Congressional Leaders Question VA’s Progress on Interoperability, Modernizing EHR System | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Congressional Leaders Question VA’s Progress on Interoperability, Modernizing EHR System

July 13, 2016
by Heather Landi
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During a U.S. Senate Appropriations Subcommittee hearing, Congressional leaders voiced strong concerns about the U.S. Department of Veterans Affairs’ (VA) progress on achieving interoperability with regard to the exchange of electronic health records with the Department of Defense (DoD), despite assertions by both departments last April certifying full interoperability.

The purpose of the July 13 hearing of the U.S. Senate Appropriations Subcommittee for Military Construction, Veterans Affairs and Related Agencies was to provide subcommittee members a review of the VA electronic health record system (called the Veterans Information Systems and Technology Architecture, or VistA), the department’s progress toward interoperability with the DoD’s electronic health record (EHR) system and plans for the future.

The DoD and VA signed off on achieving interoperability in April, after the VA implemented its Joint Legacy Viewer (JLV) last fall. The JLV is a web-based integrated system that combines electronic health records from both the DoD and the VA, which enables clinicians from both agencies to access health records. During the July 13 hearing, VA CIO LaVerne Council testified that the JLV currently has 178,000 users exchanging military service members’ and veterans’ health records.

Committee Chairman Mark Kirk (R-IL) said his vision for the DoD and VA systems is for every military service member to have “100 percent seamless transfer of the health record to the VA. “We have about 250,000 service members leaving the DoD and becoming veterans every year, that’s about 700 per day. That is a data flow that is well within the capability to cover and we need to make sure that there’s seamless continuity of care.”

During the hearing, Kirk and Committee Ranking Member Jon Tester (D-MT) voiced frustrations with what they saw as a lack of interoperability between VA and DoD’s EHR systems, despite both agencies certifying to Congress in April that the systems are fully interoperable based on mandated requirements.

Valerie Melvin, director of information management and technology resources issues at the Government Accountability Office (GAO), testified that, according to GAO, the VA was still “years away” from full interoperability with the DoD.

To this point, Sens. Kirk and Tester voiced their frustrations with VA officials that the health data contained in the JLV does not include imaging data, such as X rays or CT scans, and therefore, they said, does not provide clinicians with a patients’ complete record.

David Waltman, VistA evolution program executive and senior advisor to the Under Secretary for Health at the Veterans Affairs Administration, said the JLV contains data such as progress notes, lab reports, as well as reports from imaging studies and radiology reports. And, he said the VA was working to deliver imaging data to the JLV platform. “The challenge there is to make sure we have the bandwidth to exchange imaging for clinical purposes.”

“When are we going to be interoperable to the point that the information that DoD has, you have all the information on those medical records in your hands? When will that happen?,” Sen. Tester asked.

Council said the image viewer component of the JLV will be deployed in September. And, she noted the importance of the VA’s enterprise health data management (eHDM) platform, which is part of the department’s overall EHR enhancement efforts. “We need seamless movement of information at the active duty point of an enlisted person, even before they become a veteran.”

Kirk told VA officials to expect “pretty strong recommendations” to come from the committee on definitions of interoperability. “We need to move forward on this point so there is no net burden on service members to have 100 percent transfer of the data to the VA.”

Kirk also seemed frustrated that VA's health IT was lagging behind the capabilities of commercial health IT and the implications for patient care. He pointed out that commercial EHR vendors are moving forward on data analytics capabilities within EHRs which enables clinicians to do predictive analytics in order to predict health risks such as sepsis and even suicide risk. The VA’s JLV platform is currently incapable of data analytics, Kirk said.

Waltman with the VA said the department’s EHR systems would not have the capability for analytics until 2018. “That’s where the enterprise health management platform comes in and the digital health platform. We need an integrated capability of all the clinical data, the process management for managing clinical pathways and workflows and then the analytics so we can predict, based on the information in the record, the pathways and courses of action available, and what interventions should be taken, and the care pathways that should be taken.”

Legislators have voiced ongoing frustrations about the VA’s progress on modernizing its IT systems and the progress of achieving interoperability between the VA’s VistA and the DoD’s EHR system. Last year, the GAO designated VA health care as high risk, which is a GAO designation for programs and agencies that are vulnerable to fraud, waste, abuse and mismanagement and are most in need of transformation.

