The 2014 defense bill required the VA and the Pentagon to get their acts together on sharing health data. The agencies' two giant health systems are about to certify that they have complied.
To go by lawmakers and the Government Accountability Office, the departments of Defense and Veterans Affairs are miles away from achieving interoperability between their two sets of electronic health records.
The agencies, which together serve a patient population of some 35 million, have separate systems: The VA has its homegrown VistA, and DOD has a number of systems covering inpatient, outpatient, theater of war and other care. A plan to combine the two systems was scrapped in part because of potential costs, but more significantly because of the agencies’ failure to coordinate and standardize practices ranging from clinical care to administration to IT delivery.
The fiscal 2014 National Defense Authorization Act (NDAA) requires the DOD and VA to certify that their systems are interoperable, and they are now only months away from doing just that. In a Nov. 16 letter to the chairmen and ranking members of the House and Senate Armed Services, Veterans’ Affairs and Appropriations committees, Frank Kendall, undersecretary of Defense for acquisition, technology and logistics, attests that DOD has met its interoperability requirements under the statute.
"With this letter, we are certifying that we have not merely met this requirement, but have gone even further to integrate data from other DOD systems, including inpatient, theater and pharmacy, into this process, thereby exceeding the NDAA's requirements," Kendall wrote.
The VA is set to follow suit sometime in the current fiscal quarter, said David Waltman, chief information strategy officer at the Veterans Health Administration. However, he told reporters during a Nov. 19 briefing that he wasn't prepared to give an exact date yet.
The latest iteration of the VA and DOD's Joint Legacy Viewer is making all this possible. Chris Miller, the Pentagon official who leads the DOD/VA Interagency Program Office and who led DOD's $9 billion procurement of a commercial health records system, stressed the importance of JLV. The web-based read-only interface combines information from about 300 record systems in real time to give clinicians and benefits administrators in both departments detailed patient histories on clinical interactions as far back as the early 1990s.
JLV has its critics, however. Rep. Will Hurd (R-Texas), chairman of the House Oversight and Government Reform Committee’s IT subcommittee, complained at an Oct. 28 hearing that JLV is "not real interoperability."
Criticism from lawmakers and GAO "frustrates people like me," Miller said at the Nov. 19 press briefing. "GAO had a belief that we had to fully modernize our system to be interoperable, and I don't agree with that opinion. We can do things in the interim that really address our requirements in terms of data and really improve the decisions that we make."
"I'm not sure we're clearly able to get to a common definition of what success looks like," he added.
Some critics are seeking a system that allows any user to write to it from any location and have the data instantaneously added to the patient’s record.
This is not what JLV was designed to do. Miller said its guiding principle is "write locally, read globally." He also noted that a high percentage of users, particularly benefits administrators and analysts, have no need to add information to the system.
Currently, more than 13,000 clinicians and administrators at DOD and more than 22,000 at the VA can access JLV.
JLV was designed to fit several situations in which VA and DOD care overlaps -- for example, a "gravely wounded warrior scenario," Waltman said, in which a patient moves from the battlefield to a military hospital in Germany to a VA facility in the U.S. -- and then back to DOD for discharge. The system also accommodates retirees who might use DOD and VA systems interchangeably.
Long-tenured service members still have to deal with non-electronic records when transitioning from DOD’s care to the VA’s upon retirement. DOD is not retroactively putting records in electronic form, which means patients will have to take a pile of printed documents to be scanned or a PDF to be added to VA systems.
JLV is also working to spur modernization at DOD and the VA, and its data is already working with enhanced decision support and other advanced functionality of the VA's Enterprise Health Management Platform.
On the DOD side, Miller said, the data mapping and standardization used to support JLV will help migration to the new electronic health record system coming from Cerner, Leidos and Accenture.
DOD uses private providers for about 65 percent of its care, including care for families of active-duty service members. As the VA turns to the private sector to deliver more and more care, officials will have to decide how to extend the data in JLV to outside providers. Currently, VA and DOD users must insert biometrically enabled IDs to access the system, but there is no corollary for the private-sector health care system that fits that heightened level of security.
The focus on security and the high level of data exchange are just two reasons why Miller said interoperability between VA and DOD is "leading nationally" compared to the private sector.