in the terrorism and unconventional threats and capabilities subcommittee i would like to thank chairman smith vice chairman macintyre and ranking member wilson and ranking member miller for this joint hearing military personnel  subcommittee is tasked with oversight the defense health program to include all operations of the military health system in the terrorism and unconventional threats and capability septa miti as tasked with the oversight of all department of defense information technology is clearly a topic where our responsibilities intersect and i appreciate the willingness of the two set committees to cooperatively provide this oversight it's important to know that health i t is handled differently by the department of defen than most other i t programs and currently centrally managed by the office of the assistant secretary of defense for health affairs tri care management activity at our hearing last week on medical military construction i observed that by using the word different i was not trying to say that it was bad different or good different it's just different the military personnel subcommittee held a member briefing about military health system i t specifically problems with all the back in october of two thousand and seven your original plan was for the members to be briefed by subject matter experts but we were pleasantly surprised and impressed that the assistant secretary of defense for health affairs director of the tri care management activity dr because cells was able to attend and also brought along the deputy director of the tri care management activity major general elder granger and the military health system chief information officer mr chuck campbell during the briefing many promises were made about the plan to fix the system and after the meeting a road map was provided to the members however the committee was surprised when the former president's out to school year nine budget for the department of defense contain none of the initiatives from that road map all that was included in the budget request was fielding of the dental module of alta at the summer of two thousand and eight as a result of the groundswell of provider dissatisfaction dr said because involved the services are in the development programming and budgeting system we are fortunate to have with us today representatives from each of the services medical surgeon general first lieutenant general surgeon general of the army years looking critically at the department of defense activities developing and deploying health information technology solutions for military health care applications chairman adam smith of our subcommittee asked that i share how important health care issues are to him and his regret that he could not be here this morning but i wanted to say as vice chairman of the subcommittee on terrorism that we have been very focused on the issues including the unique acquisition challenges posed by the pressures imposed by the short development cycles of the commercial world cooperating with the military personnel subcommittee and chairwoman davis to leverage their expertise and understanding of the health care world has been an ongoing partnership and we appreciate that madam chairwoman today's hearing gets to the heart of two separate but related issues that will have broad implications on the future not only of the department of defense but also the wider issues encountered by the federal government as a whole the application of to improve the delivery of military health care to make sure that we get a better appreciation of the requirements that you need addressed by military solutions as well as the daily challenges and trying to utilize the systems that are currently available we want to make sure we have a better functioning and a user friendly system it's equally important to hear from the system developers to find out what actions they are taken to address these concerns and what actions they believe are necessary to achieve better outcomes for the systems we deploy as well as the services that are offered today's hearing will provide a baseline against which we will measure the department's progress thank you again gentlemen for being with us and thank you madam chair thank you dollars later and it appears that things are not working as advertised we all know that electronic medical records are very critical certainly the speed in which combat casualty is removed from the battlefield to higher levels the importance of ensuring in treating physicians have access to a patient's medical record and their history becomes even clear beneficiary of multiple facilities and as is the case with many veterans from the department of veterans affairs further highlighting the importance of effectively transmitting medical information between providers again four billion dollars later we have to get this right and this subcommittee is a chairman macintyre representative wilson and representative miller and distinguished members of both subcommittees thank you for the opportunity to discuss the electronic health record system for the department of one of our most for our dynamic population that was well described by congressman miller and is an enormous undertaking and i acknowledge the significant challenge to health affairs and to the entire military medical community as well as to our colleagues as a critical enabler of an evidence based and outcomes focused healthcare system to meet today's and future challenges our health care system will increasingly rely on a knowledge network which includes personal health and clinical information along with i think i think of it frankly as a knowledge centric warfare against disease  and for an injury healing environment we are doing in the healing environment with the war fighter is doing to fight and wage war using information to aggregate into knowledge in addition to greatly enhancing day to day care  that contains the clinical records of millions of patient encounters over many years affords our medical research as a potential source for clinical information that's unmatched in the civilian world since these records to a large extent come from a controlled military population this just strategic resource holds the promise of yet unknown improvements in health in optimal outcomes of health care efforts and even research breakthroughs this strategic resource could also potentially give us a huge  advantage in planning for for self protection i recall that very clever clever t v ad where the refrigerator of hair man comes to the door not because the suburban housewife or the husband has called the repairman because the refrigerator is called the repairman this is really the power of real time health surveillance through a comprehensive longitudinal