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39–466 2008

SHARING OF ELECTRONIC MEDICAL INFORMATION 

BETWEEN THE U.S. DEPARTMENT OF DEFENSE 

AND THE U.S. DEPARTMENT OF 

VETERANS AFFAIRS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

FIRST SESSION 

OCTOBER 24, 2007 

Serial No. 110–57 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

MALCOM A. SHORTER, Staff Director 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

HARRY E. MITCHELL, Arizona, Chairman 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

CIRO D. RODRIGUEZ, Texas 

GINNY BROWN-WAITE, Florida, Ranking 

CLIFF STEARNS, Florida 

BRIAN P. BILBRAY, California 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

October 24, 2007 

Page 

Sharing of Electronic Medical Information Between the U.S. Department 

of Defense and the U.S. Department of Veterans Affairs ................................. 1 

OPENING STATEMENTS 

Chairman Harry E. Mitchell ................................................................................... 1 

Prepared statement of Chairman Mitchell ..................................................... 52 

Hon. Ginny Brown-Waite, Ranking Republican Member ..................................... 2 

Prepared statement of Congresswoman Brown-Waite .................................. 52 

WITNESSES 

U.S. Department of Defense: 

Brigadier General Douglas J. Robb, M.D., Commander, 81st Medical Group, 

Keesler Air Force Base, Biloxi, MS, Department of the Air Force ............... 4 

Prepared statement of General Robb .............................................................. 53 

Colonel Keith Salzman, M.D., MPH, FAAFP, FACHE, Chief of Informatics, 

Western Region Medical Command and Madigan Army Medical Center, 

Tacoma, WA, Department of the Army .......................................................... 19 

Prepared statement of Colonel Salzman ........................................................ 65 

Lieutenant Commander James Lawrence Martin, Regional Information Systems Officer, Navy Medicine East, Medical Service Corps, Department 

of the Navy ........................................................................................................ 23 

Prepared statement of Commander Martin ................................................... 71 

Colonel Gregory Andre Marinkovich, M.D., Data Management Product Line 

Functional Manager, Clinical Information Technology Program Office, 

Military Health System, Medical Service Corps, Department of the Army 25 

Prepared statement of Colonel Marinkovich .................................................. 73 

Stephen L. Jones, DHA, Principal Deputy Assistant Secretary of Defense 

(Health Affairs) ................................................................................................. 39 

Prepared statement of Dr. Jones ..................................................................... 79 

U.S. Government Accountability Office, Valerie C. Melvin, Director, Human 

Capital and Management Information Systems Issues .................................... 13 

Prepared statement of Ms. Melvin .................................................................. 54 

U.S. Department of Veterans Affairs: 

Howard B. Green, PMP, Deputy, Operations Management, Veterans Health 

Information Technology, Office of Enterprise Development, Office of Information and Technology .................................................................................... 21 

Prepared statement of Mr. Green ................................................................... 68 

Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for 

Health, Veterans Health Administration ....................................................... 37 

Prepared statement of Dr. Cross ..................................................................... 74 

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iv 

MATERIAL SUBMITTED FOR THE RECORD 

Post Hearing Questions and Responses for the Record: 

Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking 

Republican Member, Subcommittee on Oversight and Investigations, 

Committee on Veterans’ Affairs, to Hon. David M. Walker, Comptroller 

General, U.S. Government Accountability Office, letter dated February 

5, 2008, and response from Valerie C. Melvin, Director, Human Capital 

and Management Information Systems Issues, U.S. Government Accountability Office, letter dated March 7, 2008 ....................................................... 83 

Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking 

Republican Member, Subcommittee on Oversight and Investigations, 

Committee on Veterans’ Affairs, to Hon. Robert M. Gates, Secretary, 

U.S. Department of Defense, letter dated February 5, 2008, and DoD 

responses ........................................................................................................... 92 

Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite, Ranking 

Republican Member, Subcommittee on Oversight and Investigations, 

Committee on Veterans’ Affairs, to Hon. James B. Peake, Secretary, 

U.S. Department of Veterans Affairs, letter dated February 5, 2008, 

and VA responses ............................................................................................. 96 

The Health Executive Council Highlights, FY 2003–First Quarter for FY 

2008, dated June 10, 2008 ............................................................................... 98 

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(1) 

SHARING OF ELECTRONIC MEDICAL 

INFORMATION BETWEEN THE U.S. 

DEPARTMENT OF DEFENSE AND THE 

U.S. DEPARTMENT OF VETERANS AFFAIRS 

WEDNESDAY, OCTOBER 24, 2007 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, 

Washington, DC. 

The Subcommittee met, pursuant to notice at 10:03 a.m., in 

Room 334, Cannon House Office Building, Hon. Harry E. Mitchell 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Mitchell, Space, Walz, Rodriguez, and 

Brown-Waite. 

OPENING STATEMENT OF CHAIRMAN MITCHELL 

Mr. MITCHELL. Good morning and this hearing will come to 

order. This is the Subcommittee on Oversight and Investigations. 

And today’s hearing is on Sharing of Electronic Medical Information between the U.S. Department of Defense (DoD) and the U.S. 

Department of Veterans Affairs (VA). 

I want to thank everyone for being here today and I am very 

pleased that so many people could attend this oversight hearing on 

Sharing Electronic Medical Information between the Departments 

of Defense and Veterans Affairs. 

This is a critically important issue. Thousands of our service men 

and women require and will continue to require significant medical 

care as a result of the conflicts in Iraq and Afghanistan. The most 

seriously injured of our Operation Enduring Freedom (OEF) and 

Operation Iraqi Freedom (OIF) veterans may need a lifetime of 

care. But even veterans returning with no visible injury may need 

assistance with Post Traumatic Stress Disorder (PTSD) or mild 

Traumatic Brain Injury (TBI). 

The DoD and VA are sharing more and more patients. For example, the patients at the VA’s four polytrauma rehabilitation centers 

are almost always still on active duty. And active-duty 

servicemembers will be veterans sooner or later. 

A review by the VA’s Inspector General shows that of the 

500,000 or so servicemembers who left active duty in fiscal year 

2005, 92 percent had an encounter with a military health system 

while on active duty that resulted in a diagnostic code. In other 

words, nearly all of the veterans who go to the VA to get medical 

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care will have military medical records that should be available to 

VA healthcare providers. 

If anyone can convince the American people of the importance of 

electronic medical records, it is our first panel. Specialist Channing 

Moss is an Army soldier who was shot with a rocket propelled grenade that lodged in his body. He is alive and walking today because the medical evacuation team and the combat surgeons who 

operated on him put their own lives in danger in order to remove 

live ordnance from Specialist Moss. 

Brigadier General Douglas Robb was Chief Surgeon of United 

States Central Command (CENTCOM) at the time. And he will discuss how important it was that a copy of the x-ray taken at the 

forward field hospital was available to the clinicians at Landstuhl 

before Specialist Moss arrived. 

DoD and VA have been working on electronic exchange of medical information for many years. For most of that time, the story 

is not a happy one. I am nevertheless pleased to be able to say that 

DoD and VA have made more progress in the past 12 to 18 months 

than they have made in the preceding decade. 

But there is still much to be done. There is no reason why, in 

this day and age, that DoD and VA cannot electronically share the 

information necessary to treat our servicemembers and veterans. 

We should not have to wait any longer. 

I hope and I expect that DoD and VA will tell us today that by 

no more than a year from now clinicians at DoD and VA will have 

full electronic access to the medical information they need to treat 

their patients whether that information resides in computers 

owned by DoD or the VA. 

[The prepared statement of Chairman Mitchell appears on 

p. 52.] 

Mr. MITCHELL. Before I recognize the Ranking Republican Member for her remarks, I would like to swear in our witnesses. I would 

ask all the witnesses from all the panels to please rise and raise 

your right hand. 

[Witnesses sworn.] 

Mr. MITCHELL. Thank you. 

I would now like to recognize Ms. Brown-Waite for her opening 

remarks. 

OPENING STATEMENT OF HON. GINNY BROWN-WAITE 

Ms. BROWN-WAITE. Thank you very much, Mr. Chairman, and I 

thank you for yielding. 

It is a good idea to hold this hearing to review the status of the 

electronic medical record sharing between DoD and VA. This Subcommittee has already held two hearings in the 110th Congress on 

the issue of seamless transition of our servicemembers. And in the 

109th, various hearings were also held. It is a very important 

issue. 

The first hearing of this Committee was held in March and the 

second one in May, both of which focused primarily on the sharing 

of critical medical information of wounded servicemembers and the 

sharing of that information between DoD and the VA. 

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I want to assure the witnesses here today this issue is of the utmost importance to Members of this Committee and certainly the 

full Committee and I believe every Member of Congress. 

I am very pleased that the Chairman requested that representatives from DoD testify here today. It will be important to hear their 

perspective on the timely exchange of critical medical information 

between DoD and VA for the seamless continuum of delivering 

healthcare to our servicemembers. 

I look forward to hearing the steps DoD has taken to allow critical medical information to be reviewed by VA when active-duty 

servicemembers are transferred to VA facilities. 

In addition, I will be interested in hearing from VA on whether 

technological obstacles or bureaucratic intransigence prevent this 

from occurring today. 

This past week, staff members visited Keesler Air Force Base 

and the VA medical center in Biloxi, Mississippi, to see how the Air 

Force and VA are coming together in VA/DoD resource sharing. 

Unfortunately, the progress in this area is a result of the devastation of Hurricane Katrina and the dynamic personalities of senior 

leadership at these facilities and not the ‘‘Veterans Administration 

and the Department of Defense Health Resources Sharing and 

Emergency Operations Act 1982.’’ 

It does appear, Mr. Chairman, I agree with you, that the ball has 

moved forward more in the last, say, 24 months than the last 25 

years. It is a shame that it took Hurricane Katrina, the debacle at 

Walter Reed, and the devastating wounds of war to expedite 

progress between the two largest Federal bureaucracies. 

I am also looking forward to hearing from representatives of both 

departments about how they plan to implement the recommendations of the recently released Dole-Shalala Commission report and 

the Veterans Disability Benefits Commission report. 

Again, thank you very much, Mr. Chairman, for holding this 

hearing. The issue is very important to every Member of Congress 

and I believe every American. And with that, I yield back the balance of my time. 

[The prepared statement of Congresswoman Brown-Waite appears on p. 52.] 

Mr. MITCHELL. Thank you. 

I ask unanimous consent that all Members have 5 legislative 

days to submit a statement for the record. Seeing no objections, so 

ordered. 

Before we hear from our first panel, we are going to take a look 

at a short video about Channing Moss, the soldier that I spoke 

about in my opening statement. The Subcommittee appreciates the 

cooperation of the Army Times in making this video available. 

If you would like to move around to see this, please do. 

[Video shown.] 

Mr. MITCHELL. General Robb will speak to us in a minute about 

the importance of the electronic transmission of Specialist Moss’ 

medical records. 

But before we hear from General Robb, the Subcommittee would 

like to thank the Army Times and in particular Gina Cavallaro, 

James Lee, and Chris Brass who put this video together. 

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Ms. Cavallaro, would you please stand? We want everybody to 

know that she was the first one to report this story more than a 

year ago and I would like to thank her on behalf of the Subcommittee and indeed on behalf of the country for bringing this 

truly inspiring story to light. Thank you. 

At this time, we will hear from General Robb and he will have 

5 minutes to make his presentation. Thank you. 

STATEMENT OF BRIGADIER GENERAL DOUGLAS J. ROBB, M.D., 

COMMANDER, 81ST MEDICAL GROUP, KEESLER AIR FORCE 

BASE, BILOXI, MS, DEPARTMENT OF THE AIR FORCE, U.S. 

DEPARTMENT OF DEFENSE 

General ROBB. Mr. Chairman and Members of the distinguished 

Subcommittee, thank you for inviting me here today. I am Brigadier General Douglas J. Robb and I served as the Command Surgeon, United States Central Command from 2004 to 2007. 

Currently, I am serving as the Keesler Medical Center Commander and as the Senior Market Manager for the Gulf Coast 

Multi-Service Market Office, Keesler Air Force Base, Biloxi, Mississippi. 

Thank you for the opportunity to express my advocacy for a 

healthcare information systems platform and an electronic medical 

record that supports the world-class quality healthcare that our 

military and Veterans Administration healthcare facilities provide 

to our DoD and VA beneficiaries. 

In my previous assignment as the CENTCOM surgeon, I had the 

opportunity to witness the evolution of our deployed healthcare information systems platforms that support access to patient care 

data as our wounded warriors move through the continuum of care 

from our combat casualty care lifesavers to our forward surgical 

teams, to our theater hospitals, and then on to our definitive care 

facilities at hospitals such as Landstuhl, Walter Reed, Bethesda, 

Wilford Hall, and our VA polytrauma centers. 

As you saw in the video, on March 16, 2006, Specialist Channing 

Moss was severely injured in an attack in southeastern Afghanistan. The lifesaving care performed by the combat lifesavers in his 

unit and the subsequent and surgical stabilization by the forward 

surgical team and the Bagram Theater Hospital saved his life. 

What was also lifesaving was the ability of the surgeons at 

Landstuhl Hospital in Germany who would receive Moss less than 

24 hours after his initial injury and the surgeons at Walter Reed 

to be able to view his operative notes and his x-rays before the patient arrived at their hospitals. This was accomplished via the 

Joint Patient Tracking Application (JPTA), which is part of the 

DoD’s deployed healthcare information systems platform. 

As an aside here, and you noticed in the video, that Moss said 

he was going to fight to live. And it is our task as medics in the 

combat environment to give him that opportunity to fight to live. 

And I was privileged to serve with those men and women, our medics in the Area of Rescue (AOR) who saved Moss’ life, and especially to Dr. Oh did a great job there with the forward surgical 

teams. 

Earlier that year, and again in Afghanistan, a general surgeon 

and the Commander of one of our other forward surgical teams 

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commented on his excitement when he was able to send completely 

digital trauma resuscitation and operative reports to the Bagram 

Combat Support Hospital, again before the patient arrived. 

This is something that had been his vision for our forward surgical teams for a long time. During his previous assignment, he 

had been a surgeon at Landstuhl, Germany, and was frustrated by 

the lack of medical data from the forward surgical teams’ initial 

surgical resuscitation. He was happy that this had been corrected. 

Now, currently in my position as the Senior Market Manager for 

the Gulf Coast Multi-Service Market through the collaborative and 

joint DoD and VA initiatives, we are entrusted with the in-garrison 

care of our DoD and VA beneficiaries. In this capacity, we also require a healthcare information system platform that supports access to real-time patient data for our shared population. 

Our patients are from the Gulf Coast and are treated in the DoD 

and VA hospitals and clinics that are often located in proximity 

from Biloxi to Panama City. Our goal is to provide quality services 

in a seamless manner. This requires an integrated healthcare information systems platform that is user friendly for our jointly operating DoD and VA healthcare facilities. 

Significant progress has been made in the past few years to 

bridge this gap of electronic information flow. Just last month, our 

staffs were excited when the Bidirectional Health Information System (BDHI) became available at some of our facilities. Although 

not at its full capability yet, it is a very positive step in the right 

direction in our ability to view patient care data from both VA and 

DoD facilities. 

In conclusion, as a former Combatant Command Surgeon and 

currently as the Multi-Service Market Manager, I continue to be a 

strong advocate for healthcare information systems. We need to 

support heroes like Channing Moss as they move through our deployed and garrison-based continuum of care from the combat casualty to the forward surgical resuscitation, to theater hospitalization, and finally our DoD and medical centers and clinics. 

The current capability has proven itself in contributing to the 

quality of care for our beneficiaries and with your support, I believe 

we can continue to improve upon our already existing and evolving 

capability and further share and make available the full spectrum 

of electronic health information between our Department of Defense and Department of Veterans Affairs. 

Mr. Chairman, Committee Members, thank you again for allowing me this opportunity to appear before you. 

[The prepared statement of General Robb appears on p. 53.] 

Mr. MITCHELL. Thank you, General Robb. 

I have just got a couple questions and I am not sure I understand all the acronyms or all the—— 

General ROBB. Yes, sir. 

Mr. MITCHELL [continuing]. Things that I am going to throw out 

and ask you about, but I am sure you do. It is our understanding 

that the Joint Patient Tracking Application is currently used to get 

inpatient information from the theater but that some in DoD are 

trying to require clinicians in the theater to use an application 

called Tactical Command and Control (TC2). 

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In your expert opinion, will doctors in the theater actually use 

this application, TC2, for inpatient documentation of clinical notes? 

That is one question. 

And if use of the JPTA for documenting encounters in theater is 

stopped, could this negatively impact delivery of healthcare for our 

most seriously injured as they travel through the continuum of the 

VA? 

General ROBB. Well, sir, as far as the TC2, which is the current 

inpatient platform documentation system, that was implemented 

and introduced into the theater of operations after I left as the 

Combatant Surgeon. And as a result, in my current capacity, I 

have not been keeping up as much as I maybe should with my previous job, but my views on it in general are this. 

The initial inpatient module that was introduced into the theater 

did not accomplish what it was intended to do for a couple of reasons. Primarily it was because it was not user friendly for the providers. So if something is not user friendly by the providers and 

also providing a useful note to convey patient care information and 

data from one provider to another provider, then the providers are 

probably not going to accept that as a platform to use to take care 

of, remember, their patients. 

Number two, another reason was I believe at the time that was 

a stand-alone system and it did not allow information to flow. And 

as a result, when the Joint Patient Tracking Application was introduced into the theater to track patients from level two, level three, 

all the way back to the United States, the clinicians, the providers 

themselves figured out that they can put patient care data on that 

platform that, as we described in Moss’ case, we are able to move 

patient care data along the continuum before and during and after 

the patient moved through the system. 

So that is the system that needs to be in place. The current inpatient module, if it is user friendly, and the providers decide that it 

is a useful note, okay, and it is real-time accessible, then it will be 

successful, yes, sir. 

Your second question about JPTA if it stopped right now, I think, 

again, my direction when I was the Command Surgeon was when 

the inpatient module is user friendly, provides a useful note, and 

provides real-time patient care data, and we can view inpatient 

data from real-time, before, after, and during their movement, then 

we can switch from the Joint Patient Tracking Application over to 

whatever system is going to work for us on the Armed Forces 

Health Longitudinal Technology Application (AHLTA) deployed 

platforms. 

But until then, I think we need to allow the providers the opportunity to move the patient care data that is useful to them. 

Mr. MITCHELL. Thank you. 

After seeing this video about Specialist Moss, I can imagine that 

great things are happening like that all over today. 

General ROBB. Yes, sir. 

Mr. MITCHELL. However, I understand that there still may be 

some problems getting information from the field medics to hospitals and to the VA. 

What more can be done to ensure that this process goes smoothly? 

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General ROBB. Well, again, as I described in my testimony, we 

have some monumental, I think, steps that have occurred, nothing 

occurs as fast as we want it to, but that have occurred. One of 

them is the Bidirectional Health Information System. 

And, again, when we demonstrated that, I mean, we received it 

the day before and the next day, we flicked the switch and we got 

everybody together. But the opportunity for us through a bridge 

portal to view AHLTA data in VistA, which is the DoD system, 

view it in the Veterans Administration system, and then look from 

the Veterans Administration system into the DoD system to be able 

to see outpatient notes, lab, x-rays, pharmacy, allergies, we are 

there. 

The inpatient piece of it, that is going to be fielded here. At some 

places, it is already fielded. But the ability to field it at my particular location will be by next summer. That will be a tremendous 

milestone for us to accomplish. And for us in the Gulf Coast region 

and the patients that we share with our veterans to be able to look 

at each other’s healthcare data, I am excited about that. 

The opportunity that we have had for the connections between 

the outpatient modules and then as we watch the evolution of the 

inpatient module, if that becomes connected, I know the outpatient 

is, we can view outpatient data from the field from any of our DoD 

locations and now through BDHI into the VA system. 

And once the inpatient module becomes successful, then the ability to view that again will advance again and contribute to the 

healthcare of our veterans. 

Mr. MITCHELL. Thank you. 

Ms. Brown-Waite? 

Ms. BROWN-WAITE. Thank you, Mr. Chairman. 

By the way, congratulations on your recent promotion to Brigadier General. It certainly is refreshing to see that the military still 

rewards leaders for their candor and their refreshing approach to 

real-life problems. 

Let me ask you, if JPTA did not exist in the combat theater, how 

would, for example, the operative notes and x-rays be sent with the 

patient within 24 hours from, for example, in the video that we saw 

from Afghanistan to Landstuhl, Germany to be used by the accepting surgeon there, whether it is a situation like we just saw or 

whether it is TBI? How would that information be transmitted? 

General ROBB. Well, under the old paradigm and the paradigm 

that I lived in when I first came to U.S. Central Command was we 

were moving paper records. In other words, if you had the opportunity to—I will regress a little bit. The patients move so fast 

through our system today. From the time of wounding on the battlefield to the time you are under the knife, it is sometimes as little 

as 20 minutes to your forward surgical team. 

And then you are usually in a combat theater hospital within an 

hour, sometimes two or three. And then you are at Landstuhl usually under 24 hours and sometimes you are at Walter Reed in 24 

hours. 

And so you can imagine that under the old paradigm with the 

paper record, that may not keep up with the patient. And so, you 

know, a lot of times, physicians are moving, especially in the mass 

casualty situation, are moving so fast through the system that you 

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complete the paperwork after the patient leaves. And so then it is 

hard to give the hard copy to move with the patient. 

So that was a dilemma we faced. And that is why it is important 

that we have a deployed healthcare information system platform 

that allows it so that you can enter the data. It is okay to enter 

the data after the patient leaves, but then it needs to be able to 

be viewed. 

So, you know, hypothetically you could put the data in or do the 

op note or whatever while the patient is being shipped to the next 

level. And so by the time they get to the next level, whether it is 

the theater hospital or to Walter Reed or to Landstuhl, it is in the 

system for the receiving physicians to see. And, again, that prepares that team for what is coming with them. They can anticipate 

the specialties. 

And so the clinicians, actually specifically the joint theater trauma system team, and the directors embraced this platform, the 

Joint Patient Tracking Application platform to be able to hang that 

type of data so that they could inform their colleagues along the 

continuum of care what was coming to them so they could better 

prepare for the care when they received them. 

Ms. BROWN-WAITE. Obviously that is a giant step forward. 

We have heard from providers in the combat theater that the 

current effort to document inpatient medical notes useable or very 

difficult at best that these actually were discouraged. This was 

after two failed implementations of the Composite Healthcare System (CHCS) legacy system. 

To the best of your recollection from your time in theater, was 

JPTA discouraged and, if so, by whom? And I guess we hope that 

candor is still there. 

General ROBB. Well, I am a physician by trade. And so I understand how physicians talk to each other and I understand what 

needs to be passed from one physician to another. 

My staff, myself, and then the joint theater trauma system embraced the capability that the joint theater tracking application 

brought to us besides just the patient tracking application piece of 

it. 

And as a result, we made a decision that this was the way that 

we were going to support the movement of data for en route patient 

care because it was the right thing to do. And so we supported it 

from my staff and then subsequently through the component surgeons and then down to the different levels. That was the direction 

that we gave them for inpatient documentation. And that is what 

we executed. 

Did everybody accept it? It was something different. And change 

is always difficult. 

Ms. BROWN-WAITE. But was it actually discouraged? 

General ROBB. Was it actually discouraged? There were some locations that did not embrace it as much as others, yes, ma’am. 

Ms. BROWN-WAITE. If you are not comfortable saying it now, I 

would like to know those locations so that we can make sure that 

regardless of where the injury takes place that we have the best 

records being transferred. It is not about the staff. 

General ROBB. Right. 

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Ms. BROWN-WAITE. With all due respect, it is not about the doctors who do wonderful work. It is about making sure that it is a 

system—— 

General ROBB. Yes, ma’am. 

Ms. BROWN-WAITE [continuing]. That works well on behalf of the 

patient. 

General ROBB. Yes, ma’am. 

Ms. BROWN-WAITE. Thank you very much, General. 

General ROBB. Yes, ma’am. 

Ms. BROWN-WAITE. I yield back. 

Mr. MITCHELL. Thank you. 

Congressman Walz? 

Mr. WALZ. Thank you, Chairman. 

And thank you, General. A special thank you for your service in 

where you are at in providing medical care which I think is without a doubt the best surgical and the best medical care ever given 

to warriors in the history of mankind. And that has been an amazing success story. 

And this issue and this topic of medical records is critically important. I understand, and many of us, I think, oversimplify what 

goes into this, what data needs to be on there. And I represent the 

part of Minnesota that has the Mayo Clinic and this is a conversation I have had many, many times on this, on a broader area of 

healthcare in general, and what is going to be done. 

Now, it looks like and what I am hearing is I am very optimistic, 

too, that massive progress has been made. I think for our perspective here in Congress, the end result, the progress, the improved 

medical records, it is going to help in terms of patient care, cost, 

research, all of those things that go with medical records. 

My question to you is, and I know again some of these have to 

be subjective, what do you attribute what appears to be an increased pace of change, an increased pace of trying or a sense of 

urgency to implement this idea of data sharing and electronic medical records, or do you think it has just been on a continuum and 

it is finally reaching fruition where it has gotten to where we can 

get the types of things you are talking about? 

General ROBB. Well, I think, of course, you know it was the 

President’s vision that we go this direction as a Nation. And as I 

spend time also in my professional capacity with my state organizations and associations from the State of Florida, they are wrestling again with how are they as a state going to come up with an 

electronic medical record or healthcare information systems platform to support that vision. 

If it were easy, I think one of the states would have figured this 

out already. And so I applaud the Department of Defense again for 

leading the charge. You know, sometimes we make some of our 

best advances in crisis and I think that has probably been part of 

the addition to the momentum of where we are going, the sense or 

urgency, because there is a lot of competing priorities out there. 

I believe, as we all believe, that we have the interest of our patients, whether they are civilian, whether they are veterans, or 

whether they are active duty, at heart. And I believe as a Nation 

and with the Department of Defense and with the Department of 

Veterans Affairs and the Federal Government in the lead on this, 

wwoods2 on PRODPC68 with HEARING

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I think we have the opportunity to set the standard for what is an 

electronic health record or, even bigger, what I call a health information systems platform to support patient care as we want it to 

be in the future. 

Mr. WALZ. One of the questions that always comes up here is the 

Congress’ role in providing not only oversight but resources. In 

your experience now, are the resources there to make this transition because many of us up here understand it is a scarce amount 

of resources and what we are getting out of it? 

But this issue is so broad and so important and especially in the 

care of our veterans and seamless transition. I kind of ask the 

question, the last question with a little bit of leaning toward, did 

Walter Reed wake us all up and those types of things? Was this 

one part of it? 

And I guess my question to you is, do you feel that the resources 

are there, the commitment is there to get this right this time? 

General ROBB. I think the oversight and the emphasis is there, 

absolutely. This is a tremendous monumental paradigm shift from 

where we were and to where we are going. And it is taking a lot 

of resources, probably more than we maybe had anticipated. 

I think we have the brain power to do it. I think we have some 

of the solutions. In fact, I think we have most of the solutions, at 

least to get us through the interim. The next generation of platform 

is something that we need to work on. But for the interim, for the 

next 12 to 18 to 24 months, I believe we have some solutions in 

place. 

Could we accelerate that with resources? The answer is potentially. But I am not in that business, so I do not know if we can 

go any faster if, let us say, either more manpower or money was 

thrown at it. Sir, I do not know that. 

But I know that they have a road map way ahead which you will 

hear later that I am very optimistic about in making this happen. 

And if they can have the opportunity to answer that question later, 

then they can probably tell you whether or not the resourcing piece 

of it is something that could either accelerate this or slow it down, 

yes, sir. 

Mr. WALZ [presiding]. Very good. Thank you, General. 

Mr. Rodriguez? 

Mr. RODRIGUEZ. Thank you very much. And I apologize for not 

being here, although I hear my colleague is very optimistic. 

This is my ninth year on this Committee with the absence of 2 

years, and about 5 or 8 years prior to me getting on here, we had 

been talking about this process. And so I am pleased and glad that 

we are finally making some inroads, although it has taken a long 

time. 

And we talk about it is monumental, but it is monumental from 

our part when we have been talking about this for a significant 

amount of time. And, you know, until I see it, in all honesty, I will 

not believe it. I can only react based on the fact that we know the 

Department of Defense has been stonewalling us on a couple of 

items on this area and not you personally, General. 

And I want to personally thank you for your efforts. But, you 

know, we have to get this straight because there are a lot of other 

things that took us 20 years to finally tell some of our veterans 

wwoods2 on PRODPC68 with HEARING

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from Project 112 that when they told us there was no experimental, 

you know, exercises being done on our own soldiers then we found 

out that was the case. 

So I would like to be able to get that documentation and also go 

back and addressing some of the needs of those soldiers in the sixties and seventies that we did some of those things and experimented with some of those gases and other things with them that 

the Department of Defense failed to—not failed—actually denied us 

that information for over 20 years. And, you know, I experienced 

that on this Committee. 

Now, I have also witnessed that the process to get there is, you 

know, because one after another have shown us some models of 

how we can do that and make that happen, and I want to throw 

a question to you in terms of—because at one point, I was just, you 

know—well, I am frustrated with both and that we need almost an 

external group to come in here and take care of it for you guys, 

both the Department of Defense and the VA when it comes to our 

computers, especially in terms of what happened with the loss of 

the information in the VA. 

And so I was wondering if in terms of expediting this, would it 

help to get some external groups to come in and take care of it in 

terms of the high tech stuff that is required? 

General ROBB. That is kind of out of my area of expertise. I am 

an operator and an executor. And I am the one that executes what 

you all give me. And I am not in what I will call the developmental 

arena. So, sir, I have to pass that question on to—— 

Mr. RODRIGUEZ. The second question, as we speak now, we hear 

the Department of Defense doing some diagnosing already on some 

20 something thousand personality disorders which automatically 

identifies preexisting condition. 

Are we having any other of those kind of things occurring at the 

present time, that we are going to have some additional problems 

in the future? Are there some problems specifically with some of 

that might be occurring at the Department of Defense? 

General ROBB. Sir, I do not think I understand your question. 

Mr. RODRIGUEZ. There was a group of some 20,000 soldiers that 

were identified with personality disorders. And when that occurs, 

when that soldier leaves, and I had a couple of them come and visit 

me, that presupposes a preexisting condition which means they do 

not qualify for any kind of benefits or anything when they try to 

go if that is their diagnosis. And so the Department of Defense, it 

is my understanding, did these diagnoses. 

Where are we at on that kind of stuff? 

General ROBB. Sir, that is again probably out of my area of expertise because you are talking about accession standards in the 

way we access our individuals’ preexisting conditions, of course, or 

conditions that the medical profession and through the administrative channels also believe existed prior to service. And then that 

particular condition arises or surfaces when they are in the military. 

But as far as what we are doing to better pick up on some of 

those preexisting conditions, that, sir, again, is out of my area of 

expertise. 

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Mr. RODRIGUEZ. Okay. And I would also want to go back as we 

move on this to some of our previous veterans. We want to do the 

right thing now, but we also want to go back to Vietnam and some 

of those areas where we did have and at one point had identified 

some 5,600, maybe even more, because I was gone for a couple of 

years, so close to 6,000 soldiers that we used, you know, nerve gas 

and other things on our own soldiers, and wanted to see from the 

Department of Defense, you know, later on, maybe we can get, Mr. 

Chairman, a little status report on those assessments that were 

done in the 1960s and 1970s on our soldiers because I know they 

first said that they only identified some 30 projects and then it 

went to 40 and the last I heard, it was close to 50-something 

projects where we had done experimental stuff with our own soldiers, and I want to just get, you know, and that is with the Department of Defense, I just want to get some feedback on that. 

General ROBB. Sir, again, that is again out of my area of expertise and I am not aware of that. 

Mr. RODRIGUEZ. Thank you very much for what you are doing, 

sir. A lot of the Members feel optimistic, so you must have said 

some good things. 

General ROBB. Well, I will tell you, the group of folks that I had 

a chance to work with and work for are medical professionals not 

only in the CENTCOM area of responsibility but also back here at 

our, again, our major hospitals and our clinics, and then my opportunity in my current capacity to work with the Veterans Administration. You know, we have all heard the expression from Secretary 

Nicholson this is not your father’s VA. There are a group of dedicated professionals out there in the Veterans Administration that 

care for our soldiers, sailors, airmen, Marines, coalition forces and 

they are second to none. And I am proud to be part of that team, 

yes, sir. 

Mr. RODRIGUEZ. And I hope the Department of Defense takes it 

from the perspective that file belongs to that soldier. 

General ROBB. Yes, sir. 

Mr. RODRIGUEZ. And they be able to get a grasp of it and be able 

to have it so that when they move into the VA, and it would be 

more cost effective for us as a whole, and not to mention in terms 

of that particular soldier. Thank you. 

General ROBB. Yes, sir. 

Mr. WALZ. Ranking Member Brown-Waite? 

Ms. BROWN-WAITE. General, I just wanted to thank you very 

much for being here, for your candor, and also for your ability to 

accept and promote the kind of technology that will certainly help 

the patient a whole lot more than the past. Lord only knows where 

the paper trail system is that was there. 

Thank you so much. 

General ROBB. Yes, ma’am. 

Ms. BROWN-WAITE. And please encourage others to follow suit. 

General ROBB. Yes, ma’am. 

Mr. WALZ. I would echo and associate myself with the Ranking 

Member’s comments generally. It is refreshing to hear this. We 

have a lot of work to do. Please know that we sit up here as representatives of the American people and we want nothing more 

wwoods2 on PRODPC68 with HEARING

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than to provide the highest quality care to our soldiers and our 

warriors that are out there and as they become veterans. 

So you simply need to see us as partners in this. We are glad 

to have you out there. And I thank you for your time. 

General ROBB. Thank you. 

Mr. WALZ. We will go ahead and seat the second panel, please. 

Welcome to our witnesses. Our witness today, Ms. Valerie Melvin, 

is Director of Human Capital and Management Information Systems Issues for the U.S. Government Accountability Office, the 

GAO. She will be accompanied by her Assistant Director, Ms. Barbara Oliver. We look forward to her unbiased view on this situation. 

And, Ms. Melvin, you are recognized for 5 minutes. 

STATEMENT OF VALERIE C. MELVIN, DIRECTOR, HUMAN CAPITAL AND MANAGEMENT INFORMATION SYSTEMS ISSUES, 

U.S. GOVERNMENT ACCOUNTABILITY OFFICE; ACCOMPANIED BY BARBARA OLIVER, ASSISTANT DIRECTOR, 

HUMAN CAPITAL AND MANAGEMENT INFORMATION SYSTEMS ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE 

Ms. MELVIN. Thank you. Members of the Subcommittee, I am 

pleased to be here today to continue the dialog on VA’s and DoD’s 

efforts to share electronic medical information and attempts to ensure that active-duty military personnel and veterans receive highquality healthcare. 

As you have mentioned, accompanying me today is Ms. Barbara 

Oliver, Assistant Director. 

As you know, VA and DoD have been pursuing ways to share 

medical information for nearly a decade. And since 2001, GAO has 

reported numerous times on their initiatives. 

Our last testimony before you on May 8th highlighted the key 

projects that the two departments have pursued and the substantial work that remained to achieve comprehensive electronic medical records. 

At your request, my statement today further discusses the history and status of these efforts. 

In this regard, since 1998, VA and DoD have focused on the longterm vision of a single comprehensive lifelong medical record for 

each servicemember to achieve a seamless transition between the 

departments. 

However, they have faced considerable challenges in their efforts 

to reach this goal, leading to repeated changes in the focus of and 

target dates for their initiatives. 

Our prior reviews noted weaknesses in project management, 

oversight, and accountability, and we recommended that the departments develop a comprehensive and coordinated project management plan to guide their efforts. 

Since we last testified, each Department has continued developing its own modern health information system to replace existing 

systems. The modernized systems are based on using computable 

data, that is data in a format that a computer application can act 

on, for example, to alert clinicians of a drug allergy. 

The departments have begun to implement the first release of an 

interface between their modernized data repositories and are curwwoods2 on PRODPC68 with HEARING

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rently exchanging computable outpatient pharmacy and drug allergy data at seven VA and DoD sites. 

At the same time, the departments have made progress on shortterm projects to share health information using their existing systems. Of these, the Laboratory Data Sharing Interface Application 

is currently implemented at nine sites, allowing the departments to 

share medical laboratory results. 

In addition, the Bidirectional Health Information Exchange or 

BHIE interface is allowing a two-way view of selected categories of 

health data on shared patients from VA’s and DoD’s existing health 

information systems. 

Because BHIE provides access to up-to-date information, the departments’ clinicians have expressed interest in its further use. Accordingly, since May, the departments have been expanding BHIE’s 

capabilities and implementation using the interface to connect not 

only VA and DoD but also DoD’s multiple legacy systems which 

were not previously linked. In this way, the departments have 

begun sharing more of their current information more quickly. 

