The Department of Veterans Affairs provides medical care to nearly 9 million veterans, many of whom seek health care from non-VA facilities and providers. Keeping track of all their health records is a monumental undertaking. But new technology advances are making it easier.
The military healthcare system is built around service members and a unified record follows troops wherever they go. But once they leave the military system, veterans face a bewildering world of choices – ranging from private doctors and insurance to the massive VA system. Maintaining a comprehensive health record in that maze isn’t easy.
Even after years of struggle, VA and Defense Department systems are only partially compatible. The Joint Legacy Viewer (JLV) and a patchwork of other solutions provide VA clinicians only limited direct access to veterans’ military health histories. Today, as the Defense Department begins to roll out its new electronic health records system, the hope remains that sooner rather than later the two agencies can lick this problem.
The question is how.
One option is to wait for DoD to complete its EHR rollout, then expand the system to include VA, as well. Another is to rely on JLV and several other stop-gap technical solutions now in place. But a third way could offer the best chance for progress: expanded use of health information exchanges (HIEs).
Advances in commercial HIEs could be the key to making the whole system more transparent to patients and providers alike. HIEs act as translation software, enabling disparate health systems to interpret shared data even when they use different formats and codes to organize their records.
Both DoD and VA already use HIE technology to share data today. The Bidirectional Health Information Exchange (BHIE) enables VA practitioners to see defense records now. But commercial applications have now advanced to the point where HIEs now routinely and transparently share data across the industry, suggesting that VA and DoD could share more now if they adopted those solutions.
In the state of Maine, where 12 percent of the population are veterans, VA joined a statewide HIE called HealthInfoNet in 2013. The system shares data with 37 acute care facilities and more than 500 ambulatory practices, including VA facilities across the state.
“The value of the HealthInfoNet HIE goes beyond a shared record,” explains Shaun Alfreds, chief operations officer at HealthInfoNet. “It is one patient, one record: Within three clicks, providers and patients can get a statewide view of a patient, aggregated and standardized.”
“If the VA wants to support veterans right now, then perhaps having an HIE serve as an intermediary [between the agency and DoD] might be the right solution,” Alfreds says.
Robert Guajardo, director of software engineering with General Dynamics Information Technology, agrees. “Utilizing a federal HIE will be the fastest way to share patient records between the DoD and the VA – while having the added benefit of creating a consolidated patient record that can be viewed and shared across the entire VA.”
Suzanne Cogan, a vice president with Orion Health, whose Amadeus platform underpins HealthInfoNet, says HIEs have come a long way in recent years. “In the beginning, you saw federated HIE models that were based on query and response,” she says. Back then, providers would request a record, view it, and then manually pull an image of a record into their own medical record systems. The Joint Legacy Viewer, which gives VA a window into DoD health records, follows that model.
But newer HIEs employ a centralized architecture that supports more functional records transfers.
By consolidating patient records from multiple providers in a single one-patient/one-record system, HealthInfoNet has helped streamline care, avoiding duplicative procedures and flagging providers when patients show up seeking expensive emergency room care when other options would be more cost effective.
“Some patients are using the emergency department for conditions that don’t need” that level of care, Alfreds says. With the HIE“providers can assign care management to patients so they can make better choices.”
On a macro level, the HIE also supports what Alfreds calls public health surveillance, providing state health officials the ability to monitor statewide trends in real time.
Cogan agrees: “You can do more with the curated and aggregated data, such as predictive analytics” that can spot health care needs ahead of time, so medicine or other interventions can be pre-positioned ahead of a health crisis.
For a vast agency like VA, which is transitioning from having once provided all its own care to a model where more patients now use private health care providers, HIEs promise the means for capturing, coordinating and tracking care from multiple providers.
“Soldiers leave military service where DoD medical personnel know everything about them and suddenly they are on their own,” says Cogan, who is married to an Army veteran. “It’s critical for the veterans with health care problems – especially in this era of increased veteran suicide – to get continuity of care after they leave the service.”
