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DoD News Briefing with Stephen Jones From the Pentagon

Presenter: Principal Deputy Assistant Secretary of Defense for Health Affairs Stephen Jones
November 24, 2008
                Slides accompanying Capt. Marshall and Dr. Fletcher’s portion of the briefing can be found here: http://www.defenselink.mil/news/d20081124infosharing.pdf .
 
                COL. GARY KECK (Director, Department of Defense Press Office): Well, good morning, everyone. And thank you for being here this morning for this press conference. I'm Colonel Gary Keck, the director of the Press Office. And I've been asked to introduce our distinguished members here today. 
 
                We have with us a group of briefers to discuss current and future initiatives in sharing electronic health information between the Department of Defense and the Department of Veterans Affairs. 
 
                Our first briefer will be Dr. Stephen Jones, who's the principal deputy assistant secretary of Defense for Health Affairs. Following Dr. Jones, we'll hear from Dr. Gerald Cross, principal deputy undersecretary for Health at the Veterans Health Administration. Following Dr. Cross, we'll hear from Dr. Robert M. Kolodner, who is the national coordinator for Health Information Technology at the Department of Health and Human Services. And then we will hear from Ms. Lois Kellett, acting director, DOD/VA Interagency Program Office. 
 
                And finally, we will have concluding remarks from Dr. Ross Fletcher, who's the chief of staff at Washington, D.C., Veterans Affairs Medical Center and Captain Bob Marshall, who's also a doctor at the Navy Bureau of Medicine. And they'll give an interactive presentation demonstrating electronic health information sharing to us.   
 
                After that time, we'll have question and answer period, at which all the people who have briefed will come up to the podium and be at the lectern. So when we go into Q and A, I would ask you that you specifically ask who you would like to address your question to so they can come up to the microphone so we can see and hear them well. 
 
                And with that, we'll turn it over to Dr. Jones. 
 
                DR. JONES: Good morning. And I, too, would like to welcome you here bright and early. It's great to see you. And of course, this is Thanksgiving week, so I'd like to wish everybody hopefully a great Thanksgiving. 
 
                As stated, I am Steve Jones, principal deputy assistance secretary for Defense for Health Affairs. And what we'd like to do today is to, one, kind of give you a status of where we are between the VA and DOD in electronic health-record sharing. 
 
                And, as you know, or many of you know, the health-care sector of the United States is about 17 percent of the gross national product. And while DOD and VA is but a small sector -- part of that, it is an important one, because, of course, we serve our nation's service members, their families, retirees, their families, and, of course, our nation's veterans together. 
 
                And what is an electronic health record? It's a tool. It's an information system. It provides a platform for collecting, storing, manipulating and communicating health information. Electronic health records have the potential to reduce duplicate testing, reduce adverse drug events, increase preventive care, increase adherence to evidence- based practice and improve the care of chronic diseases.   
 
                Electronic health records give clinicians access to more information more quickly. And that's what we're all about, is providing the best-quality care for our service members, our beneficiaries and our veterans. We will discuss what is currently being shared, what positive impact it's having on continuity of health care, our way forward towards more fully interoperable records, and how our work aligns with the national information-sharing efforts.   
 
                And just to correct a little bit, it's Dr. Rob Kolodner, is the way Rob pronounces his name, and Lois Kellett, Kellett.   
 
                We would also -- of course, you'll be hearing from Ms. Kellett, who is the acting director of our Interagency Program Office, which Congress mandated that we establish to help and drive and to monitor our effort. 
 
                We've been sharing electronic health records since 2001. Each year we've been able to accelerate progress as we've laid those foundations and those blocks within VA and at DOD. So we're now able to share more information. Of course, this has been very helpful as our wounded, ill and injured are treated. And you will hear some of that today. 
 
                We are working together on all these efforts. We are clearly defining the path that will lead us to a mutually beneficial solution to both departments' electronic health records needs. In fact, current health information-sharing capabilities between DOD and VA are well ahead of those in the private sector in both scope and scale.  
 
                And the accelerated progress we have is the result of taking our coordination and cooperation to unprecedented new levels with oversight in governing bodies formed to ensure that our sharing efforts continue to meet expectations.   
 
                As many of you know, we have the SOC, the Senior Oversight Committee. We also have the Joint Executive Committee, which focuses on those relationships between DOD and VA. And we have a Joint Strategic Plan, and of course electronic health records are one of those areas that the plan addresses. 
 
                Before I turn the podium over to Dr. Cross, who's the second in command for the Veterans Health Administration, just let me touch on one initiative that we've taken this last year. There was discussion, as we moved forward with major electronic records initiatives within DOD and VA, is how should we be, from an inpatient basis, organized to ensure that what we do and what they do are compatible far into the future? So we let a contract, and we asked -- Booz Allen Hamilton won the contract - and they came in and studied our requirements -- our requirements meaning DOD, and VA's requirements, as to the best path forward as we move into the future.   
 
