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Press Teleconference Roundtable on Integrated Health Records from the Pentagon

Presenters: Jonathan Woodson, Assistant Secretary of Defense for Health Affairs; Beth McGrath, Deputy Chief Management Officer; Robert Petzel, Undersecretary for Health Affairs; Roger Baker, Assistant Secretary for Information and Technology
February 05, 2013

            OPERATOR:  Welcome, and thank you for standing by.  At this time, all participants are in listen-only mode.  After the presentation, we will conduct a question-and-answer session.  To ask a question, please press star, one. 

            Now I'd like to introduce your host for today's conference, Cynthia Smith.  You may begin. 

            MRS. CYNTHIA SMITH:  Hello, media colleagues.  Thank you for joining us here today.  Today, we have representatives from DOD and V.A., who will conduct on-the-record comments to you regarding the secretary's -- Secretary Panetta and Secretary Shinseki's recent announcement regarding significant changes that both departments plan to make to the integrated health records system. 

            We have here participating on the phone line today from DOD, Dr. Jonathan Woodson.  He is the assistant secretary of Defense for Health Affairs.  We have Ms. Beth McGrath.  She is the deputy chief management officer.  From the V.A., we have Dr. Robert Petzel.  He is the undersecretary for Health Affairs.  And we also have Mr. Roger Baker.  He is assistant secretary for Information and Technology. 

            We'll begin the conversation with Mr. Baker giving you just some brief opening remarks.  And then we'll launch into the Q&A portion. 

            ASSISTANT SECRETARY ROGER BAKER:  Thank you, Cynthia.  I wanted to just preface this with just some quick comments to set the context for all of us in the room and on the call.  We met with the secretaries today to talk about changes in the integrated electronic health record program to move us forward more quickly.  They are in three major areas.  One is increasing the availability of the joint -- what's called the graphical user interface or the common clinician view of information.  Moving forward on quick wins and our ability to exchange data for use in clinical areas, what we term data interoperability.  And, finally, a change in the program strategy to accelerate the delivery of the functionality in the integrated electronic health records system and reduce the cost and risk of this situation program. 

            On the joint graphical user interface, we are moving forward to make certain that this is deployed to what are referred to [as] our polytrauma centers.  And those are the health centers that care for the most seriously injured, that we care for and exchange information on patients and that patients do more between those centers primarily from the DOD to the V.A. polytrauma centers. 

            What this user interface allows us to do is make certain that the information necessary to provide optimum care is available to clinicians so that they can see information from both DOD and V.A. care providers at the same time as they're working with the patient. 

            In the second area, we talked about moving forward on quick wins in the data interoperability space.  What this will allow us to do is that by early 2014, we will be able to exchange the most important medical information on our patients, on every one of our patients between our organizations.           

            This fulfills the president's promise under the virtual lifetime electronic record system to make that medical information available for general use inside the V.A. and DOD, but also, importantly, for the veterans and the service members themselves to download their medical record and retain it for their own use, should they choose to do that.  

            What this entails is the exchange of information in the most critical, clinical areas between V.A. and DOD in a computable format so that it is usable by clinicians to appear as a single electronic medical record in those areas to the clinician. 

            And, finally, for the broader integrated electronic health record program, the secretary has agreed to revise the strategy for that program to base the work of that program an existing -- what we've termed a core of technology, in other words, technology of an existing electronic health record system and move forward from that point.  The DOD is working towards an evaluation of their choice of on that core, and the V.A., of course, from our perspective, is utilizing the DISA (Defense Systems Information Agency) system in that area. 

            We had significant conversation with the secretaries about how that strategy will help us to reduce the costs and risk and help us delivery functionality sooner to V.A. and DOD hospitals.  Our goal there is to make certain that we are creating a single medical record for all patients effectively, so that a clinician seeing a patient from a DOD or V.A. system has all medical information from the moment they raise their right hand until the moment they're honored in one of our national shrines available to treat that individual. 

            That's kind of a quick overview on what we discussed.  Let me just for the moment ask my colleagues here if there are any areas that I missed and then move it forward to open for questions.  So, Jonathan, Beth, or Randy? 

            MS. BETH MCGRATH:  I would add that the fundamental agreement that we made -- probably two years ago -- with regard to, let's just say, the overall approach to creating this electronic health record, this integrated electronic health record remain in place, that utilization of the common data standards, the pulling together, if you will, the authoritative data sources, taking a service-oriented approach, again, data-driven, the utilization -- for those of you who live in the technology space -- of an enterprise service bus that enables us to, I'll just say, move data to the places that it needs to be, again, in a standard way. 

