemembers' 
needs.
    So that is the last piece of not just talking about the 
need, but actually using the need itself as a planning factor 
to put that integrated plan together. That is the next phase of 
sophistication we are going to get to and that should drive a 
lot of the prioritization activities to learn what it is we 
need to learn throughout that entire stack of layers of 
information processing that I just alluded to earlier.
    Mr. Rodriguez. Thank you.
    Mr. Freeman?
    Mr. Freeman. As Mr. Wu knows, I have been working with this 
for 10 years and I can honestly say in the last 3 or 4 years, 
the progress we have been able to make has moved forward 
astronomically actually in my opinion.
    And I think one of the things the earlier panel said about 
the leadership, there is true leadership support. As both Dr. 
Cross and Dr. Jones have said, they worked very closely 
together.
    And I think that as we have moved forward, it is not that 
we have created some of these applications, but I think the 
important point is that they are actually being used and they 
are benefiting the clinical care that we are providing 
veterans.
    The Bidirectional Health Information Exchange that was 
discussed earlier with you, it gets over 3,700 queries a day in 
the VA. It is being used by the provider to provide quality 
clinical care for our wounded warriors and our veterans. And I 
think that says a lot about some of the work that we have done. 
Thanks.
    Mr. Rodriguez. Let me just indicate I want to thank you and 
also just indicate there is no doubt that we will be having 
another hearing based on the Chairman's comments, next year. 
And so we are hoping that we can make up some ground in that 
area.
    And I am going to ask Mr. Wu if he has got any additional 
comments. No additional questions?
    Thank you very much. And I hope that you continue to dialog 
together. I also am one of the few that not only sits on the 
authorizing Committee, but I sit on the Appropriations 
Committee, so I would hope that you come to me and let me know 
if you need any more money. Okay?
    Thank you.
    [Whereupon, at 1:44 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

        Prepared Statement of Hon. Harry E. Mitchell, Chairman,
              Subcommittee on Oversight and Investigations
    Thank you all for coming today. I am pleased that so many people 
could attend this oversight hearing on sharing of electronic medical 
information between the Departments of Defense and Veterans Affairs. 
This is a critically important issue. Thousands of our service men and 
women require and will continue to require significant medical care as 
the result of the conflicts in Iraq and Afghanistan. The most seriously 
injured of our OEF and OIF veterans may need a lifetime of care, but 
even veterans returning with no visible injury may need assistance with 
PTSD or mild Traumatic Brain Injury.
    DOD and VA are sharing more and more patients. For example, the 
patients at the VA's four polytrauma rehabilitation centers are almost 
all still on active duty. And active duty service members will be 
veterans sooner or later. A review by the VA's Inspector General of the 
500,000 or so service members who left active duty in fiscal year 2005 
shows that 92 percent had an encounter with the military health system 
while on active duty that resulted in a diagnostic code. In other 
words, nearly all of the veterans who go to the VA to get medical care 
will have military medical records that should be available to VA 
health care providers.
    If anyone can convince the American people of the importance of 
electronic medical records, it is our first panel. Specialist Channing 
Moss is an Army soldier who was shot with a rocket propelled grenade 
that lodged in his body. He is alive and walking today because the 
medical evacuation team and combat surgeons who operated on him put 
their own lives in danger in order to remove live ordnance from 
Specialist Moss. Brigadier General Douglas Robb was chief surgeon of 
CENTCOM at the time, and he will discuss how important it was that a 
copy of the x-ray taken at the forward field hospital was available to 
the clinicians in Landstuhl before Specialist Moss arrived.
    DOD and VA have been working on the electronic exchange of medical 
information for many years. For most of that time, the story is not a 
happy one. I am nevertheless pleased to be able to say that DOD and VA 
have made more progress in the past 12 to 18 months than they made in 
the preceding decade. But there is still much to be done. There is no 
reason why, in this day and age, DOD and VA cannot electronically share 
the information necessary to treat our service members and veterans. We 
should not have to wait any longer. I hope and I expect that DOD and VA 
will tell us today that, by no more than a year from now, clinicians in 
DOD and VA will have full electronic access to the medical information 
they need to treat their patients, whether that information resides in 
computers owned by DOD or by VA.
                                 
   Prepared Statement of Hon. Ginny Brown-Waite, Ranking Republican 
          Member, Subcommittee on Oversight and Investigations
    Mr. Chairman, Thank you for yielding.
    Mr. Chairman, I would like to thank you for calling this hearing to 
review the status of the electronic medical records sharing between DOD 
and VA. This Subcommittee has already held two hearings in the 110th 
Congress on the issue of seamless transition of our servicemembers.
    The first hearing was held in March and the second in May, both of 
which focused primarily on the sharing of critical medical information 
of critically wounded servicemembers between DOD and VA.
    I would like to assure the witnesses here today, that this issue is 
of the utmost importance to all Members of this Committee, regardless 
of political affiliation. I am pleased the Chairman has requested that 
representatives from DOD testify here today. It will be important to 
hear their perspective on the timely exchange of critical medical 
information between DOD and VA for the seamless continuum of delivering 
healthcare to our servicemembers.
    I look forward to hearing the steps DOD has taken to allow all 
critical medical information to be viewed by the VA when active duty 
servicemembers are transferred to VA facilities. In addition, I will be 
interested in hearing from VA on whether technological obstacles or 
bureaucratic intransigence prevent this from occurring today.
    This past week, staff members visited Keesler Air Force Base and 
the VA Medical Center in Biloxi, Mississippi to see how the Air Force 
and the VA are coming together in VA/DOD resource sharing.
    Unfortunately, the progress in this area is a result of the 
devastation of Hurricane Katrina and the dynamic personalities of 
senior leadership at these facilities, and not the Veterans 
Administration and the Department of Defense Health Resources Sharing 
and Emergency Operations Act 1982.
    It appears that the ball has moved forward more in the last 24 
months than the last 25 years. It is a shame that it took Hurricane 
Katrina, the debacle at Walter Reed, and the devastating wounds of war 
to expedite progress between the two largest federal bureaucracies.
    I am also looking forward to hearing from representatives of both 
departments about how they plan to implement the recommendations of the 
recently released Dole/Shalala Commission Report, and the Veterans 
Disability Benefits Commission Report.
    Again, I would like to thank you, Mr. Chairman for holding this 
hearing. This issue is a top priority for our Subcommittee, and look 
forward to continuing our oversight responsibilities.
                                 
     Prepared Statement of Brigadier General Douglas J. Robb, M.D.,
   Commander, 81st Medical Group, Keesler Air Force Base, Biloxi, MS,
        Department of the Air Force, U.S. Department of Defense
INTRODUCTION
    Mr. Chairman and members of this distinguished Subcommittee, thank 
you for inviting me here today. I am Brigadier General Douglas J. Robb 
and I served as the Command Surgeon, United States Central Command from 
2004 to 2007. Currently I am serving as the Keesler Medical Center 
Commander and as the Senior Market Manager, Gulf Coast Multi-Service 
Market Office, Keesler Air Force Base, Biloxi, Mississippi. Thank you 
for the opportunity to express my advocacy for a Healthcare Information 
Systems platform and electronic medical record that supports the world 
class quality healthcare that our military and Department of Veterans 
Affairs veterans healthcare facilities provide to our DoD and VA 
beneficiaries.
HISTORICAL OVERVIEW
    In my previous assignment as the CENTCOM Surgeon, I had the 
opportunity to witness the evolution of our deployed healthcare 
information systems platforms that support access to patient care data, 
as our wounded warriors move through the continuum of care: from our 
combat casualty care life savers, to our forward surgical teams, to our 
theater hospitals, and then onto our definitive care facilities at 
Landstuhl, Walter Reed, Bethesda, Wilford Hall, and VA Polytrauma 
Centers.
    On 16 March 2006, Spc. Channing Moss was severely injured in an 
attack in southeastern Afghanistan. The lifesaving care performed by 
the combat lifesavers in his unit and the subsequent surgical 
stabilization by the forward surgical team and the Bagram Theater 
Hospital saved his life. What was also lifesaving was the ability of 
the surgeons at Landstuhl Hospital, Germany, who would receive Spc. 
Moss less than 24 hours after his initial injury, and the surgeons at 
Walter Reed to be able to view his operative notes and x-rays, before 
the patient arrived at their hospitals. This was accomplished via the 
Joint Patient Tracking Application, part of the DoD's deployed 
healthcare information systems platform.
    Earlier that year, again in Afghanistan, a general surgeon and 
commander of one of the forward surgical teams, commented on his 
excitement when he was able to send completely digital trauma 
resuscitation and operative reports to the Bagram Combat Support 
Hospital, again before the patient arrived. This is something that had 
been his vision for our forward surgical teams for a long time. During 
his previous assignment, he had been a surgeon at Landstuhl, Germany, 
and was frustrated by the lack of medical data from the forward 
surgical teams' initial surgical resuscitation.
CURRENT ACTIVITIES
    In my current position as the Senior Market Manager, Gulf Coast 
Multi-Service Market Manager, through collaborative and joint DoD and 
VA initiatives, we are entrusted with the in-garrison care of our DoD 
and VA beneficiaries. In this capacity, we also require a healthcare 
information system platform that supports access to real-time patient 
care data for our shared patient population. Our patients from the Gulf 
Coast Multi-Service Market are treated in DoD and VA hospitals and 
clinics that are often located in close proximity anywhere from Biloxi, 
to Pensacola, and continuing along the Florida Panhandle to Panama 
City. Our goal is provide quality services in a seamless manner. This 
requires an integrated healthcare information systems platform that is 
user friendly for our jointly operating DoD and VA healthcare 
facilities. Significant progress has been made in the past few years to 
bridge the gap of electronic information flow. Just last month, our 
staffs were excited when the bi-directional health information (BDHI) 
system became available at some of our facilities. Although not at its 
full capability yet, it is a very positive step in the right direction 
in our ability to view patient care data from both VA and DoD 
facilities.
CONCLUSION
    In conclusion, as a former Combatant Command Surgeon and currently 
as the Senior Market Manager for the Gulf Coast Multi-Service Market 
Office, I continue to be a strong advocate for a healthcare information 
systems platform and electronic medical record that provides real time 
access to patient care data for our DoD and VA beneficiaries, heroes 
like Spc. Canning Moss, as they move through our deployed and garrison 
based continuum of care: combat casualty care, forward surgical 
resuscitation, in-theater hospitalization and finally our DoD and VA 
medical centers and clinics. The current capability has already proven 
itself in contributing to the quality of care for our beneficiaries. 
And with your support I believe we can continue to improve upon our 
already existing and evolving capability to further share and make 
available the full spectrum of electronic health information between 
the Department of Defense and the Department of Veterans Affairs. Mr. 
Chairman, Committee Members, thank you again for allowing me the 
opportunity to appear before you.
                                 
