Congressional Leaders Question VA’s Progress on Interoperability, Modernizing EHR System

July 13, 2016
During a U.S. Senate Appropriations Subcommittee hearing, Congressional leaders voiced strong concerns about the VA's progress on achieving interoperability with the DoD's EHR system, despite both departments certifying full interoperability last April.

During a U.S. Senate Appropriations Subcommittee hearing, Congressional leaders voiced strong concerns about the U.S. Department of Veterans Affairs’ (VA) progress on achieving interoperability with regard to the exchange of electronic health records with the Department of Defense (DoD), despite assertions by both departments last April certifying full interoperability.

The purpose of the July 13 hearing of the U.S. Senate Appropriations Subcommittee for Military Construction, Veterans Affairs and Related Agencies was to provide subcommittee members a review of the VA electronic health record system (called the Veterans Information Systems and Technology Architecture, or VistA), the department’s progress toward interoperability with the DoD’s electronic health record (EHR) system and plans for the future.

The DoD and VA signed off on achieving interoperability in April, after the VA implemented its Joint Legacy Viewer (JLV) last fall. The JLV is a web-based integrated system that combines electronic health records from both the DoD and the VA, which enables clinicians from both agencies to access health records. During the July 13 hearing, VA CIO LaVerne Council testified that the JLV currently has 178,000 users exchanging military service members’ and veterans’ health records.

Committee Chairman Mark Kirk (R-IL) said his vision for the DoD and VA systems is for every military service member to have “100 percent seamless transfer of the health record to the VA. “We have about 250,000 service members leaving the DoD and becoming veterans every year, that’s about 700 per day. That is a data flow that is well within the capability to cover and we need to make sure that there’s seamless continuity of care.”

During the hearing, Kirk and Committee Ranking Member Jon Tester (D-MT) voiced frustrations with what they saw as a lack of interoperability between VA and DoD’s EHR systems, despite both agencies certifying to Congress in April that the systems are fully interoperable based on mandated requirements.

Valerie Melvin, director of information management and technology resources issues at the Government Accountability Office (GAO), testified that, according to GAO, the VA was still “years away” from full interoperability with the DoD.

To this point, Sens. Kirk and Tester voiced their frustrations with VA officials that the health data contained in the JLV does not include imaging data, such as X rays or CT scans, and therefore, they said, does not provide clinicians with a patients’ complete record.

David Waltman, VistA evolution program executive and senior advisor to the Under Secretary for Health at the Veterans Affairs Administration, said the JLV contains data such as progress notes, lab reports, as well as reports from imaging studies and radiology reports. And, he said the VA was working to deliver imaging data to the JLV platform. “The challenge there is to make sure we have the bandwidth to exchange imaging for clinical purposes.”

“When are we going to be interoperable to the point that the information that DoD has, you have all the information on those medical records in your hands? When will that happen?,” Sen. Tester asked.

Council said the image viewer component of the JLV will be deployed in September. And, she noted the importance of the VA’s enterprise health data management (eHDM) platform, which is part of the department’s overall EHR enhancement efforts. “We need seamless movement of information at the active duty point of an enlisted person, even before they become a veteran.”

Kirk told VA officials to expect “pretty strong recommendations” to come from the committee on definitions of interoperability. “We need to move forward on this point so there is no net burden on service members to have 100 percent transfer of the data to the VA.”

Kirk also seemed frustrated that VA's health IT was lagging behind the capabilities of commercial health IT and the implications for patient care. He pointed out that commercial EHR vendors are moving forward on data analytics capabilities within EHRs which enables clinicians to do predictive analytics in order to predict health risks such as sepsis and even suicide risk. The VA’s JLV platform is currently incapable of data analytics, Kirk said.

Waltman with the VA said the department’s EHR systems would not have the capability for analytics until 2018. “That’s where the enterprise health management platform comes in and the digital health platform. We need an integrated capability of all the clinical data, the process management for managing clinical pathways and workflows and then the analytics so we can predict, based on the information in the record, the pathways and courses of action available, and what interventions should be taken, and the care pathways that should be taken.”

Legislators have voiced ongoing frustrations about the VA’s progress on modernizing its IT systems and the progress of achieving interoperability between the VA’s VistA and the DoD’s EHR system. Last year, the GAO designated VA health care as high risk, which is a GAO designation for programs and agencies that are vulnerable to fraud, waste, abuse and mismanagement and are most in need of transformation.

During a hearing last month, VA officials indicated that the agency will likely look for a commercial EHR system during a discussion about its 40-year-old homegrown system. During the hearing of the Senate’s Committee on Veteran Affairs, VA Under Secretary for Health David Shulkin testified that VA officials have reached a consensus that “looking at a commercial product is probably the way to go,” and he added, “But we need to do this in a way that incorporates our ability to integrate with community providers and unique needs of veterans.”

During the July 13 hearing, Melvin with the GAO said that the VA has been working with the DoD for the past two decades to advance EHR interoperability between the two systems, however, “while the department has made progress, significant IT challenges contributed to our designating VA as high risk.” And, Melvin summarized the GAO’s concerns about the VA’s ongoing modernization efforts.

“With regard to EHR interoperability, we have consistently pointed to the troubled path toward achieving this capability. Since 1998, VA has undertaken a patchwork of initiatives with DoD. These efforts have yielded increasing amounts of standardized health data and made an integrated view of data available to clinicians. Nevertheless, a modernized VA EHR that is fully interoperable with DoD system is still years away,” Melvin said.

“In 2011, DoD and VA announced they would develop one integrated system to replace separate systems, and sidestep many of their previous challenges to achieving interoperability. However, after two years and at a cost of $560 million, the departments abandoned that plan, saying a separate system with interoperability between them could be achieved faster and at less overall cost. Yet, as they have preceded on separate paths, we continue to highlight three primary concerns with this approach,” Melvin said.

GAO has found that the VA has a lack of outcome-oriented goals and metrics for achieving interoperability. “The important question remains as to when VA intends to define the extent of interoperability it needs to provide the highest quality of care, and when the department intends to achieves this with DoD?”

Melvin also said the VA plan to modernize its VistA EHR system “raises questions about duplications with the DoD system acquisition, as the department has identified 10 areas in which they have common healthcare business needs.”

And, Melvin said that VA officials “have yet to substantiate its claim that modernizing VistA together with DoD acquiring a new system can be achieved faster and at less cost than a single joint system." “How do the DoD and VA continue to justify the need for separate systems?”

Melvin summed up her testimony, “With regard to EHR interoperability and system modernization efforts, there is uncertainty and important questions remain about what the department is prepared to accomplish, in what timeframe and at what cost."

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