In San Diego, the Department of Veterans Affairs will soon be joined by the Defense Department in an unprecedented test: the sharing of electronic health information outside the confines of the VA's highly regarded and tightly managed healthcare system and into the hurly-burly of the commercial healthcare marketplace.
The joint venture"linking VA's VistAelectronic medical record system with Kaiser's HealthConnect"represents the military community's biggest effort yet to merge health networks across the divide separating government from private sector hospital systems, officials involved in the test said.
And it may represent the most important military test of the federal government's Nationwide Health Information Network since its inception.
The term "˜pilot' is probably not the ideal word to use to describe what we have done," said Dr. John Mattison, chief medical information officer and regional director of Kaiser Permanente HealthConnect.
"We have put this system into full production, and it will be up and running from now on"this is really the first site and the initial two participants."
That said, the San Diego project involves the exchange of a limited number of data sets and does not yet include DoD or other private health networks. But the project participants plan on extending the scope of the exchanged data, adding other participants, including DoD, in short order, and expanding the program to other locations.
San Diego was chosen for the initial project because three out of four veterans in the region receive medical treatment both from VA facilities and from private providers. Of the 1,140 joint patients contacted by mail, 40 percent consented to participate in the program.
"It can take weeks for a clinic to get paper records from another provider," said Mattison. "Now it takes seconds. This results in increased efficiency and patient safety and an improvement in how we share information and deliver the best possible care."
The two systems are being connected over the NHIN, a system developed under the auspices of the U.S. Department of Health and Human Services (HHS).
"The NHIN is a secure network based on standards and protocols that allow the exchange of medical and administrative data," said Dr. Stephen Ondra, the VA's senior policy adviser for health affairs. "By linking ourselves to standards that are not tied to a single system, interoperability can happen with any system that uses those standards."
The exchange of data in either direction requires the explicit consent of the patient. Providers in either system who use the system access data in a Web-based environment from a list of patients who have consented to the data exchange.
The technical aspects to NHIN information exchange involve two pieces of software. The first is a gateway, which is essentially a secure on-ramp into the NHIN. The second is an adapter, a set of services that translate data from a home system into NHIN-compliant data. Both are opensource software, allowing multiple vendors to offer gateways and adapters.
"The software is rather easy to implement," said Andrew Wiesenthal, associate executive director of the Permanente Federation. "Another health information exchange that linked with us in a test environment was able to do it in six weeks."
"˜Fixable' processes
At this point, the two systems involved in the San Diego project are exchanging three types of medical data set: the problems list, medications taken, and allergies."These are the essential facts a physician would need to know if a patient presented in an emergency room.," said Dr. Robert Smith. chief of staff at the VA hospital in San Diego.
The participants claim that there have been little in the way of technical surprises during the course of the project. "The idea is that you build the adapter once and replicate it many times," said Mattison. "The technical work is largely done."
Among the early lessons learned, according to Tim Cromwell, director of standards and interoperability at the Veterans Health Administration, are, "acquiring and correlating patient data and learning what kinds of items to correlate patients on.
"Some of the processes we used in San Diego are not deployable to the whole country," he added, "so we want to fix and automate those."
The chief fixable processes include acquiring patients opt-ins and protecting patient privacy. "There are some good models on how to automate the opt-in process," said Mattison, "and we will be leveraging those models on NHIN infrastructure" during later phases of the project.
"What is more complicated is to vouchsafe patient privacy and to properly manage the opt-in process," said Wiesenthal. "Bringing in data safely and making sure the information is broadcast when patients want it and not broadcast when they don't want it is something each institution that wants to join is going to have to figure out.
"We who are early adopters of the NHIN have developed certain rules of the road that we think are going to be durable, but that is one of the things we have to learn more about."
"˜Biopsy, not autopsy'
The VA is hiring an outside firm to measure the outcomes of the San Diego pilot. Metrics to be checked, according to Ondra, will include the number of opportunities for the exchange of data and how many were used by providers; how many potential errors were avoided had providers been unaware of a patients' medical condition or medications; how many needless treatments were avoided because they had already been performed; and other measurements relating to the quality, safety, and efficiency of patient care.
"We're going to be learning a lot from this project," added Ondra. "We're going to be doing a biopsy and not an autopsy of this pilot. It's not going to end but it's going to represent a glide path for further development and modernization."
Future plans in San Diego include an incremental expansion of the types of data to be accessed. "We hope in the next six months to add immunizations, non-sensitive chemistry and hematology lab results, and vital signs," said Mattison. "We will continue expanding functionality until we fully use the HL7 clinical document architecture, which allows sharing of all data types." DoD is expected to join the project shortly with the addition of the Balboa Naval Hospital in San Diego, Calif. Both Ondra and Mattison said that several other health networks of varying sizes have expressed interest in joining the San Diego project and that they, too, are expected to be exchanging data before too long.
As for further geographical expansion, Kaiser is working with VA and DoD on a road map. "We expect to have very substantial geographic rollout occurring throughout the year," said Mattison.
"As we roll this capability out nationally and as other parties join," Mattison said, "we will see exponential growth in the numbers of participants who will want to take advantages of these services.
"Part of the mission of this project has been to do the groundbreaking work which will allow others to join quickly, easily and at lower cost."
