Health Information Exchange
THE BI-DIRECTIONAL HEALTH INFORMATION EXCHANGE FOSTERS NEW LEVEL OF COLLABORATION BETWEEN DOD AND VA.
When military servicemembers separate from active service, their health care becomes a concern for the Department of Veterans Affairs (VA) after having been serviced by the DoD during active duty. As Operation Iraqi Freedom was in planning nearly three years ago, defense officials recognized a pressing need to be able to transmit electronic health care information from the DoD to the VA to ensure continuity of care for its warfighters.
“We started out with the most pressing need first, met that need and moved on to the next most pressing need,” explained Colonel Bart J. Harmon, chief medical information officer in the Information Management, Technology and Reengineering Directorate of the Office of the Assistant Secretary of Defense for Health Affairs.
DoD and VA unveiled the first system, called the Federal Health Information Exchange, in May 2002 to ensure that VA would have accurate medical records for separating soldiers, sailors, airmen and Marines. After addressing this initial need, DoD and VA moved on to create an exchange to take them to the next level of health information- sharing with the Bi-directional Health Information Exchange (BHIE), Harmon told Military Medical Technology.
“What we found after that was up, in place and running is that we had a specific challenge that we needed to meet,” Harmon said. “We had patients that were still in the DoD that received health care at the VA, and we had VA patients that were seeking health care from DoD, partly because of a sharing agreement between our hospitals—sometimes with DoD fulfilling a function for VA and sometimes the other way around.”
Particularly when DoD and VA systems are co-located, one facility might offer specific services not found at the other facility, leading to a sharing of resources. But DoD and VA use two completely separate health records-keeping systems, making it difficult to access the records of a warfighter or veteran being tracked in the other system. The two departments found that confusion could result when patients moved back and forth between defense and veterans health care systems without yet separating from military service, Harmon noted. BHIE connects the VA Computerized Patient Record System and the DoD’s Composite Health Care System in those cases.
“So the Bi-directional Health Information Exchange was put in place so that even if I am still wearing an Army uniform, and I end up being referred to VA for a procedure, once I have registered at a VA location, they can pull up my DoD medical information within the VA facility,” he said. “It just continues to build a safety net of information availability around our patients across the DoD and the VA.”
SAVING TIME AND MONEY
Without the BHIE exchange, a health care provider could lack a piece of information and therefore must proceed on an incomplete history of medical procedures, Harmon said. For example, a patient may have received a lab test several weeks ago on the DoD side, but the VA doctor treating him or her now might not have access to those DoD records. Often, the doctor finds it easier to run the test again rather than to spend time tracking down paper records that could be hard to find or even misplaced.
“Making information like this available cuts down considerably on repeating lab tests and X-ray procedures that are not necessary,” Harmon said. “We have had some examples of that already where a patient is moved from one location to another, and the next location was able to see what was done at the first location, and there was no need to run a test a second time just to confirm what the first location already discovered.”
The BHIE records focus on information required by doctors and nurses to make critical decisions for their patients, Harmon noted. This information could include laboratory test results, X-ray reports, medications a patient is taking, and a patient’s known allergies. A DoD site can activate the information in the BHIE for its servicemembers that will receive treatment at a VA site, Harmon added.
“We also have an initiative that will be sharing data across the DoD and the VA from our central data repository,” he said. “So the BHIE is planned to be activated in places either where we get patients being activated out of the combat theater and we need information on patients who are on convalescent needs, they are evacuated out of the combat theater but they are still DoD patients, or in locations where there is a lot of DoD/VA sharing. So the BHIE is contributing to that next step to make information available where there is a lot of health care being exchanged between the two departments.”
Medical facilities that offered BHIE services by the end of 2005 included:
• Madigan Army Medical Center, Tacoma, WA
• William Beaumont Army Medical Center, El Paso, TX
• Eisenhower Army Medical Center, Fort Gordon, GA
• Naval Hospital Great Lakes, Great Lakes, IL
• Naval Medical Center, San Diego
• Nellis Air Force Base (AFB), NV
• National Capital Region facilities
• Walter Reed Army Medical Center, Washington, DC
• National Naval Medical Center, Bethesda, MD
• Malcolm Grow Hospital, Andrews AFB, MD
Harmon confirmed that at least two new sites would receive BHIE capabilities in 2006: Fort Bragg, NC, and Fort Hood, TX. While other sites are under consideration, DoD is rolling the system out on a case-by-case basis, wherever it makes the most sense to introduce BHIE to specific sites, he added.
In the long term, DoD plans to share information from its clinical data repository directly to the VA health data depository and thereby share information across hundreds of access points.
“That’s the longer term version and that explains some of the reason why we are not going 100 miles per hour and turning BHIE on everywhere. We are going to those places that have the most pressing need to share health information,” Harmon said.
SYSTEMS AND SUPPORT
BHIE does not actually store any of the available data, Harmon explained, but rather acts as a conduit to make data available from DoD to the VA or vice versa whenever it is required at enabled access points.
The agencies wrapped up the first increment of the program in October 2004 through enabling bi-directional exchange of outpatient pharmacy data and allergy data as well as correlating patient identification. BHIE achieved its next milestone in May 2005 with bi-directional exchange of surgical pathology reports, cytology data, microbiology data, chemistry and hematology data, lab orders data, and radiology reports, according to VA documents.
BHIE shares data through use of an Oracle 10G application server, identifying patient records in VA and DoD systems and relaying them as required. “Probably the only information that is really given to BHIE is the identity of the people,” Harmon said.
The system receives contract support from a joint VA/DoD program from Northrop Grumman Corp. On the DoD side alone, the Office of the Assistant Secretary of Defense for Health Affairs receives contract support from Science Applications International Corp. (SAIC).
AN EXAMPLE FOR GOVERNMENT
Collaboration between DoD and VA in the sharing of health records information has not gone unnoticed in other sectors of the federal government. Last October, the Government Accountability Office (GAO) released a report, titled “Results Oriented Government: Practices That Can Help Enhance and Sustain Collaboration among Federal Agencies,” in which it examined several health initiatives throughout government.
The report applauded VA and DoD for developing joint strategies to tackle a shared problem.
“As required by the Bob Stump National Defense Authorization Act for Fiscal Year 2003, VA and DoD’s Joint Executive Council, comprised of senior leadership and staff involved in health and benefit activities from both agencies, developed a joint strategic plan for the delivery of benefits and services,” the report said. “The plan identifies strategies for accomplishing each of six strategic goals. The strategies include developing joint guidelines and policies for the delivery of high-quality care and assurance of patient safety, and providing joint training in multiple disciplines.”
GAO found that the VA health care system had 7.4 million enrollees in fiscal 2004 and that VA spent $28.4 billion on the health care of 5.2 million patients, including veterans and others such as active duty servicemembers. VA maintains 157 hospitals and 900 outpatient clinics across the country.
The same year, DoD spent about $30.4 billion to provide health care for more than 9.1 million patients, which included active duty personnel, retirees and dependents. DoD provided this care at more than 530 military facilities around the world. The two organizations began sharing health information resources back in 1982, when Congress passed the Veterans’ Administration and Department of Defense Health Resources Sharing and Emergency Operations Act.
The act directed VA and DoD medical facilities to pool their resources to acquire medical and support services, thereby using federal health resources more effectively and efficiently. The Bob Stump National Defense Authorization Act for Fiscal Year 2003 required VA and DoD each to dedicate a minimum of $15 million annually for four years to fund joint programs such as BHIE. ♦