and globally deployed electronic health record accordingly and notwithstanding the shortcomings of all in our medicine of aggressively pursued research and development of tools that enable our researchers to mine our clinical data repository and our claims database in the civilian network to increase our understanding of our patient population our current and our past treatment regimen the clinical value and the safety of therapeutic medications and technologies and procedures and our vulnerabilities to current and future hostile bio warfare attacks one such program was initiated by colonel trying to cost or as a small business an innovative research program and it's called the army medical department's pharmacovigilance center with colonel koster was able to monitor adverse drug reactions on thousands if not millions of doses of drugs prescribed to our patients and assist the f d a in emerging knowledge about post marketing safety of drugs in fact our database and able t o get information that they themselves could not obtain from physicians and others and pharmacies who are dispensing these drugs another example of what we've done to leverage information technology in our cars the creation of what we call the joint theater trauma system the j e s it's built in part on a joint theater trauma registry that's coordinated by the institute of surgical research of the united states army medical research material command it provides a systematic approach to coordinate trauma care to minimize morbidity and mortality for theater injuries integrates processes to record trauma data at every level of care which are then analyzed to improve the care for each casually at every step in evacuation we conduct research and development related to trauma care we track and analyze data to determine the long term effects of treatment that we've given as a comment as and then illustration of this we've been tracking body temperature of casualties from the point of injury on the battlefield through the evacuation system and know that that that body temperature is a major determinant of survival but basically hearts don't work brains don't work blood doesn't clot cells don't fight infection and so we begin to monitor body temperature and manage it closely and has as a result of this improvements in survival and optimal recovery and these are just a few of the examples that we're using to beginning to exploit this data repositor that has been instrumental in helping the joint and coalition military medical team achieve the lowest case the tally rates from combat wounds in our history i also believe that an effective and usable electronic health record will contribute in measurably to reducing the cost of federal health care and sustaining a generous health care benefits soldiers and their families it's with this hope and promise that the army medical department energetically assume the lead for the d o d and was an early adopter of l t e unfortunately all  o has not achieved its full vision yet the services are still not effectively able to seamlessly access complete data patient data from the battlefield between military treatment facilities and between departments that is the department of defense and the veterans administration in my opinion the failures of can be attributed to the overall lack of a clear actionable strategy and poor execution from its genesis as a result of the  lack of an i m i t strategy and information medicine management and information technology strategy up to this point the army medical department has been largely frustrated by a number of obstacles that continue to impede the system's capabilities and functionality bottom line all to has simply not kept pace with the expectation at the user level nor at my corporate level our providers have been less than satisfied with its performance its reliability and its usability as a result of our provider providers discontent we the army have taken significant steps to improve usability evolves and providers accept that satisfaction after many years of working closely with health affairs on the precursor pastor the chief of family and community medicine at brook army medical center in san antonio texas last year dr pastor who's really worked tirelessly to try to improve patient safety concerns that have been spawned by duplicate patient records and alter it was brought to us and gave a presentation and she said self described super user of the system and i asked are super user proposed by your general as the best user probably in the entire region if not among the whole army medical part are you also a super fan and she said no i'm not so i said when our best and most faithful users of all to could not admit to being fans of the system i knew  really in serious problems so to address identified shortcomings with all that the provider level the army medical department recently invested significantly in a medical command and army medical command what we call medcom alter provider satisfaction as we call maps this includes investment in tools like dragon natural speak medical speak as you type individualized training and business process reengineering that's led by clinical champions and it uses wireless and desktop virtualization maps is beginning to show significant improvements in provider usability and satisfaction and our direct interviews with our patients with our providers and staff reveal that maps implementation  generated a dramatic change in the attitude among our staff i can't stress enough how critical it is that we have an accurate and comprehensive longitudinal electronic health record that's accessible at every point of care this really is our fusion of intelligence from the battlefield all the way to home station and into the for rehabilitation a long term care to reach this and stay i believe that health affairs should develop a comprehensive jointly designed overarching actionable strategy that has explicit prioritization military health system information technology investments and solution should be transparent to the services sitting here at this table and they should be jointly governed meaning that we with service input are treated as principle customer and clients of the system and that were heard and were acted upon promptly to achieve this services should have greater voting representation on the military health system i m i t decisions to better reflect the voice of the services as a customer because we're the ones who ultimately have to deliver care and we're accountable for the care and for the outcomes of our of our clinical encounters i'm cautiously optimistic that the direction that recently been taken by our assistant secretary of defense for health affairs dr the cells and by the i am mighty leadership in