Testimony before the

National Committee on Vital and Health Statistics

Subcommittee on Privacy and Confidentiality

June 7, 2005

My name is David McDaniel and I am the Deputy Director of Business Development and the operational lead of the HIPAA Program Management Office in the Veterans Health Administration (VHA), one of three distinct organizations of the Department of Veterans Affairs (VA).  VA’s mission is to serve as principal advocate for America’s veterans and their families and to ensure that they receive the care, support, and recognition they earned by their service to this Nation. VHA is charged with administration of the health programs of VA through an annual budget of more than $27 billion dollars.  As such, VHA is the nation’s largest integrated health care system.  VHA serves a patient population of more than 5 million veterans, employs nearly 200,000 individuals and operates more than 1,300 sites of care, including 162 hospitals, 850 community and facility-based clinics, 135 nursing homes and domiciliaries, and 206 readjustment centers.  We also are a major contributor to medical and scientific research, and the nation’s largest provider of graduate medical education.

My office, the VHA HIPAA Program Management Office (PMO), was established at the direction of the Under Secretary for Health and is aligned within the Chief Business Office.  We are responsible for ensuring that VHA complies with HIPAA and for providing guidance during the compliance process.  The HIPAA PMO assists offices in identifying current and future activities and initiatives that may be affected by HIPAA regulations.

In addition to VHA’s status as the nation’s largest health care provider, VHA is also perhaps the most scrutinized health system in the United States.  We have established VHA as a model health care system characterized by patient-centered, high-quality, high-value health care.  Through adoption of evidence-based practices, proactive approaches to patient safety, and use of advanced technologies, VHA’s success in improving quality, safety, and value have allowed it to emerge as an increasingly recognized leader in health care, while increasing its customer satisfaction.

VHA did not undertake this transformation to polish our reputation, but to create the best possible system of health care for our veterans.  In doing so, we have blazed a trail in the field of electronic health care records and management.  We believe that the adoption of this technology offers the possibility of ever-better health care.  The need to improve on the delivery of health care is always before us.  Among the alarming statistics concerning the health care industry today are these:

  • 1 in 7 hospital admissions occurs because care providers do not have access to previous medical records.
  • 12% of physician orders are not executed as written
  • 20% of laboratory tests are requested because previous results are not accessible
  • 98,000 Americans die each year from medical errors

In VHA, we are proud of the advances we have taken in technology that help to address some of these issues.  VHA has had automated information systems in its medical facilities since 1985, beginning with the Decentralized Hospital Computer Program information system which included extensive clinical and administrative capabilities.  The Veterans Health Information Systems and Technology Architecture (VistA), which also supported ambulatory and inpatient care, delivered significant enhancements to the original system with the release of the Computerized Patient Record System (CPRS) for clinicians in 1997.  CPRS provides a single interface for health care providers to review and update a patient’s medical record and to place orders, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests.  CPRS is flexible enough to be implemented in a wide variety of settings for a broad spectrum of health care workers and provides a consistent, event-driven, Windows-style interface.

CPRS organizes and presents all relevant data on a patient in a way that directly supports clinical decision-making.  The comprehensive cover sheet displays timely, patient-centric information, including active problems, allergies, current medications, recent laboratory results, vital signs, hospitalization, and outpatient clinic history.  This information is displayed immediately when a patient is selected and provides an accurate overview of the patient’s current status before clinical interventions are ordered.  CPRS capabilities include:

  • A Real-Time Order Checking System that alerts clinicians during the ordering session that a possible problem could exist if the order is processed;
  • A Notification System that immediately alerts clinicians about clinically significant events;
  • A Patient Posting System, displayed on every CPRS screen that alerts clinicians to issues related specifically to the patient, including crisis notes, warnings, adverse reactions, and advance directives;
  • The Clinical Reminder System that allows caregivers to track and improve preventive health care for patients and ensure timely clinical interventions are initiated.
  • Remote Data View functionality that allows clinicians to view a patient’s medical history from other VHA facilities to ensure the clinician has access to all clinically relevant data available at VHA facilities.

VistA Imaging is also operational at most VHA Medical Centers.  VistA Imaging integrates traditional medical chart information with medical images, including x-rays, pathology slides, video views, scanned documents, cardiology exam results, dental images, and similar visual data into the patient record.