                And we looked at -- one option was to continue sharing information by building on our current approach, the Bi-Directional Health Information Exchange, which is the exchange that we use to share information on health matters. Another alternative was just to use the VistA system, which is the VA inpatient system. And another option was to replace both systems and look at purchasing and developing commercial off-the-shelf systems.   
 
                After a careful review by Booz Allen Hamilton looking at all the pros and cons, they recommended that we move forward with our two systems, but linked through a service-oriented architecture. And I will let some of the more technical people explain what that means. And if you would like more information about the Booz Allen study later on, of course we can set up meetings, and we'd be glad to provide you copies of that study as we move forward.   
 
                But basically, this services-oriented architecture will allow us to move forward on the VA and the DOD side with compatible and greater opportunity from an architecture -- from a structural standpoint to share information that is needed. And that information that is needed is determined by physicians, providers on the VA and on the DOD side. So we look at this provider task force team to tell us what their priorities are, what their needs are, so that we can can, therefore, hopefully provide that information to them. 
 
                So again, thank you for being here to get a status on where we are and where we're going. And now I would like to ask Dr. Gerald Cross from the Veterans Administration to address the group. 
 
                Thank you. 
 
                DR. CROSS: Thanks, Dr. Jones. And good morning to each of you. I'm Dr. Gerald Cross. I'm the principal deputy undersecretary for health at the VA. And I'm also a veteran, a family physician, and a patient at the VA. And so it's with that perspective that I come to you this morning. 
 
                DOD and VA are already making very great strides in sharing health care data between our two electronic health care systems.  
 
                And I'm pleased to say that we're on target to meet the requirements of the 2008 National Defense Authorization Act, which Dr. Jones described. 
 
                To achieve success, we're attacking the problem of interoperability in several different ways. VA and DOD are now sharing almost all essential health information that's available electronically in a viewable format, and we call that the Bidirectional Health Information Exchange. You will commonly hear us refer to that as BHIE. 
 
                That means that a VA doctor -- and you're going to see a demonstration of this in a few minutes -- can look at veterans' DOD medical record and see if the patient has any known conditions like allergies, and the doctor can look up the vital signs and review the results of all the lab tests taken at a DOD medical facility.   
 
                Of course DOD doctors can see the same type of health information from the VA side. A VA doctor can even review discharge summaries that were written in the key DOD medical military treatment facilities. 
 
                So where would the BHIE operate? Right now I'm pleased to say that it's now up and running at all VA and DOD medical facilities. And incidentally, it hasn't been all that long since I transferred my care -- I was in the military -- from military health care to VA health care, and this information exchange was actually a benefit to me personally, in that my doctor was able to see information that had been obtained on the military side when I was in the Army. 
 
                VA and DOD are also making progress on sharing computable electronic health data for patients who are receiving care from VA and DOD at the same time. We're doing this through something called the Clinical Data Repository of DOD and the VA Health Data Repository Interface, and we now call this CHDR, C-H-D-R. It allows data transfer from DOD to become part of the VA's -- VA patient's actual medical record and vice versa. Using CHDR, C-H-D-R, DOD and VA can exchange computable allergy and pharmacy data. That means that when a doctor prescribes a drug, the IT interface automatically checks both VA and DOD systems to be sure that the patient doesn't have any allergies to the new drug. The interface also makes sure the patient isn't taking any other drugs that could harm -- that could cause a harmful reaction. 
 
                Now as of August of 2008, CHDR was in production and testing -- being used for clinical care at seven sites. Those were El Paso, Augusta, Pensacola, Puget Sound, Chicago, San Diego and Las Vegas.   
 
                Without a doubt, VA and DOD are making great progress in sharing electronic health information, and I applaud the men and women from both agencies who put their energy and their brainpower into solving these very complex problems. Their joint efforts are a testament to the power of collaboration and proof of the great things that VA and DOD can accomplish when we work together on behalf of America's heroes. Our success in this important endeavor gives us one more powerful assurance that every seriously injured or ill service member or veteran will receive outstanding care every step of the way, the kind of care that saves lives. 
 
                Let me emphasize again this is not just about technology. This is about continuity of care. This is about two agencies working together, on a very complex project, to make sure that health care is the best that we can provide and particularly that we have good continuity of care between those two large systems.   
 
                It's a great pleasure for me to be with you here this morning. And I'm going to turn things over to Dr. Kolodner.   
 
                DR. KOLODNER: Good morning. And thank you, Dr. Jones and Dr. Cross, for inviting me to participate in this great event. I'm Robert Kolodner, the national coordinator for Health IT at the Department of Health and Human Services.   
 
                DOD and VA continue to be in the forefront of health care organizations that have achieved pervasive use of health IT across all of their points of care.   
 
                They have an even more challenging task, by connecting health information from the battlefield and from remote homes of veterans. And they have an extremely successful history of working together, to share electronic health information, to ensure our American servicemembers and veterans receive safe, effective and high-quality health care.   
 
                In the not too distant future, VA and DOD will be able to provide veterans and beneficiaries with the capability to download or forward a copy of their electronic health information, from the VA and DOD electronic health records, to their own personal health records and vice versa.   
 