health affairs is going to move us in that direction i'm cautiously optimistic in closing i want to thank the committee for its interest in supportin ensuring that our great soldiers and families receive the great the best possible care by leveraging all of the available information technologies i mean as you can hear from my talk this this morning i'm really passionate about our journey toward a personalized medical care system and the role of the electronic health record is going to play in our ability to predict and prevent and preempt disease with your help i am confident that we can achieve a global of electronic health record that enhances the continuity of care and surveillance and are truly empowers our providers to deliver the best evidence based practices in the world but one that's also a mentor that helps with called clinical decision making and generate knowledge in real time the army medical department recognizes the remarkable benefits of a global electronic health record remains fully committed to partnering with health affairs to collaboratively to find a coherent way ahead for its electronic health record thank you ma'am i look for your questions thank you general we obviously let you go over and we appreciate your question davis vice chairman mcintyre ranking members wilson and other distinguished members of the committee thank you for the opportunity to testify before you today with me as captain bob marshall who is a family practitioner in the navy one of our best experts on electronic medical and military treatment facilities aboard our base stations both at home and abroad provides a world wild world wide outpatient record and all fixed military treatment facilities unlike the decentralized architecture of  previous electronic net medical record the composite health care system all that is designed around the clinical data repository a single world wide accessible database system requires software installed on thousands of personal computers  interact networks across the global information we have experienced regular performance right reliability challenges our goal is to increase the time our clinical staff spends with their patient not entering data into a computer the current application design functional mapping and workflow limitations to make this difficult clinical champions have created processes and methods passed on to others very similar to those of the army was developed to facilitate patient care and record keeping over two hundred of these recommendations were incorporated into the most recent version of all the three point three numerous hardware and software problems identified during the all to three point three beta test at naval medical center portsmouth have mostly been overcome this version is currently being installed across navy medicine and early use report generally favorable when compared to prior versions of preparation for this hearing i discussed all that with many navy medicine physicians and nurse practitioners on the positive side there is unanimous support for the immediate availability of medical information at all to provide hardly anyone desire to return to paper records that being said are providers remain largely dissatisfied amongst their top concerns or system the instability makes this difficult and frustrating almost all the providers i spoke to relate to the system going down unexpectedly recently at least once a week over mode which prevents provides access to the most recent visits in the local hospital is help but the transition requires several minutes and this can seem like a lifetime when it occurs in the middle of an early morning visit delaying not only the patient being cared for but the entire day's schedule medicine is pilot  currently in the process of getting technical requirements to provide wireless capability and our other medical centers and hospitals we support military health service plans to improve military health structure with appropriate oversight and execution of services oriented architecture approach should create systems stability and reliability modernization efforts will also make it possible to quickly integrate user friendly capabilities and reduce our reliance on outdated components which are difficult and expensive to maintain our long term goals must include solutions knowledge services mission requirements navy medicine must be able to maintain and share medical information between our operational forces and medical facilities our units routinely visit many different ports and medical facilities during each deployment we need immediate bi directional access electronic medical information between shore based hospitals ships and marine units in the field and all theaters throughout the world distinguish members of the committee thank you again for the opportunity to testify before you today i am convinced that the improvements in our electronic medical records will have a positive impact on the health of our active duty and retired sailors marines and their families thank you very much  team leader the air force medical service is on the cutting edge of preventive and restorative care and protecting the health and well being of our military forces worldwide nowhere is this more evident than in the field of information technology which is a critical component of our mission  reliability a very difficult user interface and a lack of functionality the end progress upgrade evolve to provide much needed provider requested functionality but network environment is critical to reliable operations and compliance with security requirements we need a common interface that will improve the user experience and enhance delivery of we support the evolution from outdated client server technology to the development of a service or a architect the combination of the enterprise services and medical service we thank you for your continued support and look forward to working together to improve the health of soldiers sailors airmen marines and their families and all americans and we stand ready thank you thank you very much gentlemen i know that while listening to your testimony it's not always quite as clear as to the actual participation that the services have had in trying to to move through this and i think one of our frustrations of course is that we keep hearing that there's a fix on the way you know it doesn't quite get done so could you go into a some more detail this as i see it i think there's a fundamental breach and the need to go into a project of this scope this magnitude this expands with a very clearly articulated strategy not a tactically oriented wires and ways approach but a true strategy that includes the formation of a campaign plan with lines of of approach that are going to get us to where