“We reached some great major milestones in the Military Health System over the last year,” says MHS’s Charles Hume.

“In December we completed the fielding of ALTA, which is our ambulatory electronic medical record across all Army, Navy and Air Force hospitals and clinics. That’s 65 hospitals world wide and some 400 medical clinics.”

A version of ALTA is also deployed in Iraq and Afghanistan supporting health care delivery says Hume.

“We’ve got some 88 million individuals now with electronic records in our system; we are processing over 120,000 patient encounters every day in that system. So it’s growing very fast.”

In the past year MHS has built on the information sharing that it has been doing with VA since 2001.

“Within the last year we successfully fielded a system that will cross check pharmacy and drug allergy interactions between the two departments,” explains Hume. 

“So the Veteran’s Administration and the Department of Defense each have electronic medical records where with computerized pharmacy order entry, when the physician orders a drug, whether that patient’s received the drug through DoD or VA, if there’s a counter indication, a flag will pop up with that provider in either the DOD or the VA system.”

Hume says this has been successfully field tested and it is now in the process of being expanded across both departments worldwide. “In April of 2007, ALTA achieved its certification through the commission for the certification of the ambulatory health records, so the next version of ALTA that we are about to put out in the field has been fully certified.”

VA Implementations

The programs that I oversee are the implementation of our electronic health records says VA’s Gail Graham. “VA has slowly implemented the electronic health record in all sectors -- outpatient, inpatient, long term care,” notes Graham. “In home health we are doing a lot with keeping veterans in their homes and avoiding long term care placement or other things that would take them away from their families.”

VA is also delving into personalized medicine in conjunction with HHS; looking at research in the use of genomics to improve the decision support VA provides to physicians in treating our nation’s veterans to ensure that, not only will they monitor the normal decision support things like drug interactions, but really customizing it for each patient.

Unique Native American Issues

Although the Indian Health Service has unique issues, they have been partnering with VA for more than 25 years.

“We embarked on an endeavor in conjunction with the VA to take the solutions that they had developed in the federal and states and adapt them for use in our communities,” says IHS’s Theresa Cullen. “What we bring to the table is a long and historical wealth of information working with rural, minority, under served patients in fiscally constrained situations.”

According to Cullen, despite the unique problems that come with dealing with the Native American population, the IHS has been able to effectively deploy health information technology solutions.

“Despite all those problems that constrain us and constrain many other communities throughout America,” declares Cullen, “we’ve been able to show how the effective use of Heath IT can be used, not only to improve health care delivery, but really to ultimately improve health care status.”

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June 15, 2007 • Volume 5 • Number 6

Opportunities Abound

“We are making great strides in providing services to our returning veterans involved in the global war on terror and making sure that they have seamless transitions from their military service to the Department of Defense,” says VA’s Gail Graham.

“We are looking at new things coming out of that conflict, such as the treatment of traumatic brain injury,” notes Graham. “We are really setting up electronic reminders to providers of “signs to look for”, so that we can stay abreast of that.”

VA is also deeply involved in the broader expansion of the personalized health record.

“Our veterans have access to www.myhealthyvet.org, where they can find general health information,” explains Graham. “They also can see certain parts of their record, request prescription refills and request appointments. This really drives us towards that patient involvement in their health care which is so important for all of us to keep in mind.”

VA is also broadening the of home help and home help devices such as that monitor vital signs of the patient to look for early warning signs to provide immediate assistance if necessary and to help avoid unneeded hospitalizations.

VA shares some of the same challenges as the private sector, especially in the area of health standards. “Many times for example, in the work that we’ve recently done in DoD, we are just ahead of the standards adoption curve,” says Graham.  “We are really working more and more with our private sector partners because many of our veterans and active duty members receive care outside of our circumstances as well.”

Sharing Data

Charles Hume of the Military Health Service (MHS) says a major emphasis is on sharing data with VA.

“DoD and VA have a strong relationship with the nature of our patients naturally flowing from the DoD health care system to the Veterans Administration, once they leave active service.”

“With a war going on, that’s even more compelling. So we’ve made a lot of progress in sharing data. Starting back in 2001, we moved electronic data to VA as the service members separate, but now what we are seeing is increasingly our patients are being treated back and forth between VA and DOD. And so we are sharing information in real time.”

