How a Health Information Exchange Could Improve VA Health Care

How a Health Information Exchange Could Improve VA Health Care

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.

Shaun Alfreds, chief operations officer at HealthInfoNet

Shaun Alfreds,
Chief Operations Officer, HealthInfoNet

“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:

They include:

  • 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

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Federal Leadership Needed to Fight Medicaid Fraud, Waste and Abuse

Federal Leadership Needed to Fight Medicaid Fraud, Waste and Abuse

Data analytics offers unparalleled promise to stop fraud, waste and abuse in state-run Medicaid programs, but the lack of standards and federal leadership is holding states back, experts say.

Improper payments account for about 5 cents of every Medicaid dollar, according to federal estimates, or about $29.1 billion of the $547.7 billion program in 2015 alone. Those improper payments fall into three categories:

  • Intentional deception or misrepresentation
  • The overuse or inappropriate use of services and resources
  • Provider practices that are inconsistent with sound fiscal, business or medical practices, such as providing medically uneccessary services, or beneficiary practices resulting in unnecessary Medicaid costs.

Spotting all three consistently is challenging. Investigators can dig through data and follow hunches, but the volume of claims is so great that without automation, agencies fight a losing battle. Advanced data analytics promise to improve detection, but a lack of standards and incentives has thus far left states on their own.

On the federal level, the Centers for Medicare and Medicaid Services (CMS) within the U.S. Health and Human Services Department has demonstrated success in combatting fraud, waste and abuse in Medicare. By contrast, Medicaid programs are state run, each unique in its own right and with its own data sets and formats.

That has state agencies looking for help.

Ted Dallas, Pennsylvania’s Department of Human Services

Ted Dallas
Pennsylvania’s Department of Human Services

“CMS has to be a partner with us in analytics and set emerging best practices and standards for us to reach,” says Ted Dallas, who heads Pennsylvania’s Department of Human Services. “The federal government should try to incentivize state agencies to use analytics by paying a greater percentage of Medicaid dollars to fund analytics programs.”

CMS uses its own Fraud Prevention System (FPS) to detect Medicare fraud, one similar to those used by banks and credit card companies to spot credit and debit card fraud. By applying analytics to bills as they come in, CMS can identify suspicious billing patterns. Since implementing FPS in 2011, CMS has generated $820 million in savings – a 10:1 return on investment in the program’s first three years alone.

That’s the kind of performance states would like to achieve in their individual Medicaid programs, says Pennsylvania’s Dallas.

His agency’s fraud, waste and abuse program relies today on people, rather than advanced analytics technology. The fraud team applies rules to review checks, detect claims anomalies and spot patterns. Last year, his department stopped $648 million in fraud waste and abuse through a combination of cost avoidance – catching errant payments before they were made – and cost recoveries, when the agency chases down errant payments and gets the money back. In all, the fraud program has saved the state about 5 percent of its $13 billion budget.

Yet Dallas believes he could reap even greater savings if he could leverage the expertise of CMS. He wants guidance on which data sets and formats are most useful and which tools will yield the best results. But he also understands that’s harder than it looks.

“If you’ve seen one Medicaid program, you’ve seen one Medicaid program,” Dallas says. Each state is unique. “To create one system and say it’s going to work for every state is not realistic.”

Jala Attia, General Dynamics Information Technology

Jala Attia
General Dynamics Information Technology

Jala Attia, senior program director of Program Integrity Solutions for General Dynamics Information Technology (GDIT), has spent years creating solutions to combat fraud, waste and abuse. “Today’s challenge is identifying fraud waste and abuse faster – before payments are made,” Attia says. “This responsibility is carried by every healthcare payer in the nation and impacts us all.”

Attia also believes that while strong analytics are a key factor in detection, the importance of prevention cannot be overstated. “Imagine if you could leverage all of the historical data gathered about inappropriate behavior and mitigate that risk moving forward,” she says. “Imagine the losses that can be prevented and put towards improvements of our healthcare programs.”

States are under the gun to process payments quickly to keep practitioners in the program. Participating doctors accept that Medicare may not pay them as much as other insurers, but they expect prompt and consistent payment in return. That argues for automation in pre-payment analytic work. But most states aren’t ready for that. Some don’t even have specialized fraud, waste and abuse teams, let alone automation tools.

“Right now, there is too much inconsistency in terms of what data must be reported and how to report it,” Attia says. “States need guidance and support in order to effectively measure the impact that their fraud programs have at the state level.”

Bill Fox, vice president of Healthcare and Life Sciences at MarkLogic, of Tysons Corner, Va., says CMS is moving toward setting standards, albeit slowly. He also emphasizes that the problem is bigger than simply analyzing bills. “The Holy Grail is to get as much of a diversified data set as you can,” Fox says, “including payment information, relationships between people, ownership connections, real estate records and other unstructured data.”

Those connections can turn up critical information, such as cases where investigators find fraud at one provider and later track its ownership to other providers that have been accused of the same or similar crimes.

Working against the fraud detectors are many of the same rules put in place to protect patients and providers, such as privacy rules and regulatory limitations. Another problem: legacy processing systems that use proprietary data formats or have cumbersome interfaces. These make integration both a structural problem and a technology challenge. While the technology is maturing, structural changes are always complex and time-consuming.

The Digital Accountability and Transparency Act of 2014, also called the DATA Act, could prove helpful. The measure standardized data formats for all federal billing, notes Linda Miller, who spent 10 years with the General Accountability Office (GAO) and is now a director at Grant Thornton LLP.

John Stultz, a Government Fraud Solutions Architect at database software specialist SAS, says another way CMS could show leadership in this area is by expanding existing programs.

“CMS has set up a lot of areas where they help agencies with fraud, waste and abuse,” Stultz says. “But there is more they could do in the area of establishing a clearing house, or secure information sharing environment, [containing] standard rule sets and alert scenarios that the states could apply to their own Program Integrity or payment systems.”

Stultz says states are eager for assistance and that rather than a financial incentive, what they really need is leadership. CMS could establish a “push” environment, he suggests, and the states would readily accept what they receive. “If CMS built out an environment for sharing those best practices,” he says, “it wouldn’t take much effort on the state side to add or enhance existing rule sets or payment edits.”

More standardization across state lines would also make it more difficult for fraudsters to escape detection by shutting down and setting up one state away.

Miller suggests states could help their own causes by reviewing the data they gather, making sure they are collecting it in a standard way and also requiring users to fill in all required data fields to do meaningful analysis.

“Once states have data that can be pooled together, they can use some basic tools, including Excel, to start to identify outliers and develop a common understanding of fraud indicators within a given program,” she says.

Much of the identification work will initially take place post-payment, says GDIT’s Attia, but that’s OK. “You can’t build an effective pre-payment program without an effective post-payment program,” she says. “Pre-payment and post-payment aren’t separate. They have to be built together to create an effective fraud, waste and abuse program where you learn from what has occurred in the past in order to prevent it from occurring again in the future.”

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