The House Veterans' Affairs Committee Holds A Hearing On Closing The Data Gap

4 days ago

The House Veterans' Affairs Committee held a hearing on Monday on closing the data gap.

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Transcript

00:00:00Good afternoon, the subcommittee will come to order.

00:00:03I want to start by saying I appreciate the effort of those on the panel that are here

00:00:09to testify today and appreciate your willingness to come before the committee.

00:00:12In the future, though, I would really appreciate, particularly for those here from the VA, if

00:00:17you can provide your testimony ahead of time.

00:00:19I know that a lot of work goes into that, but the subcommittee staff here, myself and

00:00:24my staff, appreciate the opportunity to review some of the commentary and remarks and everything

00:00:28ahead of these committees and would appreciate your willingness to provide that in the timelines

00:00:33that we have.

00:00:34I feel like we've been pretty generous with the timelines we've given.

00:00:38It takes everybody's cooperation to make sure that we're able to do this in a timely and

00:00:41efficient way, so I appreciate that.

00:00:44I asked the VA to appear today because of interoperability impacts and what it does

00:00:51to every veteran across our country.

00:00:55The department's testimony is critical for the subcommittee's oversight requirements.

00:01:03Now on to today's topic, of course, I kind of mentioned briefly about interoperability,

00:01:08but this is important because all across the country, right now as we're sitting here in

00:01:13this committee, a veteran somewhere is walking into a new doctor's office for the very first

00:01:17time.

00:01:18This veteran won't have any prior relationship with the provider they're encountering.

00:01:23They may not have any of their medical records on file at that particular hospital or medical

00:01:27facility.

00:01:28This doctor's office could be at a VA medical center, could be at a community care facility.

00:01:33No matter the location, the doctor will have the same question.

00:01:37How do I give this veteran the best care without knowing their medical history, without knowing

00:01:43their medication, without knowing their allergies, their lab results, whether or not this veteran

00:01:49has struggled with mental health challenges?

00:01:52There are several doctors on our panel today, and I'm sure they would agree that complete

00:01:55and accurate information is an important ingredient in high-quality health care.

00:02:01Providers want their patients' health care data to be interoperable.

00:02:05They want to be able to exchange medical records regardless of which hospital they were created

00:02:10at and use that information to treat their patients.

00:02:14I want to be clear, VA and the entire health care industry have made enormous progress

00:02:18over the last two decades, and millions of health care records are exchanged every single

00:02:22year all across our country in various ways.

00:02:25Even when data exchange does not happen, veterans still receive great health care every day

00:02:29when providers don't have access to their complete medical history.

00:02:32I know that we have very well-trained physicians who provide the absolute greatest level of

00:02:37care that they can.

00:02:38However, the best health care requires truly interoperable health care data that moves

00:02:43with the veteran regardless of which EHR is being used by the doctor and who is treating

00:02:48them.

00:02:49There are gaps that remain and opportunities for improvement.

00:02:52VA provides health care to millions of veterans every single year, including myself.

00:02:57However, roughly one-third of VA care is provided by the Community Care Network.

00:03:03Throughout their lifetime, veterans will visit an assortment of providers at the DOD, the

00:03:07VA, and private facilities.

00:03:11Every appointment produces new information.

00:03:14VA has made a ton of progress exchanging data with larger hospital systems, but struggles

00:03:18to exchange data with many smaller hospitals and physicians' offices.

00:03:24In order to live up to our commitment to veterans, VA must be able to share and use complete

00:03:29and accurate health care information with each of the community care partners.

00:03:34A big part of that is ensuring that when health care data is exchanged between VA and community

00:03:38care providers, it is standardized.

00:03:41There is only so much a provider can do with a list of lab results if each hospital documents

00:03:49and displays the results differently.

00:03:53This is the difference between a read-only file and data that is searchable, sortable,

00:03:57and able to be organized and utilized.

00:04:00The quality of the data is just as important as the quantity.

00:04:03That is why this committee put a requirement in the Dole Act for the VA to adopt health

00:04:08information interoperability standards for the Department and its community care providers.

00:04:13These standards are about data quality and will improve how VA and community care providers

00:04:18exchange data for care and benefits, patient identity matching, and more, ultimately improving

00:04:24outcomes for veterans inside and outside the VA.

00:04:28During this hearing, I hope to hear some preliminary updates on VA's strategy.

00:04:33In addition, I hope to hear about some of VA's recent progress in their plans to bridge

00:04:37the interoperability gaps that still exist.

00:04:40VA recently created the Veterans Interoperability Pledge, which allows private hospitals to

00:04:46instantly confirm whether a patient is a veteran.

00:04:49There are many health issues that are assumed to be linked to military service.

00:04:54Simply knowing that a patient is a veteran allows health care providers outside VA's

00:04:57system to give the best care, consider service-related health issues, and quickly connect them to

00:05:03the right supports where necessary.

00:05:06This is an important leap forward for data exchange between VA and community partners.

00:05:12While it is only in its infancy, I am eager to hear more about its early success and VA's

00:05:17plans to expand to more community care providers.

00:05:20VA is currently connected to over 90 percent of hospitals in America through health information

00:05:25exchanges.

00:05:26Ten years ago, though, VA exchanged less than 100,000 health care documents a year.

00:05:32Now they are exchanging millions.

00:05:35While VA is connected to roughly 90 percent of U.S. hospitals, the last 10 percent are

00:05:40the hardest to reach.

00:05:42Far less than 90 percent of physicians' offices are currently exchanging data with the VA.

00:05:47I will close by saying that many of the technical challenges around health care interoperability

00:05:52are no longer obstacles.

00:05:54What remains is for VA to organize and collaborate with its community care partners to make sure

00:05:58that the provider I mentioned earlier, who is seeing a veteran for the first time today,

00:06:04has all the information they need to provide the best care possible.

00:06:08Thank you again for being here.

00:06:09I look forward to your testimony.

00:06:11With that, I'll yield to the Ranking Member Bezinski for her opening statement as well.

00:06:16Thank you very much, Mr. Chairman, and thank you as well to the witnesses for being here

00:06:20to discuss this critical topic today.

00:06:24Interoperability is a crucial factor in ensuring safe, effective, and veteran-centric health

00:06:28care.

00:06:29It supports the care coordination that is a hallmark of VA health care.

00:06:34Unfortunately, VA's interoperability efforts have been hindered for decades by the decentralized

00:06:39nature of its electronic health record.

00:06:43In fact, one of three major goals of the Electronic Health Record Modernization, or EHRM, program

00:06:50is to implement an EHR that is interoperable with DOD and community care providers, creating

00:06:57a complete medical record for the life of the veteran.

00:07:00A complete medical record allows for better outcomes for veterans as their providers,

00:07:07wherever they receive care, have all the information they need to make the best, most clinically

00:07:12informed decisions.

00:07:14I wholeheartedly support this effort.

00:07:16However, getting from where we are today to complete interoperability is no small undertaking.

00:07:23It requires a combination of efforts from three corners, technology, people, and process.

00:07:29VA utilizes a multitude of platforms, systems, and frameworks to approach interoperability

00:07:35from a technology standpoint, from the referral of services with the Health Share Referral

00:07:41Manager, or ESRM, to the standardization of the data, DFIP, VDFEP, to the information

00:07:50sharing itself with Veteran Health Information Exchange and VA's growing work with TEFCA.

00:07:56VA appears to be throwing everything they have at interoperability.

00:08:01VA's websites tout a seamless and secure interface for VA and community providers with this infrastructure,

00:08:08but from what I've heard, that doesn't seem to be the case.

00:08:13Despite these systems getting us closer to our interoperability goals, they do not encompass

00:08:18the full picture.

00:08:19VA's legacy EHR does not allow for complete integration of medical records, even when

00:08:25they are shared through the Health Information Exchange.

00:08:28This requires clerks to locate records, download them, and then upload them to Vista A. Oracle

00:08:36Cerner's EHR has a direct link to the Exchange, allowing records to be pulled in and integrated

00:08:42in two to three clicks, though again, these records can only be pulled through if providers

00:08:49are using the Veteran Health Information Exchange, and if they know and remember to

00:08:54do it.

00:08:55Without standard use of the Exchange, providers continue to rely on sending information via

00:09:00FACS or ES, I'm sorry, or HSRM, which inevitably results in processing delays and backlogs

00:09:09and risks incomplete records that could have disastrous clinical impacts, including putting

00:09:14patient safety at risk.

00:09:17I look forward to hearing from Dr. Greenstone, a former Executive Director of Clinical Operations

00:09:23at VA, and Mr. McGraw from the Michigan Health Information Network, on systems that integrate

00:09:29referrals and document management into one workflow.

00:09:33Technology is great, but it is nothing without the people.

00:09:36It takes a highly skilled and impressively dedicated workforce to deliver the world-class

00:09:40health care and benefits the VA is known for.

00:09:44That's why the recent news of the Trump Administration's personnel actions is extremely concerning.

00:09:50Their decisions to terminate over 2,400 probationary employees and its plans to further reduce

00:09:56the VA workforce by at least 15% or 80,000 positions is abhorrent.

00:10:02These actions have already resulted in negative patient outcomes for veterans and will continue

00:10:07to do so.

00:10:08While it's great that VA purports to be exempting doctors and nurses from these cuts, that ignores

00:10:13the fact that there are dozens of other jobs, clinical and non-clinical, that make delivery

00:10:18of health care possible.

00:10:20For example, scanning and file clerks in the Health Information Management, or HIM, service

00:10:27were impacted in the Secretary's probationary employee purge.

00:10:31Without sufficient HIM scanning and filing clerks, medical records will continue to pile

00:10:36up, not being entered into the veterans' files, and further risking quality of care.

00:10:42If we expect world-class care for veterans at VA, we must ensure the VA is resourced

00:10:48and adequately to do so.

00:10:50Finally, VA's ongoing struggles with its processes have overcomplicated what was already

00:10:57a complicated process.

00:10:59Like most of VA's modernization efforts, the move toward interoperability seems to be burdened

00:11:04by training and change management challenges.