This year the two departments will begin to share even more. “We’ve been sharing mostly ancillary data, pharmacy data, laboratory data, radiology information,” explains Hume. “Then the next big step is to share the actual provider notes after an encounter, so that record of care from both departments is immediately available.

But, like VA, DoD purchases care from the private sector for about half of the care patients receive. “So the work that we are doing with VA I hope will promote a national standard on how we can share information among a much broader population.”

This is an important problem to solve because this information sharing is a long-term proposition.  No one wants a veteran who leaves the military and moves over to VA or another system have to start over again with establishing new records.

Patient Centric Care

“We need to provide patient centric care as well as to provide community and population centric care,” says IHS’s Theresa Cullen. “So IHS has really adopted the model that the four perspectives that health IT can bring to the table: the patient perspective; the provider perspective; the community perspective; and the population perspective.

All are important to try to improve health status, but for the IHS the emphasis is on trying to learn is what actually activates the patient.

“What information can we give a patient through the Health IT system?” asks Cullen.

“If we show them their data in a graphical display, are they likely to get activated? Will they say they want to control their diabetes or hypertension?”

Cullen says they can then aggregate the data that will enable assess the health care status of that individual patient within their family and within their community. And then use that data ultimately to really activate the community so that there’s recognition that the health care status of the individual patient is really contingent and dependent to some extent on the health status of a much larger arena.

Getting Action

“But right now we function in a very fragmented provider focused, payer parsed health care delivery non-system,” exclaims Dr. Bell. “In order to truly get to that person-focused arena, we need to be able to provide information to patients at the time that they need and want it.”

All of this must be done in a secure, usable way that has the appropriate policies and business cases in place.

“I would suggest that one of the major challenges we are going to face is that our current system has multiple stakeholders in it with no clear business case for any one entity to move forward to that person centric model,” says Dr. Bell.

“The alignment of the business case is our biggest challenge to moving forward along with huge workforce issues. We do not have enough workers and enough folks to train the trainers. So workforce is another big challenge.”

Private Sector Thoughts

“There’s a real opportunity to learn,” says Intel’s Jason Kimrey. “I think too often in this industry we’ve reinvented the wheel and we’ve implemented new solutions just to replace old ones. In many cases, we’ve not really learned from the good things that have already been done.”

Kimrey thinks the data sharing and interoperability between MHS and VA is really outstanding and it really should be used as a model for the health care industry at large.

Kimrey points out the issues around data sharing between agencies are really no different than the issues of sharing data between a primary care physician and the specialty physician; the issues around sharing data between a physician and a hospital; or even one hospital in one community to another hospital in another community.

“The difference is that the VA and MHS is the one doing it today. And I think there’s a lot of key things that we could learn from what they’ve done and really expand that and learn and implement and improve the overall delivery of health care throughout this country.”

For Dell’s Max Peterson, the first thing that comes to mind is the explosion of data.

“The hugs amount of data and the different types of data, plus having the ability to have a records management system that supports interoperability, security and access to all that information is a huge issue,” says Peterson.

Peterson advocates from a technology perspective for the vision of the electronic record to become a reality, there is a need to bring to the table ways and means to help customers through virtualization, through data storage technologies and through security technologies.

When it comes to interoperability Peterson notes that patients don’t want to go to one place for one provider. “People don’t stay in one place and so interoperability and the ability to access those medical records where ever the patient is, at home, on travel, at a specialist or at the primary caregiver are an enormous technology opportunity and a challenge right now also.”

For Patti Obermaier of Unisys, key opportunities for Health IT focus on the capture and the correlation of the data.

“We talked about capturing a lot of data for the patient when they are traveling around, but then the key thing is also correlating that data,” says Obermaier.

“If you are sick, what are your symptoms, what’s happening? One of the key challenges of capturing all of that information for the patients is not to overwhelm them,” notes Obermaier. “They are going to have so much information and how do you present it, will it be graphically, whatever the case may be. How do we enable the patient to be empowered in their health care and not overwhelm them with so much information?”

On more practical matters, Obermaier says the incentive for the private sector to adopt electronic health records is in incentives such as rebates or tax breaks.

“Not necessarily for the large hospital organizations, but the smaller primary care physicians in the smaller regions,” says Obermaier. She asks, “What is going to be the incentive to adopt that information?”