Beyond these two efforts, various ad-hoc processes that the departments established to provide data on severely wounded 

servicemembers to VA’s polytrauma centers are being used. These 

processes include manual work-arounds such as scanning paper 

records for transfer to incompatible systems. 

While particularly significant to the treatment of servicemembers 

who sustain traumatic injuries, as we have testified previously, 

such laborious processes are generally feasible only because the 

number of polytrauma patients is small. 

Overall, through all of these initiatives, VA and DoD are exchanging health information which is an important accomplishment. However, these exchanges are limited and significant work 

still remains to achieve the long-term goal of a comprehensive electronic medical record. 

Moreover, it remains unclear how all of the initiatives that VA 

and DoD have undertaken are to be incorporated into an overall 

strategy for a seamless exchange of health information. 

The multiple projects and ad-hoc processes being discussed today 

highlight the need for further efforts to integrate information systems and automate information exchanges. Yet, VA and DoD are 

continuing to proceed without a comprehensive project plan and 

overall strategy to effectively guide their efforts. 

As we have previously recommended, the departments need such 

a plan to help ensure success in reaching their goals. 

This concludes my prepared statement. I would be pleased to respond to any questions that you may have. 

[The prepared statement of Ms. Melvin appears on p. 54.] 

Mr. WALZ. Thank you, Ms. Melvin. 

In listening, and I think you heard on the last panel as we were 

trying to assess where we are at on this progress, what is GAO’s 

assessment as far as a timeline of a real-time viewable, useable 

platform for these medical records? Do you think it is reasonable 

or are we a year, are we 2 years, or where are we at from this 

being in place? 

wwoods2 on PRODPC68 with HEARING

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We saw, and heard General Robb talk about, that there has been 

a momentum. There has been the resources necessary. We have 

been moving toward it. We are seeing successes. 

In your opinion, where are we at in terms of before this is going 

to be up and running? 

Ms. MELVIN. We have seen definite progress in terms of the 

short-term initiatives that were mentioned today relative to the 

Bidirectional Health Information Exchange. There are other initiatives related to the laboratory data sharing interface as well as a 

number of ad-hoc processes that have been put in place, in particular to serve the polytrauma patients who are coming back into 

the country. 

From our assessment, these initiatives definitely bring additional 

capabilities and services to the clinicians by providing them with 

more information. However, I am not able to say when the departments would be at a point of having the goal of a longitudinal, comprehensive electronic medical record, which they have indicated 

was their long-term goal or mission to have, because we have not 

yet seen their final plans for actually doing that. 

As of now, we cannot state when they would have those systems 

in place. Both departments at this point have told us that they do 

not have a date for their final modernized systems which are key 

components of putting in place the overall sharing capability that 

they have talked about having. 

Mr. WALZ. So no data has been expressed? It is just a goal out 

there to try and get it done? 

The reason I ask this is I am optimistic on this. The need to get 

this done is very apparent, but I do not want to find myself in the 

position of my colleague from Texas of being here for 9 years and 

saying I can remember that conversation we had back in October 

of 2007 and here we are in 2016. 

Do you have that fear or do you think that there is a difference 

now? 

Ms. MELVIN. There is a concern that we still have from two perspectives. First of all, as I mentioned in my last response, both departments are still in the process of developing their modernized 

health information systems. Those are the two systems that we no 

longer see specific completion dates for. 

Beyond that, one of the concerns that we have repeatedly raised 

in our work is that the departments did not articulate a defined 

strategy for getting to this final mission. And within that strategy, 

we would certainly hope that there would be interim milestones as 

well as a final timeframe for accomplishing this. 

Mr. WALZ. Thank you, Ms. Melvin. 

Ms. Brown-Waite, the Ranking Member, is recognized. 

Ms. BROWN-WAITE. Thank you very much. 

I have been here. This is my fifth year here, not fifth term, but 

fifth year, and served on the Veterans’ Affairs Committee. And this 

has been an ongoing issue and it is almost to the point where it 

is like de ́ja` vu all over again because the same issue has not yet 

fully been resolved. 

I think we have come a long way. Of course, part of the problem 

is we do not have any authority over DoD in this Committee. But 

wwoods2 on PRODPC68 with HEARING

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I think that there finally seems to be a working relationship there 

and the belief that Congress is not going to just drop this issue. 

In your testimony, you stated that although there are multiple 

initiatives between the VA and the DoD, there is an important requirement to integrate and automate information exchange. I think 

you further stated that there is not a clear overall strategy to incorporate this in a seamless exchange of information. 

I have been here 5 years. Mr. Rodriguez has been here ten total, 

nine total. How many times have you stated this same finding? 

Ms. MELVIN. Well, we have been reporting on this issue since 

2001 and across the multiple reports that we have issued, we have, 

in fact, made the recommendation and reemphasized that recommendation a number of times. 

Ms. BROWN-WAITE. Do you know offhand how many? 

Ms. MELVIN. I can provide you that for the record. I do not know 

offhand at this moment, but we can certainly tell you after this 

hearing. 

[The response was provided in the Post Hearing Questions and 

Responses for the Record, which appear on p. 83.] 

Ms. BROWN-WAITE. Okay. Are you encouraged that there seems 

to finally be the realization by DoD that this has to happen? 

Ms. MELVIN. We are encouraged in seeing the different initiatives, the short-term initiatives that are being put in place. We do 

see them as an opportunity to provide more information to the clinicians in the immediate. 

What we have not seen is the actual plan that VA or DoD would 

be using to do this. So I hesitate to say that or to speak or render 

a view of the plan that DoD has at this time because we have not 

actually seen that plan. I am not familiar with the road map that 

they have indicated that they have. 

Ms. BROWN-WAITE. Have you asked to see it? 

Ms. MELVIN. We have asked for their strategies relative to what 

they are doing. We have not been informed prior to today that 

there was an actual road map. 

Ms. BROWN-WAITE. Okay. With that, I yield back the balance of 

my time. 

Mr. WALZ. Mr. Rodriguez is recognized. 

Mr. RODRIGUEZ. Let me ask you in terms of trying to get this accomplished and get it done, do we need to give you any additional 

leeway or any guidance, you know, or any additional authority to 

go in? Are you going to be going in again and reassessing where 

they are at or do you need that additional guidance from us? 

Ms. MELVIN. We have previously responded to your request for 

oversight in this particular area. So certainly to the extent that you 

would want to have additional oversight, we would certainly be 

willing to follow through with that. 

Mr. RODRIGUEZ. Because it has been an issue that I think we 

have dealt with. I think they dealt with it for 4 or 5 years prior 

to even going to GAO. And I am convinced that there is some 

movement now, but I am concerned that you mentioned just short 

term, I think mainly because our troops are coming in and it is embarrassing to leave some of these seriously injured troops out there 

and just transfer them out and fall through the cracks the way 

they have been falling through the cracks. And that is obvious now. 

wwoods2 on PRODPC68 with HEARING

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But we have to come to grips and try to come up with and require 

them to come up with a long-term strategy. 

So I would encourage the Chairman to look in terms of what we 

might have to do in asking the GAO to continue on this issue for 

further implementation of that and requiring the DoD to do that 

and maybe getting the Armed Services Committee, getting Chairman Skelton also aware of our concerns as it deals with our 

servicemember. 

And I am concerned not only with the existing one, but, you 

know, we are not going back. I am just going back on my own personal experience with them in terms of health. It is kind of like 

they drop them and then they do not particularly care anymore, 

you know, and they expect the VA to handle them. And for good 

reason, you know, if we had that information and follow the soldier, it would help us tremendously, not to mention what it would 

do to the soldier. 

So I would ask the Chairman to see if we can keep on this track 

and hopefully 10 years from now, we will not be talking about this, 

but maybe going after some of those other pockets of concerns that 

I had with those other studies. 

While I am here, and maybe you are not the one, we had asked 

for studies on Project 112. I do not know if you heard me talk about 

our soldiers that the Department of Defense had used studies on, 

health studies, you know, where they used nerve gas and other 

things on ship. 

And maybe later on, I would like to see if, you know, we can get 

a report as to where we are at on that because I have not heard 

anything. And once again, it is my fault because I have not been 

here. I was gone for 2 years. But I wanted to get an assessment 

of that and if you get me that information as to where we are at. 

And back then, we had identified, as I recall, some 5,600 soldiers, 

but we were concerned that there might have been more and 

maybe other projects that were not disclosed where we could ID additional soldiers that might have been impacted with certain forms 

of studies that were done with plombage and other things because 

we knew that there were some other exercises that took place that 

were not part of the 56 projects that were out there. 

Ms. MELVIN. Sir, I am not familiar with those studies, but we 

would be glad to go back and share your concerns and interest with 

others in our healthcare area who might be more familiar and have 

them to be in touch with you on that matter. 

Mr. RODRIGUEZ. Okay. And also if you have done any studies on 

the recent diagnosing of soldiers with personality disorders because 

the other question that would come into play if they did come in 

with preexisting condition, personality disorders, you know, schizophrenia can have an onset around that age, but those onsets are 

much earlier. 

So the question would be, why did we allow them to get into the 

military in the first place if that was the case? If you have anything on that, I would appreciate it. 

Ms. MELVIN. Okay. Will do. 

Mr. RODRIGUEZ. Thank you. 

Mr. WALZ. The gentleman from Ohio, Mr. Space, is recognized. 

Mr. SPACE. I have no questions, Mr. Chairman. Thank you. 

wwoods2 on PRODPC68 with HEARING

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Mr. WALZ. Ranking Member Brown-Waite? 

Ms. BROWN-WAITE. Mr. Chairman, I have just one other question 

for Ms. Melvin. 

Have you, in pursuing this issue, had any indication that perhaps part of DoD’s reluctance to proceed with the information sharing may be because of a concern with the security of VA’s system? 

Ms. MELVIN. We have not heard that concern expressed. I would 

say that most of our studies have focused on the VA/DoD sharing 

effort from looking within the Department of Veterans Affairs and 

the relationships that it is having with DoD. 

However, I would say that because we are talking about sharing 

data across networks in particular and a number of multiple systems involved, certainly the security aspect is very critical to what 

they are doing. 

However, we have not gotten specific statements rendered to us 

relative to concerns with that at the moment. 

Ms. BROWN-WAITE. Thank you very much. 

And with that, I yield back. 

Mr. MITCHELL [presiding]. Thank you. 

Mr. Rodriguez? 

Mr. RODRIGUEZ. Yes. One last question since the issue of the VA 

and the documentation and security of that documentation was 

raised, maybe later on, Mr. Chairman, not so much for the GAO, 

but for the Chairman to see later on in the next coming year, we 

get an assessment of where the VA is in terms of that documentation because even then, I think we have talked about trying to get 

external groups to come in and take care of the computer stuff for 

them or try to correct that. But unless the GAO has something that 

is more recent from the last testimony we received, I would like to 

get some feedback on that. 

Ms. MELVIN. We have, if you are talking about their computer 

security, in particular, we have issued a report. I believe it was on 

September 19th. What I would like to do is again have our Director 

who has the expertise relative to security issues to contact you and 

provide you specific information. 

But we have identified some problems and concerns along with 

progress relative to their overall information security management 

program that we would be glad to share with you in detail. 

Mr. MITCHELL. Thank you. All right. Thank you very much. 

Ms. MELVIN. You are very welcome. 

Mr. MITCHELL. I would like to welcome Panel Number Three to 

the witness table. Colonel Keith Salzman is the Chief of 

Informatics from Madigan Army Medical Center and the Western 

Region Medical Command. He has been taking the lead with his 

counterparts at the VA Puget Sound Healthcare System on creating a pilot program for sharing electronic medical information. 

Lieutenant Commander James Martin fulfills a similar function 

at the new truly Federal facility being created by the U.S. Navy 

and VA out of the Great Lakes and North Chicago Hospitals. Lieutenant Commander Martin has been instrumental in helping create 

a way for DoD and VA to treat patients at the same facility while 

fulfilling their missions. 

Mr. Howard Green, the Deputy for the Operations Management 

for Veterans Health Information Technology, Office of Enterprise 

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Development at the VA is here to discuss where the VA stands in 

making sure all facilities can access medical information from the 

DoD as needed. 

Finally, Colonel Greg Andre Marinkovich is here representing 

DoD’s Clinical Information Technology Program Office or CITPO 

which is the DoD organization responsible for implementing sharing agreements throughout the service and theater. 

And I would like to thank each of these gentlemen for the work 

they do on behalf of our veterans and Nation and will recognize 

Colonel Salzman and all four panelists for 5 minutes. Thank you. 

STATEMENTS OF COLONEL KEITH SALZMAN, M.D., MPH, 

FAAFP, FACHE, CHIEF OF INFORMATICS, WESTERN REGION 

MEDICAL COMMAND AND MADIGAN ARMY MEDICAL CENTER, TACOMA, WA, DEPARTMENT OF THE ARMY, U.S. DEPARTMENT OF DEFENSE; HOWARD B. GREEN, PMP, DEPUTY, 

OPERATIONS MANAGEMENT, VETERANS HEALTH INFORMATION TECHNOLOGY, OFFICE OF ENTERPRISE DEVELOPMENT, OFFICE OF INFORMATION AND TECHNOLOGY, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; LIEUTENANT COMMANDER JAMES LAWRENCE MARTIN, REGIONAL INFORMATION SYSTEMS OFFICER, NAVY MEDICINE EAST, MEDICAL 

SERVICES CORPS, DEPARTMENT OF THE NAVY, U.S. DEPARTMENT OF DEFENSE; AND COLONEL GREGORY ANDRE 

MARINKOVICH, M.D., DATA MANAGEMENT PRODUCT LINE 

FUNCTIONAL MANAGER, CLINICAL INFORMATION TECHNOLOGY PROGRAM OFFICE, MILITARY HEALTH SYSTEM, 

MEDICAL SERVICE CORPS, DEPARTMENT OF THE ARMY, U.S. 

DEPARTMENT OF DEFENSE 

STATEMENT OF COLONEL KEITH SALZMAN 

Colonel SALZMAN. Thank you very much, Mr. Chairman, Congressman Brown-Waite, and the distinguished Members of the Subcommittee, for inviting me to testify. 

I am, as said, Colonel Salzman from Madigan Army Medical Center and have the privilege of leading in the newly emerging discipline of informatics. 

We have had a long history of command support at Madigan for 

doing projects that are often funded out of hide. So having the National Defense Authorization (NDA) funds to supplement our efforts has propelled us down the path in sharing information technology. 

In the 3 years that we have had to complete the 4-year project, 

we have delivered all the deliverables that we were chartered to do 

in our business plan and all of those deliverables are in use in the 

enterprise system. So it shows the benefit of merging local development with enterprise architecture to deliver rapid turnaround 

products that can be used in the information systems. 

In addition, we have added information requirements to cater to 

polytrauma information needs as well as additional requests from 

VA providers and DoD providers as we have prioritized from critical information needs to less critical but important needs. 

At the outset of this testimony, I would underscore our assessment that the choice on many levels that we face if it is couched 

in an either/or strategy is misinformed, but we need to look at both 

wwoods2 on PRODPC68 with HEARING

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strategies in approaching the problems that we face starting with 

having the local and the enterprise teams meet together and work 

together so that both are working together on the solution and not 

the local project as an isolated project directing things or an enterprise solution directing things that does not meet local needs. 

The initial challenges surrounded learning required to overcome 

the first either/or proposition of who drove the project, enterprise 

or the local site. A critical lesson learned was both. The local site 

had access to the clinical end user community and the requirements necessary to improve the flow of information while the enterprise had ownership of the architecture and systems and which 

requirements would be built and deployed. 

At the outset, it is important to state that while this project is 

a demonstration project, all of the deliverables are being used by 

the enterprise systems of both the DoD and VA in production in 

near real time and that is meaning in seconds, not days, weeks, or 

months. 

The strategy of development based on the priority of information 

delivery shaped our work and the work cycles for this project were 

generally in six- to nine-month increments. 

The critical dialog between clinical end user and the development 

team at the local level combined with an active dialog between 

local and enterprise team members ensured that a principle of software development, namely to correct functional problems as they 

are identified in the design phase, proceeds iteratively and cost effectively. 

The savings can be significant over allowing major design problems to persist into production. This exemplifies another both solution to an either/or proposition. 

As far as AHLTA or VistA, there are strengths and weaknesses 

in both systems. That is another either/or proposition, I think, that 

is better answered with both. 

AHLTA is integrated worldwide and available 24/7. There are 

functional problems that are being worked on to improve use at the 

clinical and at the business level. 

VistA shows the benefits of local design and its adoption by end 

users who are more inclined to buy into products they create. 

The downside for the VA is the historic lack of configuration 

management. I use management intentionally as against configuration control. The VA faces big challenges in reorganization and 

must be careful not to destroy the strategy that delivered its success while addressing its Achilles heel of decentralized, unmanaged 

growth. 

The cost of imposing one system on both organizations now 

would be prohibitive. Establishing interoperability and designing a 

strategy of convergence over the next 10 to 20 years will allow both 

a solution and capitalize on best practices and less disruptive to 

changes to either system. 

These comments summarize what I would offer as a Steering 

Committee Member engaged in this project from the start. 

I would also encourage Congress to continue its support of the 

VistA program and the agencies involved. Sustaining this and 

other successful projects will enable the DoD and VA to maintain 

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forward momentum rather than losing the intellectual capital that 

brought these results about. 

And in addition to General Robb’s testimony, I think financial resources to maintain the intellectual momentum we have gained are 

necessary. And I would say that we need those to continue. Otherwise, we will get this far and then put on hold until another round 

of money comes through and you have to reassemble a team and 

start basically, go a few steps backward before you can go forwards 

again. 

I would like to thank the Committee for inviting me to testify 

and welcome questions. 

[The prepared statement of Colonel Salzman appears on p. 65.] 

Mr. MITCHELL. Thank you. 

Mr. Green, you have 5 minutes. 

TESTIMONY OF HOWARD B. GREEN 

Mr. GREEN. Thank you, Mr. Chairman. I would like to thank you 

for the opportunity to testify on sharing of electronic medical information between the Department of Defense and Department of 

Veterans Affairs, what is being done to accomplish the objectives 

and the viability of the approach. 

I have been a member of the Department of Veterans Affairs 

Health Information Technology (IT) community for over 19 years, 

serving in multiple capacities at the local, regional, and national 

level. 

Prior to joining the Office of Information and Technology in 2004, 

I was the Chief Information Officer (CIO) for the VA Heartland 

Network, Veterans Integrated Systems Network 15, and was responsible for the introduction of VA’s VistA system at all facilities 

and clinics in the region. 

Most recently, as Deputy for Operations Management within the 

Veterans Health IT portfolio, I participated as a staff member on 

the President’s Commission for America’s Returning Wounded 

Warrior and was co-author of the Information Technology chapter 

and final report recommendations. 

Following that assignment, I have been given the responsibility 

for coordinating many of the recommendations from the President’s 

Commission report. 

Formal activities related to the sharing of clinical information between VA and DoD have been ongoing since 2001. Although there 

are a number of systems that have been developed to support this 

function, for all intents and purposes, the overarching goal is the 

bidirectional exchange of computable information between VA and 

DoD in real time. 

The following are a selection of the systems that are in place to 

support the exchange of clinical information: Bidirectional Health 

Information Exchange or BHIE supports the functional interoperability between VA and DoD through the exchange of textual patient health information. Through BHIE, the two departments have 

transferred information for over 2.3 million unique patients who 

are active dual consumers. The information is viewable through 

BHIE. The BHIE interface flows to and from the following systems: 

On the VA side, we pull data from 128 VistA systems and the 

data is viewable through Computerized Patient Record System 

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(CPRS) and VistA web. On the DoD side, data is pulled from the 

composite healthcare system, clinical data record, the clinical information system (CIS), and theater medical data store. Data is then 

viewable through the AHLTA share application. 

Currently VA and DoD are bidirectionally sharing viewable information supporting ten categories of clinically relevant data including outpatient pharmacy data and anatomic pathologies, surgical 

reports, radiology text reports, and discharge summaries from several DoD sites running CIS. 

By December 2007, the goal is to expand the amount of clinical 

data exchange through BHIE to include encounter notes, patient 

focus problems list, and theater level inpatient and outpatient 

notes. 

By September 2008, VA and DoD improvements will include the 

addition of a polytrauma marker, an OIF combat veterans identifier, electronic patient handoff indicators, DoD scanning interface, 

the interagency sharing of essential health images, and much 

more. 

The clinical health data repository or CHDR is the clinical data 

interface that supports the exchange of standardized and computable data. This data can be used to support the automated clinical 

decision support tools such as drug/drug and drug/allergy order 

checking. 

Currently data from the CHDR system interface is being used at 

seven VA and DoD sites. The interface currently supports the 

movement of pharmacy and medication allergy data and will be upgraded to include chemistries and hematologies in the fourth quarter of fiscal year 2008. 

The key distinction between BHIE and CHDR is that the applications leveraging the BHIE interface often require the clinicians 

to look in several locations to retrieve health record information 

from other points of care. This often requires the clinician to interpellate based on approximation when comparing data elements due 

to the different terminologies. 

By comparison, clinical information obtained through CHDR can 

be incorporated into the same clinical view allowing for automated 

computation and thus allowing the users to readily compare like 

data. 

Collaborations such as the one between the VA Puget Sound 

Healthcare System and Madigan Army Medical Center focuses on 

specific functionality and support of limited sharing agreements 

and are vital partners in the process of demonstrating new capabilities and functions. 

By comparison, the Great Lakes Federal Healthcare Center will 

eventually push the concepts of medical and administrative data 

sharing to its limits. The goal at the Federal Healthcare Center is 

to fully integrate the clinical and administrative functions between 

the two healthcare systems. 

Planning activities are underway to develop the local project 

team to support this activity and, additionally, an enterprise level 

of team resources is being assembled to resolve technical and operational issues that are beyond the local team’s ability to address. 

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There are certainly advances in the application of information 

technology that can be applied. However, the process is complex 

and must be driven by key business decisions and not by IT. 

Mr. MITCHELL. Could you—— 

Mr. GREEN. Mr. Chairman, this—— 

Mr. MITCHELL. Okay. 

Mr. GREEN [continuing]. Does conclude my opening remarks. 

[The prepared statement of Mr. Green appears on p. 68.] 

Mr. MITCHELL. Thank you. 

Lieutenant Commander Martin? 

STATEMENT OF LIEUTENANT COMMANDER JAMES LAWRENCE 

MARTIN 

Commander MARTIN. Mr. Chairman and Members of this distinguished Subcommittee, thank you for inviting me to be here today. 

I am Lieutenant Commander James L. Martin and I serve as the 

Regional Information Systems Officer, Navy Medicine East. 

Thank you for this opportunity to talk about my personal involvement in design and implementation of the composite 

healthcare system, CHCS2, AHLTA, and the electronic medical 

record sharing between the Department of Defense and the Department of Veterans Affairs. 

The present method of sharing electronic medical information at 

Naval Health Clinic, Great Lakes is through the Bidirectional 

Health Information Exchange, BHIE, and the clinical health data 

repository, CHDR. 

The Veterans Affairs’ providers are granted read-only access to 

the Department of Defense composite healthcare system and 

AHLTA. The Department of Defense providers are granted read 

and write privileges to the Veterans Affairs’ computerized patient 

record system which resides on the Veterans Health Information 

System and Technology Architecture, VistA. 

Specifically, access to the composite healthcare system, AHLTA, 

and the computerized patient record system in North Chicago is 

achieved through a single end user device with icons on the desktop representing each of these applications. This allows for seamless patient flow from the recruit processing center clinic at recruit 

training center, Great Lakes, to the emergency room and inpatient 

facility at the North Chicago Veterans Affairs Medical Center. 

Laboratory data sharing interoperability, LDSI, is used to share 

laboratory information between these two systems. The combination of these methods listed above allows complete sharing of all 

clinical information between the Veterans Affairs and the Department of Defense providers. 

My personal involvement in this process dates back to 1992 when 

I assisted in the design and implementation of the infrastructure 

and end user device placement and support, a Composite 

Healthcare System, CHCS Legacy. 

While serving as Assistant Department Head in Naval Medical 

Information Management Center, Bethesda, my involvement included personally visiting each naval healthcare treatment facility 

prior to and during the system implementation. 

Thereafter, my role expanded in 1994 as Head Management Information Department Naval Hospital, Pensacola, where I manwwoods2 on PRODPC68 with HEARING

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aged the composite healthcare system host site for the hospital and 

its remote facilities. 

In 1997, while serving as the TRICARE Region 2 Regional Information Systems Officer, Naval Medical Center, Portsmouth, one of 

our commands was selected to be the test site for the composite 

healthcare system 2, the predecessor to AHLTA. 

From 2000 to 2004, I was the Information Systems Officer at 

Navy Medical Center, Portsmouth overseeing the test and implementation of the composite healthcare system 2 system, AHLTA. 

It was during this tour that Naval Medical Center, Portsmouth 

first populated the clinical data repository with a 25-month data 

pool from the CHCS Legacy system, placing demographic information and laboratory, pharmacy, and radiology results in the clinical 

data repository. 

From 2004 until 2006, I served as the Medical Liaison Officer, 

Space and Naval Warfare System Center, Norfolk, where I was in 

charge of design and testing of the theater medical information program maritime, TMIPM, the Navy operational version of the composite healthcare system 2 and AHLTA, designated at the time 

CHCS2 and AHLTA–T. 

Currently as the Regional Information Systems Officer for Navy 

Medicine East, I oversee all the information management and technology for the Navy military healthcare facilities that fall under 

Navy Medicine East. Naval Healthcare Clinic, Great Lakes is one 

of these commands. 

I have made five site visits in direct support of the DoD/VA initiative at Great Lakes. During these visits, I have surveyed the existing facilities and assisted in the planning and relocation of the 

Information Management/Information Technology (IM/IT) equipment to its new location at the Federal Healthcare Center. 

I attend biweekly conference calls and engineering support meetings where the design and layout of the actual IM/IT spaces is discussed. 

The other commands under Navy Medicine East that I am presently assisting with DoD/VA IM/IT initiatives include Naval Health 

Clinic, Charleston, Naval Hospital, Pensacola, Navy Hospital, Jacksonville, and Naval Medical Center, Portsmouth. 

I am also a member of the National Information Management 

and Technology Task Group for the Department of Defense and Department of Veterans Affairs Electronic Health Information Sharing Initiative. 

My responsibility as a member of this task force is to plan and 

oversee the acquisition and implementation of information systems 

that integrate VA and DoD healthcare processes at the North Chicago Federal Healthcare Center. 

Our goal is to have an interoperable information system that 

supports clinical and business operations by June 2010. We plan to 

create a single main computer room and a single main telecommunications room. 

Additionally, an information management and information technology network trust between DoD and VA must be established 

along with domain ownership and single electronic mail system. 

We are presently gathering requirements in the functional use so 

that a determination can be made on whether a combination of the 

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information systems or a new information system is required to 

meet the functional user requirements. 

The ultimate goal is to have a single point of entry to support 

the missions of both DoD and VA patient populations. At present, 

this goal is met by providing access to CHCS, AHLTA, and CPRS 

using multiple icons on a single end user device. 

Mr. MITCHELL. Could you wrap up your testimony, please? 

Commander MARTIN. Yes, sir. 

In addition to the goal of the single point of entry, we are also 

working on the consolidation of IM/IT systems of all the functional 

areas in the Federal Healthcare Center. This involves the management of development of functional requirements, assisting with 

local site integration efforts, assisting enterprise solutions, and 

communicating the status. 

I would like to conclude by saying that one of our top priorities 

is to continue finding ways for electronic medical data sharing between DoD and VA. 

Mr. Chairman, Committee Members, thank you again for this opportunity to speak about our efforts. At this time, I would be 

pleased to answer any questions you may have. 

[The prepared statement of Commander Martin appears on 

p. 71.] 

Mr. MITCHELL. Thank you. 

Colonel Marinkovich, you have 5 minutes. 

STATEMENT OF COLONEL GREGORY ANDRE MARINKOVICH 

Colonel MARINKOVICH. Mr. Chairman, Members of this distinguished Subcommittee, thank you for inviting me here today. I am 

Colonel Andre Marinkovich and I serve as the Data Architect in 

the Clinical Information Technology Program Office, that is CITPO, 

with the MHS, Military Health System. 

Thank you for this opportunity to talk about the military’s electronic health record, AHLTA, and the strides we are making in 

sharing information between the Department of Defense and the 

Department of Veterans Affairs. 

AHLTA is an enterprise-wide medical and dental outpatient clinical information system. It currently is the military’s outpatient 

EHR or electronic health record that generates, stores, and provides secure online access to longitudinal, lifelong patient 

healthcare records for the more than 9.1 million MHS beneficiaries 

seen in our military treatment facilities. 

AHLTA ensures the continuity of the Department’s health information and patient centered healthcare delivery worldwide with accessibility anywhere, any time. Worldwide deployment of AHLTA 

which began in 2004 was successfully completed in November of 

2006. Implementation support activities span 11 time zones and 

trained over 55,000 users with more than 18,000 healthcare providers. 

The current AHLTA functionality includes encounter documentation, orders, results, retrievable coding, and alerts, reminders, rolebased security, master patient index, the ability to do ad-hoc queries. 

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AHLTA use continues to grow at a significant pace. To date, we 

have had 45 million outpatient encounters recorded. It is growing 

approximately 120,000 to 112,000 per day, per workday. 

DoD and VA are also taking the first steps toward a joint electronic health system. There has recently been a contract to assess 

the DoD and VA’s business and clinical processes, design features, 

and system constraints relative to the inpatient component of an 

EHR. 

This assessment will determine and describe in narrative and 

graphic format the scope and elements of the joint inpatient electronic health record and identify those clinical and business capabilities and applications that interact with the joint inpatient electronic health record. 

An analysis of alternatives will then be conducted to develop a 

recommendation for the best technical approach. We will then implement that solution. 

Based on feedback from several AHLTA user conferences, we are 

making significant changes to the next version of AHLTA that will 

be released in December 2007. Better performance and better user 

friendliness are a couple of the things that we are going to be providing. There will also be other enhancements with the ability of 

people to use the system from multiple sites and enable mobile providers to continue to use the system seamlessly. 

Looking ahead into 2008, we plan to begin worldwide deployment 

of dental charting and eyeglass ordering. 

I would like to conclude by saying that one of our top priorities 

is to continue finding ways for AHLTA to seamlessly transfer information between the DoD and the VA, ensuring continuity of quality care for returning wounded warriors. 

With your support, we will continue building on our achievements and sharing electronic health information in support of the 

men and women who serve and have served this country. 

Mr. Chairman, Committee Members, thank you again for this opportunity to speak about our efforts. And at this time, I would be 

pleased to answer any questions you may have. 

[The prepared statement of Colonel Marinkovich appears on 

p. 73.] 

Mr. MITCHELL. I want to thank all of you. And I wanted to apologize before the bell rings that we are about to be called for a vote 

which means we will take a vote and I am not sure how many 

votes there will be. Okay. So it will be about a half hour in between. But we can get started with some of the questions anyway 

until the bell rings, but I wanted to apologize. We will take a break 

and recess and come back. 

The last two panels explained the importance and necessity for 

electronically sharing medical records. You are all on the ground 

doing it. And the question is for the DoD folks. 

In your opinion, what obstacle is most responsible for getting in 

the way of sharing electronic medical records with the VA? Anyone? 

Colonel MARINKOVICH. I think the biggest obstacle has been that 

the DoD has been working to develop and deploy a system that has 

only recently been finished. And I think since that time, since basiwwoods2 on PRODPC68 with HEARING

27 

cally December of 2006, we have made really significant strides in 

terms of being able to share information. 

Our systems simply did not have all of the electronic information 

that we wanted to share and I think now we are beginning to have 

all that and have those capabilities. So I think once things become 

electronic, the sharing becomes easier and all the work that we 

have been doing with BHIE and with CHDR are going to bear 

fruits. 

Mr. MITCHELL. Mr. Green, first of all, do you agree with the assessment of what has been holding us up? 

And, secondly, I know the VA has been actively researching and 

implementing electronic medical records. I am also aware that integrating these systems with DoD records has been challenging. 

What is standing in the way of getting all of this medical information into a readable and computable format and how long will 

that take to do that? 

Mr. GREEN. Well, I would certainly agree with the statements of 

Colonel Marinkovich. 

The question is somewhat complex. As far as how long it will 

take, we do have plans to complete delivery of the medical record 

through the end of fiscal year 2008. However, and what you have 

seen is, you know, a slow progression from 2001 forward. 

Some of the issues are as Colonel Marinkovich stated, but you 

also have to understand that the state of the industry is not exactly 

rushing ahead of us to say this is how we should do it. A lot of the 

territory that we are stepping into is new ground. 

There are no standards in certain spaces that we are working 

with and we are having to derive those standards in advance of, 

say, what the national interests may come to conclude. 

So there are a lot of technical challenges. I have seen a lot of activity in the past 24 months which is extremely pleasing and great 

to see. We have a long road to go. and we are working as collaboratively as we have ever worked in the past. 

Mr. MITCHELL. Thank you. 

And one last question for anyone on the panel. Are there any 

possible Health Insurance Portability and Accountability Act 

(HIPAA) restraints or constraints that are standing in the way? 

Colonel SALZMAN. Well, I think both agencies probably need to 

answer independently, but I know on our side, we follow all the 

HIPAA requirements as everyone should. So I do not think there 

are constraints. There are simply things we have to do to make 

sure we cover those bases. 

Mr. MITCHELL. And the reason I ask that is because we have 

heard before that the reason there is no sharing of these records 

from DoD to VA is because of HIPAA and that it takes a long time. 

I am just wanting to make sure that, if that is a problem and that 

has held up any transfer of records that we take care of that as 

quickly as we can. 

Colonel MARINKOVICH. I think you are asking a question that 

really should not be addressed necessarily to technical people. We 

all believe, I think, and I think we would all agree that there 

should be role-based security down to the level of an individual patient. 

wwoods2 on PRODPC68 with HEARING

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And so our systems should be able to accommodate whatever 

HIPAA tells us to do. And I think, historically, we have had some 

issues with that because we have needed to get that kind of ironed 

out. 

Mr. GREEN. I would agree. Certainly we are progressing very 

sensitively through this area. As a member of Dole-Shalala Commission, we actually looked into that and did not see any overwhelming HIPAA constraints that would preclude the sharing of 

data. In fact, there are sharing agreements that support it. 

But it is something that we do not take lightly. We do not want 

to end up in a situation where we are jeopardizing the privacy of 

either personal health or identifier information. 

Mr. MITCHELL. Thank you. 

Would you like to ask some before we—as soon as Ms. BrownWaite gets through, we are going to take our recess and go vote. 

Ms. BROWN-WAITE. Just a couple of things. I believe that we 

have held hearings in the past where it was absolutely clarified 

that there are no HIPAA problems. So please, gentlemen, do not 

use that as an excuse. That issue is off the table. There are not any 

HIPAA problems. 

Do you all agree? 

Colonel MARINKOVICH. Absolutely, ma’am. 

Ms. BROWN-WAITE. I think in the past, it was a great thing to 

use as an excuse, but it should not be. That show is over. 

Let me ask a question. I have been told this and I would like a 

response. Do the various branches of the military use, for example, 

the same kind of x-ray, magnetic resonance imaging (MRI) equipment so that it can be even within the branches shared? So if you 

all use separate systems, is that part of the complicated problem 

here? 

And, you know, there is certainly an ability to save money by 

bulk purchasing. Why is this not done? I mean, why are all these 

separate systems out there? And any one of you all can just jump 

right in here. 

Colonel MARINKOVICH. I think that is for me to answer. The 

MHS, Military Health System, has not had an overarching radiology PACS approach. And so it has been left up to the responsibility of the services and the sites themselves to procure those 

kinds of systems. 

Now, part of the reason for that is that those systems are medical devices and so they fall under a different set of rules and regulations relative to electronic health records. 

And so I think you are absolutely correct. If we had enough 

money to go in and tear out everything we had and put in something new, that would be a positive thing. But because things have 

been bought over various periods of time, the life cycles are completely out of step. 

Ms. BROWN-WAITE. So the health system in DoD has been there 

for—— 

Colonel MARINKOVICH. I am talking about PACS, ma’am. 

Ms. BROWN-WAITE. I beg your pardon? 

Colonel MARINKOVICH. I apologize. I am talking about the radiology systems, what are called picture archiving—— 

wwoods2 on PRODPC68 with HEARING

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Ms. BROWN-WAITE. Correct. It has been there. This is not new 

technology, guys. Okay? It is not new. Why not consolidate? Why 

suddenly say, gee, we have disparate systems? 

