**Transcript of Cyberseminar**

**Timely Topics of Interest**

**Health Information Exchange in the VA**

**Presenters: Michael Weiner, MD, MPH;  David Haggstrom, MD, MAS; Alissa Russ, PhD**

**9-24-2012**

**Health Information Exchange in the VA**

**9-24-2012**

Moderator:We have Dr. Michael Weiner, the Director and Principal Investigator of the Center of Excellence on Implementing Evidence-Based Practice as well as at the University Center for Health Services and Outcomes Research and Regenstrief Institute's Health Services Research Program. He is also an Associate Professor of Medicine in Indiana University’s Division of General Internal Medicine and Geriatrics located in the Indianapolis VA Medical Center. Joining him today 

is Dr. David Haggstrom, he is a Core Investigator also at the Center of Excellence on Implementing Evidence-Based Practice. Also, we have Dr. Alissa Russ she is also Core Investigator at CIEBP. Both of those doctors are located in Indianapolis VA Medical Center. Finally, joining us on the call but not doing part of the presentation we do have Kenneth Boockvar who is a co-PI at the Center for Study of Healthcare Across Systems and Sites of Care located in the Bronx VAMC. I would like to thank each of our experts for presenting for us today. At this time, are you prepared to share your screen Mike?

 Dr. Michael Weiner:Yes. 

Moderator:Okay you should see a pop up now go ahead and accept. 

Dr. Michael Weiner:Okay, thank you very much for the introduction. Today’s topic is Health Information Exchange in the VA. I would like to welcome everyone in the audience today. I just want to mention Ken Boockvar is not presenting today, but he did help and participate in the planning, content, and organization of today’s presentation. We decided to streamline things a little bit and have three presenters today instead of four. 

The agenda for today: first we will talk about the need for Health Information Exchange; talk about health information organizations; current approaches to Health Information Exchange; learn about some insights from end-users and gain an appreciation for frameworks, measures and research issues. We will save some time for questions and discussion at the end. What is not on the agenda today is a comprehensive review of information exchange, results of VA evaluation studies, and extensive technical details. In thinking about the need for Health Information Exchange it helps to start with understanding that Veterans make transitions in care and even within the VA there really it not a closed system of care. About half of Veterans receive some of their care outside the VA, estimates go up to about 70%. The pie chart shows some results from a recently published article in *JAMA* indicating that most Veterans actually have non-VA coverage, about 56% and among VA enrollees about half of Veterans, or more than 80% of older Veterans also have Medicare. Twenty-five percent have at least two non-VA Federal Health Plans. 

Many Veterans get care in multiple places. This slide shows some data from 1999 from an article published by Denise Hynes and colleagues. They indicated that among Medicare eligible Veterans who use outpatient services that only Medicare services were used by 36% and 46% used both VA services and Medicare services. More recent data from 2009 in an article by Trivedi and colleagues showed that among Medicare Advantage in Veterans that both Medicare Advantage services and VA services were used by half of Veterans in this group and 35% used only Medicare Advantage services. 

Among this group, the dual enrollment increased by 90% from 2004 to 2009. The VA, which paid for much of the care of these patients, paid thirteen billion dollars for the Medicare Advantage enrollees over the period of six years. These findings illustrate that Veterans really are receiving care in many places at cost to the VA. There is a need to understand what kind of services are being provided and how to improve the coordination and quality of care as well as the cost. You may have heard of meaningful use of electronic health record systems. This refers to using electronic health record technology to improve the care, coordination, and security while engaging patients. Three stages of meaningful use have been developed, the first stage in 2011 and 2012 refers to capturing and sharing data. More specifically, it includes at least three points, first, entry of basic patient data into electronic health records; electronic prescribing with decision support and the ability to exchange structured health information. In 2014, stage two will be required, not just optional or recommended. Among eligible providers and hospitals, they must electronically transmit a summary in at least ten percent of transfers or referrals. So, meaningful use is an important part of how we organize care in today’s health system. 