00:11:08Additionally, the variation of VA's clinical workflows makes the data standardization needed

00:11:14for interoperability difficult, and the agreements with community care providers and third-party

00:11:19administrators leaves VA with little recourse for accountability.

00:11:24The lack of connectivity depends on the user.

00:11:27Some community care providers are unaware of the health information exchanges, and their

00:11:32practices don't possess mature enough systems to utilize it.

00:11:36Providers are not trained adequately to use the tools defaulting to their comfortable

00:11:40workflows like faxes, fax machines, and phone calls.

00:11:45By reverting to these antiquated workflows, providers and veterans may face weeks or even

00:11:50months-long delays in accessing their records due to processing backlogs, backlogs that

00:11:56will likely only become lengthier with the Trump administration's cuts to the VA workforce

00:12:01and IT contract support.

00:12:04I look forward to today's discussion, but also think we need to have a bigger conversation

00:12:08with Oracle and the third-party administrators for the community care network in future meetings

00:12:14on their efforts to increase awareness, training, and use of interoperability tools, and how

00:12:20they're going to hold both VA and community care providers accountable.

00:12:25Ultimately, we must be realistic about what we are expecting VA to do, and with what resources,

00:12:32especially when we operate in an environment as we are today, with an administration that

00:12:37wants VA to do more with less.

00:12:40I believe this conversation today will be enlightening, and I look forward to further

00:12:44work on this topic.

00:12:46Thank you, Mr. Chairman, and I yield back.

00:12:50I appreciate that.

00:12:51I'll now introduce our witnesses from the Department of Veteran Affairs.

00:12:55We have Dr. Jonathan Nebaker, Chief Medical Informatics Officer and Executive Director

00:13:01of Clinical Informatics.

00:13:02Did I say that correctly?

00:13:03Very good.

00:13:04Thank you, Doctor.

00:13:05Dr. Lori Pretula, Deputy Chief Information Officer for the Electronic Health Record Modernization

00:13:14Integration Office.

00:13:17Also joining us from the great state of Michigan, of course, is Mr. Rick McGraw, Chief Growth

00:13:23Officer for the University of Michigan Health Information Network Shared Services.

00:13:29And Dr. Andrew Rosenberg, Chief Information Officer at Michigan Medicine.

00:13:38And finally, we have Dr. Leo Greenstone, Chief Medical Officer at Signature Performance.

00:13:45Very good.

00:13:46Thank you all again, each one of you, for being here today.

00:13:50And I ask the witnesses to please stand and raise your right hand.

00:13:55Do you solemnly swear, under penalty of perjury, that the testimony you are about to provide

00:13:59is the truth, the whole truth, and nothing but the truth?

00:14:03Thank you, and let the record reflect that all witnesses have answered in the affirmative.

00:14:08And going in order, Dr. Nebaker, you are now recognized for five minutes to deliver your

00:14:12opening statement on behalf of VA.

00:14:14Good afternoon, Chairman Barrett, Ranking Member Budzinski, and distinguished members

00:14:20of the subcommittee.

00:14:21Joining me here today is Dr. Laura Pertula, Deputy Chief Information Officer of the Electronic

00:14:27Health Record Modernization Integration Office.

00:14:30Thank you for the opportunity to discuss the interoperability between the Department of

00:14:34Veterans Affairs and communities beyond VA.

00:14:38Our efforts to expand veterans' access to care, both inside and outside VA, mean more

00:14:43veterans are using their benefits to seek care.

00:14:47Recently enacted laws, like the Compact and Mission Acts, empower veterans to seek care

00:14:52from the community providers when it's in the best interest, or for veteran, best interest

00:14:56for the veteran, or when VA care is unavailable.

00:14:59As a result, the need for care coordination and exchange of health information among VA

00:15:05and community providers has surged.

00:15:08The exchange and use of healthcare data are essential for ensuring that veterans have

00:15:11better access, better health, and reduced out-of-pocket expenses.

00:15:17In 2009, VA and DoD began allowing clinicians to view shared data to reduce reliance on

00:15:23paper records.

00:15:24Launched in 2014, the Joint Longitudinal Viewer, or JLV, provided a more reliable and user-friendly

00:15:32solution.

00:15:33In January 2025 now, over 110,000 VA employees accessed and opened 2.2 million community

00:15:43care documents in JLV.

00:15:46User surveys showed JLV improved patient outcomes, saved time, and reduced duplicative testing.

00:15:52The Joint Health Information Exchange, commonly referred to as JE, established by VA and DoD

00:15:58in 2020, has significantly improved federal EHR interoperability.

00:16:04It connects well over 100,000 provider sites through two national exchanges, eHealth Exchange

00:16:10and Commonwealth.

00:16:11In January 2025 alone, JE exchanged over 360 million documents for 18 million patient matches.

00:16:20The Trusted Exchange Framework and Common Agreement, also known as TEFCA, is a nationwide

00:16:25framework for health information sharing.

00:16:28VA aims to participate in TEFCA, contract with a qualified health information network

00:16:33provider, and be fully functional and tested for purposes of treatment by early December

00:16:382025.

00:16:40Key considerations include accurate patient matching and cost.

00:16:44The deployment of the federal electronic health record will also advance this interoperability

00:16:48agenda.

00:16:50Despite the significant progress, VA continues to address connectivity gaps, especially with

00:16:55small provider organizations not using a top five EHR system.

00:17:00While about 80% of veterans actively enrolled in VA care visit at least one, sorry, while

00:17:0780% of veterans actively enrolled in VA care visit at least one provider connected to a

00:17:12national exchange, only 30% of providers billing VA for community care are connected to eHealth

00:17:18Exchange or Commonwealth.

00:17:21Connectivity to state or metropolitan exchanges via regional health information organizations

00:17:25or RIOs may help close this gap.

00:17:28Moreover, RIOs enhance care coordination by offering unique services like longitudinal

00:17:32viewers and push notifications that national exchanges currently do not.

00:17:38VA is collaborating with industry partners to improve data quality gaps which impact

00:17:42clinical decision support, quality measurement, population health, and benefits adjudication.

00:17:49Examples of challenges include incorrect weights, missing serum sodium values, incomprehensible

00:17:54codes, and misclassified allergies.

00:17:57Stakeholders are developing open source technologies to objectively code data quality and provide

00:18:01improvement suggestions.

00:18:04The Veteran Interoperability Pledge demonstrates a cost-effective approach to interoperability

00:18:08yielding significant benefits for veterans.

00:18:11Launched in 2023 with 13 high-quality healthcare systems, VIP addresses goals beyond TEFCA

00:18:18including identifying veterans, connecting them with VA and community resources, and

00:18:23ensuring reliable care coordination.

00:18:26Our partners have already identified over 200,000 veterans that may benefit from the

00:18:31COMPACT and PACT acts.

00:18:33VA plans to expand VIP membership to more healthcare systems, payers, and technology

00:18:38companies prioritizing automation and benefits determination and care coordination.

00:18:44These efforts will ensure that VA can connect veterans to federal, state, and donated benefits.

00:18:49VA remains committed to putting veterans at the center of its operations focusing on customer

00:18:54service and convenience which interoperability makes easier.

00:18:58We appreciate the subcommittee's commitment and oversight to ensure VA serves veterans

00:19:02with excellence and we look forward to responding to any questions you may have.

00:19:11Thank you, Doc.

00:19:12Appreciate it.

00:19:13The written statement of Dr. Nebaker will be entered into the hearing record and I think

00:19:21we're moving next to Mr. McGraw, is that correct?

00:19:26Dr. Pertula, do you have separate?

00:19:28Okay, very good.

00:19:29And then, Doc, I'll get back to you in just a moment.

00:19:31But I think we're going next to Mr. McGraw for your remarks for five minutes.

00:19:40Thank you for the opportunity to testify today about the vital role that health information

00:19:43exchanges play in their operability of our overall healthcare infrastructure.

00:19:48Today I will concentrate my testimony on the over 10 million residents of Michigan with

00:19:52over 461,000 veterans of our military services.

00:19:56Michigan Health Information Network is our statewide HIE.

00:20:00MIHEN was formed in 2010 as a public-private partnership with the Health Information Technology

00:20:04Commission housing the Department of Health and Human Services.

00:20:08MIHEN was designed to play a pivotal role in advancing healthcare interoperability by

00:20:12facilitating seamless information sharing across Michigan's healthcare ecosystem.

00:20:18Since MIHEN's inception in 2010, we have interfaced with nearly 80 individual electronic

00:20:22health record systems and two national networks that only represent a limited number of use

00:20:26cases.

00:20:27A use case is a unique instance of sharing specific information regarding patients and

00:20:32their health.

00:20:33MIHEN, however, operates over 50 use cases for our clients, ranging from hospitals, primary

00:20:38care facilities, payers, community mental health facilities, skilled nursing facilities,

00:20:43and local city and county health departments, to name a few.

00:20:46From the 5,300-plus healthcare facilities connected to MIHEN, we have routed over 8.3

00:20:51billion messages to enhance care coordination and vital data delivery across the state.

00:20:56For example, 97 percent of all state admission, discharge, and transfer summaries pass through

00:21:00MIHEN today.

00:21:02MIHEN's direct interfaces with local healthcare facilities' EHRs provides instantaneous record

00:21:08submissions immediately following an encounter with a patient.

00:21:11In less than four minutes, that information is received, verified, and routed to our portal

00:21:16where the patient's longitudinal record is updated with their latest information.

00:21:20Our most recent use case is collaborating with a mobile technology company to route

00:21:23real-time data from ambulances en route to emergency rooms.

00:21:28Emergency medical technicians en route will have access to a patient's electronic medical

00:21:31records while also transmitting current vitals to the receiving emergency department.

00:21:36Alerts sent to the ED will notify them that the patient en route so they have access to

00:21:40the patient's longitudinal record from MIHEN.

00:21:43The best quality healthcare is not only local, but it is in near real-time.