           Prepared Statement of Valerie C. Melvin, Director,
        Human Capital and Management Information Systems Issues,
                 U.S. Government Accountability Office
                             GAO Highlights
   Information Technology--VA and DOD Continue to Expand Sharing of 
 Medical Information, but Still Lack Comprehensive Electronic Medical 
                                Records
Why GAO Did This Study
    The Department of Veterans Affairs (VA) and the Department of 
Defense (DOD) are engaged in ongoing efforts to share medical 
information, which is important in helping to ensure high-quality 
health care for active-duty military personnel and veterans. These 
efforts include a long-term program to develop modernized health 
information systems based on computable data: that is, data in a format 
that a computer application can act on--for example, to provide alerts 
to clinicians of drug allergies. In addition, the departments are 
engaged in short-term initiatives involving existing systems.
    GAO was asked to testify on the history and current status of the 
departments' efforts to share health information. To develop this 
testimony, GAO reviewed its previous work, analyzed documents about 
current status and future plans and interviewed VA and DOD officials.
What GAO Recommends
    GAO has previously made several recommendations on this topic, 
including that VA and DOD develop a detailed project management plan to 
guide their efforts to share patient health data. While the departments 
agreed with these recommendations, a comprehensive overall strategy 
that incorporates all of the ongoing activities still needs to be 
implemented.
What GAO Found
    For almost a decade, VA and DOD have been pursuing ways to share 
health information and to create comprehensive electronic medical 
records. However, they have faced considerable challenges in these 
efforts, leading to repeated changes in the focus of their initiatives 
and target completion dates. Currently, the two departments are 
pursuing both long- and short-term initiatives to share health 
information. Under their long-term initiative, the modern health 
information systems being developed by each department are to share 
standardized computable data through an interface between data 
repositories associated with each system. The repositories have now 
been developed, and the departments have begun to populate them with 
limited types of health information. In addition, the interface between 
the repositories has been implemented at seven VA and DOD sites, 
allowing computable outpatient pharmacy and drug allergy data to be 
exchanged. Implementing this interface is a milestone toward the 
departments' long-term goal, but more remains to be done. Besides 
extending the current capability throughout VA and DOD, the departments 
must still agree to standards for the remaining categories of medical 
information, populate the data repositories with this information, 
complete the development of the two modernized health information 
systems, and transition from their existing systems.
    While pursuing their long-term effort to develop modernized 
systems, the two departments have also been working to share 
information in their existing systems. Among various short-term 
initiatives are a completed effort to allow the one-way transfer of 
health information from DOD to VA when service members leave the 
military, as well as ongoing demonstration projects to exchange limited 
data at selected sites. One of these projects, which builds on the one-
way transfer capability, developed an interface between certain 
existing systems that allows a two-way view of current data on patients 
receiving care from both departments. VA and DOD are now expanding the 
sharing of additional medical information by using this interface to 
link other systems and databases. The departments have also established 
ad hoc processes to meet the immediate need to provide data on severely 
wounded service members to VA's polytrauma centers, which specialize in 
treating such patients. These processes include manual workarounds 
(such as scanning paper records) that are generally feasible only 
because the number of polytrauma patients is small. While these 
multiple initiatives and ad hoc processes have facilitated degrees of 
data sharing, they nonetheless highlight the need for continued efforts 
to integrate information systems and automate information exchange. At 
present, it is not clear how all the initiatives are to be incorporated 
into an overall strategy focused on achieving the departments' goal of 
comprehensive, seamless exchange of health information.
                               __________
    Mr. Chairman and Members of the Subcommittee:
    I am pleased to be a part of today's continuing dialog on efforts 
by the Department of Veterans Affairs (VA) and the Department of 
Defense (DOD) to share electronic medical information. Over most of the 
past decade, the departments have been pursuing initiatives to share 
electronic medical information to help ensure that active-duty military 
personnel and veterans receive high-quality health care. The 
departments' efforts have included working toward a long-term vision of 
a single ``comprehensive, lifelong medical record'' \1\ that would 
allow each service member to transition seamlessly between the two 
departments, as well as more short-term efforts focused on meeting 
immediate needs to exchange health information, including responding to 
current military crises.
---------------------------------------------------------------------------
    \1\ In 1996, the Presidential Advisory Committee on Gulf War 
Veterans' Illnesses reported on many deficiencies in VA's and DOD's 
data capabilities for handling service members' health information. In 
November 1997, the President called for the two agencies to start 
developing a ``comprehensive, lifelong medical record for each service 
member,'' and in 1998 issued a directive requiring VA and DOD to 
develop a ``computer-based patient record system that will accurately 
and efficiently exchange information.''
---------------------------------------------------------------------------
    Since 2001, we have reported or testified numerous times on the 
various initiatives undertaken by the departments to develop the 
capability to share health information. Our last testimony before this 
Subcommittee on May 8, 2007, highlighted key projects that the 
departments have pursued in this regard and the progress of their 
activities.\2\ At your request, my statement today further discusses 
the history and current status of the departments' efforts.
---------------------------------------------------------------------------
    \2\ GAO, Information Technology: VA and DOD Are Making Progress in 
Sharing Medical Information, but Are Far from Comprehensive Electronic 
Medical Records, GAO-07-852T (Washington, D.C.: May 8, 2007).
---------------------------------------------------------------------------
    The information in my testimony is based largely on our previous 
work in this area. To describe the history and current status of the 
departments' efforts to exchange patient health information, we 
reviewed our previous work, analyzed documents on various health 
initiatives, and interviewed VA and DOD officials about current status 
and future plans. We conducted our work in support of this testimony 
during October 2007 in the Washington, D.C., area. Information on costs 
that have been incurred for the various projects was provided by 
responsible officials at each department. We did not audit the reported 
costs and thus cannot attest to their accuracy or completeness. All 
work on which this testimony is based was conducted in accordance with 
generally accepted government auditing standards.
Results in Brief
    VA and DOD have been pursuing initiatives to share data between 
their health information systems and create comprehensive electronic 
medical records since 1998, following a call for the development of a 
comprehensive, integrated system to allow the two departments to share 
patient health information. However, the departments have faced 
considerable challenges in project planning and management, leading to 
repeated changes in the focus of their initiatives and target 
completion dates. In prior reviews of their efforts, we noted 
management weaknesses such as inadequate accountability and poor 
planning and oversight and made recommendations for improvement, 
including the development of a comprehensive and coordinated project 
management plan that defines the technical and managerial processes 
necessary to satisfy project requirements and to guide their 
activities. In response, by July 2002, VA and DOD revised their 
strategy, refocusing the project and dividing it into long-term and 
short-term initiatives. For the long term, both departments are 
modernizing their health information systems to replace their existing 
(legacy) systems and enable the new systems to share data and, 
ultimately, to have interoperable \3\ electronic medical records. 
Unlike the legacy systems, the modernized systems are to be based on 
computable data--data that can be automatically processed in a 
healthcare system to, for example, provide alerts to clinicians on drug 
allergies, or to plot graphs of changes in vital signs such as blood 
pressure. For the short-term initiative, the departments focused on 
sharing information in existing systems.
---------------------------------------------------------------------------
    \3\ Interoperability is the ability of two or more systems or 
components to exchange information and to use the information that has 
been exchanged.
---------------------------------------------------------------------------
    VA and DOD have made progress in both their long-term and short-
term initiatives, but much work remains to achieve the goal of 
interoperable electronic medical records and a seamless transition 
between the two departments. In the long-term project to develop 
modernized health information systems, the departments have begun to 
implement the first release of the interface between their modernized 
data repositories, and computable outpatient pharmacy and drug allergy 
data are being exchanged at seven VA and DoD sites. However, 
significant work remains, including agreeing to standards for the 
remaining categories of medical information and populating the data 
repositories with all this information. Regarding their short-term 
projects to share information in existing systems, the departments 
completed the Federal Health Information Exchange in 2004, and as of 
this month reported transferring clinical data on more than 4 million 
veterans. In addition, they have made progress on two demonstration 
projects: (1) the Laboratory Data Sharing Interface, deployed at nine 
localities, allows the departments to communicate orders for lab tests 
and their results electronically and (2) the Bidirectional Health 
Information Exchange allows a real-time, two-way view of certain 
outpatient health data from existing systems \4\ at all VA and DoD 
sites, and certain inpatient discharge summary data \5\ at all VA sites 
and 13 large DOD sites. Further, the two departments have undertaken ad 
hoc activities to accelerate the transmission of health information on 
severely wounded patients from DOD to VA's four polytrauma centers, 
which care for veterans and service members with severe traumatic brain 
injuries or disabling injuries, to more than one physical region or 
organ system. These ad hoc processes include manual workarounds, such 
as scanning paper records and individually transmitting radiological 
images, which are generally feasible only because the number of 
polytrauma patients is small (according to VA officials, about 460 with 
traumatic brain injuries to date).
---------------------------------------------------------------------------
    \4\ DOD's Composite Health Care System (CHCS) and VA's VistA 
(Veterans Health Information Systems and Technology Architecture).
    \5\ Specifically, inpatient discharge summary data stored in VA's 
VistA and DOD's Clinical Information System (CIS), a commercial health 
information system customized for DOD.
---------------------------------------------------------------------------
    Through all of these efforts, VA and DOD are exchanging health 
information. However, these exchanges have been limited, and it is not 
yet clear how they are to be integrated into an overall strategy to 
reach the departments' long-term goal of a comprehensive, seamless 
exchange of health information. Accordingly, as we have previously 
recommended, it remains critical for the departments to develop a 
comprehensive project plan that can guide their efforts to completion.
Background
    In their efforts to modernize their health information systems and 
share medical information, VA and DoD start from different positions. 
As shown in table 1, VA has one integrated medical information system--
the Veterans Health Information Systems and Technology Architecture 
(VistA)--which uses all electronic records. All 128 VA medical sites 
thus have access to all VistA information.\6\ (Table 1 also shows, for 
completeness, VA's planned modernized system and its associated data 
repository.)
---------------------------------------------------------------------------
    \6\ A site represents one or more facilities--medical centers, 
hospitals, or outpatient clinics--that store their electronic health 
data in a single database.

          Table 1: VA Medical Information Systems and Data Base
------------------------------------------------------------------------

------------------------------------------------------------------------
System name                                                 Description
------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Legacy systems
----------------------------------------------------------------------------------------------------------------
VistA                                         Veterans Health Information            Existing integrated health
                                                   Systems and Technology                    information system
                                                             Architecture
----------------------------------------------------------------------------------------------------------------
Modernized system and repository
----------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------

------------------------------------------------------------------------
HealtheVet VistA                          Modernized health information
                                        system based on computable data
------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
HDR                                                Health Data Repository       Data repository associated with
                                                                                              modernized system
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of VA data.


    In contrast, DOD has multiple medical information systems (table 2 
illustrates certain selected systems). DOD's various systems are not 
integrated, and its 138 sites do not necessarily communicate with each 
other. In addition, not all of DOD's medical information is electronic: 
some records are paper-based.

    Table 2: Selected DoD Medical Information Systems and Data Bases
------------------------------------------------------------------------

------------------------------------------------------------------------
System name                                                 Description
------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Legacy systems
----------------------------------------------------------------------------------------------------------------
CHCS                                         Composite Health Care System           Primary existing DoD health
                                                                                             information system
----------------------------------------------------------------------------------------------------------------
CIS                                           Clinical Information System   Commercial health information system
                                                                            customized for DoD; used by some DoD
                                                                                      facilities for inpatients
----------------------------------------------------------------------------------------------------------------
ICDB                                         Integrated Clinical Database     Health information system used by
                                                                                      many Air Force facilities
----------------------------------------------------------------------------------------------------------------
TMDS                                           Theater Medical Data Store        Database to collect electronic
                                                                                  medical information in combat
                                                                            theater for both outpatient care and
                                                                                               serious injuries
----------------------------------------------------------------------------------------------------------------
JPTA                                    Joint Patient Tracking Application  Web-based application primarily used
                                                                            to track the movement of patients as
                                                                             they are transferred from location
                                                                             to location, but may include text-
                                                                                      based medical information
----------------------------------------------------------------------------------------------------------------
Modernized system and repository
----------------------------------------------------------------------------------------------------------------
AHLTA                                                Armed Forces Health LongitudiModernized health information
                                               Technology Application \a\       system, integrated and based on
                                                                                                computable data
----------------------------------------------------------------------------------------------------------------
CDR                                              Clinical Data Repository       Data repository associated with
                                                                                              modernized system
----------------------------------------------------------------------------------------------------------------
\a\ Formerly CHCS II.
Source: GAO analysis of DOD data.


VA and DOD Have Been Working to Exchange Health Information Since 1998
    For nearly a decade, VA and DOD have been undertaking initiatives 
to exchange data between their health information systems and create 
comprehensive electronic records.\7\ However, the departments have 
faced considerable challenges in project planning and management, 
leading to repeated changes in the focus and target completion dates of 
the initiatives.
---------------------------------------------------------------------------
    \7\ Initially, the Indian Health Service (IHS) was also a party to 
this effort, having been included because of its population-based 
research expertise and its longstanding relationship with VA. However, 
IHS was not included in a later revised strategy for electronically 
sharing patient health information.
---------------------------------------------------------------------------
    As shown in figure 1, the departments' efforts have involved both 
long-term initiatives to modernize their health information systems \8\ 
and short-term initiatives to respond to more immediate information-
sharing needs.
---------------------------------------------------------------------------
    \8\ DOD began efforts to modernize its existing health information 
system (CHCS) in 1997 and VA began efforts to modernize its existing 
health information system (VistA) in 2001.
---------------------------------------------------------------------------
 Figure 1: Timeline of Selected VA/DOD Electronic Medical Records and 
                          Data Sharing Efforts
[GRAPHIC] [TIFF OMITTED] 39466A.001


    The departments' first initiative was the Government Computer-Based 
Patient Record (GCPR) project, which aimed to develop an electronic 
interface that would allow physicians and other authorized users at VA 
and DOD health facilities to access data from each other's health 
information systems. The interface was expected to compile requested 
patient information in a virtual record (that is, electronic as opposed 
to paper) that could be displayed on a user's computer screen.
    We reviewed the GCPR project in 2001 and 2002, noting disappointing 
progress exacerbated in large part by inadequate accountability and 
poor planning and oversight, which raised questions about the 
departments' abilities to achieve a virtual medical record. We 
determined that the lack of a lead entity, clear mission, and detailed 
planning to achieve that mission made it difficult to monitor progress, 
identify project risks, and develop appropriate contingency plans.\9\ 
In both years, we recommended that the departments enhance the 
project's overall management and accountability. In particular, we 
recommended that the departments designate a lead entity and a clear 
line of authority for the project; create comprehensive and coordinated 
plans that include an agreed-upon mission and clear goals, objectives, 
and performance measures; revise the project's original goals and 
objectives to align with the current strategy; commit the executive 
support necessary to adequately manage the project; and ensure that it 
followed sound project management principles.
---------------------------------------------------------------------------
    \9\ GAO, Veterans Affairs: Sustained Management Attention Is Key to 
Achieving Information Technology Results, GAO-02-703 (Washington, D.C.: 
June 12, 2002) and Computer-Based Patient Records: Better Planning and 
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-
01-459 (Washington, D.C.: Apr. 30, 2001).
---------------------------------------------------------------------------
    In response, by July 2002, the two departments had revised their 
strategy, refocusing the project and dividing it into two initiatives. 
A short-term initiative, the Federal Health Information Exchange 
(FHIE), was to enable DOD to electronically transfer service members' 
health information to VA when the members left active duty. VA was 
designated as the lead entity for implementing FHIE, which was 
completed in 2004. A longer-term initiative was to develop a common 
health information architecture that would allow a two-way exchange of 
health information. The common architecture is to include standardized, 
computable data, communications, security, and high-performance health 
information systems (these systems, DOD's Composite Health Care System 
II and VA's HealtheVet VistA, were already in development, as shown in 
the figure).\10\ The departments' modernized systems are to store 
information (in standardized, computable form) in separate data 
repositories: DOD's Clinical Data Repository (CDR) and VA's Health Data 
Repository (HDR). The two repositories are to exchange information 
through an interface named CHDR.\11\
---------------------------------------------------------------------------
    \10\ DOD's existing Composite Health Care System (CHCS) was being 
modernized as CHCS II, now renamed AHLTA (Armed Forces Health 
Longitudinal Technology Application). VA's existing VistA system was 
being modernized as HealtheVet VistA.
    \11\ The name CHDR, pronounced ``cheddar,'' combines the names of 
the two repositories.
---------------------------------------------------------------------------
    In March 2004, the departments began to develop the CHDR interface. 
They planned to begin implementation by October 2005; \12\ however, 
implementation of the first release of the interface (at one site) 
occurred in September 2006, almost a year beyond the target date. In a 
report in June 2004, \13\ we identified a number of management 
weaknesses that could have contributed to this delay and made a number 
of recommendations, including creation of a comprehensive and 
coordinated project management plan. The departments agreed with our 
recommendations and took steps to improve the management of the CHDR 
initiative, designating a lead entity with final decision-making 
authority and establishing a project management structure. However, as 
we noted in subsequent testimony, \14\ the initiative did not have a 
detailed project management plan that described the technical and 
managerial processes necessary to satisfy project requirements 
(including a work breakdown structure and schedule for all development, 
testing, and implementation tasks), as we had recommended.
---------------------------------------------------------------------------
    \12\ December 2004 VA and DOD Joint Strategic Plan.
    \13\ GAO, Computer-Based Patient Records: VA and DOD Efforts to 
Exchange Health Data Could Benefit from Improved Planning and Project 
Management, GAO-04-687 (Washington, D.C.: June 7, 2004).
    \14\ GAO, Computer-Based Patient Records: VA and DOD Made Progress, 
but Much Work Remains to Fully Share Medical Information, GAO-05-1051T 
(Washington, D.C.: Sept. 28, 2005) and Information Technology: VA and 
DOD Face Challenges in Completing Key Efforts, GAO-06-905T (Washington, 
D.C.: June 22, 2006).
---------------------------------------------------------------------------
    In October 2004, responding to a congressional mandate, \15\ the 
departments established two more short-term initiatives: the Laboratory 
Data Sharing Interface, aimed at allowing VA and DOD facilities to 
share laboratory resources, and the Bidirectional Health Information 
Exchange (BHIE), aimed at giving both departments' clinicians access to 
records on shared patients (that is, those who receive care from both 
departments).\16\ As demonstration projects, these initiatives were 
limited in scope, with the intention of providing interim solutions to 
the departments' needs for more immediate health information sharing. 
However, because BHIE provided access to up-to-date information, the 
departments' clinicians expressed strong interest in expanding its use. 
As a result, the departments began planning to broaden this capability 
and expand its implementation considerably. Extending BHIE connectivity 
could provide each department with access to most data in the other's 
legacy systems, until such time as the departments' modernized systems 
are fully developed and implemented. According to a VA/DOD annual 
report \17\ and program officials, the departments now consider BHIE an 
interim step in their overall strategy to create a two-way exchange of 
electronic medical records.
---------------------------------------------------------------------------
    \15\ The Bob Stump National Defense Authorization Act for Fiscal 
Year 2003 (Pub. L. No. 107-314, Sec. 721, Dec. 2, 2002) mandated that 
the departments conduct demonstration projects to test the feasibility, 
advantages, and disadvantages of measures and programs designed to 
improve the sharing and coordination of health care and health care 
resources between the departments.
    \16\ To create BHIE, the departments drew on the architecture and 
framework of the information transfer system established by the FHIE 
project. Unlike FHIE, which provides a one-way transfer of information 
to VA when a service member separates from the military, the two-way 
system allows clinicians in both departments to view, in real time, 
limited health data (in text form) from the departments' current health 
information systems.
    \17\ December 2004 VA and DOD Joint Strategic Plan.
---------------------------------------------------------------------------
    The departments' reported costs for the various sharing initiatives 
and the modernization of their health information systems through 
fiscal year 2007 are shown in table 3.

