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					The Next Generation of DoD/VA Health
Information Technology

Bob Marshall, MD MPH MISM
CMIO, Madigan Healthcare System
Director, Medical Informatics Fellowship
   Describe existing health data sharing initiatives
   Explain the direction from the Secretaries of Defense
    and Veterans Affairs to pursue a joint, common
       To allow seamless transition of a Service member's medical
        information between the military healthcare system and the
        Veterans Affairs healthcare system
   Describe the synergies and common business
    processes already identified
       Common data standards
       Data center consolidation
       Common clinical applications
       Common user interface
   Current Electronic Health Record (EHR)
   Current health data sharing
       DoD and VA
       Virtual Lifetime Electronic Record (VLER) Health
   What’s next for EHR
       EHR milestones (1979 – 2011)
       Integrated EHR (iEHR)

   Working to maximize speed, availability, and
    usability of the current EHR
   Supporting legacy systems to ensure timely
    access to and use of clinical systems
• Essentris
• Composite Health Care System
• AHLTA-Theater
• Theater Medical Information Program
  CHCS Cache (TC2)
• Theater Medical Data Store (TMDS)
  AHLTA Release 3.3         User-requested capabilities and
                            enhancements designed to improve clinical
  upgrade deployed          encounter documentation and workflow
     worldwide              processes

   Essentris inpatient      Complete for DoD’s 58 hospitals
capability implementation
                            Targeted for late FY 2012 -- Will provide
                            product upgrades to improve system speed,
    AHLTA-Theater           availability, and usability in support of
    enhancements            healthcare delivery in the Theater

  AHLTA Clinical Data       Targeted for FY 2012 -- Will upgrade the
   Repository (CDR)         primary database and provide capabilities to
     stabilization          support improvements to system speed,
                            availability, and usability
                                                                                                                *As of Dec 2011

DoD                                                                                                VA
Data on Shared Patients
 • Current Viewable Data
   – Outpatient pharmacy data, laboratory and                                                           All VA Medical Facilities
     radiology results
   – Inpatient laboratory and radiology results       Two-way, on-demand view of
                                                                                                    • 4.2 million correlated patients,
   – Discharge summaries (58* DoD sites =             health data available in real-
                                                      time                                            including
     100% of inpatient beds)                                                                          1.9 million patients not in FHIE
   – Inpatient consultations, operative reports,   Bidirectional Health Information Exchange          repository
     history and physical reports, transfer        Live data flow beginning 2004; data from 1989
                                                                                                    • 148,700 average weekly FHIE/BHIE
     summary notes, initial evaluation notes,      forward
     procedure notes, evaluation and                                                                  4th qtr FY 2011
     management notes, pre-operative                 Viewable data exchange between all
     evaluation notes, and post-operative            DoD and VA medical facilities as of July
                                                                                                    • Computable pharmacy and allergy
     evaluation and management notes (58*            2007                                             exchange
     DoD sites - available to all DoD providers                                                       on more than 1,317,360
     and VA providers enterprise wide)
   – Allergy data and problem list data
   – Theater clinical data: Theater inpatient
     notes, outpatient encounters, and ancillary
     clinical data
   – Ambulatory encounters, procedures, and
     vital signs
   – Family, social, and other history, and
 • Current Computable Data (limited VA sites) –
   enables drug-drug and drug allergy safety
   checks and alerts
     – Pharmacy data
     – Medication allergy data
        Current* Health Data Sharing
                                                    DoD and VA
DoD                                                                                        VA
                                                                                                    All VA Medical Facilities

Data on Separated Service Members                  One-way, monthly transfer of                 • 92.6 million lab results
 • Outpatient pharmacy data, lab and radiology     health data                                  • 15.0 million radiology reports
                                                                                                • 95.7 million pharmacy records
 • Inpatient laboratory and radiology results   Federal Health Information Exchange
 • Allergy data                                                                                 • 113 million standard ambulatory data
                                                Live data flow beginning 2002; data from
 • Consult reports                              1989 forward
 • Admission, disposition, transfer data                                                        • 5.2 million consultation reports
 • Standard ambulatory data record elements                                                     • 3.3 million deployment-related health
                                                   Health data on more than 5.8
   (including diagnosis and treating physician)                                                   assessments on more than 1.5 million
                                                   million Service members
 • Pre-/post-deployment health assessments                                                        individuals
 • Post-deployment health reassessments