00:21:48For security and privacy considerations, MIHEN is a business associate to the largest

00:21:51health and government systems in Michigan, provides security and privacy of healthcare

00:21:55data while ensuring it is interoperable and accessible.

00:21:58MIHEN and our major technology vendors are certified under HITRUST R2 certification.

00:22:03This industry-leading certification requires external penetration testing, security in

00:22:07operations, and security during the development of custom applications, ultimately ensuring

00:22:12best practices across all our systems and services.

00:22:15MIHEN designed our active care relationship service model, which allows real-time association

00:22:21of patients with their providers using the information found in the data ingested by

00:22:25MIHEN.

00:22:26This service restricts patient data access to only those providers that actively care

00:22:30for that patient.

00:22:32With all of this in mind, let's consider a veteran's healthcare journey.

00:22:35If a veteran goes to their primary care doctor that uses one EHR, but also goes to a community

00:22:40mental health facility that uses a different EHR, and also sees a specialist on a third

00:22:45EHR, without an HIE like MIHEN, these providers wouldn't be able to access critical patient

00:22:50information from those other encounters.

00:22:54Because of MIHEN's broad network of connectivity, MIHEN has all interactions from all three

00:22:57facilities available in that patient's longitudinal record to improve overall care coordination.

00:23:02Today, however, in Michigan, the VA and DOD are a blind spot to a veteran's overall healthcare.

00:23:08The VA does not only not submit data through the network, but cannot access its patients'

00:23:12records from encounters outside of the VA.

00:23:16From a provider perspective, HIEs bring critical value.

00:23:19A 2024 survey of primary care physicians found that 81% spend less time with their patients

00:23:24than they'd like, 57% write prescriptions or refer patients out due to time constraints,

00:23:3046% report a lack of adequate time with patients as a top stressor, and almost two-thirds feel

00:23:35their work is more transactional rather than relational.

00:23:38Accessing patient information within an HIE's longitudinal record has shown that a provider

00:23:42can save up to 15 minutes per patient per visit, while the cost of this access is nominal.

00:23:47Today, the VA does not comprehensively see interactions outside of its facilities, and

00:23:52like the patient journey example I gave you, community care facilities cannot see veterans'

00:23:56interactions with the VA hospital either.

00:23:59There is no such thing as a lifetime record of a veteran's healthcare residing in one

00:24:03EHR system.

00:24:04It simply does not exist.

00:24:07There is also no such thing as a national exchange with a handful of EHRs that can replace

00:24:11the infrastructure we have spent the last 14 years perfecting.

00:24:15We can and we must do better to provide higher quality care to our veterans in Michigan.

00:24:19There is always potential for improvement, and I believe we can achieve it with the right

00:24:22strategy, support, and collaboration.

00:24:25Thank you for the time and attention to this important issue.

00:24:27Your support and understanding is greatly appreciated.

00:24:29Thank you, Mr. McGraw.

00:24:32The important statement of Ms. McGraw will be entered into the hearing record.

00:24:35Dr. Rosenberg, you are now recognized for five minutes to deliver your opening statement

00:24:39on behalf of Michigan Medicine.

00:24:41Well, good afternoon, and I want to use my time to emphasize three areas in my statement.

00:24:47I want to take the perspective of a provider in particular, but also with an organization

00:24:54that's providing the care in the communities that we've discussed.

00:24:59Changing the information that we're talking about is not controversial.

00:25:02This is common sense.

00:25:04It is a common expectation that we as providers have, our nurses, our doctors, our administrators,

00:25:10it's a common expectation of patients and their families.

00:25:13So this is a good discussion for us to be having.

00:25:17And I would also say it's really an ethical responsibility.

00:25:20So the providers feel very, very strongly to do this and to do it well, as you've already

00:25:25mentioned.

00:25:26The reality is when I think about some of us, Dr. Neveker, Dr. Greenstone, and I, when

00:25:31we were training, we did health information exchange a few times a day at best.

00:25:37And usually it was a packet of papers and an envelope and occasionally later on a CD

00:25:41that we would hand walk down and try to get the images loaded.

00:25:45And the reality is these are at very, very good places really only 10 years ago.

00:25:51And now, as you've already mentioned, we're doing a lot of health information exchange.

00:25:55At Michigan Medicine alone, across our large health system and our somewhat unique role

00:26:00in the state, within our electronic medical record, we're exchanging over 220,000 records

00:26:07a day.

00:26:09With our excellent state HIE, we're exchanging tens of thousands of records and results,

00:26:15particularly admission, discharge, and transfer notices that are critical in that infrastructure

00:26:21to make this work for a community doctor or others to know when a veteran has been

00:26:26seen or not.

00:26:28Within our VA itself, although somewhat new, we're exchanging almost 3,000 records a day

00:26:37and especially as we, Michigan Medicine, sign on to the QHIN via our EHR and with the VA

00:26:45already involved in eHealth Exchange, those numbers are going to go up more and more and

00:26:50more.

00:26:51From where we were to where we are now is a very good news story.

00:26:55Obviously, we want to do better.

00:26:57So why is that happening?

00:26:59I was recently in the UK, I was lecturing at some very good health systems and they

00:27:04were challenged exchanging information even within their own health system.

00:27:09Whereas for us, because of the networks we have, Commonwealth, Cary Quality, and especially

00:27:14now TEFCA, the frameworks and the networks themselves, eHealth Exchange, and I would

00:27:20argue that the direct EHR to EHR and EHR into these nodes is the way that we're expanding

00:27:28the use of this.

00:27:29We have good to very good government regulations.

00:27:32We have agreed upon open standards, HL7 CCDA, the FHIR standard.

00:27:39We have a very good set of agreed upon data elements and categories with USCDI.

00:27:45We have a number of tools that are currently working to give us those numbers that I've

00:27:49just mentioned and even more that are in my statement that we can focus on.

00:27:54So then the third element of this is what are our challenges?

00:28:00Within health information exchange, one of the challenges that all providers right now

00:28:04are having as we get more digital are the digital systems themselves.

00:28:09We have an enormous amount of data that we can look up, whereas before we couldn't.

00:28:13We have an enormous need to document these, not just for patient care, but for quality

00:28:18care and efficiency and improvements, and health information exchange is no different

00:28:23from that.

00:28:24We want to do it, and yet at the same time, we're also overwhelmed with all of the other

00:28:28work that our doctors, nurses, and others have to do.

00:28:32And also, we know that with all these options, we have to choose.

00:28:37Which do we use?

00:28:38How do we sign up?

00:28:39How long does it take to sign up for one versus another?

00:28:41So these are things that we can continue to improve upon, because as I said, in the end,

00:28:46we're so much better now.

00:28:48But the reality is, we know that we can still do better.

00:28:51So I'll yield the rest of my time, but hopefully that's helpful.

00:28:54Thank you, Doc, appreciate your testimony.

00:28:58We will enter that.

00:29:02Your written statement will be entered into the hearing record.

00:29:06And Dr. Greenstone, you're now recognized for five minutes to deliver your opening statement

00:29:09on behalf of Signature Performance, and thank you as well for being here today.

00:29:14Thank you, Chairman Barrett.

00:29:16Good evening, member Budzinski.

00:29:17It's a pleasure to be here to talk to you about interoperability between the VA and

00:29:20the community.

00:29:21I come to you as a former VA physician for over 18 years, primary care doctor, as well

00:29:28as an executive at the local Ann Arbor VA for 11 years, and a senior executive in the

00:29:33Office of Community Care for six and a half years.

00:29:36And now, I'm working in the private sector for Signature Performance, where we're focused

00:29:40on decreasing administrative costs and burden within the industry.

00:29:46So there is no question that we absolutely agree that interoperability is so important

00:29:51and so necessary, and it's also, we have to recognize, it's been really, really hard.

00:29:56People have been working at this for a couple of decades now, and you can hear the incredible

00:30:02progress that has, in fact, been made over the years.

00:30:06One of the things that I think is critically important to recognize is that, I'm going

00:30:12to give you a perspective from the Veteran Community Care Program that I care deeply

00:30:14about, is that we absolutely have to, as the Ranking Member mentioned, focus not just on

00:30:22technology, but on people and processes, because the technology will not be fully adopted unless

00:30:29we have pretty much ubiquitous and reliable tools.

00:30:34And that's why, within healthcare today, we still have a lot of use of those tools, telephones

00:30:39and fax machines, and a lot of that is used today within VA to actually get records back

00:30:45and forth.

00:30:46And we want to get rid of that.

00:30:47I'd love to sunset fax machines, but boy, are they still pretty active today.

00:30:53And one of the things that I think is critical as well is that VA really needs to stay, and

00:30:59they've been really good at doing this, but staying in lockstep with HHS, in lockstep

00:31:05with industry, understanding what's happening with the EHR vendors, what's happening in

00:31:12the community, and staying very close with their colleagues at the Integrated Veteran

00:31:16Care Office within VA, so that we can ensure that VA staff, as well as the community care

00:31:22network providers, are working very closely together to try and ensure that there are

00:31:27workflows that utilize a lot of the technologies that we've been hearing about, and workflows

00:31:32that really support the work that individual folks are doing.

00:31:36So we have to have thoughtful change management for the implementation of these great technologies

00:31:42that we've been talking about.

00:31:44Within the Veteran Community Care Program, we not only have to make sure that providers

00:31:49in the community are receiving appropriate clinical information about the veterans that

00:31:53have been referred to them, but those providers also need an authorization.

00:31:59So the way things stand now within the Veteran Community Care Program, it requires an authorization.

00:32:03And so that means that the provider in the community needs to know what the VA is authorizing,

00:32:08what the VA will be paying for, how long is that a referral for, and for some services,

00:32:14how many visits are available.

00:32:17That referral and authorization is not available in the exchange today, but perhaps it could

00:32:21be, and that may be a future.

00:32:24And so when we look at the solutions going forward, there are a couple of things that

00:32:29I think would be valuable to think about in the short term and perhaps even a little longer.