During a hearing last month, VA officials indicated that the agency will likely look for a commercial EHR system during a discussion about its 40-year-old homegrown system. During the hearing of the Senate’s Committee on Veteran Affairs, VA Under Secretary for Health David Shulkin testified that VA officials have reached a consensus that “looking at a commercial product is probably the way to go,” and he added, “But we need to do this in a way that incorporates our ability to integrate with community providers and unique needs of veterans.”

During the July 13 hearing, Melvin with the GAO said that the VA has been working with the DoD for the past two decades to advance EHR interoperability between the two systems, however, “while the department has made progress, significant IT challenges contributed to our designating VA as high risk.” And, Melvin summarized the GAO’s concerns about the VA’s ongoing modernization efforts.

“With regard to EHR interoperability, we have consistently pointed to the troubled path toward achieving this capability. Since 1998, VA has undertaken a patchwork of initiatives with DoD. These efforts have yielded increasing amounts of standardized health data and made an integrated view of data available to clinicians. Nevertheless, a modernized VA EHR that is fully interoperable with DoD system is still years away,” Melvin said.

“In 2011, DoD and VA announced they would develop one integrated system to replace separate systems, and sidestep many of their previous challenges to achieving interoperability. However, after two years and at a cost of $560 million, the departments abandoned that plan, saying a separate system with interoperability between them could be achieved faster and at less overall cost. Yet, as they have preceded on separate paths, we continue to highlight three primary concerns with this approach,” Melvin said.

GAO has found that the VA has a lack of outcome-oriented goals and metrics for achieving interoperability. “The important question remains as to when VA intends to define the extent of interoperability it needs to provide the highest quality of care, and when the department intends to achieves this with DoD?”

Melvin also said the VA plan to modernize its VistA EHR system “raises questions about duplications with the DoD system acquisition, as the department has identified 10 areas in which they have common healthcare business needs.”

And, Melvin said that VA officials “have yet to substantiate its claim that modernizing VistA together with DoD acquiring a new system can be achieved faster and at less cost than a single joint system." “How do the DoD and VA continue to justify the need for separate systems?”

Melvin summed up her testimony, “With regard to EHR interoperability and system modernization efforts, there is uncertainty and important questions remain about what the department is prepared to accomplish, in what timeframe and at what cost."

 

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HL7 Model Identifies Clinical Genomics Workflows, Use Cases

January 16, 2019
by David Raths, Contributing Editor
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Domain Analysis Model covers pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics

HL7’s Clinical Genomics Work Group has published an HL7 Domain Analysis Model (DAM) to identify common workflows and use cases to facilitate scalable and interoperable data standards for the breadth of clinical genomics scenarios.

The Domain Analysis Model (DAM), which has underdone a rigorous ISO/ANSI-compatible balloting process, covers a myriad of use cases, including emerging ones such as pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics.

The effort “builds on the DAM Clinical Sequencing work that is already being used to design precision medicine workflows at hospitals across the country,” said Gil Alterovitz, Ph.D., an HL7 Clinical Genomics Work Group co-chair, in a prepared statement. He also serves as a Harvard professor with the Computational Health Informatics Program/Boston Children’s Hospital.

The Clinical Sequencing DAM fueled the design of FHIR Genomics, the subset of HL7’s FHIR standard designed to communicate clinical genomic information. “By extending to broader domains, it can serve as a standard going forward to aid in the design of workflows, exchange formats as well as other areas,” Alterovitz added,

The document presents narrative context and workflow diagrams to guide readers through the stages of each use case and details steps involving the various stakeholders such as patients, health care providers, laboratories and geneticists. This contextual knowledge aids in the development and implementation of software designed to interpret and communicate the relevant results in a clinical computer system, especially a patient's electronic health record.

The HL7 Clinical Genomics Work Group developed several new applications and refinements in the Domain Analysis Model beyond its original scope of clinical sequencing. One notable addition is the analysis of the common workflows for pre-implantation genetic diagnosis (PGD). For those undergoing in-vitro fertilization, advanced pre-implantation genetic screening has become increasingly popular as it avoids the implantation of embryos carrying chromosomal aneuploidies, a common cause of birth defects. Implementers can follow the workflow diagram and see the context for each transfer of information, including the types of tests performed such as blastocyst biopsy and embryo vitrification.

As the clinical utility of proteomics (detecting, quantifying and characterizing proteins) and RNA-sequencing increases, the DAM also outlines clinical and laboratory workflows to capitalize on these emerging technologies.