According to Obermaier, the second challenge is how do we use this information?

“Is it really driving better health care? It’s going to include quality, it’s going to save costs, and it is going to where we can actually track it to the outcomes of our health. So I think those are the two challenges. Not only the incentive to adopt it but then the usability of the information.”

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June 15, 2007 • Volume 5 • Number 6

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June 15, 2007 • Volume 5 • Number 6

Working Together To Coordinate The Nation’s Health IT Effort

Dr. Karen Bell is the director, Office of Health IT Adoption, Office of the National Coordinator for Health Information Technology at HHS.

The Office of the National Coordinator was founded by an executive order in April of 2004. Their charge is, as the title suggests, to coordinate activities related to health information technology both within the federal government and externally. Coordination is in four different arenas.

The first is in the area of governance. The American Health Information Community was founded in July of 2005 and is chaired by Secretary Leavitt, HHS Secretary.

According to Dr. Bell, its primary function is to set priorities for the national Health IT agenda; to make health information available to everyone electronically that needs it at the time of care; and also for public health purposes. In order to achieve that vision, the American Health Information Community is comprised of both public and private high level executives.

“That community is informed by a number of work groups that make recommendations as well,” explains Dr. Bell. “So in addition to the priorities we have a number of recommendations coming forward from the work group. And the very exciting piece of this is that these recommendations and priorities are in fact listened to.”

Among the successes that achieved in the past year have been the August 2006 Executive Order that essentially required the federal government to adopt standards for interoperability in information sharing as well as improved encouragement to do that in our federal contracting.

“In addition to that the American Health Information Committee has made a number of other recommendations that have been followed as well and those are all available on our web site www.hhs.gov/healthit,” says Dr. Bell.

The second area of progress in is the area of technology. “Perhaps the biggest step forward there has been the results of the Health Information Technology Standards panel,” says Dr. Bell. “This has harmonized a number of standards for Health IT to ensure that information can be interoperable.”

The third big area is privacy and security.

“We have a contract with the National Governors Association to really look at what states are doing around privacy and security,” notes Dr. Bell. “We also have formed a subgroup or workgroup of the American Health Information Committee to tackle the very big issues around privacy and security, so we are moving forward with that as well.”

The fourth area is adoption.

“No matter what you build, if people don’t use it then it doesn’t bring value,” says Dr. Bell. “In the adoption arena there have been a number of successes also. One of the things that we have learned in our contacts with our international colleagues is that without clear definitions of adoptions, it’s very hard to understand whether we are making progress or not.”

Dr. Bell is getting help from companies such as Unisys, which supports the federal government is three areas: infrastructure, systems integration and development, and consulting.

Industry Steps Up

According to Unisys’s Patti Obermaier, providing infrastructure helps ensure interoperability.

“We are building large infrastructures to support the interoperability of these systems and creating systems so people can access the information, and be able to use it.” Unisys also provides consulting services geared specifically to figure out ways to help the health industry whether it is hospitals, physicians, nurses, or even American consumers.

Intel is not always the name that you think of when you think of health care, but it is leading ingredient supplier to the industry whether it’s desk tops, servers, notebooks says Jason Kimrey. “We feel it’s incumbent on us to make sure that people get the advantage of the technology that we are coming out with and really take advantage of the possibilities that’s needed in no greater place than the health care industry.”

Kimrey says Intel is working very hard within the health care industry to make sure that the latest technology that’s coming out from its partners is used to help in the delivery of care.

“We are doing that in three key areas,” explains Kimrey. “One is in health care IT space; another is in the personal health arena and lastly in the policy and standards.”

Dell is another industry giant deeply committed to serving the health care community and the public, says Max Peterson.

“On a national level, Dell is involved through things like the Technology CEO Council and our own dedicated health care review to help set standards and to help make sure that technology is addressing the needs of the nation’s health care system.”

One area is cost and in turn productivity. “There’s a tremendous opportunity to help improve productivity, drive costs down and keep them in control, and also to improve outcomes,” declares Peterson.

Dell’s federal initiative includes listening to customers and responding with technology solutions that meet their specific needs. “There’s a lot of work that we are doing with ALTA and the VA,” says Peterson.

“The second thing is to share best practices, so we try and take some of the experience we’ve got from our health care division and our technology and research and bring it appropriately to the federal market place.”

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