Connecting the Docs

Written by Al Staropoli

MMT 2009 Volume: 13 Issue: 6 (September)

Switching from paper and pen to the electronic health record might be a difficult task for many in the future, but not for the Department of Defense and the Department of Veterans Affairs. Both departments already have several years of experience in using electronic systems to support their patients and providers. The problem, though, has been the ease of communications—or sometimes lack thereof—between the two systems, as members of the military move from active duty and the DoD medical system into the VA system. Much has been discussed about the fate of these systems since the announcement in April 2009 by President Obama, Secretary of Veterans Affairs Eric Shinseki and Secretary of Defense Robert Gates that the VA and DoD would create a Joint Virtual Lifetime Electronic Record (VLER). The VLER would contain health care and benefits information for all of those in the military.

Currently there are no formal plans set for the development of VLER, but speculation has ranged from the melding of the two systems to the scrapping of one in favor of the other to the development of a completely new system. Each of the systems has its own strengths, partially because of their design. “There really are a different set of requirements between the DoD and the VA,” said Dr. Robert Wah, vice president and chief medical officer of CSC’s Government Health Services division, who most recently served as the acting deputy national coordinator for health information technology at HHS. “So to think that we would have the same system meet those requirements is not always realistic.”

The Veterans Health Information Systems and Technology Architecture (VistA) was formally introduced in the 1990s by the VA, but its conceptual vision began in the 1970s. VistA is the electronic replacement of the old “paper and pen” charts that physicians use to access patient lab results, health histories, diagnoses, X-rays, medical notes and more. The DoD’s similar system, the Armed Forces Health Longitudinal Technology Application (AHLTA), has capabilities similar to VistA and came about in 2005.

Experts say creating a completely new system would be unlikely because of the effort already devoted to integration of the existing two systems. “Changing horses midstream is a difficult and expensive effort that requires a tremendous amount of planning and a lot of money,” said Dr. Dave Parker, the chief medical officer for health information technology programs at Northrop Grumman, an AHLTA contractor. “Pragmatically it would be very difficult for either organization to up-and-change anytime soon. Plus, the timeline for the VLER is such that this is not even something one can consider. It’s clearly going to be about leveraging the existing infrastructure, backend and databases.”

INTEROPERABILITY QUANDARY

Most of the discussion surrounding the two systems over the past years has focused on interoperability—the ability of systems to share and process information. But making these systems “talk” is not easy, due to their individual complexity.

Take VistA for example. While many believe it is one program, VistA is actually an integrated information system that consists of nearly 100 programs. One of them, VistA Imaging, allows health care providers to see X-rays, pathology slides and wound photos on a computer monitor. Video content, such as endoscopies, can also be seen along with a patient’s full health record.

Another VistA program, the Computerized Patient Record System (CPRS), allows providers to view patient medications and lab results going back many years. CPRS also allows physicians to graph changes in values such as blood pressure over time alongside other vital signs or medical images, making it a powerful tool to establish trends or understand disease progression.

CPRS can also be used to place a variety of electronic clinical orders, significantly cutting down on time when compared with traditional paper orders used to order pharmacy prescriptions or blood tests. With VistA there are no file rooms for health records and no X-ray film to be stored.

VistA is exceedingly flexible and has operated from remote environments during stateside emergencies such as Hurricane Katrina, when patient data, X-rays and other information was accessed remotely to treat patients, even though the New Orleans VA Medical Center was partially under water. Through VistA, patient information can be shared nearly instantly with other providers among more than 1,300 sites in the VA health care system.

FAR-FLUNG NETWORKS

To get an idea of the complexity of the system, consider that nearly 7 million veterans are enrolled in it and on a monthly basis VistA stores more than 20 million images and serves 1.2 million patients. AHLTA is equally complex but also different.

“What differentiates us from other health care organizations is that we see patients on ships, submarines, areas where there are no communications or where we don’t have the ability to set up a server room to run our computers off a big server,” said Captain Michael Weiner, acting deputy program manager and chief medical officer at DoD’s Defense Health Information Management System. “We’ve taken a system that is traditionally used in a hospital and adapted it for use in the theater.”