                                                                                                    4 VA Polytrauma Centers
                                                      One-way transfer of health data               (Tampa, Richmond,
                                                      initiated at time of decision to              Minneapolis, Palo Alto)
                                                      transfer patient
                                                                                                • Radiology images for more than 470
Data on OIF/OEF Polytrauma Patients                                                               patients
 • Radiology images                                Live data flow beginning March 2007
 • Scanned medical records                                                                      • Scanned records for more than 570
                                                      From Walter Reed National Military          patients
                                                      Medical Center in Bethesda and
                                                      Brooke AMC
   DoD clinicians view VLER information via the
    military EHR
   VLER facilitates exchange of information with
    other federal and civilian organizations
   Data from DoD CDR drawn, formatted, and
    transmitted via the Nationwide Health
    Information Network (NwHIN) cloud
   Qualified Exchange members use this data to
    support healthcare delivery to Service Members

September 30, 2011

• Health Record Data:
 – HITSP C32 subset
 – Advance Directives *
 – Encounters
 – Immunizations*
 – Insurance Provider
 – Procedures
 – Unstructured Documents:
    Consults/Referrals
    Discharge Summaries
    Results of Diagnostic Studies
    Procedure Notes
    History & Physicals

• Partners:
 – Madigan Army Medical Center
 – VA Puget Sound Health Care System
 – MultiCare Health Org
 – Franciscan Health, Group Health, Providence Health#

                • *will display but not send   #planned partners
NOTE -- The health record
depicted here contains
sample test data used for
demonstration purposes

Oct 2011:
Secretary of Defense
and Secretary of VA
signed IPO Charter

   The DoD/VA Interagency Program Office to be
    the single point of accountability for iEHR and
   iEHR is characterized by:
       Best of breed approach that includes legacy, COTS,
        open source, and custom systems
       End-to-end agile development (speed to market)
       Maintenance of legacy EHRs (for a while)
       Commitment to contain healthcare costs and provide
        higher value based healthcare delivery systems

                                                                             Secretary of
                              Secretary of Defense
                                                                            Veterans Affairs
                              DEPSECDEF / VCJCS                               DEPSEC VA

                                      Board                                                             HHS (ONC),
                                                                                               National Health IT Task Force
                                                             iEHR Program

                                                     Data Centers       Identity Mgmt
                                                                                                  Open Source
                                                      DoD - DISA         DoD- DMDC
Functional/Perf                                                                                    Custodial
Requirements                                       Innovation & Dev                                  Agent           CEO
                                                    Test Bed - TBD
Data Standards & Compliance                                                                           BoD
Architectural Requirements
                               Test & Evaluation

                                                   Apps/Capabilities   Apps/Capabilities
Clinical/Ops Workflow                                    VA                  DoD
                                                                                                        Community Gov./Oversight
Bus. Process Reengineering                           Common GUI           Joint ESB
                                                        VA                   DoD                        Mainline Maint. & Extend
                               IV&V /

                                                                                                        Test & Cert. Protocols
                                                   Translation/CIIF          CSB
                                                        TBD                  TBD                        Distribution & Licensure

   Common DoD-VA Requirements: HL7 EHR-S Functional Model with DoD and VA vetted Extensions (SV-4)
                 Common DoD-VA Integrated Health Business Reference Model (OV-5)
                       Common DoD-VA “To Be” Process Flow Model (OV-6C)
                                                            (Common GUI)