What is Health Information Exchange? This term has been described and defined as the electronic movement of health related information among organizations according to nationally recognized standards. Health Information Exchange includes the exchange of both clinical and administrative data and frequently involves organizations that are not just diverse but are competing with each other. We need governance and standards to help with this process and to support medical decisions and care. A public/private organization called the Health Information Technology Standards Panel or HITSP help to initiate and formalize standards for Health Information Exchange. They describe the continuity of care document, it summarizes a patient’s medical status. Since this time in development, newer groups and approaches have evolved, one of these is called HL7 or Health Level 7. 

A network that is nationwide has developed called the Nationwide Health Information Network. This network establishes the standard services and policies that enable Health Information Exchange via the internet. The diagram shown here just depicts this process and how it connects many different diverse organizations within a single coordinating approach. The new hand exchange is a set of collaborators exchanging information that includes Federal and Public Health entities, integrated delivery networks, private organizations and health information organizations. This exchange is actually being renamed and reorienting using a term called Healthy Way rather than New Hand Exchange. You may hear the term Healthy Way increasingly in the future. 

What kinds of information are being exchanged? This slide shows examples of exchangeable information. You can see the many different kinds that include key components of clinical encounters including things like problem lists; advance directives; progress notes and discharge summaries; medications; plans of care; procedures; vital signs and diagnostic results. Actually, many of these elements are specified in the standards themselves. Health information organizations have formed in addition to nationwide health information networks and these organizations help oversee Health Information Exchange. They make use of their recognized standards and provide interoperability, security, confidentiality. They ensure the authorization of those who access information. The United States has many health information organizations. In 2009, there were about 197, these are identified in an article published last year, they were described. About half of these are actually not exchanging information at this time or at the time of the survey in 2009. They were organizations that were in planning, almost half were operational. I do not have data more recent than 2009 but at this time about 14% of hospitals and three percent of ambulatory practices were covered by the operational health information organizations. You will note here that only about a third were financially viable and that highlights the challenge of establishing a sustainable business model for this kind of operation. The U.S. government did provide a great deal of startup funding for health information organizations to become established and get started but that funding is likely temporary. 

One of the successful health information organizations is in Indiana called the Indiana Health Information Exchange. This exchange has set up a statewide network with a virtual record, as we call it, where providers can go into this shared record system. IHI operates the largest Health Information Exchange in the U.S. with over twelve million patients, nineteen thousand physicians and ninety hospitals. It covers encounters from about 90% of care provided at Indianapolis area hospitals with over a million health transactions daily and the organization partners with the Regenstrief Institute based out of Indiana University. 

What consumers think about Health Information Exchange is important so that security and control can be considered in the design and implementation of these information exchanges. A survey was published from a New York study of 170 consumers and this was published earlier this year. About two-thirds of the respondents were comfortable with the basic process of Health Information Exchange, which includes automatic centralized data storage of medical records. The survey also found that 93% of respondents indicated that a primary care doctor should have emergency access to these records without the permission of the patient. In most cases however, routine viewing by primary care doctors should require permission from the patient according to the survey. You can see here some of the additional responses. Most respondents wanted or indicated the desire to be able to stop viewing of the records by healthcare providers and to determine which parts of the medical record should be shared. 

Just over half said that they would trust the medical practice to regulate security and privacy. What is happening in the VA right now with Health Information Exchange? In 2009, President Obama announced the virtual lifetime electronic record initiative to help for streamlined transitions of patients and their administrative and medical records from the time of military service onward. VLER established five capability areas defined by functionality and capability area one is called VLER Health. It is chartered with the DoD and VA interagency program office to pursue interoperability with private sector providers. An integrated electronic health record system will use information exchange to facilitate care for individuals served not just by the Department of Defense and the VA but by other agencies. The intended benefits are continuity of care, quality, timeliness, safety and redundancy. That is decrease in redundancy of things like diagnostic testing. 