00:32:34So one is, let the VA take advantage of the Dole Act, where there is incentive to actually

00:32:41have TPAs in the community care network and their providers work together, because all

00:32:47of the TPAs, OptumServe, TriWest, they have VISN-based provider groups that go out and

00:32:56can in fact work with providers in the CCN network and those providers who get a fair

00:33:03number of referrals, but they can ensure that those providers are connected to an exchange,

00:33:08that's connected to a QHIN, that that information will be available for VA providers to be able

00:33:14to see and best care for veterans.

00:33:16And that that information can be made available to VA providers and other staff within the

00:33:23PPMS.

00:33:24This is the Provider Profile Management System, it is the directory for the Veteran Community

00:33:28Care Program of all those providers.

00:33:30And so then VA has opportunity to send referrals to those providers who actually are connected

00:33:35to exchange.

00:33:36And that means I may want to do that because I know I can actually get access to the data

00:33:40that I need to care for veterans.

00:33:42The other thing to consider is, you know, they have this closed loop referral data transfer

00:33:51process that is something that's worth further investigating.

00:33:55So what I mean is this, is that when a VA provider writes an order and that veteran

00:33:59opts to go to the community, the authorization and associated medical documentation is passed

00:34:06through the infrastructure of the exchange into the EHR of the receiving provider.

00:34:12And then when that veteran is seen, that provider's information that they generate

00:34:16is passed on into VA's EHR.

00:34:20And therefore you have this closed loop referral and medical documentation system that is in

00:34:26play today in some places and it's something that the VA may want to consider.

00:34:30So thank you for your time and I look forward to further questions.

00:34:33Thank you, Doctor.

00:34:35The written statement, Dr. Greenstone, will be entered into the hearing record.

00:34:39With the opening statements complete, we'll now proceed to questioning and I will now

00:34:43recognize myself for five minutes.

00:34:46Again, thank you all for being here and for the time and attention you put toward this.

00:34:52A few questions I had just jotted down based on some of your opening statements.

00:34:59Dr. Rosenberg, maybe you could answer this and Dr. Greenstone too.

00:35:05Do you know of examples where we have duplicated procedures, whether it's testing or other

00:35:14procedures, diagnoses, tools that you have, things like that, where we have duplicated

00:35:18that because of a lack of transferability of medical records or the cumbersome nature

00:35:24of it or the lack of interoperability that would apply?

00:35:28And I'll let both of you answer that question separately.

00:35:32Sure, I can certainly start with that, Chairman Barrett.

00:35:36I can give an example.

00:35:37I was in the clinic at the VA last summer and I saw a veteran who said, hey doc, I passed

00:35:42out about two weeks ago and went to an outside hospital.

00:35:44I'm like, oh my goodness.

00:35:47And so I looked to see if that was cared, that was actually authorized by VA, and it

00:35:51was.

00:35:52I went into our systems to look to see whether facts had come in and it hadn't.

00:35:57I then went to the joint longitudinal viewer to ping the exchange and look, I saw a record

00:36:03from the ER from where he was.

00:36:05When I opened it, I was excited because I thought I was going to see everything I needed

00:36:10and all I saw was a problem list, meds and allergies, and at the top of the problem list

00:36:14it said syncope, which means he passed out.

00:36:17That's what he already told me.

00:36:19So then I had to ask my clerk to try and call over to get the information faxed and so then

00:36:24I have this veteran in front of me who I have to start from square one to order tests

00:36:28to figure out what the heck was going on with him, do his exam, his history, and I probably

00:36:33was ordering things that may have already been done, but I had to do all that I had

00:36:37available.

00:36:38As you mentioned before, hey, good docs, we do what we have to do, but I will bet you

00:36:43that I ended up doing things that may have already been done, but I didn't have access

00:36:47to do that, but I had to come up with a treatment plan.

00:36:52And that to me is not based upon the ability to send data back and forth.

00:36:57It's based on the perhaps data protocols of how we organize these things so that you're

00:37:02able to access it and read what it says and interface with it in a usable way.

00:37:07Is that, am I understanding that correctly?

00:37:10Even when providers within my great state of Michigan are connected, not all the information

00:37:14is readily available.

00:37:15Right?

00:37:16So we talked about quality of data and we talked about all the data, like notes, very

00:37:20often office notes aren't there, procedure notes may not be available.

00:37:23And so the question is, why aren't all those things available when folks have connections

00:37:28and therefore some information is available?

00:37:30We need better information to be able to make clinical decisions.

00:37:33Sure.

00:37:34Okay.

00:37:35Dr. Rosenberg?

00:37:36Quantifying your excellent question is a bit difficult, but I'll give you my impression.

00:37:39It's probably somewhere in the thirds, and it depends on the situation.

00:37:45So a patient arriving in an emergency department where you know nothing about them, we're going

00:37:50to be repeating or we're going to be drawing and sending labs and imaging no matter what

00:37:56we find.

00:37:59Sometimes it would be helpful to know what pre-existing conditions or data, labs, imaging

00:38:07existed before, but it's usually not that we're going to either rely on those data,

00:38:13rely on what might be old data for the situation.

00:38:17Another third would be where we have some data, but we need more complete data or different.

00:38:24It will depend on if we're primary care or we're quaternary care itself.

00:38:29I think the area that you're focusing on that's especially important is when the data are

00:38:35more expensive and difficult to get, a biopsy for example, an expensive or difficult radiologic

00:38:44study that we would normally not get, or that we would want to compare to.

00:38:49Those are still elements where depending on the system, the proximity, the closeness,

00:38:55we will either have those data or we won't.

00:38:58And so I think where efficiency would be gained is that, as I've mentioned before, the common

00:39:06elements of medications, of basic labs, of conditions and documentation where you can

00:39:13frequently find the results of data, even if it's not a discrete variable, will help

00:39:18some of that gap.

00:39:21And I would argue that for those things that really are difficult to get and expensive,

00:39:26those would be interesting and good targets.

00:39:28For example, my HIN fits into that in the ability to act as a broker of where a biopsy

00:39:34result is from another element that we can commonly get to where we sometimes close those

00:39:39gaps.

00:39:40But to quantify that I think would be difficult.

00:39:42Sure.

00:39:44I do appreciate that.

00:39:45I know my first round of questions have just run out of time, but I want to recognize the

00:39:50ranking member for your questions.

00:39:52Sure.

00:39:53Thank you, Chairman.

00:39:54And actually to kind of build on your initial question, I wanted to ask Dr. Nebaker from

00:39:59the VA, because in your testimony you talked about how the federal system is 90% interoperable

00:40:09with hospitals today.

00:40:10I think the question, after we've heard from both Dr. Greenstone and Dr. Rosenberg and

00:40:16those experiences, how are you measuring interoperability and how are you certifying that?

00:40:26I find it hard to believe where that 90% is coming from based on at least Dr. Greenstone's

00:40:32story.

00:40:33Yes.

00:40:34So thanks for the question.

00:40:38That number comes from eHealth Exchange that has looked at who we're connected to and knows

00:40:44a number of hospitals that are in each healthcare organization that we're connecting to.

00:40:49So that's where that 90% comes from.

00:40:53And do you know how they gauge that?

00:40:55So I could speculate, but I'm not sure.

00:40:58I mean, each organization has a website that usually states the number of hospitals that

00:41:04they have.

00:41:05The American Hospital Association also has similar information on it.

00:41:09So I imagine it's, again, speculation, but I imagine that's how they arrived at that

00:41:13number.

00:41:14Okay.

00:41:15And can I ask you, continuing just about community care providers, what is the requirement for

00:41:22community care providers to return records to the VA?

00:41:27So I might want to ask you to clarify the question.

00:41:35So for my practice, for example, most of the documents that I'm looking for are actually

00:41:40not paid for by VA.

00:41:42It just happens to be the way my patients are in the Salt Lake City area is.

00:41:48And so there are no requirements, obviously, for those people.

00:41:52When they go out and use their own health insurance to get a specialty appointment or

00:41:56they're seeing sometimes a primary care physician, I practice primary care geriatrics.

00:42:02Then there's the community care documents that there is a requirement to return documentation

00:42:09on.

00:42:10And that's as far as I can go, because I'm not overseeing the IVC community care network

00:42:16contract.

00:42:19So it's possible, basically, you're seeing a veteran and that their complete record might

00:42:23not be completely captured, is what you're saying, because it's not all required to be

00:42:28passed back to the VA.

00:42:30Yes.

00:42:31And so as Dr. Greenstone was stating, I saw a guy who had a really healthy 88-year-old

00:42:39guy last Friday.

00:42:41And I said, how's everything going?

00:42:43No problems at all, doc.

00:42:45I'm doing great.

00:42:46And so then I open up JLV, click on the button, up comes these records.

00:42:50And I say, oh, well, you were in the hospital two months ago for a urinary tract infection.

00:42:56And so that actually prevented me from ordering a whole raft of lab tests and everything that

00:43:00I was thinking about ordering at the time.

00:43:03But more often than not, that was an emergency room visit.

00:43:07So those are usually in there, not always.

00:43:10It's kind of a mystery to us as to why we deal primarily with HCA, with Intermountain

00:43:16Healthcare that currently has Oracle, and the University of Utah that has Epic.

00:43:20And from all of those institutions, I'm often missing, inexplicably, data that I would expect

00:43:27from a hospitalization, not so much from hospitalizations, but from emergency room visits.

00:43:31And also doctor's office visits are rarely there.

00:43:35And so what Dr. Greenstone was talking about, and also Mr. McCormick, about getting the

00:43:43office visits, that's kind of really valuable data.

00:43:48And because of the way that people craft their continuity of care documents, it's often not

00:43:54driven by office visits, but more by emergency room visits and hospitalizations.

00:44:00And so there is a bit of a gap in recent hospital visits.

00:44:04Sometimes if there's an emergency room visit or hospitalization after a consult, a specialty

00:44:11care visit, then we'll see those information.

00:44:14But not for recent specialty care visits.

00:44:17Again, not paid for by the VA network.

00:44:21And we can take for the record and get back to you what the requirement is on the VA contract.

00:44:29I would be very interested in that, and what the timeliness is of community care providers

00:44:34as well to provide that information back to the VA.