                                                   Applications and Services
           DoD Unique                      Common (Joint) Applications & Services                                VA Unique
     Battlefield                                           Personal                                        Nursing        Long Term
                   Pediatrics              Pharmacy                       Laboratory    Blood Mgmt
       Care                                              Health Record                                      Home             Care

      Military                             Disability      Inpatient      Emergency     Document         Rehabilitative    Transient
                   Obstetrics              Evaluation    Orders Mgmt      Dept Care       Mgmt
     Readiness                                                                                               Care          Outreach

      Enroute                                              Consult &                     Operating                Occupational
                   Veterinary              Dental Care                   Immunization
       Care                                              Referral Mgmt                  Room Mgmt                  Health (VA)

                                                 Common Interface Standards
                                               Common Services Broker
                          (includes Enterprise Service Bus (ESB) and Infrastructure Services)
                                                 Common Interface Standards

                                                    Common Data Centers

                                Common Information Interoperability Framework (CIIF)
                          Common Information Model, Common Terminology Model,
                          Information Exchange Specifications, Translation Service
                    Common Data Standards: SNOMED CT and Extensions, LOINC and RxNorm
Common DoD-VA Measures of Effectiveness, Measures of Performance and Key Performance Parameters
                                  Joint DoD/VA                           DoD Only                    VA Only
Presentation Layer Work Group Deliverables
   January 2011: Developed
    requirements for the initial iEHR
    provider GUI
   July 2011: Deployed iEHR GUI at
    Tripler (JANUS 4.0)
   Charge for December 2011:
       Deploy current Tripler GUI in North
       Deliver recommendation for iEHR GUI
        go-forward strategy (focus on FY12-13)
Clinician View (Home Page)

                             NOTE -- The health record
                             depicted here contains
                             sample test data used for
                             demonstration purposes

Clinician View (Patient Summary)

                         NOTE -- The health record
                         depicted here contains
                         sample test data used for
                         demonstration purposes
Notional portal-based approach allows for portlet re-use

                                           NOTE -- The health record
                                           depicted here contains
                                           sample test data used for
                                           demonstration purposes

                        FY 11        FY12                 FY13              FY14                FY15                FY16            FY17              *iEHR Capability Sets
                                                                                                                                                      as identified by the ICIB
                                                            Presentation Layer / GUI
                                                                                                                                                      5 Dec 2011
       1.0 Investment

                                                             Target: 6+capabilities per set
                                                                                                                                                                    Capability Sets 3-8
                            Capability Set 1 Initiation          Set 2
                                                                            Set 3                                                                            •   Patient Portal Infrastructure
                                                                                        Set 4
                                                                                                                 Sets 5-8                                    •   Anesthesia Documentation
                                                                                                                                                             •   Operating Room Management
                                                                                                                                                             •   Medical Device Management
                                                  Information Infrastructure Capability Set
                                                                                                                                                             •   Disease Management
                                                                                                                                                             •   Disconnected Care
                                                                                                                                                             •   Business Intelligence
    Information Infrastructure                      Capability Set 0B                       Capability Set 1A                     Capability Set 2
         Capability Set 0A                         (Common Services)                                                                                         •   Patient Questionnaire
      (Enabling Capabilities)                                                                                              • Anatomic Pathology              •   Patient Consent
                                              • Enrollment Eligibility              • Pharmacy
                                                                                      o Inpatient & Outpatient             • Disability Evaluation           •   Patient Education
•     Identity Management                     • Orders Service
                                                                                        Orders Fulfillment                 • Dental Care                     •   Alerts and Reminders
•     Access Control                          • Clinical Decision Support
                                                                                      o Inventory Management               • Credentialing                   •   Patient Self Report
•     Presentation Layer (GUI)                  (CDS)
                                                                                      o Allergies                          • Pharmacy                        •   DoD/VA Registries
•     SSO-CM                                  • Barcoding
                                                                                      o CDS                                  o Barcoding                     •   NCAT (TBI Testing)
•     Information Model and                   • Secure Messaging
                                                o Provider-Provider                 • Immunization                           o Mail Order                    •   Global Image Access
      Terminology Services
                                                o Patient-Provider                  • Consult & Referral                   • Personal Health Record          •   Patient Safety Reports
•     Federated Data Repository
      / Data Warehouse                                                                Management                           • Radiology/Imaging               •   Teleconsultation
•     Network and Security                                                                                                                                   •   Document Management
                                                                                           Capability Set 1B                                                 •
      Architecture                                                                                                                                               Blood Management
•     SOA Architecture                                                              •   Care Management                                                      •   Private Sector Data Access
                                                                                    •   Emergency Department Care                                            •   Nutrition Care
                                                                                    •   Laboratory                                                           •   XML Forms Tool
                                                                                    •   Registration                                                         •   Utilization Management
                                                                                    •   Scheduling Appoint                                                   •   Genomics
                                                                                    •   Documentation                                                        •   Encounter Coding