There are currently 13 active sites in the VA or DoD that are exchanging data with their private sector partners. The VA and DoD have four sites together and there are additional nine sites in VA facilities that have regional pilot projects that are active in information exchange. These are working with their local or regional private sector partners and sending data outside and inside the VA. An opt-in process requires Veterans to complete an authorization form essentially providing consent. Among these various active pilot sites, there are more than fifty-two thousand Veterans who have completed this process. The Veteran’s identity is then authenticated and an authorization form is validated and entered into the system. It is important to note that in some cases, the NwHIN Exchange Partner, which is the private partner, may require an additional consent to be filed providing permission for that partner to release data to the VA. Correlation or matching of patients occurs across systems. It is required to exchange data. These systems try to match Veteran’s identity to the NwHIN Exchange Partner Systems. In cases where Social Security numbers are missing or there is an absence of visits or other factors, matching may not be possible. An evaluation is currently underway by the VA and the VLER Health Initiative. 

I will show you a few screenshots that give you a view of what clinicians see when they look at the system. You can see here a CPRS cover sheet and there is something highlighted in red in the middle that indicates that this patient is enrolled in the VLER Health Program. This particular indicator on the cover sheet varies across institutions. It may appear somewhat differently and in some facilities, it may not appear at all on the cover sheet at the moment. By going into Vista Web, one can then find Health Information Exchange data from multiple sources. A double dagger sign next to links on the left hand side indicate the presence of non-VA data. Two kinds of data are available. There is a health record summary and there is aggregated data. The Summary of Care Record, also called C32, contains data about multiple sections of the medical record such as allergies, encounters, procedures and so on. These summaries can then be viewed in sections such as the ones that are shown here. You can see for this example patient that there are multiple allergies noted; a history of encounters; a history of procedures with details, dates and information about the source or provider. The date range available in this particular kind of Summary of Care Record is predefined by the health information organization. 

Medication, vital signs and lab results are available such as shown on this slide and includes details such as dispensing date and specific laboratory result values. Problem lists are also available such as shown at the top of this slide. The aggregated view on the other hand shows data from more than one health information organization and this contains much of the same kinds of data but just from multiple sources. For VA data from multiple facilities, date ranges can be specified for various types of data; but for non-VA data the date ranges can be specified only for clinical notes. In many of these pilot sites, clinical notes are available. They are not available yet in all pilot sites but it is anticipated that they will become available. The details of these notes can be obtained when they are available. Showing taxed based reports that have been stored in the system and are available to the VA providers. 

Initial usage is starting to be evaluated. The system has been used by physicians, physician’s assistants, nurses, pharmacy staff and others. About five percent of matched Veterans have had at least one inbound disclosure, meaning that a VA provider has viewed the data from one of the partners. In some cases, Veterans may not have had encounters or clinicians might choose not to view data or be unaware of data and this would affect the rate of inbound disclosure because the inbound disclosure or message occurs on demand when a provider tries to access it. Overall, providers have indicated a  positive experience with this, while they have noted that there are certain areas of improvement that are desired such as the time required to retrieve data and the way the data are displayed. The current disclosures rate is actually similar to the rate from a published study from Tennessee that you will hear about a little bit later today. 

It is important to remember some of the technical dimensions, the benefits and risks relative to usual care, for example. Although the system is still in the expansion phase and the improvement phase, it is certainly faster than usual care, which often involves faxing requests to hospitals and waiting for replies, sometimes a process that can take hours or days. 

There is a need for usability. Usability can be defined as the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use. A little bit of a mouthful but an important concept and with that I am going to turn the presentation over to Alissa Russ who is going to talk about some findings from other systems that have been studied. 

Dr. Alissa Russ:Thank you Dr. Weiner. There have been a handful of studies that have started to look at end user experiences of Health Information Exchange. I am going to present an overview of three studies today. These studies provide an important initial look at how end-users perceive Health Information Exchange and experiences with Health Information Exchange to date. 

The first study by Hincapie utilized focus groups. Each of these studies actually used different research methods. I thought that was interesting and valuable. This particular study focused on Health Information Exchange in Arizona system and recruited almost 30 physicians for the investigation. Some of the key findings were that physicians are using Health Information Exchange in a variety of ways in their workflow and using the system for different aspects of patient care and at different times during the patient care activity. 

