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Health IT Strategic Framework

Attachment 2

IV. VA/DoD Collaborative Approaches to Facilitate the Transfer of Affordable Health Information Technologies

VA and DoD each have a lengthy and comprehensive history developing and implementing electronic health record systems. This history translates into significant purchasing power and intellectual capital capable of exerting influence upon the health information technology (IT) industry as a whole. VA and DoD are the largest providers of health care in the United States. They have combined annual health care budgets in excess of $50 billion dollars, close to 12 million beneficiaries, and approximately 1600 health care sites and locations. Jointly and separately the Departments could exert significant influence of the provision of affordable technologies to the rural and medically underserved populations of this Nation.

A. Knowledge Transfer of Information Exchange Lessons

The Departments have made significant progress with development of electronic data exchanges. As such, VA and DoD are major catalysts in moving the industry toward use of interoperable health information technologies that improve health care delivery, patient safety and population health management. Within the Departments, the focus of this work has been on the creation of a seamless transition for those military service members who separate from service and seek care from VA. VA and DoD believe that their model of cooperation and joint development work can serve as a model among Federal agencies and for national cooperation.

In April 2002, the Departments adopted a strategy to develop interoperable electronic health records in 2005. This cross-cutting initiative, the VA/DoD Joint Electronic Health Records Plan, - HealthePeople (Federal), brings together the common adoption of standards, the development of interoperable data repositories, and joint or collaborative development of software applications to build a replicable model of data exchange technologies.

Federal Health Information Exchange

As part of this Plan, the Departments have worked on and are planning a series of progressive data exchange initiatives. In May of 2002, the Departments began the electronic transfer of clinical information from DoD to VA on separated or retired service members. As of June 2004, DoD has transferred clinical information on over 2.27 million prior service members to VA through the Federal Health Information Exchange (FHIE). FHIE continues to transfer clinical information from the DoD Composite Healthcare System (CHCS) to the FHIE Data Repository, where it is available for viewing by VA clinicians using VA's CPRS. Claims adjudicators from the Veterans Benefit Administration also may access FHIE data using the Compensation and Pension Records Interchange system. The data available includes laboratory results, outpatient government and retail pharmacy prescriptions, radiology reports, admission, disposition and transfer messages, discharge summaries, consult reports, and outpatient coding elements from the Standard Ambulatory Data Record.

CHCS/VistA Data Sharing Interface

The Departments are presently engaged in the next step of their data exchange work: development of a real time bi-directional exchange of limited data sets for shared patients. The CHCS/VistA Data Sharing Interface (DSI) work will leverage already developed joint DoD/VA infrastructure, IT investments, VA/DoD test facilities, and existing personnel resources to quickly create a real-time, bi-directional interface. DSI will permit a Military Treatment Facility to share clinical data capable of computational actions with any VA medical center where a shared patient presents for care.

Other efforts under exploration include two projects in Hawaii. The first project includes development work that permits electronic transmission of pharmacy orders between Tripler Army Medical Center and VA Honolulu Medical Center for dispensing. This interface allows pharmacy orders written at the DoD facility to be transmitted electronically and filled at VA pharmacy. The second project, Janus, allows DoD providers to retrieve patient data from the VA's VistA patient record system. It provides a single Graphical User Interface (GUI) front end that links to a web application to pull data from VistA, to provide end-users on Tripler's CHCS with VistA patient record information.

Clinical Data Repository/Health Data Repository Interoperability

Beyond bi-directional data exchange in present systems, the Departments also are developing an interface between the DoD Clinical Data Repository of the Composite Health Care System II (CHCS II) and the VA Health Data Repository of HealtheVet-VistA. This initiative, known as "CHDR" (Clinical Data Repository/Health Data Repository) will support the real time bi-directional exchange of health data by the end of FY 2005. Phase I of this effort is the acquisition of a pharmacy prototype that will demonstrate the bi-directional exchange of computable outpatient pharmacy data, allergy information, and patient demographics in a lab environment by October 2004. The prototype is under development and on schedule. Phase II is the further development of the CHDR interface to enable its use in clinical settings. Using clinical decision support applications, providers in both Departments will be able to access and use relevant clinical data to make important medical decisions for their patients, regardless of whether that information resides in VA or DoD systems.