            The V.A. agreed probably two years ago and has moved out quite smartly on moving their systems, if you will, and their data into the DISA data centers, again, to ensure that we've got interoperability across the enterprise, so that the information can be made available.  So I think all those things are -- it's important to reiterate that the approach we're taking really remains fundamentally consistent.  Again, you heard Roger mention the graphical user interface.  We want the same common look and feel across the perspective enterprises as we're seeing patients.  So data-driven, standard space, common presentation layer, all that is in the same. 

            The piece that we're really focused on now from a -- I'll call it the EHR (electronic health records) proper is, is there a way to mitigate, minimize risk, accelerate schedule by taking, let's say, a slightly different approach to, we'll say, the insides, if you will, of a system or an application. 

            UNDER SECRETARY PETZEL:  I would just make a comment briefly that the reason that we chose the V.A.'s five polytrauma centers and the two primary polytrauma facilities in DOD, San Antonio and Walter Reed, is because these patients are exchanged back and forth between the two systems quite regularly.  There's a lot of interaction between them.  There's a lot of movement from the V.A. for a while and then back to DOD and the V.A.  So we felt that this was one of the best places that demonstrate the utility of having this new graphical user interface that allows us to look at both sets of records at the same time. 

            ASSISTANT SECRETARY WOODSON:  Right.  And the other item I would put forward is that there's been a lot of good work that has gone on, in terms of data mapping and terminology, so that we can further the work of interoperability.  These are all fundamental things that will allow us to transfer information from one agency or department to the other. 

            MRS. SMITH:  Great.  This is Cynthia Smith.  With that, we'll begin the question-and-answer period.  If the members of the press could please identify themselves before asking the question, that would be appreciated. 

            OPERATOR:  Once again, if you would like to ask a question, please press star, one.  And to withdraw your question, please press star, two.  One moment for the first question.  First question is from Kevin Frecking.  Your line is open. 

            Q:  Hello, thank you for taking my call.  I'm with the Associated Press.  My question is, you said that by early 2014 you'll be able to exchange the most important medical information of all patients.  Is that the same goal as full integration of patient records by 2017? 

            MR. BAKER:  No.  The information we'll be able to exchange in 2014 is what our clinicians describe as the most important information to them as they see a patient that could come from the other system.  Technically, we define that as seven information domains, for example, information on prescriptions or information on lab results that will be exchanged on all patients, and most critically, in a standard data format at the point in 2014, so the data looks exactly the same between the two systems. 

            In 2017, the goal is that we're exchanging all patient information, and there are well more than 40, you know, domains when you think about everything from images, notes, and other items forward to make common between the two organizations. 

            Probably even more critically, what we're talking about by 2017 is that the system that we operate on, the software that we use, will be highly common at that point.  And so it is a substantial software change by 2017, where the 2014 date is primarily oriented around the data interoperability.  

            I'm sorry, that was Roger Baker.  We should identify ourselves, as well.  So, Beth, or Jonathan, or Randy, anything else? 

            Sorry, we're done here if you wanted to follow up. 

            Q:  Well, I just do -- you know, as a layman, could you explain in a little more detail what you mean by the most important medical information?  And what I'm looking for, really, just kind of common examples that people would understand. 

            ASSISTANT SECRETARY JONATHAN WOODSON:  This is Jon Woodson.  As Roger sort of indicated, it would be that clinical information that's important to caring for patients and follow-up care, so medications, allergies, lab tests, clinical notes would be important information that doctors would want to see to care for a patient properly. 

            Q:  And then just finally, you're going to be able to do this by early 2014.  What were you thinking -- what was the timeline previously? 

            ASSISTANT SECRETARY ROGER BAKER:  So I believe previously we had been aiming at the larger set of data and wrapping it all into the 2017 date.  What the secretary has challenged us to do was find some high-value, quick wins that would provide real value across the organizations based on that data.  And utilizing those most critical data areas in a standard data format is, in fact, a significant quick win for those patients that are seen between the two organizations. 

            Q:  Okay, thank you. 

            OPERATOR:  Your next question is from Phil Stewart.  Your line is open. 

            Q:  Yeah, hi.  Thanks for doing this, because otherwise I think a lot of us would be lost.  So can you explain, if you would, how much money was spent building the perfect system or the ideal system that now isn't -- that's been foregone?  And how much money are you going to save by going this route as opposed to the other one?  Thanks. 