Physicians did perceive Health Information Exchange as valuable, particularly for preventing duplicate medications and testing. The study also identified some challenges of Health Information Exchange for the healthcare providers. One in particular was limited data availability that occurred within this particular exchange system. Providers had expected some data that was not actually available within the system and spent a lot of time searching through the Health Information Exchange expecting to see this data and then when they did not find it and found out it was actually was not available were frustrated with that. They also reported some findings about workflow efficiency or at least perceived workflow efficiency. Providers that tried to access Health Information Exchange reported a negative effect on workflow, although certainly compared to usual care it could still be quite positive. 

The other physicians were relying on other members of the healthcare team to retrieve information. That is kind of a mixed interpretation of that. On the one hand ideally we would want a Health Information Exchange system that physicians could access on their own and feel like it is efficient to use. In this case, physicians that relied on others reported increased perceived workflow efficiency. 

The second study by Gadd, et al conducted a cross-sectional survey. This was a different Health Information Exchange system in the Mid-South eHealth Alliance. They used a questionnaire and surveyed over 150 healthcare providers. Some of the key findings from this study were that they identified three usability factors that were positive predictors of the use of Health Information Exchange. One was the healthcare providers’ overall reaction about usability and overall perception of the usability of the Health Information Exchange system. The second factor was the ability to learn the system when they are first being introduced the Health Information Exchange. The third was the functionality that was available in the system. 

Some other key findings from this particular study that they reported that consolidating the data rather than aggregating or providing large amounts of data may facilitate the initial implementation and use of Health Information Exchange. They recommended focusing on meeting the basic expectations of the end-users. 

One finding the authors reported was particularly surprising to them was that providers indicated that the usability was more important than the trust and the data sources. The office has hypothesized that the amount of trust that providers felt towards other health information organizations or healthcare organizations would influence Health Information Exchange use, but it turns out that was not the case. One identified challenge was the need to improve interface navigation. 

The third and final study that I will talk about today was actually on the same Mid-South Health Information Exchange. Again it was a qualitative study, this time looking at emergency departments and ambulatory clinics. These authors used direct observation and interviews of healthcare providers. Similar to what we saw earlier, they reported that workflow varied by site and the provider’s role. On the slide here there are several different specific things that Health Information Exchange was used for that they observed. These authors also identified some challenges and one was a fragmentation of information. The Health Information Exchange did bring together data from other health organizations but taking a big picture view there was still quite a bit of fragmented data. 

The providers talked about how they had to use the EHR system at their own site as well as associated sites. The Health Information Exchange and then also were retrieving some information still on paper.

So in summary, each of these studies reported that healthcare providers are finding value in Health Information Exchange for patient care. There is likely a core set of data that providers are using from Health Information Exchange, possibly focusing on those key components and making sure those components are well designed in terms of usability is an important step for facilitating adoption. That relates to the third point here that providing information in a useful format is as important as providing more data and data from other organizations. 

Finally, in the long term, the goal is to really create systems that will consolidate data from all sources to maximize decision-making and facilitate effective patient care. With that I am going to turn it over to Dr. David Haggstrom.

Dr. David Haggstrom:Thank you Alissa. For this last portion of the talk, I am going to talk about frameworks within which to consider Health Information Exchange; measures that have been proposed to evaluate the value of Health Information Exchange and research that has applied some of these measures within discreet study designs. 

This first slide describes an evaluation framework that was proposed by Brian Dixon and Marc Overhage who gained experience working with Indiana Health Information Exchange. One of the points I would like to make with this figure is there are many dimensions to consider in evaluating Health Information Exchange, including implementation such as what architectural choices are made or how decision support is implemented. Technology, such as how standards are achieved and policy such as whether information exchange should be implemented at the local or national level. Value is highlighted here because it is the dimension I will spend the majority of my time addressing, specifically cost, financial indicators, and clinical outcomes associated with value. One thing I note is that the VA clinical outcomes are not yet known, although that is not a unique situation in that the affect of Health Information Exchange on clinical outcomes in general is not well known. 

