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

1. 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…

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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)

17. 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

18. * 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. 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

27. 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

28. 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