                They will be able to choose the ability to use VA's My HealtheVet or external personal health records, from private providers, from insurers, from employers or independent vendors.   
 
                And since so many VA and DOD beneficiaries receive care in the private sector, either as part of their benefits or in addition to their DOD and VA care, these two departments have served as lead partners with Health and Human Services in the Federal Health Architecture or FHA initiative.   
 
                FHA has been a highly successful e-gov initiative. It has provided a venue for over 20 government agencies to work together to advance their use of health IT.   
 
                With their strong partnership, DOD and VA are helping us to move toward a shared vision of a federal health IT environment that is interoperable with the private sector and supports the national health IT agenda. That will enable better care, increased efficiency and improved population health.   
 
                Through FHA, VA and DOD are partnering with HHS and the private sector to test and implement and nationwide solution for the secure exchange of electronic health information.    
 
                In a cooperative activity with 16 private-sector entities and several other federal agencies, VA and DOD have been among the most energetic participants. Together with these other eight organizations, they are working to define and test the set of standards, specifications and agreements necessary to create the Nationwide Health Information Network, or NHIN. 
 
                The NHIN will be a shared standard scalable solution, a virtual health information highway that can provide a secure nationwide interoperable health information infrastructure across the Internet. This information highway will link together providers, consumers, pharmacies, laboratories, public health agencies, researchers, and others involved in supporting and advancing health and health care.  
 
                This critical component of the national health IT agenda will enable health information to follow the consumer, be available for clinical decision making, and support appropriate use of health information beyond direct patient care to improve the health and wellbeing of individuals and communities. 
 
                And DOD and VA have been leading the charge. DOD and VA participated in our first trial implementation of the NHIN at the meeting of the American Health Information Community this past September 23rd. This event showcased the technical capability of electronically sharing the summary records of test patients among 18 federal and private sector entities. 
 
                Included was a wounded warrior scenario that followed the care of a soldier injured in Iraq as his summary health record was seamlessly exchanged from Iraq and the National Naval Medical Center in Bethesda to providers in three different states and their VA medical centers, to facilitate and coordinate his care and to make sure that he had the continuity of care that Dr. Cross referred to. 
 
                The second and final trial implementation of the NHIN will be held in Washington, D.C., at the Grand Hyatt Hotel on December 15th and 16th. At the next event, important new capabilities of the NHIN and the exchange of critical additional health information will be demonstrated beyond that of the summary record. 
 
                If you have a chance to attend, I'd encourage you to do so, joining over 600 people who have already signed up to attend. If you come there, you'll see dedicated VA and DOD staff working with their public and private sector colleagues to lay the foundation for the nationwide interoperable health IT infrastructure that will benefit you, your family, your friends, and all of us across America. 
 
                For years, VA and DOD have been exchanging a much more robust set of information with each other than will be seen at the December meeting. The nation is fortunate to be able to leverage and benefit from the extensive knowledge and experience these two departments have gained through their joint efforts to help create and launch a broadbased nationwide solution for exchanging this electronic health information. 
 
                And this initiative, the NHIN, will be of direct benefit to veterans and other DOD and VA beneficiaries, by enabling the seamless transfer of their care, and delivery of high quality, high value care to them in VA and DOD facilities and in the private sector, by ensuring that their health information is available whenever and wherever they receive care. 
 
                I'm excited about the demonstration we're about to see here today. These health information sharing capabilities that you'll see can provide you with a glimpse into the future availability of health information, that will one day be routine everywhere in this country via the NHIN. Their achievements represent great progress towards our nation's goals of using health IT to enable patient-centered health care and to improve population health. 
 
                MS. KELLETT: Good morning. I'm Lois Kellett, and I'm the acting director of the DOD-VA Interagency Program Office. I was very pleased to be asked to step into this role by Dr. Jones while we are trying to go through the search to find the real director of the Interagency Program Office. 
 
                The deputy director, Mr. Cliff Freeman, is from VA. I'm from DOD. And jointly, we're heading up the office to achieve what Congress set out to do. The focus isn't that we're the Interagency Program Office. The focus is achieving interoperability of electronic health records. We're well on our way towards that goal, as you'll see in just a little bit. 
 
                The Interagency Program Office is a little bit unique, in that it is made up of both DOD and VA staff. As such, we will report to the VA-DOD Joint Executive Council, which is co-chaired by the undersecretary of Defense for Personnel and Readiness, and the deputy secretary of Veterans Affairs. So that this is an office that will have input and governance from both DOD and VA. 
 
                Our focus is on interoperability of electronic health records. That scope was expanded a bit by the Senior Oversight Committee that Dr. Jones mentioned. They expanded their scope to also include oversight and management looking at personnel and benefits electronic data sharing. I think this is key because that gives the Interagency Program Office the ability to identify those areas that may be cross- cutting and span both health and personnel and benefits arenas. 
 