In a review of the literature, the first study that I would highlight is randomized controlled trial of Health Information Exchange among providers of HIV care. The design of this study was robust and involved randomization at the patient level. The setting where the study was performed included six infectious disease clinic paired with nine ancillary settings. These settings were largely community-based organizations focused upon HIV case management. Two hundred and fifty-four individuals with HIV were randomized into the study and intervention consisted of Health Information Exchange over the course of two years for each patient. Outcomes measured as well as information exchanged included HIV viral loads; CD4 counts, and antiretroviral prescriptions. Outcomes collected by a patient survey included: hospitalizations, emergency department use, and quality of life. Overall the results of the study were negative and there are no statistically significant differences although antiretroviral use was slightly higher among the intervention group. In discussion, the authors noted that the effect of the exchange may have been limited by the limited data set of information that was exchanged. Also from the measurement standpoint, investigators did not have direct access to information about which providers accessed exchange data or when. 

The next study I am going to describe was done by investigators at the Regenstrief Institute in an emergency department setting. This is another randomized controlled trial with randomization taking place at the patient level. The setting involved a large urban hospital or electronic medical record data shared with two emergency departments chosen because of a large amount of patient crossover among institutions. The study was larger than the previous involving about sixteen thousand encounters in each study group. Intervention information was made available to ED physicians both as a printed abstract, as well as through an online portal. Outcomes measured included: charges, hospital admissions, repeat emergency visits, and a survey of emergency physician satisfaction with the Health Information Exchange. We have results: implementation of the Health Information Exchange decreased charges by twenty-six dollars per encounter at one hospital but there was no effect at the other hospital. There was no difference in admission rates or repeat emergency visits. When asked, physicians found the patient problem list and medication information most useful. 

In explaining the differences between the two sites the authors noted the differences in the integration of the information into workflow, specifically at the hospital where there was an effect, the information was placed in the chart for provider review before they saw the patients. The hospital where there was no effect the information was placed in the patient room so that the provider did not see it until he or she entered the exam room. 

The next study I am going to describe also took place in an emergency care setting. It was done by a group of investigators at Vanderbilt University led by Mark Frisse. Rather than a randomized design, this study involved a matched case control study. The study where it was performed included all major emergency departments in Memphis, Tennessee. The number of participants or patient encounters covered was also about sixteen thousand patients. In terms of cases, or exposures to Health Information Exchange these were emergency visits that were involved with health information access. This occurred from August 2007 to August 2008. The controls to which these cases were compared were emergency visits where there is no health information access. These controls were matched by age; gender; race; care delivery site; discharge diagnostic code; primary payer. The outcomes which the investigators focused upon were: hospital admissions from the emergency department; admissions for observation; laboratory testing; head CT or body CT; chest x-ray or ankle x-ray and echocardiograms. 

As Mike Weiner noted in his presentation, Health Information Exchange data was accessed at about seven percent of emergency visits. I think in these early stages of investigation it is somewhat difficult to establish whether this is too high or too low although it is similar to previous experiences including the VA. 

In terms of outcomes, there were 11 emergency departments in this population that directly accessed only Health Information Exchange data by a browser. Among these EDs, there was a decrease in hospital admissions and there was also significant increase in head CT and chest x-ray. There was a twelfth emergency department that relied more on printed summaries than the browser and in this emergency department there was also a significant decrease in hospital admissions and there were significant increases in head CT, body CT and lab tests, or significant decreases. This group also provided a financial summary of the impact of Health Information Exchange. They noted health information access was associated with annual cost savings of almost two million dollars. When they factored in the annual operating cost of the Health Information Exchange, they still concluded that health information access reduced overall costs by almost a million dollars. Hospital admission reductions accounted for 98% of these cost reductions. 

So as an interim summary of these empiric studies, investigators concluded that the amount of information exchanged is an important factor to consider when evaluating the effect of Health Information Exchange upon quality and access to transaction data; about who accesses the data and when may considerably strengthen the study design. 

Based upon the differences across settings, it is also clearly important to consider mixed methods to best understand the results of quantitative evaluations. Overall, the evidence gathered in these studies suggests Health Information Exchange exerts a downward pressure on costs. This is important because this outcome is clearly important to stakeholders both inside the VA and out. We should also remember that quality is important too, we’ll consider how to address the quality issue in a few slides. 

