The Department of Defense (DoD) and the Department of Veterans Affairs (VA) operate the two largest health care systems in the United States. The DoD maintains 63 hospitals and 826 clinics, and in partnership with civilian doctors through its TRICARE insurance system cares for about 9.2 million patients. The VA has more than 1,400 hospitals and clinics and cares for approximately 55 million veterans a year. Caring for so many patients and treating an equally large variety of medical conditions is an enormous challenge. Were it not for the two departments’ extensive and innovative use of the latest technologies the task would be overwhelming. These innovations touch on every level of the two departments’ health care systems – from electronic medical records file sharing to state-of-the-art treatment facilities to high-tech prosthetics and more.
The most vital part of the two departments’ health care operations is their electronic file sharing systems. The most innovative prosthetics, the best drugs, the greatest doctors and nurses are worthless and helpless without timely, accurate, and detailed medical information about a patient. At the very least, treatment can be delayed. At worst, medical errors – sometimes with fatal consequences – can occur. It is a testament to the DoD and VA’s commitment to providing the best care possible to their patients that they have been in the forefront of creating comprehensive electronic medical record systems. The prestigious New England Journal of Medicine revealed in a 2008 study published in its April 16, 2009, issue that only about 1.5 percent of the nation’s private sector hospitals have a comprehensive electronic medical records (EMR) system.
The VA uses the Veterans Health Information Systems and Technology Architecture software popularly known as VistA. The DoD uses the Armed Forces Health Longitudinal Technology Application, or AHLTA. An updated version in use now is AHLTA-T. VistA is an award-winning open source software developed by doctors and technicians within the VA. Developed in the 1970s and implemented in the 1980s, it has been constantly updated since then.
The reason that the two health record systems exist is the result of the distinct, yet parallel, needs of the DoD and the VA. Lt. Col. William E. Geesey, the commander and product manager for Medical Communications for Combat Casualty Care (MC4) Product Management Office, explained on the NextGov blog on Feb. 25, 2009, “VistA does not meet the battlefield needs of DoD because it cannot operate in [the battlefield] environment. If VistA is fielded instead of AHLTA-T, commanders and medical staff will lose battlefield capabilities, reducing situational awareness for combatant commanders and hindering continuity of care because information will remain stagnant at those non-communicating servers.” He went on to note another important factor, that of unfamiliarity. “The vast majority of Reserve battlefield EMR users do not work in DoD or VA facilities and therefore have no experience using AHLTA, AHLTA-T, or VistA,” he added. “Oftentimes their first encounter with this EMR system is when their boots hit the ground in theater.”
The flagship of VistA is the Computerized Patient Record System (CPRS). CPRS is an integrated, comprehensive suite of clinical applications that work together to create a longitudinal view of the veteran’s electronic health record. Its capabilities include the Real-Time Order Checking System, a notification system to alert clinicians to clinically significant events, and a Clinical Reminder System. In the July 23, 2009, issue Dr. Josh H. Lipschutz wrote to The New England Journal of Medicine that the VHA has been successfully using CPRS “for the past 10 years to manage the care of approximately 8 million veterans. This system is highly reliable, and because it is government shareware, it is available free of charge. The only criticism I have heard about CPRS is that it does not allow for billing, which is something that could be added. CPRS should be made the nationwide standard tomorrow or, better yet, today.” Dr. Ashish K. Jha of Boston Veterans Affairs Hospital added that the system “is an excellent tool. It is clinically intuitive and has all the features necessary to allow clinicians to deliver high-quality care.”
In 2006, the Department of Veterans Affairs received the prestigious Innovations in American Government Award for its CPRS software. The annual award, sponsored by Harvard University’s Ash Institute for Democratic Governance and Innovation at the Kennedy School of Government, and administered in partnership with the Council for Excellence in Government, honors excellence and creativity in the public sector.
CPRS is available to all interested parties as a free download on the VA Web site at www1.va.gov/cprsdemo. The Web site contains instructions for installation and contact links regarding any questions. As of September 2009, CPRS Version 26.76 was available.