we want to go and and i don't see that this is ever been developed or fully articulated in fact several years ago quite surprisingly to us it was articulated we did not have a strategy and we look forward to seeing that emerge where we are hearing that again today from the leadership of i m i t within the n h s that we need and are there formulating a strategy quite frankly ma'am i think this frustrates many of us that our level who have been looking for that strategy for some time to include one that allows us his services to have a powerful voice as customers and clients to this process and formulating and then being held to the execution of that strategy with your indulgence i'll just ask dr pocket as anything else that he wants to have first of all i just want to be half of the army medical providers that  have really taken the brunt of the electronic health record adoptions and let me just thank them first because they really have been wonderful citizens i want to feel professionals in this era very challenging times with the war and processes it is changing there are some good things happening now with with the governance process changes being proposed but i think naturally of the size of the organization we are i believe that this is between the customer the provider and the patient and where that the systems are being made strategically about i am mighty systems the longer that is the harder it is to meet the customer's needs i think that's just natural order of magnitude of the size and therefore i think the services who really are responsible as generous will make most of the care of our provider care of our patients and our beneficiaries i think we have to have greater representation and that's not just serving and sitting on a governing board it's really about a more active participation and i'm very confident that dr sells and the mit leadership at health affairs is wanting to do that and there are some proposed actions to do that i would agree with that there has been recent movement in a positive way in oversight the deputy surgeon general on this or camel meat as a as a committee which discuss the portfolio for all of all of the military health system experts use the system as best we can to take care of patients is really a partial solution to a system that needs to be basically i think that you'll hear in the next panel about their plan to go  way that certain specialists we really can't overcome and to were able to customize on those for specialists which again was a service oriented architecture should be something that would be easier to overcome so i truly compared to the last this data sharing with our partners largely due to a lack of a national electronic medical record what we really need is a single standard electronic medical record for the country and i know that's being discussed in many forms and that  great boon to all of us medicine across the country is largely a cottage industry and many of our specialist we are people too and the network do not have an electronic medical record in their system and certainly not one that's compatible with ours in most cases  promote on your behalf or on behalf of the department of defense that could expedite this in terms of the other partners you have to deal with the other stakeholders in my personal opinion the best way forward for that would be to drive for a national electronic medical record based on a common standard that all medical facilities in the country adopt i think only until we get to that what we truly interactive throughout the country thank you  older technology i'm not a wirehead i'm just told the stuff both systems need major overhauls neither system is adaptable to the others entirely and i think we're at a point now where we realize that what we really need to do is to departments and i think both departments secretaries are taking the lead on this is to build a so called service oriented architecture where you work in a web enabled environment on common programs that both program both departments require but you can both access information sort of in the middle we already have bi directional flow of information from one system to the other it is probably most prominent a richmond minneapolis or powell so that information is exchanged and brought back again but i'm i'm with all my colleagues and saying that one of our big problems is our civilian network you know  t i was a hospital commander for cars and fifteen years ago we started off the tri care program in that region it bothered me that i was held to standards of quality and access whereas outside the gate i was also held to standards of timeliness of paying the bill now that got us to transform our bill paying in the d o d system of tri care to being one of the nation's leader in timeliness of web enabled almost instantaneous approval and paying a bill to physicians offices but we didn't force the transformation of electronic records that went along with the bait the building all we did was ensure that the bill got paid to those that we counseled that are sent our patients to but not that we had timely clinical information brought back into the hospitals that referred it terribly frustrating in that again it comes back to the basic structure of the system that needs to be changed again you're going to hear service oriented architecture again and again and again we believe that will provide a backbone to which we can attach many systems as long as the interface allows that we can attach almost any electronic system onto that and use it within our system by directional transmission of data from the military to the available in others besides the trauma system the trauma centers but not perhaps totally nationwide one thing i would put forward is as you well know the hospital in north chicago and the navy hospital great lakes are merging and that's been an interesting exercise on lots of fronts and one of the things that does is really give us a lab in which we can figure out how to do immediate transmission of data between the two systems i think we will probably not get to a common system there but we will have coexistence of the two systems which need to interact day to day which is really going to be our reality and hopefully up north chicago we can help take that forward  from our standpoint there has been significant progress in terms of the data dictionary that have been developed are allowing us to create interpreters to bring data together at the central repository the difficulties become that whereas the use is regional databases and we very much rely on a central database the they have a much more robust and less downtime on their systems because of the regional ba think that when we look at our transient population going slowly to