In terms of mixed methods research, the group in Tennessee, report led by Kevin Johnson provided a good example of this. In conjunction with financial evaluation I have already described, the research team also performed a mixed quantitative and qualitative evaluation that included the following methods:  review of cross‐sectional log data where they looked at overall usage trends; user logon statistics, and the data types accessed by users. They also performed semi‐structured interviews with providers accompanied by direct observation in emergency departments of the workflow involved with Health Information Exchange use. The sampling of results from the study include the quantitative findings that there are higher rates of access for return visits which suggests that HIE was used most often with patients who are most likely to have additional data. High rates of access also occurred among sites that addressed the most underserved populations; patients with high levels of comorbidity and sites provided access to clerks, nurses and providers as opposed to just providers. In interviews, providers noted the reason for accessing the information exchange as retrieving additional history; reason occurring among 29% of respondents;  preventing repeat tests and comparing new to retrieved results. Three percent also reported using the Health Information Exchange to avoid hospitalizations.

Shifting to another research group, Lisa Kern, Rainu Kaushal, a Health Information Exchange team in New York were commissioned by AHRQ to consider what quality metrics may best be reported from electronic records as well as what metrics may be most sensitive to Health Information Exchange. They performed a literature review and identified quality measures from several well-known sources such as Ambulatory Care Quality Alliance, the National Quality Forum, Ambulatory Care Measures and the NCQAs HEDIS measures. Group performed two rounds of quantitative rating of the individual metrics. For this process, a large panel of national experts both validated the rating process and then assessed final metrics based upon the criteria of feasibility of delivering data to the point of care; feasibility of reporting data electronically; potential impact on medical decision making; clinical importance, and a global rating. Several new measures were developed to capture additional expected effects of Health Information Exchange, especially measures related to reduced utilization. 

Here I want to provide preliminary conceptual framework within which to consider these various empiric studies as well as to guide future research. The framework presented here is a hybrid and it includes some ideas proposed by Kaushal, et al and others. Simply put, the model assumes there is clinical data residing elsewhere than the point of care and through some type of Health Information Exchange, whether through traditional methods such as fax, phone or mail, or electronic Health Information Exchange, that information is or is not brought to bear on medical decisions at the point of care. Ultimately, this information exchange and these decisions result in changes in the quality or cost of care. Factors that moderate the effect of Health Information Exchange upon how it is used at the point of care, thus its influence upon quality, include what can be called information process and capacity. Or the mountain types of clinical data available elsewhere. Information processing requirements include characteristics of both patient, like socio-demographics and comorbidity and the provider, such as how connected the provider is to other providers through referral. 

This slide returns to the AHRQ project of intergroup and describes the specific measures proposed. In rating the measures, the group was asked to assume a perspective of a Board Certified community-based primary care physician who has been in practice for ten years; has a relatively stable panel of patients and has an interoperable EHR. As you can see, the measures of quality chosen here were largely focused upon ambulatory care measures and the broad categories of prevention, chronic disease care, mental health follow up and the management of osteoporosis. 

The new measures of quality that the group developed in part focused upon one of the key potential outcomes of Health Information Exchange that is the reduction of unnecessary testing. One can see echoes of this approach in the main evaluation studies that have been done to date that I discussed previously. This group proposed that for routine blood tests, routine and high cost imaging tests, and certain cardiac tests, one could assess the frequency within which these tests were done and also assess whether they were repeated within a certain pre-defined interval ranging from ten days for certain blood tests to 90 days for cardiac tests. Other domains that were proposed is both reportable and sensitive to Health Information Exchange included discharge medication documentation, referrals, follow up after discharge, ambulatory care sensitive hospitalization and readmissions. Further detail about these measures can be found in the final AHRQ report posted online. 

I would also direct you to a Health Information Exchange evaluation toolkit that is posted on the AHRQ website. This toolkit is intended to guide groups toward a realistic and achievable evaluation plan within their own context to help identify what is important to stakeholders and includes mixed methods approaches to evaluation. 