                We will also take our guidance on the clinical side from the DOD- VA Interagency Clinical Informatics Board. This is a group made up of DOD and VA physicians that will guide us in terms of our IT data sharing. They'll set the priorities: What is it that our clinicians need? What things that we aren't sharing today do they consider to be the most important thing for us to share in the future? That will be even after we achieve our level of interoperability mandated in September of 2009 in the legislation, but where do we go beyond that? What do your clinicians need to provide care? That changes over time, as medicine itself changes, as clinicians' needs change, and the state of standards in the nation and where we're going as a nation under the Department of Health and Human Services, as Dr. Kolodner was talking. We’ll keep -- keep adapting and continue to expand to meet our clinicians' needs. 
 
                I don't want to stand in the way between us and the demonstration. I think that will speak more to you than any of the nice words that any of us have said so far on interoperability of electronic health data. So I'd like to turn this over now to Dr. Ralph Fletcher and Captain Campbell (sic) for the demonstration. Thank you. 
 
                 (Unidentified voice off mike) We're going to go with Captain Marshall, first.   
 
                CAPT. MARSHALL: Good morning. I'm Captain Bob Marshall. I'm currently director of Clinical Informatics for Navy Medicine and I'm also adjunct clinical faculty at the DeWitt Army Community Hospital family medicine residency program.    
 
                And I have been using AHLTA for about four years, since it first came out. And we -- I was at Puget Sound, and so I've had -- actually had the opportunity to see the CHDR in action. And it's actually very cool.   
 
                The reason why it's important on the DOD side to have this tool is because we have patients who are dual consumers, so they actually get care at the VA and at the DOD at the same time. And so there's a need for us to be able to not duplicate all kinds of lab result -- or lab tests and radiology tests and things like that. So it actually saves money. Plus, we actually know what the patients are getting at the VA, so we can coordinate care better. 
 
                The other thing is we also have patients who have been injured in Iraq or Afghanistan or elsewhere that go to the VA to the polytrauma center or to get rehab and then they come back on active duty to be seen and taken care of at the DOD hospitals. And so it's important for us to be able to have that transition of care and coordination of care to be able to know what was done at the VA and -- when they come back into DOD system. 
 
                Next slide. This is how -- back slide.   
 
                This is actually how you access -- this is the -- this is what AHLTA looks like. And despite what you may have heard, AHLTA works actually much better than what most people think it does. And this is the BHIE data viewer here. You just click on this and then the next slide shows you what comes up, which is the summary slide. And on the summary slide, we actually have the access, looking back at 12 months, of all these outpatient medications and such. And then we actually also have clinical notes and problem lists and things like that that we can access as well. 
 
                And you'll note that on one side there it says "more" and that allows to us to even dig deeper and farther back. And also, each one of those is actually a hyperlink to actually get -- dig deeper into each individual thing. 
 
                Next slide.   
 
                So this is vital signs. This shows you vital signs over 18 months. And so we can actually drill down into all these vital signs and know what has been going on with their vital signs at the VA.   
 
                And you can see all these are at -- from the VA in El Paso. But by the same token, we can also see theater data through the same viewer. So if this patient had actually gone from theater to a VA and then back to us, we could actually see both sets of data. 
 
                Next slide.   
 
                And this is lab data. Again, this is from several VA hospitals. But again, this is also theater data as well, so we can actually click on all these, see what the tests were done and the entire panel of tests, and then we can actually determine what needs to be repeated or not. And again, this saves money and improves quality of care. 
 
                Next.   
 
                And this actually shows encounters. Now, there's a difference between clinical notes and encounters. In encounters, what we do is we actually get a very brief summary of what the encounter was, what the diagnosis codes were, any labs or those sort of things that were done, as well as what the recommended follow-up is. So it's a very brief summary of what has been actually done at the encounter. So this is VA health, if you want a very quick reference to be able to know what was done at the VA or, again, in theater. 
 
                Next slide.   
 
                And this is actually clinical notes. We can see the full clinical note that was done at the VA or, again, in theater, on our patients. And so we actually know, from a continuity-of-care perspective, what was done, so that we can actually continue that care and not repeat things and actually have -- as you well know, one of the biggest problems in civilian health care is transition of care and coordination of care. And this allows us to really move forward on that.   
 
                Next. 
 
                And again, this is theater data. And this happens to be from Fleet Hospital 15, but it doesn't matter whether this was at -- in Djibouti, with the force there, or in Iraq with one of the Combat Support Hospitals or one of the surgical companies, or in Afghanistan with one of the Fleet Hospitals, or whatever is there, we can get this data.   
 
                This comes through what's called a Theater Medical Data Store, and it comes right into the system. We can view this data. Eventually we'll actually be able to view this data directly in AHLTA, once the -- a thing called the Theater Medical Data Interface is completed in about a year. But even so, we can actually see this theater data very well.   
 
                Next. 
 
                And I'm going to now turn this over to Dr. Ross Fletcher, who is the chief of staff at the Washington VA hospital, and then we'll take questions later. 
 
                DR. FLETCHER: Well, it's my pleasure to come here today, in part because it renews a lot of links that I've had in the past with Dr. Kolodner. I think we've gone back several decades, dedicated to this electronic health record.   
 
                Could I have the first -- next slide, please? 
 