Could DoD and VA ever rally around a single electronic health record solution? Travis Dalton, senior vice president with the Federal Division of Cerner, which is providing the Pentagon’s new electronic health records system, says that is one long-range vision behind that program. In addition to implementing the core EHR program requirements and connecting to VA and other systems, Cerner is working with DoD and discussing advanced tools that could identify soldiers at risk for ailments like post-traumatic stress or suicide, for example. “You move from just treating patients to early at-risk identification,” he says. “Our goal is connecting the continuum of care with relevant information from enlistment to the grave.”
Cerner’s Genesis EHR system achieved initial operational capability this winter and was launched at Fairchild Air Force Base, Wash., in February; eventually, it will cover the entire department along with 325,000 health care providers across the nation.
Centralizing on a single EHR for DoD and VA based on the same integrated platform would be ideal, Dalton says, especially considering the military’s unique security requirements. “However, as a company we realize that not all of our clients will have just one supplier or system,” he says. “We are and have always been at the forefront of interoperability and are committed to it.”
At Fairchild, Cerner is piloting its HIE as a go-between, linking the new EHR system and the JLV. That system will support:
- Real-time on-demand patient summary, or continuity of care document (CCD)
- Clinical notes for all specialties
- Dental CCD
- Dental notes
Those records are provided as a read-only image, however, which limits some utility.
The eventual goal is that DoD health providers, including forward surgical units, overseas hospitals, and stateside rehabilitation, will trust and use the EHR system enough to supplant paper records, allowing VA full access to a comprehensive electronic record.
Open Architecture Solution
The question is how to get there. George Hou, managing director and national account manager with the VA unit at InterSystems, another global health technology company, sees HIEs as the key to increased interoperability for VA.
“The VA cannot afford to develop and maintain custom software for health data interoperability,” he says. “And solely relying on the open source community to contribute innovation is not feasible. The license might be free, but the sustainment costs, as we have seen with some other VA-funded open-source development programs, would be prohibitive. We believe that open architecture gets you something at a lower cost, lower risk and shorter time to capability.
“While a new [electronic health record system] is an enormous multi-year project,” Hou says, “you can install the technology for an HIE as the core to a digital health platform, start to transition components into the environment, and immediately begin to see incremental value.”
InterSystems has worked with VA for the past 36 years, providing core technology within its VistA health care system environment. Leveraging an HIE with its existing investment in VistA could immediately provide a more holistic view of VA patients and almost instantly improve outcomes, he says. “This goes far beyond the EMR,” Hou explains. “The infrastructure the VA is putting in place can and will be leveraged to do so much more. The VA soon may have the capability to leverage their information to take improved action in many areas of care delivery, such as mental health, age-related disease, chronic disease, and issues related to the environment, such as toxic smoke or material exposure.”
To achieve that, VA must develop a comprehensive HIE strategy that puts the agency in a leadership role so that others will want to follow its example, Hou argues.
“The last WWI combat veteran [Frank Buckles] passed while I was at the VA, in 2011, 93 years after the cessation of hostilities,” Baker recalls. “We will be caring for those wounded in Iraq and Afghanistan for at least that long.”
That’s why preserving the comprehensive military record for veterans is so important, he says. “The full documentation of exactly what happened to them when they served, their personnel, service, medical, exposure, and other records, can be needed for many, many years down the road. The VA needs the full record, now, while it’s available, to provide the best possible care and services for the next 93 years for our veterans.”
How DoD, VA Share Data Today
The Department of Defense and Department of Veterans Affairs use a number of piecemeal systems to share clinical data from one agency to the next. The Bidirectional Health Information Exchange enables that two-way sharing in these systems:
- The Joint Legacy Viewer: Gives providers read-only access to health data such as admissions, appointments, allergies and immunizations, inpatient and discharge summaries lab panel results, and more.
- The Virtual Lifetime Electronic Record (VLER): Enables veterans to support limited sharing of health records with VA and participating non-VA providers using a health information exchange (HIE)
- The Health Artifact and Image Management Solution (HAIMS): Provides global visibility and access to radiographs, clinical photographs, electrocardiographs, waveforms, audio files, video and scanned documents and provides an electronic Service Treatment Record (STR) to the Veterans Benefits Administration (VBA)
- My HealtheVet: Provides veterans with an online personal health record