                        Table 3: Reported Costs of VA and DOD Initiatives Since Inception
----------------------------------------------------------------------------------------------------------------
                Project                           VA expenditure                      DOD expenditure
----------------------------------------------------------------------------------------------------------------
HealtheVet VistA                          $681.7 million through FY 2006                                   ----
----------------------------------------------------------------------------------------------------------------
AHLTA                                                               ----         $954.3 million through FY 2007
                                                                                                   (estimated).
----------------------------------------------------------------------------------------------------------------
Joint initiatives:
----------------------------------------------------------------------------------------------------------------
CHDR                                                         4.1 million         DOD does not account for these
                                                                                           projects separately.
----------------------------------------------------------------------------------------------------------------
FHIE                                                        65.5 million
----------------------------------------------------------------------------------------------------------------
LDSI                                                         2.8 million
----------------------------------------------------------------------------------------------------------------
BHIE                                                         6.3 million
----------------------------------------------------------------------------------------------------------------
Total                                                      $78.7 million         $89.7 million through FY 2007.
----------------------------------------------------------------------------------------------------------------
Source: VA and DOD data.


    Beyond these initiatives, in January 2007, the departments 
announced a further change to their information-sharing strategy: their 
intention to jointly develop a new inpatient medical record system. On 
July 31, 2007, they awarded a contract for a feasibility study.\18\ 
According to the departments, adopting this joint solution is expected 
to facilitate the seamless transition of active-duty service members to 
veteran status, and make inpatient health care data on shared patients 
immediately accessible to both DOD and VA. In addition, the departments 
believe that a joint development effort could enable them to realize 
significant cost savings. We have not evaluated the departments' plans 
or strategy for this new system.
---------------------------------------------------------------------------
    \18\ The contract is for a 6-month base period, with a follow-on 6-
month option period. The cost for the 6-month base period is about $2 
million.
---------------------------------------------------------------------------
Other Evaluations Have Recommended Strengthening the Management and 
        Planning of the Departments' Health Information Initiatives
    Throughout the history of these initiatives, evaluations besides 
our own have found deficiencies in the departments' efforts, especially 
with regard to the lack of comprehensive planning. For example, a 
recent presidential task force identified the need for VA and DOD to 
improve their long-term planning.\19\ This task force, reporting on 
gaps in services provided to returning veterans, noted problems in 
sharing information on wounded service members, including the inability 
of VA providers to access paper DOD inpatient health records. The task 
force stated that although significant progress has been made towards 
sharing electronic information, more needs to be done, and recommended 
that VA and DOD continue to identify long-term initiatives and define 
the scope and elements of a joint inpatient electronic health record. 
In addition, in fiscal year 2006, Congress did not provide all the 
funding requested for HealtheVet VistA because it did not consider that 
the funding had been adequately justified.
---------------------------------------------------------------------------
    \19\ Task Force on Returning Global War on Terror Heroes, Report to 
the President (Apr. 19, 2007).
---------------------------------------------------------------------------
VA and DOD Are Exchanging Limited Medical Information, but a Seamlessly 
        Shared Medical Record Will Require Much More Work
    VA and DOD have made progress in both their long-term and short-
term initiatives to share health information. In the long-term project 
to modernize their health information systems, the departments have 
begun, among other things, to implement the first release of the 
interface between their modernized data repositories. The departments 
have also made progress in their short-term projects to share 
information in existing systems, having completed two initiatives, and 
are making important progress on another. In addition, the departments 
have undertaken ad hoc activities to accelerate the transmission of 
health information on severely wounded patients from DOD to VA's four 
polytrauma centers. However, despite the progress made and the sharing 
achieved, the tasks remaining to reach the goal of a shared electronic 
medical record are substantial.
VA and DOD Have Begun Deployment of a Modernized Data Interface
    In their long-term effort to share health information, VA and DOD 
have completed the development of their modernized data repositories, 
agreed on standards for various types of data, and begun to populate 
the repositories with these data.\20\ In addition, they have now 
implemented the first release of the CHDR interface. According to the 
departments' officials, all DOD sites can now access the interface, and 
it is expected to be available across VA when necessary software 
updates are released. (Currently 103 of 128 VA sites have received 
these updates.) \21\ At seven sites, VA and DOD are now exchanging 
limited medical information for shared patients: specifically, 
computable outpatient pharmacy and drug allergy information.
---------------------------------------------------------------------------
    \20\ DOD has populated CDR with information for outpatient 
encounters, drug allergies, and order entries and results for 
outpatient pharmacy/lab orders. VA has populated HDR with patient 
demographics, vital signs records, allergy data, and outpatient 
pharmacy data; in July, the department added chemistry and hematology, 
and in September, microbiology.
    \21\ The Remote Data Interoperability software upgrade provides the 
capability for the automated checks and alerts allowed by computable 
data.
---------------------------------------------------------------------------
    CHDR is the conduit for exchanging computable medical information 
between the departments. Data transmitted via the interface are 
permanently stored in each department's new data repository, CDR, and 
HDR. Once in the repositories, these computable data can be used by DOD 
and VA at all sites through their existing systems. CHDR also provides 
terminology mediation (translation of one agency's terminology into the 
other's). The departments' plans call for further developing the 
capability to exchange computable laboratory results data through the 
interface during fiscal year 2008.
    Although implementing this interface is an important 
accomplishment, the departments are still a long way from completing 
the modernized health information systems and comprehensive 
longitudinal health records. While DOD and VA had originally projected 
completion dates of 2011 and 2012, respectively, for their modernized 
systems, the departments' officials told us that there is currently no 
scheduled completion date for either system. VA is evaluating a 
proposal that would result in completion of its system in 2015; DOD is 
evaluating the impact of the new study on a joint inpatient medical 
record and has not indicated a new completion date.
    Further, both departments have still to identify the next types of 
data to be stored in the repositories. The departments will then have 
to populate the repositories with the standardized data. This involves 
different tasks for each department. Specifically, while VA's medical 
records are already electronic, it must still convert them into the 
interoperable format appropriate for its repository. DOD, in addition 
to converting current records from its multiple systems, must also 
address medical records that are not automated. As pointed out by a 
recent Army Inspector General's report, some DOD facilities are having 
problems with hard copy records.\22\ The report also identified 
inaccurate and incomplete health data as a problem to be addressed. 
Before the departments can achieve the long-term goal of seamless 
sharing of medical information, all of these tasks and challenges will 
have to be addressed. Accordingly, it is essential that the departments 
develop a comprehensive project plan to guide these efforts to 
completion, as we have previously recommended.
---------------------------------------------------------------------------
    \22\ Inspector General, Army, Army Physical Disability Evaluation 
System Inspection (March 2007).
---------------------------------------------------------------------------
Short-Term Projects Are Allowing VA and DOD to Exchange Limited Health 
        Information
    In addition to the long-term effort previously described, the two 
departments have made some progress in meeting immediate needs to share 
information in their respective legacy systems through short-term 
projects which, as mentioned earlier, are in various stages of 
completion. They have also set up special processes to transfer data 
from DOD facilities to VA's polytrauma centers in a further effort to 
more effectively treat Traumatic Brain Injuries and other especially 
severe injuries.
One-Way Transfer Capability Is Operational
    DOD has been using FHIE to transfer information to VA since 2002. 
According to DOD officials, 194 million clinical messages on more than 
4 million veterans had been transferred to the FHIE data repository as 
of September 2007, including laboratory results, radiology results, 
outpatient pharmacy data, allergy information, consultation reports, 
elements of the standard ambulatory data record, and demographic data. 
Further, since July 2005, FHIE has been used to transfer pre- and post-
deployment health assessment and reassessment data; as of September 
2007, VA had access to data for more than 793,000 separated service 
members and demobilized Reserve and National Guard members who had been 
deployed. Transfers are done in batches once a month, or weekly for 
veterans who have been referred to VA treatment facilities. According 
to a joint VA/DOD report, \23\ FHIE has made a significant contribution 
to the delivery and continuity of care of separated service members as 
they transition to veteran status, as well as to the adjudication of 
disability claims.
---------------------------------------------------------------------------
    \23\ December 2004, VA and DOD Joint Strategic Plan.
---------------------------------------------------------------------------
Laboratory Interface Initiative Allows VA and DOD to Share Lab 
        Resources
    One of the departments' demonstration projects--the Laboratory Data 
Sharing Interface (LDSI)--is now fully operational and is deployed when 
local agencies have a business case for its use and sign an agreement. 
It requires customization for each locality and is currently deployed 
at nine locations. LDSI currently supports a variety of chemistry and 
hematology tests, and, at one of the nine locations, anatomic pathology 
and microbiology tests.
    Once LDSI is implemented at a facility, the only nonautomated 
action needed for a laboratory test is transporting the specimens. If a 
test is not performed at a VA or DOD doctor's home facility, the doctor 
can order the test, the order is transmitted electronically to the 
appropriate lab (the other department's facility or in some cases a 
local commercial lab), and the results are returned electronically.
    Among the benefits of the LDSI interface, according to VA and DOD, 
are increased speed in receiving laboratory results and decreased 
errors from manual entry of orders. The LDSI project manager in San 
Antonio stated that another benefit of the project is the time saved by 
eliminating the need to rekey orders at processing labs to input the 
information into the laboratories' systems. Additionally, the San 
Antonio VA facility no longer has to contract out some of its 
laboratory work to private companies, but instead uses the DOD 
laboratory.
Two-Way Interface Allows Real-Time Viewing of Text Information
    Developed under a second demonstration project, the BHIE interface 
permits a medical care provider to query selected health information on 
patients from all VA and DOD sites and to view that data onscreen 
almost immediately. It not only allows the two departments to view each 
other's information, but it also allows DOD sites to see previously 
inaccessible data at other DOD sites.
    VA and DOD have been making progress on expanding the BHIE 
interface. As initially developed, the interface provided access to 
information in VA's VistA and DOD's Composite Health Care System, but 
it is currently being expanded to query data in other DOD systems and 
databases. In particular, the interface has been expanded to DOD's:

      Modernized data repository, CDR, which has enabled 
department-wide access to outpatient data for pharmacy and inpatient 
and outpatient allergy, radiology, chemistry, and hematology data since 
July 2007, and to microbiology data since September 2007.
      Clinical Information System (CIS), an inpatient system 
used by some DOD facilities; the interface enables bidirectional views 
of discharge summaries and is currently deployed at 13 large DOD sites.
      Theater Medical Data Store, which became operational in 
October 2007, enabling access to inpatient and outpatient clinical 
information from combat theaters.

    The departments are also taking steps to make more data elements 
available through BHIE. VA and DOD staff told us that by the end of the 
first quarter of fiscal year 2008, they plan to add provider notes, 
procedures, and problem lists. Later in fiscal year 2008, they plan to 
add vital signs, scanned images and documents, family history, social 
history, and other history questionnaires. In addition, a VA/DOD 
demonstration site in El Paso began sharing radiological images between 
the VA and DOD facilities in September 2007 using the BHIE/FHIE 
infrastructure.\24\
---------------------------------------------------------------------------
    \24\ To create BHIE, the departments drew on the architecture and 
framework of the information transfer system established by the FHIE 
project.
---------------------------------------------------------------------------
Types of Data Shared by DOD and VA Are Growing but Remain Limited
    Although VA and DOD are sharing various types of health data, the 
type of data being shared has been limited and significant work remains 
to expand the data shared and integrate the various initiatives. Table 
4 summarizes the types of health data currently shared via the long- 
and short-term initiatives we have described, as well as additional 
types of data that are currently planned for sharing. While this gives 
some indication of the scale of the tasks involved in sharing medical 
information, it does not depict the full extent of information that is 
currently being captured in the health information systems at VA and 
DOD.