00:44:39And then what recourse the VA has if you're running into community care providers that

00:44:44just aren't providing that type of timely information.

00:44:48Because to me, interoperability would be, if it's successful, it's capturing the full

00:44:53picture for the veteran patient, not just some, and we're eliminating those gaps.

00:44:58So I'll yield back to the chairman.

00:45:02»» Sure.

00:45:03Thank you very much.

00:45:04Just following up on that, Dr. Nebucher, is that missing data that you're talking about,

00:45:10is the reason for that because that record doesn't exist, or because it's not being displayed?

00:45:16Because you can't access it?

00:45:17Because it's not, you know, sent through the system?

00:45:22What do you attribute most of that to?

00:45:24»» So we're not getting those records because they're not being sent from the system.

00:45:28So remember, it's a query system that we use typically from these exchanges.

00:45:34We send the query out, say, hey, give us your documents.

00:45:37And they say, okay, here are the documents.

00:45:39And then the excellent portal, the gateway that Dr. Fertula and Oracle and others have

00:45:45worked on to provide for us collates all those documents and gives them to us.

00:45:49But a lot of those data just aren't getting there in the first place.

00:45:53»» And that's, where's the pinch point in that?

00:45:57Like what is it that the system that collates it, the system that you're querying?

00:46:04I mean, if you were to look up my name and my date of birth and social security number,

00:46:09it would probably give you all my medical records is my assumption.

00:46:12And it sounds like what you're saying is some of that might be missing.

00:46:15»» Yes.

00:46:16Yes.

00:46:17And so the EHRs do really well at what the EHRs were designed for, which is storing records

00:46:25and transactions for our lab tests and radiology tests and that sort of thing.

00:46:29And it's, they could use some work on getting those data into their external gateway and

00:46:36then pushing those out in response to a query.

00:46:40»» Okay.

00:46:41And I might need some more guidance around if they have the information and they're sending

00:46:49some of it, why aren't they sending all of it?

00:46:53Like it seems to me like it would be an equal amount of work to send all of it, maybe even

00:46:57harder to only send some of it because you're stopping part of that.

00:47:01»» We don't think it's intentional, right, when you're leaving out information.

00:47:05And so I think, you know, that would be a nice experiment to talk with some of our partners

00:47:09in the VIP Pledge, for example.

00:47:12Why are you getting everything there consistently?

00:47:15»» Okay.

00:47:16And then that Veteran Information Pledge, am I saying that correctly, is that the name

00:47:23of that program?

00:47:24»» Veteran Interoperability Pledge.

00:47:26»» Yes.

00:47:27One question I had about that is, I know some veterans are not eligible for VA care because

00:47:33of the status of their discharge.

00:47:36Does that account for that in that system or not?

00:47:40»» So the Veteran Interoperability Pledge, the first piece of work we did was around

00:47:45the Veteran Confirmation API.

00:47:47This is also known as the DIC Sporting Good API.

00:47:51So what this does is use draws on DOD records that are stored at the VA and uses the Title

00:47:5838 definition of a veteran.

00:48:00So whatever that definition is at the time, demographic information are sent to the API,

00:48:07the Application Program Interface on our side.

00:48:10We send back a simple confirmed or not confirmed answer.

00:48:14»» Okay.

00:48:15So that would be determined by the definition within that.

00:48:19Not necessarily all of the protocols like a general discharge, dishonorable.

00:48:24»» So that goes into that Title 38, but it's a legal definition created by Congress.

00:48:28»» Okay.

00:48:29All right.

00:48:30Okay.

00:48:32Mr. McGraw, I know that MIHAN has quite a bit of market share throughout Michigan.

00:48:45Providers and other things through Michigan are included within that.

00:48:50Can you, I guess, explain if you have records outside of Michigan, or we have snowbirds

00:48:58who go down to Florida, for example, and then come back to Michigan and spend a predominant

00:49:02share of their time outside of the state, what is the process by which their records

00:49:07would be able to transfer back and forth, or is that still a coverage gap that exists?

00:49:12»» We do have, we pay a certain amount of money, several hundred thousand dollars

00:49:17a year for access to the three national exchanges.

00:49:21So we don't just keep the records within the state of Michigan.

00:49:25So if they do snowbird down to Florida, and we know that they snowbird down to Florida

00:49:29and they come back, we will ping those exchanges to get that data from the national exchanges.

00:49:33All of our clients can access those national networks through an aggregated volume that

00:49:39we have purchased from those exchanges.

00:49:41So they don't have to go one-on-one.

00:49:43The whole state of Michigan can come through us.

00:49:45We connect to those exchanges to fill in those gaps.

00:49:48»» Okay.

00:49:49Is the, are the VA facilities in Michigan part of MIHAN?

00:49:53»» Today they are not.

00:49:55»» Okay.

00:49:56Dr. Rosenberg, with the amount of time I have left, if you can tell us, I know that Michigan

00:50:03Medicine and the Ann Arbor VA, just as an anecdotal example, have quite an arrangement

00:50:07between the two of them together.

00:50:09How is that information shared without using MIHAN?

00:50:13Like what is the functional way in which that patient information is shared across both

00:50:18sides?

00:50:21»» For geographically nearly co-located and very tightly managed academic veteran

00:50:27affairs, where if not all, most of the faculty who work at the Veteran Affairs Hospital are

00:50:34less than a mile away from the campus as you saw recently.

00:50:39So right now, I would say more of the exchanges from interpersonal discussions with each other

00:50:44and the fact that the care delivery are frequently similar teams.

00:50:49That of course doesn't scale rural America or even within the state of Michigan.

00:50:55The more contemporary digital methods as I've mentioned now are the beginning of our use

00:51:01of Care Equality and then TEFCA to start exchanging those core records.

00:51:08One thing I wanted to mention from the previous conversation, I think it's helpful for us

00:51:12to talk about core records, medications, allergies, problems.

00:51:17From more complex, a primary care visit would be part of a core record, basic labs.

00:51:24But for example, as a cardiac anesthesiologist intensivist, the kind of data that I need

00:51:30to do very special critical care or even anesthesiology are not typically in core medical records.

00:51:37And that's where the expanded use of the data, the data elements within TEFCA will

00:51:42improve the further exchange of those kinds of records.

00:51:47And then final point, there is very importantly, very privileged, very confidential data that

00:51:54we want to be careful about, that we make sure that the patient and their consent is

00:51:59allowing that data to be sent very, very specifically.

00:52:04Medical health, substance use and things like that.

00:52:08So when we talk about the records that we're sharing, I do think it will be helpful for

00:52:13us to stage out what we mean by those specific elements.

00:52:18Thank you, Doctor.

00:52:23Thank you, Member Brzezinski.

00:52:24Do you have further questions?

00:52:25I do.

00:52:26I actually just kind of wanted to go back to what Dr. Rosenberg brought us back to,

00:52:30which is this bi-directional community care VA complete interoperability record.

00:52:36And I wanted to ask both Dr. Greenstone, Mr. McGraw, and Dr. Rosenberg a little bit more

00:52:41about where you believe that disconnect is.

00:52:46And if you could speak, I guess the three of you could each speak to where you think

00:52:50that disconnect could be.

00:52:51But I think from Dr. Rosenberg, what you were saying though is, you're not suggesting though

00:52:56that like a complete, like the mental health record or substance use, that should all still

00:53:00be encompassed within a record of a veteran.

00:53:03Absolutely.

00:53:04Yes.

00:53:05I think appropriate like some other confidential data frequently behind extra levels of protection,

00:53:11but it's absolutely part of the medical record.

00:53:14What I'd say, I would say there's not so much a disconnect right now.

00:53:18My opening statements, I really mean that.

00:53:20I think it's a evolution and maturity.

00:53:24For us, for example, and I'll use Michigan Medicine, it might not be as indicative of

00:53:29across the country, but it probably is.

00:53:33It takes a certain administrative workload to procure, contract, and administratively

00:53:40set up these systems.

00:53:42That is not a, that's not a criticism of the network or the exchanges or the frameworks,

00:53:48but it is a reality.

00:53:50For us, EPIC to EPIC works extremely well, and that's one reason why EPIC has such a

00:53:57large exchange of information among itself.

00:54:00I suspect as Oracle Cerner continues to roll out, we'll enjoy those benefits of contemporary

00:54:06EHRs connecting to each other as well, and or I should say probably through the QHINs

00:54:13as part of TEFCA.

00:54:15I also think that while query-based, as Dr. Nebaker pointed out, is still perhaps the

00:54:20predominant method of getting that data, there are also mechanisms now for push, as Dr. Nebaker

00:54:27mentioned.

00:54:28And as push starts to occur, and as expanded data within this framework occurs, those disconnects,

00:54:37which are really not disconnects, but those gaps will narrow from the common data to the

00:54:42more sophisticated to the more nuanced data.

00:54:44Okay.

00:54:45Mr. McGraw, would you be willing to add anything?

00:54:48Yeah.

00:54:49A lot of the disconnects we see in the state of Michigan is around connectivity, the local

00:54:55facilities, EHR systems.

00:54:58The two impediments that we see the most is really a time constraint.

00:55:03Sometimes the implementation of that connectivity could be up to six months.

00:55:07Sometimes it's a fiscal constraint, so the EHR companies, you know, they're not charity

00:55:12organizations, they're for-profit companies, so they'll charge thousands of dollars to

00:55:16disconnect and then an annual maintenance fee.

00:55:19So, you know, the facilities will ask, you know, is the juice worth the squeeze?

00:55:25And the juice in the state of Michigan is we really work well with our payer partners,

00:55:31and they put incentives together.

00:55:33Those incentives incentivize facilities to submit data, and what MyHen does is we get

00:55:39that data that comes in.

00:55:40It is a push, so the second that record is saved, as I mentioned in my testimony, it

00:55:44is pushed to us within four minutes it's available on the longitudinal record.

00:55:48So that push comes to us, and the incentives are there's a lot of information in an admission,

00:55:54discharge, and transfer document.