a regional basis them will not serve us well we have to have that central data or a positive tori's so we can pull from anywhere in the world the difficulty is when you use the client server technology which also has been based upon you really are reliant upon a system that has to have one hundred percent connectivity one hundred percent of the time and you can't quite get there clearly vista has a better user interface when you talk with the physician on the side they are much happier with their interface on the other side of that are structured data and so it has given us much greater compute ability and much greater ability in terms of surveillance and our ability to call out and do some knowledge development we currently have four years worth of data twenty five terabytes from multiple databases that gives us incredible ability of our pop health to look at such things as indicators and trends in terms of busy even real time identifying new diseases as they arise and so i think there are advantages to both systems and in some manner we need to merge their user interface with our data capability how we do that is something we're working very big and i look forward to working with you and my colleagues for unified just thank you very much yes mr miller thank you ma'am simple question to each of you do your folks spend more time working with or working around also  and i come back to this is important at the corporate level our ability to roll up information has allowed us to do some things that we could never do before but it's not at the level we like frankly we leverage what the air force has done somewhat independent of of health affairs to get information about population health which is extraordinarily powerful so at the at the corporate level i'd say we're still doing work arounds at the again i would reiterate the one thing that i heard over and over was the fact that we do have information available to us on a worldwide basis with four years of data in there right now is not something that our providers want to see go away they do not want to go back to an elect c paper record they want to fix the one we got with worldwide capacity and to go back to what general green was saying about regional versus worldwide capacity if you look at where all of our services are and if you look at the time the frequency of moves of all of our service members in all three services were all over the place so to have a regional health record that would require several times a day to go fetch information in a slow timeframe from another data source would not be helpful i'm going to answer this in an interesting way to part first part my own in my talks with our specialist and our primary care physician and if you talk with a primary care physician i'd say probably sixty her since you are user a recent visit to eglin air force base and i learned that it appears that when our wounded soldiers are out of germany back home that there is a problem and this may be for the next panel as well with our infrastructure to be able to load of information that is being transferred back and my question is are we putting our that long as three to five hours to get to that and so i think that's what you're referring to and it's something that we recently had a visit out to landstuhl to try and find solutions to try and decrease that time  around or come in and out there's something inherently different because other businesses deal with the global mobile aspect of it i think that your questions are very good when it's one that we ask all the time because we're aware of other systems that are non medical that allow us to do that all i can tell you is first of all i need to i feel compelled to say and i think all of us are feeling is a little bit we need to be very careful not pile on to a system that  is giving us capabilities that we frankly never had before and you know one thing former secretary of defense secretaries who barely one said about our rollout of tri care when people started throwing stones at the primary care based managed care system we were standing up when did we ever become an astrologer for the old system of episodic care where people didn't get care except in lines and i say the same thing about this you've heard us that there are tremendous advantages of the system we have though imperfect frankly duplicate records have always existed in a system so your physician you know this in our file systems of hard copies we have duplicated records the problem is reliant on a single electronic record where you're told you can depend upon it and you don't have people cleaning up the duplicate records as they do in our files that's an issue when we did a survey in the eisenhower medical center many years ago before this program came in time that was developed that looked to be the best solution what we are afraid of is several things one is we really don't have a backup for that so that system goes down and we are going to have a difficult time we also have as general grange pointed out a vast amount of data in that system so we can't simply turn that off and go to a new system we need to figure out some way to have data stored in multiple sites that we can immediately get at and the other issue that i would bring up is that our global and mobile is system with a standard system a standard standard as the banking system has to be able to truly interact throughout the world thank you dr fleming is next and i just want to remind all of us that we have a center camp pendleton charleston really enjoyed my time and i remember well the handwritten charts that we carried around none of which by the way i could read which is very interesting how i was able to practice medicine mike a little bit more yes now what i said is that actually the database as i understand it is is a tree driven set of sort of like check boxes tree driven and since there are so many data points just because the wide diversity in medicine there are many templates available there graphical you end up having to go through a number of these data points clicking buttons very time consuming and when the information is going from where you are all the way to the central repository and back bandwidth you've got all sorts of things are really slow that process down is very difficult also in the issue of interoperability i don't ever that we'll all be on the same system that is civilian and military what's most important is not what's  happening as you design your chart note but that you can read somebody else's chart and that's really what interrupt ability is all about but one of the things i think is interesting it sounds like that the whole backbone of technology a system needs to be updated and you're web based now as i understand it pretty much