Other Technologies

In addition to the data exchange initiatives that support data transfer of multiple clinical data sets, VA and DoD have completed and/or are enhancing several other technologies that support data exchange:

Laboratory: Laboratory Data Sharing and Interoperability (LDSI) software permits electronic ordering of labs and results retrieval and permits the Departments to use one another as reference laboratories. This electronic capability eliminates the manual re-keying of data and contributes to patient safety.
Credentialing: The Departments are demonstrating the use of a jointly developed interface between the DoD Centralized Credentials Quality Assurance System and the VA VetPro Credentialing system. This credentialing interface decreases the time and resources needed to process credentialed providers who practice in both VA/DoD health care settings.
Outpatient Pharmacy: The Consolidated Mail Out Pharmacy (CMOP) application was jointly developed and is in use at three joint locations. CMOP supports VA's refilling of outpatient prescription medications from DoD's MTFs at the option of the beneficiary.

Much of this work can be shared with regional, state, and local entities through knowledge transfer of lessons learned. Both Departments are active in organizations and forums such as Healthcare Information and Management Systems Society and the annual Toward an Electronic Patient Record conference, and routinely share experiences at both national and local level industry events.

B. Adoption of Common Standards and Terminologies

VA and DoD have achieved the common adoption of an initial set of standards through the Consolidated Health Informatics (CHI) initiative. See Table 3. In partnership with HHS, VA and DoD are lead partners in the CHI project, one of the 24 eGov initiatives supporting the President's Management Agenda. The goal of the CHI initiative is to establish Federal health information interoperability standards as the basis for electronic health data transfer in Federal health activities and projects.

DoD and VA have established an initial joint strategy for data standards which focuses on maximizing the utilization of the CHI standards in future systems development and acquisitions and influencing Standards Development Organizations (SDOs) in further standards work. The Target List of VA/DoD standards is attached at Appendix B. This Federal government effort has the potential to catalyze industry to adopt common terminologies and standards, thereby reducing software development costs and producing more affordable electronic health record technologies.

Standard	Description
Table 3 Approved and Adopted CHI Standards
HL7 2.4 and higher XML	Health Level 7 messaging standards to ensure that each Federal agency can share information that will improve coordinated care for patients such as entries of orders, scheduling appointments and tests and better coordination of the admittance, discharge and transfer of patients. Health Level & vocabulary standards for demographic information, units of measure, immunizations, and clinical encounter and HL7 Clinical Document Architecture standard for text base reports.
NCDCP Scripts	Certain National Council on Prescription Drug Programs (NCDCP) standards for ordering drugs from retail pharmacies to standardize information between health care providers and the pharmacies. These standards already have been adopted under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and will be adopted in the three Federal departments that aren't covered by HIPAA will also use the same standards.
IEEE1073	The Institute of Electrical and Electronics Engineers 1073 (IEEE1073) series of standards that allow for health care providers to plug medical devices into information and computer systems that allow health care providers to monitor information from an ICU or through telehealth services on Indian reservations, and in other circumstances.
LOINC	Laboratory Logical Observation Identifier Name Codes (LOINC) to standardize the electronic exchange of clinical laboratory results.
DICOM	Digital Imaging Communications in Medicine (DICOM) standards that enable images and associated diagnostic information to be retrieved and transferred from various manufacturers' devices as well as medical staff workstations.
SNOMED-CT	The College of American Pathologists Systematized Nomenclature Medicine Clinical Terms (SNOMED-CT) for laboratory results contents, non-laboratory interventions and procedures, anatomy, diagnosis and problems, and nursing.
HIPAA	The Health Insurance Portability and Accountability Act (HIPAA) transactions and code sets for electronic exchange of health related information to perform billing and administrative functions. These are the same standards now required under HIPAA for health plans, health clearinghouses and those health care providers who engage in certain electronic transactions.
Federal Terminologies	A set of Federal terminologies related to medications, including the Food and Drug Administration’s names and codes for ingredients, manufactured dosage forms, drug products and medication packages the National Library of Medicine’s RxNORM for describing clinical drugs and the VA’s National Drug File Reference Terminology (NDF-RT) for specific drug classifications.
HUGN	The Human Gene Nomenclature (HUGN) for exchanging information regarding the role of genes in biomedical research in the federal sector.
EPA Substance Abuse Registry System	The Environmental Protection Agency’s Substance Registry System for non-medicinal chemicals of importance to health care.