Colonel MARINKOVICH. I think that is going to have to be something I will have to leave to Mr.—— 

Ms. BROWN-WAITE. And, you know, this is not something that 

today we should immediately change. It has been coming. You 

know that the sharing issue, it is not new. It has been here for a 

very long time. 

And to have even this complicated system, these systems out 

there that are not even—would it be accurate to say that, you 

know, every time that it is transferred over to a hospital that there 

is a problem? Would that be an accurate thing to say if the receiving entity does not have the same ability? 

Colonel MARINKOVICH. Well, once again, you are asking a question that is a little bit outside of my expertise. I can tell you that 

if you are talking about the access to these kinds of radiology images for certain kinds of uses that we are in the process of putting 

together an integration effort that has made significant strides. We 

have also worked with the folks down in El Paso who—— 

Ms. BROWN-WAITE. Colonel, I do not mean to be rude. I really do 

want to hear your answer. We do have to go to vote. 

Colonel MARINKOVICH. Not a problem, ma’am. 

Ms. BROWN-WAITE. Mr. Chairman, if I am unable to come back 

after the vote, I would ask that Art Wu, Minority Subcommittee 

Counsel, take my place instead. 

As you know, Mr. Bilbray is from California and he rightfully 

went to be home with his constituents during the tragic fires that 

are taking place. 

Mr. MITCHELL. So without objection. 

Ms. BROWN-WAITE. Thank you. 

Mr. MITCHELL. Thank you. 

This hearing is recessed. 

[Recess.] 

Mr. RODRIGUEZ [presiding]. Thank you very much. I know the 

Chairman hopefully will be making it pretty soon. Let me once 

again just thank you not only for your service but for your testimony. 

Some of you, I gather, had the opportunity to listen to the testimony of the GAO report. Do you all have any comments in terms 

of their findings and the problems that were identified from their 

findings? 

Mr. GREEN. Having reviewed those findings in the past and, you 

know, through many efforts, you know, we have made a lot of 

progress. I have to agree. And we continue making progress. 

Is there a need to focus our energy, create a strategic direction 

between the two departments that is tangible, that we can build 

to? I think that is the opportunity that exists. 

And that is one of the points that I clearly take away from the 

GAO report, that a combined plan is necessary that is tangible, 

sets expectations, objectives, and that we can build to. So I would 

be remiss if I said I did not agree. 

Mr. RODRIGUEZ. But the GAO has indicated that you have not 

come up with a long-term plan. And I know the military. If they 

wwoods2 on PRODPC68 with HEARING

30 

are good for something, they are really good for planning. I know 

you have them all over and I am sure you have some on the shelf. 

So what is the problem? 

Mr. GREEN. We have plans to deliver, and I invite my other colleagues here to comment, but we have plans to deliver specific 

functionality. How that equates into the long-term strategy is 

somewhat vague. 

But we are not doing the wrong things. There is absolutely no 

question in my mind that the things that we do are the right 

things. It is just how do they fit into the overall strategy of how 

VA and DoD need to support our population into the future. 

Mr. RODRIGUEZ. Colonel, anyone else? 

Colonel MARINKOVICH. Well, I was going to start by just apologizing that I do not have full visibility to be able to answer the 

question completely. But I know the 2 years that I have spent at 

CITPO and the Military Health System has demonstrated to me 

that there is just an increasing commitment to share. 

And I know that just in this last year, we have been working to 

share electronic documents and radiology images for regular providers between the DoD and the VA in a way that, you know, is 

just very encouraging to me. I spent a lot of time working with the 

VA people and our DoD colleagues to achieve that. The visibility 

again is just not—— 

Mr. RODRIGUEZ. And, by the way, I was glad that Colonel is it 

Salzman? 

Colonel SALZMAN. Salzman. 

Mr. RODRIGUEZ [continuing]. That you indicated the need for resources in order to make that happen. Although, as I recall, we 

have pumped a good amount of—I cannot quote you the amount in 

the past—whether it has gone for that purpose, I do not know— 

but we have kicked in some resources in the past. 

But you need to let us know the amount of resources that are 

needed in order to make this happen because I think it can be 

more cost effective in the long term, not to mention that it would 

be much better for our soldiers for them to be able to have that 

folder and make better decisions when it comes to benefits and 

other types of treatment. 

Yes, sir. Go ahead, Colonel. 

Colonel SALZMAN. Thanks for that support. The problem is that 

where the money is allocated makes a difference in what programs 

get supported and how it goes forward. There are so many requirements out there that are dedicated and focus on one area. To sustain, that requires some intention, you know, from Congress 

through DoD and VA to the specific projects. 

Mr. RODRIGUEZ. And it is my understanding that your program 

is running out of money. Is it because it was not allocated sufficient 

resources or what? 

Colonel SALZMAN. No, no. It is not that. It is ending as far as fiscally. That is the end of that project. And therein lies the problem 

that if you identify toward the end of a project something that has 

been successful, the lag time in getting legislation to support that 

in the future—— 

Mr. RODRIGUEZ. That is why the GAO has indicated that you 

have not come up with a plan, a long-term plan that would go bewwoods2 on PRODPC68 with HEARING

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yond a year, 2 years, 3 years, whatever. And that is why that is 

essential so that those resources can continue to flow. 

Colonel SALZMAN. And part of it is the lessons learned that you 

gain as you go through the process. The feedback loop to Congress 

to legislate specifically, that lag time does not inform the legislative 

process, I think. 

Mr. RODRIGUEZ. And, Lieutenant Commander Martin, did you 

want to make any comments on the GAO and the fact that I know 

you have been engaged for a good 15 years? You know, what has 

been the problem? 

Commander MARTIN. Well, sir, it is my opinion that we do have 

a schedule. It depends on what we are working specifically on. If 

you take North Chicago for an example, you know, our timeline is 

2010. So we have built a schedule to have your facility operational 

in 2010 with the systems that the functional users are identifying. 

Mr. RODRIGUEZ. Okay. Let me go ahead and get, Mr. Wu, do you 

have any questions? 

Mr. WU. Yes, I do, Mr. Rodriguez. Thank you very much. 

Commander Martin, looking at your testimony—and, Mr. 

Rodriguez and Chairman Mitchell, appreciate the opportunity for 

the Ranking Member to have the questions asked through her 

Counsel—you have been working at this since 1992. Can you tell 

me what the original deployment date was for CHCS1 and 2? 

Commander MARTIN. The original deployment date for CHCS1? 

Mr. WU. Its implementation. 

Commander MARTIN. I do not know that off the top of my head, 

sir. I know what my schedule was in the Navy and we had CHCS1 

implemented on the Navy side on schedule. I mean, we followed it. 

I did that for 24 months between 1992 and 1994. 

Mr. WU. Don’t you think the original, or maybe someone else out 

there may know, don’t you think that implementation date was 

supposed to have been probably a decade ago? Anyone? 

Colonel MARINKOVICH. I think the answer to that question may 

be able to come more easily from the next panel. But are you asking CHS1, sir, or CHS2? 

Mr. WU. When do you think CHS1 started? 

Colonel MARINKOVICH. I know when I was in Tripler, it was one 

of the beta sites and that was 1989. 

Mr. WU. Right. It originally started in 1987. We are in 2007. We 

are talking about 2010. And VA has got to follow the lead of DoD 

in order to get that integrated system, correct? 

Mr. GREEN. Sir, if you are asking that VA has plans to create 

an integrated system that go out several years, I think the current 

year target is 2014 or so and that we have been in the process of 

doing this for several years. That is correct. 

Mr. WU. All right. Commander Martin, I have another question 

for you if you do not mind. You stated in your testimony that your 

mutual goals with VA is to have an interoperable information system that supports joint clinical and business operations at the joint 

venture at Great Lakes Naval Training Center in North Chicago by 

June 2010. 

And I think we all look forward to that happening. I think that 

will be the model on a lot of the governance issues between VA and 

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32 

DoD that can be ironed out, at least at that test site, maybe not 

uniquely, geographically unique to that. 

My question to you is, right now does DoD trust VA’s IT security 

measures? 

Commander MARTIN. In my opinion, sir, they trust them. The 

issue is whether or not the VA is recognized as a trusted agent 

with DoD which is separate. 

Mr. WU. Okay. Are they a trusted agent? 

Commander MARTIN. As of today, sir, in my opinion, no. 

Mr. WU. And I also understand the DoD’s distrust of VA’s IT 

issues and vulnerabilities has resulted in DoD placing its own servers in VA’s four polytrauma centers. Is this true? 

Commander MARTIN. I am not an expert in that area, sir. I could 

not answer that one. 

Mr. WU. Mr. Green? 

Mr. GREEN. I am not an expert either. There may be somebody 

in the panel behind me that can address that. 

Mr. WU. So you are punting? 

Mr. GREEN. I am punting, yes, sir. 

Mr. WU. Let us say that it is true. What does that indicate to 

you? 

Mr. GREEN. The placement of servers in the VA application in 

order to support or VA environment in order to support DoD applications, it would indicate that we are adding layers of complexity 

in order to achieve the end goal. 

Mr. WU. Okay. A question collectively for the panel, not to put 

any of you on the spot. This whole issue of interoperability exchange and timely exchange of information, do you think this is a 

technological barrier that is taking this 20-year tango down this 

path or is there a cultural will issue? 

Colonel MARINKOVICH. I would have to say from my vantage 

point, it is a little bit of a combination of both because the question 

is what data do you want to share. And if the answer is, well, what 

you put in CHCS, then I agree completely. It should not have 

taken us 20 years to share what is in CHCS with what is in VistA, 

basically being very similar systems. 

But if you are talking about the rest of the EHR, I think that 

has only begun in the last 5 or 6 years to be truly an industry in 

itself and I think we are pretty close to being able to deploy that 

kind of capability between the two agencies or the readability, the 

readable electronic health record. 

Mr. WU. Anyone else? Colonel Salzman. 

Colonel SALZMAN. Yes, sir. As far as interoperability, and I did 

not get to those comments in my testimony, but I think that that 

is where we are now capable of doing that technologically. 

But if you look at the private healthcare sector, they are facing 

the same problem. And I think by breaking ground, the DoD and 

VA are leading in the efforts to demonstrate interoperability and 

that the private sector will follow that path as we extend it into 

Regional Health Information Organizations (RHIOs) and into the 

national health information network. So I do not see us in looking 

at private healthcare sector as being behind. I think we are in the 

lead. And that—— 

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33 

Mr. WU. I do not think there is an argument there even though 

I have seen a couple meltdowns on the RHIO attempts. 

Colonel SALZMAN. Right. 

Mr. WU. Is that not correct? San Diego melted. I mean, as the 

private sector, public sector initiatives and DoD and VA are leading 

the way. 

I am just asking after 15, 20, however many years you want to 

call it, the GAO says a decade, we say two decades, some say 25 

years, is why have we not moved, or as the opening statement of 

Ms. Brown-Waite is we have seen probably more movement and in 

Chairman Mitchell’s statement as citing more movement in the last 

24 to 18 months than we have in the last 20 years? What do you 

attribute that to? 

Mr. GREEN. Well, the standards are being developed kind of by 

Health Level 7 and different organizations, so there is, I think 

somebody mentioned it before, we are kind of charting uncharted 

territory, and so there is a learning curve that has to happen in 

doing that. 

Colonel MARINKOVICH. I would say, too, I mean, from my vantage 

point, it is because we are being pushed to do that. I mean, I appreciate visionary leaders like General Dunn, who used to lead us 

at Madigan, who would set the bar way out in front and say make 

it happen. And I think it is leadership that makes these things 

happen. So we appreciate it. 

Commander MARTIN. Yes, sir. I have to agree. I think in my 

opinion, anything is technically possible. Now it is defining, meeting the mission of the VA and meeting the mission of DoD and deciding what are those data fields and elements that we absolutely 

have to share and now we are finally at the point where those are 

being defined by the functional providers. And once we have that 

information, the technology will follow, giving them the information 

they need as the functional experts. 

Mr. WU. Thank you. And I appreciate the latitude that the Chair 

has offered us. 

And piggybacking on Ms. Brown-Waite’s questioning of you, Colonel Marinkovich, you know, talking about the PACS system, talking about the multiple MRI, ophthalmoradiography capabilities we 

have within the services and even within the VA, multiple, multiple systems that do not communicate with each other, what would 

be your reaction, and I am not asking you to speak for the Department, about an interoperable clause in the procurement of major 

medical IT or medical devices with an IT component of both DoD 

and VA purchases where there is a standard utilized where there 

has to be a sign-off that there is an interoperability issue or possibility that that is addressed during the procurement phase? 

Colonel MARINKOVICH. I am strongly in favor of such a thing. I 

have to tell you. I devoted much of the last maybe 6 or 7 years to 

standards organizations and the reason we do not follow standards 

is we do not have discipline. I mean, that is what you need to have 

to follow standards. 

But I think that is only part of it. Once we have done that, we 

then still need to have an overarching governance and an overarching management structure to make the systems that could talk 

wwoods2 on PRODPC68 with HEARING

34 

to each other actually connect. So I agree with you. You are absolutely—— 

Mr. WU. I appreciate that. 

Your indulgence one more time, Mr. Rodriguez. I have a question 

for this panel and the next panel is an issue that you see in the 

press quite a bit now as we talk about our wounded warriors come 

back from OIF and OEF is TBI, mental health component, PTSD, 

and how they are related perhaps sometimes, many times. 

What are we doing about capturing that information and sharing 

that information? I do not see any of that in anyone’s testimony, 

in any of the briefings we have had on what we are doing as these 

soldiers and servicemembers transition to the VA. 

How do they get treated if there is no PTSD record or record of 

medical annotation or any other mental health issue or what you 

need to capture on the requirements under TBI if you are going to 

screen? How is the VA going to do that or how does VA work a 

compensation and pension claim for those diagnoses if that information is not being transferred in some format? I am not even talking electronically to the VA. How does the VA do their job if they 

do not get the information? 

I know that mental health records are held separately. I used to 

be in the Army, an inpatient admin, and those mental health 

records are kept separately or retired separately. I do not see 

where they are merged. So if they are not merged, where do they 

go to and how does VA get access to them? 

Colonel SALZMAN. If I could answer from how we do that locally 

and we are trying to design a model for expanding to the enterprises, which we always keep in sight, we have a swap process. I 

do not know if you were able to see that when you were out there, 

but that interview process captures all the survey information. 

Mr. WU. Actually, we did see that, Colonel Salzman. Is that Madigan specific? 

Colonel SALZMAN. Yes, sir. And that—— 

Mr. WU. And what about the other 65 facilities? 

Colonel SALZMAN. Well, the DoD is looking at that. What happened was there was a mandate to come up with a solution but no 

overarching process to do that. And so of necessity, which is what 

usually happens, and particularly with TBI, you have a new requirement and you have to address it. And there is not an enterprise process that addresses it effectively to deliver a solution that 

handles the soldier in front of you. 

Mr. WU. It was pretty impressive what you did at Madigan on 

that issue, but what you are saying, I do not know, Mr. Rodriguez, 

is if you have PTSD or TBI, then we should send you to Madigan 

then because no other place can screen you well? 

Colonel SALZMAN. Well, the benefit of doing it there is that you 

can develop a model, test it, see how it works, and then you can 

share it enterprise-wide. And so the TBI question is not a simple 

question. It is complicated for the neuropsychologist to answer. 

So thinking that we can diagnose and have a treatment plan that 

is cookie cutter and you can spread across the enterprise at this 

point, I think, oversimplifies the problem. And so what we are 

doing is going through the steps to validate like the screening procwwoods2 on PRODPC68 with HEARING

35 

ess. If you take the two screening questions that were supposed to 

be put into the post-deployment interview—— 

Mr. WU. Right. Are there any other military treatment facilities 

(MTFs) that are doing this or just—— 

Colonel SALZMAN. Yes, sir. 

Mr. WU [continuing]. Madigan? 

Colonel SALZMAN. No. There are other MTFs. 

Mr. WU. How many? 

Colonel SALZMAN. Colorado kind of had the lead because they 

had done it before we did it and they used the Air Force Academy, 

the psychiatrists there as their referral. So they had one provider 

to refer to. 

But the problem is if your filter is too open, you would get 80 

percent of people coming through. If you refine that filter with 

background questions, you can cut it down to 16 to 20 percent 

which we did in our pilot program. So—— 

Mr. WU. I appreciate that. We are looking to see exactly what 

the requirement is and how you implement that or address that enterprise-wide though. 

Thank you very much, Mr. Rodriguez. 

Mr. RODRIGUEZ. Okay. Thank you very much. 

And let me, one quick question or maybe two, yes or no on the 

part of each of you. 

In your opinion, could the Department of Defense and the VA 

start to share all the noncomputable data that exists right now on 

our soldiers’ healthcare and pull that off within 12 months? Yes or 

no? All the data that is not in the computers, paperwork, information. 

Colonel MARINKOVICH. Yes. 

Mr. RODRIGUEZ. Okay. 

Colonel MARINKOVICH. It is currently in our EHR systems, yes. 

Mr. RODRIGUEZ. Within 12 months, you say yes. Thank you. 

Mr. GREEN. The electronic data, the plans are to share that, yes. 

Mr. RODRIGUEZ. Within 12 months, you think you can pull it off? 

Mr. GREEN. That is the plan, yes. 

Commander MARTIN. In my opinion, yes, sir. 

Mr. RODRIGUEZ. The question is, can you do it, can you pull it 

off within 12 months? 

Mr. GREEN. Yes. 

Commander MARTIN. In my opinion, yes, sir. 

Colonel SALZMAN. I will agree, yes, sir. 

Mr. RODRIGUEZ. Okay. We will probably have a hearing in 12 

months and see where we are at, in 6 months. 

Let me ask you one additional. And, Colonel Marinkovich—— 

Colonel MARINKOVICH. Marinkovich, yes, sir. 

Mr. RODRIGUEZ. Yeah. Sorry about pronunciation. You indicated 

that leadership was one of the obstacles in putting the document 

files and the imaging and the progress or the lack of progress in 

development of the Department of Defense electronic medical 

record systems and being able to get that through. 

Any other obstacles there besides leadership? 

Colonel MARINKOVICH. If I could be so bold as to correct a little 

bit. What I said was that leadership is what makes us move forward. And I do not think it is an obstacle. It is just a requirement. 

wwoods2 on PRODPC68 with HEARING

36 

You cannot work in an organization like ours or the VA, I would 

think, without the leaders agreeing and the leaders having a vision. 

And I think the point I was trying to make is that over the last 

maybe 3 years, I have just seen an enormous amount of leadership 

and vision from the leaders that I have had to work for. And I 

think that is why we have made a lot of progress to this point. 

Mr. RODRIGUEZ. Is it safe to say it just has not been a priority 

on the part of the Defense, DoD? 

Colonel MARINKOVICH. If you are asking prior to that, sir, I just 

cannot answer. It is outside of my experience. But I know now the 

people that I work with within my experience, there is no doubt it 

is the highest priority. 

Mr. RODRIGUEZ. Any of you want to comment? Have you all seen 

the reports of the GAO on your lack of performance in that area? 

Have you all seen it? Say yes or no. 

Colonel MARINKOVICH. Yes, I have seen it, sir. 

Colonel SALZMAN. Yes. 

Mr. GREEN. Yes. 

Commander MARTIN. Yes, sir. 

Mr. RODRIGUEZ. So all of you have seen that lack of performance 

in that area? Okay. And so we are saying that within 12 months, 

we can try to pull off some major things and that you are going 

to let us know if you need additional resources. 

Colonel SALZMAN. Yes, sir. 

Colonel MARINKOVICH. Yes, sir. 

Commander MARTIN. Yes, sir. 

Mr. GREEN. Yes. 

Mr. RODRIGUEZ. Mr. Wu, any last questions? 

Mr. WU. No, sir. 

Mr. RODRIGUEZ. Thank you very much. Thank you for being 

here. Thank you. 

Let me welcome panel four to the witness table. Dr. Gerald Cross 

is the Principal Deputy Under Secretary for Health at the Department of Veterans Affairs. Dr. Stephen Jones is the Principal Deputy Assistant Secretary of Defense for Health Affairs at the Department of Defense. 

Gentlemen, we welcome you for your insight and I would ask for 

each of you to introduce yourselves when you make your comments. 

I want to recognize Dr. Cross. 

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STATEMENTS OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL 

DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS; ACCOMPANIED BY PAUL TIBBITS, M.D., DEPUTY 

CHIEF INFORMATION OFFICER, OFFICE OF ENTERPRISE DEVELOPMENT, OFFICE OF INFORMATION AND TECHNOLOGY, 

U.S. DEPARTMENT OF VETERANS AFFAIRS, AND CLIFF FREEMAN, DIRECTOR, VA/DOD INTERAGENCY PROGRAMS, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; AND STEPHEN L. JONES, DHA, PRINCIPAL DEPUTY ASSISTANT SECRETARY OF DEFENSE 

(HEALTH AFFAIRS) U.S. DEPARTMENT OF DEFENSE; ACCOMPANIED BY CHARLES CAMPBELL, ACTING CHIEF INFORMATION OFFICER, TRICARE MANAGEMENT ACTIVITY, U.S. DEPARTMENT OF DEFENSE, AND DAVID GILBERTSON, PROGRAM MANAGER, CLINICAL INFORMATION TECHNOLOGY 

PROGRAM OFFICE, U.S. DEPARTMENT OF DEFENSE 

STATEMENT OF GERALD M. CROSS, M.D., FAAFP 

Dr. CROSS. Sir, I am pleased to be here today. 

And I wanted to point out that we have given you some handouts. We have two that we provided to the Members and I believe 

we have a poster for the audience over here behind us that reflects 

our timelines. 

Good morning, Mr. Chairman and Members of the Subcommittee. Accompanying me are Dr. Paul Tibbits to my right, Mr. 

Cliff Freeman farther to the right. 

VA is working with DoD to move efficiently to exchange medical 

information to better serve our clinicians caring for servicemembers 

and veterans. And although we have recently made significant 

progress in sharing health data, we realize that we still have more 

work to do together. 

Today my comments will focus on five components of data exchange, video teleconferencing, scanned information, bidirectional 

exchange of text, and the exchange of computable data, and case 

tracking using a veterans tracking application called VTA. 

First, my staff report that video teleconferences for physicians 

and nurses at VA polytrauma centers with their colleagues at Walter Reed and periodically those at Bethesda are very effective, offering a format where the clinicians can directly exchange information and ask questions. These conferences also enhance collaborative relationships. 

VA level one polytrauma centers now receive digital radiographic 

images and scanned inpatient information for all patients transferred from several military treatment facilities. These facilities include Walter Reed and Bethesda. The inpatient information arrives 

at our polytrauma centers level one in the form of nonsearchable 

PDF files. 

The bidirectional health information exchange supports the realtime bidirectional exchange of current medical—— 

[Bells ring for votes in the House.] 

Mr. RODRIGUEZ. It reminds you that you still might be in school. 

Dr. CROSS. Yes, sir. It is interesting to compete with that. 

wwoods2 on PRODPC68 with HEARING

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The Bidirectional Health Information Exchange supports the 

real-time bidirectional exchange of current medical data in the 

form of noncomputable text between VA and DoD treatment facilities for all of our shared patients. These data include, here is what 

it includes, discharge summaries, emergency room reports, theater 

data, inpatient and outpatient laboratory data, pharmacy data, radiological text reports. 

In addition, BHIE functionality is being expanded, and here is a 

key point, to facilitate the sharing of additional key data to include 

clinical encounter notes, problem list, and vital signs. 

In 2008, we plan to have more viewable data. Viewable data will 

include vital signs, scanned documents, and family and social history reports. 

The interface between the DoD clinical data repository and VA 

health data repository known as CHDR permits us to share computable allergy and pharmacy data between the departments. 

By computable, we mean these data augment automatic decision 

support capability so that VA and DoD providers treating the same 

patients see automatic alerts when a prescription order would result in adverse drug or allergy interaction. 

This interface is being used by DoD and VA providers at seven 

locations where large populations of patients receive care from both 

VA and DoD healthcare systems. 

The work to make data computable between two different 

healthcare systems is very complex and requires complete standardization of data. VA and DoD with the U.S. Department of 

Health and Human Services and others are leading the national effort to identify standards that are robust and mature enough to 

support full interoperability between computer systems. This work 

is also dependent upon the prioritization of these data by our clinical communities within VA and DoD and the ability of each department to get these data into our data repositories in a standardized format. 

Despite these complexities, the IT staff has informed me that 

jointly we are doing the work to begin sharing laboratory data in 

computable format by the end of 2008. Beyond laboratory, we are 

analyzing the feasibility of sharing vital signs, orders, radiology reports, encounters, immunizations, and problem list in computable 

format. The order in which these domains are standardized and 

shared in computable format will be prioritized by both VA and 

DoD clinicians. 

As you aware, sharing inpatient data is a particular challenge 

since most of the historical data is not in computable standardized 

electronic format. VA and DoD now have a study underway that 

will address sharing inpatient data. VA and DoD have agreed that 

any joint inpatient record will utilize the look and feel of VA’s 

award-winning VistA records as a benchmark or target system. 

I want to emphasize that in my view, it is important to build on 

VA’s electronic health record that has clinical functionality, highly 

praised by doctors and nurses, and is credited with helping VA 

achieve national benchmarks for quality as well as national award 

recognition. 

VA has achieved the ability to assess patient tracking data enterprise-wide using Veterans Tracking Application. VTA is a modified 

wwoods2 on PRODPC68 with HEARING

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version of DoD’s Joint Patient Tracking Application. Our case managers can now access VTA to assist with tracking patients treated 

at both VHA and DoD facilities. VTA is compatible with DoD’s 

JPTA allowing overnight electronic transfer of clinical data on 

medically evacuated patients. 

Finally, our departments are collaborating in the development of 

an information interoperability plan. The IT staff expect this to be 

drafted as early as 2008 and proceed toward the concurrence and 

clearance for a final plan later in 2008. This plan will be recommended to the deputy secretaries of both departments and subsequently overseen by the Joint Executive Council (JEC), Health 

Executive Council (HEC), and the Benefits Executive Council 

(BEC). 

This plan will serve as the strategic organizing framework for 

current and future work to set the scope and milestones necessary 

to measure progress toward the intermediate goals and an end 

state needed to continuously improve service to veterans and members of the Armed Forces. 

Sir, my colleagues and I stand ready to answer your questions. 

[The prepared statement of Dr. Cross appears on p. 74.] 

Mr. RODRIGUEZ. Dr. Jones? 

STATEMENT OF STEPHEN L. JONES, DHA 

Dr. JONES. Thank you, Mr. Chairman. 

It is a pleasure to be here and I would like to go on record and 

join your comments and that of the Chairman as to thanking those 

great men and women who serve in the Military Health System 

and serve our folks in harm’s way and also for the veterans 

healthcare workers that do such a great job in treating wounded 

warriors. So thank you, sir. 

Joining me today is Chuck Campbell, the MHS CIO, and Colonel 

Gilbertson, who is a technical individual, particularly in theater 

programs. 

Thank you for inviting me to update you on activities to improve 

sharing of electronic health information between the Department of 

Defense and Department of Veterans Affairs. 

Since I last spoke to you in May of this year, we have made substantial progress in sharing information and it is gratifying to 

know that even the GAO recognize that progress is being made. 

Yet, we know that much work lies ahead. 

Today across town, our military medical leaders are meeting 

with former Senator Dole, with each other, and with VA participation to help move organizations to the next level of service coordination and systems integration on behalf of our veterans, particularly our wounded warriors returning from Iraq and Afghanistan. 

We know we need to cut through the bureaucratic barriers and 

that has become quite evident to all of us in this room. Today I will 

let you know about the aggressive actions underway to do exactly 

that. 

DoD recently directed a significant change. As you have heard, 

as of October 6, VA providers now can access theater clinical data 

for patients who transfer to the VA for care or evaluation. The theater clinical data includes inpatient notes and outpatient encounters, as well as pharmacy, laboratory, radiology, and other imporwwoods2 on PRODPC68 with HEARING

40 

tant clinical information. This means that VA doctors are able to 

see clinical information on and better prepare for treating severely 

injured patients before they arrive in VA facilities. 

We have also taken steps to better integrate and understand our 

two cultures. In addition to sharing information, we are sharing 

people. 

Just a few weeks ago, we exchanged our most senior Information 

Technical Officer. Chuck Hume, our former Deputy CIO for the 

Military Health System, moved over to the VA. And Chuck Campbell, the former Deputy CIO for Health for the Veterans Health Administration, joined us as our new Chief Information Officer. 

This exchange is about more than two people. It signals a new 

level of trust, respect, and commitment for change that is evident 

in DoD and VA staff alike and provides an intensified focus on improving our service to wounded warriors. 

Here are the major points of progress we have achieved or will 

achieve this year. One, continuity of care. For patients treated at 

both VA and DoD facilities, providers can view electronic health 

data from both departments. 

By the end of 2007 calendar year, all essential health data will 

be, in the words of the President’s Commission on Care for America’s Returning Wounded Warriors, ‘‘Immediately viewable by any 

clinician, allied health professional, or program administrator who 

needs that at a VA or DoD facility.’’ 

Two, continuity of care for polytrauma patients. In response to 

the urgent need for VA providers at polytrauma centers to have as 

much information as possible on inpatients transferring for their 

care, DoD began sending electronic health information such as—— 

Mr. RODRIGUEZ. Dr. Jones, I apologize. I have less than 4 minutes to go vote. Let me recess and I will be right back. 

Dr. JONES. All right, sir. Thank you, sir. 

Mr. RODRIGUEZ. Thank you. I apologize. 

[Recess.] 

Mr. RODRIGUEZ. Would you like to continue with your testimony? 

Do you want to continue with your testimony? 

Dr. JONES. Thank you, sir. And thank you for your quickness in 

getting over and getting back. 

Mr. RODRIGUEZ. There were two votes. 

Dr. JONES. Sir, we were talking about the polytrauma centers 

and I would just like to echo Dr. Cross’ comments. 

Having visited each of the polytrauma centers, it has been operational and working well. And one of the reasons is because they 

do include VTC conferences between the sending and receiving hospitals which enhance communication between the caregivers and 

the family members and patients. 

Three, medical services coordination. DoD and VA have extended 

the sharing concept to include coordination of our other medical 

services. For example, when a DoD and VA medical facility does 

not have the equipment or personnel needed to process certain 

types of lab tests, DoD can send the test to a VA lab for processing 

or VA can send the test to a DoD lab. The end result is expedited 

testing and results shared electronically enhancing the quality of 

care for our patients. 

wwoods2 on PRODPC68 with HEARING

41 

Four, a joint inpatient electronic health record. Since our announcement in March to assess the feasibility of DoD and VA developing a joint electronic inpatient health record, we have awarded a joint contract to conduct a study and we will see those findings in the next several months. 

We know that DoD medical staff require a flexible, mobile, and 

highly scalable electronic information system in the combat theater 

that we describe as one system in garrison and one in theater. 

We will also ensure our unique theater medical systems work 

with the VA to support continuity of care for our veterans. It is the 

agency’s goal to take the best from the DoD and VA systems in designing this joint inpatient system. 

Five, joint governance. VA and DoD electronic health information 

collaboration is a major component of the Department’s joint strategic plan. The Under Secretary of Defense for Personnel and 

Readiness and the VA Deputy Secretary, Co-Chair the Joint Executive Council. Supporting the JEC is the Health Executive Council 

Co-Chaired by the Assistant Secretary for Defense of Health Affairs and the VA Under Secretary for Health. 

In addition, the Chief Information Officers of the Military Health 

System and the VHA Co-Chair the Health Executive Council’s Information Management/Information Technology Work Group. 

Through these joint governance efforts, an unprecedented degree 

of collaboration between VA and DoD is occurring. We understand 

each other’s mission and we are ensuring change occurs at the 

right levels. 

Six, standards adoption. According to many experts, together 

DoD and VA lead the Nation in health information technology, implementation of interoperable standards, and electronic health information sharing. 

The Certification Commission of the Healthcare Information 

Technology, an independent, nonprofit organization, that serves as 

the Department of Health and Human Services certification entity 

for electronic health records systems recently certified AHLTA, our 

electronic health system, assuring our users, partners and patients 

that our information system meets all basic criteria for 

functionality, interoperability, and security. 

In conclusion, as always, we appreciate the insights and recommendations and guidance of this Committee. We are all working 

toward the same end, to provide the highest quality care for our 

Nation’s heroes, past and present. And we recognize that we need 

to work together to achieve our goals as efficiently and effectively 

as possible. 

Thank you for allowing me the opportunity to appear before you 

and to testify about DoD/VA electronic health information sharing 

achievements, goals, and plans. Thank you. 

[The prepared statement of Dr. Jones appears on p. 79.] 

Mr. RODRIGUEZ. Thank you, Dr. Jones. 

And both, Dr. Jones and Dr. Cross, do you want any of the individuals that are with you to make any comments or testimony? 

Dr. JONES. No, sir. 

Dr. CROSS. No, sir. 

Mr. RODRIGUEZ. Okay. Thank you. 

wwoods2 on PRODPC68 with HEARING

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Good to see, David, Colonel Gilbertson. I know that we have a 

good friend in common back in San Antonio, so good seeing you. 

Okay? And thank you for being here with us. 

And all of you, thank you for your service and what you have 

done for us. 

Let me quickly ask: The Chairman of the Committee, full Committee and the Ranking Member also of the full Committee requested that I ask you this question and it is in reference to, I 

think, Lieutenant Colonel Mike Fravell that we ask to stay in 

Washington and remain engaged in the development of the JPTA 

and VTA. 

And it is our understanding that the VA wants Mr. Fravell to 

continue to consult on the VTA, but that he has been shut out of 

the future efforts with JPTA. And the question would be that some 

of us felt that, in fact the Chairman and others, that would not be 

advantageous to keeping him managing the program since he contributed to much of the success. Do you want to comment on that? 

Dr. JONES. Sir, the individual you speak of did a great job in 

helping develop JPTA. But as you know, decisions as to assignments are made by the services. So I will be glad to get back on 

the record to you and pass your question to the service if that is 

appropriate, sir. 

[The following was subsequently received:] 

Lieutenant Colonel (LTC) Michael Fravell will remain assigned in Washington in a position where he can make an impact to the information technology enterprise as the Director of Engineering for AHLTA. In his role, he 

is not only assisting with Joint Patient Tracking Application (JPTA), but 

he is contributing to the entire Department of Defense (DoD) electronic 

health record. Since the Assistant Secretary for Health Affairs oversees the 

DoD component of the joint venture with the Department of Veterans Affairs (VA), LTC Fravell is involved in projects with the VA. LTC Fravell has 

also been made available to the VA as a consultant on the Veterans Tracking Application, and he is involved with developing additional functionality 

in the JPTA. 

Mr. RODRIGUEZ. Okay. And then let me also, Dr. Jones, compared to other Department of Defense and VA applications, the 

JPTA and VTA are relatively inexpensive, almost no new development has been done since the JPTA, in the 18 months, even though 

the user community is asking for new functionalities. 

So why hasn’t the Department of Defense medical health systems 

embraced this technology and expanded its capabilities? 

Dr. JONES. Let me ask Colonel Gilbertson if he would address 

that question, please. 

Colonel GILBERTSON. Sir, on the development of JPTA, the continued efforts from theater in terms of growing the JPTA application are indeed continuing. JPTA is part of the DoD family of systems or is now part of the enterprise solution. 

In fact, we are now building out the functionality of JPTA so that 

all of the information that is in JPTA becomes part of the medical 

record. That was the primary challenge with JPTA is it was its 

own system, a separate stovepipe system. So that information 

never made it into that longitudinal health record. 

So by keeping the functionality of JPTA is really what the providers wanted and making it part of the enterprise system, we are 

now able to make sure that all of that information is captured in 

wwoods2 on PRODPC68 with HEARING

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the electronic health record so that it can be shared to all DoD and 

VA providers. So that is really where our effort is at. 

So we are definitely still developing against JPTA, the current 

application, and we are trying to enhance it based on the feedback 

that we got from Landstuhl and other providers. We were just out 

there last week and we are very much engaged with the actual 

users to make sure that what we are building continues to meet 

their needs. 

Mr. RODRIGUEZ. Thank you. 

Mr. Wu? 

Mr. WU. Thank you, Mr. Rodriguez. 

Dr. Jones, piggybacking on Mr. Rodriguez’s question here on 

Lieutenant Colonel Fravell, and not to beat a dead horse to death 

here, is if my memory serves me correctly, I have a copy of a letter 

from Dr. Kussman, our now Under Secretary of Health, and Admiral Cooper, our Under Secretary of Benefits, letter that went to 

DoD asking for an extension on Lieutenant Colonel Fravell. 

And there is a subsequent letter signed by Chairman Filner and 

Mr. Buyer to then acting Secretary Garens saying that they would 

like an extension of Lieutenant Colonel Fravell, I am not sure if 

we ever got a response to that or not, to continue the work of JPTA 

and VTA. 