00:55:56So today, 27 of those elements are incentivized.

00:56:01We have physician organizations that do transition of care that say this is not enough for us

00:56:06to do transition of care.

00:56:07Can you go back to the payers and can they incent the facilities to provide more?

00:56:11So those incentives are financial incentives.

00:56:13So the conformance comes through us.

00:56:15We look if 95% of what they submit to us has all columns filled in, and then we check the

00:56:22box and we tell the payer they are eligible for the incentive program.

00:56:26I think the mention before was someone mentioned something about quality.

00:56:30Today it's a quantity thing, but at MyHen we're really ahead of other HIEs in the country,

00:56:37and our next phase is the data that you're coming in meets the quality standpoint, but

00:56:42is the data quality?

00:56:43Is it usable?

00:56:44Or is there just stuff in a particular area of the data?

00:56:50Or can we use it for gaps in care, population health management?

00:56:53So we're moving away from quantity and getting into the quality, but that is how we incent

00:56:58people, and those are the impediments I see today.

00:57:01It's not enough incentives.

00:57:02There's no interoperability issue.

00:57:04There's an incentive misalignment.

00:57:06May I add something about the incentive?

00:57:08It's not so much for us to do the work as I mentioned before, but as Mr. McGraw said,

00:57:13it's around the quality.

00:57:15It is expensive.

00:57:16It takes people with expertise and the time explicitly to make sure the data quality,

00:57:22the data entry, the data mapping work, and we audit to make sure it works well.

00:57:27MyHIN, our HIE, our EHR provider, and I would argue really this broader TEFCA goal is to

00:57:38incentivize organizations to be able to have the resources to do that quality, and that

00:57:44ongoing quality check.

00:57:46Because we get some of those data wrong, it is amplified, it is copied, and it could be

00:57:53very difficult.

00:57:54Do you mind if I ask Dr. Greenstone?

00:57:56Dr. Greenstone, do you want to add anything as well, please?

00:58:01Well, I will say that everything you've heard is things that we've absolutely seen and experienced.

00:58:07In my organization, we work very closely with numerous critical access hospitals where they

00:58:12don't have big IT departments, and so some of them have the ability to connect, but there

00:58:18may not be knowledge of how to do it.

00:58:19They may not have the funding to be able to do it.

00:58:21They don't fully understand it.

00:58:23I was talking to Mr. McGraw until two years ago.

00:58:26He was unfamiliar with the exchanges, and he wasn't alone, and still, when I look at

00:58:32where veterans are seen in a lot of these rural places, these small hospitals and health

00:58:36systems are not connected.

00:58:38They don't know, they don't understand, and that's where this opportunity for our TPAs

00:58:44to go out there.

00:58:45If they're seeing veterans, let's go out there and help them actually get connected and find

00:58:50ways to do that and use incentives to help them in that way.

00:58:54I'd also say that it's been wonderful in the last year that in practicing, when I have

00:58:59veterans who go to Michigan Medicine, I can find almost everything I need when I actually

00:59:05ping the exchange for queries.

00:59:07I think that before that, I'd be so frustrated.

00:59:09They're across the street.

00:59:10They're our friends.

00:59:11I have to call somebody as opposed to, in my workflow, being able to find it, but now

00:59:15we can, and I think that's what we want to see everywhere in all states and territories

00:59:20where veterans are, and when they are traveling, like the chairman mentioned, they go down

00:59:24to Florida and not to Arizona.

00:59:25We need to be able to ping the exchange and be able to see the records when those veterans

00:59:29are in the community out there, and then be able to use JLV to see when they're seeing

00:59:34another VA medical center.

00:59:37That's very helpful.

00:59:38Thank you, and the more discussion we have, the more questions I end up writing down,

00:59:45so I'll start just from ones I haven't written down so I don't forget them first.

00:59:50Mr. McGrath, you were mentioning that for those people that aren't within your network

00:59:54of, you know, within Michigan, for example, and transferring data back and forth, that

00:59:58you're part of a broader, bigger network to, you know, switch to other regional areas,

01:00:03things like that.

01:00:06Does that then, is that part of the service that you offer to the subscribers within your

01:00:13networks that they're not having to subscribe to a separate network in order to do that?

01:00:17Correct.

01:00:18So, we have obviously all the information in the state of Michigan, and then we work

01:00:24with those national exchanges.

01:00:26We buy in bulk the ability to ping those national exchanges, several million pings a month for

01:00:31our clients, and then they can all go through us to those national exchanges so that they

01:00:36don't have to work directly with thousands of individual clients.

01:00:39Sure, and then you were saying the whole longitudinal record and pushing record forward and, you

01:00:44know, a few minutes only to kind of update that record, and forgive my ignorance, but

01:00:51my HIN, you're not storing the actual patient information, right?

01:00:56You're merely transferring it to the EHR that is actually storing that record, so...

01:01:01All that data in the state of Michigan is stored in our cloud-based servers, so we do

01:01:07store all that information.

01:01:08And the longitudinal record that we're talking about as access is my HIN's portal, so we

01:01:12do store for HIPAA rules all that...

01:01:16Okay, so an individual with their principal record through their network that they're

01:01:23a part of, Oracle, Epic, whichever it is, they're not actually storing that information.

01:01:28They're logging into your server.

01:01:30They're bouncing signal to your server that has that patient's record stored there.

01:01:36And that way, if they go somewhere else, the idea being that it would automatically

01:01:39update so the next time they go to their local doctor's office, it already has the urgent

01:01:43care, emergency care visit that they had six weeks ago or something like that.

01:01:47Yeah, it's in both.

01:01:49So as soon as they save that record, it's always going to be in the EHR system for seven

01:01:53years or more.

01:01:54The second that they save it, then a copy of that is sent to us within seconds.

01:01:59And then within four minutes, it's on our longitudinal record.

01:02:01Okay.

01:02:02So even if they go across town to somewhere else, that provider should be able to see

01:02:07it in there as well.

01:02:08But you actually...

01:02:09If they're attached to our network, even if they're not attached to the network, let's

01:02:12say they're not submitting data to us, they still have access through our portal to see

01:02:17that patient's interaction everywhere outside of them.

01:02:20So there are people that use our portal to see the longitudinal record of a patient for

01:02:25all their interactions.

01:02:27They may not have started submitting data to us yet.

01:02:30So they can see that.

01:02:31And as I mentioned in my testimony, we have connected to, I say nearly 80 for dramatic

01:02:36effect, but it's 79 EHR systems that we've connected to in our 14-year history.

01:02:42Okay.

01:02:43And then Dr. Rosenberg, I think it was you that mentioned the sensitive nature of some

01:02:50records that we want to make sure we're keeping as secured and stored safely as possible.

01:02:59Some number of years ago, I worked for the state treasurer, and this was an issue we

01:03:03had with people's tax information.

01:03:05We didn't want people browsing the governor's tax returns or something like that.

01:03:10Is there a similar mechanism through MIHEN to make sure that somebody...

01:03:18Is there a mechanism by which you could tell if somebody was trying to open a patient's

01:03:22record when they didn't need access to it for that nefarious purpose?

01:03:28Even if they're a licensed provider, right?

01:03:31You hear about this occasionally with law enforcement officers looking up somebody's

01:03:35record who they don't actually have a reason to, and then that violates the protocol for

01:03:40the record management.

01:03:42Yeah.

01:03:43That's our active care relationship service, ACERS, and that means that you have to have

01:03:47an interaction with that patient in order to view their record.

01:03:52One of the things we also have is what we call common key services.

01:03:56Sometimes a patient might have their name spelled different ways in different EHR systems,

01:04:03and then we commonize that and give them one unique identifier.

01:04:06Think of it as a social security number for your medical history in the state of Michigan,

01:04:11and then only providers that have interactions with that patient in their EMRs are allowed

01:04:16to see that patient's record.

01:04:18You couldn't just log into our system and look up anybody's healthcare information.

01:04:22It is extremely...

01:04:23Because you have access, you don't have...

01:04:25It's not just once you're in the door, you can just go start cruising around or something.

01:04:30Correct.

01:04:31There are several avenues to do this.

01:04:36One, as you've mentioned, is to assure that the people asking for the data are appropriate,

01:04:44and that changes.

01:04:45That's, again, to the previous comment of the expense it takes to maintain those records

01:04:51and make sure that they're up to date.

01:04:53EPIC has a concept of break the glass, either for accessing data or accessing data within

01:05:00the record itself.

01:05:02If I remember when I was doing telecritical care for the VA, there was, within VISTA,

01:05:07a similar way to identify when some data you may be wanting to look at was a bit more privileged,

01:05:14a bit more protected.

01:05:16But then there's also indirect methods.

01:05:19The reality is, if I look at a medication list and I see an antidepressant on the medication

01:05:26list, I don't have to have access to the problem list to potentially see that a patient may

01:05:32have a mental health condition.

01:05:36That's important for all of us to know.

01:05:38There are layers, and then there are matrices, almost, of where these data come together.

01:05:44I think part of the complexity, part of those gaps, as we mentioned, is to try to do it

01:05:49properly.

01:05:50If anything, we're probably a bit conservative to start with.

01:05:54That's one reason of many why we might not be as fast in some areas.

01:05:59All right.

01:06:03Thank you, Member Bozinski.

01:06:05Thank you, Chairman.

01:06:06I know we've talked a lot about, or somewhat about, people and the importance of people

01:06:10as it relates to interoperability.

01:06:14But we also can acknowledge that a lot of the functionality is still happening manually

01:06:19through FACTS or HSRM.

01:06:23And with these systems, clerks and health information management, or HIM, staff must

01:06:28manually upload documents to the VA's EHRs.

01:06:34So Dr. Nebker, I'd like to know, how many individuals in this workforce have been impacted

01:06:41by the mass terminations carried out since January 20th of 2025?

01:06:47Thanks for that question.

01:06:48I just don't have the answer for that.

01:06:52Sorry.

01:06:53Would you be able to get us the answer?

01:06:54We'll take it back, yes, ma'am.

01:06:56Okay.

01:06:57So we'll be able to.

