DoD/VA Health Information Technology Collaboration Joint Venture Conference October 18, 2011

Session Objectives 4/16/2017 Discuss the current DoD/VA health data sharing initiatives Discuss factors influencing the need to broaden data sharing initiatives to include private sector and other agency providers Discuss how the Departments are jointly looking to the future…

DoD/VA Data Sharing Stakeholders 4/16/2017 Beneficiaries Providers Military and Veterans and Service Organizations Military Services Government Accountability Office Office of Management and Budget Congress Executive Branch

Military Health System (MHS) 4/16/2017 Over 9.6 Million Beneficiaries 42% active duty, 58% retirees and dependents Direct Care: Over 700 fixed medical and dental facilities Purchased Care: Over 380,000 civilian providers accept TRICARE

MHS Electronic Health Record (EHR) Footprint (Sustaining Base) 4/16/2017 MHS Electronic Health Record (EHR) Footprint (Sustaining Base) Supporting transient patient populations and transient health care teams AHLTA – Worldwide Covers Every Time Zone 9.6 Million Beneficiaries 190 Million Outpatient Encounters 140,000 Additional Encounters Daily 77,000 Active Users 110,000 End User Devices White House Medical Unit MHS Inpatient Solution 59 Sites (100% of DoD Inpatient Beds) Deployment completed in April 2011

MHS EHR Footprint (Theater) 4/16/2017 Operation Enduring Freedom/ Operation Iraqi Freedom Over 4.5 Million Outpatient and over 63,000 Inpatient Clinical Encounters captured electronically Over 11.3 Million Orders for Ancillary Services (inpatient and outpatient laboratory, radiology, and pharmacy) Iraq, Qatar, Kuwait, Afghanistan EHR capability on board ships

Department of Veterans Affairs (VA) 4/16/2017 Over 8.1 million enrollees Increase of over 105 percent since 1995 (2.5 million enrollees) Over 5.7 million patients Older, sicker and poorer patient populations Over 1,300 Direct care sites 152 medical centers/hospitals 784 clinics (hospital, community-based and independent) 277 counseling centers 134 nursing homes Source: VHA Statistics, VHA Policy and Planning, October 7, 2010

Department of Veterans Affairs (VA) (continued) 4/16/2017 Department of Veterans Affairs (VA) (continued) Over 86,000 Health Care Providers 15,000 Physicians 38,000 Nurses 33,000 Allied Health Professionals 10,000 fewer employees than 1995 Affiliations with 127 Academic Health Systems 25,000 affiliated physicians, 36,000 residents and fellows, and 25,000 medical students 114,000 trainees in all disciplines Nearly half of all US health professionals (65% of US physicians and 50% of US psychologists) have had some training in a VA facility $1.7 Billion in Research (Rehabilitation, Health Services, Clinical, and Basic)

Motivations for Sharing Data 4/16/2017 Close proximity or co-located facilities Joint venture sites/local sharing agreements Reserve/Guard medical care Care in VA post-demobilization Care in MHS when remobilized Service members post-separation Continuity of care Determination of benefits

Point of Separation Lab results Radiology reports Outpatient Rx data 4/16/2017 327 million messages (DoD to VA) on 5.7 million retired or discharged Service members Lab results Radiology reports Outpatient Rx data Allergy information Discharge summaries Consult reports Admission/discharge/ transfer information Standard ambulatory data record elements Demographic data Pre-/post-deployment health assessments Post-deployment health reassessments* *Transmitted weekly for individuals referred to VA for care or evaluation

Shared Patients Allergies Inpatient notes (from DoD Essentris sites) 4/16/2017 Supports care for more than 4.1 million patients to date DoD providers access VA data through AHLTA VA providers access DoD data through *VistA CPRS or VistAWeb Specialists in VBA access DoD data through *CAPRI Allergies Outpatient pharmacy Demographics Inpatient and outpatient lab results Radiology reports Ambulatory encounter notes Procedures Problem lists Inpatient notes (from DoD Essentris sites) Theater clinical data Vital signs Family history, social history, other history Questionnaires * VistA – Veterans Health Information Systems and Technology Architecture * CPRS – Computerized Veterans Health System * CAPRI – Compensation and Pension Record Interchange