I do not know if you would like to comment on that at all. 

Colonel GILBERTSON. As I was saying, the JPTA is part of our enterprise solution. And as you know, AHLTA ultimately, because 

AHLTA is going to collect the whole patient record, is a critical 

part of what we are doing throughout the entire MHS. 

Lieutenant Colonel Mike Fravell is assigned in a position where 

he can make the greatest impact to the enterprise over the long 

run as the Director of Engineering for AHLTA. So in his role, he 

is not only affecting the future evolution of JPTA, he is now affecting the entire product, the entire DoD electronic health record. 

And because we also oversee the DoD component of the joint venture with the VA, the DoD/VA sharing, he is intimately involved 

in all sharing information projects with the VA to include VTA. 

And I have made him available to the VA as a consultant on future developments of the Veterans Tracking Application and he is 

intimately involved with the developer of the additional 

functionality in JPTA which is Colonel Hines, who is also in this 

room. 

So in his current role, he is positioned to go beyond what he has 

been able to do before and actually make a huge impact on the entire DoD and the entire VA as the Director of Engineering for our 

electronic health record. 

Mr. WU. Is he working on VTA, JPTA interface right now? 

Colonel GILBERTSON. Yes, he is. Well, he is working as a consultant. The VA has their own program office and their own way of developing. And he is intimately involved in identifying the requirements for not only VTA, but also he was with us last week when 

we went to Landstuhl and he helped understand what our future 

is for JPTA and its integration into AHLTA. 

Mr. WU. Well, maybe you can shed some light. We have been 

looking at this issue for some time, especially when it came to 

light, and there was a Washington Post article where JPTA was 

wwoods2 on PRODPC68 with HEARING

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abruptly cut off from the polytrauma center in Richmond while the 

doctor was on—I think that has been resolved. I think they all said 

it was a security issue. It was just shut off in the middle of a program. 

JPTA, actually I saw JPTA being demonstrated by Colonel Dr. 

Rhonda Cornum probably 2 years ago at a conference. She was at 

a Commanders’ conference. Said you want to see medical information being transferred, I will show you. It is not a medical record, 

but it is a tracking application, but essential medical information 

tracked on that is attached to it as a PDF. 

Now, Dr. Jones, AHLTA, AHLTA–T, this year, how much has 

DoD TRICARE Management Activity going to spend on AHLTA 

and the deployment? Three hundred million dollars plus, I think; 

is it not? 

Dr. JONES. The program manager should have it. 

Mr. WU. The program manager should have it right down to the 

penny, right? 

Colonel GILBERTSON. The life cycle cost for AHLTA right now is 

at $5 billion, but that also is going to include the inpatient and the 

ancillary replacements for the Legacy. So to date, we have spent 

just over $1 billion on AHLTA and the sustainment of CHCS which 

is now part of AHLTA. 

Mr. WU. CHCS1, 2, AHLTA, AHLTA–T, the rebranding. Is there 

any difference between AHLTA and CHCS2? 

Colonel GILBERTSON. Yes. They are totally different applications. 

AHLTA is an enhancement upon CHCS. So it sits on top of CHCS. 

It does not survive without CHCS. So the Legacy CHCS is part of 

AHLTA. You cannot have one without the other. 

Mr. WU. Okay. Then someone needs to correct what we were 

hearing as that there is no difference. It is just a rebranding. 

Colonel GILBERTSON. No. There is a significant difference. What 

AHLTA does is it now documents the clinical encounter. CHCS was 

primarily an ancillary system that supported our labs, pharmacy, 

radiology, admissions, discharge, transfers, billing. Now we have a 

tool that took it from 101 different locations and brought all that 

data together and made it semantically interoperable across the entire enterprise. 

It used to be when I moved from one station, when I left San Antonio and went to Hawaii, I had a blank record in Hawaii. There 

was no electronic information available in Hawaii because all of 

our systems were disconnected. AHLTA brought those all together. 

So now when I moved here from San Antonio, my entire medical 

record moved with me. And that is what AHLTA did. 

Mr. WU. All right. Would you describe AHLTA as in Dr. Jones’ 

words, to track healthcare most effectively in theater, a flexible, 

mobile, and highly scalable electronic information system is necessary? Does that describe AHLTA? 

Colonel GILBERTSON. Can you repeat the question, sir? 

Mr. WU. I am taking the text right out of Dr. Jones’ testimony. 

I am just asking if that is AHLTA where he says to track 

healthcare most effectively in theater, a flexible, mobile, and highly 

scalable electronic information system is necessary? Is that 

AHLTA? 

wwoods2 on PRODPC68 with HEARING

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Colonel GILBERTSON. I think today that it is becoming more 

AHLTA than it was 2 years ago. AHLTA was—— 

Mr. WU. Does JPTA do that? 

Colonel GILBERTSON. Say again, sir. 

Mr. WU. Does the medical attachments, the PDFs to JPTA, 

would that describe Dr. Jones’ statement there? 

Colonel GILBERTSON. JPTA, if you have the infrastructure. When 

JPTA was implemented in theater, the theater had matured to a 

point where they had the bandwidth and it provided a connectivity 

all the way back to the United States. 

What Dr. Jones was talking about is a system that can work on 

a ship, it can work on initial deployments when you have no communications, and it can work far forward on the battlefield in the 

hands of a medic. JPTA is not that system. AHLTA is that system. 

Mr. WU. If we had the Channing Moss issue today with the surgical team forward Afghanistan and Dr. Oh, that information and 

what was captured there, could that be captured under AHLTA 

today? Since it came under JPTA, I am just wondering what the 

evolution is here. 

Colonel GILBERTSON. Today without JPTA, that information can 

be captured. It would be captured through the current TMIP suite 

and the radiology images would be captured and moved as they are 

today from a PACS server in theater, that is called Med Web, to 

Landstuhl. So, yes, today without JPTA, all that information could 

have been captured and moved. At the time, the answer is no. 

Mr. WU. Okay. Thank you very much. 

Now, under the current system that you are describing, if a 

Channing Moss situation happened again today, are you saying 

that Landstuhl’s accepting physician as that patient is arriving 

from the mobile air staging facility out of theater would have all 

that information that you just described? 

Colonel GILBERTSON. If the systems were used as designed, in 

other words, if the system that was used to enter that information 

was the AHLTA solution in theater, that information would have 

been available to the Landstuhl provider today. 

Mr. WU. If that situation happened today, would the current system be able to capture that information as depicted in that video 

clip? 

Colonel GILBERTSON. The current systems in place would capture 

that information and move it back. 

Mr. WU. Thank you. 

I think we heard you talk about taking JPTA data and 

populating AHLTA. Are we saying, and I think that Ms. Embry 

may have said this to Mr. Buyer last year, is that there is no further money and further development of any other applications 

under JPTA? Is that true or false? 

Colonel GILBERTSON. That is not true. We just invested in JPTA 

integration into the electronic health record. So—— 

Mr. WU. I understand that. But besides the integration effort, 

any other applications? 

Colonel GILBERTSON. Additional dollars specifically to JPTA? 

Mr. WU. Right. Correct. 

Colonel GILBERTSON. Well, once it is part of the enterprise, the 

dollars that are spent on JPTA modifications will come out as 

wwoods2 on PRODPC68 with HEARING

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modifications to the DoD TMIP suite. So there could be depending 

on the requirement. And JPTA brings functionality that will be 

used and if that functionality needs to be expanded, then investment will be made in that functionality. So—— 

Mr. WU. To the best of your knowledge, there is no new money 

earmarked to new JPTA applications as of today, is there? 

Colonel GILBERTSON. Well, JPTA will cease to be its own application. So as we invest in AHLTA and AHLTA–T, we will invest in 

enhancing JPTA along with the rest of the AHLTA suite. 

Mr. WU. Okay. Thank you very much. 

Dr. Cross, in your testimony, you stated that DoD and VA have 

funded a study to study the mutual development of a joint inpatient electronic health record. I understand that initiative took 

place this year. 

Dr. CROSS. Correct. 

Mr. WU. Can you tell why it has taken 15, 20 years to get to this 

point? 

Dr. CROSS. I think this is a point in time where the situation was 

right to do this. I think you can certainly argue that it should have 

been looked at before. 

I will ask my colleagues here to comment on that as well. 

Mr. WU. I mean, I could go back and look at the congressional 

intent, the legislation, all the way back to 1982, the various legislative initiatives we had. 

I have asked GAO to go back on our recess break to look at how 

many studies they have done and maybe a GAO study of all the 

GAO studies to see how many recommendations on this issue have 

been issued in the last decade where the recommendations have 

not been implemented. 

I am just wondering. What was the impetus to all of a sudden 

January 2007 to do this? 

Dr. CROSS. Actually, there was a good meeting between Dr. Jones 

and myself in my office where we discussed what we could do next 

and we moved that forward. 

Mr. WU. Okay. 

Dr. JONES. I think it is a number of factors. One is, as Dr. Cross 

said, we are working more closely together than we ever had before. I mean, we switched. You know, we have Chuck Campbell, 

who was working over at the VA, and Chuck Hume was working 

over. So we are working more closely together. 

We realized the need, as somebody mentioned earlier, because of 

the Walter Reed issues and all the various task forces and committees puts additional impetus on making it happen and making it 

happen faster and making it happen right. 

And then thirdly, I think with us, we were getting ready to invest more heavily into our inpatient record. We now, as you heard 

by an earlier person that testified, the AHLTA which was started 

as an outpatient record was only implemented into each of our 

medical centers last December, so we are the next phase was to 

move more aggressively into the inpatient. 

And it is my understanding that the VA was looking at VistA to 

upgrade because it was time that they needed to refresh because 

of the Legacy system they have. So all those factors, I think, came 

together to, you know, make this time is right. 

wwoods2 on PRODPC68 with HEARING

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And this is not just a study to inform us. This is a study to inform us so that we can take action. And I would be surprised if we 

do not take the information from that study and make it happen. 

Mr. WU. I have one question and one more than that. I think 

that Mr. Rodriguez asked the question. Do you think you will be 

able to implement Dole-Shalala within the timeframe? 

Dr. JONES. Well, again, I think it depends on, you know, all of 

the issues of Dole-Shalala I cannot speak of. The thrust of both 

agencies and Secretary England, Secretary Gates, and I know on 

our VA counterparts is to implement as much as we can between 

the two agencies under existing law. 

Of course, those things that we cannot implement because of law 

or because of legislative packages will be considered by this body 

and the Senate. But we are—— 

Mr. WU. Sir, do you see those legislative initiatives coming up 

any time soon? 

Dr. JONES. It is my understanding that those packages have been 

delivered last week or the week before, I am not certain of the 

time, by the two secretaries. 

Mr. WU. Thank you, sir. 

Dr. CROSS. May I echo that we take that very seriously. Great 

emphasis and importance is given to that project. Some of the testimony that I included in my oral statement today related to time 

factors and so forth of what we are doing, I think, relate to that. 

And on many issues outside of the IT world, which is probably 

mostly outside of the IT world, we are moving forward aggressively 

as we can to implement those things. 

Dr. TIBBITS. Let me add to that since I am the Co-Chair of Lines 

of Action 4 (LOA4) (eBenefits portal) which is the IT portion of this 

senior Oversight Committee process with Dr. Jones. And for just 

the IT slice of your question, yes, we are very committed to it. 

We have a very aggressive series of meetings going on right now 

this month to gather requirements from all the other lines of action. We are now deeply engaged in costing out those requirements 

from an IT perspective, the IT support to all those other lines of 

action. 

We will be presenting that IT plan sometime in the month of November whenever we are told to go present it to both deputy secretaries and that will subsequently result in certain decisions and actions with respect to funding and monitoring with a scoreboard-like 

approach of our progress. 

So the Administration is very committed to that and we, I think, 

have everybody engaged as much as we possibly could in trying to 

make that happen at all levels of both the departments. 

Mr. WU. Dr. Tibbits, would it be safe to assume that in the requirements identification that you would have a TBI component 

there, a mental health, and a PTSD component there? 

Dr. TIBBITS. That is correct. There is a line of action, too, which 

is specifically focused on that. 

Mr. WU. Okay. Dr. Cross, one last question. 

Thank you for indulging me, Mr. Rodriguez. 

Dr. Cross, you also stated VA and DoD are committed to ensuring an ongoing partnership to optimize health delivery to veterans 

wwoods2 on PRODPC68 with HEARING

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and military beneficiaries. Probably for the record, I would say 

here, it be a little onerous to do that now. 

Could you highlight since 2003 when we created the HEC and 

the JEC all initiatives emanating from DoD, VA’s Health Executive 

Committee, direct cost of these initiatives, specific measurable outcomes, everything that has been accomplished? 

Dr. CROSS. Certainly I think we could do that for the record. 

[The Health Executive Council Highlights, FY 2003–First Quarter for FY 2008, dated June 10, 2008, appears on p. 98.] 

Mr. WU. Thank you very much. 

Thank you, Mr. Rodriguez. 

Mr. RODRIGUEZ. Thank you very much. 

And both, Dr. Jones and Dr. Cross, thank you very much for your 

testimony. 

Let me, as you have indicated, that we seem to have made some 

significant progress with your dialog. I would just encourage you 

to keep dialoguing with each other. This is really essential for our 

soldiers and our veterans to try to make this happen as smoothly 

as possible and as quickly as possible. 

And so that it just makes sense for anyone who is providing access to healthcare to our soldiers that data and that folder or whatever the documentation is with that soldier that they have access 

after they leave the military and become veterans so that we can 

best not only treat them but see what we can do in terms of meeting their needs. And I think it would behoove us to try to move as 

quickly as possible. 

And I would ask you once again, I guess, Dr. Jones and Dr. 

Cross, are there any other obstacles out there that we as a Congress can look at to try to make that happen as quickly as possible? 

Dr. CROSS. Let me say very clearly that we support the generosity that Congress has shown with us. The cooperation that we 

have had, there is a new atmosphere, I think, between DoD and 

VA. We meet very frequently. We know each other on a first name 

basis. We are taking all of these initiatives very seriously and in 

many ways, it is a new world. 

Mr. RODRIGUEZ. Thank you. 

Dr. JONES. And I would just echo that, Mr. Chairman. I believe 

that Congress has been more than adequate and has already given 

us some funding in DoD to address TBI, PTSD, and mental health, 

and we are aggressively moving forward in those areas. 

Mr. RODRIGUEZ. Because I would think that hopefully our next 

step, I know in some of the areas already, I know in El Paso, both 

the VA and the DoD, they are in the same facility. They might not 

communicate as much, but at some point, hopefully they will start 

communicating when they are providing access to healthcare. 

And I have other communities and there are some throughout 

the country where it would be ideal for both, you know, the Department of Defense and the VA to get together in providing access to 

healthcare not only to our soldiers but also to our veterans. And 

where they could do that together, it just makes all the sense in 

the world in terms of being cost effective, not to mention in terms 

of getting access to our soldiers. 

And so are there any now in terms of, I asked you what we could 

do, are there any obstacles there that both the Department of Dewwoods2 on PRODPC68 with HEARING

49 

fense and the Department of Veterans Affairs have that you still 

feel that you need to overcome? 

Dr. Jones? 

Dr. JONES. I think our main areas that we need to continue to 

pursue aggressively, which we are, the challenges that are before 

us are to ensure that we have funding at the same time that the 

VA has funding so that we can move forward with the various 

projects in tandem. 

Secondly, on our side, it is helpful for us to—as you know, we 

have different color money in Washington and we have to have research and development money, sustained money, implementation 

funds, so there is different funds. 

So we just need to make sure that we have adequate funding in 

the appropriate categories that can allow us to rapidly move forward as we come forward with our plans that Dr. Tibbits mentioned to ensure that we are meeting the needs, to implement DoleShalala. That is going to take funding. Congress, we hope you will 

consider that. 

And, secondly, once we get the plan to have the joint inpatient 

record, that is going to take funding. So, again, we will be able to 

provide you the necessary justifications so that you will see fit to 

make that funding available. Those would be my comments, sir. 

Mr. RODRIGUEZ. Thank you. 

Dr. Cross? 

Dr. CROSS. I will ask my IT colleagues, Dr. Tibbits, and others 

to comment as well. 

But this is plowing new ground. We are out in front of our many 

civilian healthcare systems where they are still using paper 

records, where they are still transferring information by mail. And 

we are way out in advance of that. We are pioneering for the country, I think, on how to do this. 

And I just hope that we can have the understanding that we are 

on, I think, the cutting edge of learning how to do this. 

I will ask my IT colleagues to comment as well. 

Dr. TIBBITS. Well, thank you, Dr. Cross, and thank you for the 

question. The learning is a key piece of this. 

[The chart is attached to Dr. Cross’ statement, which appears on 

p. 79.] 

Dr. TIBBITS. Dr. Cross pointed out that as you look at the chart 

there on the easel, the dots get closer together as you go from left 

to right. The activity is becoming much more intense. 

But the learning also has to happen and learning at all levels 

anywhere from setting requirements all the way down to deep in 

the bows of how a server is configured and not so much HIPAA, 

but more so the information security policies of both departments. 

A lot of exploration and learning has to happen there. 

There is, however, a great interest, a great commitment on the 

part of the Administration to do so. The need could not be greater 

to serve our Nation’s heroes which would bring me to my sort of 

last point here while I have the microphone for this time, this 

question. 

And that is taking the need of our Nation’s heroes, taking the 

need and formulating that into a plan. I think you have heard a 

lot of conversation, particularly from the GAO, but others also, 

wwoods2 on PRODPC68 with HEARING

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about the importance of such a plan. If we were and which we are 

doing now, by the way, once we have properly depicted that need, 

the high priority needs for information exchange to best serve our 

active-duty members and veterans, then we will have a framework 

to better explain how all this activity that you see here fits together, how the remaining activity that is already scheduled that 

you see there fits together, and what is the gap with respect to the 

need and what you do not see on that chart. That plan we will 

have together probably, let us say, by spring of next year. I would 

call that an information interoperability plan. 

I want to be very careful to emphasize that information interoperability, the sharing of data, can jumpstart, as you see there on 

that board, can jumpstart the service to the way we treat, care for 

servicemembers and veterans before we ever decide to jointly develop software. 

So while this study is going on and we are trying to figure out 

from a cost perspective will it save money and can it move the departments forward to jointly develop software, the data plan can 

help us now in the short term, in the medium term, and in the long 

term to meet veterans’ needs and servicemembers’ needs. 

So that is the last piece of not just talking about the need, but 

actually using the need itself as a planning factor to put that integrated plan together. That is the next phase of sophistication we 

are going to get to and that should drive a lot of the prioritization 

activities to learn what it is we need to learn throughout that entire stack of layers of information processing that I just alluded to 

earlier. 

Mr. RODRIGUEZ. Thank you. 

Mr. Freeman? 

Mr. FREEMAN. As Mr. Wu knows, I have been working with this 

for 10 years and I can honestly say in the last 3 or 4 years, the 

progress we have been able to make has moved forward astronomically actually in my opinion. 

And I think one of the things the earlier panel said about the 

leadership, there is true leadership support. As both Dr. Cross and 

Dr. Jones have said, they worked very closely together. 

And I think that as we have moved forward, it is not that we 

have created some of these applications, but I think the important 

point is that they are actually being used and they are benefiting 

the clinical care that we are providing veterans. 

The Bidirectional Health Information Exchange that was discussed earlier with you, it gets over 3,700 queries a day in the VA. 

It is being used by the provider to provide quality clinical care for 

our wounded warriors and our veterans. And I think that says a 

lot about some of the work that we have done. Thanks. 

Mr. RODRIGUEZ. Let me just indicate I want to thank you and 

also just indicate there is no doubt that we will be having another 

hearing based on the Chairman’s comments, next year. And so we 

are hoping that we can make up some ground in that area. 

And I am going to ask Mr. Wu if he has got any additional comments. No additional questions? 

Thank you very much. And I hope that you continue to dialog together. I also am one of the few that not only sits on the authorizing Committee, but I sit on the Appropriations Committee, so I 

wwoods2 on PRODPC68 with HEARING

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would hope that you come to me and let me know if you need any 

more money. Okay? 

Thank you. 

[Whereupon, at 1:44 p.m., the Subcommittee was adjourned.] 

wwoods2 on PRODPC68 with HEARING

(52) 

A P P E N D I X 

Prepared Statement of Hon. Harry E. Mitchell, Chairman, 

Subcommittee on Oversight and Investigations 

Thank you all for coming today. I am pleased that so many people could attend 

this oversight hearing on sharing of electronic medical information between the Departments of Defense and Veterans Affairs. This is a critically important issue. 

Thousands of our service men and women require and will continue to require significant medical care as the result of the conflicts in Iraq and Afghanistan. The most 

seriously injured of our OEF and OIF veterans may need a lifetime of care, but even 

veterans returning with no visible injury may need assistance with PTSD or mild 

Traumatic Brain Injury. 

DOD and VA are sharing more and more patients. For example, the patients at 

the VA’s four polytrauma rehabilitation centers are almost all still on active duty. 

And active duty service members will be veterans sooner or later. A review by the 

VA’s Inspector General of the 500,000 or so service members who left active duty 

in fiscal year 2005 shows that 92 percent had an encounter with the military health 

system while on active duty that resulted in a diagnostic code. In other words, nearly all of the veterans who go to the VA to get medical care will have military medical records that should be available to VA health care providers. 

If anyone can convince the American people of the importance of electronic medical records, it is our first panel. Specialist Channing Moss is an Army soldier who 

was shot with a rocket propelled grenade that lodged in his body. He is alive and 

walking today because the medical evacuation team and combat surgeons who operated on him put their own lives in danger in order to remove live ordnance from 

Specialist Moss. Brigadier General Douglas Robb was chief surgeon of CENTCOM 

at the time, and he will discuss how important it was that a copy of the x-ray taken 

at the forward field hospital was available to the clinicians in Landstuhl before Specialist Moss arrived. 

DOD and VA have been working on the electronic exchange of medical information for many years. For most of that time, the story is not a happy one. I am nevertheless pleased to be able to say that DOD and VA have made more progress in 

the past 12 to 18 months than they made in the preceding decade. But there is still 

much to be done. There is no reason why, in this day and age, DOD and VA cannot 

electronically share the information necessary to treat our service members and veterans. We should not have to wait any longer. I hope and I expect that DOD and 

VA will tell us today that, by no more than a year from now, clinicians in DOD and 

VA will have full electronic access to the medical information they need to treat 

their patients, whether that information resides in computers owned by DOD or by 

VA. 

f 

Prepared Statement of Hon. Ginny Brown-Waite, Ranking Republican 

Member, Subcommittee on Oversight and Investigations 

Mr. Chairman, Thank you for yielding. 

Mr. Chairman, I would like to thank you for calling this hearing to review the 

status of the electronic medical records sharing between DOD and VA. This Subcommittee has already held two hearings in the 110th Congress on the issue of 

seamless transition of our servicemembers. 

The first hearing was held in March and the second in May, both of which focused 

primarily on the sharing of critical medical information of critically wounded 

servicemembers between DOD and VA. 

I would like to assure the witnesses here today, that this issue is of the utmost 

importance to all Members of this Committee, regardless of political affiliation. I am 

pleased the Chairman has requested that representatives from DOD testify here 

today. It will be important to hear their perspective on the timely exchange of critwwoods2 on PRODPC68 with HEARING

53 

ical medical information between DOD and VA for the seamless continuum of delivering healthcare to our servicemembers. 

I look forward to hearing the steps DOD has taken to allow all critical medical 

information to be viewed by the VA when active duty servicemembers are transferred to VA facilities. In addition, I will be interested in hearing from VA on whether technological obstacles or bureaucratic intransigence prevent this from occurring 

today. 

This past week, staff members visited Keesler Air Force Base and the VA Medical 

Center in Biloxi, Mississippi to see how the Air Force and the VA are coming together in VA/DOD resource sharing. 

Unfortunately, the progress in this area is a result of the devastation of Hurricane 

Katrina and the dynamic personalities of senior leadership at these facilities, and 

not the Veterans Administration and the Department of Defense Health Resources 

Sharing and Emergency Operations Act 1982. 

It appears that the ball has moved forward more in the last 24 months than the 

last 25 years. It is a shame that it took Hurricane Katrina, the debacle at Walter 

Reed, and the devastating wounds of war to expedite progress between the two largest federal bureaucracies. 

I am also looking forward to hearing from representatives of both departments 

about how they plan to implement the recommendations of the recently released 

Dole/Shalala Commission Report, and the Veterans Disability Benefits Commission 

Report. 

Again, I would like to thank you, Mr. Chairman for holding this hearing. This 

issue is a top priority for our Subcommittee, and look forward to continuing our 

oversight responsibilities. 

f 

Prepared Statement of Brigadier General Douglas J. Robb, M.D., 

Commander, 81st Medical Group, Keesler Air Force Base, Biloxi, MS, 

Department of the Air Force, U.S. Department of Defense 

INTRODUCTION 

Mr. Chairman and members of this distinguished Subcommittee, thank you for 

inviting me here today. I am Brigadier General Douglas J. Robb and I served as 

the Command Surgeon, United States Central Command from 2004 to 2007. Currently I am serving as the Keesler Medical Center Commander and as the Senior 

Market Manager, Gulf Coast Multi-Service Market Office, Keesler Air Force Base, 

Biloxi, Mississippi. Thank you for the opportunity to express my advocacy for a 

Healthcare Information Systems platform and electronic medical record that supports the world class quality healthcare that our military and Department of Veterans Affairs veterans healthcare facilities provide to our DoD and VA beneficiaries. 

HISTORICAL OVERVIEW 

In my previous assignment as the CENTCOM Surgeon, I had the opportunity to 

witness the evolution of our deployed healthcare information systems platforms that 

support access to patient care data, as our wounded warriors move through the continuum of care: from our combat casualty care life savers, to our forward surgical 

teams, to our theater hospitals, and then onto our definitive care facilities at 

Landstuhl, Walter Reed, Bethesda, Wilford Hall, and VA Polytrauma Centers. 

On 16 March 2006, Spc. Channing Moss was severely injured in an attack in 

southeastern Afghanistan. The lifesaving care performed by the combat lifesavers 

in his unit and the subsequent surgical stabilization by the forward surgical team 

and the Bagram Theater Hospital saved his life. What was also lifesaving was the 

ability of the surgeons at Landstuhl Hospital, Germany, who would receive Spc. 

Moss less than 24 hours after his initial injury, and the surgeons at Walter Reed 

to be able to view his operative notes and x-rays, before the patient arrived at their 

hospitals. This was accomplished via the Joint Patient Tracking Application, part 

of the DoD’s deployed healthcare information systems platform. 

Earlier that year, again in Afghanistan, a general surgeon and commander of one 

of the forward surgical teams, commented on his excitement when he was able to 

send completely digital trauma resuscitation and operative reports to the Bagram 

Combat Support Hospital, again before the patient arrived. This is something that 

had been his vision for our forward surgical teams for a long time. During his previous assignment, he had been a surgeon at Landstuhl, Germany, and was frustrated by the lack of medical data from the forward surgical teams’ initial surgical 

resuscitation. 

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CURRENT ACTIVITIES 

In my current position as the Senior Market Manager, Gulf Coast Multi-Service 

Market Manager, through collaborative and joint DoD and VA initiatives, we are 

entrusted with the in-garrison care of our DoD and VA beneficiaries. In this capacity, we also require a healthcare information system platform that supports access 

to real-time patient care data for our shared patient population. Our patients from 

the Gulf Coast Multi-Service Market are treated in DoD and VA hospitals and clinics that are often located in close proximity anywhere from Biloxi, to Pensacola, and 

continuing along the Florida Panhandle to Panama City. Our goal is provide quality 

services in a seamless manner. This requires an integrated healthcare information 

systems platform that is user friendly for our jointly operating DoD and VA 

healthcare facilities. Significant progress has been made in the past few years to 

bridge the gap of electronic information flow. Just last month, our staffs were excited when the bi-directional health information (BDHI) system became available at 

some of our facilities. Although not at its full capability yet, it is a very positive 

step in the right direction in our ability to view patient care data from both VA and 

DoD facilities. 

CONCLUSION 

In conclusion, as a former Combatant Command Surgeon and currently as the 

Senior Market Manager for the Gulf Coast Multi-Service Market Office, I continue 

to be a strong advocate for a healthcare information systems platform and electronic 

medical record that provides real time access to patient care data for our DoD and 

VA beneficiaries, heroes like Spc. Canning Moss, as they move through our deployed 

and garrison based continuum of care: combat casualty care, forward surgical resuscitation, in-theater hospitalization and finally our DoD and VA medical centers and 

clinics. The current capability has already proven itself in contributing to the quality of care for our beneficiaries. And with your support I believe we can continue 

to improve upon our already existing and evolving capability to further share and 

make available the full spectrum of electronic health information between the Department of Defense and the Department of Veterans Affairs. Mr. Chairman, Committee Members, thank you again for allowing me the opportunity to appear before 

you. 

f 

Prepared Statement of Valerie C. Melvin, Director, 

Human Capital and Management Information Systems Issues, 

U.S. Government Accountability Office 

GAO Highlights 

Information Technology—VA and DOD Continue to Expand Sharing of 

Medical Information, but Still Lack Comprehensive Electronic Medical 

Records 

Why GAO Did This Study 

The Department of Veterans Affairs (VA) and the Department of Defense (DOD) 

are engaged in ongoing efforts to share medical information, which is important in 

helping to ensure high-quality health care for active-duty military personnel and 

veterans. These efforts include a long-term program to develop modernized health 

information systems based on computable data: that is, data in a format that a computer application can act on—for example, to provide alerts to clinicians of drug allergies. In addition, the departments are engaged in short-term initiatives involving 

existing systems. 

GAO was asked to testify on the history and current status of the departments’ 

efforts to share health information. To develop this testimony, GAO reviewed its 

previous work, analyzed documents about current status and future plans and interviewed VA and DOD officials. 

What GAO Recommends 

GAO has previously made several recommendations on this topic, including that 

VA and DOD develop a detailed project management plan to guide their efforts to 

share patient health data. While the departments agreed with these recommendations, a comprehensive overall strategy that incorporates all of the ongoing activities 

still needs to be implemented. 

What GAO Found 

For almost a decade, VA and DOD have been pursuing ways to share health information and to create comprehensive electronic medical records. However, they have 

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1 In 1996, the Presidential Advisory Committee on Gulf War Veterans’ Illnesses reported on 

many deficiencies in VA’s and DOD’s data capabilities for handling service members’ health information. In November 1997, the President called for the two agencies to start developing a 

‘‘comprehensive, lifelong medical record for each service member,’’ and in 1998 issued a directive 

requiring VA and DOD to develop a ‘‘computer-based patient record system that will accurately 

and efficiently exchange information.’’ 2GAO, Information Technology: VA and DOD Are Making Progress in Sharing Medical Information, but Are Far from Comprehensive Electronic Medical Records, GAO–07–852T (Washington, D.C.: May 8, 2007). 

faced considerable challenges in these efforts, leading to repeated changes in the 

focus of their initiatives and target completion dates. Currently, the two departments are pursuing both long- and short-term initiatives to share health information. Under their long-term initiative, the modern health information systems being 

developed by each department are to share standardized computable data through 

an interface between data repositories associated with each system. The repositories 

have now been developed, and the departments have begun to populate them with 

limited types of health information. In addition, the interface between the repositories has been implemented at seven VA and DOD sites, allowing computable outpatient pharmacy and drug allergy data to be exchanged. Implementing this interface is a milestone toward the departments’ long-term goal, but more remains to be 

done. Besides extending the current capability throughout VA and DOD, the departments must still agree to standards for the remaining categories of medical information, populate the data repositories with this information, complete the development 

of the two modernized health information systems, and transition from their existing systems. 

While pursuing their long-term effort to develop modernized systems, the two departments have also been working to share information in their existing systems. 

Among various short-term initiatives are a completed effort to allow the one-way 

transfer of health information from DOD to VA when service members leave the 

military, as well as ongoing demonstration projects to exchange limited data at selected sites. One of these projects, which builds on the one-way transfer capability, 

developed an interface between certain existing systems that allows a two-way view 

of current data on patients receiving care from both departments. VA and DOD are 

now expanding the sharing of additional medical information by using this interface 

to link other systems and databases. The departments have also established ad hoc 

processes to meet the immediate need to provide data on severely wounded service 

members to VA’s polytrauma centers, which specialize in treating such patients. 

These processes include manual workarounds (such as scanning paper records) that 

are generally feasible only because the number of polytrauma patients is small. 

While these multiple initiatives and ad hoc processes have facilitated degrees of 

data sharing, they nonetheless highlight the need for continued efforts to integrate 

information systems and automate information exchange. At present, it is not clear 

how all the initiatives are to be incorporated into an overall strategy focused on 

achieving the departments’ goal of comprehensive, seamless exchange of health information. 

Mr. Chairman and Members of the Subcommittee: 

I am pleased to be a part of today’s continuing dialog on efforts by the Department of Veterans Affairs (VA) and the Department of Defense (DOD) to share electronic medical information. Over most of the past decade, the departments have 

been pursuing initiatives to share electronic medical information to help ensure that 

active-duty military personnel and veterans receive high-quality health care. The 

departments’ efforts have included working toward a long-term vision of a single 

‘‘comprehensive, lifelong medical record’’ 1 that would allow each service member to 

transition seamlessly between the two departments, as well as more short-term efforts focused on meeting immediate needs to exchange health information, including 

responding to current military crises. 

Since 2001, we have reported or testified numerous times on the various initiatives undertaken by the departments to develop the capability to share health information. Our last testimony before this Subcommittee on May 8, 2007, highlighted 

key projects that the departments have pursued in this regard and the progress of 

their activities.2 At your request, my statement today further discusses the history 

and current status of the departments’ efforts. 

The information in my testimony is based largely on our previous work in this 

area. To describe the history and current status of the departments’ efforts to exchange patient health information, we reviewed our previous work, analyzed documents on various health initiatives, and interviewed VA and DOD officials about 

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3 Interoperability is the ability of two or more systems or components to exchange information 

and to use the information that has been exchanged. 4DOD’s Composite Health Care System (CHCS) and VA’s VistA (Veterans Health Information 

Systems and Technology Architecture). 5Specifically, inpatient discharge summary data stored in VA’s VistA and DOD’s Clinical Information System (CIS), a commercial health information system customized for DOD. 

current status and future plans. We conducted our work in support of this testimony 

during October 2007 in the Washington, D.C., area. Information on costs that have 

been incurred for the various projects was provided by responsible officials at each 

department. We did not audit the reported costs and thus cannot attest to their accuracy or completeness. All work on which this testimony is based was conducted 

in accordance with generally accepted government auditing standards. 

Results in Brief 

VA and DOD have been pursuing initiatives to share data between their health 

information systems and create comprehensive electronic medical records since 

1998, following a call for the development of a comprehensive, integrated system to 

allow the two departments to share patient health information. However, the departments have faced considerable challenges in project planning and management, 

leading to repeated changes in the focus of their initiatives and target completion 

dates. In prior reviews of their efforts, we noted management weaknesses such as 

inadequate accountability and poor planning and oversight and made recommendations for improvement, including the development of a comprehensive and coordinated project management plan that defines the technical and managerial processes 

necessary to satisfy project requirements and to guide their activities. In response, 

by July 2002, VA and DOD revised their strategy, refocusing the project and dividing it into long-term and short-term initiatives. For the long term, both departments 

are modernizing their health information systems to replace their existing (legacy) 

systems and enable the new systems to share data and, ultimately, to have interoperable 3 electronic medical records. Unlike the legacy systems, the modernized systems are to be based on computable data—data that can be automatically processed 

in a healthcare system to, for example, provide alerts to clinicians on drug allergies, 

or to plot graphs of changes in vital signs such as blood pressure. For the shortterm initiative, the departments focused on sharing information in existing systems. 

VA and DOD have made progress in both their long-term and short-term initiatives, but much work remains to achieve the goal of interoperable electronic medical 

records and a seamless transition between the two departments. In the long-term 

project to develop modernized health information systems, the departments have 

begun to implement the first release of the interface between their modernized data 

repositories, and computable outpatient pharmacy and drug allergy data are being 

exchanged at seven VA and DoD sites. However, significant work remains, including 

agreeing to standards for the remaining categories of medical information and 

populating the data repositories with all this information. Regarding their shortterm projects to share information in existing systems, the departments completed 

the Federal Health Information Exchange in 2004, and as of this month reported 

transferring clinical data on more than 4 million veterans. In addition, they have 

made progress on two demonstration projects: (1) the Laboratory Data Sharing 

Interface, deployed at nine localities, allows the departments to communicate orders 

for lab tests and their results electronically and (2) the Bidirectional Health Information Exchange allows a real-time, two-way view of certain outpatient health data 

from existing systems 4 at all VA and DoD sites, and certain inpatient discharge 

summary data 5 at all VA sites and 13 large DOD sites. Further, the two departments have undertaken ad hoc activities to accelerate the transmission of health information on severely wounded patients from DOD to VA’s four polytrauma centers, 

which care for veterans and service members with severe traumatic brain injuries 

or disabling injuries, to more than one physical region or organ system. These ad 

hoc processes include manual workarounds, such as scanning paper records and individually transmitting radiological images, which are generally feasible only because the number of polytrauma patients is small (according to VA officials, about 

460 with traumatic brain injuries to date). 