                The number of programs are listed here -- Federal Health Information Exchange -- which has been going on since 2002, several million records -- every person going from the DOD to become a veteran at discharge has all his data shifted over to us, and we are able to see it, as you'll see.   
 
                The Bidirectional Health Information Exchange was from the same platform and treats active dual consumers, as you've heard. The CHDR, which is computable data, combines the DOD's Clinical Data Repository with the VA's Health Data Repository for drug-drug interaction and allergies. 
 
                The severely wounded warrior program actually takes all images and text from Walter Reed and sends them to the VA Polytrauma sites. The beauty of that is that since they are in the remote image view, I at my hospital can see those immediately if I see one of those patients. 
 
                And then recently there is a remote view of VA and DOD images in a program called VistA image exchange. 
 
                I thought it'd be best to show this program by going through actual patients that we have seen. The first one is a dual user. He came to us as a service member, while he was at Walter Reed, and we treated him for his traumatic brain injury. He had served in Bosnia, Iraq and Afghanistan. I asked him how often he had been exposed to IED blasts, and he said it was about 11 times.  This particular one had ruptured his tympanic membrane and also caused -- not severe, but some traumatic brain injury.   
 
                Next. Next slide. 
 
                This is the way we see our record, and if the arrow -- if the remote data available up in the upper right-hand corner is blue, there is data available. And you can see that if we list where the data comes from, Defense Department is on that list. And simply by clicking that area and then going down to reports, to the lower right- hand tab, we see the next frame, which -- look over to your left and you see Department of Defense records. We can see the allergy, expanded ADT, the consults, the discharge summaries, the labs and further. We'll go through some of these. 
 
                Can you go back to that last slide? 
 
                Now this is a consult. As you can see, it's been clicked off, and we can read the consult from DOD. 
 
                Next. 
 
                Shows progress notes. This particular progress note was from the field hospital, 14th, and shows a note describing the injury that this patient underwent, which was a blast which allowed shrapnel to go to his right-sided -- of head, and it was taken out. The IED blast, with fragment in the right forehead area, is the final diagnosis, as you can see. This is a theater note from Afghanistan. So here I am in the hospital treating this patient. I can see exactly what the doctor saw when he first saw this patient, which is really quite beneficial. 
 
                If we go to the next slide, you'll see a second way we can do that same note, which is through VistAWeb. So we have two choices for viewing. Everywhere you see the red arrows where there's a cross, there is DOD data. So the DOD data populates this record quite thoroughly. 
 
                Next. 
 
                We can actually choose between the remote data view, which you saw, and the VistAWeb by the fact that the current program splits this button and allows both choices. 
 
                Next. 
 
                Pharmacy -- I'm now clicked off, as you can see up -- on the upper left, and the Washington data has come in. The Defense Department data is still initializing. If I wait just a little while, the next view is to see all of the medications. Notice they're from Bethesda Navy, Walter Reed, and these are relatively recent. 
 
                Next slide. 
 
                So I'll take off that window. You can see the medications that have been dispensed July '08. Now he's been a veteran for quite some time, but he still gets all his medications from Walter Reed. And if I were not able to see what those medications were, I would be greatly hampered as a physician. So this Bilateral Health Information Exchange, allowing all of the medications being dispensed by Walter Reed to be seen by the doctor in the VA, is critical to the care of the patient. 
 
                If I go down on this, you can see that he was also -- had medications dispensed in Landstuhl, Germany; Walter Reed; Bethesda Navy; Eisenhower; Camp Shelby and, lo and behold, CVS pharmacy. So the private-sector medications are being seen on these records, along with the medications from either Walter Reed or Bethesda Navy. We can see all of them, and in sequence, and we're missing nothing as we look for the medications the patient is on.   
 
                Next. This is a second patient. The patient was -- had all of the information downloaded to us as she left the DOD. And the reason why I show it is, it's the DeLorenzo TRICARE Health Clinic at the Pentagon.   
 
                I happened to be there for two years myself when I was in the Army. The medications on the Federal Health Information Exchange go back to 1989. I was there a little bit earlier than that.   
 
                Next slide. This is the same patient's chemistries. And simply by clicking on flag, we can alter; we can see only those, only those chemistries that are high or low. And thus we can look at it much quicker and cleaner.   
 
                Next, please. Second patient is a severely wounded warrior who was at DOD and then polytrauma site and then the VA. Had an IED blast causing traumatic brain injury and a fractured spine.   
 
                Next. And on this, we can see the bilateral, bidirectional health information exchange with the allergies. First, Washington, the patient has not been seen there, so it was not assessed.   
 
                Next. But at Brooke, Martin, Bethesda Navy, penicillin is the allergy.   
 
                Now, because of the computable data being on both sides, if I tried to order penicillin on this patient, I would be warned not to do so.   
 
                Next. And this is the warning. Patient has no allergy assessment where I am. But previous remote sites show penicillin allergy to be present. And this is just a diagram showing that this CHDR on the white is on both sides and contains information from the Clinical Data Repository on the DOD side and the Health Data Repository on our side.   
 