Computable Data 4/16/2017 Supports interoperability between DoD’s Clinical Data Repository (CDR) and VA’s Health Data Repository (HDR) Standardized, computable outpatient pharmacy and medication allergy data Computable data supports real time drug-drug and drug-allergy checks using data from both DoD and VA For shared patients set as “active dual consumers,” data is seen enterprise-wide

Wounded Warrior Image Transfer 4/16/2017 Digital radiology images and scanned medical records for severely wounded warriors sent from DoD to VA when the decision is made to transfer the patient (inpatient to inpatient) Data push at time of referral Walter Reed Army Medical Center National Naval Medical Center Brooke Army Medical Center Tampa Polytrauma Center Palo Alto Polytrauma Center Minneapolis Polytrauma Center Richmond Polytrauma Center From 2007 to present: Images for more than 440 patients Scanned records for more than 545 patients

Image Sharing – DoD Capability 4/16/2017 Image Sharing – DoD Capability DoD Health Artifact and Image Management Solution (HAIMS) Global awareness of and global access to artifacts and images, including: Scanned documents Digital radiographs (X-rays, CTs, MRIs, mammography, and sonograms) Clinical photographs Video EKGs and echocardiographs Phase 1 Limited User Testing completed in September 2011; report to Services Phase 2 development well underway

Image Sharing – VA Capability 4/16/2017 VA VistA Imaging System Facilitates clinical decisions Provides clinicians with multimedia component of patient record Images are integrated into patient record Records are available on the clinician’s desktop Enables VA image sharing enterprise-wide Clinical images, scanned documents, motion video, electrocardiograms and other non-textual data files VA enhancements will enable view of DoD HAIMS data

Image Sharing – VA Capability (cont) 4/16/2017 Image Sharing – VA Capability (cont)

4/16/2017 What’s Next? Continue to expand the DoD document scanning and image sharing capability as approved by the Services NeuroCognitive Assessment Tool (NCAT) Traumatic Brain Injury/Behavioral Health (TBI/BH) Medical Evaluation Tool – Information Technology Initiative (MEB-ITI)

A Look to the Future 4/16/2017 DoD and VA currently share significant and unprecedented amounts of health data More than half of DoD and VA health care comes from private sector providers DoD and VA need access to private sector health documentation to create a true lifetime electronic health care record

* From the 2011 MHS Stakeholders Report 4/16/2017 A Week in the MHS* 23,300 Inpatient Admissions 5,100 direct care 18,200 purchased care 1.8 Million Outpatient Visits 809,000 direct care 1.001 million purchased care 3.5 Million Claims Processed 2.6 Million Prescriptions 924,000 direct care 1.44 million retail pharmacies 228,000 mail order 2,400 Births 1,000 direct care 1,400 purchased care * From the 2011 MHS Stakeholders Report

Average Monthly Purchased Care in VA 4/16/2017 Annually, VA processes more than 1 million purchased line items for non-VA medical care with the following monthly averages: 234 unique patients for pharmacy 11,051 unique patients for inpatient admissions 72,659 unique patients for outpatient visits 3,885 unique patients for dental visits 213 unique patients for child birth delivery

Challenges… The New England Journal of Medicine April 16, 2009 “1.5% US Hospitals have a comprehensive electronic records system” “7.6% US Hospitals have a basic electronic records system” “17% US Hospitals have computerized provider-order entry for medications” “Very low levels of adoption of electronic health records in US Hospitals” Conclusion “The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.” 20

American Recovery and Reinvestment Act (ARRA) of 2009 In December 2009, HHS Secretary Sebelius announced plans to establish health IT "Beacon Communities" $235 million set aside to fund nationwide Beacon Community Program The program will take communities at the cutting edge of EHR adoption and health information exchange and push them to a new level of health care quality and efficiency Potential Beacon Communities should have local institutions and health information exchange (HIE) networks wanting to partner with MTFs and VAMCs To ensure initiatives are in-line with enterprise initiatives Services work through Service CIOs/CMIOs

Future State – Where Are We Going? 4/16/2017 On April 9, 2009, President Obama directed DoD and VA to create a Virtual Lifetime Electronic Record (VLER) that: “will ultimately contain administrative and medical information from the day an individual enters military service throughout their military career and after they leave the military.” - President Barack Obama Source: Washington Post, April 9, 2009