            MR. BAKER:  So this is Roger Baker again.  I guess I'll just start with that one.  We have really just been ramping up on the larger-scale system.  You know, the doctors spent to this point will continue on.  So, for example, what we've been doing to this point is pulling together the common requirements between the organizations for, for example, a common pharmacy system or a common laboratory system.  And so all that is valuable as we move forward in building the joint system, even if it's based on existing technology.  We still want to have common applications inside of there. 

            At this point, I can't quantify the savings on beginning from an existing core, because we have a couple of decisions left to make in there.  But I think we're all -- you know, we all believe that they're significant savings.  We had at one point said that the development of this system was going to cost -- I believe the number we had was $4 billion that we used -- 

            MS. MCGRATH:  Approximately. 

            MR. BAKER:  Yeah, so we -- you know, relative to that, we still see significant savings in basing on an existing core versus -- versus building it all from scratch, if you will.

            MS. MCGRATH:  And I would characterize -- I'm going to assume I don't have to introduce myself, because I'm the only female of the four of us, but it's really, to me, more of a cost avoidance conversation than a cost savings discussion.  I think that certainly both departments have put money in their budgets to replace or modernize their legacy systems.

            I think when we proceeded down a path of integrated electronic health record, we did do, as is required for every IT system here in the Defense Department, a -- you know, a cost-benefit analysis and a full-blown, if you will, engineering estimate.

            And so it was, I'm going to say, a part of the estimates and things that we did looking at the risk of the program to say, you know what, there's probably a better way, again, looking at commercial -- what's happening in industry.  If we started from something as opposed to -- like a core, as opposed to building it sort of brick by brick, there are opportunities to, again, reduce risk, reduce our cost estimate, and then also deliver within the timeframes that we're talking about. 

            Q:  Okay, but can you give me some sort of sense on -- I mean, is this going to be half as expensive as the $4 billion, you know, less than that?  Are you saving billions?  Are you saving millions? 

            MS. MCGRATH:  So to be honest, we do -- I'd be, I'll just say, guessing if I was to give you -- to quantify, you know -- because what we're doing is, I want to provide the same level of fidelity on the engineering estimate, and I would be giving you a guess.

            I think that there's enough analysis that has been done that says that, you know, if you start from something and you're not integrating all the pieces, certainly your integration risks and costs are going to go down.  What we need to do is then quantify that to say, okay, how much less integration are we doing, now taking this different approach?  And then we'll need to quantify that as we put together a budget. 

            Q:  But it was an educate decision reasonably to do this, so why was the decision taken, then, if it wasn't also driven by costs and the desire -- I mean, obviously, you can speed up some of these benchmarks by not creating a whole new system.  But, I mean, there must have been some factors in play here, right? 

            MS. MCGRATH:  Oh, absolutely.  And I think what I'm trying not to give you is a specific number, because I certainly believe that the simplification of the approach, starting from a core as opposed to building it again, you have less integration to do.  Therefore, your costs will be less.  What we haven't sort of gotten to the level of fidelity I think that you're looking for is how much less specifically. 

            Q:  Well, not specifically, because I said millions or billions.  That's pretty broad. 

            MS. MCGRATH:  Oh, I would say hundreds of millions. 

            Q:  Okay, thank you. 

            UNDERSECRETARY ROBERT PETZEL:  This is Randy Petzel, Dr. Petzel.  It's really a matter -- in my mind -- of cost, which I think we all uniformly agree that this is going to be a less expensive way to get to IOC and schedule.  This is going to be something that -- it will allow us to be able to get to what we originally described as the initial operating capacity. 

            Q:  Excellent.  Thanks. 

            OPERATOR:  The next question is from Matt McLaughlin.  Your line is open. 

            Q:  Hi, this is Matt McLaughlin from FedTech Magazine.  I was hoping someone could talk about how DOD and V.A. were able to resolve differences between authentication systems that you're using to get users into the IEHRs (integrated electronic health records). 

            MR. BAKER:  Sure, Matt.  This is Roger Baker.  One of the things we talked about today -- and I apologize that we didn't cover it in the beginning, but we thought it was pretty technical -- we have agreed that V.A. and DOD are moving towards a single identity management system, primarily based around what DMDC does right now for DOD, but incorporating the V.A. business requirements into that.

            That is both patient -- it's primarily patient-oriented, but we'll look at that also from an employee standpoint.  But it is -- it is a fundamental agreement that we've had for the last two years, from the beginning of starting on the IEHR, but we reinforced today -- we've actually made great progress in that area.  We had a significant discussion with the secretaries about how fundamental it is for two large organizations like this to merge their identity management systems.  It's a key piece of what we're doing to make certain that we're always talking about exactly the same patient and that -- that we agree on the attributes of the individuals as we go forward. 

