VA Report Identifies HIE Barriers to Improving Care Coordination

Sept. 8, 2020
Expansion of VA Direct usage to all facilities would increase information sharing and improve the timeliness of health information exchange, OIG says

A review by the Veterans Administration Office of Inspector General (OIG) found that although most VA facilities are using health information exchange tools, barriers remain to widespread adoption, and 22 of 48 facilities surveyed reported exchanging health information by scanning, faxing, or mailing patient information.

The OIG recently conducted a review to determine how VA facilities and community providers use HIEs in their respective communities to share information and coordinate care for patients enrolled at a VA facility, and to identify any barriers that may be preventing utilization.

The OIG surveyed and interviewed the 48 lower complexity Level 2 and 3 Veterans Health Administration (VHA) facilities. The OIG also interviewed staff from the Veterans Health Information Exchange (VHIE) Program Office, and met with the Office of Information Technology, Office of Community Care, Office of Rural Health, Cerner, and two state HIEs.

VA Exchange uses the eHealth Exchange to query and share health information with community partners. VA Direct is a secure email type exchange that uses the DirecTrust protocol to allow for the exchange of health information with community partners.

The VHIE Program Office Director reported that all 140 VA facilities have access to VA Exchange and VA Direct; however, only 28 of the 140 VA facilities have implemented VA Direct. Facilities not utilizing VA Direct reported that they were not provided training facilitated by DirectTrust, did not have community partners using DirectTrust, or were using other HIEs. The OIG report stated that “expansion of VA Direct usage to all facilities would increase the instances of health information sharing and improve the timeliness of health information exchange while efforts continue with development of community partnerships through VA Exchange.”

Following publication of the report, DirectTrust President and CEO Scott Stuewe issued a statement noting that "the VA OIG report provides valuable insight and recommendations on how to enhance the Veterans Health Information Exchange program.”

Stuewe noted that DirectTrust is a volunteer-driven membership organization and standards body serving as custodian of the Direct Standard, the foundation of Direct Secure Messaging. "As such, DirectTrust is not set up to provide end-user training. Typically, vendors provide training on how to use Direct within their platform, as Direct Secure Messaging is implemented differently across vendor platforms.  We’re pleased to report that the DirectTrust EHR Roundtable, in which the VA participates, recognizes the variability in utilization across vendors, and is creating ‘best practices’ guidelines to advance the usability and utilization of Direct Secure Messaging.”

“Further, VA community partners do not need to be a member of DirectTrust for VA facilities to share information with them using Direct Secure Messaging. Any organization can utilize the Direct Standard. The services of a DirectTrust-accredited health information service provider (HISP) are required only to participate in the secure exchange of trusted, identity-verified endpoints within the DirectTrust Network.”

The VHIE Program Office did point to some HIE success stories. For instance, it stated Walgreens Pharmacy, one of the larger organizations that is a “trusted [community] partner,” provides VA information for patients who have received flu shots. “With the click of a button, VA providers will be able to see the entire medication and immunization history of VA-enrolled patients who receive their prescription and immunization needs at Walgreens.”

Based on survey responses and follow-up interviews from 48 facilities, the OIG found 46 facilities reported using VA Exchange or VA Direct, or both, and only two facilities reported not using either VA Exchange or VA Direct. Additionally, 22 of the 48 facilities reported exchanging health information by scanning, faxing, or mailing patient information. This included the two sites that did not use either VA Exchange or VA Direct.

The OIG noted that facilities’ challenges for sharing information included the need for additional training, an increase in community partners, and an understanding of how to use the program.

In addition, facilities reported technology challenges to viewing community health information through VA Exchange, including the dual sign-on requirement for VHA providers to first sign into the electronic health record and then sign into the Joint Legacy Viewer (JLV) to access community partner patient information. The JLV data quality was not ideal, information naming and access was not user friendly, and facilities reported a cumbersome process that resulted in delays in finding needed information.

VA has two contracts establishing community coordination for VHIE. The OIG found VA has 56 VHIE community coordinator positions to support facilities and Veterans Integrated Service Networks through their responsibilities for the infrastructure, outreach, and training of general and rural health communities and users. The OIG found that the degree the coordinators were engaged ranged from a high level of participation to little or no participation. Additionally, during interviews, some staff identified a turnover of coordinators created a barrier for staff knowledge and ability to use the programs. “With the addition of more training, communication, and future planned technological changes, VHA could more effectively streamline the continuity of care received by veterans,” the report said.

In addition, the Electronic Health Records Modernization effort currently under way should alleviate some of the technology challenges experienced with the use of VHIE, the report noted.  EHR vendor Cerner reported the implementation of Millennium/Power Chart would eliminate the need for dual sign-in to review community care documents and allow for exchange accesses between VHA, the Department of Defense, and community providers.

The OIG made four recommendations to the Under Secretary for Health related to the need for increased utilization of VA Direct, education for staff and veterans on VA Exchange and VA Direct, expansion of community partnerships, and use of contract VHIE community coordinators:

1. The Under Secretary for Health reviews the barriers related to the utilization of VA Direct and ensures the Veterans Health Information Exchange Program Office increases the number of facilities using VA Direct as a secure option to share health information.

2. The Under Secretary for Health ensures the Veterans Health Information Exchange Program Office evaluates the VA Exchange and VA Direct training and education programs and increases accessibility to Veterans Health Administration staff, community partners, and veterans.

3. The Under Secretary for Health ensures the Veterans Health Information Exchange Program Office increases the number of community partners, including more state exchanges and other Health Information Exchange stakeholders, to facilitate the expansion of bidirectional health information exchange.

 4. The Under Secretary for Health confirms the Veterans Health Information Exchange Program Office evaluates the performance work statements of the Veterans Health Information Exchange community coordinators and ensures compliance with the scope of work.

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