                                                                            Common Graphic User Interface (GUI)

ORGANIZATIONAL INFOSTRUCTURE                                  Notional iEHR Infostructure: Standards-based Connectivity -- ICIB 11/15
    Registries Data                          Population Health Data                                                EHR Data                                          Data
      & Services                                  & Services                                                       & Services                                      Warehouse
                EAI IP
                EAI IP

             ICIB Recommended FOCUS                                                       Implementation Standards
                                       EAI IP                 EAI IP                 EAI IP             EAI IP              EAI IP         EAI IP
             Architecture Standards                                                       • Patient Registry
                EAI IP

             • EHR Svc. Platform Conceptual                                               • HL7 Provider Registry
               Architecture                                                               • HL7 Pharmacy
                EAI IP

             • EHR Use Cases                                                              • Laboratory
                                                                                             EAI IP
             • FHIM/EHR Data Model                                                        • Public Health Services Standards
                         EAI IP                                                               EAI IP
             • EHR-S Services Model                                                       • Public Health Surveillance Standards
         EHR IS
             • EHR Interoperability Profiles                                              • Diagnostic Imaging/Teleradiology
 EHR SCP     • Terminology Standards
                          EHR IP                     EHR IP                 EHR IP             EHR IP
                                                                                         • Clinical IP Standards
                                                                                                                      EHR IP
                                                                                                     Messaging IP Standards
                                                                                                                                        EHR IP                  EHR IP
 Standards                        EHR IP Standards       EHR IP Standards       EHR IP Standards EHR             EHR                         EHR IP Standards       EHR IP Standards
             • Terminology implemented in EHR IP
                  EHR IP      EHR IP
                                                                                          • Technical Standards
                                                                                               EHR IP                 EHR IP            EHR IP                  EHR IP
               data messaging standards

POINT OF SERVICE Public Health                          Pharmacist              Radiologist        Lab Clinician           Physician/       Physician/              Physician/
                                  Provider                                                                                  Provider         Provider                Provider

• Facilitates development
  of business process-
  based common services
• Promotes system
• Provides enterprise
  application integration
• Improves application
• Enhances speed to

   September 2011-- Memorandum of
    Agreement between DoD and VA to
    consolidate VA data centers into existing
    Defense Information Systems Agency (DISA)
    data centers
   By 2015 -- The Departments expect to have
    consolidated more than 800 data centers
                   Strategy and Goals
• Establish core data centers that will support enterprise
• Increase mission effectiveness, enhance security, and
  improve efficiency across the enterprise                 21
   Strengthen the SME-engineer collaboration
     Users provide requirements
     Cognitive/industrial engineers interpret
      requirements and design functional solutions
     Software engineers code the solutions

   Establish evidence-based heuristics and
    evidence-based metrics
   Create and manage analysis agenda to include
    experts outside IPO to resolve key issues
   Address issues of open source and “app store”

   Enhancing the current EHR in an effort to
    improve speed, availability, and usability
   Sharing more and more health data with
    partners to support healthcare delivery for
    our beneficiaries across the continuum of care
   DoD and VA working together on the next-
    generation EHR


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