Another key difference is that while VistA focuses primarily on an adult veteran population, AHLTA supports not only all those in service, but also their families and other individuals, providing care from pediatric to geriatrics. Like VistA, AHLTA is also a “family” of systems that work together to impact more than 9 million beneficiaries, processing 132,000 encounters with patients every day and 2.2 million prescriptions every year.

The system allows health care providers to schedule patients, order tests and prescribe medications. The patient’s record can contain lab and radiology reports, immunization information, allergies and medical alerts, discharge summaries and more. AHLTA includes a modified version of the system for use in theater, called AHLTA Theater. This version allows users in theater to document care, order lab and X-ray services, prescribe medications, and send these data to the system’s principal data repository. To move farther forward, a stripped-down version of the system called AHLTA Mobile has also been developed.

“At the very tip of the spear is a handheld device that is able to document care at the point of injury,” Weiner said. “A field medic is able to document the injury right there and then. This is important because everyone who takes care of that patient after that moment in time wants to be able to know what actually happened at the point of injury and what care was delivered at the point of injury.”

AHLTA Mobile also features aids for diagnoses and treatment decisions and contains electronic medical reference libraries, which eliminate the need to carry bulky, heavy books.

ARE WE TALKING?

Interoperability between the DoD and VA is not new. The 1982 VA and DoD Health Resources Sharing and Emergency Operations Act encouraged both departments to create a more efficient health care system. But it wasn’t until 2001 that the first patient health information was transferred electronically from DoD to the VA. Since then, the departments have increased the type and amount of information shared.

In the early 2000s, the agencies jointly developed the Federal Health Information Exchange (FHIE). This allowed the transfer of health information from the DoD to the VA at the servicemember’s time of separation. The FHIE is used to transfer a variety of data on a monthly basis, including inpatient and outpatient laboratory results and radiology reports, allergy information, consultation reports, diagnostic codes, discharge summaries and more. From 2002 to 2008, the FHIE transmitted health information from the DoD to VA on over 2.2 million veterans, including over 27.6 million laboratory, 28.4 million pharmacy, and 4.8 million radiology clinical messages as well as 400,000 consult reports.

To expand sharing capabilities, the DoD and VA developed the Bidirectional Health Information Exchange (BHIE). Released in 2007, the BHIE allows the two systems to exchange some types of data on patients receiving care from both departments on a real-time basis, including theater clinical data, outpatient encounters, pharmacy data, medical allergy data, lab results, vital signs data and patient histories. Information on more than 3.3 million shared patients, including more than 117,980 theater patients, is available through BHIE.

The main challenge at this time is that the systems don’t share all data. This is because they use different vocabularies for domains. While the two systems are “talking” to each other, the holy grail of exchange is complete computable interoperability—that is, data that can be processed and used algorithmically.

Challenges such as these are expected of any complex systems, especially newly developed systems, experts noted, and AHLTA and VistA are some of the country’s largest and most ambitious health IT efforts.

“My point of view on this is that I think the two departments are getting way less credit than they deserve for what they’re doing— frankly because they are doing more interoperability than anybody else in the world,” said Parker. “Consider that there are nearly 7,000 VA requests for DoD data every day and 3,000 requests the other way, with thousands of medications and allergies being exchanged in computable format.”

Still, the promise of the VLER for complete sharing of information represents a whole other level of patient care, potentially showing the way to do electronic health care for the U.S. population as a whole.

“What many people may not be aware [of], is that [this project potentially is] bigger than DoD and VA,” speculates Parker. “[Some people] are talking about the federal health record, which is basically patient access to all federal health record data. This is consistent with what the administration would like to see in broad terms; it’s a conceptual framework that marries pretty well with the VLER.” Ultimately, the power of a network lies in its interconnection. “The first step is to move from paper to electron. Once we get to electron, we need to connect everything together,” said CSC’s Wah, whose company is working on efforts to connect large regions of the U.K.’s health IT systems.

With an interconnected system of electronic health records, one can do very powerful things, such as personalizing the care of patients, said Wah. He believes one of the keys to interconnectivity lies in connecting “data islands”—isolated organizations that are currently using electronic health records.

“Ultimately we’ll be moving toward a nationwide health information network where all these data islands in the country are connected,” he said.

While this may happen in the distant future, it’s clear that interoperability between VistA and AHLTA will be intensified in the upcoming years. The full details on the fate of the VLER, however, still lie ahead. ♦

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