Through all of these efforts, VA and DOD are exchanging health information. 

However, these exchanges have been limited, and it is not yet clear how they are 

to be integrated into an overall strategy to reach the departments’ long-term goal 

of a comprehensive, seamless exchange of health information. Accordingly, as we 

have previously recommended, it remains critical for the departments to develop a 

comprehensive project plan that can guide their efforts to completion. 

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6 A site represents one or more facilities—medical centers, hospitals, or outpatient clinics— 

that store their electronic health data in a single database. 

Background 

In their efforts to modernize their health information systems and share medical 

information, VA and DoD start from different positions. As shown in table 1, VA 

has one integrated medical information system—the Veterans Health Information 

Systems and Technology Architecture (VistA)—which uses all electronic records. All 

128 VA medical sites thus have access to all VistA information.6 (Table 1 also 

shows, for completeness, VA’s planned modernized system and its associated data 

repository.) 

Table 1: VA Medical Information Systems and Data Base 

System name Description 

Legacy systems 

VistA Veterans Health Information 

Systems and Technology 

Architecture 

Existing integrated health 

information system 

Modernized system and repository 

HealtheVet VistA Modernized health information 

system based on computable data 

HDR Health Data Repository Data repository associated with 

modernized system 

Source: GAO analysis of VA data. 

In contrast, DOD has multiple medical information systems (table 2 illustrates 

certain selected systems). DOD’s various systems are not integrated, and its 138 

sites do not necessarily communicate with each other. In addition, not all of DOD’s 

medical information is electronic: some records are paper-based. 

Table 2: Selected DoD Medical Information Systems and Data Bases 

System name Description 

Legacy systems 

CHCS Composite Health Care System Primary existing DoD health 

information system 

CIS Clinical Information System Commercial health information 

system customized for DoD; used by 

some DoD facilities for inpatients 

ICDB Integrated Clinical Database Health information system used by 

many Air Force facilities 

TMDS Theater Medical Data Store Database to collect electronic 

medical information in combat 

theater for both outpatient care and 

serious injuries 

JPTA Joint Patient Tracking 

Application 

Web-based application primarily 

used to track the movement of 

patients as they are transferred 

from location to location, but may 

include text-based medical 

information 

Modernized system and repository 

AHLTA Armed Forces Health 

Longitudinal Technology 

Application a

Modernized health information 

system, integrated and based on 

computable data 

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7 Initially, the Indian Health Service (IHS) was also a party to this effort, having been included because of its population-based research expertise and its longstanding relationship with 

VA. However, IHS was not included in a later revised strategy for electronically sharing patient 

health information. 8DOD began efforts to modernize its existing health information system (CHCS) in 1997 and 

VA began efforts to modernize its existing health information system (VistA) in 2001. 9GAO, Veterans Affairs: Sustained Management Attention Is Key to Achieving Information 

Technology Results, GAO–02–703 (Washington, D.C.: June 12, 2002) and Computer-Based Patient Records: Better Planning and Oversight by VA, DOD, and IHS Would Enhance Health Data 

Sharing, GAO–01–459 (Washington, D.C.: Apr. 30, 2001). 

CDR Clinical Data Repository Data repository associated with 

modernized system 

aFormerly CHCS II. 

Source: GAO analysis of DOD data. 

VA and DOD Have Been Working to Exchange Health Information Since 

1998 

For nearly a decade, VA and DOD have been undertaking initiatives to exchange 

data between their health information systems and create comprehensive electronic 

records.7 However, the departments have faced considerable challenges in project 

planning and management, leading to repeated changes in the focus and target completion dates of the initiatives. 

As shown in figure 1, the departments’ efforts have involved both long-term initiatives to modernize their health information systems 8 and short-term initiatives to 

respond to more immediate information-sharing needs. 

Figure 1: Timeline of Selected VA/DOD Electronic Medical Records and 

Data Sharing Efforts 

The departments’ first initiative was the Government Computer-Based Patient 

Record (GCPR) project, which aimed to develop an electronic interface that would 

allow physicians and other authorized users at VA and DOD health facilities to access data from each other’s health information systems. The interface was expected 

to compile requested patient information in a virtual record (that is, electronic as 

opposed to paper) that could be displayed on a user’s computer screen. 

We reviewed the GCPR project in 2001 and 2002, noting disappointing progress 

exacerbated in large part by inadequate accountability and poor planning and oversight, which raised questions about the departments’ abilities to achieve a virtual 

medical record. We determined that the lack of a lead entity, clear mission, and detailed planning to achieve that mission made it difficult to monitor progress, identify 

project risks, and develop appropriate contingency plans.9 In both years, we recommended that the departments enhance the project’s overall management and accountability. In particular, we recommended that the departments designate a lead 

entity and a clear line of authority for the project; create comprehensive and coordinated plans that include an agreed-upon mission and clear goals, objectives, and 

performance measures; revise the project’s original goals and objectives to align with 

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10DOD’s existing Composite Health Care System (CHCS) was being modernized as CHCS II, 

now renamed AHLTA (Armed Forces Health Longitudinal Technology Application). VA’s existing VistA system was being modernized as HealtheVet VistA. 11The name CHDR, pronounced ‘‘cheddar,’’ combines the names of the two repositories. 12December 2004 VA and DOD Joint Strategic Plan. 13GAO, Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data 

Could Benefit from Improved Planning and Project Management, GAO–04–687 (Washington, 

D.C.: June 7, 2004). 14GAO, Computer-Based Patient Records: VA and DOD Made Progress, but Much Work Remains to Fully Share Medical Information, GAO–05–1051T (Washington, D.C.: Sept. 28, 2005) 

and Information Technology: VA and DOD Face Challenges in Completing Key Efforts, GAO– 

06–905T (Washington, D.C.: June 22, 2006). 15The Bob Stump National Defense Authorization Act for Fiscal Year 2003 (Pub. L. No. 107– 

314, § 721, Dec. 2, 2002) mandated that the departments conduct demonstration projects to test 

the feasibility, advantages, and disadvantages of measures and programs designed to improve 

the sharing and coordination of health care and health care resources between the departments. 16To create BHIE, the departments drew on the architecture and framework of the information transfer system established by the FHIE project. Unlike FHIE, which provides a one-way 

transfer of information to VA when a service member separates from the military, the two-way 

system allows clinicians in both departments to view, in real time, limited health data (in text 

form) from the departments’ current health information systems. 17December 2004 VA and DOD Joint Strategic Plan. 

the current strategy; commit the executive support necessary to adequately manage 

the project; and ensure that it followed sound project management principles. 

In response, by July 2002, the two departments had revised their strategy, refocusing the project and dividing it into two initiatives. A short-term initiative, the 

Federal Health Information Exchange (FHIE), was to enable DOD to electronically 

transfer service members’ health information to VA when the members left active 

duty. VA was designated as the lead entity for implementing FHIE, which was completed in 2004. A longer-term initiative was to develop a common health information 

architecture that would allow a two-way exchange of health information. The common architecture is to include standardized, computable data, communications, security, and high-performance health information systems (these systems, DOD’s 

Composite Health Care System II and VA’s HealtheVet VistA, were already in development, as shown in the figure).10 The departments’ modernized systems are to 

store information (in standardized, computable form) in separate data repositories: 

DOD’s Clinical Data Repository (CDR) and VA’s Health Data Repository (HDR). The 

two repositories are to exchange information through an interface named CHDR.11

In March 2004, the departments began to develop the CHDR interface. They 

planned to begin implementation by October 2005; 12 however, implementation of 

the first release of the interface (at one site) occurred in September 2006, almost 

a year beyond the target date. In a report in June 2004, 13 we identified a number 

of management weaknesses that could have contributed to this delay and made a 

number of recommendations, including creation of a comprehensive and coordinated 

project management plan. The departments agreed with our recommendations and 

took steps to improve the management of the CHDR initiative, designating a lead 

entity with final decision-making authority and establishing a project management 

structure. However, as we noted in subsequent testimony, 14 the initiative did not 

have a detailed project management plan that described the technical and managerial processes necessary to satisfy project requirements (including a work breakdown 

structure and schedule for all development, testing, and implementation tasks), as 

we had recommended. 

In October 2004, responding to a congressional mandate, 15 the departments established two more short-term initiatives: the Laboratory Data Sharing Interface, 

aimed at allowing VA and DOD facilities to share laboratory resources, and the 

Bidirectional Health Information Exchange (BHIE), aimed at giving both departments’ clinicians access to records on shared patients (that is, those who receive 

care from both departments).16 As demonstration projects, these initiatives were 

limited in scope, with the intention of providing interim solutions to the departments’ needs for more immediate health information sharing. However, because 

BHIE provided access to up-to-date information, the departments’ clinicians expressed strong interest in expanding its use. As a result, the departments began 

planning to broaden this capability and expand its implementation considerably. Extending BHIE connectivity could provide each department with access to most data 

in the other’s legacy systems, until such time as the departments’ modernized systems are fully developed and implemented. According to a VA/DOD annual report 17

and program officials, the departments now consider BHIE an interim step in their 

overall strategy to create a two-way exchange of electronic medical records. 

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18The contract is for a 6-month base period, with a follow-on 6-month option period. The cost 

for the 6-month base period is about $2 million. 19Task Force on Returning Global War on Terror Heroes, Report to the President (Apr. 19, 

2007). 

The departments’ reported costs for the various sharing initiatives and the modernization of their health information systems through fiscal year 2007 are shown 

in table 3. 

Table 3: Reported Costs of VA and DOD Initiatives Since Inception 

Project VA expenditure DOD expenditure 

HealtheVet VistA $681.7 million through FY 2006 —— 

AHLTA —— $954.3 million through FY 2007 

(estimated). 

Joint initiatives: 

CHDR 4.1 million DOD does not account for these 

projects separately. 

FHIE 65.5 million 

LDSI 2.8 million 

BHIE 6.3 million 

Total $78.7 million $89.7 million through FY 2007. 

Source: VA and DOD data. 

Beyond these initiatives, in January 2007, the departments announced a further 

change to their information-sharing strategy: their intention to jointly develop a new 

inpatient medical record system. On July 31, 2007, they awarded a contract for a 

feasibility study.18 According to the departments, adopting this joint solution is expected to facilitate the seamless transition of active-duty service members to veteran 

status, and make inpatient health care data on shared patients immediately accessible to both DOD and VA. In addition, the departments believe that a joint development effort could enable them to realize significant cost savings. We have not evaluated the departments’ plans or strategy for this new system. 

Other Evaluations Have Recommended Strengthening the Management 

and Planning of the Departments’ Health Information Initiatives 

Throughout the history of these initiatives, evaluations besides our own have 

found deficiencies in the departments’ efforts, especially with regard to the lack of 

comprehensive planning. For example, a recent presidential task force identified the 

need for VA and DOD to improve their long-term planning.19 This task force, reporting on gaps in services provided to returning veterans, noted problems in sharing 

information on wounded service members, including the inability of VA providers 

to access paper DOD inpatient health records. The task force stated that although 

significant progress has been made towards sharing electronic information, more 

needs to be done, and recommended that VA and DOD continue to identify longterm initiatives and define the scope and elements of a joint inpatient electronic 

health record. In addition, in fiscal year 2006, Congress did not provide all the funding requested for HealtheVet VistA because it did not consider that the funding had 

been adequately justified. 

VA and DOD Are Exchanging Limited Medical Information, but a Seamlessly Shared Medical Record Will Require Much More Work 

VA and DOD have made progress in both their long-term and short-term initiatives to share health information. In the long-term project to modernize their health 

information systems, the departments have begun, among other things, to implement the first release of the interface between their modernized data repositories. 

The departments have also made progress in their short-term projects to share information in existing systems, having completed two initiatives, and are making important progress on another. In addition, the departments have undertaken ad hoc 

activities to accelerate the transmission of health information on severely wounded 

patients from DOD to VA’s four polytrauma centers. However, despite the progress 

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20DOD has populated CDR with information for outpatient encounters, drug allergies, and 

order entries and results for outpatient pharmacy/lab orders. VA has populated HDR with patient demographics, vital signs records, allergy data, and outpatient pharmacy data; in July, the 

department added chemistry and hematology, and in September, microbiology. 21The Remote Data Interoperability software upgrade provides the capability for the automated checks and alerts allowed by computable data. 22 Inspector General, Army, Army Physical Disability Evaluation System Inspection (March 

2007). 

made and the sharing achieved, the tasks remaining to reach the goal of a shared 

electronic medical record are substantial. 

VA and DOD Have Begun Deployment of a Modernized Data Interface 

In their long-term effort to share health information, VA and DOD have completed the development of their modernized data repositories, agreed on standards 

for various types of data, and begun to populate the repositories with these data.20

In addition, they have now implemented the first release of the CHDR interface. According to the departments’ officials, all DOD sites can now access the interface, and 

it is expected to be available across VA when necessary software updates are released. (Currently 103 of 128 VA sites have received these updates.) 21 At seven 

sites, VA and DOD are now exchanging limited medical information for shared patients: specifically, computable outpatient pharmacy and drug allergy information. 

CHDR is the conduit for exchanging computable medical information between the 

departments. Data transmitted via the interface are permanently stored in each department’s new data repository, CDR, and HDR. Once in the repositories, these 

computable data can be used by DOD and VA at all sites through their existing systems. CHDR also provides terminology mediation (translation of one agency’s terminology into the other’s). The departments’ plans call for further developing the capability to exchange computable laboratory results data through the interface during 

fiscal year 2008. 

Although implementing this interface is an important accomplishment, the departments are still a long way from completing the modernized health information 

systems and comprehensive longitudinal health records. While DOD and VA had 

originally projected completion dates of 2011 and 2012, respectively, for their modernized systems, the departments’ officials told us that there is currently no scheduled completion date for either system. VA is evaluating a proposal that would result in completion of its system in 2015; DOD is evaluating the impact of the new 

study on a joint inpatient medical record and has not indicated a new completion 

date. 

Further, both departments have still to identify the next types of data to be stored 

in the repositories. The departments will then have to populate the repositories with 

the standardized data. This involves different tasks for each department. Specifically, while VA’s medical records are already electronic, it must still convert them 

into the interoperable format appropriate for its repository. DOD, in addition to converting current records from its multiple systems, must also address medical records 

that are not automated. As pointed out by a recent Army Inspector General’s report, 

some DOD facilities are having problems with hard copy records.22 The report also 

identified inaccurate and incomplete health data as a problem to be addressed. Before the departments can achieve the long-term goal of seamless sharing of medical 

information, all of these tasks and challenges will have to be addressed. Accordingly, 

it is essential that the departments develop a comprehensive project plan to guide 

these efforts to completion, as we have previously recommended. 

Short-Term Projects Are Allowing VA and DOD to Exchange Limited 

Health Information 

In addition to the long-term effort previously described, the two departments have 

made some progress in meeting immediate needs to share information in their respective legacy systems through short-term projects which, as mentioned earlier, are 

in various stages of completion. They have also set up special processes to transfer 

data from DOD facilities to VA’s polytrauma centers in a further effort to more effectively treat Traumatic Brain Injuries and other especially severe injuries. 

One-Way Transfer Capability Is Operational 

DOD has been using FHIE to transfer information to VA since 2002. According 

to DOD officials, 194 million clinical messages on more than 4 million veterans had 

been transferred to the FHIE data repository as of September 2007, including laboratory results, radiology results, outpatient pharmacy data, allergy information, 

consultation reports, elements of the standard ambulatory data record, and demographic data. Further, since July 2005, FHIE has been used to transfer pre- and 

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23December 2004, VA and DOD Joint Strategic Plan. 24To create BHIE, the departments drew on the architecture and framework of the information transfer system established by the FHIE project. 

post-deployment health assessment and reassessment data; as of September 2007, 

VA had access to data for more than 793,000 separated service members and demobilized Reserve and National Guard members who had been deployed. Transfers 

are done in batches once a month, or weekly for veterans who have been referred 

to VA treatment facilities. According to a joint VA/DOD report, 23 FHIE has made 

a significant contribution to the delivery and continuity of care of separated service 

members as they transition to veteran status, as well as to the adjudication of disability claims. 

Laboratory Interface Initiative Allows VA and DOD to Share Lab Resources 

One of the departments’ demonstration projects—the Laboratory Data Sharing 

Interface (LDSI)—is now fully operational and is deployed when local agencies have 

a business case for its use and sign an agreement. It requires customization for each 

locality and is currently deployed at nine locations. LDSI currently supports a variety of chemistry and hematology tests, and, at one of the nine locations, anatomic 

pathology and microbiology tests. 

Once LDSI is implemented at a facility, the only nonautomated action needed for 

a laboratory test is transporting the specimens. If a test is not performed at a VA 

or DOD doctor’s home facility, the doctor can order the test, the order is transmitted 

electronically to the appropriate lab (the other department’s facility or in some cases 

a local commercial lab), and the results are returned electronically. 

Among the benefits of the LDSI interface, according to VA and DOD, are increased speed in receiving laboratory results and decreased errors from manual 

entry of orders. The LDSI project manager in San Antonio stated that another benefit of the project is the time saved by eliminating the need to rekey orders at processing labs to input the information into the laboratories’ systems. Additionally, the 

San Antonio VA facility no longer has to contract out some of its laboratory work 

to private companies, but instead uses the DOD laboratory. 

Two-Way Interface Allows Real-Time Viewing of Text Information 

Developed under a second demonstration project, the BHIE interface permits a 

medical care provider to query selected health information on patients from all VA 

and DOD sites and to view that data onscreen almost immediately. It not only allows the two departments to view each other’s information, but it also allows DOD 

sites to see previously inaccessible data at other DOD sites. 

VA and DOD have been making progress on expanding the BHIE interface. As 

initially developed, the interface provided access to information in VA’s VistA and 

DOD’s Composite Health Care System, but it is currently being expanded to query 

data in other DOD systems and databases. In particular, the interface has been expanded to DOD’s: 

• Modernized data repository, CDR, which has enabled department-wide access to 

outpatient data for pharmacy and inpatient and outpatient allergy, radiology, 

chemistry, and hematology data since July 2007, and to microbiology data since 

September 2007. 

• Clinical Information System (CIS), an inpatient system used by some DOD facilities; the interface enables bidirectional views of discharge summaries and is 

currently deployed at 13 large DOD sites. 

• Theater Medical Data Store, which became operational in October 2007, enabling access to inpatient and outpatient clinical information from combat theaters. 

The departments are also taking steps to make more data elements available 

through BHIE. VA and DOD staff told us that by the end of the first quarter of 

fiscal year 2008, they plan to add provider notes, procedures, and problem lists. 

Later in fiscal year 2008, they plan to add vital signs, scanned images and documents, family history, social history, and other history questionnaires. In addition, 

a VA/DOD demonstration site in El Paso began sharing radiological images between 

the VA and DOD facilities in September 2007 using the BHIE/FHIE infrastructure.24

Types of Data Shared by DOD and VA Are Growing but Remain Limited 

Although VA and DOD are sharing various types of health data, the type of data 

being shared has been limited and significant work remains to expand the data 

shared and integrate the various initiatives. Table 4 summarizes the types of health 

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25 In particular, clinicians require access to discharge notices, which describe the treatment 

given at previous medical facilities and the status of patients when they left those facilities. 26Polytrauma centers care for veterans and returning service members with injuries to more 

than one physical region or organ system, one of which may be life threatening, and which result in physical, cognitive, psychological, or psychosocial impairments and functional disability. 27The four Polytrauma Rehabilitation Centers are in Richmond, Virginia; Tampa, Florida; 

Minneapolis, Minnesota; and Palo Alto, California. 

data currently shared via the long- and short-term initiatives we have described, as 

well as additional types of data that are currently planned for sharing. While this 

gives some indication of the scale of the tasks involved in sharing medical information, it does not depict the full extent of information that is currently being captured 

in the health information systems at VA and DOD. 

Table 4—Data Elements Made Available and Planned by DOD–VA 

Initiatives 

Initiative 

Data elements 

Comments 

Available Planned 

CHDR Outpatient pharmacy 

Drug allergy 

Laboratory data Computable data are 

exchanged between one 

department’s data repository 

and the other’s. 

FHIE Patient demographics 

Laboratory results 

Radiology reports 

Outpatient pharmacy 

information 

Admission discharge transfer 

data 

Discharge summaries 

Consult reports 

Allergies 

Data from the DOD Standard 

Ambulatory Data Record 

Pre- and post-deployment 

assessments 

None One-way batch transfer of text 

data from DOD to VA occurs 

weekly if discharged patient 

has been referred to VA for 

treatment; otherwise monthly. 

LDSI Laboratory orders 

Laboratory results (chemistry, 

hematology and microbiology 

at two localities) 

Microbiology 

Anatomic pathology 

Noncomputable text data are 

transferred. 

BHIE Outpatient pharmacy data 

Drug and food allergy 

information 

Surgical pathology reports 

Microbiology results 

Cytology reports 

Chemistry and hematology 

reports 

Laboratory orders 

Radiology text reports 

Inpatient discharge 

summaries and/or emergency 

room notes from CIS at 13 

DOD and all VA sites 

Provider notes 

Procedures 

Problem lists 

Vital signs 

Scanned images and 

documents 

Family history 

Social history 

Other history questionnaires 

Radiology images 

Data are not transferred but 

can be viewed. 

Source: GAO analysis of VA and DOD data. 

Special Procedures Provide Information to VA Polytrauma Centers 

In addition to the information technology initiatives described, DOD and VA have 

set up special procedures to transfer medical information to VA’s four polytrauma 

centers, which treat active duty service members and veterans severely wounded in 

combat.25 Some examples of polytrauma include Traumatic Brain Injury, amputations, and loss of hearing or vision.26

When service members are seriously injured in a combat theater overseas, they 

are first treated locally. They are then generally evacuated to Landstuhl Medical 

Center in Germany, after which they are transferred to a military treatment facility 

in the United States, usually Walter Reed Army Medical Center in Washington, 

D.C.; the National Naval Medical Center in Bethesda, Maryland; or Brooke Army 

Medical Center, at Fort Sam Houston, Texas. From these facilities, service members 

suffering from polytrauma may be transferred to one of VA’s four polytrauma centers for treatment.27

At each of these locations, the injured service members will accumulate medical 

records, in addition to medical records already in existence before they were injured. 

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According to DOD officials, when patients are referred to VA for care, DOD sends 

copies of medical records documenting treatment provided by the referring DOD facility along with them. The DOD medical information is currently collected in several different systems: 

1. In the combat theater, electronic medical information may be collected for a variety of reasons, including routine outpatient care, as well as serious injuries. 

These data are stored in the Theater Medical Data Store. As mentioned earlier, 

the BHIE interface to this database became operational in October. 

2. At Landstuhl, inpatient medical records are paper-based (except for discharge 

summaries). The paper records are sent with a patient as the individual is 

transferred for treatment in the United States. DOD officials told us that the 

paper record is the official DOD medical record, although AHLTA is used extensively to provide outpatient encounter information for medical records purposes. 

3. At the DOD treatment facility (Walter Reed, Bethesda, or Brooke), additional 

inpatient information is recorded in CIS and outpatient pharmacy and drug information are stored in CDR; other health information continues to be stored 

in local CHCS databases. 

When service members are transferred to a VA polytrauma center, VA and DOD 

have several ad hoc processes in place to electronically transfer the patients’ medical 

information: 

• DOD has set up secure links to enable a limited number of clinicians at the 

polytrauma centers to log directly into CIS at Walter Reed and Bethesda Naval 

Hospital to access patient data. • Staff at Walter Reed, Brooke, and Bethesda medical centers collect paper 

records, print records from CIS, scan all these, and transmit the scanned data 

to the four polytrauma centers. DOD staff pointed out that this laborious process is feasible only because the number of polytrauma patients is small. According to VA officials, 460 severe Traumatic Brain Injury patients had been treated 

at the polytrauma centers through fiscal year 2007. According to DOD officials, 

the medical records for 81 patients planned for transfer or already at a VA 

polytrauma center were scanned and provided to VA between April 1 and October 11 of this year. Digital radiology images were also provided for 48 patients. • Staff at Walter Reed and Bethesda are transmitting radiology images electronically to the four polytrauma centers. Access to radiology images is a high priority for polytrauma center doctors, but like scanning paper records, transmitting these images requires manual intervention: when each image is received 

at VA, it must be individually uploaded to VistA’s imagery viewing capability. 

This process would not be practical for large volumes of images. • VA has access to outpatient data (via BHIE) from all DOD sites, including 

Landstuhl. 

These special efforts to transfer medical information on seriously wounded patients represent important additional steps to facilitate the sharing of information 

that is vital to providing polytrauma patients with quality health care. 

In summary, VA and DOD are exchanging health information via their long- and 

short-term initiatives and continue to expand sharing of medical information via 

BHIE. However, these exchanges have been limited, and significant work remains 

to fully achieve the goal of exchanging interoperable, computable data. Work still 

to be done includes agreeing to standards for the remaining categories of medical 

information; populating the data repositories with all this information; completing 

the development of HealtheVet, VistA, and AHLTA; and transitioning from the legacy systems. To complete this work and achieve the departments’ ultimate goal of 

a maintaining a lifelong electronic medical record that will follow service members 

as they transition from active to veteran status, a comprehensive and coordinated 

project management plan that defines the technical and managerial processes necessary to satisfy project requirements and to guide their activities continues to be 

of vital importance. We have previously recommended that the departments develop 

such a plan and that it include a work breakdown structure and schedule for all 

development, testing, and implementation tasks. Without such a detailed plan, VA 

and DOD increase the risk that the long-term project will not deliver the planned 

capabilities in the time and at the cost expected. Further, it is not clear how all 

the initiatives we have described today are to be incorporated into an overall strategy toward achieving the departments’ goal of a comprehensive, seamless exchange 

of health information. 

This concludes my statement. I would be pleased to respond to any questions that 

you may have. 

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Contacts and Acknowledgments 

If you have any questions concerning this testimony, please contact Valerie C. 

Melvin, Director, Human Capital and Management Information Systems Issues, at 

(202) 512–6304 or melvinv@gao.gov. Other individuals who made key contributions 

to this testimony are Barbara Oliver, Assistant Director); Nancy Glover, Glenn Spiegel, and Amos Tevelow. 

Related GAO Products 

Computer-Based Patient Records: Better Planning and Oversight by VA, DOD, and 

IHS Would Enhance Health Data Sharing. GAO–01–459. Washington, D.C.: April 

30, 2001. 

Veterans Affairs: Sustained Management Attention Is Key to Achieving Information Technology Results. GAO–02–703. Washington, D.C.: June 12, 2002. 

Computer-Based Patient Records: Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health Systems. 

GAO–04–271T. Washington, D.C.: November 19, 2003. 

Computer-Based Patient Records: Sound Planning and Project Management Are 

Needed to Achieve a Two-Way Exchange of VA and DOD Health Data. GAO–04– 

402T. Washington, D.C.: March 17, 2004. 

Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data 

Could Benefit from Improved Planning and Project Management. GAO–04–687. 

Washington, D.C.: June 7, 2004. 

Computer-Based Patient Records: VA and DOD Made Progress, but Much Work 

Remains to Fully Share Medical Information. GAO–05–1051T. Washington, D.C.: 

September 28, 2005. 

Information Technology: VA and DOD Face Challenges in Completing Key Efforts. 

GAO–06–905T. Washington, D.C.: June 22, 2006. 

DOD and VA Exchange of Computable Pharmacy Data. GAO–07–554R. Washington, D.C.: April 30, 2007. 

Information Technology: VA and DOD Are Making Progress in Sharing Medical 

Information, but Are Far from Comprehensive Electronic Medical Records, GAO–07– 

852T. Washington, D.C.: May 8, 2007. 

Information Technology: VA and DOD Are Making Progress in Sharing Medical 

Information, but Remain Far from Having Comprehensive Electronic Medical 

Records, GAO–07–1108T. Washington, D.C.: July 18, 2007. 

f 

Prepared Statement of Colonel Keith Salzman, M.D., MPH, FAAFP, FACHE, 

Chief of Informatics, Western Region Medical Command and Madigan 

Army Medical Center, Tacoma, WA, Department of the Army, U.S. Department of Defense 

Chairman Mitchell, Congresswoman Brown-Waite and distinguished Members of 

the Subcommittee, thank you for inviting me to discuss the information technology 

sharing project between Madigan Army Medical Center and VA Puget Sound. I am 

Colonel Keith Salzman, a physician and a DoD/AMEDD leader in the newly emerging discipline of Informatics and it is my privilege to serve as the Chief of 

Informatics at Western Regional Medical Command/Madigan Army Medical Center 

where we enjoy a long history of command support for our work in Informatics. 

I arrived at Madigan as the announcement was made that Madigan and VA Puget 

Sound would be working together to share electronic clinical information. I joined 

the team as a steering Committee Member. While the submission for the information sharing project occurred prior to my arrival, I have been on the project since 

its inception and continue to the present. We have completed all of the business 

plan objectives in 3 years of a 4 year project and are using the remaining funds to 

provide additional requests for document exchange that support polytrauma information needs as well as other key documents and data types that contribute to extending interoperability, on the approval of the DoD–VA oversight Committee Members. 

The Madigan-VA Puget Sound project arose in response to congressional requirements for the DoD and VA to each contribute set aside funding for 4 years to collaborate on sharing clinical information and care to improve healthcare services to 

shared patients. At the outset of this testimony I would underscore our assessment 

that; the choice on many levels between ‘either’, ‘or’ is more appropriately answered 

as ‘both’. I will explain as I review this project. 

This particular demonstration was undertaken in response to section 722 of the 

FY 2003 National Defense Authorization Act which required no less than three demwwoods2 on PRODPC68 with HEARING

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onstration projects of DoD/VA coordinated systems involving budget/financial management; staffing/assignment; and Information Management/Information Technology (IM/IT). Madigan and VA Puget Sound were selected for this project based 

on the established clinical sharing that was in place and the need to improve the 

exchange of clinical information to provide care for the mutual patients cared for 

at Madigan Army Medical Center, and the American Lake and Seattle VA centers 

that make up the VA Puget Sound Healthcare System. 

The initial challenges surrounded the learning required to overcome the first ‘either-or’ proposition of who drove the project: enterprise or the local site. A critical 

first lesson learned was—‘both’. The local site had access to the clinical end user 

community and the requirements necessary to improve the flow of information while 

the enterprise had ownership of the architecture and systems in which requirements 

would be built and deployed. At the outset it is important to state that while this 

project is a demonstration project, all of the deliverables are being used by the enterprise systems of both the DoD and VA in production, in near real time (meaning 

seconds to minutes as a rule, not instantaneous or days to weeks). 

After the initial assembly of local and enterprise teams and review and approval 

of a detailed business plan, the teams moved forward with iterative delivery of tangible products implemented and delivered for use in enterprise systems (SHARE for 

the DoD view) and Remote Data View in the Computerized Patient Record System 

(CPRS the VA view) of the Bi-Directional Health Information Exchange (BHIE) validated dual beneficiary patients. The work cycles for this project were generally 6– 

9 months in duration. 

A second lesson learned was that while each system had its own test patients, 

shared test patients served the same purpose for interoperability (that purpose 

being validating information compilation and flow within the shared framework). 

While not as profound, the benefit of ‘either-or’ answered in ‘both’ facilitated testing, 

training and expansion of functionality. 

The critical dialog between clinical end user and the development team at the 

local level, combined with an active dialog between local and enterprise team members, ensured that a principle of software development (namely to correct functional 

problems as they are identified in the design phase) proceeds iteratively and cost 

effectively. The savings can be significant over allowing major design problems to 

persist into production. This exemplifies another ‘both’ solution to an ‘either-or’ 

proposition. 

Regarding requirements specifications, we observed that keeping the user requirements in sight while drafting the statement of work and contracting progress will 

save re-doing a product after-the-fact. A case in point is work on delivery of specified 

note types. The initial requirement was for seven note types. Through a disconnected process of contracting, the requirement was interpreted as all notes, creating 

an information retrieval and storage problem, unintended consequences of assumptions made by contractors making assumptions about what the end users really 

needed. The experience was used later in our development of requirements by keeping an open dialog between the end users and the enterprise-another ‘both’ solution. 

With regard to the elephant in the room—establishing either AHLTA or VistA 

across both Departments-we observed the following: 

There are strengths and weaknesses in both systems that complement each other. 

AHLTA is integrated world-wide and available 24/7. There are functionality problems that are being worked to improve use at the clinical and business level. VistA 

shows the benefits of local design in its adoption by end users who are more inclined 

to buy into a product they created. The downside is the historic lack of configuration 

management. I use management intentionally as against configuration control. The 

VA faces big challenges in reorganization and must be careful not to destroy the 

strategy that delivered its success while addressing its Achilles heel of decentralized, unmanaged growth. The cost of imposing one system on both organizations 

now would be prohibitive. Establishing interoperability and designing a strategy of 

convergence over the next 10–20 years will allow a ‘both’ solution that capitalizes 

on best practices and less disruptive changes to either system. 

By using an interoperable approach, the DoD and VA, who own about 50% of the 

penetration of the Electronic Medical Record (EMR) on the national level, can pave 

the way for interoperability as use of the EMR extends from large organizations to 

the small provider groups and individual patients who constitute the majority of the 

Nation and who are not benefiting from an EMR. We are using the strategy of interoperability to extend to our indirect care providers in TRICARE and CHAMP–VA 

to capture the documentation that occurs outside of our EMRs. The extension makes 

a natural bridge to Regional Health Organizations. 

A key to success in our strategy was to use messaging standards (HL7 (Health 

Level 7), Clinical Document Architecture (CDA), Release 1 and 2), which conform 

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to security documentation requirements and integrate with the enterprise constraints from the local level. As stated at the beginning, this partnership between 

a local development cell immersed in the end user environment and the enterprise 

for configuration management is a critical model/partnership to succeed in developing software and hardware solutions for clinical-business processes that support 

healthcare delivery for our beneficiaries. 

An observation regarding COTS (commercial off the shelf) solutions for federal 

agencies is that common products such as identity management and Single Sign On/ 

Context management solutions can be purchased in bulk with significant efficiencies 

for the government. 

In the end, we found that crossing new frontiers in collaborative work between 

federal agencies and local/enterprise ends of those agencies underscored our finding 

that ‘both’ solutions work better than ‘either-or’ solutions. 

These comments summarize what I would offer as a steering Committee Member 

engaged in this project from the start. Subject to your questions I would like to 

thank the Subcommittee again for allowing us to share our insights on this critical 

work that is progressing successfully. I would also encourage Congress to continue 

its support of this program and each of the agencies involved. I look forward to your 

questions. 

Appendix A: Data Currently Being Shared 

• Outpatient medications 

• Allergies 

• Lab—Chemistry, Hematology, Micro, Path, etc 

• Radiology Text Reports 

• Pre and Post Deployment Assessments 

• Post Deployment Health Re-Assessment 

• Discharge Summaries (DoD Essentris Sites and VA) 

• MAMC legacy outpatient notes to VA 

• Theater Clinical Data 

• Op Reports, Surgical Reports, History & Physical, Consult Results and Progress 

Notes (Fall 2007) 

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Appendix B: 

f 

Prepared Statement of Howard B. Green, PMP, Deputy, Operations Management, Veterans Health Information Technology, Office of Enterprise 

Development, Office of Information and Technology, U.S. Department of 

Veterans Affairs 

Thank you, Mr. Chairman. I would like to thank you for the opportunity to testify 

on the Sharing of Electronic Medical Information between the Department of Defense and the Department of Veterans Affairs, what is being done to accomplish the 

objectives, and the viability of the approach. 

I have been a member of the Department of Veterans Affairs Health IT community for over 19 years serving in multiple capacities at the local, regional Veteran 

Integrated Services Network (VISN) and national level. Prior to joining the Office 

of Information and Technology in 2004, I was the Chief Information Officer for the 

Heartland Network (VISN 15) and was responsible for the introduction of VA’s 

VistA system at all facilities and clinics in the region. Most recently, as Deputy for 

Operations Management within the Veterans Health IT Portfolio, I participated as 

a staff member on the President’s Commission for America’s Returning Wounded 

Warriors, and with my DoD counterpart was responsible for the creation of the information technology chapter and final report recommendations. Following that assignment, I have been given the responsibility for coordinating many of the recommendations from the President’s Commission report. 