HL7 notes that future challenges arise from uncertainty about the specific storage location of genomic data, such as a Genomics Archive and Computer/Communication System (GACS), as well as the structure of a patient’s genomic and other omics data for access on demand, both by clinicians and laboratories. Best practices in handling such considerations are being formulated within HL7 and include international input from across the spectrum of stakeholders. In parallel, the HL7 Clinical Genomics Work Group has been preparing an implementation guide for clinical genomics around many of these use cases, to be leveraged alongside the newly published HL7 FHIR Release 4 standard.

 

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ONC Releases Interoperability Standards Advisory Reference 2019

January 15, 2019
by Heather Landi, Associate Editor
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The Office of the National Coordinator for Health IT (ONC) has released the 2019 Interoperability Standards Advisory (ISA) Reference Edition, which serves as a “snapshot” view of the ISA.

The 2019 Interoperability Standards Advisory represents ONC’s current assessment of the heath IT standards landscape. According to ONC, this static version of the ISA won’t change throughout the year, while the web version is updated on a regular basis. The ISA contains numerous standards and implementation specifications to meet interoperability needs in healthcare and serves as an open and transparent resource for the industry.

The Interoperability Standards Advisory (ISA) process represents the model by which ONC coordinates the identification, assessment, and public awareness of interoperability standards and implementation specifications that can be used by the healthcare industry to address specific interoperability needs including, but not limited to, interoperability for clinical, public health, research and administrative purposes. ONC encourages all stakeholders to implement and use the standards and implementation specifications identified in the ISA as applicable to the specific interoperability needs they seek to address. Furthermore, ONC encourages further pilot testing and industry experience to be sought with respect to standards and implementation specifications identified as “emerging” in the ISA.

The newest ISA reference edition includes improvements made based on comments provided by industry stakeholder during the public comment period, which ended Oct. 1, according to a blog post written by Steven Posnack, executive director of ONC’s Office of Technology, Chris Muir, standards division director, Office of Technology, and Brett Andriesen, ONC project officer. ONC received 74 comments on the ISA this year, resulting in nearly 400 individual recommendations for revisions.

According to the blog post, the ISA contains “a variety of standards and implementation specifications curated by developers, standards gurus, and other stakeholders to meet interoperability needs (a term we use in the ISA to represent the purpose for use of standards or implementation specifications – similar to a use case) in healthcare.”

“The ISA itself is a dynamic document and is updated throughout the year, reflecting a number of substantive and structural updates based on ongoing dialogue, discussion, and feedback,” Posnack, Muir and Andriesen wrote.

The latest changes to the reference manual include RSS feed functionality to enable users to track ISA revisions in real-time; shifting structure from lettered sub-sections to a simple alphabetized list; and revising many of the interoperability need titles to better reflect their uses and align with overall ISA bets practices. According to the ONC blog post, the updates also include several new interoperability needs, including representing relationship between patient and another person; several electronic prescribing-related interoperability needs, such as prescribing weight-based dosing and request for refills; and operating rules for claims, enrollment and premium payments.

The latest changes also include more granular updates such as added standards, updated characteristics and additional information about interoperability needs.

The ONC officials wrote that the ISA should be considered as an open and transparent resource for industry and reflects the latest thinking around standards development with an eye toward nationwide interoperability.

The ISA traditionally has reflected recommendations from the Health IT Advisory Committee and its predecessors the HIT Policy Committee and HIT Standards Committee and includes an educational section that helps decode key interoperability terminology.

 

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ONC Report: Health IT Progress Stifled by Technical, Financial Barriers

January 15, 2019
by Heather Landi, Associate Editor
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While progress has been made in the adoption of health IT across the U.S. healthcare industry, significant interoperability hurdles remain, including technical, financial and trust barriers, according to a report from the Office of the National Coordinator for Health Information Technology (ONC).

Currently, the potential value of health information captured in certified health IT is often limited by a lack of accessibility across systems and across different end users, the ONC report stated.

The annual report from the U.S. Department of Health and Human Services (HHS) and ONC to Congress highlights nationwide health IT infrastructure progress and the use of health data to improve healthcare delivery throughout the U.S.

The report, “2018 Report to Congress: Annual Update on the Adoption of a Nationwide System for the Electronic Use and Exchange of Health Information,” also reflects progress on the implementaions of the Federal Health IT Strategic Plan 2015-202 and the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap.