Here are some conclusions I would draw about research evaluating Health Information Exchange. Conceptual frameworks can help inform the consideration of factors that may influence the effect of HIE which is patient and provider characteristics including the complexity of the patient and the complexity of the provider’s practice. Characteristics of the information itself may also influence the effect of HIE such as the mountain types of information available. We should remind ourselves of the importance of the information used in clinical decision-making to realize its effect; consider methods to explore and test its effect upon medical decision-making before, during, and after the patient encounter. In addition to cost, Health Information Exchange has the potential to influence and hopefully improve both the underuse and overuse of medical services. And finally, in conducting evaluations we need to consider the impact of HIE in multiple settings. Previous studies considered the emergency department and measures are available to assess the impact upon ambulatory or primary care. We should also consider the impact of Health Information Exchange in other healthcare settings such as specialty care or hospital based inpatient care. With that I will end my comments and turn over the microphone to Mike Weiner to provide some concluding comments and lead us into the discussion. 

Dr. Michael Weiner:Thanks David. Summary comments from today and some take home points. First in the U.S., Health Information Exchange is showing early signs of benefit for healthcare. The VLER program is improving, expanding, and evaluating its Health Information Exchange program. This program is expected to roll out to ultimately facilities throughout the VA system and will include other institutions. There is a need to address technical issues, usability, patients’ preferences and sustainability of these approaches and of course much research is needed. 

I would like to thank the group shown on the slide. They represent the VLER Health Team, collaborators and partners at Westat and other folks including people here at Roudebush VA Medical Center and Regenstrief Institute. It is now time for a little question and answer session and I believe Molly is going to let us know if there are any questions from the audience. 

Molly:Thank you all, yes we do have some questions that have come in. Before we get started I know a bunch of people joined us after the top of the hour so for you to submit a question or comment for the presenters, please use the question function located on the right hand side of your screen on the Go To Webinar dashboard. Just simply type it in and press send and we will get to it in the order that it was received. Thank you. 

The first question that came in today is for Dr. Weiner. Can you please point me to any data standards for the electronic exchange of administrative data, for example full time equivalents employed?

Dr. Michael Weiner:I do not know of a standard for that particular metric, but some of the factors that are built into those exchange standards refer to administrative kinds of elements. I could go back to our sources and look for those. If you do want to send me an email message with specific details that you need, I would be glad to search for those. 

Molly:Thank you for that response. The next question: does anyone on the call know if the VA system has a total joint registry in the works? This would be a data set of Veterans who have received total joint replacements for all facilities to access for purposes of revision surgery and data analysis. 

Dr. Michael Weiner:There are some resources that are becoming available in general. For example, the VINCI system VA informatics and computing infrastructure is providing a resource containing clinical data from facilities throughout the VA that is available to researchers for analysis. One could use a system like that to study procedures or treatments of various kinds. Do you guys have any other?

Dr. David Haggstrom: I do not. 

Dr. Michael Weiner:Okay. You might look up VINCI and there’s a VINCI website online at the VA website. 

Molly:Thank you very much. The next question, how many VA Medical Centers are currently using VLER now?

Dr. Michael Weiner:There are 13 sites that are active pilot sites in VLER, four include both VA and Department of Defense data and nine are VA only sites. All 13 of these sites are partnering with their regional private partners to exchange data with their communities. In other words, data about Veterans are sent to the partner organization and data about the Veterans from the partner organizations are sent into the VA. That is 13 institutions and the number will continue to increase. 

Molly:Thank you for that response. The next question we have, do you see any opportunity for adding nursing sensitive data such as risks for pressure ulcers, falls, and cognitive issues?

Dr. Michael Weiner:I do think there is a need to have lots of kinds of data. What has happened with these standards in the development of things like the summary of care record and the continuity of care document is a starting point where the most critical elements of care have been assembled into one kind of structured document. It certainly does not contain all of the kinds of care. Over time, I think it would just be natural for us to expect that the availability of different kinds of data will increase. Of course I do not personally maintain these systems or establish the standards. I think it is well recognized that we need vast kinds of data that are not currently available to providers at the point of care. 