                                         Table 4--Data Elements Made Available and Planned by DOD-VA Initiatives
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                   Data elements
                       Initiative                        ----------------------------------------------------------------            Comments
                                                                     Available                        Planned
--------------------------------------------------------------------------------------------------------------------------------------------------------
CHDR                                                                Outpatient pharmacy                                LabComputable data are exchanged
                                                                           Drug allergy                                   between one department's data
                                                                                                                            repository and the other's.
--------------------------------------------------------------------------------------------------------------------------------------------------------
FHIE                                                               Patient demographics                            None   One-way batch transfer of text
                                                                                       Laboratory results                    data from DOD to VA occurs
                                                                      Radiology reports                                    weekly if discharged patient
                                                                    Outpatient pharmacy                                     has been referred to VA for
                                                                            information                                   treatment; otherwise monthly.
                                                           Admission discharge transfer
                                                                                   data
                                                                    Discharge summaries
                                                                        Consult reports
                                                                              Allergies
                                                             Data from the DOD Standard
                                                                 Ambulatory Data Record
                                                               Pre- and post-deployment
                                                                            assessments
--------------------------------------------------------------------------------------------------------------------------------------------------------
LDSI                                                                                   Laboratory orders   Microbiology     Noncomputable text data are
                                                                                       Laboratory resAnatomic pathology                    transferred.
                                                          hematology and microbiology at
                                                                        two localities)
--------------------------------------------------------------------------------------------------------------------------------------------------------
BHIE                                                           Outpatient pharmacy data                  Provider notes    Data are not transferred but
                                                                  Drug and food allergy                      Procedures                  can be viewed.
                                                                            information                   Problem lists
                                                             Surgical pathology reports                     Vital signs
                                                                   Microbiology results    Scanned images and documents
                                                                       Cytology reports                  Family history
                                                               Chemistry and hematology                  Social history
                                                                                reports    Other history questionnaires
                                                                                       Laboratory orderRadiology images
                                                                 Radiology text reports
                                                          Inpatient discharge summaries
                                                            and/or emergency room notes
                                                          from CIS at 13 DOD and all VA
                                                                                  sites
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: GAO analysis of VA and DOD data.


Special Procedures Provide Information to VA Polytrauma Centers
    In addition to the information technology initiatives described, 
DOD and VA have set up special procedures to transfer medical 
information to VA's four polytrauma centers, which treat active duty 
service members and veterans severely wounded in combat.\25\ Some 
examples of polytrauma include Traumatic Brain Injury, amputations, and 
loss of hearing or vision.\26\
---------------------------------------------------------------------------
    \25\ In particular, clinicians require access to discharge notices, 
which describe the treatment given at previous medical facilities and 
the status of patients when they left those facilities.
    \26\ Polytrauma centers care for veterans and returning service 
members with injuries to more than one physical region or organ system, 
one of which may be life threatening, and which result in physical, 
cognitive, psychological, or psychosocial impairments and functional 
disability.
---------------------------------------------------------------------------
    When service members are seriously injured in a combat theater 
overseas, they are first treated locally. They are then generally 
evacuated to Landstuhl Medical Center in Germany, after which they are 
transferred to a military treatment facility in the United States, 
usually Walter Reed Army Medical Center in Washington, D.C.; the 
National Naval Medical Center in Bethesda, Maryland; or Brooke Army 
Medical Center, at Fort Sam Houston, Texas. From these facilities, 
service members suffering from polytrauma may be transferred to one of 
VA's four polytrauma centers for treatment.\27\
---------------------------------------------------------------------------
    \27\ The four Polytrauma Rehabilitation Centers are in Richmond, 
Virginia; Tampa, Florida; Minneapolis, Minnesota; and Palo Alto, 
California.
---------------------------------------------------------------------------
    At each of these locations, the injured service members will 
accumulate medical records, in addition to medical records already in 
existence before they were injured. According to DOD officials, when 
patients are referred to VA for care, DOD sends copies of medical 
records documenting treatment provided by the referring DOD facility 
along with them. The DOD medical information is currently collected in 
several different systems:

    1.  In the combat theater, electronic medical information may be 
collected for a variety of reasons, including routine outpatient care, 
as well as serious injuries. These data are stored in the Theater 
Medical Data Store. As mentioned earlier, the BHIE interface to this 
database became operational in October.
    2.  At Landstuhl, inpatient medical records are paper-based (except 
for discharge summaries). The paper records are sent with a patient as 
the individual is transferred for treatment in the United States. DOD 
officials told us that the paper record is the official DOD medical 
record, although AHLTA is used extensively to provide outpatient 
encounter information for medical records purposes.
    3.  At the DOD treatment facility (Walter Reed, Bethesda, or 
Brooke), additional inpatient information is recorded in CIS and 
outpatient pharmacy and drug information are stored in CDR; other 
health information continues to be stored in local CHCS databases.

    When service members are transferred to a VA polytrauma center, VA 
and DOD have several ad hoc processes in place to electronically 
transfer the patients' medical information:

      DOD has set up secure links to enable a limited number of 
clinicians at the polytrauma centers to log directly into CIS at Walter 
Reed and Bethesda Naval Hospital to access patient data.
      Staff at Walter Reed, Brooke, and Bethesda medical 
centers collect paper records, print records from CIS, scan all these, 
and transmit the scanned data to the four polytrauma centers. DOD staff 
pointed out that this laborious process is feasible only because the 
number of polytrauma patients is small. According to VA officials, 460 
severe Traumatic Brain Injury patients had been treated at the 
polytrauma centers through fiscal year 2007. According to DOD 
officials, the medical records for 81 patients planned for transfer or 
already at a VA polytrauma center were scanned and provided to VA 
between April 1 and October 11 of this year. Digital radiology images 
were also provided for 48 patients.
      Staff at Walter Reed and Bethesda are transmitting 
radiology images electronically to the four polytrauma centers. Access 
to radiology images is a high priority for polytrauma center doctors, 
but like scanning paper records, transmitting these images requires 
manual intervention: when each image is received at VA, it must be 
individually uploaded to VistA's imagery viewing capability. This 
process would not be practical for large volumes of images.
      VA has access to outpatient data (via BHIE) from all DOD 
sites, including Landstuhl.

    These special efforts to transfer medical information on seriously 
wounded patients represent important additional steps to facilitate the 
sharing of information that is vital to providing polytrauma patients 
with quality health care.
    In summary, VA and DOD are exchanging health information via their 
long- and short-term initiatives and continue to expand sharing of 
medical information via BHIE. However, these exchanges have been 
limited, and significant work remains to fully achieve the goal of 
exchanging interoperable, computable data. Work still to be done 
includes agreeing to standards for the remaining categories of medical 
information; populating the data repositories with all this 
information; completing the development of HealtheVet, VistA, and 
AHLTA; and transitioning from the legacy systems. To complete this work 
and achieve the departments' ultimate goal of a maintaining a lifelong 
electronic medical record that will follow service members as they 
transition from active to veteran status, a comprehensive and 
coordinated project management plan that defines the technical and 
managerial processes necessary to satisfy project requirements and to 
guide their activities continues to be of vital importance. We have 
previously recommended that the departments develop such a plan and 
that it include a work breakdown structure and schedule for all 
development, testing, and implementation tasks. Without such a detailed 
plan, VA and DOD increase the risk that the long-term project will not 
deliver the planned capabilities in the time and at the cost expected. 
Further, it is not clear how all the initiatives we have described 
today are to be incorporated into an overall strategy toward achieving 
the departments' goal of a comprehensive, seamless exchange of health 
information.
    This concludes my statement. I would be pleased to respond to any 
questions that you may have.
Contacts and Acknowledgments
    If you have any questions concerning this testimony, please contact 
Valerie C. Melvin, Director, Human Capital and Management Information 
Systems Issues, at (202) 512-6304 or melvinv@gao.gov. Other individuals 
who made key contributions to this testimony are Barbara Oliver, 
Assistant Director); Nancy Glover, Glenn Spiegel, and Amos Tevelow.
Related GAO Products
    Computer-Based Patient Records: Better Planning and Oversight by 
VA, DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459. 
Washington, D.C.: April 30, 2001.
    Veterans Affairs: Sustained Management Attention Is Key to 
Achieving Information Technology Results. GAO-02-703. Washington, D.C.: 
June 12, 2002.
    Computer-Based Patient Records: Short-Term Progress Made, but Much 
Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD 
Health Systems. GAO-04-271T. Washington, D.C.: November 19, 2003.
    Computer-Based Patient Records: Sound Planning and Project 
Management Are Needed to Achieve a Two-Way Exchange of VA and DOD 
Health Data. GAO-04-402T. Washington, D.C.: March 17, 2004.
    Computer-Based Patient Records: VA and DOD Efforts to Exchange 
Health Data Could Benefit from Improved Planning and Project 
Management. GAO-04-687. Washington, D.C.: June 7, 2004.
    Computer-Based Patient Records: VA and DOD Made Progress, but Much 
Work Remains to Fully Share Medical Information. GAO-05-1051T. 
Washington, D.C.: September 28, 2005.
    Information Technology: VA and DOD Face Challenges in Completing 
Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
    DOD and VA Exchange of Computable Pharmacy Data. GAO-07-554R. 
Washington, D.C.: April 30, 2007.
    Information Technology: VA and DOD Are Making Progress in Sharing 
Medical Information, but Are Far from Comprehensive Electronic Medical 
Records, GAO-07-852T. Washington, D.C.: May 8, 2007.
    Information Technology: VA and DOD Are Making Progress in Sharing 
Medical Information, but Remain Far from Having Comprehensive 
Electronic Medical Records, GAO-07-1108T. Washington, D.C.: July 18, 
2007.

                                 
 Prepared Statement of Colonel Keith Salzman, M.D., MPH, FAAFP, FACHE, 
 Chief of Informatics, Western Region Medical Command and Madigan Army 
Medical Center, Tacoma, WA, Department of the Army, U.S. Department of 
                                Defense
    Chairman Mitchell, Congresswoman Brown-Waite and distinguished 
Members of the Subcommittee, thank you for inviting me to discuss the 
information technology sharing project between Madigan Army Medical 
Center and VA Puget Sound. I am Colonel Keith Salzman, a physician and 
a DoD/AMEDD leader in the newly emerging discipline of Informatics and 
it is my privilege to serve as the Chief of Informatics at Western 
Regional Medical Command/Madigan Army Medical Center where we enjoy a 
long history of command support for our work in Informatics.
    I arrived at Madigan as the announcement was made that Madigan and 
VA Puget Sound would be working together to share electronic clinical 
information. I joined the team as a steering Committee Member. While 
the submission for the information sharing project occurred prior to my 
arrival, I have been on the project since its inception and continue to 
the present. We have completed all of the business plan objectives in 3 
years of a 4 year project and are using the remaining funds to provide 
additional requests for document exchange that support polytrauma 
information needs as well as other key documents and data types that 
contribute to extending interoperability, on the approval of the DoD-VA 
oversight Committee Members.
    The Madigan-VA Puget Sound project arose in response to 
congressional requirements for the DoD and VA to each contribute set 
aside funding for 4 years to collaborate on sharing clinical 
information and care to improve healthcare services to shared patients. 
At the outset of this testimony I would underscore our assessment that; 
the choice on many levels between `either', `or' is more appropriately 
answered as `both'. I will explain as I review this project.
    This particular demonstration was undertaken in response to section 
722 of the FY 2003 National Defense Authorization Act which required no 
less than three demonstration projects of DoD/VA coordinated systems 
involving budget/financial management; staffing/assignment; and 
Information Management/Information Technology (IM/IT). Madigan and VA 
Puget Sound were selected for this project based on the established 
clinical sharing that was in place and the need to improve the exchange 
of clinical information to provide care for the mutual patients cared 
for at Madigan Army Medical Center, and the American Lake and Seattle 
VA centers that make up the VA Puget Sound Healthcare System.
    The initial challenges surrounded the learning required to overcome 
the first `either-or' proposition of who drove the project: enterprise 
or the local site. A critical first lesson learned was--`both'. The 
local site had access to the clinical end user community and the 
requirements necessary to improve the flow of information while the 
enterprise had ownership of the architecture and systems in which 
requirements would be built and deployed. At the outset it is important 
to state that while this project is a demonstration project, all of the 
deliverables are being used by the enterprise systems of both the DoD 
and VA in production, in near real time (meaning seconds to minutes as 
a rule, not instantaneous or days to weeks).
    After the initial assembly of local and enterprise teams and review 
and approval of a detailed business plan, the teams moved forward with 
iterative delivery of tangible products implemented and delivered for 
use in enterprise systems (SHARE for the DoD view) and Remote Data View 
in the Computerized Patient Record System (CPRS the VA view) of the Bi-
Directional Health Information Exchange (BHIE) validated dual 
beneficiary patients. The work cycles for this project were generally 
6-9 months in duration.
    A second lesson learned was that while each system had its own test 
patients, shared test patients served the same purpose for 
interoperability (that purpose being validating information compilation 
and flow within the shared framework). While not as profound, the 
benefit of `either-or' answered in `both' facilitated testing, training 
and expansion of functionality.
    The critical dialog between clinical end user and the development 
team at the local level, combined with an active dialog between local 
and enterprise team members, ensured that a principle of software 
development (namely to correct functional problems as they are 
identified in the design phase) proceeds iteratively and cost 
effectively. The savings can be significant over allowing major design 
problems to persist into production. This exemplifies another `both' 
solution to an `either-or' proposition.
    Regarding requirements specifications, we observed that keeping the 
user requirements in sight while drafting the statement of work and 
contracting progress will save re-doing a product after-the-fact. A 
case in point is work on delivery of specified note types. The initial 
requirement was for seven note types. Through a disconnected process of 
contracting, the requirement was interpreted as all notes, creating an 
information retrieval and storage problem, unintended consequences of 
assumptions made by contractors making assumptions about what the end 
users really needed. The experience was used later in our development 
of requirements by keeping an open dialog between the end users and the 
enterprise-another `both' solution.
    With regard to the elephant in the room--establishing either AHLTA 
or VistA across both Departments-we observed the following:
    There are strengths and weaknesses in both systems that complement 
each other. AHLTA is integrated world-wide and available 24/7. There 
are functionality problems that are being worked to improve use at the 
clinical and business level. VistA shows the benefits of local design 
in its adoption by end users who are more inclined to buy into a 
product they created. The downside is the historic lack of 
configuration management. I use management intentionally as against 
configuration control. The VA faces big challenges in reorganization 
and must be careful not to destroy the strategy that delivered its 
success while addressing its Achilles heel of decentralized, unmanaged 
growth. The cost of imposing one system on both organizations now would 
be prohibitive. Establishing interoperability and designing a strategy 
of convergence over the next 10-20 years will allow a `both' solution 
that capitalizes on best practices and less disruptive changes to 
either system.
    By using an interoperable approach, the DoD and VA, who own about 
50% of the penetration of the Electronic Medical Record (EMR) on the 
national level, can pave the way for interoperability as use of the EMR 
extends from large organizations to the small provider groups and 
individual patients who constitute the majority of the Nation and who 
are not benefiting from an EMR. We are using the strategy of 
interoperability to extend to our indirect care providers in TRICARE 
and CHAMP-VA to capture the documentation that occurs outside of our 
EMRs. The extension makes a natural bridge to Regional Health 
Organizations.
    A key to success in our strategy was to use messaging standards 
(HL7 (Health Level 7), Clinical Document Architecture (CDA), Release 1 
and 2), which conform to security documentation requirements and 
integrate with the enterprise constraints from the local level. As 
stated at the beginning, this partnership between a local development 
cell immersed in the end user environment and the enterprise for 
configuration management is a critical model/partnership to succeed in 
developing software and hardware solutions for clinical-business 
processes that support healthcare delivery for our beneficiaries.
    An observation regarding COTS (commercial off the shelf) solutions 
for federal agencies is that common products such as identity 
management and Single Sign On/Context management solutions can be 
purchased in bulk with significant efficiencies for the government.
    In the end, we found that crossing new frontiers in collaborative 
work between federal agencies and local/enterprise ends of those 
agencies underscored our finding that `both' solutions work better than 
`either-or' solutions.
    These comments summarize what I would offer as a steering Committee 
Member engaged in this project from the start. Subject to your 
questions I would like to thank the Subcommittee again for allowing us 
to share our insights on this critical work that is progressing 
successfully. I would also encourage Congress to continue its support 
of this program and each of the agencies involved. I look forward to 
your questions.
                               __________
                Appendix A: Data Currently Being Shared
      Outpatient medications
      Allergies
      Lab--Chemistry, Hematology, Micro, Path, etc
      Radiology Text Reports
      Pre and Post Deployment Assessments
      Post Deployment Health Re-Assessment
      Discharge Summaries (DoD Essentris Sites and VA)
      MAMC legacy outpatient notes to VA
      Theater Clinical Data
      Op Reports, Surgical Reports, History & Physical, Consult 
Results and Progress Notes (Fall 2007)
                               __________
                              Appendix B:
[GRAPHIC] [TIFF OMITTED] 39466A.002