or not you're not web based it's not in a s p format or it's all client server right now so it's  machine and then they talk back to that to the central that or it doesn't talk back in the sense of that or for data repository every time you put information and that when you go from the subjective objective to the assessment plan to disposition into the signature things that at those points it writes back to the c d r is it possible to just simply download the entire record work on it completely and then send it back up it's not designed that way and the reason why is is i think what's really coming online among the private systems that's become very popular physicians are responding quite well is the use of artificial intelligence is there any plans to use that computer interface because if you look at a lot of large parts of the challenges it really is about how do you practice that care keep an eye on the patient and spend that time and not away from the patient and document care so looking at speech check knology plus the billeted to take that language and turn it into computer full text so if i say patients of thirty six year old female with cervical cancer that all those terms that age becomes a computer toltecs along with other terminologies those are what we're working on with other universities that are leading this effort so those are still in the research areas but i think that several the questions sir including yours really get at the lack of the national lack of national standards in this area recently as you know also national coordinator h h s has really lead this effort called the national health information network really that's what's going to drive our national road to get that vision of what the electronic health record would do for our nation we believe and we are actively working on the federal participation in building an adapter so that when we when you hear about the system to  in the second panel you'll hear that our path actually convergence to that so as we build our coherent system sixty percent of our beneficiaries as you know get taken care of on the outside ability to bring that information back and have an integrator approach he's going to be critical as we move to the future and that's what's got to be planned so armies invested army leadership particularly sees that there isn't and that that i believe is really ultimately the way we need to go  think the ultimate point we need to be it in that think this would help out a lot with the civilian military interface is that every american has a a medical record someplace on a server i know yours or in bring that up today or at least a copy of that record or the participant authorized add to it or just or whatever and then send it back down i think that would be a way that these two systems could work very well together thank  rework of the entire program the backbone you'll hear about in the next panel as long as certain code is written into any program that would be able to be inserted into our system and we'd be able to remove something else the good and wants the ideal system and frequently one that from a friend who's using it outside the gate or in practice somewhere else and so what we've tried to do is first of all break the tie within the army and we're going to have this is that it's not web based and there's clear consensus that we need to make sure that we have a service connected between department of defense and a veterans administration and that's saying which is not right now and it's not web based and i think these are o goals i think we also need to understand also though when when you look at private industry and we need to bring h h s in that a little look at the fact that they got about nineteen billion dollars stimulus funding for a job and we need to be working this together because you have been at the forefront even though it's not perfect and we need to figure out what's going on you know you have in the forefront as far as electronic medical records and as we understand there's been a lot of economic investment a current help defray technology systems in the department i think ultimately it'll be more cost effective develop a single electronic home medical record foundation architecture what you talked before about the service connected architecture that can serve both the department of defense and the veterans administration and allow fully in operable medical records throughout the lives of our service members i was with general shinseki this morning and i relayed those concerns to him but that with that in mind i think we you know this need to update all day is a great vote the public and the private sectors so my question that a panel what steps you know if any are you taking the ensure that and the updated version of all to our defense will partner well with the private sector information think back to the national health information network site because i think your statement about partnership with h h s is critical because there is a national effort going on to ensure that we make would we accelerate the adoption of electronic health records and then connect it to standards based communication we clearly are taking steps now building an adapter and what you're hearing the second panel was allowed that adapter to communicate with the rest of the the united states so that as the electronic health record adoption that goes from some percent today to hopefully ten fifteen and perhaps fifty percent in the next ten years we'll be able to draw upon that and really lead the nation through our size and our need for network providers on the outside so i believe that your your statement about the national health information network and our framework and what you'll hear next about the so our service or it architecture generation of medical information technology software will become what is that for the nationwide standard if you happen to i would rather defer to dr sells and his leadership to talk specifically about that but i believe that  has a permanent seat on the also national coordinator on the national health information network we are currently i finished with the pilot of the development of the dr and army is the lead for that development so i believe we are actually participating in not only the adapt but setting the standards but congressman i just have to be candid in saying that for the short term our challenge right now is to make sure our providers stay on board with us i mean if they leave the system or abandon their use simply because it's not user friendly then it doesn't matter what our architectural changes for the v a are similarly i as a corporate leader in army medicine has to be able to demonstrate utility at the corporate level and improving in population health