VA and DoD work with the American National Standards Institute's (ANSI) and Healthcare Informatics Standards Board (HISB) to influence the adoption and implementation of nationally and internationally approved standards. Both VA and DoD participate on the Health Level Seven (HL7), an ANSI-accredited SDO that is working across the industry to establish a set of standard functions for electronic records. A VA nurse informaticist co-chairs the HL7 Electronic Health Record work group. VA and DoD representatives jointly chair the Governmental Projects Special Interest Group. VA representatives also co-chair the Conformance Special Interest Group, the Patient Administration Technical Committee, and Process Improvement.

VA and DoD also participate in the National Health Information Infrastructure (NHII) Taskforce.

The focus of the taskforce is on activities to help the health care industry create and adopt a national health information infrastructure. The purpose is to create a comprehensive knowledge-based network of interoperable systems capable of providing information for sound decision support available anywhere and at any time it is needed.

The benefits of NHII would be:

Improved patient safety;
Improved quality of care;
Effectively shared decision support;
Better understanding of health care costs;
Monitored and protected pubic health; and
Better informed health care consumers.

VA and DoD are working to define Department enterprise architectures that will fully align with the lines of business within each organization, including the delivery of health care. VA and DoD are working closely to ensure that both enterprise architectures support health data interoperability as well as optimal information management to support shared care delivery.

Recognizing the value that coordinated delivery of health care would bring to our Nation, VA and DoD are actively engaged with HHS in the Federal Health Architecture (FHA) initiative. As co-leads of the electronic health record FHA subgroup, the Departments ensure that FHA activities are closely tied to Federal EHR initiatives. The FHA initiative has as its goals: 1) improved coordination and collaboration on government health IT solutions and investments; and 2) improved efficiency, standardization, reliability, and availability of comprehensive health information solutions. Part of this work includes identifying relevant data and technical industry standards, including those set by the private sector, that would support identified Federal business requirements.

The Departments' independent and collaborative efforts toward standards and architecture could serve as a model for local or regional architecture efforts in communities, and between private sector health care providers. Further, as is identified by the FHA initiative, a published Federal architecture based on common standards could induce private sector technology firms to reduce software development costs. This savings would then be passed on to health care providers across all settings, including those settings that necessarily rely on government (e.g., Federal, local or state) funding and assistance.

In addition to the joint work in this area conducted by VA and DoD, VA works with other Federal partners to promote the shared use of standards and terminologies. These efforts are represented in Appendix C. Through the above mentioned areas and participation in other varied professional and standards development organizations, VA and DoD seek to influence local, state, and national agencies as well as private industry to cooperate in adopting and implementing common standards.

C. TeleHealth Technologies Used for Long Distance Consultations and Distance Learning

Telehealth applications have been successfully utilized to extend medicine to remote areas of the world, disaster assistance teams, and ships at sea. Thus, telehealth technologies are uniquely suited to support the delivery of health care to rural and medically underserved populations that experience shortages in qualified resources within their local communities. Telehealth is defined as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. VA and DoD have several successful joint ventures in using telehealth technologies, as outlined in Appendix D.

Last revised: July 27, 2004

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