                                 
    Prepared Statement of Howard B. Green, PMP, Deputy, Operations 
     Management, Veterans Health Information Technology, Office of 
  Enterprise Development, Office of Information and Technology, U.S. 
                     Department of Veterans Affairs
    Thank you, Mr. Chairman. I would like to thank you for the 
opportunity to testify on the Sharing of Electronic Medical Information 
between the Department of Defense and the Department of Veterans 
Affairs, what is being done to accomplish the objectives, and the 
viability of the approach.
    I have been a member of the Department of Veterans Affairs Health 
IT community for over 19 years serving in multiple capacities at the 
local, regional Veteran Integrated Services Network (VISN) and national 
level. Prior to joining the Office of Information and Technology in 
2004, I was the Chief Information Officer for the Heartland Network 
(VISN 15) and was responsible for the introduction of VA's VistA system 
at all facilities and clinics in the region. Most recently, as Deputy 
for Operations Management within the Veterans Health IT Portfolio, I 
participated as a staff member on the President's Commission for 
America's Returning Wounded Warriors, and with my DoD counterpart was 
responsible for the creation of the information technology chapter and 
final report recommendations. Following that assignment, I have been 
given the responsibility for coordinating many of the recommendations 
from the President's Commission report.
Systems Supporting the Exchange of Clinical Information
    Formal activities related to the sharing of clinical information 
between the Department of Veterans Affairs (VA) and the Department of 
Defense (DoD) have been ongoing since 2001. Though there are a number 
of systems that have been developed to support this function, for all 
intents and purposes the overarching goal is to bidirectionally 
exchange computable information between VA and DoD in real-time. The 
following systems are in place to support this exchange of clinical 
information.

      Federal Health Information Exchange (FHIE): is the one-
way transfer of separated service member health data from DoD to VA.
      Bi-Directional Health Information Exchange (BHIE): 
supports functional interoperability between VA and DoD through the 
exchange of textual patient health information such as provider notes, 
non-computable test results, discharge summaries for all service 
member/veterans known as active dual consumers.
      Clinical Health Data Repository (CHDR): utilizes 
established data standards, and terminology services to enable exchange 
of standardized and computable health record data between VA and DoD.
      Laboratory Data Systems Interchange (LDSI): supports the 
lab reference model by providing an interoperable interagency 
application for lab order entry and results reporting.
      Imaging Pilots and Demonstrations: demonstrate the most 
efficient approaches to the transmission of medical images and 
clinically relevant documentation.
Effectiveness of Selected Clinical Information Exchange Systems:
    The FHIE system has supported the transfer of more than 187 million 
pieces of discharge related health information on over 3.8 million 
patients who have separated from the military. FHIE continues to 
exchange health record data for separated service members.
    BHIE is currently the bidirectional medical exchange interface 
having transferred information for over 2.3 million unique patients who 
are active dual consumers of both healthcare systems. Currently, VA and 
DoD are bidirectionally sharing viewable outpatient pharmacy data, 
anatomic pathology/surgical reports, cytology results, microbiology 
results, chemistry and hematology laboratory results, laboratory order 
information, radiology text reports, food and drug allergy information, 
and discharge summaries from several DoD sites running CIS. The 
Information through the BHIE interface flows to and from the following 
systems: VA's 128 VistA Systems and DoD's Composite Health Care System 
(CHCS), Clinical Data Record (CDR), AHLTA Share, CIS, and Theater 
Medical Data Store systems. There are plans to expand the amount of 
clinical data exchanged through BHIE. Encounter notes, patient focused 
problem lists such as on going treatment for diabetes or hypertension, 
procedures, and theater level inpatient & outpatient notes will be 
available by December 2007. By September 2008, VA and DoD improvements 
will include the addition of a polytrauma Marker and OEF/OIF Combat 
Veterans Identifier, Electronic Patient Handoff indicators, a DoD 
Scanning Interface, the Interagency Sharing of Essential Health Images, 
Provider Notes, Theater Data, Vital Signs, and Patient Histories. Site 
specific information regarding the volume of data passed through BHIE 
through September 2007 can be found at the end of this testimony.
    CHDR is the clinical data exchange interface that supports the 
exchange of standardized and computable data that can be used to 
support automated clinical decision support tools such as drug/drug and 
drug/allergy order checking. Currently CHDR data is viewable at all VA 
sites and several DoD sites. In addition, VA drug-drug and drug-allergy 
order checks are performed based on data from all VA systems and data 
from CHDR. User interface applications leveraging the BHIE interface 
often require the clinicians to look in several locations to retrieve 
health record information from other points of care. This often 
requires the clinician to interpolate based on approximation when 
comparing data elements due to the use of different terminologies. By 
comparison clinical information obtained through the CHDR interface can 
be incorporated into the same clinical view, automated computations, 
and edits allowing the user to readily compare like data. The CHDR 
interface currently supports the movement of pharmacy and medication 
allergy data and will be upgraded to include laboratory Chemistry and 
Hematology data in the fourth quarter of FY 2008.
    The Veterans Tracking Application (VTA) is the VA's interface to 
DoD's Joint Patient Tracking Application (JPTA) and supports the 
passage of information related to the location of wounded, injured or 
ill service members being transferred from theater to Military 
Treatment Facilities in the Continental United States (CONUS), who may 
be transitioning to the VA. VTA is a critical tool used to support the 
benefit claims and seamless transition processes.
    The El Paso Clinical Imaging Demonstration leverages the existing 
BHIE framework to exchange clinical images, descriptive data and 
reports between the VA and DoD facilities. As a result of this 
demonstration, six sites have been selected for installation and 
testing of the El Paso Imaging prototype are (in order of 
installation): Great Lakes/North Chicago, Evans Army Community 
Hospital/Eastern Colorado Health Care System, Landstuhl Regional 
Medical Center, National Capital Area (Walter Reed Army Medical Center, 
National Naval Medical Center, Washington DC VA), VA Polytrauma Centers 
at Richmond and Tampa, Keesler Medical Center/VA Gulf Coast Health Care 
System.
    In general, the volume of medical information that is being 
exchanged is growing at a substantial rate. Every effort is being made 
to meet the standard of ``essential'' data referenced in the report of 
the President's Commission on America's Returning Wounded Warriors.
    As it relates to achieving the stated objectives of the projects 
referenced above, the impact of senior leadership in driving the two 
organizations in the right direction can not be understated. The Joint 
Executive Committee (JEC) has been a driving force in setting the long 
term direction toward true electronic health record and veteran 
benefits data interoperability. The addition of the Senior Oversight 
Committee (SOC), the Overarching Integrated Project Team (OIPT) and 
Lines of Action (LOA) sub-committees have sharpened the focus and 
intensity of leadership engagement, expanded leadership engagement to 
include Under Secretaries and top-level General and Flag Officers, and 
elevated the topic to the level of the Deputy Secretaries of both 
Departments, intended to achieve results by addressing cross-
organizational issues and dependencies related to returning wounded 
service members and veterans.
The Role of Puget Sound Health Care System and Madigan Army Medical 
        Center, the Great Lakes Federal Health Care System, and other 
        sites in testing and supporting critical data exchange:
    Sharing agreements such as the one developed in Tacoma, Washington, 
between the Puget Sound Health Care System and Madigan Army Medical 
Center (aka Team Puget Sound) demonstrate new capabilities and 
functions within products such as BHIE and CHDR. In the Seattle/Tacoma 
region the two sites are leveraging the BHIE interface in support of 
inpatient services provided to VA at Madigan Army Medical Center. The 
primary focus is the exchange of discharge summaries and other 
clinically relevant inpatient notes. Through these efforts new 
functionality can be fully tested and incorporated into future national 
releases.
    While collaborations such as the one in the northwest tend to focus 
on specific functionality in support of limited sharing agreements, the 
Great Lakes Federal Health Care Center will eventually push the 
concepts of medical and administrative data sharing too its limits. The 
goal in Federal Health Care Center is to fully integrate the clinical 
and administrative functions between two health care systems. Planning 
activities are underway to develop the local project team required to 
manage the information technology requirements needed to support the 
new organization. Initial activities include the preparation of an 
integrated project schedule reflecting the expected delivery of local 
and national capabilities so that the gaps can be evaluated and 
resolved. Additionally, an enterprise-level team of resources is being 
assembled to resolve technical and operational issues that are beyond 
the local team's ability to address. The new Great Lakes System will 
exercise every element of both clinical and administrative operations; 
a planned and deliberate approach must be taken to ensure that the 
business goals are met. There are certainly advances in the application 
of information technology that can be applied, however, the process is 
complex and must be driven by key business decisions and not by IT.
    I would like to thank you Mr. Chairman for giving me the 
opportunity to testify about the progress being made in clinical 
information sharing between VA and DoD and I will gladly take any 
questions at this point.

                                     BHIE Statistics (as of 25 September 07)
----------------------------------------------------------------------------------------------------------------
                                            Number of   Number of                          Number of   Number of
                   MTF                     correlated      new              MTF           correlated      new
                                            Patients    patients*                          Patients    patients*
----------------------------------------------------------------------------------------------------------------
Tripler AMC                                  179,304      52,064            NACC Groton      78,321      33,833
----------------------------------------------------------------------------------------------------------------
Womack AMC                                   129,737      41,541                MacDill      70,025      40,028
----------------------------------------------------------------------------------------------------------------
Leonard Wood ACH                             112,676      31,876                    NCA     316,981     121,345
----------------------------------------------------------------------------------------------------------------
Irwin ACH                                     42,079      13,543               NH Camp Lejeu136,008      40,672
----------------------------------------------------------------------------------------------------------------
Eisenhower AMC                               246,781      96,654       Wright-Patterson     101,188      47,201
----------------------------------------------------------------------------------------------------------------
Martin ACH                                   139,410      39,402        Wm Beaumont AMC     124,275       6,199
----------------------------------------------------------------------------------------------------------------
Fox AHC                                       25,061      10,753      NH Corpus Christi      39,399      19,202
----------------------------------------------------------------------------------------------------------------
Wilford Hall MC                              601,170     227,103            Madigan AMC     201,519      63,392
----------------------------------------------------------------------------------------------------------------
Darnall ACH                                  135,239      40,465                       Lands436,716C    100,922
----------------------------------------------------------------------------------------------------------------
Elmendorf                                     40,717      13,153         NMC Portsmouth     303,976      97,422
----------------------------------------------------------------------------------------------------------------
Keesler                                      171,436      70,101           NH Pensacola     112,551      40,413
----------------------------------------------------------------------------------------------------------------
O'Callaghan FH                                75,777      22,619              NH Great Lakes134,931      36,955
----------------------------------------------------------------------------------------------------------------
Kirtland                                      77,066      55,796        NH Jacksonville     135,111      54,682
----------------------------------------------------------------------------------------------------------------
Lyster AHC                                    30,868      12,355          NMC San Diego     243,934      60,644
----------------------------------------------------------------------------------------------------------------
Bassett ACH                                   22,357       5,711                    NH Lemoor23,752       8,711
----------------------------------------------------------------------------------------------------------------
David Grant MC                               150,067      68,902          NH Charleston     119,450      36,356
----------------------------------------------------------------------------------------------------------------
Evans ACH                                    107,596      40,602      NH Camp Pendleton     165,589      49,444
----------------------------------------------------------------------------------------------------------------


Total # of Unique Patients **     2,386,625           1,033,658
------------------------------------------------------------------------
 * Patients not in the FHIE Domain.
** Columns do not add to the total, since patients have been seen at
  multiple facilities.