In the report, ONC notes that most hospitals and health care providers have a digital footprint. As of 2015, 96 percent of non-federal acute care hospitals and 78 percent of office-based physicians adopted certified health IT. The increase in health IT adoption means most Americans receiving health care services now have their health data recorded electronically.

However, hurdles to progress still remain. For example, ONC notes that many certified health IT products lack capabilities that allow for greater innovation in how health information can be securely accessed and easily shared with appropriate members of the care team. “Such innovation is more common in other industries. Also, lack of transparent expectations for data sharing and burdensome experiences for health care providers limit the return on investment for health care providers and the value patients are able to gain from using certified health IT,” the report authors wrote.

While health information is increasingly recorded in a digital format, rather than paper, this information is not always accessible across systems and by all end users—such as patients, health care providers and payers, the report authors note. Patients often lack access to their own health information, healthcare providers often lack access to patient data at the point of care, particularly when multiple healthcare providers maintain different pieces of data, own different systems or use health IT solutions purchased form different developers, and payers often lack access to clinical data on groups of covered individuals to assess the value of services provided by their customers.

Currently, patients electronically access their health information through patient portals that prevent them from easily pulling from multiple sources or health care providers. Patient access to their electronic health information also requires repeated use of logins and manual data updates, according to the report. For healthcare providers and payers, interoperable access and exchange of health records is focused on accessing one record at a time. “Without the capability to access multiple records across a population of patients, healthcare providers and payers will not benefit from the value of using modern computing solutions—such as machine learning and artificial intelligence—to inform care decisions and identify trends,” the report authors wrote.

Looking at the future state, the report authors contend that certified health IT includes important upgrades to support interoperability and improve user experience. Noting ONC’s most recent 2015 edition of certification criteria and standards, these upgraded capabilities will show as hospitals and healthcare provider practices upgrade their technology to the 2015 edition, the report authors state.

“As HHS implements the provisions in the Cures Act, we look forward to continued engagement between government and industry on health IT matters and on the role health IT can play to increase competition in healthcare markets,” the report authors wrote, noting that one particular focus will be open APIs (application programming interfaces). The use of open APIs will support patients’ ability to have more access to information electronically through, for example, smartphones and mobile applications, and will allow payers to receive necessary and appropriate information on a group of members without having to access one record at a time.

Healthcare industry stakeholders have indicated that many barriers to interoperable access to health information remain, including technical, financial, trust and business practice barriers. “In addition, burden arising from quality reporting, documentation, administrative, and billing requirements that prescribe how health IT systems are designed also hamper the innovative usability of health IT,” the report authors wrote.

The report also outlines actions that HHS is taking to address these issues. Federal agencies, states, and industry have taken steps to address technical, trust, and financial challenges to interoperable health information access, exchange, and use for patients, health care providers, and payers (including insurers). HHS aims to build on these successes through the ONC Health IT Certification Program, HHS rulemaking, health IT innovation projects, and health IT coordination, the report authors wrote.

In accordance with the Cures Act, HHS is actively leading and coordinating a number of key programs and projects, including “continued work to deter and penalize poor business practices that lead to information blocking,” for example.

The report also calls out HHS’ efforts to develop a Trusted Exchange Framework and a Common Agreement (TEFCA) to support enabling trusted health information exchange. “Additional actions to meet statutory requirements within the Cures Act including supporting patient access to personal health information, reducing clinician burden, and engaging health and health IT stakeholders to promote market-based solutions,” the report authors wrote.

Moving forward, collaboration and innovation are critical to the continued progress on the nationwide health IT infrastructure. To that end, the HHS report authors recommend that the agency, and the health IT community overall, focus on a number of key steps to accelerate progress. Namely, health IT stakeholders should focus on improving interoperability and upgrading technical capabilities of health IT, so patients can securely access, aggregate and move their health information using their smartphones, or other devices, and healthcare providers can easily send, receive and analyze patient data.

The health IT community also should focus on increasing transparency in data sharing practices and strengthen technical capabilities of health IT, so payers can access population-level clinical data to promote economic transparency and operational efficiency, which helps to lower the cost of care and administrative costs, the report authors note.

Health IT developers and industry stakeholders also needs to prioritize improving health IT and reducing documentation burden, time inefficiencies and hassle for healthcare providers so clinicians and physicians can focus on their patients rather than their computers.

 

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