improvement and evidence based practice is so we're in a short term kind of battle right now just to keep the gains that we've made over the last five years and joshua mark i'm absolutely i'm talking about the fact that the top three reasons why people leave the health care system that the power defense or v a is because of the electronic medical records i understand it's cumbersome and it's not perfect but i do think that there is a consensus within the market population in the congress united states and frankly now the white house that  electronic medical records is the most cost effective and efficient way to provide health care is where we really reduce savings and frankly the department of defense and the veterans administration are going to be at the forefront and general you know your brother ranger you know ranger lead the way and i think that they have an incredible moment right now in our country's history with information technology and you know we're going to be work with you as a congress i do think it's going to have t billion so i thank you very much for continued service to our nation and i look forward to partner with every single one of you thank you and we're going to move to the second panel but can i just get a i guess a temperature from you on this i mean do before anybody else and it is proven successful for us we're in the middle of a transition right now our providers are frustrated with it is not the perfect system but again they would not go back to a paper record for a trade of having information handy and it's our job to make it more this is to demonstrate the way i have in this show that this has extraordinary promise and as the congressman said we can be at the forefront on behalf of the american people on the public for how this does as i said forward to the next panel and if you can move out this quickly as possible we're not going take a break because we're really under a time crunch and kind of let a lot of the five minute rules pass because we you all have some important things to share  next is the chief information officer of the military health system mr charles campbell and the military health system architect mr tommy morris and finally we have heard applaud hines the program manager for the dance defense health information management system again i want to thank you all for being here we look forward and mr tim hart i'm sorry acting deputy assistant secretary of defense for command trolling computers thank you so much for being here we look forward to your testimony obviously you were referenced on many occasions  by the first panel and we hope to really get the nuts and bolts from you as well thank you technical questions i'll have to electronic medical records as you know in principle to foster better care have to have fewer lost records the records ought to be legible the system should provide reminders when you overlook something and it should also help to identify trends and should help the system as a whole to make use of these trends to generate new knowledge and eventually to decrease costs but we have been challenge here some of the challenges you've heard about for years for now the thumb drives that people find so help the importance of operating in these very difficult environments afghanistan and ships that go from port to port the importance of ago and began to hear complaints about that i took a hard look at it and the first step was to ask our inspector general and our other legal people to look at this and they did point out ok great thank you and what i'd like to do it to ask you if you could give us some specific date what's the timeline here integrate that with what where you expect to have completed certain tasks and do that is as well as as you can since we've been looking at this for a long time and also can you incorporate into that basic cost as well what are our responsibilit point in which we developed a draft plan that we put out for staffing to begin the initiative some of the components of already been done with a draft document went out for staff into the  i heard comments and some of our earlier testimony in that there is no plan and i beg to differ but there is a plan and it had been stepped out actually to the services the only non developed and that was delivered on ten february we also have delivered a prototype graphical user interface that will allow our providers to interact in the development process for the new user interface this unified user interface actually has the ability to work over both alter and test with the newer type web services capabilities or as people mentioned earlier service oriented architecture approach thirty one may we anticipate having the final framework for that graphical user interface so we can begin to point over different systems and pilots to be able to rapidly do this rather than taking years to develop we've actually done some of these things in m is that the current systems that we have who are to benchmark what our costs would be it would be astronomical using the state of the technology industry advisory panel and read teams we put together they're actually reviewing the blueprints to allow us to develop open standard open architecture blueprint of which anybody can build and that's important again it's being delivered to the d o d which will then go out to our line services as well as our functional communities for review to ensure what we're doing meets their needs which is extremely important see some of the other things that we've done if i could mention we've actually started so in the timelines we've actually started making changes based on the feedback from industry so we can implement industry best practices into our own processes historically we haven't done that we've been  not encumbered necessarily but tied to the acquisition roles which weren't necessarily conducive to rapid development rapid prototyping so some of the things that we did that and i'll give you an example in our contractors typically what we do when we accept delivery of products from their vendors we go did they deliver on time on schedule on budget what we didn't do historically is we didn't add a couple pieces on there which the industry does to themselves for example of intel and microsoft or to partner they would look at certain things give each other before they partner in this is that they deliver quality product at work and to the users yes ma'am could you tell us a little bit more about the red team who sits on that yes ma'am there's three components to what we developed as a red team at the guidance of mr campbell and others the first part is an industry advisory panel the industry advisory panel consist of and i'll try to get these off the my head or i'll provide them at a later