                                 
   Prepared Statement of Lieutenant Commander James Lawrence Martin, 
   Regional Information Systems Officer, Navy Medicine East, Medical 
   Service Corps, Department of the Navy, U.S. Department of Defense
    Mr. Chairman and Members of this distinguished Subcommittee, thank 
you for inviting me to be here today. I am LCDR James L. Martin and I 
serve as the Regional Information Systems Officer, Navy Medicine East.
    Thank you for this opportunity to talk about my personal 
involvement in the design and implementation of the Composite 
Healthcare System (CHCS), CHCS II, AHLTA and the Electronic Medical 
Record Sharing between the Department of Defense and the Department of 
Veterans Affairs.
Status of Electronic Medical Record Sharing Naval Health Clinic Great 
        Lakes
    The present method of sharing electronic medical information at 
Naval Health Clinic, Great Lakes, is through the Bi-Directional Health 
Information Exchange (BHIE) and the Clinical Data Repository/Health 
Data Repository (CHDR). The Veterans Affairs providers are granted read 
only access to the Department of Defense (DoD) Composite Health Care 
System (CHCS) and AHLTA. The Department of Defense (DoD) Providers are 
granted read and write privileges to the Veterans Affairs Computerized 
Patient Record System (CPRS) which resides on the Veterans Health 
Information Systems and Technology Architecture (VistA).
    Specifically, access to the Composite Health Care System, AHLTA and 
the Computerized Patient Record System in North Chicago is achieved 
through a single end user device with icons on the desk top 
representing each of these applications. This allows for seamless 
patient flow from the Recruit Processing Center Clinic at Recruit 
Training Center, Great Lakes to the Emergency Room and Inpatient 
Facility at North Chicago Veterans Affairs Medical Center. Laboratory 
Data Sharing Interoperability (LDSI) is used to share Laboratory 
information between these two systems. The combination of these methods 
listed above allows complete sharing of all Clinical Information 
between the Veterans Affairs and Department of Defense Providers.
Regional Information Systems Officer Involvement in this Process
    My personal involvement in this process dates back to 1992 when I 
assisted in the design and implementation of the Infrastructure and End 
User Device placement in support of Composite Health Care System (CHCS 
Legacy) while serving as Assistant Department Head, Naval Medical 
Information Management Center, Bethesda. My involvement included 
personally visiting each Naval Healthcare Treatment Facility prior to 
and during system implementation.
    Thereafter, my role expanded in 1994 as the Head, Management 
Information Department, Naval Hospital Pensacola, where I managed the 
Composite Health Care System Host Site for the Hospital and its remote 
facilities. In 1997, while serving as the TRICARE Region II Regional 
Information Systems Officer, Naval Medical Center Portsmouth, one of 
our Commands was selected to be the Test Site for Composite Health Care 
System II, the predecessor to AHLTA. From 2000 to 2004, I was the 
Information Systems Officer at Naval Medical Center Portsmouth 
overseeing the testing and implementation of the Composite Health Care 
System II. It was during this tour that Naval Medical Center Portsmouth 
first populated the Clinical Data Repository (CDR) with a 25 month data 
pull from Composite Health Care System (Legacy CHCS) placing 
demographic information and Laboratory, Pharmacy and Radiology results 
in the Clinical Data Repository. From 2004 until 2006 I served as the 
Medical Liaison Officer, Space and Naval Warfare Systems Center, 
Norfolk, where I was in charge of the design and testing of the Theater 
Medical Information Program-Maritime (TMIP-M) the Navy Operational 
Version of Composite Health Care System II and AHLTA designated CHCS 
II-T and AHLTA-T.
    Currently, as the Regional Information Systems Officer for Navy 
Medicine East, I oversee all Information Management and Technology for 
the Navy Military Healthcare Facilities that fall under Navy Medicine 
East. Naval Health Clinic Great Lakes is one of these Commands.
    I have made five site visits in direct support of the DoD/VA 
initiative at Great Lakes. During these visits I have surveyed the 
existing facilities and assisted in planning of the relocation of the 
IM/IT equipment to its new location at the Federal Healthcare Clinic. I 
attend biweekly conference calls and engineering support meetings where 
the design and layout of the actual IM/IT spaces is discussed.
    The other Commands under Navy Medicine East that I am presently 
assisting with DoD/VA IM/IT initiatives include Naval Health Clinic 
Charleston, Naval Hospital Pensacola, Naval Hospital Jacksonville and 
Naval Medical Center Portsmouth. I am also a member of the National 
Information Management and Technology Task Group for the Department of 
Defense and Department of Veterans Affairs Electronic Health 
Information Sharing Initiative. My responsibility as a member of this 
task force is to plan and oversee the acquisition and implementation of 
information systems that integrate VA and DoD health care processes at 
the North Chicago Federal Healthcare Clinic.
Future Activities
    Our goal is to have an interoperable information system that 
supports clinical and business operations by June 2010. We plan to 
create a single (main) computer room and a single (main) 
telecommunications room. Additionally, an Information Management and 
Information Technology Network Trust between DoD and VA must be 
established, along with domain ownership and a single electronic email 
system.
    We are presently gathering requirements from the functional users 
so that the determination can be made on whether a combination of 
information systems or a new information system is required to meet the 
functional user requirements. The ultimate goal is to have a single 
point of entry to support the missions of both DoD and VA patient 
populations. At present, this goal is met by providing access to CHCS, 
AHLTA and CPRS using multiple icons on a single end user device.
    In addition to the goal of a single point of entry we are also 
working on the consolidation of IM/IT systems for all of the functional 
areas in the Federal Healthcare Clinic. This involves managing the 
development of functional requirements, assisting with local site 
integration efforts, assisting with enterprise solutions and 
communicating the status.
Conclusion
    I would like to conclude by saying that one of our top priorities 
is to continue finding ways for Electronic Medical Data Sharing between 
DoD and VA.
    Mr. Chairman, Committee Members, thank you again for this 
opportunity to speak about our efforts. At this time I would be pleased 
to answer any questions you may have.

                                 
  Prepared Statement of Colonel Gregory Andre Marinkovich, M.D., Data 
   Management Product Line Functional Manager, Clinical Information 
  Technology Program Office, Military Health System, Medical Services 
       Corps, Department of the Army, U.S. Department of Defense
Introduction
    Mr. Chairman and Members of this distinguished Subcommittee, thank 
you for inviting me to be here today. I am COL Gregory Andre 
Marinkovich and I serve as the Data Management Product Line Functional 
Manager in the Clinical Information Technology Program Office within 
the Military Health System (MHS). Thank you for this opportunity to 
talk about the military's electronic health record, AHLTA, and the 
strides we are making in sharing information between the Department of 
Defense and the Department of Veterans Affairs.
Historical Overview
    AHLTA, an enterprise-wide medical and dental outpatient clinical 
information system, is the military's current outpatient Electronic 
Health Record (EHR). It generates, stores, and provides secure online 
access to lifelong patient healthcare records for more than 9.1 million 
MHS beneficiaries seen in military treatment facilities. AHLTA ensures 
the continuity of the Department's health information and patient-
centered healthcare delivery with worldwide accessibility anytime, 
anywhere.
    Worldwide deployment of AHLTA, which began January 2004, was 
successfully completed to all DoD military treatment facilities 
worldwide in November 2006. Implementation support activities spanned 
11 time zones and included training for over 55,000 users, to include 
more than 18,000 health care providers. Current AHLTA functionality 
includes encounter documentation, order entry/results retrieval, 
encounter coding support, alerts and reminders, role-based security, 
health data dictionary, master patient index, and ad hoc query 
capability.
Current Activities
    AHLTA use continues to grow at a significant pace.

      To date, AHLTA has processed over 45 million outpatient 
encounters.
      AHLTA is currently processing approximately 112,000 
outpatient encounters per workday.

    DoD and VA also are taking the first steps toward a joint 
electronic health record system. A contract to assess VA's and DoD's 
business and clinical processes, design features, and system 
constraints relevant to the inpatient component of an electronic health 
record has been awarded. This assessment will determine and describe, 
in narrative and graphic format, the scope and elements of a joint 
inpatient electronic health record and identify those clinical and 
business capabilities and applications that interact with the joint 
inpatient electronic health record. An analysis of alternatives will 
then be conducted to develop a recommendation for the best technical 
approach. We will implement the solution in a manner that builds in 
data interoperability.
Future Activities
    Based on feedback from several AHLTA user conferences, we are 
making changes to the next version that will be more provider-friendly. 
This is scheduled to be released in December 2007. Enhancements that 
are scheduled to begin deployment in December 2007 will include the 
ability for patients to provide their signatures electronically for 
medical forms, and multi-site user account access, which will enable 
``mobile'' providers to use AHLTA from multiple locations.
    Looking ahead to 2008, we plan to begin worldwide deployment of 
dental charting and documentation, and eyeglass ordering and 
management.
Conclusion
    I would like to conclude by saying that one of our top priorities 
is to continue finding ways for AHLTA to seamlessly transfer 
information between DoD and VA, thereby ensuring continuity of quality 
care for returning wounded warriors. With your support, we will 
continue building on our achievements in sharing electronic health 
information in support of the men and women who serve and have served 
this country.
    Mr. Chairman, Committee Members, thank you again for this 
opportunity to speak about our efforts. At this time I would be pleased 
to answer any questions you may have.