            So that's a great question.  We thought it was a pretty technical piece of this, but it is a key to what we're doing. 

            MS. MCGRATH:  And I would just say, DMDC, for those who don't know, is the Defense Manpower Data Center, and they handle all of our, I'll just say, personnel-related information within the Department of Defense.  And, again, we thought it was very important that, once we assigned them a unique identifier, that they carried that with them as they moved to the -- to the V.A., if you will, so that there is no question that, you know, who the individuals are -- so they can find their records, they have access to their information, and also then the clinical providers know who they're working on or servicing. 

            Q: Yes. 

            Q:  All right.  That pretty much answered my question.  Thank you. 

            OPERATOR:  The next question is from Leo Shane.  Your line is open. 

            Q:  Yeah, hi.  With the downloadable documents here, how do you -- they'll be in a format that clinicians outside of the DOD and V.A. will be able to read?  And is that for everyone in the system now?  Or is that just for new troops, new veterans getting into the system? 

            MR. BAKER:  So, Leo, this is Roger Baker.  This is a follow-on to the Blue Button Initiative, if you're familiar with that.  Right now, service members and veterans that go to the -- go to our websites, our medical websites, can download an initial document that provides medical information about their care onto their own PC. 

            What -- what you can do now at the V.A. -- and soon from a DOD standpoint -- is download something called the C32 in the arcadia of this, but it is a very standard format published by HHS (Health and Human Services) for downloading of all the medical information on an individual onto their PC. 

            So you'll be able to have the DOD data and the V.A. data is exactly the same format.  And importantly, HHS has been running with V.A. some innovation initiatives for people to propose interfaces that would allow that data to be displayed either at a clinicians or just to the individual, so that they can do the same sort of things that we do with the data, like see it out over time, or, you know, graphical displays of the information. 

            Very powerfully -- and I want to reiterate this about Blue Button -- many private-sector organizations have picked up Blue Button, as well, and allow you to download your medical information.  So this downloadable of the whole record may be driven by V.A. and DOD, but it's something that has really taken hold in the private sector.  We heard today that over 80 million citizens have access to a Blue Button from their medical care provider to download their medical information.  And we expect this C32 format to move out across those organizations, as well. 

            Q:  Okay.  And in terms of -- this will be for everyone in the DOD and V.A. systems or just folks cycling in, in 2014? 

            MR. BAKER:  So it is for everyone in the systems.  They have to sign on to one of our medical websites and get authenticated.  Obviously, this is sensitive information, so we want to make certain that the person downloading it is actually authorized to have the information.  And we have a lot of procedures around that.  But once they're authorized to see the information, anyone who's seen in the -- in the system can download it. 

            Q:  Okay, thanks. 

            OPERATOR:  Your next question is from Marianne McGee.  Your line is open. 

            Q:  Hi, you answered a question I had about the patient ID management.  And one other question I had was, you know, besides that and also the authentication issues you just brought up, what are the other big privacy and data security issues that you'll be dealing with as you integrate these systems? 

            MR. BAKER:  Oh, I will -- I'll just start a little bit and then I'll turn this over to Ms. McGrath, as well.  Security and privacy are just fundamental in this system.  You know, we as organizations live with that all day, every day.  So there are a lot of aspects of this. 

            One of the things that I would add into this that we're doing is bringing our networks closer together so that we're able to exchange the information between V.A. and DOD clinicians so that a V.A. doctor working next to a DOD doctor can easily exchange information in a secure fashion.  And that is -- is one of the largest lifts in this program, is creating what we call the medical community of interest, to ensure that all the clinicians can work together and exchange information easily. 

            But, you know, rather than give you a whole long list of all the information security things, I'll just tell you that it is a fundamental and thought-about-every-day piece of this program. 

            So, Beth, any other -- 

            MS. MCGRATH:  Yeah, I would just add, part of where the department is going holistically in our infrastructure is really under our DOD CIO and their respective military department CIOs, is to establish this joint information environment, which really optimizes the network that has the right level of security protocols, but also enables data to flow in a real-time fashion.  And I think we really are looking across the department to ensure that -- we've gotten rid of the things we don't need any more from a network perspective and optimize our investment.  