01:06:58Yes.

01:06:59Okay.

01:07:00Because I was obviously very relieved when Judge Alsup came back and said that those

01:07:04probationary employees that were terminated need to be rehired, but then the administration

01:07:11immediately put those same 2,400 employees on administrative leave.

01:07:17Do you know why the VA decided to put those 2,400 employees on administrative leave?

01:07:23I'm sorry.

01:07:24I really do not know.

01:07:26Would you be able to follow up with the committee on the rationale behind that?

01:07:31Sure.

01:07:32Okay.

01:07:34My esteemed colleagues will help with that, yes.

01:07:37Okay.

01:07:39Are individuals in this workforce, well, let me say this, have any of the HIM staff, do

01:07:47you know, taken the fork in the road?

01:07:50Again, I don't have that information, but we can take it back.

01:07:55Okay.

01:07:56Great.

01:07:57So the VA plans to make VA fully operational with QHIN participation by December 2025 without

01:08:05many of these critical skilled staff that are needed to carry out this work.

01:08:10How are you looking at that with these folks off?

01:08:14So I think I can answer that one.

01:08:17And so really the people that do that work are in central office for connecting the QHIN,

01:08:25and I'm not aware that we have any problem with the current federal staff to meet the

01:08:32needs of connecting to the QHIN and rolling that out to the local facilities.

01:08:39My next question is for Dr. Pertula.

01:08:43The subcommittee has heard reports of several canceled contracts that support the EHRM project.

01:08:50How many contracts or other support services have been cut by DOJ since January 20th of

01:08:562025?

01:08:57So we have received the request for information for all this contract, and the office is currently

01:09:02reviewing those.

01:09:03And I am sure that as soon as that's completed, we will be providing it to this community.

01:09:09Okay.

01:09:10At least one of these terminated contracts we know focuses on supporting interoperability

01:09:14across VA, DoD, and community providers.

01:09:18While some of these have been reinstated, the contractor stated that the smaller workload

01:09:22quote probably isn't enough for them to keep doing business with the VA in the long-term

01:09:27end quote.

01:09:29What would be the impact of losing such a contractor support for the EHRM program?

01:09:36I'm not aware of the contract that you're talking about, so we can take it back to the

01:09:40record and see what the impact would be on that one.

01:09:44Okay.

01:09:45I just want to say I think it's extremely concerning that the VA's witnesses today do

01:09:49not have answers to these important questions around staffing and contract support.

01:09:54Without this information, the committee is significantly inhibited in its requirement

01:09:59to perform oversight of the department's activities.

01:10:02I look forward to receiving this information from VA in a timely manner and working with

01:10:07Chairman Barrett to continue oversight of this program.

01:10:12I have another question for Dr. Nebker.

01:10:15Has VA performed any audits of providers where veterans may seek care in the community to

01:10:21see if they are connected to the exchange?

01:10:25So yes.

01:10:26And so we are right now, as I mentioned earlier, going through all of the academic affiliates

01:10:32to make sure that they're connected.

01:10:34The University of Michigan just recently connected with us on that matter, so now we're going

01:10:40to go systematically through all the academic affiliates.

01:10:43In addition to people that aren't yet connected, we also have a data quality monitoring program

01:10:51and by which we look at all the messages that are coming across.

01:10:54Those are saved in an Oracle location and right now we have a bit of a contract pause

01:11:01trying to get those data back to the VA, but we expect that to be resolved shortly.

01:11:06Dr. Perdula's team is doing a great job with that.

01:11:09And then we actually sample the data to look for data quality problems and we do, based

01:11:15on various scenarios for what care coordination of what is quality sufficient, and then we

01:11:20go back to the healthcare systems and help them improve the quality of data that they're

01:11:24sending us.

01:11:25Okay.

01:11:26Okay.

01:11:27Thank you and I yield back to Chairman Barrett.

01:11:32Dr. Nebker, just briefly, is it, I know that in Michigan we learned that there's a lot

01:11:39of, VA is not part of the local or regional health information exchange.

01:11:44Is it common or unusual for VA facilities to be members of the regional HIEs?

01:11:51So we are not members of any of the regional HIEs.

01:11:58We have been in discussions on this topic for, I don't know, 10 years about how do we

01:12:03participate or not.

01:12:04I wasn't involved in most of those discussions previously.

01:12:07Neither was I.

01:12:08I've only been here two months.

01:12:10What we are looking for now, so right now there are 50, over 50 regional health information

01:12:19networks that are connected to eHealth Exchange.

01:12:24Eight of those are connected to a QHIN, to the eHealth Exchange QHIN.

01:12:28The rest are in the traditional network.

01:12:31So our strategy is we will join a QHIN and many of the RIOs, and we were in discussions

01:12:41with some of those, all those that we've talked to are planning on joining the QHIN.

01:12:47And so we will then get connectivity to those regional health information networks through

01:12:53TEFCA.

01:12:54Okay.

01:12:55And then I know the Indian Health Services currently is the only federal agency that's

01:13:01connected to a QHIN right now.

01:13:02Is that the case?

01:13:06Given that the other of the federal are on our gateway, yeah.

01:13:09There's only two, correct?

01:13:10To my knowledge, yes.

01:13:11Okay.

01:13:12Do you know which EHR they use?

01:13:17So Indian Health Services uses a variant of VISTA.

01:13:20A lot of it's based on VISTA, and they have, it's called RPMS, CPRS, RPMS, it's a similar

01:13:27shared technology, but a little bit different.

01:13:29Okay.

01:13:30So they don't have one of, I guess, the more mainline modernized EHRs that VA is currently

01:13:36going through the process of upgrading?

01:13:38Correct.

01:13:39They have contracted with Oracle to provide that, but not joining.

01:13:44It's time to get ready.

01:13:46And I have, of course, a lot of friends in that organization, but they are just starting

01:13:51their journey towards their implementation.

01:13:54Okay.

01:13:55And then VA is not sure yet which of the QHINs, now is it true that Oracle is trying to create

01:14:04their own QHIN?

01:14:05Is that also accurate?

01:14:07Yes.

01:14:08Okay.

01:14:09So right now VA, the reason we have to do this, it takes a little bit of time, is we

01:14:13have to do it with DOD.

01:14:16And so the firm is hosting some of those discussions, and Dr. Petula's team is really doing a lot

01:14:20of the heavy lifting as far as the technical approach.

01:14:25And we should have a decision on that fairly soon.

01:14:28And sorry, the second part of your question?

01:14:33Oracle is creating their own, and then would it be natural to assume that that will follow,

01:14:39that VA and DOD will follow into that?

01:14:41So I wouldn't make any assumptions.

01:14:44I don't make assumptions on this category.

01:14:46It's logical that that might happen.

01:14:49There are testing and certification requirements that take about a year to get through after

01:14:58there's an establishment of a QHIN.

01:15:01And so you have to talk to Oracle about how they're meeting those timelines.

01:15:06But I would add that the barriers for switching, for entry and switching among QHINs are extremely

01:15:13low.

01:15:14And so if Oracle comes up with a great product and it's better than what else we're seeing,

01:15:18the price is right, it would be logical for us to switch to an Oracle solution.

01:15:23Okay.

01:15:25And then could you explain also through TEFCA, which will establish these kind of framework

01:15:33for these QHINs with quality of information and everything else, how is that, or how can

01:15:40that address VA's interoperability gaps that exist in some of the examples we heard about

01:15:45today?

01:15:47So TEFCA is primarily about the trust framework, about what can we exchange, the legal framework

01:15:53for trusting each other to exchange information.

01:15:56And then about the pipes, that's the QHIN part, the qualified, not quality, but qualified

01:16:01health information network.

01:16:04So we're using the same technology to exchange the data.

01:16:06So QHIN we believe will solve a large, with active Rio help, and we really need the help

01:16:13from the Rios, will solve a lot of the connectivity problem.

01:16:18But there's still the data quality program that this does not, it's pretty much silent

01:16:22on data quality.

01:16:23Okay.

01:16:24Are there discussions in place around that standardization, if you will, and where do

01:16:32those go in this process?

01:16:34Yeah, I gotta say, I really appreciate your interest in these questions, it's such a nerdy

01:16:38topic.

01:16:39But, so right now, Levitt Partners is leading a coalition around data quality.

01:16:46It involves CMS, it used to involve CDC, they're replacing a member there.

01:16:52And then payers, some of the blues are participating.

01:16:57Also other data exchange and quality organizations, NCQA is participating.

01:17:02And so the goal of this collaborative is to address exactly the data quality problem,

01:17:08because all of us want to be able to provide better decision support, better quality management

01:17:13of the care, better population health, et cetera, and we need data we can compute on.

01:17:19So for example, our studies have shown that only 35% of our people can we tell from that

01:17:26information exchange over the HIEs whether they need a colonoscopy for screening or not.

01:17:32So it's very poor data that we're currently getting.

01:17:35It's not 100% bad, but big gaps.

01:17:39And so there's a lot of progress on this, and I see that we're over time a little bit.

01:17:45But there's a vendor that stepped up to donate and will provide through open source some

01:17:49of their technology to provide really objective scoring of data.

01:17:53And that is also accompanied with, hey, this is what you might be doing wrong, because

01:17:58the data came out this way.

01:17:59So it's going to be a really powerful initiative, and we're hoping that insurance companies

01:18:05like Myhen has a tight partnership with their payers.

01:18:09They recognize the value of this interoperability, not only the connectivity, but also the quality

01:18:14of the data.

01:18:15We hope that they'll be writing in their contracts data quality provisions to really incentivize

01:18:20for us this change of high quality data, not just data.

01:18:27Member Brzezinski.

01:18:28Thank you, Chairman.

01:18:29Dr. Greenstone, can you share, what is the utilization rate of these tools that VA utilizes

01:18:36like HSRM, JLV, and the Veterans Health Information Exchange among community care providers?

01:18:45Sure.

01:18:46I can clearly speak to HSRM, which I was a product owner for for many years.

01:18:52And HSRM is the referral and authorization system for VA.