Systems Supporting the Exchange of Clinical Information 

Formal activities related to the sharing of clinical information between the Department of Veterans Affairs (VA) and the Department of Defense (DoD) have been 

ongoing since 2001. Though there are a number of systems that have been developed to support this function, for all intents and purposes the overarching goal is 

to bidirectionally exchange computable information between VA and DoD in realtime. The following systems are in place to support this exchange of clinical information. 

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• Federal Health Information Exchange (FHIE): is the one-way transfer of separated service member health data from DoD to VA. • Bi-Directional Health Information Exchange (BHIE): supports functional interoperability between VA and DoD through the exchange of textual patient health 

information such as provider notes, non-computable test results, discharge summaries for all service member/veterans known as active dual consumers. • Clinical Health Data Repository (CHDR): utilizes established data standards, 

and terminology services to enable exchange of standardized and computable 

health record data between VA and DoD. • Laboratory Data Systems Interchange (LDSI): supports the lab reference model 

by providing an interoperable interagency application for lab order entry and 

results reporting. • Imaging Pilots and Demonstrations: demonstrate the most efficient approaches 

to the transmission of medical images and clinically relevant documentation. 

Effectiveness of Selected Clinical Information Exchange Systems: 

The FHIE system has supported the transfer of more than 187 million pieces of 

discharge related health information on over 3.8 million patients who have separated from the military. FHIE continues to exchange health record data for separated service members. 

BHIE is currently the bidirectional medical exchange interface having transferred 

information for over 2.3 million unique patients who are active dual consumers of 

both healthcare systems. Currently, VA and DoD are bidirectionally sharing 

viewable outpatient pharmacy data, anatomic pathology/surgical reports, cytology 

results, microbiology results, chemistry and hematology laboratory results, laboratory order information, radiology text reports, food and drug allergy information, 

and discharge summaries from several DoD sites running CIS. The Information 

through the BHIE interface flows to and from the following systems: VA’s 128 VistA 

Systems and DoD’s Composite Health Care System (CHCS), Clinical Data Record 

(CDR), AHLTA Share, CIS, and Theater Medical Data Store systems. There are 

plans to expand the amount of clinical data exchanged through BHIE. Encounter 

notes, patient focused problem lists such as on going treatment for diabetes or hypertension, procedures, and theater level inpatient & outpatient notes will be available by December 2007. By September 2008, VA and DoD improvements will include the addition of a polytrauma Marker and OEF/OIF Combat Veterans Identifier, Electronic Patient Handoff indicators, a DoD Scanning Interface, the Interagency Sharing of Essential Health Images, Provider Notes, Theater Data, Vital 

Signs, and Patient Histories. Site specific information regarding the volume of data 

passed through BHIE through September 2007 can be found at the end of this testimony. 

CHDR is the clinical data exchange interface that supports the exchange of standardized and computable data that can be used to support automated clinical decision 

support tools such as drug/drug and drug/allergy order checking. Currently CHDR 

data is viewable at all VA sites and several DoD sites. In addition, VA drug-drug 

and drug-allergy order checks are performed based on data from all VA systems and 

data from CHDR. User interface applications leveraging the BHIE interface often 

require the clinicians to look in several locations to retrieve health record information from other points of care. This often requires the clinician to interpolate based 

on approximation when comparing data elements due to the use of different 

terminologies. By comparison clinical information obtained through the CHDR interface can be incorporated into the same clinical view, automated computations, and 

edits allowing the user to readily compare like data. The CHDR interface currently 

supports the movement of pharmacy and medication allergy data and will be upgraded to include laboratory Chemistry and Hematology data in the fourth quarter 

of FY 2008. 

The Veterans Tracking Application (VTA) is the VA’s interface to DoD’s Joint Patient Tracking Application (JPTA) and supports the passage of information related 

to the location of wounded, injured or ill service members being transferred from 

theater to Military Treatment Facilities in the Continental United States (CONUS), 

who may be transitioning to the VA. VTA is a critical tool used to support the benefit claims and seamless transition processes. 

The El Paso Clinical Imaging Demonstration leverages the existing BHIE framework to exchange clinical images, descriptive data and reports between the VA and 

DoD facilities. As a result of this demonstration, six sites have been selected for installation and testing of the El Paso Imaging prototype are (in order of installation): 

Great Lakes/North Chicago, Evans Army Community Hospital/Eastern Colorado 

Health Care System, Landstuhl Regional Medical Center, National Capital Area 

(Walter Reed Army Medical Center, National Naval Medical Center, Washington 

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DC VA), VA Polytrauma Centers at Richmond and Tampa, Keesler Medical Center/ 

VA Gulf Coast Health Care System. 

In general, the volume of medical information that is being exchanged is growing 

at a substantial rate. Every effort is being made to meet the standard of ‘‘essential’’ 

data referenced in the report of the President’s Commission on America’s Returning 

Wounded Warriors. 

As it relates to achieving the stated objectives of the projects referenced above, 

the impact of senior leadership in driving the two organizations in the right direction can not be understated. The Joint Executive Committee (JEC) has been a driving force in setting the long term direction toward true electronic health record and 

veteran benefits data interoperability. The addition of the Senior Oversight Committee (SOC), the Overarching Integrated Project Team (OIPT) and Lines of Action 

(LOA) sub-committees have sharpened the focus and intensity of leadership engagement, expanded leadership engagement to include Under Secretaries and top-level 

General and Flag Officers, and elevated the topic to the level of the Deputy Secretaries of both Departments, intended to achieve results by addressing cross-organizational issues and dependencies related to returning wounded service members and 

veterans. 

The Role of Puget Sound Health Care System and Madigan Army Medical 

Center, the Great Lakes Federal Health Care System, and other sites in 

testing and supporting critical data exchange: 

Sharing agreements such as the one developed in Tacoma, Washington, between 

the Puget Sound Health Care System and Madigan Army Medical Center (aka 

Team Puget Sound) demonstrate new capabilities and functions within products 

such as BHIE and CHDR. In the Seattle/Tacoma region the two sites are leveraging 

the BHIE interface in support of inpatient services provided to VA at Madigan 

Army Medical Center. The primary focus is the exchange of discharge summaries 

and other clinically relevant inpatient notes. Through these efforts new functionality 

can be fully tested and incorporated into future national releases. 

While collaborations such as the one in the northwest tend to focus on specific 

functionality in support of limited sharing agreements, the Great Lakes Federal 

Health Care Center will eventually push the concepts of medical and administrative 

data sharing too its limits. The goal in Federal Health Care Center is to fully integrate the clinical and administrative functions between two health care systems. 

Planning activities are underway to develop the local project team required to manage the information technology requirements needed to support the new organization. Initial activities include the preparation of an integrated project schedule reflecting the expected delivery of local and national capabilities so that the gaps can 

be evaluated and resolved. Additionally, an enterprise-level team of resources is 

being assembled to resolve technical and operational issues that are beyond the 

local team’s ability to address. The new Great Lakes System will exercise every element of both clinical and administrative operations; a planned and deliberate approach must be taken to ensure that the business goals are met. There are certainly 

advances in the application of information technology that can be applied, however, 

the process is complex and must be driven by key business decisions and not by IT. 

I would like to thank you Mr. Chairman for giving me the opportunity to testify 

about the progress being made in clinical information sharing between VA and DoD 

and I will gladly take any questions at this point. 

BHIE Statistics (as of 25 September 07) 

MTF 

Number 

of correlated 

Patients 

Number 

of new 

patients* 

MTF 

Number 

of correlated 

Patients 

Number 

of new 

patients* 

Tripler AMC 179,304 52,064 NACC Groton 78,321 33,833 

Womack AMC 129,737 41,541 MacDill 70,025 40,028 

Leonard Wood ACH 112,676 31,876 NCA 316,981 121,345 

Irwin ACH 42,079 13,543 NH Camp Lejeune 136,008 40,672 

Eisenhower AMC 246,781 96,654 Wright-Patterson 101,188 47,201 

Martin ACH 139,410 39,402 Wm Beaumont AMC 124,275 6,199 

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BHIE Statistics (as of 25 September 07)—Continued 

MTF 

Number 

of correlated 

Patients 

Number 

of new 

patients* 

MTF 

Number 

of correlated 

Patients 

Number 

of new 

patients* 

Fox AHC 25,061 10,753 NH Corpus Christi 39,399 19,202 

Wilford Hall MC 601,170 227,103 Madigan AMC 201,519 63,392 

Darnall ACH 135,239 40,465 Landstuhl RMC 436,716 100,922 

Elmendorf 40,717 13,153 NMC Portsmouth 303,976 97,422 

Keesler 171,436 70,101 NH Pensacola 112,551 40,413 

O’Callaghan FH 75,777 22,619 NH Great Lakes 134,931 36,955 

Kirtland 77,066 55,796 NH Jacksonville 135,111 54,682 

Lyster AHC 30,868 12,355 NMC San Diego 243,934 60,644 

Bassett ACH 22,357 5,711 NH Lemoore 23,752 8,711 

David Grant MC 150,067 68,902 NH Charleston 119,450 36,356 

Evans ACH 107,596 40,602 NH Camp Pendleton 165,589 49,444 

Total # of Unique Patients ** 2,386,625 1,033,658 

* Patients not in the FHIE Domain. 

** Columns do not add to the total, since patients have been seen at multiple facilities. 

f 

Prepared Statement of Lieutenant Commander James Lawrence Martin, 

Regional Information Systems Officer, Navy Medicine East, Medical Service Corps, Department of the Navy, U.S. Department of Defense 

Mr. Chairman and Members of this distinguished Subcommittee, thank you for 

inviting me to be here today. I am LCDR James L. Martin and I serve as the Regional Information Systems Officer, Navy Medicine East. 

Thank you for this opportunity to talk about my personal involvement in the design and implementation of the Composite Healthcare System (CHCS), CHCS II, 

AHLTA and the Electronic Medical Record Sharing between the Department of Defense and the Department of Veterans Affairs. 

Status of Electronic Medical Record Sharing Naval Health Clinic Great 

Lakes 

The present method of sharing electronic medical information at Naval Health 

Clinic, Great Lakes, is through the Bi-Directional Health Information Exchange 

(BHIE) and the Clinical Data Repository/Health Data Repository (CHDR). The Veterans Affairs providers are granted read only access to the Department of Defense 

(DoD) Composite Health Care System (CHCS) and AHLTA. The Department of Defense (DoD) Providers are granted read and write privileges to the Veterans Affairs 

Computerized Patient Record System (CPRS) which resides on the Veterans Health 

Information Systems and Technology Architecture (VistA). 

Specifically, access to the Composite Health Care System, AHLTA and the Computerized Patient Record System in North Chicago is achieved through a single end 

user device with icons on the desk top representing each of these applications. This 

allows for seamless patient flow from the Recruit Processing Center Clinic at Recruit Training Center, Great Lakes to the Emergency Room and Inpatient Facility 

at North Chicago Veterans Affairs Medical Center. Laboratory Data Sharing Interoperability (LDSI) is used to share Laboratory information between these two systems. The combination of these methods listed above allows complete sharing of all 

Clinical Information between the Veterans Affairs and Department of Defense Providers. 

Regional Information Systems Officer Involvement in this Process 

My personal involvement in this process dates back to 1992 when I assisted in 

the design and implementation of the Infrastructure and End User Device placement in support of Composite Health Care System (CHCS Legacy) while serving as 

Assistant Department Head, Naval Medical Information Management Center, Bewwoods2 on PRODPC68 with HEARING

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thesda. My involvement included personally visiting each Naval Healthcare Treatment Facility prior to and during system implementation. 

Thereafter, my role expanded in 1994 as the Head, Management Information Department, Naval Hospital Pensacola, where I managed the Composite Health Care 

System Host Site for the Hospital and its remote facilities. In 1997, while serving 

as the TRICARE Region II Regional Information Systems Officer, Naval Medical 

Center Portsmouth, one of our Commands was selected to be the Test Site for Composite Health Care System II, the predecessor to AHLTA. From 2000 to 2004, I was 

the Information Systems Officer at Naval Medical Center Portsmouth overseeing 

the testing and implementation of the Composite Health Care System II. It was during this tour that Naval Medical Center Portsmouth first populated the Clinical 

Data Repository (CDR) with a 25 month data pull from Composite Health Care System (Legacy CHCS) placing demographic information and Laboratory, Pharmacy 

and Radiology results in the Clinical Data Repository. From 2004 until 2006 I 

served as the Medical Liaison Officer, Space and Naval Warfare Systems Center, 

Norfolk, where I was in charge of the design and testing of the Theater Medical Information Program-Maritime (TMIP–M) the Navy Operational Version of Composite 

Health Care System II and AHLTA designated CHCS II–T and AHLTA–T. 

Currently, as the Regional Information Systems Officer for Navy Medicine East, 

I oversee all Information Management and Technology for the Navy Military 

Healthcare Facilities that fall under Navy Medicine East. Naval Health Clinic Great 

Lakes is one of these Commands. 

I have made five site visits in direct support of the DoD/VA initiative at Great 

Lakes. During these visits I have surveyed the existing facilities and assisted in 

planning of the relocation of the IM/IT equipment to its new location at the Federal 

Healthcare Clinic. I attend biweekly conference calls and engineering support meetings where the design and layout of the actual IM/IT spaces is discussed. 

The other Commands under Navy Medicine East that I am presently assisting 

with DoD/VA IM/IT initiatives include Naval Health Clinic Charleston, Naval Hospital Pensacola, Naval Hospital Jacksonville and Naval Medical Center Portsmouth. 

I am also a member of the National Information Management and Technology Task 

Group for the Department of Defense and Department of Veterans Affairs Electronic 

Health Information Sharing Initiative. My responsibility as a member of this task 

force is to plan and oversee the acquisition and implementation of information systems that integrate VA and DoD health care processes at the North Chicago Federal 

Healthcare Clinic. 

Future Activities 

Our goal is to have an interoperable information system that supports clinical and 

business operations by June 2010. We plan to create a single (main) computer room 

and a single (main) telecommunications room. Additionally, an Information Management and Information Technology Network Trust between DoD and VA must be established, along with domain ownership and a single electronic email system. 

We are presently gathering requirements from the functional users so that the determination can be made on whether a combination of information systems or a new 

information system is required to meet the functional user requirements. The ultimate goal is to have a single point of entry to support the missions of both DoD 

and VA patient populations. At present, this goal is met by providing access to 

CHCS, AHLTA and CPRS using multiple icons on a single end user device. 

In addition to the goal of a single point of entry we are also working on the consolidation of IM/IT systems for all of the functional areas in the Federal Healthcare 

Clinic. This involves managing the development of functional requirements, assisting with local site integration efforts, assisting with enterprise solutions and communicating the status. 

Conclusion 

I would like to conclude by saying that one of our top priorities is to continue finding ways for Electronic Medical Data Sharing between DoD and VA. 

Mr. Chairman, Committee Members, thank you again for this opportunity to 

speak about our efforts. At this time I would be pleased to answer any questions 

you may have. 

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Prepared Statement of Colonel Gregory Andre Marinkovich, M.D., Data 

Management Product Line Functional Manager, Clinical Information 

Technology Program Office, Military Health System, Medical Services 

Corps, Department of the Army, U.S. Department of Defense 

Introduction 

Mr. Chairman and Members of this distinguished Subcommittee, thank you for 

inviting me to be here today. I am COL Gregory Andre Marinkovich and I serve 

as the Data Management Product Line Functional Manager in the Clinical Information Technology Program Office within the Military Health System (MHS). Thank 

you for this opportunity to talk about the military’s electronic health record, 

AHLTA, and the strides we are making in sharing information between the Department of Defense and the Department of Veterans Affairs. 

Historical Overview 

AHLTA, an enterprise-wide medical and dental outpatient clinical information 

system, is the military’s current outpatient Electronic Health Record (EHR). It generates, stores, and provides secure online access to lifelong patient healthcare 

records for more than 9.1 million MHS beneficiaries seen in military treatment facilities. AHLTA ensures the continuity of the Department’s health information and 

patient-centered healthcare delivery with worldwide accessibility anytime, anywhere. 

Worldwide deployment of AHLTA, which began January 2004, was successfully 

completed to all DoD military treatment facilities worldwide in November 2006. Implementation support activities spanned 11 time zones and included training for 

over 55,000 users, to include more than 18,000 health care providers. Current 

AHLTA functionality includes encounter documentation, order entry/results retrieval, encounter coding support, alerts and reminders, role-based security, health 

data dictionary, master patient index, and ad hoc query capability. 

Current Activities 

AHLTA use continues to grow at a significant pace. 

• To date, AHLTA has processed over 45 million outpatient encounters. • AHLTA is currently processing approximately 112,000 outpatient encounters 

per workday. 

DoD and VA also are taking the first steps toward a joint electronic health record 

system. A contract to assess VA’s and DoD’s business and clinical processes, design 

features, and system constraints relevant to the inpatient component of an electronic health record has been awarded. This assessment will determine and describe, in narrative and graphic format, the scope and elements of a joint inpatient 

electronic health record and identify those clinical and business capabilities and applications that interact with the joint inpatient electronic health record. An analysis 

of alternatives will then be conducted to develop a recommendation for the best 

technical approach. We will implement the solution in a manner that builds in data 

interoperability. 

Future Activities 

Based on feedback from several AHLTA user conferences, we are making changes 

to the next version that will be more provider-friendly. This is scheduled to be released in December 2007. Enhancements that are scheduled to begin deployment in 

December 2007 will include the ability for patients to provide their signatures electronically for medical forms, and multi-site user account access, which will enable 

‘‘mobile’’ providers to use AHLTA from multiple locations. 

Looking ahead to 2008, we plan to begin worldwide deployment of dental charting 

and documentation, and eyeglass ordering and management. 

Conclusion 

I would like to conclude by saying that one of our top priorities is to continue finding ways for AHLTA to seamlessly transfer information between DoD and VA, 

thereby ensuring continuity of quality care for returning wounded warriors. With 

your support, we will continue building on our achievements in sharing electronic 

health information in support of the men and women who serve and have served 

this country. 

Mr. Chairman, Committee Members, thank you again for this opportunity to 

speak about our efforts. At this time I would be pleased to answer any questions 

you may have. 

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Prepared Statement of Gerald M. Cross, M.D., FAAFP, Principal Deputy 

Under Secretary for Health, Veterans Health Administration, U.S. Department of Veterans Affairs 

Mr. Chairman, Madame Ranking Member Brown-Waite and Members of the Subcommittee, thank you for providing the opportunity to report the progress made by 

the Department of Veterans Affairs (VA) to share electronic medical records with 

the Department of Defense (DOD). We have made progress toward developing secure, interoperable electronic medical record systems and I am here today to discuss 

the current status of our efforts and the work that is underway to achieve electronic 

health record interoperability. 

Overview 

Today, VA and DOD are sharing electronic health data bidirectionally to support 

the care of shared patients. Additionally, VA and DOD are sharing more data than 

ever before on our seriously wounded service members and veterans who are 

transitioning from military facilities to VA facilities and polytrauma centers. The 

availability of these data to VA and DOD providers enhances our ability to provide 

world class care to veterans, active duty service members receiving care from both 

systems, and to our wounded warriors returning from theaters of operation in Iraq 

and Afghanistan. Ensuring that we have accurate, comprehensive and timely medical data to treat our Nation’s heroes remains a top priority of this department. 

In recent months, we have built upon our earlier successful development of oneway and bidirectional exchanges of text and computable data. Today, VA providers 

are able to access more electronic inpatient data from DOD than ever before. DOD 

also has a study underway, funded by VA and DOD, to examine our development 

of a joint inpatient electronic health record with DOD. Additionally, for the first 

time, VA has access to critical medical electronic data from current theater of operations, to treat wounded warriors coming to our facilities. The challenges of sharing 

large amounts of data from disparate electronic systems remain complex. Our processes are not perfect, and I will discuss that below. However, we are working to provide as much electronic data as possible as quickly as possible in support of our returning warriors and shared patient populations. We are now sharing data from 

multiple settings, including outpatient, inpatient, and theater, as well as tracking 

information to improve our case management and coordination. These accomplishments reaffirm our commitment to develop interoperable electronic health records 

with DOD. Moreover, we believe our current capabilities to share electronic medical 

data demonstrate progress toward our goal. 

Active Joint Governance 

VA and DOD efforts to achieve interoperability are jointly governed at the highest 

levels of our departments. Our VA Acting Secretary and the Under Secretary of Defense for Personnel and Readiness continue to cochair the DOD/VA Joint Executive 

Council (JEC). The JEC provides Executive and overarching leadership of all VA/ 

DOD collaborative activities, including the development of interoperable electronic 

medical records. Since 2003, VA and DOD have documented these activities in the 

DOD/VA Joint Strategic Plan (JSP) that is maintained by the JEC. The JSP contains measurable strategic goals, objectives and milestones for our collaborative 

work with DOD, including electronic medical data sharing. VA and DOD work to 

update the JSP each year and progress under the JSP is reported to the JEC on 

a monthly basis. Under the leadership of the JEC and the clear goals contained in 

the JSP, VA and DOD realized success in meeting JSP health data sharing milestones. 

VA’s Under Secretary for Health and the DOD Assistant Secretary of Defense for 

Health Affairs cochair the VA/DOD Health Executive Council (HEC), a Subcommittee of the JEC. The HEC is responsible for coordination of those joint activities related to health care and is committed to ensuring that our ongoing partnership optimizes health delivery to veterans and military beneficiaries. The HEC Information Management and Information Technology Work Group, cochaired by the 

VHA Chief Information Officer for Health Information Technology Systems and the 

Military Health System Chief Information Officer, maintains day to day responsibility for health information technology work and, most importantly, for the implementation of our joint electronic health record and data sharing initiatives. 

Theater and Inpatient Data Supporting the Seriously Ill and Wounded 

At no other time has it been more important for VA and DOD to overcome some 

of the ongoing complexities of sharing disparate electronic health data. VA and DOD 

are firmly committed to supporting the seamless care of our injured men and 

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cilities for longer term care and rehabilitation. Our Nation’s heroes deserve nothing 

less. In cooperation with our sharing partner, our most recent accomplishments to 

report have focused on the development of electronic solutions to support these seriously ill and wounded patients. 

VA and DOD have charted the Senior Oversight Committee (SOC) for the Wounded, and Injured. Co-chaired by the Acting VA Secretary and the DOD Deputy Secretary, the SOC works in conjunction with the JEC to ensure targeted focus on the 

population of men and women injured in OEF and OIF and now returning for treatment. Underneath the SOC, VA and DOD have organized several Lines of Actions 

(LOAs), with one LOA specifically focused on data sharing. The purpose of the data 

sharing LOA is to ensure that appropriate beneficiary and medical information is 

visible, accessible and understandable by each departments and that available electronic information is shared. Since the formation of the SOC and LOAs, the President’s Commission on Care for America’s Returning Wounded Warriors (President’s 

Commission) has recommended that VA and DOD share all essential health, administrative and benefit data in viewable format initially, within 12 months. Heeding 

this recommendation, we have worked with DOD to accelerate and enhance our existing data exchanging to meet this target. Today, VA and DOD are on target to 

ensure that these essential data which are available electronically will be viewable 

between the departments by October 2008. Additionally, VA and DOD are now actively developing a plan to establish technology support for the newly formed position of Federal Recovery Coordinator. This Recovery Coordinator will support seriously ill and wounded patients by maintaining on the ground oversight and coordination for all essential clinical and non-clinical aspects of the recovery care plan. 

We anticipate documenting an information technology plan to support this position 

by November of this year. 

Our most notable achievements demonstrating our commitment to wounded warriors is the sharing of theater and inpatient data. For the first time, DOD medical 

data captured electronically in the theater of operations are now viewable in text 

format to any VA provider treating these wounded warriors. We accomplished this 

in September of 2007 by leveraging an existing bidirectional data exchange. Subsequently, we are implementing a plan that will permit us to share unprecedented 

amounts of the available inpatient electronic data from DOD. Currently, VA providers are able to view electronic discharge summaries, emergency department 

notes, and other narrative documents captured during inpatient encounters at 13 

major DoD facilities that use the Essentris Clinical Information System (CIS)TM. 

These 13 facilities include the Military Treatment Facilities that are key to supporting returning combat veterans, such as Walter Reed Army Medical Center (Walter Reed) and Bethesda national Naval Medical Center (Bethesda), and have greatly 

contributed to our ability to provide seamless care to these wounded warriors. This 

work was accomplished, due in large part, to the innovation of our local clinicians 

and informatics professionals in the field, at locations such as the Puget Sound VA 

Healthcare System and Madigan Army Medical Center. Cooperative efforts between 

VA and DOD are systemic, reaching all the way down to our facilities. 

In addition to sharing available electronic documentation, DOD is sending digital 

radiology images and scanned inpatient paper records that do not originate in electronic format. These capabilities are in place between the key military treatment 

facilities that receive these patients in the Continental United States (CONUS), 

(Walter Reed, Bethesda, and Brooke Army Medical Center), and VA polytrauma 

centers located in Tampa, Richmond, Minneapolis and Palo Alto. 

VA and DOD continue to maintain the highly secure and audited direct connection allowing viewing access to the data in the inpatient electronic data systems at 

Walter Reed and Bethesda by clinicians at the four polytrauma centers. Using these 

connections allows authorized VA clinicians to view real-time DOD data on wounded 

service members and combat veterans who are coming to or have transferred to the 

VA from these DOD facilities. VA and DOD are working to expand our electronic 

capabilities enterprise wide. We have already successfully demonstrated our capability to leverage bidirectional data exchange to support image sharing with the El 

Paso pilot. We are now working to expand this pilot to other active sharing locations 

and are on target to document a plan to share images enterprise wide by March 

2008. As is commonly understood, much of the DOD inpatient data is not available 

electronically. Despite this ongoing challenge, VA and DOD quickly developed these 

capabilities as interim solutions to support these patients while we work to expand 

our electronic capabilities. To ensure that we provide full support in the face of 

these ongoing challenges, VA continues to embed Transition Patient Advocates and 

social workers at key facilities. At minimum, all pertinent medical records not available electronically are at least copied and transferred with the patient. Our enwwoods2 on PRODPC68 with HEARING

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hanced inpatient capabilities support and bolster the seamless transition of these 

patients. It is our goal that no patient will fall through the cracks. 

In January of 2007, VA and DOD announced a study to explore the development 

of a joint inpatient electronic health record system. Since that time, VA and DOD 

have actively pursued this initiative. We are now under contract with a prominent 

and independent third party firm that is conducting the analysis of alternatives. To 

date, we have made progress by documenting the scope and elements of those joint 

inpatient data elements that would need electronic support. This work includes conducting comprehensive surveys of industry best practices in this area. We anticipate 

we will have a final report by July 2008. A common inpatient electronic health 

record will support the transfer of our most seriously injured patients between DOD 

facilities and VA facilities as well as broad enterprise-level data sharing between 

VA and DOD clinicians for all shared patients. 

Requirement to Share Psychological Health Data and TBI Data 

In order to ensure comprehensive continuation of services, and to better leverage 

the world-class care that is already available to patients at VA’s centers of excellence for Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injuries, and 

other diagnoses impacting psychological health, it is necessary for VA and DOD to 

improve routine and appropriate sharing of mental health data. VA has a need to 

receive these data from DOD. 

Sharing of information on mental health conditions and other sensitive matters 

is important in a number of different contexts. Most simply, they can be divided into 

areas where the sharing of information is needed to facilitate clinical care of veterans or servicemembers who receive care in both systems, either sequentially or 

in parallel, and information used for administrative or command purposes. 

For clinical purposes, our systems should work toward minimizing barriers for 

transmittal to the greatest extent possible. Examples of mental health information 

that would support the VA in serving veterans include records of acute stress disorders, other mental health conditions, and suicidal behaviors, as well as head trauma. Having this information on returning veterans would be important to guide 

treatment and monitoring plans. 

For other purposes, VA, as an agency that functions in the community in parallel 

to civilian providers of health care, the issues may be more complex. For example, 

in developing principles about disclosure of information about mental health conditions from VA to DOD, VA must balance its responsibilities as a civilian community 

health care provider with those as part of a DOD/VA system. Viewed from community standards, it is important to honor patient privacy values, while from the VA/ 

DOD perspective, it is important to provide relevant information to DOD that may 

have an impact on the efficiency of the fighting force. This issue is being addressed 

in ongoing discussion within VA. 

Ongoing Support for Separated Service Members and Shared Patients 

In addition to our accelerated efforts to support our most seriously injured patients, VA and DOD continue the ongoing implementation of our Joint Electronic 

Health Records Interoperability (JEHRI) plan. The HEC IM/IT Work Group continues to manage the implementation of JEHRI and the maintenance and enhancement of our one-way and bidirectional data exchanges. Today, VA continues to receive all clinically relevant data that are available in DOD’s legacy system, the 

Composite Health Information System (CHCS), on service members separated from 

active military service. These data are viewable through our shared Federal Health 

Information Exchange repository by VA clinicians and disability claims staff using 

VA health and administrative information systems. To date, DOD has transferred 

electronic health data on over 4 million unique separated service members to VA. 

Of these individuals, VA has provided care or benefits to the more than 2 million 

veterans who have sought care or benefits from VA. The data transferred for viewing includes outpatient pharmacy data, allergy information, laboratory results, 

consults, admission, disposition and transfer information, medical diagnostic coding 

data, and military pre- and post-deployment health assessment (PPDHA) and reassessment (PDHRA) data on separated and demobilized National Guard and Reserve 

members. DOD has made almost 2 million of these PPDHA and PDHRA forms 

available for viewing by VHA clinicians and VBA staff. 

In addition to ongoing maintenance of our one-way data exchange, VA and DOD 

continue to bidirectionally exchange viewable and computable electronic data on 

shared patients. Currently, VA and DOD are bidirectionally sharing viewable outpatient pharmacy data, anatomic pathology/surgical reports, cytology results, microbiology results, chemistry and hematology laboratory results, laboratory order information, radiology text reports and food and drug allergy information. We also are 

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maintaining our ongoing exchange of computable allergy and pharmacy data supporting automatic drug-drug and drug-allergy interaction checks at seven locations. 

The development of this joint capability is complete. The departments are now 

working together to expand implementation across both enterprises by addressing 

issues such as user training, site specific issues related to identification and flagging 

of active dual consumers for whom this capability is in place, and ongoing deployment of department system dependencies related to HealtheVet. 

As mentioned above, and in keeping with the recommendation of the Presidential 

Commission, VA and DOD are leveraging our bidirectional exchanges to expand the 

types of data shared and to share all essential information by October 2008. By December of this year, our providers will have access to viewable encounter notes, 

problem lists, and procedures from DOD’s modern system, AHLTA. By June 2008, 

we will add vital signs and by October 2008 enterprise wide capability to view 

scanned documents, such as paper inpatient records. By March 2008, VA and DOD 

will document a plan to support the enterprise wide bidirectional sharing of digital 

images. This work will leverage the successful imaging pilot in El Paso and incorporate the work that will soon get underway at expanded pilot locations. By the 

fourth quarter of 2008, VA and DOD will deploy our computable laboratory capability to support automatic decision support using electronic laboratory result data 

transferred bidirectionally. 

Enhanced Tracking Capability (Veterans Tracking Application) 

This month, VA achieved the ability to access patient tracking data enterprise 

wide using the Veterans Tracking Application (VTA). As reported previously, VTA 

is a modified version of the DOD developed Joint Patient Tracking Application 

(JPTA). Our facility based liaisons, such as case managers, can now access VTA 

from VistA Web to assist with the coordination of care for patients treated at both 

VHA and DOD. This coordination includes the tracking of these patients as service 

members move from the battlefield through Landstuhl, Germany, to stateside military treatment facilities and into our VA polytrauma and medical centers. VTA is 

completely compatible with JPTA allowing overnight electronic transfer of critical 

tracking data on medically evacuated patients. 

Previously, we testified that our JPTA/VTA interface would support the transfer 

of medical data from the theater. DOD’s recent successful efforts to consolidate theater clinical data and to make it viewable to VA through our bidirectional data exchange overcame that effort. As mentioned above, VA clinicians access clinical data, 

including theater clinical data, through the Bidirectional Health Information Exchange. Our JPTA/VTA interface now supports the provision of viewable tracking 

data. The VTA database of seriously injured OEF/OIF service members and veterans is used as the authoritative source for the movement of theater patients and 

supports and documents contacts with veterans and service members. VTA is now 

a critical tool in the support of our seamless case management of patients. VTA also 

continues to support the benefit claims process and consolidates data from across 

all major components, DOD, VHA and VBA into a veteran centric record enhancing 

our case management capabilities. 

Ongoing Collaboration and Dependence on Standards 

VA and DOD’ continue to work closely with the Department of Health and 

Human Services (HHS) and other partners on national efforts to align our 

groundbreaking work on data exchanges with the nationwide effort to support 

health interoperability. These efforts are led by the HHS National Coordinator for 

Health Information Technology and will include ongoing efforts to identify mature 

standards, study infrastructure interoperability, and work closely with commercial 

healthcare providers to foster a global interoperability infrastructure. 

The President’s Commission recognized the complexity of achieving full data 

interoperability and tailored its recommendation to initially share data in viewable 

format versus computable format. Mature standards are necessary and evolved technologies are critical dependencies to the seamless exchange of all data. As these 

health data and communication standards mature and are identified, we will adopt 

and implement the standards into the systems we are modernizing. VA and DOD 

continue to play a leadership role in these efforts. Our VA/DOD Health Architecture 

Interagency Group continues to participate in and contribute to standards related 

organizations such as Healthcare Information Technology Standards Panel (HITSP) 

and Health Level 7(HL7) to improve the availability of shared health information. 

Current efforts are focused on areas such as case management and disability evaluation. 

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Conclusion 

VA and DOD have achieved progress toward sharing all available electronic data 

and remain committed to efforts that will help us to reach our final goal. Under the 

leadership of the JEC and the HEC, we are marching forward to implement enhancements to existing data exchanges while identifying attainable opportunities to 

support our most seriously ill and wounded warriors and combat veterans. We assure you that we continue to work toward a long-term strategy that will support 

full enterprise wide electronic data interoperability. Never before have we been able 

to access data from the theater and provide care to our veterans and rehabilitating 

service members using the amount of inpatient data currently available from DOD. 

Our efforts are subject to tremendous interest by the President and Congress, and 

we are working hard to ensure that recommendations coming from bodies such as 

the President’s Commission, the Task Force on the Returning Global War on Terror 

Heroes, chaired by our own Acting Secretary, and the Veterans Disability Benefits 

Commission, are evaluated and incorporated, where feasible, to ensure we form a 

complete and comprehensive approach to sharing health data in support of our veterans and service members 

To continue our successes, we ask for your continued support as we each work 

to modernize and update our existing technologies. VA has been recognized many 

times over for the world-class care it provides to veterans. Our electronic health 

record is second to none in its fully integrated electronic capabilities across all settings of care. More work is needed to update our world-class system and to ensure 

that it uses state of the art technologies and tools that will better support data 

interoperability. Thank you for the opportunity to appear before you and provide 

you the status of our ongoing efforts. My colleagues and I are happy to answer any 

questions you or other Members of the Subcommittee might have. 

VA/DoD Interoperability Acronyms 

Health Care Delivery Systems 

AHLTA—Armed Forces Health Longitudinal Technology Application—DoD’s next 

generation Electronic Record System—formerly CHCS II 

CHCS—Composite Health Care System—DoD legacy system housing order entry/ 

labs/radiology/allergy/meds, largely used for ambulatory care 

CIS—Clinical Information System (new name is Essentris Clinicomp)—DoD’s 

standalone inpatient system installed in most major military treatment facilities. 

CPRS—Computerized Patient Record System 

HealtheVet—Next generation of VistA based on computable data 

JPTA—DoD’s Joint Patient Tracking Application 

TMDS—DoD’s Theater Medical Data Store 

VistA—Veterans Health Information Systems and Technology Architecture 

VistA Web—The VistA web-based application for viewing remote data (VA and 

DoD) 

VTA—Veterans Tracking Application 

Other 

TPA—Transition Patient Advocates 

Health Care Exchange Systems 

BHIE—Bidirectional Health Information Exchange 

CHDR—Clinical Data Repository/Health Data Repository (Interoperability 

Project) 

FHIE—Federal Health Information Exchange (formerly GCPR) 

Groups/Organizations/Plans 

AHIC—American Health Information Community 

CHI—Consolidated Health Informatics 

BEC—DoD/VA Benefits Executive Council 

HEC—DoD/VA Health Executive Council 

JEC—DoD/VA Joint Executive Council 

JEHRI—DoD/VA Joint Electronic Health Records Interoperability 

JSP—Joint Strategic Plan 

LOA—Line of Action 

MTF—Military Treatment Facilities 

ONCHIT—Office of the National Coordinator for Health Information Technology 

SOC—Senior Oversight Committee 

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f 

Prepared Statement of Stephen L. Jones, DHA, Principal Deputy Assistant 

Secretary of Defense (Health Affairs), U.S. Department of Defense 

INTRODUCTION 

Mr. Chairman and members of this distinguished Subcommittee, thank you for 

inviting me to discuss the sharing of electronic health information between the Department of Defense (DoD) and Department of Veterans Affairs (VA). We are making great strides in sharing electronic health information, but we have more to do. 