                Next. This is an image that was sent over with this particular patient. And this says, as you can see, Richmond outside. But what it is referring to is that these are all Walter Reed tracings. And if I use my tools for looking at images, I can see quite readily that this is a well-set device supporting his fractured spine.   
 
                Next. You can see that the top two spinal processes are intact. But the third one down is split. And that's where -- that's what this is in place. It is very helpful for me, as the physician, to be able to look back not just at the text or the radiologist's view of this but at the actual image and compare it with the image I'm about to get for the patient.   
 
                Third patient was also dual care, came over to us after she had been hit by a truck in Kuwait, severe traumatic injury, was in coma when she came to our hospital. It was thought that she probably would not survive. And then we did some further tests.   
 
                Next. This is the way the view again appears. Traumatic brain injury is the lead diagnosis, as you can see in the upper left.   
 
                Next. And the CAT scan showed large ventricles. As you can see, the brain is pushed out to the side. And this is in part why she was not waking up.   
 
                We had a later CAT scan, as you can see on the right. 
 
                Next slide. 
 
                This was done after that tube was placed inside the ventricles, decompressed them, and she became awake, started talking, started walking. I got an e-mail from her in this past September that she was going home.  
 
                If she had a headache or something of that sort, we would want to go immediately back to these images, which we can see from her current home, which is in California. The Palo Alto site would have it, and anywhere in the VA would have it as well, with remote image view. 
 
                Next. Next. 
 
                The ViX is a new program which allows us not to just have the images shipped over, as they are in the severely wounded warrior program, but allows us to actually see into the PAC (ph) files, the X- ray files, in the DOD, and similarly allows DOD to see into our files. And it's present now in El Paso, Denver, North Chicago, Washington. We are hoping it will also get to Richmond and Tampa, which are our polytrauma sites, where these veterans go when they're severely injured. And it allows us to seamlessly click on DOD, instead of Salt Lake or Alaska, as all the VA hospitals will be listed, and DOD as well. And when we click on the DOD images, we see the images inside those areas. 
 
                Next. 
 
                This shows the value of that. This is a Beaumont X-ray on the left showing a solitary nodule in the lung. It was very helpful to reach over into El Paso's X-rays and see that the nodule was also present.   
 
                There's been some talk about archiving these images, and we have been very resistant to that because this is -- some say it's five years, but notice this is six years -- very, very helpful to have the old image and have it immediately available to the doctors taking care of the patient. 
 
                Next. 
 
                This is a similar patient. Notice how many hospitals the patient has been at. DOD is one of them; New Mexico, Miami and so forth. To follow this man's knee operations would be very difficult if I wasn't able to reach in and grab any one of those images from all of those sites. 
 
                Next. 
 
                This is the pictures that we are able to see. They're very nice. There is a replaced knee on the right and the -- on the right-hand side, which is the left knee; and on the left-hand side, which is the right knee. 
 
                Next.  
 
                One of the other advantages of having all this data available is that we can analyze the data and see if we can improve the care of the patients. 
 
                Next. 
 
                This is -- these are cities that we've put together, 15 cities. This particular reach into the Health Data Repository was stimulated by Dr. Kolodner, and since he was in the audience, I thought I'd put it up. But notice that in the VA hospitals in 15 cities we've gone from 50 percent control of hypertension to 70 percent control, which is truly remarkable. And it's in large part because of the electronic health record and its reminder system. 
 
                But every summer we control better than every winter, and that gives you the sinusoidal curve. So the winters are worse than the summers. Now we're learning to control the winter a little bit more severely, and we'll bring those numbers above 70 into the 80 zone, which actually occurs in this -- in our hospital at the current time. 
 
                Next slide. 
 
                It does appear as though the hot cities in red have as much variation as the cold cities in blue; thus we can't let our -- we can't say that, well, it's warm here; we're not going to have this effect. The effect occurs in both places. 
 
                Next. 
 
                And it also seems that age with our system has become immaterial.  
 
                Early on, the younger people, in green, were easier to control than the older people, but as time went on and our system of electronic record and treating people very much the same occurred, indeed all -- people of all ages are being treated equally well at a very high level.  
 
                Next. 
 
                And we're doing that in the presence of a weight gain. The weight is gaining in the winter months, as well, and as a matter of fact, we're bringing the pressure down, which is in green, but it's well observed and one of our major new approaches would be to reduce weight and get a further improvement in blood pressure control. 
 
                So we're using the Health Data Repository to exchange data for individual patients, but we're also taking the same data and changing the way we practice medicine. And to have all of this data in one place, as it is in DOD and the VA and the CHDR as it currently exists, makes us very much better able to treat our patients for the long range. 
 
                Thank you very much. 
 
                DR. JONES: Now the group is available to take any questions that you might have. And again, if you want to direct it to a specific person, if you could state that, we would appreciate it. 
 
                Q:   I think this question would be for you, Dr. Jones, but it could be for anyone. Could you please quantify the progress that you all are making so far? And we're hearing -- you know, you said we're well ahead of similar efforts in the private sector, both in skills and scale. Well, compared to what? And how far along are DOD and VA in making this happen across the system for all current patients? 
 