Molly:Thank you for that reply. The next question we do have three more pending, what software package is used for HL7 processing?

Dr. Michael Weiner:I do not know the answer to that. Anybody here in the room? No. I have some head nodding. The folks doing the presentation today, we’re HSR&D scientists, we do partner with the folks mentioned at the VLER Health Team and some of the other implementation teams. We know many of the technical details but not all of them and I do not have the answer to your question. If you send it along to me I would be glad to try to find an answer. 

Molly:Thank for making yourself available for follow up. We do still have three pending questions, a couple more have come in. Are there plans to address current constraints when attempting to view CPRS and lab orders sent by other facilities? In other words we currently cannot view or enter CPRS for Veterans traveling through our VISN? 

Dr. Michael Weiner: I am not sure I fully understand that question. For sites that are not currently part of the pilot, there is a good chance that this exchange program will come online for you at some point. The timing of that is determined by the VLER Health Program and other factors. I do not know if I answered your question completely. Other folks in the room here?

Dr. David Haggstrom:I am not sure what the question refers to in terms of if a Veteran is seen at a point of care, one has the ability to enter orders at that point of care. Can one plan ahead to put a prepackaged set of orders if someone is traveling into a new region? Maybe that is what that refers to. I am not certain you can currently. 

Dr. Michael Weiner:I think also the question is about usability issues with the active pilot. There are evaluation plans underway and factors being considered for how to improve the usability of the current system. So, yes, those things will be assessed and improved over time. 

Molly:Thank you both for those responses. I did let our attendee know they are welcome to write in to further clarify their question. The next one we have in the queue: what are the approaches to tackle privacy and confidentiality concerns while making the information available for multiple users, research, QI, and support of routine clinical care?

Dr. Michael Weiner:It is possible to conduct research in this area. We have an active IIR study that is funded by HSR&D to do just that here in Indianapolis. David Haggstrom is the principal investigator of that study. Through our usual IRB approval processes, we find ways to get access to the data in ways that protect the security and confidentiality of the participants. As mentioned, the VA is currently taking a fairly conservative approach by ensuring that consent is provided by each Veteran to actually participate in the clinical implementation of the program. Whether that changes in the future, I think it may be a matter of public health interests and whether there is a shift in patient preferences or whether they would like to provide consent or not. I mentioned the issue about the need to access data in emergency situations. We have been able to work here with both our VA facility and our regional partner to establish access to certain kinds of data for research purposes and I think that would be possible in other settings as well, just as we access the  VA systems routinely for a wide variety of studies. 

Molly:Thank you for that reply. Our final question is, it seems clear that Health Information Exchange is a fruitful research topic for VA. How do we advance the research for Health Information Exchange in VA?

Dr. Michael Weiner:It is an excellent question. I certainly agree with the response and I would say that we need a research agenda in this area. We need some funding programs that will allow and facilitate these kinds of important studies that can lower the cost and improve the quality of care for Veterans and military service members. I think that the scientific community here in the VA and nearby should organize and create an agenda and capacity to fund work in this area. We do not currently have much underway but we’d like to have a lot more. I hope that this can grow. 

Molly:Thank you very much for that reply. That is our final question so at this time I would like to allow any of you to make some concluding comments for our audience.

Dr. Michael Weiner:We do not have other remarks but really welcome this as an opening to ongoing dialogue and encourage any communications that others would like to make with us to develop new work, new studies, collaborations. Again, get in touch with us by phone, email or come visit us. Thanks for attending. 

Molly:Great, thank you to all of our presenters and all of our attendees for joining us today and for the lively discussion. As you exit today’s cyber seminar you will be prompted to fill out a survey. It should load on your web browser within just a few seconds so please do take the time to give our presenters insight or feedback on our program. It helps us provide you with a more quality product. Also, please do note that the session has been recorded and will be posted on our cyber seminar archive catalogue web page by the end of the week. Thank you once again and this does conclude today’s HSR&D cyber seminar. 

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