MC4 is the DoD’s first and most comprehensive battlefield medical recording system. It has been in use for more than 10 years, and since September 2009 has enabled the capture of more than 11.5 million electronic patient encounters. It is used by 40,000 deployable medical professionals trained on medical information management systems on the front lines and 30,000 systems have been fielded to 750 units with medical personnel, to include Stryker Brigades, Army National Guard and Reserves, and all active divisional units throughout 14 countries.
Geesey participated in an open meeting with past and present MC4 product managers in May 2009 in order to address lessons learned and preview plans to advance battlefield medical recording using MC4. He said, “The move from paper to digital medical records, a transformation the new administration is striving for in the civilian health care industry, has been occurring on the battlefield for the past six years. To continue transforming medical business practices in the war zone, we need to leverage Army partnerships and institutionalize MC4 use at home and abroad.”
The MC4 program was chartered in May 1999 in order to meet presidential and congressional objectives set forth by Title 10 in 1997, which called for a medical tracking system for all deployed service members. It began as an Army-only program and was originally deployed to Kuwait, Iraq, and Qatar in 2003. Since then it has been put into use by Air Force, Navy, and Army special operations forces medical personnel in 14 countries.
MC4 integrates, fields, and supports a comprehensive medical information system, enabling lifelong electronic medical records, streamlined medical logistics, and enhanced situational awareness for Army tactical forces.
In August 2009, the MC4 system was honored with two of the most prestigious government information technology awards: the Government Computer News (GCN) Agency Award and the Federal Computer Week (FCW) Rising Star Award. Both recognize MC4’s role in expanding and supporting the electronic medical recording mission on the battlefield and most recently in battalion aid stations.
The weak link in the system, acknowledged by everyone, is the transferal process of medical records that occurs when active duty personnel are discharged. DoD and the VA began developing a bidirectional health information exchange in 2004. The goal was to have a completely interoperable system in place by September 2009. When progress stalled, Congress mandated in the National Defense Authorization Act for Fiscal Year 2008 that the two departments create a joint interagency program office to act as a single point of accountability.
On April 9, 2009, President Barack Obama, flanked by Secretary of Defense Robert M. Gates and Secretary of Veterans Affairs Eric K. Shinseki, stated, “Currently, there is no comprehensive system in place that allows for a streamlined transition of health records between DoD and the VA, and that results in extraordinary hardship for an awful lot of veterans who end up finding their records lost, unable to get their benefits processed in a timely fashion.
“And that’s why I’m asking both departments to work together to define and build a seamless system of integration with a simple goal: When a member of the Armed Forces separates from the military he or she will no longer have to walk paperwork from a DoD duty station to a local VA health center. Their electronic records will transition along with them and remain with them forever.” Obama went on to say, “This would represent a huge step towards modernizing the way health care is delivered and benefits are administered.”
Known as a Virtual Lifetime Electronic Record, the president pointed out that the integration of the two departments’ medical systems would cut red tape, reduce the number of administrative mistakes, and make a veteran’s complete military medical record available to VA health care providers, allowing them to better address medical issues that a patient has.
The study pointed out that, “VA hospitals have used electronic health records for more than a decade with dramatic associated improvements in clinical quality.” This study followed an earlier six-year analysis of the VA system published on May 29, 2003, by The New England Journal of Medicine that studied the change in preventive, acute, and chronic quality-of-care indicators in the VA before and after it initiated a reengineering of its health care system that included electronic record keeping and sharing. The study revealed that after the reengineering, “the percentage of patients receiving appropriate care was 90 percent or greater for 9 of 17 quality-of-care indicators and exceeded 70 percent for 13 of 17 indicators.” And it concluded by stating, “Many of the principles adopted by the VA in its quality-improvement projects, including an emphasis on the use of information technology, performance measurement and reporting, realigned payment policies, and integration of services to achieve high-quality, effective, and timely care, have recently been recommended for the health care system as a whole by the Institute of Medicine.” Department of Veterans Affairs Under Secretary for Health Dr. Michael J. Kussman said, “VA’s electronic health record system has largely eliminated errors stemming from lost or incomplete medical records, making us one of the safest systems in the health care industry.”