time if you can provide us for the record but i think that the key here is to for us to get an understanding of how engaged it is how how often the team has met and is that information really shared with the services  services are actually invited us part of the red team in the in the schedule we've actually to start with this initiative historically would have taken about nine months to develop a blueprint that's based on industry best practices and the feedback that i've gotten from the industry partners the industry folks to participate in this is open so we can actually engage other partners based on the needs but what we did is those organizations just want to run assess of employment and service oriented architecture approach for their corporations they did  profit for their businesses we need to do it to streamline to be able to deliver quality products and service our user communities if you want our services and we went to them and asked them at that if their senior most engineers could participate as  a consultant on our blueprint so as we move forward we can ensure that it's an open architecture open standard so that's the level of participation and we've active we've now had three meetings and actually we have another one on that coming up on the twenty sixth of march in two days in which we actually bring forward parts of the blueprint the graphical user interface the standards of which we're building to as well as implementing industry best practices in our acquisition and how we and we've actually began implementing some components for the stabilisation of the clinical data repository components because in the blueprint in initiative we've actually looked at we have taken a holistic look at the systems in the architecture currently and identified some problems in the technologies that were delivered to us one example of a technology that was delivered to us as part of all by our contractors was a component called and another component called x m l proxy x m l proxy was a prototype developed by another one of the companies that's in our production system that was never verified and validated and it was delivered in our product which is a problem as far as the costs are going forward we've already  some of the features and some of the systems that we currently have in place because you don't need to replace the entire system at one time you can do in the phase approach must like much like the industry partners have and their best practices alternately will be able to recoup some of the costs going forward and should after we implement the blueprint come up with a realization within the next couple years of some of that cost or cost avoidance i hesitate to give you a cost as a total because we haven't finalized would not want to use the real name today to alter the armed forces health longitudinal technology application i mean most of all i don't know what it stands for most of us and all of us don't  think you all touched on that maybe mr morris would be the person i was but start with you don't know why was this not from the get go a web based system it seems like some of the problems we've been talking about would have been i can't compare you to bank of america the enterprise architecture strategy moving ahead is going to be a web based strategy and it takes into account those systems so this is a holistic approach not just a patch to a broken system where an old legacy system this is a complete if you like as well and we have the graphical user interface which is probably one of the pieces you're interested in we already have the prototype developed and that will actually be delivered as a framework to develop to thirty one of this year and we talked about accelerating the timelines for being able to do that and that's just one example our enterprise service bus which allows a robber ability of our legacy systems and modern systems is already developed it was actually delivered so this past february strategy right now that we're projecting is less than a three year strategy because we've already started to implement some of the best practices from industry into our business practice today so instead of taking decades to develop solutions we're talking allows us to do it allows us to build certain standards and so when we build services that we can use within department of defense some of those services can be built by the can be built by the indian health service department of today but next year this time we will have tremendous capability in the areas i have and patient systems that we hope to have a contract award today we also have the capability to support  don't think customers really understand that but there are rules and regulations and laws that deal but the five thousand that we must follow at the same time in the war effort we are we have the responsibility to provide capability now and sometimes they don't go hand in hand we have to provide capability now but at the same time we have to work through the acquisition model to marry up and to be honest with you lately that the in the medical information program is a perfect example of that where we had critical information as you heard you know green talked about when he was at a loss to before they didn't have the information coming to the we getting the information from the last two for the continuity of it i will say from this perspective we have provided from the services batiste painting with us in terms of all the new technology that we actually bring and they also sit on our board selection board in terms of the and your opinion colonel that this is a system that the private industry could tap into down the line when you look at h h s and private providers are we using the standards response in this the real issue that i continue to pick up though is if everybody's at the table if someone's listening and if we're actually moving and changing to do what's best because this is all about the men and perhaps a september timeframe would be helpful in coming back to the committees and having a chance to to see what that progress has been because one of the difficulties that we face here is it was a long time to kind of being bring folks back together and we know because often you know reports come out the morning of a of a year ng that it does focus some of that activity and so perhaps we can have a date in september that we can come back and understand if we've met some of those three month time lines that you suggested and if we're really on target trying to integrate the tech the technologies and certainly interface with a national standard system that we hope to have up in a few years and it's just it's critical for the country as well as for the military we'll do that ok thank you all so much for being here