Cooperation between DoD and VA in the area of health information sharing is 

vital for effective management and efficient delivery of programs and benefits that 

our Nation’s Veterans and Service members deserve. DoD recognizes Congressional 

concerns regarding the time it has taken the two Departments to establish the current level of interoperability. Let me assure you that DoD and VA share the ultimate goals of this and other Congressional bodies seeking to address the needs of 

the Nation’s heroes. We have been working together in earnest and have made significant progress in sharing electronic health information since our first efforts in 

2001. In particular, I would like to highlight current sharing activities, recent accomplishments, and some of what we hope to accomplish going forward. 

HISTORICAL OVERVIEW 

DoD and VA began sharing electronic health information in 2001 and have continually enhanced and expanded the types of information we share as well as the ways 

in which we share the information. At times it has not been an easy road, and there 

is always room for improvement in an effort as large and as crucial as this one. 

Nonetheless, DoD and VA have come a long way in the areas of health information 

technology, interoperability standards, and health information sharing. By working 

together at the top levels of DoD and VA, we have established policies that enable 

each Department to address its unique requirements while also addressing requirements that we share. 

CURRENT ACTIVITIES 

Continuity of Care for Shared Patients. For patients treated at both VA and 

DoD facilities, providers can view electronic health data from both Departments. By 

the end of 2007, all essential health data will be, in the words of the President’s 

Commission on Care for America’s Returning Wounded Warriors, ‘‘immediately 

viewable by any clinician, allied health professional, or program administrator who 

needs it’’ at a DoD or VA facility. Health data currently accessible by DoD and VA 

providers includes allergy information, outpatient medications, inpatient and outpatient laboratory results, radiology reports, demographic details to identify the patient, Pre- and Post-Deployment Health Assessments, and Post-Deployment Health 

Reassessments. To that list we can now add, as of earlier this month, vital clinical 

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data captured in the Theater of operations, including inpatient notes, outpatient encounters, and ancillary clinical data, such as pharmacy data, allergies, laboratory 

results, and radiology reports. This development is a significant accomplishment in 

our efforts to enhance the continuity of care for Service members returning from 

Iraq, Afghanistan, Kuwait, and other forward locations. Other recent developments 

include expanding our efforts to share inpatient information electronically. Specifically, over the past several months we have expanded the sharing of electronic discharge summaries to include the 13 DoD facilities with the greatest inpatient volume. Previously only five DoD facilities had been capable of sharing discharge summaries. This capability will be extended to include Landstuhl Regional Medical Center in 2008. As the primary receiving location for patients coming out of Theater, 

Landstuhl is a critical link in the electronic health information chain. 

By December 2007, we will be sharing encounters and clinical notes, procedures, 

problem lists, inpatient consultations, and operative reports, further enhancing continuity of care for our shared patients. In 2008, we will add vital signs, family history, social history, other history, and questionnaires and forms. 

Drug-Drug and Drug-Allergy Interaction Checking. Outpatient pharmacy 

and drug allergy data are now available in a standardized format for patients receiving treatment from both DoD and VA. This standardization enables our information systems to run vital safety checks. Drug-drug interaction and drug-allergy 

checks can now be run using data from both Departments, further enhancing patient safety. Currently, this capability is operational in the following seven locations: 

• William Beaumont Army Medical Center/El Paso VA Health Care System; 

• Eisenhower Army Medical Center/Augusta VA Medical Center; 

• Naval Hospital Pensacola/VA Gulf Coast Health Care System; 

• Madigan Army Medical Center/VA Puget Sound Health Care System; 

• Naval Health Clinic Great Lakes/North Chicago VA Medical Center; 

• Naval Hospital San Diego/VA San Diego Health Care System; and 

• Mike O’Callaghan Federal Hospital and VA Southern Nevada Health Care System. 

For this capability to work properly, the individual must have a record in the Defense Manpower Data Center/Defense Enrollment and Eligibility Reporting System 

(DEERS)—DoD’s ‘‘gold standard’’ for person identification. More than 6 million veterans, primarily those who separated from Service prior to the establishment of 

DEERS, were recently added to the DEERS database. With that completed, we are 

now ready for all DoD sites to implement this data sharing initiative. Even now 

however, all DoD and VA facilities—not just those listed above—have access to the 

shared DoD and VA pharmacy and allergy data for a patient if that patient should 

present to their facility for care. 

Continuity of Care for Polytrauma Patients (Wounded Warriors). Earlier 

this year, in response to the urgent need for VA providers at Polytrauma Centers 

to have as much information as possible on inpatients transferring to their care, 

DoD began sending electronic health information directly to the Polytrauma Centers. When providers determine that a severely wounded, injured, or ill patient 

should be transferred to a VA Polytrauma Center for care, DoD sends radiology images and scanned paper medical records electronically to the receiving facility. This 

effort began in March 2007 with a pilot project, sharing information from one DoD 

facility to one VA Polytrauma Center, and quickly expanded to include the three primary DoD facilities treating incoming severely wounded warriors—Walter Reed 

Army Medical Center, National Naval Medical Center, and Brooke Army Medical 

Center—and the four level 1 VA Polytrauma Centers—Tampa, Richmond, Palo Alto, 

and Minneapolis. 

Separated Servicemembers (Potential VA Patients). More than 4 million 

former Service members eligible for VA health care now have electronic health information accessible to their new provider should they seek care at a VA facility. In 

2001, DoD transmitted electronic health information for Service members who had 

separated since 1989. Monthly transfers of health information for newly separated 

Service members began in 2002 and continue today. Electronic health information 

available to VA providers includes the following data elements: 

• Outpatient pharmacy data, laboratory and radiology results; 

• Inpatient laboratory and radiology results; 

• Allergy data; 

• Consult reports; 

• Admission, disposition, transfer data; 

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• Standard ambulatory data record elements (including diagnosis and treating 

physician); • Pre- and post-deployment health assessments; and • Post-deployment health reassessments. 

When the former Service member presents to VA for care or evaluation, the VA 

provider can access this information from within the VA electronic medical record. 

Business Practice Coordination. DoD and VA have extended the sharing concept to include coordination of business practices. For example, the Laboratory Data 

Sharing Initiative (LDSI) established bidirectional electronic exchange of laboratory 

chemistry orders and results when one Department’s lab acts as a reference lab for 

the other. In other words, when it will speed the process of getting a lab result, DoD 

can send a test to a VA lab for processing or VA can send a test to a DoD lab. The 

end result is expedited testing and results, enhancing the quality of care for our patients. Expanding the LDSI capability, DoD and VA have added laboratory anatomic 

pathology and microbiology orders and results retrieval. This enhanced functionality 

became operational at Brooke Army Medical Center and VA South Texas Health 

Care System in May 2007. The LDSI capability can be expanded to include other 

sites should they demonstrate that the capability would enhance quality of care and 

make sense from a business perspective. 

DoD and VA are also exploring other opportunities for coordinating business practices to support Veterans and Service members and their families. These opportunities include an eHealth portal to improve accessibility of information for patients 

and expanded image sharing. In both cases, DoD and VA will explore opportunities 

in search of the best ways to coordinate business practices to achieve the greatest 

benefit for the patients we serve. 

DoD’s Electronic Health Record Meets Unique Needs. Sharing electronic 

health information with VA is just one function of the DoD electronic health record. 

DoD has many unique requirements that have shaped the development of its electronic health record system. 

Theater. To track health care most effectively in Theater, a flexible, mobile, and 

highly scalable electronic information system is necessary. DoD’s electronic health 

record operates on the full spectrum of hardware, according to what is available or 

practical in a given location or situation. DoD providers at fixed facilities—what 

most of us think of as hospitals—can use desktop computers. Providers at Combat 

Support Hospitals—sometimes nothing more than tents in the desert—use laptops 

that can operate in a standalone mode or as part of a small network. Medics in the 

field can use handheld devices that are later synched with a laptop or desktop to 

add valuable information to the patient’s electronic health record. DoD’s electronic 

health record, on all platforms, is designed to collect highly structured medical data, 

enabling us to identify potential natural disease outbreaks and chemical or biological attacks much faster than ever before in Theater. DoD’s Theater health care mission also necessitates that an electronic health record system be operational in situations and places where external communications are often sporadic or unreliable. 

Additionally, because health care information from Theater supports command and 

control efforts, our electronic health record system needs to fit within the greater 

DoD information technology infrastructure. 

One System in Garrison and Theater. When our providers deploy, they must be 

provided with familiar tools to maximize their readiness. Therefore, we need to use 

one electronic health record system in garrison and in Theater. Multiple systems 

could delay deployment of health care providers as they learn the ‘‘Theater’’ system 

or could negatively affect the quality of care in Theater as providers use a system 

with which they are either unfamiliar or less familiar. 

Our Beneficiary Population. DoD’s beneficiaries include millions of people who relocate every few years. To maintain accurate and complete electronic health records 

for such a mobile population requires a centralized clinical data repository. As DoD 

providers and patients alike move from one part of the country to another, or from 

one end of the world to another, they benefit from a system that maintains complete 

records with information from more than 60 major hospitals and medical centers 

and more than 400 clinics in a single, electronic health record—accessible from DoD 

facilities around the globe. 

JOINT INPATIENT ELECTRONIC HEALTH RECORD 

DoD and VA have developed or acquired separate outpatient electronic health 

record systems to meet unique needs. For inpatient care, however, the Departments 

are exploring the possibility of a joint electronic health record solution. The timing 

for examining this potentially ground-breaking effort is right, as both Departments 

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currently plan to modernize, upgrade, or integrate inpatient records with their outpatient electronic health records and must find an interoperable solution. A joint inpatient solution that meets the needs of both Departments could further enhance 

continuity of care, better meet requirements for joint facilities, and leverage economies of scale in terms of development and integration costs, license fees, and hardware purchases. 

We have taken the first steps in this effort to examine the potential for a joint 

system by working closely to award a contract to assess VA’s and DoD’s business 

and clinical processes, design features, and system constraints relevant to the inpatient component of an electronic health record. This assessment will determine and 

describe, in narrative and graphic format, the scope and elements of a joint inpatient electronic health record and identify those clinical and business capabilities 

and applications that interact with the joint inpatient electronic health record. An 

analysis of alternatives will then be conducted to develop a recommendation for the 

best technical approach. We will implement the solution in a manner that builds 

data interoperability in as a fundamental precept. Our goal is for a solution to address the information needs of the end users in all inpatient care venues from the 

forward surgical units in Theater to the domiciliary care facilities in VA. A joint solution could provide users with all essential inpatient data—regardless of where in 

DoD or VA that data was acquired—as the patient moves through the continuum 

of care from Theater to home again. The requirements analysis will be complete in 

2008, after which we will establish an acquisition or development timeline based on 

the assessment of alternatives. 

INTENSIFIED FOCUS ON WOUNDED WARRIORS 

In the words of Secretary Gates, ‘‘Apart from the war itself, this department and 

I have no higher priority’’ than taking care of those who have ‘‘stepped forward to 

serve.’’ Over the last several months DoD and VA have accelerated our electronic 

health information sharing initiatives to support America’s heroes. We have received 

and are responding to the recommendations of various commissions and task forces, 

including the Independent Review Group, the Department of Veterans Affairs Interagency Task Force on Returning Global War on Terror Heroes, and most recently, 

the Veterans Disability Benefits Commission. Under the auspices of a Senior Oversight Committee and Overarching Integrated Product Team, I along with Dr. Paul 

Tibbits have had the privilege of cochairing the team for DoD/VA Data Sharing. Not 

only are we focusing on sharing health, personnel, and administrative data electronically between DoD and VA, but we are also working with other teams to determine the information technology needed to support reengineered business processes 

that better support our wounded warriors. 

In addition, we are working to implement the recommendations of the President’s 

Commission on Care for America’s Returning Wounded Warriors. We will: 

• By next July, in order to implement our new Recovery Plans for wounded, make 

patient data much more accessible—to begin with, in viewable form. All essential health, administrative, and benefits data must be immediately viewable by 

any clinician, allied health professional, or program administrator who needs it. • Continue the work under way at present to create a fully interoperable information system that will meet the long-term administrative and clinical needs of 

all military personnel over time. • Develop a plan for a user-friendly, tailored, and specific services and benefits 

portal for service members, veterans, and family members. 

Over the next several months, DoD/VA teams will define information technology 

requirements, enabling the two Departments to begin the work necessary to make 

all appropriate demographic, personnel, and medical information on Service members, Veterans, and their beneficiaries visible, accessible, and understandable 

through secure and interoperable information management systems. We will work 

to provide the information technology needed to care for and track the status of our 

wounded warriors through their transition to Veteran status. DoD and VA are now 

working more collaboratively across health and personnel organizational lines than 

ever before. Our overall goal is to ensure appropriate beneficiary and medical information is visible, accessible, and understandable through secure and interoperable 

information management systems. 

JOINT GOVERNANCE 

VA/DoD electronic health information collaboration is a major component of the 

Departments’ Joint Strategic Plan. The goals of the Joint Executive Council are described in the Joint Strategic Plan for Fiscal Years 2007 through 2009 and cover 

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a full spectrum of VA/DoD health-related sharing. The Under Secretary of Defense 

for Personnel and Readiness and the VA Deputy Secretary cochair the Joint Executive Council, whose members include senior DoD and VA health managers involved 

in sharing initiatives. This Council was established in 2002 and now meets quarterly to provide leadership oversight of interdepartmental cooperation at all levels 

and to oversee the efforts of the Health Executive Council and Benefits Executive 

Council. The Assistant Secretary of Defense (Health Affairs) and VA Under Secretary for Health cochair the Health Executive Council, which was formed to establish a high-level program of cooperation and coordination in a joint effort to reduce 

costs and improve health care for all our beneficiaries. The Chief Information Officers of the Military Health System and the VA cochair the Health Executive Council’s Information Management/Information Technology workgroup. 

NATIONAL STANDARDS ADOPTION AND IMPLEMENTATION 

DoD and VA lead the Nation in health information technology, implementation 

of interoperability standards, and electronic health information sharing. DoD’s electronic health record system has been awarded pre-market, conditional certification 

by the Certification Commission for Healthcare Information Technology, an independent, non-profit organization that sets the benchmark for electronic health 

record systems. Full certification for DoD’s electronic health record system is expected in December 2007 when we begin deploying the next major enhancement. As 

we implement, acquire, or upgrade health information technology systems used for 

the direct exchange of health information between agencies and with non-Federal 

entities, we shall utilize, where available, health information technology systems 

and products that meet recognized interoperability standards. 

DoD and VA will continue to be driving forces in National initiatives such as the 

American Health Information Community, the Health Information Technology 

Standards Panel, the Health Information Technology Policy Council, and the Federal Health Architecture. DoD and VA support Executive Order 13410, issued in August 2006, which requires Federal agencies to use recognized health interoperability 

standards to promote the direct exchange of health information between agencies 

and with non-federal entities. Because such a significant portion of the American 

population is eligible for health care through Medicare, DoD, VA, and Federal employee health programs, our efforts can have a dramatic effect on private sector 

adoption of health information technology and will ultimately affect our ability to 

exchange electronic health information with private sector providers. 

CONCLUSION 

Providing the best possible care for America’s returning wounded warriors is a top 

priority for DoD and VA. Electronic health information sharing is unquestionably 

a key component of enhancing the quality and continuity of the care both Departments deliver. We have made great strides since our initial sharing efforts, building 

on the foundation established beginning in 2001. We have accelerated our expansion 

of the types of data shared and methods of sharing in recent months to support urgent needs. In the coming months, we will continue to explore additional projects 

such as a joint inpatient electronic health record and expanded image sharing. 

As always, we appreciate the insights, recommendations, and guidance of this and 

other Congressional and federal bodies. We are all working toward the same end— 

to provide the highest quality care for our Nation’s heroes, past and present—and 

we need to work together to achieve our goals as efficiently and effectively as possible. Thank you for allowing me the opportunity to appear before you and to testify 

about DoD/VA electronic health information sharing achievements, goals, and plans. 

f 

Committee on Veterans’ Affairs 

Subcommittee on Oversight and Investigations 

Washington, DC. 

February 5, 2008 

Honorable David M. Walker 

Comptroller General 

U.S. Government Accountability Office 

441 G St., NW 

Washington, DC 20548 

Dear Mr. Walker: 

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1GAO, Information Technology: VA and DOD Continue to Expand Sharing of Medical Information, but Still Lack Comprehensive Electronic Medical Records, GAO–08–207T (Washington, 

D.C.: Oct. 24, 2007). 2GAO, Computer-Based Patient Records: Better Planning and Oversight by VA, DOD, and IHS 

Would Enhance Health Data Sharing. GAO–01–459 (Washington, D.C.: Apr. 30, 2001) and Veterans Affairs: Sustained Management Attention Is Key to Achieving Information Technology Results, GAO–02–703 (Washington, D.C.: June 12, 2002) and Computer-Based Patient Records: VA 

and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project 

Management, GAO–04–687 (Washington, D.C.: June 7, 2004). 

On Wednesday, October 24, 2007, the Subcommittee on Oversight and Investigations of the House Committee on Veterans’ Affairs held a hearing on the sharing 

of electronic medical information between the Department of Defense (DoD) and the 

Department of Veterans Affairs (VA). 

During the hearing, the Subcommittee heard testimony from Ms. Valerie Melvin, 

Director of the Human Capital and Management Information Systems Issues team. 

Ms. Melvin was accompanied by Ms. Barbara Oliver, Assistant Director for Human 

Capital and Management Information Systems Issues. As a follow-up to that hearing, the Subcommittee is requesting that the following questions be answered for 

the record: 

1. Since 2001, how many times has the Government Accountability Office reported on the issue of electronic medical records sharing between DoD and VA 

with recommendations, and how many of the recommendations have been actually implemented by DoD and VA? 

We request you provide responses to the Subcommittee no later than close of business, Friday, March 7, 2008. 

Sincerely, 

HARRY E. MITCHELL 

Chairman 

GINNY BROWN-WAITE 

Ranking Republican Member 

U.S. Government Accountability Office 

Washington, DC. 

March 7, 2008 

Hon. Harry E. Mitchell, Chairman 

Hon. Ginny Brown-Waite, Ranking Member 

Subcommittee on Oversight and Investigations 

Committee on Veterans’ Affairs 

House of Representatives 

Subject: Subcommittee Post-Hearing Question Concerning Efforts by the Departments of Veterans Affairs and Defense to Share Electronic Medical Information 

This letter responds to your request of February 5, 2008, that we provide you with 

an answer to your question related to our October 24, 2007, testimony.1 At that 

hearing, we discussed efforts by the Department of Veterans Affairs (VA) and Department of Defense (DOD) to exchange patient health information. Your question 

and our response follow. 

Since 2001, how many times has the Government Accountability Office reported on 

the issue of electronic medical records sharing between DOD and VA with recommendations, and how many of the recommendations have been actually implemented by DOD and VA? 

Since 2001, we have issued three reports 2 that included recommendations pertaining to DOD’s and VA’s efforts to electronically share medical information. Our 

reports highlighted the activities being taken by the departments to electronically 

exchange health care data as well as management challenges that they have faced 

in doing so. We pointed out that management weaknesses, such as inadequate accountability and poor planning and oversight, had led to repeated changes in the 

focus of the departments’ initiatives and target completion dates. We determined 

that the lack of a lead entity, clear mission, and detailed planning made it difficult 

to monitor the departments’ progress, identify project risks, and develop appropriate 

contingency plans. 

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3The long-term initiative includes the interface between the departments’ new repositories 

(DOD’s Clinical Data Repository and VA’s Health Data Repository), referred to as CHDR. Two 

short-term initiatives include a one-way transfer of medical information from DOD to VA on personnel leaving active duty, the Federal Health Information Exchange (FHIE), and a two-way 

view of medical information in existing systems on shared patients, the Bidirectional Health Information Exchange (BHIE). 

As a result of the weaknesses we identified, our reports included a total of eight 

recommendations to encourage progress in VA’s and DOD’s efforts to achieve the capability to share information electronically. These recommendations focused on 

strengthening the management and oversight of the departments’ initiatives by establishing a lead entity with final decisionmaking authority, providing Executivelevel support, instituting sound project management principles, and agreeing to 

clear goals, objectives, and performance measures. In addition, we recommended 

that the departments develop a comprehensive and coordinated project management 

plan that defines the technical and managerial processes necessary to satisfy project 

requirements and to guide their activities. 

As of October 2007, VA and DOD had fully implemented seven of our recommendations, achieving a measure of success in sharing limited health information 

electronically. However, the departments had not completed actions on our recommendation to develop a comprehensive coordinated project management plan. 

The departments provided us with a project management plan that included the exchange of pharmacy data, but had not completed a detailed project management 

plan to guide their various initiatives to share electronic health information. According to VA, when the plan is completed, it will contain milestones and will further 

define sharing capabilities to support the long-term ability of VA and DOD to share 

electronic health data. Without such a detailed plan, VA and DOD increase the risk 

that the long-term project will not deliver the planned capabilities in the time and 

at the cost expected. Our recommendations and the departments’ actions to address 

them are summarized in enclosure I. 

In addition to the aforementioned reports, since 2001 we have testified 14 times 

on VA and DOD efforts to electronically share patient health information with each 

other. Our statements discussed the progress made by the departments in exchanging health information via various long- and short-term initiatives 3 and reiterated 

actions that the departments needed to take to address our recommendations. We 

pointed out that the exchanges of health information between VA and DOD have 

been limited and that significant work remained to fully achieve the goal of exchanging health information seamlessly between the departments. This includes 

each department’s development of its next generation health information system 

that is critical to delivery of health care to its patients. We also reiterated the need 

for the departments to develop a comprehensive and coordinated project management plan. Our testimonies are summarized in enclosure II. 

In responding to your question, we relied on past work related to our reviews of 

VA’s and DOD’s actions since 2001 toward sharing patient health information. We 

reviewed our prior reports and testimonies on the departments’ health information 

sharing efforts. We conducted this performance audit from February 2008 to March 

2008. All work on which this correspondence is based was conducted in accordance 

with generally accepted government auditing standards. 

Should you or your office have any questions on matters discussed in this letter, 

please contact me at (202) 512–6304 or by e-mail at melvinv@gao.gov. Key contributors to this letter were Barbara Oliver and Eric Trout. 

Sincerely yours, 

Valerie C. Melvin 

Director, Human Capital and 

Management Information Systems Issues 

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Enclosure I: Actions Taken by VA and DOD on GAO Recommendations 

Report date/ 

number 

Recommendations to VA and 

DOD 

Actions taken by VA and/or 

DOD 

June 7, 2004 

GAO–04–687 

Develop an architecture for the 

electronic interface between their 

health systems that includes 

system requirements, design 

specifications, and software 

descriptions. 

The departments implemented this 

recommendation. They developed 

an architecture for the electronic 

interface that includes major 

elements required in a complete 

architecture. For example, it 

defines system requirements and 

allows these to be traced to the 

functional requirements; it includes 

the design and control 

specifications for the interface 

design; and it includes design 

descriptions for the software. 

Select a lead entity with final 

decisionmaking authority for their 

effort to share patient health 

information. 

The departments implemented this 

recommendation by establishing 

project accountability and 

implementing a joint project 

management structure. 

Specifically, the Health Executive 

Council was established as the lead 

entity for the project. 

Establish a project management 

structure to provide day-to-day 

guidance and accountability for 

their investments in and 

implementation of the interface 

capability. 

The departments implemented this 

recommendation. The joint project 

management structure consists of a 

Program Manager from VA and a 

Deputy Program Manager from 

DOD to provide day-to-day 

guidance for this initiative. 

Additionally, the Health Executive 

Council established the DOD/VA 

Information Management/ 

Information Technology Working 

Group and the DOD/VA Health 

Architecture Interagency Group, to 

provide programmatic oversight 

and to facilitate interagency 

collaboration on sharing initiatives 

between DOD and VA. 

Create and implement a 

comprehensive and coordinated 

project management plan for the 

electronic interface that defines the 

technical and managerial processes 

necessary to satisfy project 

requirements and includes (1) the 

authority and responsibility of each 

organizational unit; (2) a work 

breakdown structure for all of the 

tasks to be performed in 

developing, testing, and 

implementing the software, along 

with schedules associated with the 

tasks; and (3) a security policy. 

The departments took action but 

have not yet fully implemented this 

recommendation. The departments 

provided GAO with a project 

management plan that included 

the exchange of pharmacy data, 

but have not completed a detailed 

project management plan to guide 

the long-term efforts to share data. 

According to VA, when the plan is 

completed, it will contain 

milestones and further define 

sharing capabilities to support the 

long-term ability of VA and DOD to 

share electronic health data. 

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Enclosure I: Actions Taken by VA and DOD on GAO Recommendations— 

Continued 

Report date/ 

number 

Recommendations to VA and 

DOD 

Actions taken by VA and/or 

DOD 

June 12, 2002 

GAO–02–703 

Revisit the original goals and 

objectives of the Government 

Computer-Based Patient Record 

(GCPR) initiative to determine if 

they remain valid, and where 

necessary, revise the goals and 

objectives to be aligned with the 

current strategy and direction of 

the project. 

The departments implemented this 

recommendation. They reevaluated 

and revised the original goals and 

objectives of the initiative. A May 

3, 2002, memorandum of 

agreement between VA and DOD 

established the Federal Health 

Information Exchange (FHIE) 

effort. DOD has been using FHIE 

to transfer information to VA since 

2002. According to DOD officials, 

194 million clinical messages on 

more than 4 million veterans had 

been transferred to the FHIE data 

repository as of September 2007. 

Commit the Executive support 

necessary for adequately managing 

the project, and ensure that sound 

project management principles are 

followed in carrying out the 

initiative. 

The departments implemented this 

recommendation. The departments 

committed the Executive support 

necessary for adequately managing 

the FHIE project. VA committed 

Executive support for the project 

by way of monthly updates 

provided by the FHIE program 

manager to the VA chief 

information officer, as well as 

quarterly updates to the joint VA/ 

DOD Executive Council. They also 

ensured that project management 

principles were followed in carrying 

out the initiative. VA procured and 

implemented project management 

software to better track the 

assignment and status of project 

tasks and initiatives. 

April 30, 2001 

GAO–01–459 

Direct their health chief 

information officers to designate a 

lead entity with final 

decisionmaking authority and 

establish a clear line of authority 

for GCPR. 

The departments implemented this 

recommendation. By July 2002, VA 

and DOD had finalized a 

memorandum of agreement 

designating VA as the lead entity 

for implementing the program. 

Create comprehensive and 

coordinated plans to ensure that 

the agencies can share 

comprehensive, meaningful, 

accurate, and secure patient health 

data. These plans should include 

an agreed-upon mission and clear 

goals, objectives, and performance 

measures, and they should 

capitalize on existing medical IT 

capabilities. 

The departments implemented this 

recommendation. By July 2002, VA 

and DOD had revised their 

strategy for the initiative into longand short-term efforts and had 

made progress toward 

electronically sharing patient 

health data. The departments had 

renamed the short-term portion of 

their initiative the Federal Health 

Information Exchange. 

Source: GAO. 

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Enclosure II: GAO Testimony on VA and DOD Sharing of Patient Health 

Information 

Testimony date/ 

number Summary of Results 

October 24, 2007 

GAO–08–207T 

Under their long-term initiative, the modern health information 

systems being developed by each department are to share standardized 

computable data through an interface between data repositories 

associated with each system. The repositories have now been 

developed, and the departments have begun to populate them with 

limited types of health information. In addition, the interface between 

the repositories has been implemented at seven VA and DOD sites, 

allowing computable outpatient pharmacy and drug allergy data to be 

exchanged. Nevertheless, the departments must still agree to 

standards for the remaining categories of medical information, 

populate the data repositories with this information, complete the 

development of the two modernized health information systems, and 

transition from their existing systems. Further, the departments have 

established ad hoc processes to meet the immediate need to provide 

data on severely wounded service members to VA’s polytrauma 

centers, which specialize in treating such patients. While these 

multiple initiatives and ad hoc processes have facilitated degrees of 

data sharing, they nonetheless highlight the need for continued efforts 

to integrate information systems and automate information exchange. 

At present, it is not clear how all the initiatives are to be incorporated 

into an overall strategy focused on achieving the departments’ goal of 

comprehensive, seamless exchange of health information. 

September 19, 2007 

GAO–07–1246T 

VA achieved a milestone in the long-term effort to share electronic 

health information with DOD, having begun to exchange limited 

medical data with DOD (at selected sites) through an interface 

between the data repositories for the modern health information 

systems that each department is developing. Nevertheless, to achieve 

their long-term vision, VA and DOD have much work still to do (such 

as extending the current capability throughout both departments), and 

the two departments have not yet projected a final completion date for 

the whole initiative. 

July 18, 2007 

GAO–07–1108T 

VA and DOD have made progress in both their long-term and shortterm initiatives to share health information, but much work remains 

to achieve the goal of a shared electronic medical record and seamless 

transition between the two departments. In the long-term project to 

develop modernized health information systems, the departments have 

begun to implement the first release of the interface between their 

modernized data repositories, and computable outpatient pharmacy 

and drug allergy data are being exchanged at seven VA and DOD 

sites. However, significant work remains including agreeing to 

standards for the remaining categories of medical information and 

populating the data repositories with all this information. The two 

departments have also made progress in their short-term projects to 

share information in existing systems. Through all these efforts, VA 

and DOD are achieving exchanges of health information. However, 

these exchanges are as yet limited, and it is not clear how they are to 

be integrated into an overall strategy toward achieving the 

departments’ long-term goal of comprehensive, seamless exchange of 

health information. Consequently, it remains essential for the 

departments to develop a comprehensive project plan to guide their 

efforts to completion, in line with our earlier recommendations. 

May 8, 2007 

GAO–07–852T 

In the long-term project to develop modernized health information 

systems, the departments have begun to implement the first release of 

the interface between their modernized data repositories, and 

computable outpatient pharmacy and drug allergy data are being 

exchanged at seven VA and DOD sites. Although the data being 

exchanged are limited, implementing this interface is a milestone 

toward the long-term goal of modernized systems with interoperable 

electronic medical records. Besides completing the Federal Health 

Information Exchange (FHIE), the departments have made progress 

on two demonstration projects. In addition to their technology efforts, 

the two departments have undertaken ad hoc activities to accelerate 

the transmission of health information on severely wounded patients 

from DOD to VA’s four polytrauma centers, which care for veterans 

and service members with disabling injuries to more than one physical 

region or organ system. 

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Enclosure II: GAO Testimony on VA and DOD Sharing of Patient Health 

Information—Continued 

Testimony date/ 

number Summary of Results 

June 22, 2006 

GAO–06–905T 

VA and DOD are implementing limited, near-term demonstration 

projects, and they are making progress toward their long-term effort to 

share electronic patient health data. The Bidirectional Health 

Information Exchange, implemented at 16 sites, allows the two-way 

exchange of health information on shared patients in text format. The 

Laboratory Data Sharing Interface application, implemented at 6 sites, 

is used to facilitate the electronic transfer/sharing of orders for 

laboratory work and the results of the work. In their longer term 

efforts to achieve a virtual medical record, VA and DOD have more to 

do to achieve the two-way electronic data exchange capability 

originally envisioned. They have made progress in, for example, 

preparing data for exchange, and they have implemented three of our 

four earlier recommendations. However, they have not yet developed a 

clearly defined project management plan that gives a detailed 

description of the technical and managerial processes necessary to 

satisfy project requirements, as we recommended. Moreover, the 

departments have experienced delays in their efforts to begin 

exchanging computable patient health data. 

September 28, 2005 

GAO–05–1051T 

VA and DOD had begun to implement applications that exchange 

limited electronic medical information between the departments’ 

existing health information systems. These applications were 

developed through two information technology demonstration projects: 

(1) Bidirectional Health Information Exchange is a project to achieve 

the two-way exchange of health information on shared patients, 4 and 

(2) Laboratory Data Sharing Interface is an application used to 

facilitate the electronic transfer/sharing of orders for laboratory work 

and the results of the work. Since our last report on the departments’ 

efforts to achieve a virtual medical record, VA and DOD have taken 

several actions, but the departments continue to be far from achieving 

the two-way electronic data exchange capability originally envisioned. 

The departments have implemented three recommendations that we 

made in June 2004, but have not yet developed a clearly defined 

project management plan that gives a detailed description of the 

technical and managerial processes necessary to satisfy project 

requirements, as we previously recommended. Moreover, the 

departments have experienced delays in their efforts to begin 

exchanging computable patient health data; they have not yet fully 

populated the data repositories that are to store the medical data for 

their future health systems. 

May 19, 2004 

GAO–04–811T 

VA and DOD are proceeding with actions intended to support the 

sharing of health data, but continue to be far from achieving the twoway electronic data exchange capability envisioned in the 

HealthePeople (Federal) strategy. The departments are continuing to 

take actions to develop their individual health information systems 

that are critical to exchanging patient health information and to define 

data standards that are essential to the common sharing of health 

information. In addition, department officials stated that they are 

proceeding with a pharmacy data prototype initiative, begun in March 

2004, to satisfy a mandate of the Bob Stump National Defense 

Authorization Act for Fiscal Year 2003, 5 as an initial step toward 

achieving HealthePeople (Federal). At this stage, however, they have 

not developed a strategy to explain how this project will contribute to 

defining the technological solution for the data exchange capability. As 

such, VA and DOD continue to lack a clearly defined architecture and 

technological solution for developing the electronic interface and 

associated capability for exchanging patient health information 

between their new systems. Moreover, the departments remain 

challenged to articulate a clear vision of how this capability will be 

achieved, and in what timeframe. 

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Enclosure II: GAO Testimony on VA and DOD Sharing of Patient Health 

Information—Continued 

Testimony date/ 

number Summary of Results 

March 17, 2004 

GAO–04–402T 

VA and DOD had made little progress since November 2003 toward 

defining how they intended to achieve the two-way exchange of patient 

health information under the HealthePeople (Federal) initiative. While 

VA officials recognized the importance of an architecture to describe in 

detail how the departments would electronically interface their health 

systems, they continued to rely on a less-specific, high-level strategy— 

in place since September 2002—to guide the development and 

implementation of this capability. The departments intended to rely on 

a pharmacy prototype project undertaken in March 2004 to better 

define the electronic interface needed to exchange patient health data, 

but had not fully determined the approach or requirements for this 

undertaking. Thus, there was little evidence of how this project would 

contribute to defining a specific architecture and technological solution 

for achieving a two-way exchange of patient health information. These 

uncertainties were further complicated by the absence of sound project 

management to guide the departments’ actions on the HealthePeople 

(Federal) initiative. Although progress toward defining data standards 

continued, delays had occurred in VA’s and DOD’s development and 

deployment of their individual health information systems, critical for 

achieving the electronic interface. 

November 19, 2003 

GAO–04–271T 

The one-way transfer of health information resulting from VA’s and 

DOD’s near-term solution—the FHIE—represented a positive 

undertaking and had enabled electronic health data from separated 

(retired or discharged) service members contained in DOD’s Military 

Health System Composite Health Care System to be transmitted 

monthly to a VA FHIE repository, giving VA clinicians more ready 

access to DOD health data, such as laboratory, pharmacy, and 

radiology records, on almost two million patients. The departments’ 

longer term strategy to enable electronic, two-way information 

sharing—HealthePeople (Federal)—was farther out on the horizon, 

and VA and DOD faced significant challenges in implementing a full 

data exchange capability. Although a high-level strategy existed, the 

departments had not clearly articulated a common health information 

infrastructure and architecture to show how they intended to achieve 

the data exchange capability or what they would be able to exchange 

by the end of 2005. Critical to achieving the two-way exchange was 

completing the standardization of the clinical data that the 

departments planned to share. 

September 26, 2002 

GAO–02–1054T 

VA and DOD reported some progress in achieving the capability to 

share patient health care data under the Government Computer-Based 

Patient Record (GCPR) initiative. The agencies had, since March 2002, 

formally renamed the initiative the Federal Health Information 

Exchange and begun implementing a more narrowly defined strategy 

involving the one-way transfer of patient health data from DOD to VA; 

a two-way exchange was planned by 2005. 

March 13, 2002 

GAO–02–369T 

VA had achieved limited progress in its joint efforts with DOD and the 

Indian Health Service 6 to create an interface for sharing data in their 

health information systems, as part of GCPR. Strategies for 

implementing the project continued to be revised, its scope had been 

substantially narrowed from its original objectives, and it continued to 

operate without clear lines of authority or comprehensive, coordinated 

plans. Consequently, the future success of this project remained 

uncertain, raising questions as to whether it would ever fully achieve 

its original objective of allowing health care professionals to share 

clinical information via a comprehensive, lifelong medical record. 