In a prepared statement to the Senate Committee on Armed Services, Subcommittee on Personnel on April 29, 2009, Rear Adm. Gregory Timberlake, acting director Department of Defense/Veterans Affairs Interagency Program Office, said that both departments are looking to expand interoperability capabilities.
“Both departments and the IPO [Interagency Program Office] recognize that ‘interoperability’ does not have a discrete end point, as technologies and standards continue to evolve. The departments and the IPO will continue to take a leading role in the continued development of electronic health records data sharing,” he said.
“Looking ahead, the departments believe that they are close to settling on a dramatic new approach to information sharing that takes advantage of cutting-edge developments in the IT industry to create a single virtual lifetime electronic record that captures a service member’s relevant health and benefits information from the time of accession to the time of burial. Through the departments’ joint adoption of a strictly defined set of uniform software standards, an architectural framework can be created that is capable of integrating the best software health IT systems from both the private sector and the government. This method of information sharing has the potential to revolutionize the way that health and benefits data is shared between the departments.”
It is a testimony to VistA’s value, adaptability, and efficiency that it has been in operation for more than three decades. But a few years ago the VA laid the foundation for the next generation of software, one designed to better fit with the next generation integration technology being jointly developed by the VA and the Department of Defense. The VA is presently operating a HealtheVet pilot program at VA medical centers in Albany, Buffalo, Canandaigua, and Syracuse, N.Y.; Bath and Portland, Maine; Bay Pines, Va.; Washington, D.C.; and Tampa, Fla. The purpose of this Pilot Program is to demonstrate how the VA can provide veterans with secure electronic copies of their medical records via the Internet. Presently a HealtheVet pilot registrant can obtain electronic copies of key portions of their electronic health records; have confidence that their health information is stored in secure, encrypted files; can personally update or correct medical information; track personal health metrics; access a Health Education Library and health assessment tools; and grant access to all or select sections of their medical records to others on an as-needed basis.
The bulk of the news about electronic medical records centers on the storage and maintenance of them in dedicated “brick and mortar” medical facilities. The concept of a service member’s medical records following him or her is generally understood to be the equivalent of a “copy-and-paste mouse click” transferal function. But, a new option is now available, one in which service members literally carry inside their bodies all of their records in the form of an implanted chip.
Radio-frequency identification (RFID) technology became practical in 1973 and since then has been used in a wide variety of ways, including passports, highway tool collection devices in vehicles, identification chips implanted in animals, and inventory tracking. In 1998, experiments were conducted with RFID chip implants in humans. In 2004, the Food and Drug Administration approved its use in humans. RFID chips contain the medical history of the patient as well as the patient’s prescriptions, all of which can be updated as needed. The biggest advantage is that it improves patient safety by reducing medication errors. Nurses use an RFID reader to check a patient’s identification and medication before administering any drugs. It is also useful in emergency situations where the patient is incapable of informing emergency responders of any pre-existing condition.
Despite the high-level support to establish complete interoperability between the two departments, progress has not been as fast as hoped. On July 14, 2009, in a prepared statement before the Subcommittee on Oversight and Investigations, House Veterans’ Affairs Committee, Valerie C. Melvin, director of information management and human capital issues, Government Accountability Office (GAO), said, “VA and DoD have continued to increase electronic health information interoperability, and have taken steps to meet the six objectives that they identified as necessary to achieve full interoperability by Sept. 30, 2009.” But full interoperability by that deadline would not be attained. She stated that the GAO recommended that “to better improve the management of VA’s and DoD’s efforts to achieve fully interoperable electronic health record systems, our draft report recommends that the secretaries of Defense and Veterans Affairs emphasize the interagency program office’s establishment of a project plan and a complete and detailed integrated master schedule.” But while the pilot program for HealtheVet has passed a number of security risk assessments, but problems remain. HealtheVet was planned to become fully operational in 2012, but delays have pushed back its full implementation to 2018. So, while Obama’s goal of having a smooth flow of a service member’s medical records from the Department of Defense to the Department of Veterans Affairs is closer, much work remains.
This article was first published in The Year in Veterans Affairs and Military Medicine: 2009-2010 Edition.