On the medication side, Bar Code Medication Administration addresses the serious issue of inpatient medication errors by electronically validating and documenting medications for inpatients.  It ensures that the patient receives the correct medication in the correct dose, at the correct time, and visually alerts staff when the proper parameters are not met.

HealtheVet Desktop is an application framework that will host the new generation of VHA clinical applications. Care Management is the first application to run on the new HealtheVet Desktop and is an enhancement of CPRS designed to assist health care providers in identifying clinical interventions that might otherwise be missed.  Care Management provides an automated method for tracking follow-up actions/tasks for a panel of patients for a designated period of time. Implementation of the Care Management project will improve patient care by:

  • Ensuring that appropriate clinical interventions are provided on a timely basis;
  • Ensuring that clinical notifications are processed on a timely basis;
  • Reducing the amount of time primary care providers spend reviewing individual patient records; and
  • Reducing the risk of erroneous data entry

These technologies have shown their worth in the increased quality of care in VHA, which compares favorably to the best performers in the industry in 18 performance quality indicators in areas such as breast cancer screening, cholesterol screening, diabetes care and pneumococcal immunization. At the same time, VHA has outscored the private sector in customer satisfaction in ambulatory care, inpatient care, and pharmacy services, as well as in the overall satisfaction scores. VHA is proud of our accomplishments and we are working to share our knowledge with others who hope to improve the availability and quality of health care to all citizens.

However, as the move toward implementing electronic health records across all health care in the United States picks up speed, we are becoming more aware of the impact that these initiatives have on privacy and confidentiality of health records—as well as the impact that privacy laws and regulations are having on the ability of health care providers to implement these strategies.

As someone who deals daily with the issues surrounding the privacy of health records, I can tell you that the promise of a national health information infrastructure remains a lofty and valued goal.  Reaching that goal will require a concentrated effort to overcome hurdles to sharing information, both as a result of the many varied privacy laws with which we must comply and in the daunting task of finding a means of coordinating and facilitating the progress toward that goal in an environment where everyone brings an agenda to the table.

The internal development and implementation of the electronic health record and its component parts was not difficult for VHA as long as we were working internally.  But looking externally—even to a partner as close to us as the Department of Defense—we began to encounter regulatory barriers to accomplishing the mission that the President had set out for us.  For example, the need to share medical records between VHA and DoD is obvious.  However, our efforts to streamline the sharing of data with DoD has met with difficulty because of the various laws designed to protect the data each department holds and in the interpretations of those laws.  Many of the laws we must consider are common to each of our departments—the Privacy Act and the HIPAA Privacy Rule, for example—but each department has interpreted those laws—and even the guidance provided about those laws—somewhat differently.  In addition each department has its own privacy and confidentiality laws and procedures that also must be reconciled.  This struggle to understand and apply privacy legislation in partnership with other organizations is not unique to VHA and DoD.  I anticipate that as broader populations begin discussing how to make information sharing a reality, the same struggle to gain a common understanding of how to protect the privacy of a patient’s information will be a paramount issue to overcome.

VHA is approached by private, non-federal entities with an invitation to participate in local or regional health information organizations. This benefits our veteran patients who may be receiving fee basis care or care by providers through private insurance by making healthcare information available to all concerned providers for a more holistic approach.  VHA must reconcile federal laws with local or state laws regarding privacy—particularly privacy of medical records in each state where we participate in these organizations.  VHA has facilities in all 50 states as well as Puerto Rico, Guam and the Philippines.

We do not advocate the wholesale repudiation of any of our privacy laws.  VHA is firmly committed to protecting the privacy of our veterans’ records.  But we realize that our ability to expand on the advancements seen in the VHA health care system requires walking a fine line between protecting privacy by limiting access to records and the disclosures necessary to enhance the accessibility and quality of care.  The technology that would allow us to partner with other providers to enhance care is available.  But we haven’t overcome the legal hurdles necessary to allow us to effectively share the data.  We look forward to a United States health care arena where this balance can be found, where a patient’s right to protection of his individually identifiable health information and the health care provider’s ability to know all the necessary information to provide high quality, well-informed care can co-exist.

On behalf of VHA, I thank you for the opportunity to share our experience and insights with this subcommittee.