01:18:59And what it creates is the true authorization that providers in the community need to have

01:19:04so they know what VA is authorizing, and there's a referral number that has to be associated

01:19:09with the claims that are actually submitted.

01:19:12There are approximately 130,000 providers in the community, in the community care network,

01:19:18who are provisioned to use HSRM as the means by which they receive their referrals, as

01:19:24well as having access in one click to the entire veteran medical record in an organized

01:19:31way.

01:19:32The challenge, however, is that it's only for veterans who are seen in that 165 sort

01:19:38of medical centers that are still on our legacy VISTA CPRS system.

01:19:43So those five facilities that are on Oracle Cerner have not had that data in Oracle moved

01:19:49over to our middleware VDIF that actually HSRM actually uses to show the data.

01:19:57So that we know that, let's say if you receive as a provider in the community more than two

01:20:01referrals a day, about 75% of those providers are using HSRM to receive their referrals

01:20:09and to upload medical documents.

01:20:12If you receive more than 10, we're talking 95% to 100% of providers.

01:20:16So if those providers who get a lot of referrals want to organize their data and their referrals,

01:20:21and they do that within HSRM, so that's why they log in, that's why they see the entire

01:20:25veteran medical record, and that's why many of them will then upload data.

01:20:30Some of them are challenged because some VA medical centers are like, hey, our back-end

01:20:34people are using faxes and phone calls and scanning all day long.

01:20:37We don't want to use HSRM.

01:20:39Send us faxes.

01:20:40And that's a problem that still exists today when VA medical centers are telling folks

01:20:45to fax and not utilize a system that providers want to use because it makes it easy for them

01:20:50to actually do their work.

01:20:51And that's a great point, and fax machines have come up a few times, I think, today.

01:20:56So I would like to ask Dr. Nebker, when we're talking about interoperability and things

01:21:02like fax machines are coming up, what is the VA's plan to address this reliance and push

01:21:09people to utilize more interoperable tools like HSRM or the exchange?

01:21:18So thanks for that.

01:21:19So back when I was starting out as a young faculty member at the University of Utah,

01:21:24I had what then seemed to be a very large contract with Medicaid, and we were providing

01:21:29really great decision support on drugs when people were prescribing drugs together that

01:21:34they should never prescribe together, like Viagra and nitrates, for example.

01:21:40The providers loved it.

01:21:41We went out and we asked them, you know, what do you think about these forms we're mailing

01:21:46to you back in those days?

01:21:47And they said, they're great.

01:21:49We love them.

01:21:50But I just take them, I throw them in the garbage.

01:21:53And so why?

01:21:54Because 3% of their patient volume is Medicaid, and they can't create workflows in their office

01:22:00to deal with 3% of their volume.

01:22:04And so my answer is, we've got to join the rest of the community, and Dr. Greenstone

01:22:09was really emphasizing this in his opening comments, we've got to do things the same

01:22:14way as the rest of the community.

01:22:16And then thankfully, I mean, the Elizabeth Dole Act was really a gift in this, Section

01:22:20108 was a gift in this matter, because directing the Secretary of VA to work with the Secretary

01:22:26of HHS, because it's that teamwork, right?

01:22:29So here we are as the largest integrated healthcare provider in the country, and we're

01:22:33not part of that health community, right?

01:22:38So really, to bring together to have a more cohesive policymaking, I think is really going

01:22:42to be important to address that.

01:22:43And if you have any further technical questions about that, Dr. Pertula could cover those.

01:22:47Would you like to add anything, Dr. Pertula?

01:22:50Yeah, we've been working on interoperability, as you all said, probably about 20 years,

01:22:55whether it's healthcare or otherwise.

01:22:58And we will continue to do that, consistently improving, whether it is e-faxing and turning

01:23:03them into something else.

01:23:05We have plans as well for bringing some of that interoperability more into rural communities

01:23:11and helping them.

01:23:12We have secure messaging as well that they can use, so that instead of faxing, they can,

01:23:17well, email if they have that ability, so that then we start having also some more computable

01:23:23information.

01:23:24But as Dr. Nebaker and the rest of the panel here have said, we really need to get into

01:23:29everybody really working towards semantic interoperability, right?

01:23:33Making sure that our data models are similar, if not the same.

01:23:38Open source is a great way for us to start really looking into what do others do that

01:23:43can help us, so that it's not a closed door or behind the door kind of discussion around

01:23:48interoperability.

01:23:50I yield back.

01:23:54I know I've got to go to closing remarks because, unfortunately, we have to move on to other

01:23:59activities.

01:24:00But, Dr. Nebaker, just, and I can follow up with you later, but when you talked about

01:24:05quality of record and everything else, I don't know if that means the data itself through

01:24:13the system or like how a physician describes a certain thing.

01:24:17I'll give you an example.

01:24:18When I was in Ann Arbor last week, a few days ago, they said that carpal tunnel condition,

01:24:25you know, procedure could be categorized one of several different ways by the physician.

01:24:30And the next physician looking it up may not look at it through the same lens, perhaps.

01:24:37And I just would be curious, I mean, we spent a lot of time making sure we had standardized

01:24:41language in the Army for the things that we did there.

01:24:44I assume that's probably a goal in medicine as well.

01:24:49But happy to ask you some of those follow-ups offline unless you've got some brief comments

01:24:54you want to make.

01:24:55Very briefly.

01:24:56So the kind of the nuanced classification of diseases is what we think about more for

01:25:01internal interoperability when we're generating the data.

01:25:05The kinds of quality that I was talking about before is about getting those data that are

01:25:10in the EHR and that are great in the EHR across that divide to where they're actually

01:25:16going out in a way that can be read.

01:25:19So you're talking ones and zeros, not human interfacing.

01:25:23So are they getting the right information in the right slot?

01:25:26Are the units for blood pressure, you know, millimoles per liter instead of millimeters

01:25:31of mercury, which is very different?

01:25:34Are they plausible values?

01:25:36Is the blood pressure, you know, 500?

01:25:40We're seeing these data quality programs when they're going from the EHR to the being

01:25:44pushed out to the exchanges, the data is getting scrambled.

01:25:47Okay.

01:25:48That's how you crash a lunar module when you have one guy measuring meters and the other

01:25:53guy measuring feet.

01:25:54So okay.

01:25:55All right.

01:25:57Really appreciate all of your testimony, each of you, for being here today.

01:26:03Definitely learned quite a bit from your testimony.

01:26:06I'm only slightly more confused than when I started, so that shows that we're making

01:26:09progress.

01:26:10VH is the largest health care system in the nation, but it only represents, oh, I'm sorry,

01:26:18Member Baczynski.

01:26:19Go ahead.

01:26:20You can do your statement first.

01:26:21Sure.

01:26:22Thank you, Mr. Chairman.

01:26:23I'll get this right over the next two or three times.

01:26:25It's okay.

01:26:26We're in it together.

01:26:27I appreciate the testimony and answers from our witnesses this afternoon.

01:26:31Providing a truly seamless and secure interoperability program is crucial for our veterans to be

01:26:36able to seek the care they need.

01:26:38There have been a series of active interoperability efforts, but there are still major issues

01:26:43that need to be addressed about the sharing of information between the VA and the non-VA

01:26:49providers.

01:26:50I'm glad to see that the VA is actively taking steps to figure out how to securely exchange

01:26:55information so veterans can continue to receive care inside and outside of the VA.

01:27:01While these efforts are on the right track, I would be remiss to not acknowledge the impact

01:27:06of the recent personnel actions on VA's ability to ensure that veterans have a complete medical

01:27:12record.

01:27:13It's critical that VA have sufficient staffing in OIT and EHRM, as well as the clinical settings,

01:27:21to ensure that VA can participate in the information exchange processes, otherwise

01:27:26our veterans are the ones that will suffer.

01:27:29Relying on only technology alone is not going to work for a seamless exchange of information.

01:27:36We need to work together to figure out how to produce complete medical records for our

01:27:40veterans so they can receive the care that they so rightfully deserve.

01:27:45Thank you so much, Mr. Chairman, and I yield back.

01:27:50And I want to thank the Ranking Member for participating and being here for the entire

01:27:53committee hearing today.

01:27:55And I want to thank our witnesses, and as I was beginning to say, the VA is the largest

01:27:59health care system in the nation, of course, has more medical records perhaps than any

01:28:03other system out there, but still only represents about 3% of all U.S. hospitals.

01:28:10So while it is the largest, it is still not the majority by any stretch.

01:28:16Veterans are people at the end of the day, and the other 97% of hospitals will always

01:28:20play a role in veterans' health care.

01:28:22As I said in my opening remarks, roughly one-third of VA care is currently gone through the community.

01:28:28The health care data in the community care network will always form a large part of the

01:28:32complete picture of a veteran's medical history.

01:28:37Republicans on this committee have prioritized making sure that veterans have access to community

01:28:40care when they are eligible for it and are given the opportunity to choose what is best

01:28:44for them and placing them in the driver's seat.

01:28:46Part of how we make VA stronger and deliver better outcomes for veterans is to continue

01:28:50moving the ball forward on interoperability so there is that seamless ability and no coverage

01:28:55gap exists.

01:28:56This includes VA producing a thorough, actionable plan on health care information interoperability

01:29:00standards, expanding the VA Veterans Interoperability Pledge and fostering more direct information

01:29:08exchange with community partners, building stronger partnerships for providers like Michigan

01:29:13Medicine as well as health information exchanges like MyHen that we learned a lot from today

01:29:17and appreciate that, participating in TEFCA to bridge the data exchange gaps with community

01:29:22care providers that still exist.

01:29:25I urge the VA to be a leader in interoperability and build on the progress of recent years.

01:29:30Americans' veterans have much to gain from your work, and I thank you all again for participating

01:29:35in today's hearing.

01:29:36I ask unanimous consent that all members have five legislative days to revise and extend

01:29:41their remarks and include extraneous material without objection so ordered.

01:29:46And with that, we are adjourned.

The House Veterans' Affairs Committee Holds A Hearing On Closing The Data Gap

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