VLER Initiative – Goal 4/16/2017 To provide seamless access to electronic records for Service members and Veterans through a single portal Success is dependent on the existence of an electronic health record (EHR) capability in each participating organization While VLER builds on that capability, the capability is separately developed and funded

VLER Initiative – Transition 4/16/2017 Historical data from 1989 forward, live data flow as of 2002, bidirectional data flow as of 2004, all DoD and VA medical facilities as of July 2007 Health Bank or PHR Support Organization Community #1 Integrated Delivery System Community Health Centers Community #2 CDC VA CMS DoD SSA State and Local Governments Labs Pharmacies The Internet Standards, Specifications and Agreements for Secure Connections Mobilizing Health Information Nationwide Bidirectional Health Information Exchange Health data on more than 5.7 million Service members 4.1 million correlated patients 89.0 million lab results 14.5 million radiology reports 92.2 million pharmacy records 110 million standard ambulatory data records 4.9 million consultation reports 3.3 million deployment-related health assessments on more than 1.5 million individuals (As of August 31, 2011) Current DoD/VA Health Information Exchange Underway Nationwide Health Information Network Legend: CDC – Centers for Disease Control & Prevention CMS – Centers for Medicare & Medicaid Services PHR – Personal Health Record SSA – Social Security Administration

VLER Capability Areas (VCAs) *Suspense dates are tentative and subject to change

VLER Initiative – VCA1 Pilots Six Month Increments March 25, 2011 Health Record Data: HITSP C32 subset (from Tidewater) Vital Sign Chemistry Lab Result Partners: 92nd Medical Group, Fairchild AFB Spokane VA Medical Center Inland Northwest Health System Spokane Pilot Puget Sound Pilot September 26, 2011 HITSP C32 subset (from Spokane) Advance Directive * Encounter Immunizations* Insurance Provider Procedures Unstructured Documents: Consults/Referrals Discharge Summaries Results of Diagnostic Studies Procedure Notes History & Physicals Madigan Army Medical Center VA Puget Sound Health Care System MultiCare Health Org * will display but not send September 15, 2010 HITSP C32 subset (from San Diego) Comment Hematology Lab Result Naval Medical Center Portsmouth VA Medical Center Hampton Med Virginia Tidewater Pilot November 16, 2010 Additional Partners: McDonald Army Health Center (MCAHC), Fort Eustis 633 Medical Group, Langley AFB January 31, 2010 Health Record Data: Healthcare Information Technology Standards (HITSP) C32 subset: Allergy/Drug Sensitivity Condition Healthcare Provider Information Source Language Spoken Medication Person Information Emergency Contact San Diego VA Medical Center Naval Medical Center San Diego Kaiser Permanente in San Diego San Diego Pilot

VLER Initiative – VCA2 VCA 2 expands health information from the set exchanged in VCA 1 to include the exchange of additional electronic health information for Veterans Benefits Administration and Social Security Administration disability claims adjudication Use Cases complete September 2011 Concept of Operations and functional requirements development underway Initial operating capability by December 2012 Full operating capability by December 2014

Integrated Electronic Health Record (iEHR) Conceptual Architecture Common Interface Standards Presentation (Common GUI) Common Data Centers Common Services Broker (includes Enterprise Service Bus (ESB) and Infrastructure Services) Common Information Interoperability Framework (CIIF) Common Information Model, Common Terminology Model, Information Exchange Specifications, Translation Service Common Data Standards: SNOMED CT and Extensions, LOINC and RxNorm Pharmacy Disability Evaluation Dental Care Personal Health Record Inpatient Orders Mgmt Consult & Referral Mgmt Immunization Laboratory Emergency Dept Care Nursing Home Rehabilitative Care Long Term Transient Outreach DoD Unique VA Unique Common (Joint) Applications & Services Battlefield Care Pediatrics Military Readiness Obstetrics Enroute Care Veterinary Operating Room Mgmt Blood Mgmt Document Mgmt Applications and Services Common DoD-VA Requirements: HL7 EHR-S Functional Model with DoD and VA vetted Extensions (SV-4) Common DoD-VA Integrated Health Business Reference Model (OV-5) Common DoD-VA “To Be” Process Flow Model (OV-6C) Common DoD-VA Measures of Effectiveness, Measures of Performance and Key Performance Parameters Occupational Health (VA) DoD Only VA Only Joint DoD/VA