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Enclosure II: GAO Testimony on VA and DOD Sharing of Patient Health 

Information—Continued 

Testimony date/ 

number Summary of Results 

February 27, 2002 

GAO–02–478T 

DOD’s and VA’s numerous databases and electronic systems for 

capturing mission-critical data, including health information, were not 

linked, and information could not be readily shared. DOD had several 

initiatives under way to link many of its information systems—some 

with VA. For example, to create a comprehensive, lifelong medical 

record for service members and veterans and to allow health care 

professionals to share clinical information, the departments, along 

with the Indian Health Service, initiated the GCPR project in 1998. 

However, several factors, including planning weaknesses, competing 

priorities, and inadequate accountability, made it unlikely that they 

would achieve a GCPR or realize its benefits in the near future. To 

strengthen management and oversight of the project, we recommended 

designating a lead entity with clear lines of authority for the project 

and the creation of comprehensive and coordinated plans for sharing 

meaningful, accurate, and secure patient health data. For the near 

term, DOD and VA had decided to reconsider their approach to GCPR 

and focus on allowing VA to access selected service members’ health 

data captured by DOD, such as laboratory and radiology results, 

outpatient pharmacy data, and patient demographic information. 

However, GCPR would not provide VA with access to information on 

the health status of personnel when they entered military service; on 

medical care provided to Reservists while not on active duty; or on the 

care military personnel received from providers outside DOD, 

including those from TRICARE.7

January 24, 2002 

GAO–02–377T 

DOD improved its medical surveillance system under Operation Joint 

Endeavor. However, system problems included lack of a single, 

comprehensive electronic system to document and access medical 

surveillance data. Some DOD initiatives to improve information 

technology capability were several years away from full 

implementation. The ability of VA to fulfill its role in serving veterans 

and providing backup to DOD in times of war was to be enhanced as 

DOD increased its medical surveillance capability. GCPR was a joint 

DOD/VA initiative in conjunction with the Indian Health Service to 

link information systems. However, because of planning weaknesses, 

competing priorities, and inadequate accountability, it was unlikely 

that the departments would accomplish GCPR or realize its benefits in 

the near future. To strengthen management and oversight of the 

initiative, we again recommended designating a lead entity with clear 

lines of authority for the project and the creation of comprehensive and 

coordinated plans for sharing meaningful, accurate, and secure patient 

health data. 

October 16, 2001 

GAO–02–173T 

DOD and VA were establishing a medical surveillance system for the 

health care needs of military personnel and veterans. The system was 

to collect and analyze uniform information on deployments, 

environmental health threats, disease monitoring, medical 

assessments, and medical encounters. We identified weaknesses in 

DOD’s medical surveillance capability and performance in the Gulf 

War and Operation Joint Endeavor, and uncovered deficiencies in its 

ability to collect, maintain, and transfer accurate data. The 

department had several initiatives under way to improve the 

reliability of deployment information and to enhance its information 

technology capabilities, although some initiatives were several years 

away from full implementation. VA’s ability to serve veterans and 

provide backup to DOD in times of war was to be enhanced as DOD 

increased its medical surveillance capability. GCPR was one initiative 

to link the departments’ information systems. However, because of 

planning weaknesses, competing priorities, and inadequate 

accountability, it was unlikely that they would accomplish GCPR or 

realize its benefits in the near future. To strengthen management and 

oversight of the initiative, we recommended designating a lead entity 

with clear lines of authority for the project and the creation of 

comprehensive and coordinated plans for sharing meaningful, 

accurate, and secure patient health data. 

Source: GAO. 

(310918) 

4Shared patients receive care from both VA and DOD clinicians. For example, veterans may receive outpatient care from VA clinicians and be hospitalized at a military treatment facility. 5P.L. 107–314, sec. 724 (2002). 

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6 Initially, the Indian Health Service was also a party to this effort, but was not included in a later revised 

strategy for electronically sharing patient health information. 7TRICARE is the Department of Defense’s worldwide health care program for active duty and retired uniformed services members and their families. 

f 

Committee on Veterans’ Affairs 

Subcommittee on Oversight and Investigations 

Washington, DC. 

February 5, 2008 

Honorable Robert M. Gates 

Secretary 

U.S. Department of Defense 

1000 Defense Pentagon 

Washington, DC 20301–1000 

Dear Secretary Gates: 

On Wednesday, October 24, 2007, the Subcommittee on Oversight and Investigations of the House Committee on Veterans’ Affairs held a hearing on the sharing 

of electronic medical information between the Department of Defense (DoD) and the 

Department of Veterans Affairs (VA). 

During the hearing, the Subcommittee heard testimony from Dr. Stephen Jones, 

Principal Deputy Assistant Secretary for Defense for Health Affairs; and Colonel 

Gregory Andre Marinkovich, M.D., Data Management Product Line Functional 

Manager, Clinical Information Technology Program Office (CITPO). Dr. Jones was 

accompanied by Mr. Charles Campbell, Acting Chief Information Officer, TRICARE 

Management Activity; and Colonel David Gilbertson, Program Manager, CITPO. As 

a follow-up to that hearing, the Subcommittee is requesting that the following questions be answered for the record: 

1. Please provide the Subcommittee with a list of each medical information sharing initiative currently being worked on by DoD and VA, and a timeline for 

completion of each such initiative. 

2. What is being done to train medical providers prior to deployment to the theatre on the use of AHLTA–T in order to provide full utilization of the system 

once in theatre? 

3. The Subcommittee has heard that there is insufficient or insufficiently reliable 

bandwidth to ensure the electronic transmission of medical information from 

the current CENTCOM combat theaters to DoD medical facilities outside of 

theater, or between medical facilities within theater. Please tell the Subcommittee what steps DoD is taking to resolve these bandwidth issues, provide 

a timeline for implementation of these steps, and state in detail how DoD intends to provide sufficient support within theater to the maintenance of adequate bandwidth for medical information. 

4. Should there be an interoperability requirement for major medical IT systems 

and devices that are procured by both DoD and VA? Are DoD and VA, or either 

one, developing standards to ensure that information generated by major medical systems and devices procured by the departments are bidirectionally electronically accessible? 

5. Is DoD in the process of developing an enterprise inpatient electronic medical 

record system? If so, please provide a description of this development and provide a timeline for completion. 

6. What steps, if any, is DoD taking to transfer data from CIS (Essentris) to the 

Clinical Data Repository? 

We request you provide responses to the Subcommittee no later than close of business on Friday, March 7, 2008. 

Sincerely, 

HARRY E. MITCHELL 

Chairman 

GINNY BROWN-WAITE 

Ranking Republican Member 

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Hearing Date: October 24, 2007 

Committee: HVA 

Members: Congressman Mitchell, Congresswoman Brown-Waite 

Witness: Dr. Jones 

Medical Information Sharing 

Question #1: Please provide the Subcommittee with a list of each medical information sharing initiative currently being worked on by DoD and VA, and a timeline 

for completion of each such initiative. 

Answer: Since 2001, the Department of Defense (DoD) and the Department of 

Veterans Affairs (VA) have made tremendous progress in sharing electronic health 

information, with a noticeable increase this past year. Accelerated efforts in response to the emerging and urgent needs for increased support of care that both 

Departments deliver to America’s returning Wounded Warriors are possible, in large 

part, because of the foundation both Departments have worked to establish. This 

foundation includes advanced information technology products required to share information, a firm commitment from top leaders of both Departments to work as 

closely as possible to support a common mission, and established processes and policies that enable DoD and VA to work together effectively. Under the VA/DoD Joint 

Strategic Plan, health information technology data sharing initiatives are prioritized 

by DoD and VA leadership. 

Current Health Data Sharing: 

• Inpatient and outpatient laboratory and radiology results, allergy data, outpatient pharmacy data, demographic data, and theater clinical data, including 

inpatient notes, outpatient encounters, and ancillary clinical data, such as pharmacy data, allergies, laboratory results, and radiology reports is available 

through AHLTA, DoD’s electronic health record, and through Veterans Health 

Information Systems & Technology Architecture (VistA), VA’s electronic health 

record, for patients treated by both Departments 

• Inpatient discharge summaries from 13 of DoD’s largest inpatient facilities 

• Radiology images for severely wounded and injured Service members for patients transferring from Walter Reed Army Medical Center (WRAMC), National 

Naval Medical Center (NNMC) Bethesda, and Brooke Army Medical Center 

(BAMC) to the VA Polytrauma Centers in Tampa, Richmond, Palo Alto, and 

Minneapolis 

• Paper medical records scanned to create portable document format documents 

for electronic transmission for patients transferring from WRAMC, BAMC and 

NNMC to the VA Polytrauma Centers in Tampa, Richmond, Palo Alto, and 

Minneapolis 

• Pre- and Post-Deployment Health Assessments and Post-Deployment Health 

Re-assessments for separated Service members and demobilized Reserve and 

National Guard members who have deployed 

• Laboratory (chemistry) order entry and results retrieval shared among DoD, VA 

and commercial reference laboratories. Laboratory Data Sharing Initiative is 

available for use throughout DoD and is actively being used on a daily basis 

between DoD and VA at several sites where one Department uses the other as 

a reference lab. Anatomic Pathology/Microbiology functionality became operational at BAMC and VA South Texas Health Care System in 2007, and is 

available to other sites with a business case for its use 

• When a Service member’s active duty term ends, DoD transmits to VA inpatient 

and outpatient laboratory and radiology results, outpatient pharmacy data, allergy information, consult reports, admission, disposition and transfer information, elements of the standard ambulatory data records and demographic data 

Timeline: 

• Recovery Care Coordinator Information Technology Support Plan 

(in response to the President’s Commission on Care for America’s 

Wounded Warriors) 

Nov 2007 

• Bidirectional, real-time view of provider notes, procedures, and 

problem lists 

Dec 2007 

• Discharge summaries for inpatient mental health from Landstuhl 

Regional Medical Center (LRMC) 

Dec 2007 

• Plan for eBenefits Web portal (in response to President’s Commission on Care for America’s Wounded Warriors report) Dec 2007 

• Inpatient consults and operative reports (Madigan Army Medical 

Center and VA Puget Sound) 

Dec 2007 

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• Inpatient consults and operative reports (additional 13 inpatient 

sites) 

Mar 2008 

• Draft DoD/VA Information Interoperability Plan Mar 2008 

• Plan for enterprise-wide image sharing Mar 2008 

• Discharge summaries from LRMC for medical/surgical, recovery 

room, intensive care unit, and operating room 

Mar 2008 

• Bi-directional, real-time view of vital signs Jun 2008 

• Analysis of alternatives for joint inpatient record Aug 2008 

• Bi-directional, real-time view of family history, social history, 

questionnaires, and forms 

Sep 2008 

• Computable laboratory data exchange Sep 2008 

Medical Provider Training 

Question #2: What is being done to train medical provider prior to deployment 

to the theatre on the use of AHLTA–T in order to provide full utilization of the system once in theatre? 

Answer: The Theater Medical Information Program (gram (TMIP) provides wartime medical forces support applications to the Army, Navy and Air Force for deployment and sustainment operations in the theater environment. TMIP supports 

all medical functional areas, including command and control, medical logistics, blood 

management, patient regulation and evacuation, medical threat/intelligence, health 

care delivery, manpower and training, and medical capability assessment and 

sustainment analysis. TMIP integrates information from other medical systems, including AHLTA–T, Defense Blood Standard System, and Defense Medical Logistics 

Standard Support (DMLSS). The military Services are responsible for ensuring 

users are adequately trained to use these systems. The Air Force provides AHLTA– 

T training for all providers prior to deployment. The Navy does not provide AHLTA– 

T training prior to deployment, but training supported by the Army Medical Communications for Combat Casualty Care (MC4) occurs during a general orientation 

upon arrival in theater. The Army MC4 training program for providers includes the 

following levels of TMIP application training: 

• Pre-deployment—Active, Reserve, and Guard units receive classroom training 

before being deployed, using the same systems they will use in theater 

• Collective Unit Training—occurs during unit deployment training exercises, 

such as those conducted at the Joint Readiness Training Center 

• Institutional Familiarization Training—MC4 is working with the Army Medical 

Department Center and School, and the Special Forces School to incorporate 

MC4 familiarization training into their curriculums 

• Reception, Staging, Onward movement and Integration training in Kuwait— 

unit and individual training at Kuwait staging area prior to unit arrival in the 

area of responsibility 

• Theater Training—Embedded MC4 trainers provide classroom and over-theshoulder training onsite, in theater 

• Computer-based Training—online and compact disk versions of training available worldwide 

Theater Bandwidth 

Question #3: The Subcommittee has heard that there is insufficiently reliable 

bandwidth to ensure the electronic transmission of medical information from the 

currently CENTCOM combat theaters to DoD medical facilities outside of theater 

or between medical facilities with theater. Please tell the Subcommittee what steps 

DoD is taking to resolve these bandwidth issues, provide a timeline for implementation of these steps, and state in detail how DoD intends to provide sufficient support 

within theater to the maintenance of adequate bandwidth for medical information. 

Answer: Based on the August 23, 2007 Joint Urgent Operational Need (JUON), 

United States Central Command (USCENTCOM) is working with Service components (Army-Central Command, Air Force-Central Command, Navy-Navy Central 

Command, and Marines-Marine Central Command) and the Joint Task Forces to 

identify gaps in the transmission of medical information and images within the 

USCENTCOM Area of Responsibility. Based on these requirements, USCENTCOM 

will conduct an analysis of theater bandwidth upgrade alternatives, to include technical capabilities, costs, and implementation/sustainment plans, and provide a detailed request for assistance to the Director, Command, Control, Communications, 

and Computer Systems, Joint Staff early in the 2nd quarter of fiscal year 2008. If 

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approved, the theater bandwidth upgrade project should be completed within approximately 200 days of receipt of funds. 

Inter-Departmental IT Interoperability Requirement 

Question #4: Should there be an interoperability requirement for major medical 

IT systems and devices that are procured by both DoD and VA? Are DoD and VA, 

or either one, developing standards to ensure the information generated by major 

medical systems and devices procured by the departments a bidirectional electronically accessible. 

Answer: 

• The Department of Defense (DoD) is focused on interoperability for information 

technology systems, devices and the bidirectional sharing of medical information 

when appropriate. An explicit mandate to address interoperability is not required. • DoD and the Department of Veterans Affairs (VA) already share a tremendous 

amount of electronic health information and lead the Nation in sharing computable health data. • DoD and VA are members of the American Health Information Community and 

actively participate with the Healthcare Information Technology Standards 

Panel to collaborate on and advance the development, adoption, and implementation of interoperable electronic health information capabilities, standards, and 

business practices that enhance the sharing of medical information with the 

federal and private sectors. • The VA/DoD Joint Strategic Plan has a number of objectives that focus on increasing the bidirectional electronic health data access between DoD and VA. • DoD actively participates in and contributes to standards development organizations such as Health Level 7, which is an all-volunteer, not-for-profit organization involved in the development of international healthcare standards. • DoD and VA are engaged in an assessment of the requirements and approach 

for a joint inpatient electronic health record (EHR) and plan to provide a recommendation for the inpatient EHR by August 2008. 

Future DoD Enterprise Electronic Medical Record System 

Question #5: Is DoD in the process of developing an enterprise inpatient electronic medical record system? If so, please provide a timeline for completion. 

Answer: The Military Health System (MHS) currently uses the Essentris system 

for inpatient electronic health record (EHR) support at 17 military treatment facilities representing 45% of the MHS inpatient workload. The Department of Defense 

(DoD) and the Department of Veterans Affairs (VA) are collaborating on an assessment of requirements and an approach for a joint inpatient electronic health record. 

Anticipated benefits of this initiative include: 

• Leverage economies of scale 

• Facilitate exchange of inpatient data, thereby improving continuity of care 

• Accelerate the adoption and implementation of standards to promote interoperability 

• Better meet requirements for joint facilities 

Key elements of this joint initiative include: 

• Analyze the clinical processes and feasibility over the initial 6-month period 

from August 2007—January 2008 

• Document and assess DoD and VA inpatient clinical processes, workflows, and 

requirements 

• Identify the areas of commonality and the areas of uniqueness 

• Determine the benefits and the impacts on DoD and VA timelines and costs for 

deploying a common inpatient EHR solution 

• Analyze alternatives, develop the business case and produce a recommendation 

for the joint inpatient EHR approach by August 2008 

Transfer of Data from CAS to Clinical Data Repository 

Question #6: What steps, if any, is DoD taking to transfer data from CAS 

(Essentris) to the Clinical Data Repository? 

Answer: The Military Health System (MHS) recognizes the need and benefit of 

providing secure, enterprise-wide access to inpatient clinical data within the AHLTA 

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Clinical Data Repository (AHLTA–CDR). The MHS is currently focused on two key 

initiatives in support of this goal. 

The MHS is conducting a prototype effort at Madigan Army Medical Center to determine the feasibility of transferring Essentris inpatient data to the AHLTA–CDR. 

Because Essentris is an interim MHS inpatient system, the focus of this effort has 

been on defining the key inpatient documentation that should be transferred. Current inpatient documentation under consideration includes inpatient history and 

physical condition data, discharge summaries, operative reports, and inpatient consultation reports. 

The MHS is also developing the Document, File, and Image-Enabled (DFIEA) capability within AHLTA to improve the transfer, storage, and access of many types 

of clinical data, to include the transfer of inpatient information from Essentris to 

the AHLTA–CDR. The DFIEA capability is targeted for DoD-wide activation in the 

4th quarter of FY 2008. The MHS anticipates completion of plans for transferring 

Essentris inpatient notes into DFIEA in the 1st quarter of fiscal year 2009. 

f 

Committee on Veterans’ Affairs 

Subcommittee on Oversight and Investigations 

Washington, DC. 

February 5, 2008 

Hon. James B. Peake 

Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Secretary Peake: 

On Wednesday, October 24, 2007, the Subcommittee on Oversight and Investigations of the House Committee on Veterans’ Affairs held a hearing on the sharing 

of electronic medical information between the Department of Defense (DoD) and the 

Department of Veterans Affairs (VA). 

During the hearing, the Subcommittee heard testimony from Dr. Gerald M. Cross, 

Principal Deputy Under Secretary for Health; and Howard B. Green, Deputy Director of the Health Management Office in the Office of Information and Technology 

(OI&T). Dr. Cross was accompanied by Dr. Paul Tibbits, Deputy Chief Information 

Officer, OI&T; and Mr. Cliff Freeman, Director of VA/DoD Interagency Programs, 

Veterans Health Administration. As a follow-up to that hearing, the Subcommittee 

is requesting that the following questions be answered for the record: 

1. Please provide the Subcommittee with a list of each medical information sharing initiative currently being worked on by DoD and VA, and a timeline for 

completion of each such initiative. 

2. Should there be an interoperability requirement for major medical IT systems 

and devices that are procured by both DoD and VA? Are DoD and VA, or either 

one, developing standards to ensure that information generated by major medical systems and devices procured by one department be electronically accessible by the other department? 

We request you provide responses to the Subcommittee no later than close of business on Friday, March 7, 2008. 

Sincerely, 

HARRY E. MITCHELL 

Chairman 

GINNY BROWN-WAITE 

Ranking Republican Member 

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Questions for the Record 

Hon. Harry E. Mitchell, Chairman 

Hon. Ginny Brown-Waite, Ranking Republican Member 

House Veterans’ Affairs Committee 

Oversight and Investigations Subcommittee 

October 24, 2007 

Sharing of Electronic Medical Information Between Department of Defense 

and Department of Veterans Affairs 

Question 1: Please provide the Subcommittee with a list of each medical information sharing initiative currently being worked by the Department of Defense (DoD) 

and VA, and a timeline for completion of each such initiative: 

Response: By September 2008, Department of Veterans Affairs (VA) and DoD 

health data sharing improvements will include the addition of: 

Data Sharing Initiative Target Completion 

(by the end of) 

Inpatient consults March 2008 

Operative reports March 2008 

Plan for movement of medical images March 2008 

Laboratory data sharing interface for reference labs April 2008 

Vital signs June 2008 

Joint inpatient phase 2 analysis—technical feasibility July 2008 

Family history September 2008 

Questionnaires and forms September 2008 

Other history September 2008 

Social history September 2008 

Bi-directional health information exchange—VA–DoD imaging September 2008 

Question 2: Should there be an interoperability requirement for major medical 

IT systems and devices that are procured by both DoD and VA? Are DoD and VA, 

or either one, developing standards to ensure that information generated by major 

medical systems and devices procured by one department be electronically accessible 

by the other department? 

Response: An interoperability requirement for major medical information technology (IT) devices procured by both VA and DoD should, and in fact does, exist. 

VA currently adheres to industry standards for medical device compliance. 

Information exchange between VA and DoD systems is of the utmost importance. 

This is why VA and DoD both adhere to common standards for the exchange of information between their interoperable systems. VA complies with industry standards for medical equipment whenever possible. The following is a sampling of some 

of the standards with cross-program impacts. 

• DICOM (http://medical.nema.org/): used for imaging devices. All VA-procured 

imaging devices are DICOM-compliant, as are internally developed and procured imaging software systems. 

• HL7 (http://www.hl7.org/): a device interoperability standard. VA adheres to 

HL7 standards in a number of manners, both applications and devices. 

• Laboratory standards: VA procures lab equipment that meet industry laboratory equipment standards. 

VA and DoD are committed to compliance with health data standards as they are 

identified, recommended and recognized by the Department of Health and Human 

Services (HHS). VA and DoD also participate in the Healthcare Information Technology Standards Panel (HITSP) a public-private initiative that develops and recommends harmonized interoperability specifications. Additionally, the HHS Office of 

the National Coordinator for Health Information Technology is developing model 

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contract language to assist Federal agencies to comply with interoperability standards requirements set forth in Executive Order 13410. 

f 

Health Executive Council Highlights 

FY2003—Q1 FY2008 

June 10, 2008 

Patient Safety Working Group 

Purpose: 

The Patient Safety Working Group will oversee the design, development, and distribution of joint patient safety initiatives, consistent with legal requirements on 

uses of quality assurance information. 

Accomplishment(s): 

✔ Signed Data Use Agreements (DUAs) in May 2008 to allow the sharing of information. Sharing information between Departments will allow the Working 

Group to produce monthly progress reports related to unintentionally retained 

surgical items, incorrect surgery, invasive procedures, falls and inpatient suicides. The summary reports will show analyses of selected subtypes of events, 

and information on root causes and contributing factors that lead to these 

types of adverse events in health care systems, as well as examples of interventions implemented in both systems. 

Evidence Based Practice Working Group 

Purpose: 

The Evidence Based Practice Working Group will use clinically diverse and collaborative groups to develop, update, adapt, adopt and/or revise four evidence-based 

clinical practice guidelines (EBCPGs) annually. EBCPGs reduce variation in care, 

optimize patient outcomes, and improve the overall health of beneficiaries. 

Accomplishment(s): 

✔ Created tools to support a culture that uses evidence-based clinical practices 

including web based interactive tools, pocket cards, PDA-friendly versions of 

EBCPGs and educational videos. 

Measureable Outcome(s): 

Completed nine new EBCPGs since FY2005. Numerous EBCPGs reviewed. 

Mental Health Working Group 

Purpose: 

The Mental Health Working Group will work together to explore mechanisms to 

identify individuals with serious mental health issues or who are at risk for suicide 

in order to insure appropriate assessment and indicated treatment are offered. The 

Working Group will also coordinate to plan and implement shared training programs to increase the use of evidence-based psychotherapy and pharmacotherapy 

approaches in both Departments. 

Accomplishment(s): 

✔ Trained 119 providers on how to conduct Cognitive Processing Therapy for Post 

Traumatic Stress Disorder and how to teach others to conduct this psychotherapy. 

✔ Ensured clinicians were aware that relevant Clinical Practice Guidelines 

(CPGs) were applicable to both DoD and VA. Provided clinicians with clear direction on each Department’s mental health diagnosis/treatment regimens. 

Communicated the availability of data in Bidirectional Health Information Exchange (BHIE) relevant to the treatment of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. 

✔ Coordinated Blue Ribbon and Expert Panels to meet June 11–13, 2008 to prepare formal recommendations for joint VA/DoD Suicide Prevention activities. 

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Graduate Medical Education Working Group 

Purpose: 

The Graduate Medical Education (GME) Working Group will examine opportunities for greater VA/DoD GME collaboration and conduct a needs assessment of GME 

programs which may have been adversely impacted by the Base Realignment and 

Closure (BRAC) Act. 

Accomplishment(s): 

✔ Selected San Diego as the pilot site for the Seamless Transition for Trainees 

Program. The focus of this pilot project is on reducing red tape and streamlining access to educational resources for VA and DoD trainees as they transition between sites. 

✔ Completed a pilot project placing military physician residents in VA-affiliated 

university programs. As part of the program, DoD medical residents rotated 

through VA facilities and provided care to VA patients under the supervision 

of VA and university faculty. Lessons learned will form the basis of program 

expansion. 

Continuing Education and Training Working Group 

Purpose: 

The Continuing Education and Training Working Group will enhance the existing 

shared training partnership between VA and DoD to provide additional and improved shared training by optimizing the distributed learning architecture which 

supports the sharing of continuing education and in-service training programs for 

health care professionals in VA and DoD. 

Accomplishment(s): 

✔ Completed Distributed Learning Architecture Research Project and Satellite 

Broadcast Initiative. 

✔ Established and managed a VA/DoD Facility Based Educators community of 

practice to increase communications between and among VA and DoD facility 

based educators. 

✔ Conducting pilot program for leaders and managers at the North Chicago Joint 

Federal Health Care Facility (VA & U.S. Navy). 

Measureable Outcome(s): Shared 254 programs in FY 07 

Cost Avoidance: Shared 254 programs with cost avoidance of $7.5 million in FY 

07. First quarter of FY 08 number increased 44% over same period last year. 

Cost: JIF Funding Received: Distributed Learning Architecture Research 

Project—$400,000 and Satellite Broadcast Initiative—$3.2 million 

Deployment Health Working Group 

Purpose: 

The Deployment Health Working Group will identify opportunities to share information between DoD and VA on 1) health surveillance of military populations, including identification of cohorts with specific exposures or diseases, 2) the assessment and screening of deployed populations, and 3) follow-up medical care of deployed populations. 

Accomplishment(s): 

✔ Analyzed VA health care utilization among Southwest Asian War Veterans. 

✔ Developed the assessment form and procedures for the post-deployment health 

reassessment (PDHRA), to screen for physical health and mental health concerns at 90 and 180 days after return from their deployments, in order to determine if referral for further medical evaluation is warranted. PDHRA information can be communicated electronically via the Federal Health Information 

Exchange (FHIE). 

✔ Conducted medical surveillance activities and planning activities related to depleted uranium exposure and pandemic flu. 

✔ Collaborated in the development of risk communication and outreach products 

to service members and veterans related to military health issues, including 

occupational and environmental exposures. For example, DoD launched a Web 

site entitled the Deployment Health and Family Readiness Library and the VA 

published several products for health care providers related to endemic infectious diseases of the Middle East. 

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✔ Developed an inventory of more than 350 DoD and VA research projects related to the health of deployed service members and veterans. 

Information Management/Information Technology Working Group 

Purpose: 

The Information Management/Information Technology Working Group will support interoperable enterprise architectures and data management strategies to support timely and accurate delivery of benefits and services. 

Accomplishment(s): 

✔ Completed the Federal Health Information Exchange (FHIE) in 2004, and 

transferred clinical data on more than 4 million veterans as of September 

2007. 

✔ The Bidirectional Health Information Exchange (BHIE) allows a real-time, 

two-way view of certain outpatient health data from existing systems at all VA 

and DoD sites, and certain inpatient discharge summary data at all VA sites 

and 13 large DoD sites. 

✔ The Joint Patient Tracking Application/VA Tracking Application (JPTA) allows 

real time tracking of patients from point of injury to arrival in continental U.S. 

Joint access now enables VAMCs to contact patients and encourage them to 

enroll in VA healthcare. 

Measureable Outcome(s): 

Performance Measure Status 

The number of DoD service members with historical data transferred to VA; 4.3 million as of March 

2008. 

The number of patients flagged as ‘‘active dual consumers’’ for VA/ 

DoD electronic health record data exchange purposes; 

18,160 as of May 1, 

2008. 

The number of Pre- and Post-Deployment Health Assessment 

(PPDHA) forms and PDHRA forms transferred to VA; 

2.2 million as of March 

2008. 

The number of individuals with PPDHA and PDHRA forms transferred to VA; 894,000 as of March 

2008. 

The number of chemistry and anatomic pathology/microbiology laboratory tests processed using the Laboratory Data Sharing Initiative; Over 350,000 reported 

as of May 2008. 

The number of patients for which digital images have been transmitted electronically from Walter Reed Army Medical Center, National Naval Medical Center Bethesda and Brooke Army Medical 

Center to VA Polytrauma Centers at Tampa, Palo Alto, Richmond 

and Minneapolis; 

84 as of March 2008. 

The number of patients for which medical records have been 

scanned and sent electronically from Walter Reed Army Medical 

Center, National Naval Medical Center Bethesda and Brooke 

Army Medical Center to VA Polytrauma Centers at Tampa, Palo 

Alto, Richmond and Minneapolis. 

133 as of March 2008. 

Acquisition and Medical Materiel Management Working Group 

Purpose: 

The Acquisition and Medical Materiel Management (A&MMM) Working Group 

will assess VA and DoD processes related to the acquisition of goods and services 

and make recommendations to achieve joint operational and business efficiencies. 

Accomplishment(s): 

✔ Developed Product Data Bank (PDB) for standardization of product files as a 

precursor to a joint electronic catalog. 

✔ Through PDB synchronization process, created an accurate master item 

records covering 93 percent ($407 million) of DoD top buys and 57 percent 

($323 million) of VA top buys as of 2007. Twenty VA sites have been trained 

on the use of this tool. 

✔ FY 2007 joint/shared contracts exceeded $580 million. 

✔ The Defense Supply Center in Philadelphia (DSCP) had sales under these 

shared contracts just over $102 million through the third quarter of FY 2007. 

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✔ Reverse Distribution contracts (‘‘pharmaceutical returns’’) were awarded to six 

suppliers in 2007. 

Cost Savings: Annual savings in outdated pharmaceuticals are estimated to be 

$49 million. Projected return on investment for PDB is $40 million through FY2010. 

Cost: JIF Funding Received: $15.1 million for PDB development over the period 

FY2006–FY2010 

Pharmacy Working Group 

Purpose: 

The Pharmacy Working Group will identify pharmaceuticals and commonly used 

products and manufacturers for potential joint contracting action and continue to 

seek new joint contracting opportunities. 

Accomplishment(s): 

✔ In FY 07 VA and DoD spent $389 million on Joint national pharmaceutical 

contracts. 

✔ Continue to review expiring contracts for conversion to joint contracts, including brand-to-generic conversions and new molecular entities used in the ambulatory setting. 

Cost Avoidance: In FY 07 VA estimated cost avoidance for DoD/FDA Shelf Life 

Extension Program (SLEP) participation was $7.3 million 

Financial Management Working Group 

Purpose: 

The Financial Management Working Group will review the Memorandum of 

Agreement and scoring criteria for the DoD–VA Health Care Sharing Incentive 

Fund or Joint Incentive Fund (JIF) to ensure proper emphasis is given to corporate 

direction, task force/review group recommendations, and new legislation. The JIF’s 

purpose is to carry out a program to identify, provide incentives to, implement, fund, 

and evaluate creative coordination and sharing initiatives at the facility, intra-regional, and nationwide level. 

Accomplishment(s): 

✔ Projects have been funded by JIF (JIF II) to support the Dole/Shalala commission 

• DoD/VA Digital Imaging and Scanned Document Sharing Phase IIB 

This project will allow digital images for critically wounded warriors to be 

imported into the VA and DoD picture archive and communications systems 

(PACs) in an organized and timely manner. Currently images are manually 

stored on CDs and require several days to import. 

• DoD/VA Digital Imaging and Scanned Document Sharing Phase III 

This project is a follow on to Phase IIB described above. It addresses critical 

national-level needs in treating our Wounded Warriors by providing the capability for automatic electronic bidirectional sharing of medical digital images and scanned documents between the DoD and VA. 

• DoD/VA eBenefits Portal Phase III 

The scope for the eBenefits Portal initiative is to initially leverage and integrate existing portals/Web sites. The eBenefits Portal infrastructure will be 

the platform to integrate self-service applications and other online services. 

The interface design goal is to give Wounded Warriors a central access point 

to online services with improved information architecture. The eBenefits 

Portal is a phased project. Phase III personalizes the eBenefits Portal capabilities to the needs of the wounded, ill, or injured service member. 

• Armed Forces Institute of Regenerative Medicine (AFIRM) Program 

The U.S. Army Medical Research and Material Command is establishing two 

AFIRM programs dedicated to repairing battlefield injuries through the use 

of regenerative medicine. This project funded one of the two AFIRM programs. 

Measureable Outcome(s): 

$148 million of the $160 million contributed to JIF by DoD and DVA from FY2003 

through FY2007 has been used to fund 69 projects. 

Cost: $160 million as stated above 

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Joint Facility Utilization and Resource Sharing Working Group/Joint 

Market Opportunities 

Purpose: 

The Joint Facility Utilization and Resource Sharing Working Group will oversee 

VA and DoD efforts to jointly implement the National Defense Authorization Act 

(NDAA) Demonstration Projects in budget and financial management, coordinated 

staffing and assignment, and medical information and information technology management. The Working Group, through its Ad Hoc Joint Market Opportunities 

(JMO) Working Group, will assess additional health care markets serving large, 

multi-Service, DoD and VA populations. 

Accomplishment(s): 

✔ NDAA Demonstration Projects were completed. A preliminary report has been 

provided to the HEC. The final report is in process. 

✔ The JMO Working Group was redirected by Deputy Secretary of Veterans Affairs Gordon H. Mansfield and Under Secretary of Defense for Personnel and 

Readiness David S.C. Chu in March 2008 to focus on sharing at four specific 

sites. 

• VA Pacific Island Heath Care System/Tripler Army Medical Center, Honolulu, Hawaii 

• Mike O’Callaghan Federal Hospital, Las Vegas, NV 

• Eastern Colorado Health Care System/Buckley Air Force Base Medical Clinic, Denver 

• VA Gulf Coast Veterans Health Care System/Keesler Air Force Base, Biloxi, 

MS 

✔ Plans continue to be implemented for the first Federal Health Care Center 

(FHCC). The facility is scheduled to be operational by 2010. The FHCC will 

be a fully integrated partnership between Naval Hospital Great Lakes (NHGL) 

and North Chicago Veterans Affairs Medical Center (NCVAMC). This unique 

VA/DoD integration will operate under a single Chain of Command and serve 

beneficiary populations as if it were both a Military Treatment Facility and a 

VA Medical Center. 

Cost savings for FHCC: Mental Health operations—$1 million annually 

Cost avoidance for FHCC: Navy Blood Bank—$850K to $3.1 million 

Cost reduction for FHCC: ICU/CCU operations reduced total costs by $920K 

Contingency Planning Working Group 

Purpose: 

The Contingency Planning Working Group will collaborate to ensure that plans 

and readiness capabilities adequately support DoD combatant command contingency 

requirements and national emergency situations. 

Accomplishment(s): 

✔ In FY 2007, VA and DoD began implementing the VA/DoD Memorandum of 

Agreement Regarding the Referral of Active Duty Military Personnel Who Sustain Spinal Cord Injury, Traumatic Brain Injury, or Blindness to Veterans Affairs Medical Facilities for Health Care and Rehabilitative Services, signed on 

December 13, 2006. The Departments reached agreement on an implementation plan that, when fully adopted, will make significant operational enhancements to the existing nationwide system of patient receiving centers. 

✔ Efforts to expand bilateral training opportunities, develop enhanced readiness 

indicators for patient receiving centers, and increase opportunities to participate in national-level exercises were initiated in FY 2007. 

Seamless Transition 

Purpose: 

The goal of seamless transition is to coordinate medical care and benefits during 

the transition from active duty to veteran status to ensure continuity of services. 

Although the HEC is not assigned to report on this topic it has been active in several accomplishments related to the seamless coordination of veteran benefits. 

Accomplishment(s): 

✔ Launched the VHA/VBA OEF/OIF Case Management Program creating a fully 

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sistance in applying for VA benefits beginning while the service members are 

still on active duty. 

✔ Created the VA/DoD Family Transition Initiative to improve the transition 

process for families of seriously injured, inpatient Service members transferring to VA Poly-trauma Centers. 100 veterans’ ombudsmen being hired to support initiative. 

Æ 

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