                                 
 Prepared Statement of Gerald M. Cross, M.D., FAAFP, Principal Deputy 
   Under Secretary for Health, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Mr. Chairman, Madame Ranking Member Brown-Waite and Members of the 
Subcommittee, thank you for providing the opportunity to report the 
progress made by the Department of Veterans Affairs (VA) to share 
electronic medical records with the Department of Defense (DOD). We 
have made progress toward developing secure, interoperable electronic 
medical record systems and I am here today to discuss the current 
status of our efforts and the work that is underway to achieve 
electronic health record interoperability.
Overview
    Today, VA and DOD are sharing electronic health data 
bidirectionally to support the care of shared patients. Additionally, 
VA and DOD are sharing more data than ever before on our seriously 
wounded service members and veterans who are transitioning from 
military facilities to VA facilities and polytrauma centers. The 
availability of these data to VA and DOD providers enhances our ability 
to provide world class care to veterans, active duty service members 
receiving care from both systems, and to our wounded warriors returning 
from theaters of operation in Iraq and Afghanistan. Ensuring that we 
have accurate, comprehensive and timely medical data to treat our 
Nation's heroes remains a top priority of this department.
    In recent months, we have built upon our earlier successful 
development of one-way and bidirectional exchanges of text and 
computable data. Today, VA providers are able to access more electronic 
inpatient data from DOD than ever before. DOD also has a study 
underway, funded by VA and DOD, to examine our development of a joint 
inpatient electronic health record with DOD. Additionally, for the 
first time, VA has access to critical medical electronic data from 
current theater of operations, to treat wounded warriors coming to our 
facilities. The challenges of sharing large amounts of data from 
disparate electronic systems remain complex. Our processes are not 
perfect, and I will discuss that below. However, we are working to 
provide as much electronic data as possible as quickly as possible in 
support of our returning warriors and shared patient populations. We 
are now sharing data from multiple settings, including outpatient, 
inpatient, and theater, as well as tracking information to improve our 
case management and coordination. These accomplishments reaffirm our 
commitment to develop interoperable electronic health records with DOD. 
Moreover, we believe our current capabilities to share electronic 
medical data demonstrate progress toward our goal.
Active Joint Governance
    VA and DOD efforts to achieve interoperability are jointly governed 
at the highest levels of our departments. Our VA Acting Secretary and 
the Under Secretary of Defense for Personnel and Readiness continue to 
cochair the DOD/VA Joint Executive Council (JEC). The JEC provides 
Executive and overarching leadership of all VA/DOD collaborative 
activities, including the development of interoperable electronic 
medical records. Since 2003, VA and DOD have documented these 
activities in the DOD/VA Joint Strategic Plan (JSP) that is maintained 
by the JEC. The JSP contains measurable strategic goals, objectives and 
milestones for our collaborative work with DOD, including electronic 
medical data sharing. VA and DOD work to update the JSP each year and 
progress under the JSP is reported to the JEC on a monthly basis. Under 
the leadership of the JEC and the clear goals contained in the JSP, VA 
and DOD realized success in meeting JSP health data sharing milestones.
    VA's Under Secretary for Health and the DOD Assistant Secretary of 
Defense for Health Affairs cochair the VA/DOD Health Executive Council 
(HEC), a Subcommittee of the JEC. The HEC is responsible for 
coordination of those joint activities related to health care and is 
committed to ensuring that our ongoing partnership optimizes health 
delivery to veterans and military beneficiaries. The HEC Information 
Management and Information Technology Work Group, cochaired by the VHA 
Chief Information Officer for Health Information Technology Systems and 
the Military Health System Chief Information Officer, maintains day to 
day responsibility for health information technology work and, most 
importantly, for the implementation of our joint electronic health 
record and data sharing initiatives.
Theater and Inpatient Data Supporting the Seriously Ill and Wounded
    At no other time has it been more important for VA and DOD to 
overcome some of the ongoing complexities of sharing disparate 
electronic health data. VA and DOD are firmly committed to supporting 
the seamless care of our injured men and women returning from the 
battlefield to military facilities and eventually to VA facilities for 
longer term care and rehabilitation. Our Nation's heroes deserve 
nothing less. In cooperation with our sharing partner, our most recent 
accomplishments to report have focused on the development of electronic 
solutions to support these seriously ill and wounded patients.
    VA and DOD have charted the Senior Oversight Committee (SOC) for 
the Wounded, and Injured. Co-chaired by the Acting VA Secretary and the 
DOD Deputy Secretary, the SOC works in conjunction with the JEC to 
ensure targeted focus on the population of men and women injured in OEF 
and OIF and now returning for treatment. Underneath the SOC, VA and DOD 
have organized several Lines of Actions (LOAs), with one LOA 
specifically focused on data sharing. The purpose of the data sharing 
LOA is to ensure that appropriate beneficiary and medical information 
is visible, accessible and understandable by each departments and that 
available electronic information is shared. Since the formation of the 
SOC and LOAs, the President's Commission on Care for America's 
Returning Wounded Warriors (President's Commission) has recommended 
that VA and DOD share all essential health, administrative and benefit 
data in viewable format initially, within 12 months. Heeding this 
recommendation, we have worked with DOD to accelerate and enhance our 
existing data exchanging to meet this target. Today, VA and DOD are on 
target to ensure that these essential data which are available 
electronically will be viewable between the departments by October 
2008. Additionally, VA and DOD are now actively developing a plan to 
establish technology support for the newly formed position of Federal 
Recovery Coordinator. This Recovery Coordinator will support seriously 
ill and wounded patients by maintaining on the ground oversight and 
coordination for all essential clinical and non-clinical aspects of the 
recovery care plan. We anticipate documenting an information technology 
plan to support this position by November of this year.
    Our most notable achievements demonstrating our commitment to 
wounded warriors is the sharing of theater and inpatient data. For the 
first time, DOD medical data captured electronically in the theater of 
operations are now viewable in text format to any VA provider treating 
these wounded warriors. We accomplished this in September of 2007 by 
leveraging an existing bidirectional data exchange. Subsequently, we 
are implementing a plan that will permit us to share unprecedented 
amounts of the available inpatient electronic data from DOD. Currently, 
VA providers are able to view electronic discharge summaries, emergency 
department notes, and other narrative documents captured during 
inpatient encounters at 13 major DoD facilities that use the Essentris 
Clinical Information System (CIS)\TM\. These 13 facilities include the 
Military Treatment Facilities that are key to supporting returning 
combat veterans, such as Walter Reed Army Medical Center (Walter Reed) 
and Bethesda national Naval Medical Center (Bethesda), and have greatly 
contributed to our ability to provide seamless care to these wounded 
warriors. This work was accomplished, due in large part, to the 
innovation of our local clinicians and informatics professionals in the 
field, at locations such as the Puget Sound VA Healthcare System and 
Madigan Army Medical Center. Cooperative efforts between VA and DOD are 
systemic, reaching all the way down to our facilities.
    In addition to sharing available electronic documentation, DOD is 
sending digital radiology images and scanned inpatient paper records 
that do not originate in electronic format. These capabilities are in 
place between the key military treatment facilities that receive these 
patients in the Continental United States (CONUS), (Walter Reed, 
Bethesda, and Brooke Army Medical Center), and VA polytrauma centers 
located in Tampa, Richmond, Minneapolis and Palo Alto.
    VA and DOD continue to maintain the highly secure and audited 
direct connection allowing viewing access to the data in the inpatient 
electronic data systems at Walter Reed and Bethesda by clinicians at 
the four polytrauma centers. Using these connections allows authorized 
VA clinicians to view real-time DOD data on wounded service members and 
combat veterans who are coming to or have transferred to the VA from 
these DOD facilities. VA and DOD are working to expand our electronic 
capabilities enterprise wide. We have already successfully demonstrated 
our capability to leverage bidirectional data exchange to support image 
sharing with the El Paso pilot. We are now working to expand this pilot 
to other active sharing locations and are on target to document a plan 
to share images enterprise wide by March 2008. As is commonly 
understood, much of the DOD inpatient data is not available 
electronically. Despite this ongoing challenge, VA and DOD quickly 
developed these capabilities as interim solutions to support these 
patients while we work to expand our electronic capabilities. To ensure 
that we provide full support in the face of these ongoing challenges, 
VA continues to embed Transition Patient Advocates and social workers 
at key facilities. At minimum, all pertinent medical records not 
available electronically are at least copied and transferred with the 
patient. Our enhanced inpatient capabilities support and bolster the 
seamless transition of these patients. It is our goal that no patient 
will fall through the cracks.
    In January of 2007, VA and DOD announced a study to explore the 
development of a joint inpatient electronic health record system. Since 
that time, VA and DOD have actively pursued this initiative. We are now 
under contract with a prominent and independent third party firm that 
is conducting the analysis of alternatives. To date, we have made 
progress by documenting the scope and elements of those joint inpatient 
data elements that would need electronic support. This work includes 
conducting comprehensive surveys of industry best practices in this 
area. We anticipate we will have a final report by July 2008. A common 
inpatient electronic health record will support the transfer of our 
most seriously injured patients between DOD facilities and VA 
facilities as well as broad enterprise-level data sharing between VA 
and DOD clinicians for all shared patients.
Requirement to Share Psychological Health Data and TBI Data
    In order to ensure comprehensive continuation of services, and to 
better leverage the world-class care that is already available to 
patients at VA's centers of excellence for Post Traumatic Stress 
Disorder (PTSD), Traumatic Brain Injuries, and other diagnoses 
impacting psychological health, it is necessary for VA and DOD to 
improve routine and appropriate sharing of mental health data. VA has a 
need to receive these data from DOD.
    Sharing of information on mental health conditions and other 
sensitive matters is important in a number of different contexts. Most 
simply, they can be divided into areas where the sharing of information 
is needed to facilitate clinical care of veterans or servicemembers who 
receive care in both systems, either sequentially or in parallel, and 
information used for administrative or command purposes.
    For clinical purposes, our systems should work toward minimizing 
barriers for transmittal to the greatest extent possible. Examples of 
mental health information that would support the VA in serving veterans 
include records of acute stress disorders, other mental health 
conditions, and suicidal behaviors, as well as head trauma. Having this 
information on returning veterans would be important to guide treatment 
and monitoring plans.
    For other purposes, VA, as an agency that functions in the 
community in parallel to civilian providers of health care, the issues 
may be more complex. For example, in developing principles about 
disclosure of information about mental health conditions from VA to 
DOD, VA must balance its responsibilities as a civilian community 
health care provider with those as part of a DOD/VA system. Viewed from 
community standards, it is important to honor patient privacy values, 
while from the VA/DOD perspective, it is important to provide relevant 
information to DOD that may have an impact on the efficiency of the 
fighting force. This issue is being addressed in ongoing discussion 
within VA.
Ongoing Support for Separated Service Members and Shared Patients
    In addition to our accelerated efforts to support our most 
seriously injured patients, VA and DOD continue the ongoing 
implementation of our Joint Electronic Health Records Interoperability 
(JEHRI) plan. The HEC IM/IT Work Group continues to manage the 
implementation of JEHRI and the maintenance and enhancement of our one-
way and bidirectional data exchanges. Today, VA continues to receive 
all clinically relevant data that are available in DOD's legacy system, 
the Composite Health Information System (CHCS), on service members 
separated from active military service. These data are viewable through 
our shared Federal Health Information Exchange repository by VA 
clinicians and disability claims staff using VA health and 
administrative information systems. To date, DOD has transferred 
electronic health data on over 4 million unique separated service 
members to VA. Of these individuals, VA has provided care or benefits 
to the more than 2 million veterans who have sought care or benefits 
from VA. The data transferred for viewing includes outpatient pharmacy 
data, allergy information, laboratory results, consults, admission, 
disposition and transfer information, medical diagnostic coding data, 
and military pre- and post-deployment health assessment (PPDHA) and 
reassessment (PDHRA) data on separated and demobilized National Guard 
and Reserve members. DOD has made almost 2 million of these PPDHA and 
PDHRA forms available for viewing by VHA clinicians and VBA staff.
    In addition to ongoing maintenance of our one-way data exchange, VA 
and DOD continue to bidirectionally exchange viewable and computable 
electronic data on shared patients. Currently, VA and DOD are 
bidirectionally sharing viewable 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. We also are maintaining our ongoing exchange of computable 
allergy and pharmacy data supporting automatic drug-drug and drug-
allergy interaction checks at seven locations. The development of this 
joint capability is complete. The departments are now working together 
to expand implementation across both enterprises by addressing issues 
such as user training, site specific issues related to identification 
and flagging of active dual consumers for whom this capability is in 
place, and ongoing deployment of department system dependencies related 
to HealtheVet.
    As mentioned above, and in keeping with the recommendation of the 
Presidential Commission, VA and DOD are leveraging our bidirectional 
exchanges to expand the types of data shared and to share all essential 
information by October 2008. By December of this year, our providers 
will have access to viewable encounter notes, problem lists, and 
procedures from DOD's modern system, AHLTA. By June 2008, we will add 
vital signs and by October 2008 enterprise wide capability to view 
scanned documents, such as paper inpatient records. By March 2008, VA 
and DOD will document a plan to support the enterprise wide 
bidirectional sharing of digital images. This work will leverage the 
successful imaging pilot in El Paso and incorporate the work that will 
soon get underway at expanded pilot locations. By the fourth quarter of 
2008, VA and DOD will deploy our computable laboratory capability to 
support automatic decision support using electronic laboratory result 
data transferred bidirectionally.
Enhanced Tracking Capability (Veterans Tracking Application)
    This month, VA achieved the ability to access patient tracking data 
enterprise wide using the Veterans Tracking Application (VTA). As 
reported previously, VTA is a modified version of the DOD developed 
Joint Patient Tracking Application (JPTA). Our facility based liaisons, 
such as case managers, can now access VTA from VistA Web to assist with 
the coordination of care for patients treated at both VHA and DOD. This 
coordination includes the tracking of these patients as service members 
move from the battlefield through Landstuhl, Germany, to stateside 
military treatment facilities and into our VA polytrauma and medical 
centers. VTA is completely compatible with JPTA allowing overnight 
electronic transfer of critical tracking data on medically evacuated 
patients.
    Previously, we testified that our JPTA/VTA interface would support 
the transfer of medical data from the theater. DOD's recent successful 
efforts to consolidate theater clinical data and to make it viewable to 
VA through our bidirectional data exchange overcame that effort. As 
mentioned above, VA clinicians access clinical data, including theater 
clinical data, through the Bidirectional Health Information Exchange. 
Our JPTA/VTA interface now supports the provision of viewable tracking 
data. The VTA database of seriously injured OEF/OIF service members and 
veterans is used as the authoritative source for the movement of 
theater patients and supports and documents contacts with veterans and 
service members. VTA is now a critical tool in the support of our 
seamless case management of patients. VTA also continues to support the 
benefit claims process and consolidates data from across all major 
components, DOD, VHA and VBA into a veteran centric record enhancing 
our case management capabilities.
Ongoing Collaboration and Dependence on Standards
    VA and DOD' continue to work closely with the Department of Health 
and Human Services (HHS) and other partners on national efforts to 
align our groundbreaking work on data exchanges with the nationwide 
effort to support health interoperability. These efforts are led by the 
HHS National Coordinator for Health Information Technology and will 
include ongoing efforts to identify mature standards, study 
infrastructure interoperability, and work closely with commercial 
healthcare providers to foster a global interoperability 
infrastructure.
    The President's Commission recognized the complexity of achieving 
full data interoperability and tailored its recommendation to initially 
share data in viewable format versus computable format. Mature 
standards are necessary and evolved technologies are critical 
dependencies to the seamless exchange of all data. As these health data 
and communication standards mature and are identified, we will adopt 
and implement the standards into the systems we are modernizing. VA and 
DOD continue to play a leadership role in these efforts. Our VA/DOD 
Health Architecture Interagency Group continues to participate in and 
contribute to standards related organizations such as Healthcare 
Information Technology Standards Panel (HITSP) and Health Level 7(HL7) 
to improve the availability of shared health information. Current 
efforts are focused on areas such as case management and disability 
evaluation.
Conclusion
    VA and DOD have achieved progress toward sharing all available 
electronic data and remain committed to efforts that will help us to 
reach our final goal. Under the leadership of the JEC and the HEC, we 
are marching forward to implement enhancements to existing data 
exchanges while identifying attainable opportunities to support our 
most seriously ill and wounded warriors and combat veterans. We assure 
you that we continue to work toward a long-term strategy that will 
support full enterprise wide electronic data interoperability. Never 
before have we been able to access data from the theater and provide 
care to our veterans and rehabilitating service members using the 
amount of inpatient data currently available from DOD. Our efforts are 
subject to tremendous interest by the President and Congress, and we 
are working hard to ensure that recommendations coming from bodies such 
as the President's Commission, the Task Force on the Returning Global 
War on Terror Heroes, chaired by our own Acting Secretary, and the 
Veterans Disability Benefits Commission, are evaluated and 
incorporated, where feasible, to ensure we form a complete and 
comprehensive approach to sharing health data in support of our 
veterans and service members
    To continue our successes, we ask for your continued support as we 
each work to modernize and update our existing technologies. VA has 
been recognized many times over for the world-class care it provides to 
veterans. Our electronic health record is second to none in its fully 
integrated electronic capabilities across all settings of care. More 
work is needed to update our world-class system and to ensure that it 
uses state of the art technologies and tools that will better support 
data interoperability. Thank you for the opportunity to appear before 
you and provide you the status of our ongoing efforts. My colleagues 
and I are happy to answer any questions you or other Members of the 
Subcommittee might have.

