The Veterans Health Administration (VHA) within the U.S. Department of Veterans Affairs (VA) has been a leader in the use of health information technology for more than two decades. The VHA developed one of the world's first electronic health record systems, and it is estimated that as many as half of the U.S. hospitals with a fully operational EHR system are VA hospitals. In addition, the VHA has developed a personal health record (PHR) service for veterans and a picture archiving and communication system (PACS) that fully integrates with its EHR system.
While the VHA's budget, staff and patient population likely dwarf those of the average health care organization, the administration's use of international standards for data exchange and willingness to embrace emerging health care technologies such as telehealth and clinical data analytics can be an example for many providers.
- What is the structure of the VHA?
- What is the VistA EHR system?
- What is MyHealtheVet?
- How is the VHA using telehealth?
- How is the VHA using clinical data analytics?
- How are the VA and Department of Defense collaborating?
Led by the Under Secretary for Health, the Veterans Health Administration maintains a budget of $47 billion and a staff of 239,000 at more than 1,400 sites, which range from hospitals to nursing homes to counseling centers. Offices within the VHA, which is one of three administrations within the U.S. Department of Veterans Affairs, address public policy, patient safety, research and development, quality and performance, and health information, among other concerns.
Given its size and influence, the administration not surprisingly plays a key role in developing federal health IT strategy. A VA representative sits on the federal Health IT Policy Committee as well as its workgroups discussing meaningful use, the Nationwide Health Information Network, strategic policy, patient enrollment standards and health information exchange (HIE) governance. In addition, there's a VA representative on the Health IT Standards Committee, its vocabulary task force and its privacy and security standards workgroup.
The VHA's electronic health record system, known as Veterans Health Information Systems and Technology Architecture, or VistA, is among the oldest and most widely used EHR systems in the world. Born in the late 1970s as the Decentralized Hospital Computer Program and developed using the M, or MUMPS, programming language, VistA was first introduced in 1996.
VistA can be used in both ambulatory and inpatient settings and includes modules for computerized physician order entry (CPOE) and e-prescribing, among others. The EHR system supports Health Level 7 International (HL7) standards for health information exchange.
The VHA has also created a picture archiving and communications system known as VistA Imaging, which is integrated with VistA. VistaA Imaging supports the Digital Imaging and Communications in Medicine (DICOM) standard for image exchange and, like its EHR counterpart, is one of the most widely used medical image management systems in the world.
Under the Freedom of Information Act, both VistA and VistA Imaging are available as public domain software. As a result, non-VA health care facilities in several states use the VistA EHR system. In addition, the Department of Defense's EHR technology, Composite Health Care System, uses the same codebase as the VistA EHR.
My HealtheVet is the Veterans Health Administration's personal health record (PHR) service. Patients can view appointments, receive wellness reminders and, in the case of certain VA clinics, communicate with physicians. In addition, My HealtheVet offers a feature called the Blue Button, which lets users download and print their protected health information, as well as a Track Health option that teaches healthy eating, exercise and sleep habits.
The Veterans Health Administration currently offers three levels of telehealth services -- real-time telehealth, which consists of virtual consultations at VA clinics with specialists located elsewhere; home telehealth, which remotely monitors a patient's vital signs and other symptoms, and store-and-forward telehealth, which captures protected health information (PHI), X-rays and other data and forwards it to another site for evaluation.
More than one-third of the veterans of the wars in Iraq and Afghanistan live in rural areas. Many also suffer from complex psychological conditions such as post-traumatic stress disorder. To accommodate veterans in rural areas -- and, admittedly, to help control health care costs -- the VHA aims to expand its use of telehealth.
In addition, VA CIO Roger Baker has said the VA must be iPad-friendly. The health service has 100,000 residents rotating among facilities, and a mobile device such as the Apple Inc. iPad, which can access the Internet through WiFi or 3G connections, would make the job of those residents much easier, Baker said.
Since VistA provides a massive repository of information in a consistent file format, the VHA is able to conduct extensive patient data analysis. For example, a look at data from three VA clinics has helped physicians adjust hypertension treatment to account for seasonal fluctuations in blood pressure and for differing factors such as location, weight, age and gender. In addition, the recently launched Million Veteran Program aims to collect (and deidentify) PHI from volunteer veterans as a means of studying how genetics affect overall health.
The Virtual Lifetime Electronic Record (VLER) initiative, announced in 2009, is part of an effort to provide military personnel with continuous health care from active duty through veteran status. The VLER initiative is using Nationwide Health Information Network (NHIN) standards to ease the process of health information exchange between the VA and Department of Defense (DoD), as well as the Social Security Administration and private health providers such as Kaiser Permanente.
Along with the VLER initiative, several other VA/DoD health information sharing projects are underway.
- Under the Federal Health Information Exchange (FHIE) program, which began in 2002, each month the DoD transfers service members' PHI to a joint repository accessible by the VHA. This data includes demographics, lab results, pharmacy data and so on.
- The Bidirectional Health Information Exchange (BHIE) builds on the FHIE program and, as its name implies, allows for two-way sharing of PHI for patients eligible to receive care from both the DoD and the VA. BHIE data includes pre- and post-deployment health assessments, discharge summaries and progress notes.
- Developed in 2006, the Clinical Data Repository/Health Data Repository, or CHDR, is an interface between the DoD's Clinical Data Repository and the VA's Health Data Repository. It, too, supports bidirectional data exchange -- in this case, pharmacy data such as drug-drug and drug-allergy interactions.
- Finally, the Laboratory Data Sharing Interoperability (LDSI) initiative supports the exchange of chemistry and hematology lab orders and results among the VA, DoD and commercial laboratories. It supports the Logical Observation Identifier Name Codes (LOINC) and Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) data standards.
This collaboration is not without challenges. In October 2010, it was revealed that, in one instance, sensitive patient data from a physician's progress note, entered as free-form text in a field in the VistA EHR system, had been transmitted to the DoD's EHR system without consent. As one expert analysis suggested, this over-disclosure of EHR data presents two issues -- the use (and control) of free-form text fields within all EHR systems and the difficulty of identifying a clear consent model for the health information exchange process.
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