                DR. JONES: Well, first let me take a crack at it, and then I'd like to ask Dr. Kolodner, since he looks at it from a national level, also to comment.   
 
                But first, as mentioned, we have the clinical board, which are the physicians from VA and DOD that we look to to kind of define what is interoperability and what priority should we be focusing on. Again, I hope what all of us have emphasized is health information as a tool, which the goal is to provide better-quality care. So again, hopefully that a tool is serving those physicians and providers that we're here so that they can therefore provide better care. So that's the first kind of look is to determine whether we think they're meeting the benchmark. 
 
                The second is, of course, expectations. And as you know, we report to a board of governors, called the Congress. In our committees, there are great expectations in Congress that we should be leading the nation, that we have spent considerable funding in both agencies in developing electronic health records, and therefore we should be setting the standard, if you will, for the nation in doing that. 
 
                We believe we are, in participating with the national coordinator, Dr. Kolodner, and others. I mean, we believe that our participation in that and setting standards is critical. But I'll let him comment to that.   
 
                So, again, when we bring in experts nationally from other major hospital systems, from the industry, electronic health data industry, they tell us that we are leading the pack. So that's what we go by. 
 
                I think we're all learning, insofar as the benchmarks that we want to use, again, and how do we determine what progress is being made. But again, it goes to quality care. You know, we are moving those health care indicators within our system, and the VA has a number of published articles through the years that show that, you know, they're among -- one of the best systems now in the nation. 
 
                And a lot of that goes back, in many people's opinion, to electronic health data. 
 
                So, that's kind of the way we look at it from our standpoint. Other experts, internal experts, and hopefully we will continue to refine what benchmarks we'll be using. But let me ask Dr. Kolodner to kind of comment on that too. 
 
                Q:     If the benchmarks are a moving target, what do you tell members of Congress when they say what percent of records are now transferable between DOD and VA? What's the hard answer? 
 
                MS. KELLETT: If I may, to give a little bit more granularity to the question on what percentage of records or how many records, how do we measure our progress? Currently VA has access to health information on over 4.5 million service members or prior service members. Those include things like over 2.4 million pre- and post- deployment health assessments, which is one of the things that’s key to VA in treatment on more than 971,000 members that have been deployed overseas and have returned. 
 
                We can say that for inpatient data we're sharing discharge summaries. Right now, that's coming from 50 percent of DOD inpatient hospital beds. By the end of 2009 we'll be sharing discharge summaries from somewhere between 70 and 80 percent of DOD's inpatient hospital beds. We can give stats, and we do often to Congress, on the number of lab results, the number of radiology results, those kinds of real hard quantitative numbers on the types of things that have been shared. 
 
                And if we look at monthly, our clinicians, both DOD and VA, access the systems that Dr. Fletcher showed over 328,000 queries. So it's more than knowing that we built a system that will exchange this data. We can measure how often our clinicians are actually using and accessing that data to help them in that provision of clinical care. 
 
                Q     Did you say DOD and VA have access to 4.5 million records? 
 
                MS. KELLETT: Right, all of those start in DOD. You start as a service member and become a veteran, so most of our DOD folks already have access to that data, but now VA has access as well. 
 
                Q     Is that all current service members and some military -- 
 
                MS. KELLETT: That is not all current. In terms of -- that would include separated service members and some current service members. VA only has access to current service member data if they're actually treating that patient. So they can't go in and just start surfing around and looking for someone that is still on active duty, a service member, that is not presenting to VA for care. At the point that they present for care, so they are in both the DOD's patient list and in the Veterans' Health Administration patient list, then the clinician has access to the health information. 
 
                And Dr. Kolodner, if you could continue. 
 
                DR. KOLODNER: I'm Bob Kolodner, just to give you a little perspective. Across the country about 17 percent of physicians have access to electronic health records as they're using -- as they're delivering care, as compared to all outpatient care in VA and DOD. For hospitals, the numbers are still preliminary and we'll get better numbers in January, but it's something about under 20 percent of hospitals have electronic health records fully deployed and used in at least one ward, whereas that's, again, pervasive throughout VA and extensive throughout DOD. 
 
                So the use of electronic health records itself is much more widespread and actually exceeds that in other countries in terms of its pervasive use on both inpatient and outpatient. With regard to the exchange of information, the CHDR activity that Dr. Fletcher talked about, is something where the information moves across -- it's actually incorporated into the receiving electronic health record and used for decision-making. As far as I know, that's the first time that that's ever happened across systems anywhere in the country and maybe anywhere in the world. So that gives you an idea of some of the kinds of advances the VA and DOD have achieved together. 
 
                Q     Dr. Jones, and this can be for any of you who might be able to answer it, but just to follow up on Bill's point, what we were seeing was a little hard for me to understand whether we were seeing what you hope the future holds or what you currently are able to access. And to the extent you're able to exchange information like Dr. Fletcher had shown us, is that only certain types: Wounded Warriors, for example, that you're able to do it? And is it only inpatient versus outpatient? Can you just quantify how the universe of this information flow is set today? 
 