                               __________
                    VA/DoD Interoperability Acronyms
Health Care Delivery Systems
    AHLTA--Armed Forces Health Longitudinal Technology Application--
DoD's next generation Electronic Record System--formerly CHCS II
    CHCS--Composite Health Care System--DoD legacy system housing order 
entry/labs/radiology/allergy/meds, largely used for ambulatory care
    CIS--Clinical Information System (new name is Essentris 
Clinicomp)--DoD's standalone inpatient system installed in most major 
military treatment facilities.
    CPRS--Computerized Patient Record System
    HealtheVet--Next generation of VistA based on computable data
    JPTA--DoD's Joint Patient Tracking Application
    TMDS--DoD's Theater Medical Data Store
    VistA--Veterans Health Information Systems and Technology 
Architecture
    VistA Web--The VistA web-based application for viewing remote data 
(VA and DoD)
    VTA--Veterans Tracking Application
Other
    TPA--Transition Patient Advocates
Health Care Exchange Systems
    BHIE--Bidirectional Health Information Exchange
    CHDR--Clinical Data Repository/Health Data Repository 
(Interoperability Project)
    FHIE--Federal Health Information Exchange (formerly GCPR)
Groups/Organizations/Plans
    AHIC--American Health Information Community
    CHI--Consolidated Health Informatics
    BEC--DoD/VA Benefits Executive Council
    HEC--DoD/VA Health Executive Council
    JEC--DoD/VA Joint Executive Council
    JEHRI--DoD/VA Joint Electronic Health Records Interoperability
    JSP--Joint Strategic Plan
    LOA--Line of Action
    MTF--Military Treatment Facilities
    ONCHIT--Office of the National Coordinator for Health Information 
Technology
    SOC--Senior Oversight Committee

    [GRAPHIC] [TIFF OMITTED] 39466A.003
    

                                 
Prepared Statement of Stephen L. Jones, DHA, Principal Deputy Assistant 
   Secretary of Defense (Health Affairs), U.S. Department of Defense

                              INTRODUCTION

    Mr. Chairman and members of this distinguished Subcommittee, thank 
you for inviting me to discuss the sharing of electronic health 
information between the Department of Defense (DoD) and Department of 
Veterans Affairs (VA). We are making great strides in sharing 
electronic health information, but we have more to do.
    Cooperation between DoD and VA in the area of health 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 
information since our first efforts in 2001. In particular, I would 
like to highlight current sharing activities, recent accomplishments, 
and some of what we hope to accomplish going forward.

                          HISTORICAL OVERVIEW

    DoD and VA began sharing electronic health information in 2001 and 
have continually enhanced and expanded the types of information we 
share as well as the ways in which we share the information. 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 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.

                           CURRENT ACTIVITIES

    Continuity of Care for Shared Patients. For patients treated at 
both VA and DoD facilities, providers can view electronic health data 
from both Departments. By the end of 2007, all essential health data 
will be, in the words of the President's Commission on Care for 
America's Returning Wounded Warriors, ``immediately viewable by any 
clinician, allied health professional, or program administrator who 
needs it'' at a DoD or VA facility. Health data currently accessible by 
DoD and VA providers includes allergy information, outpatient 
medications, inpatient and outpatient laboratory results, radiology 
reports, demographic details to identify the patient, Pre- and Post-
Deployment Health Assessments, and Post-Deployment Health 
Reassessments. To that list we can now add, as of earlier this month, 
vital clinical data captured in the Theater of operations, including 
inpatient notes, outpatient encounters, and ancillary clinical data, 
such as pharmacy data, allergies, laboratory results, and radiology 
reports. This development is a significant accomplishment in our 
efforts to enhance the continuity of care for Service members returning 
from Iraq, Afghanistan, Kuwait, and other forward locations. Other 
recent developments include expanding our efforts to share inpatient 
information electronically. Specifically, over the past several months 
we have expanded the sharing of electronic discharge summaries to 
include the 13 DoD facilities with the greatest inpatient volume. 
Previously only five DoD facilities had been capable of sharing 
discharge summaries. This capability will be extended to include 
Landstuhl Regional Medical Center in 2008. As the primary receiving 
location for patients coming out of Theater, Landstuhl is a critical 
link in the electronic health information chain.
    By December 2007, we will be sharing encounters and clinical notes, 
procedures, problem lists, inpatient consultations, and operative 
reports, further enhancing continuity of care for our shared patients. 
In 2008, we will add vital signs, family history, social history, other 
history, and questionnaires and forms.

    Drug-Drug and Drug-Allergy Interaction Checking. 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 and 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)--DoD's ``gold standard'' for 
person identification. More than 6 million veterans, primarily those 
who separated from Service prior to the establishment of DEERS, were 
recently added to the DEERS database. With that completed, we are now 
ready for all DoD sites to implement this data sharing initiative. Even 
now however, 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.

    Continuity of Care for Polytrauma Patients (Wounded Warriors). 
Earlier this year, 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 began sending electronic 
health 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 Servicemembers (Potential VA Patients). More than 4 
million former Service members eligible for VA health care now have 
electronic health information accessible to their new provider should 
they seek care at a VA facility. In 2001, DoD transmitted electronic 
health information for Service members who had separated since 1989. 
Monthly transfers of health information for newly separated Service 
members began in 2002 and continue today. Electronic health 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 medical record.

    Business Practice Coordination. DoD and VA have extended the 
sharing concept to include coordination of business practices. For 
example, the Laboratory Data Sharing Initiative (LDSI) established 
bidirectional electronic exchange of laboratory chemistry orders and 
results when one Department's lab acts as a reference lab for the 
other. In other words, when it will speed the process of getting a lab 
result, DoD can send a test to a VA lab for processing or VA can send a 
test to a DoD lab. The end result is expedited testing and results, 
enhancing the quality of care for our patients. Expanding the LDSI 
capability, DoD and VA have added laboratory anatomic pathology and 
microbiology orders and results retrieval. This enhanced functionality 
became operational at Brooke Army Medical Center and VA South Texas 
Health Care System in May 2007. The LDSI capability can be expanded to 
include other sites should they demonstrate that the capability would 
enhance quality of care and make sense from a business perspective.
    DoD and VA are also exploring other opportunities for coordinating 
business practices to support Veterans and Service members and their 
families. These opportunities include an eHealth portal to improve 
accessibility of information for patients and expanded image sharing. 
In both cases, DoD and VA will explore opportunities in search of the 
best ways to coordinate business practices to achieve the greatest 
benefit for the patients we serve.

    DoD's Electronic Health Record Meets Unique Needs. Sharing 
electronic health information with VA is just one function of the DoD 
electronic health record. DoD has many unique requirements that have 
shaped the development of its electronic health record system.
    Theater. To track health care most effectively in Theater, a 
flexible, mobile, and highly scalable electronic information system is 
necessary. DoD's electronic health record operates on the full spectrum 
of hardware, according to what is available or practical in a given 
location or situation. DoD providers at fixed facilities--what most of 
us think of as hospitals--can use desktop computers. Providers at 
Combat Support Hospitals--sometimes nothing more than tents in the 
desert--use laptops that can operate in a standalone mode or as part of 
a small network. Medics in the field can use handheld devices that are 
later synched with a laptop or desktop to add valuable information to 
the patient's electronic health record. DoD's electronic health record, 
on all platforms, is designed to collect highly structured medical 
data, enabling us to identify potential natural disease outbreaks and 
chemical or biological attacks much faster than ever before in Theater. 
DoD's Theater health care mission also necessitates that an electronic 
health record system be operational in situations and places where 
external communications are often sporadic or unreliable. Additionally, 
because health care information from Theater supports command and 
control efforts, our electronic health record system needs to fit 
within the greater DoD information technology infrastructure.
    One System in Garrison and Theater. When our providers deploy, they 
must be provided with familiar tools to maximize their readiness. 
Therefore, we need to use one electronic health record system in 
garrison and in Theater. Multiple systems could delay deployment of 
health care providers as they learn the ``Theater'' system or could 
negatively affect the quality of care in Theater as providers use a 
system with which they are either unfamiliar or less familiar.
    Our Beneficiary Population. DoD's beneficiaries include millions of 
people who relocate every few years. To maintain accurate and complete 
electronic health records for such a mobile population requires a 
centralized clinical data repository. As DoD providers and patients 
alike move from one part of the country to another, or from one end of 
the world to another, they benefit from a system that maintains 
complete records with information from more than 60 major hospitals and 
medical centers and more than 400 clinics in a single, electronic 
health record--accessible from DoD facilities around the globe.

                JOINT INPATIENT ELECTRONIC HEALTH RECORD

    DoD and VA have developed or acquired separate outpatient 
electronic health record systems to meet unique needs. For inpatient 
care, however, the Departments are exploring the possibility of a joint 
electronic health record solution. The timing for examining this 
potentially ground-breaking effort is right, as both Departments 
currently plan to modernize, upgrade, or integrate inpatient records 
with their outpatient electronic health records and must find an 
interoperable solution. A joint inpatient solution that meets the needs 
of both Departments could further enhance continuity of care, better 
meet requirements for joint facilities, and leverage economies of scale 
in terms of development and integration costs, license fees, and 
hardware purchases.
    We have taken the first steps in this effort to examine the 
potential for a joint system by working closely to award a contract to 
assess VA's and DoD's business and clinical processes, design features, 
and system constraints relevant to the inpatient component of an 
electronic health record. This assessment will determine and describe, 
in narrative and graphic format, the scope and elements of a joint 
inpatient electronic health record and identify those clinical and 
business capabilities and applications that interact with the joint 
inpatient electronic health record. An analysis of alternatives will 
then be conducted to develop a recommendation for the best technical 
approach. We will implement the solution in a manner that builds data 
interoperability in as a fundamental precept. Our goal is for a 
solution to address the information needs of the end users in all 
inpatient care venues from the forward surgical units in Theater to the 
domiciliary care facilities in VA. A joint solution could provide users 
with all essential inpatient data--regardless of where in DoD or VA 
that data was acquired--as the patient moves through the continuum of 
care from Theater to home again. The requirements analysis will be 
complete in 2008, after which we will establish an acquisition or 
development timeline based on the assessment of alternatives.

                 INTENSIFIED FOCUS ON WOUNDED WARRIORS

    In the words of Secretary Gates, ``Apart from the war itself, this 
department and I have no higher priority'' than taking care of those 
who have ``stepped forward to serve.'' Over the last several months DoD 
and VA have accelerated our electronic health information sharing 
initiatives to support America's heroes. We have received and are 
responding to the recommendations of various commissions and task 
forces, including the Independent Review Group, the Department of 
Veterans Affairs Interagency Task Force on Returning Global War on 
Terror Heroes, and most recently, the Veterans Disability Benefits 
Commission. Under the auspices of a Senior Oversight Committee and 
Overarching Integrated Product Team, I along with Dr. Paul Tibbits have 
had the privilege of cochairing the team for DoD/VA Data Sharing. Not 
only are we focusing on sharing health, personnel, and administrative 
data electronically between DoD and VA, but we are also working with 
other teams to determine the information technology needed to support 
reengineered business processes that better support our wounded 
warriors.
    In addition, we are working to implement the recommendations of the 
President's Commission on Care for America's Returning Wounded 
Warriors. We will:

      By next July, in order to implement our new Recovery 
Plans for wounded, make patient data much more accessible--to begin 
with, in viewable form. All essential health, administrative, and 
benefits data must be immediately viewable by any clinician, allied 
health professional, or program administrator who needs it.
      Continue the work under way at present to create a fully 
interoperable information system that will meet the long-term 
administrative and clinical needs of all military personnel over time.
      Develop a plan for a user-friendly, tailored, and 
specific services and benefits portal for service members, veterans, 
and family members.

    Over the next several months, DoD/VA teams will define information 
technology requirements, enabling the two Departments to begin the work 
necessary to make all appropriate demographic, personnel, and medical 
information on Service members, Veterans, and their beneficiaries 
visible, accessible, and understandable through secure and 
interoperable information management systems. We will work to provide 
the information technology needed to care for and track the status of 
our wounded warriors through their transition to Veteran status. DoD 
and VA are now working more collaboratively across health and personnel 
organizational lines than ever before. Our overall goal is to ensure 
appropriate beneficiary and medical information is visible, accessible, 
and understandable through secure and interoperable information 
management systems.

                            JOINT GOVERNANCE

    VA/DoD electronic health information collaboration is a major 
component of the Departments' Joint Strategic Plan. The goals of the 
Joint Executive Council are described in the Joint Strategic Plan for 
Fiscal Years 2007 through 2009 and cover a full spectrum of VA/DoD 
health-related sharing. The Under Secretary of Defense for Personnel 
and Readiness and the VA Deputy Secretary cochair the Joint Executive 
Council, whose members include senior DoD and VA health managers 
involved in sharing initiatives. This Council was established in 2002 
and now meets quarterly to provide leadership oversight of 
interdepartmental cooperation at all levels and to oversee the efforts 
of the Health Executive Council and Benefits Executive Council. The 
Assistant Secretary of Defense (Health Affairs) and VA Under Secretary 
for Health cochair the Health Executive Council, which was formed to 
establish a high-level program of cooperation and coordination in a 
joint effort to reduce costs and improve health care for all our 
beneficiaries. The Chief Information Officers of the Military Health 
System and the VA cochair the Health Executive Council's Information 
Management/Information Technology workgroup.

             NATIONAL STANDARDS ADOPTION AND IMPLEMENTATION

    DoD and VA lead the Nation in health information technology, 
implementation of interoperability standards, and electronic health 
information sharing. DoD's electronic health record system has been 
awarded pre-market, conditional certification by the Certification 
Commission for Healthcare Information Technology, an independent, non-
profit organization that sets the benchmark for electronic health 
record systems. Full certification for DoD's electronic health record 
system is expected in December 2007 when we begin deploying the next 
major enhancement. As we implement, acquire, or upgrade health 
information technology systems used for the direct exchange of health 
information between agencies and with non-Federal entities, we shall 
utilize, where available, health information technology systems and 
products that meet recognized interoperability standards.
    DoD and VA will continue to be driving forces in National 
initiatives such as the American Health Information Community, the 
Health Information Technology Standards Panel, the Health Information 
Technology Policy Council, and the Federal Health Architecture. DoD and 
VA support Executive Order 13410, issued in August 2006, which requires 
Federal agencies to use recognized health interoperability standards to 
promote the direct exchange of health information between agencies and 
with non-federal entities. Because such a significant portion of the 
American population is eligible for health care through Medicare, DoD, 
VA, and Federal employee health programs, our efforts can have a 
dramatic effect on private sector adoption of health information 
technology and will ultimately affect our ability to exchange 
electronic health information with private sector providers.

                               CONCLUSION

    Providing the best possible care for America's returning wounded 
warriors is a top priority for DoD and VA. Electronic health 
information sharing is unquestionably a key component of enhancing the 
quality and continuity of the care both Departments deliver. We have 
made great strides since our initial sharing efforts, building on the 
foundation established beginning in 2001. We have accelerated our 
expansion of the types of data shared and methods of sharing in recent 
months to support urgent needs. In the coming month