            And really establishing a medical community of interest allows us or provides us a really good use case to identify the barriers from a security and access perspective to enable the communication not only across the defense enterprise, but with our V.A. partners from a networking perspective.  And so I think it will be trailblazing and really fundamental to ensuring that we can deliver the data in the real-time way that we're talking about here. 

            Q:  Thank you. 

            MRS. SMITH:  Excuse me, this is Cynthia Smith.  We have time for two more questions. 

            OPERATOR:  The next question is from Nicole Johnson.  Your line is open. 

            Q:  Hi, thanks for taking my question.  Two quick ones.  I just wanted to clarify what being able to exchange the most important medical information and then the user interface.  For 2014, are we talking about select locations?  I know in the past, Roger, you've talked about San Antonio and Hampton Roads, but I wanted to be clear on where we're talking and who that -- who's involved in that or actually whose information are just at the certain locations are we talking? 

            DR. PETZEL:  This is Randy Petzel.  The IOC intends to have that exchange available in San Antonio and at Hampton Roads.  The graphic user interface, which we're rolling out right now and have committed to roll out to the polytrauma centers, in addition to that, we're going to roll it out to the joint base in Elmendorf in Alaska and the Anchorage V.A. Medical Center and make plans to roll this graphic user interface out into other locations as it's being -- you know, as it's being evolved. 

            So the GUI (graphic user interface) is going to go to a number of places in an iterative fashion.  The IOC (initial operating capability) is going to be limited at the present time, as I understand it, to those facilities. 

            Roger? 

            MR. BAKER:  So let me, Nicole, then fill in the other part of that.  The data interoperability piece actually will be for all patients in -- in both organizations.  What we're going to do is, if you will, map or marry up the data in the main DOD database, called the CDR (container design retrieval), with the main V.A. database, called the CDW (corporate data warehouse), and exchange at an enterprise level that information, so that will be information on all patients in both organizations across those seven information domains.  And that's -- that also is early 2014. 

            Q:  Okay, thank you.  And then, in terms of funding and, you know, with all that's going on in the current budget environment, and what may or may not happen with automatic budget cuts, are you at all concerned of what the potential impact could be on this effort?  Or do you all feel -- will this be one of the areas that, you know, funding will continue kind of -- as cyber, you know, where talks have been to increase funding in that are.  What I guess do you all see as the potential impacts on this effort? 

            DR. WOODSON:  Well, this is John Woodson.  Of course we're very concerned about the effects continuing resolutions and sequestration and many of the financial pressures.  I think, though, that what we've mapped out as a strategy, of course, takes into account an increasingly more austere fiscal environment, and that's why we're driving and accelerating the program and reducing risk and accelerating schedule to make sure that we're as efficient in this process as possible. 

            It's really hard, though, to globally predict the future and what the impact will -- if full sequestration goes into effect, that is a much more dire scenario than if we just have a continuing resolution.  So, you know, we can't answer that question obviously specifically, except to say that we do have concerns about the fiscal environment and particularly some draconian measures that may take place as a result of decisions that have been made. 

            MR. BAKER:  This is Roger again.  And I just want to point out, a global piece that we -- that kind of goes unsaid here, but we should say it, electronic health record systems is implemented by V.A. and DOD are proven and documented to both save lives and save money.  So we're talking about an investment in a system that is going to increase the quality of care for millions, and we mean tens of millions of individuals, as well as help us control the cost of health care across the health care systems that serve those folks. 

            So, you know, there are studies out there that look at the investment in electronic health records versus the return, and I know that at least one that has it at about two-to-one return on a very conservative basis.  So this is an investment and a system designed to increase quality of care and save dollars in our health care business.  I think that's an important recognition, as we talk about the dollars from our investing here. 

            ASSISTANT SECRETARY WOODSON:  Let me make one additional point here, though, that what we've outlined is really a sincere commitment to delivering on the promise that our national leaders and the Department of Defense and Veterans Administration has made to improving the seamless handoff of service members to veteran status and ensuring that they get prompt benefits and all of the important follow-up care with no gaps in those services. 

            So this is utmost importance to us delivering on the promise, so we're fully committed to getting this project done.  And, yes, we have to address the fiscal environment, but I think we're taking a very prudent approach to reducing risk, accelerating schedule, and achieving data interoperability. 

            MRS. SMITH:  Great.  This is Cynthia Smith.  This will conclude our presentation today.  I just wanted all of the members of the press to know that we will post a full transcript of this discussion on defense.gov within the next couple of hours or so.  So please watch out for that, and thank you for your participation today. 

            OPERATOR:  This concludes today's conference call.  You may now disconnect.