                DR. JONES: Let me ask Dr. Fletcher to address that. 
 
                DR. FLETCHER: I can tell that from a users point of view I can see -- these are coming from actual patients. This is not a test, so what you see is what I see and I see on my patients. And pharmacy data I'm seeing on all dual users, as we discussed, and all people that have passed from DOD to VA. And I see increasing numbers of notes. 
 
                If I were to look a year ago I would not see as many notes as I am seeing now, but most of the AHLTA notes from the outpatient are coming into the system, and increasingly the inpatient notes. The patients that are in the polytrauma segment are separated and they're sent -- very complete in those instances. But the VHIE is working very, very solidly in all sectors where if I'm seeing the patient and he's my patient to be seen, I can see the information on chemistries and labs and radiology reports and a lot of the notes and discharge summaries and things of that sort, which is very, very important for what we call clinical interoperability, if you will. 
 
                Q     Of the patients that you see, that have had some care in the DOD system, how many of those patients do you have access to electronic records? 
 
                DR. FLETCHER: I have access to virtually all of those patients. And any patient I see in the VA, who's been in DOD, I can see this cadre of information. It is complete and I can see it with either of the two viewers. 
 
                Q     There used to be an incompatibility problem. For example, with images you didn't have access electronically to those images, you actually had to look at hard copies. It might be some time ago, but you have access to all types of information that you would need on that patient? 
 
                DR. FLETCHER: As far as the images go, the program I mentioned, ViX, is new, but it does allow me literally to go into the William Beaumont pacs (ph) and see the x-rays that were taken there on my system. And I can see them within a few minutes. It may take a minute or two to come down but once they're on my system I get to look at them and compare them with the films that I'm seeing elsewhere in the whole of VA. 
 
                So wherever the patient has been seen in the VA, I can see all of those images. And wherever the patient is in DOD, if they have this set up, we're in business in William Beaumont. It's set up in North Chicago. Walter Reed is very soon. 
 
                DR. KELLETT: And that was the caveat I was going to make, Dr. Fletcher, is that the actual image itself is at limited sites still. And a portion of that is specific to our Wounded Warriors. If they're transferring as an inpatient from Walter Reed, Bethesda or Brooke to one of the four main VA polytrauma centers at Richmond, Tampa, Minneapolis or Palo Alto, we manually push all of those images for those severely wounded, ill and injured service members. 
 
                The other images that are available are from those few sites where we are testing this capability to share images between DOD and VA. We started that in El Paso, Texas and are now operational in Chicago, Walter Reed and soon a few more sites this year. From that we will get our lessons learned in terms of infrastructure, usage, how much bandwidth does it really eat up? 
 
                Because, you know, sometimes you hear anecdotally, oh, these images are huge. But we want to see, what is the impact? And then we can make more rational decisions between DOD and VA on how we progress with sharing this enterprise to enterprise. 
 
                DR. JONES: We'll take one more question and then we will have to break. But again, if you have additional questions that don't get answered please follow up and we'll make sure that you get the answer. 
 
                Q     Dr. Jones, you mentioned funding. Can you explain how funding is handled between VA and DOD to make sure that efforts aren't duplicated towards finding solutions? And also, is it possible to get an estimate on the amount of funding that's been spent, for example, in the last five or 10 years and what's expected to spend in FY '09?  
 
                DR. JONES: As you know, each department goes through its own internal processes to reach decisions on funding. And I believe that's where the interagency program office is going to be very helpful to us, to ensure that those priorities that were placed as we move to an interoperability are similar, so that that can be considered on the DOD side and the VA side, so that we have compatibility. If we're working on a system and the VA's not ready to accept it or if they've got a system built that can accept, and we don't have the sending capability, we aren't making much progress. So it's my belief that that's where the IPO, the Interagency Program Office, is going to be very helpful to us. 
 
                As far as specific figures, I don't have them right on the top of my head, but Lois do you know the -- DOD is in the one billion dollar kind of range on spending on IT, health IT, per year. And that's on a total budget of about, of course round figures, about $40 billion a year. So we probably should be spending more, but that's in round figures what we're spending now. And VA, I don't know. We'll have to get you, why don't you let us get you those specific figures so we'll be correct on that? 
 
                Okay, one more quick one. 
 
                Q     For Dr. Jones, has your office and has DOD as a whole adopted the conclusions of the Booz Allen report? And what affect is that going to have on information sharing going forward? 
 
                DR. JONES: We have. That report was completed late this summer. It has been considered and reviewed by all of the necessary VA officials as well as DOD officials and have been briefed to the health information -- health executive committee and the Beck (ph) executive committee and the joint executive committee and has been accepted. We are now in the process of a way ahead, if you will, as how we're going to implement and move forward with the recommendations that they have made. So that's going to, again, I think that's going to be a very good method that will ensure that we're working together in a compatible fashion as we develop within our agencies, but yet ensure that we've got interoperability. 
 
                Thank you very much.
 
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