▶ 0:10:00Good afternoon, the subcommittee will come to order. I want to start by saying um I appreciate the uh effort of those uh on the panel that are here to testify today and appreciate your willingness to come before the committee. Future though, I would really appreciate, particularly for those here from the VA, if you can provide your testimony ahead of time.
▶ 0:10:17I know that um a lot of work goes into that, but you know, the subcommittee staff here, myself and my staff, appreciate the opportunity to review some of the commentary and remarks and everything ahead of uh ahead of these committees and would appreciate your willingness to provide that in the timelines that we have. I feel like we've been pretty um generous with the timelines we've given, and it takes everybody's cooperation to make sure that we're able to do this in a timely and efficient way. So, appreciate that.
▶ 0:10:43Um I asked the VA to appear today um because of interoperability impacts and what it does to every veteran across our And the department's testimony is critical for this subcommittee's oversight um Uh now uh on to today's topic.
▶ 0:11:03Of course, uh I kind of mentioned briefly about interoperability, but this is important because all across the country, right now as we're sitting here in this committee, a veteran somewhere is walking into a new doctor's office for the very first This veteran won't have any prior relationship with the provider they're and they may not have any of their medical records on file at that particular hospital or medical facility. This doctor's office could be at a VA medical center, could be at a community care facility.
▶ 0:11:32No matter the location, the doctor will have the same question. How do I give this veteran the best care without knowing their medical history? Without knowing their medication, without knowing their allergies, their lab results, whether or not this veteran has struggled with mental health There are several doctors on our panel today, and I'm sure they would agree that complete and accurate information is an important ingredient in high-quality health care.
▶ 0:11:59Providers want their patients' health care data to be interoperable. They want to be able to exchange medical records regardless of which hospital they were created at and use that information to treat their patients. I want to be clear. VA and the entire health care industry have made enormous progress over the last two decades, and millions of health care records are exchanged every single year all across our country in various ways.
▶ 0:12:24Even when data exchange does not happen, veterans still receive great health care every day when providers don't have access to their complete medical history. I know that we have very well-trained physicians who provide the absolute greatest level of care that they can. However, the best health care requires truly interoperable health care data that moves with the veteran regardless of which EHR is being used by the doctor and who is treating them. There are gaps that remain and opportunities for improvement.
▶ 0:12:51VA provides health care to millions of veterans every single year, including However, roughly 1/3 of VA care is provided by the community care network. Throughout their lifetime, veterans will visit an assortment of providers at the DoD, the VA, and private facilities.
▶ 0:13:09Every appointment produces new VA has made a ton of progress exchanging data with larger hospital systems, but struggles to exchange data with many smaller hospitals and physicians' In order to live up to our commitment to veterans, VA must be able to share and use complete and accurate health care information with each of the community care partners.
▶ 0:13:32A big part of that is ensuring that when health care data is exchanged between VA and community care providers, it is There's only so much a a provider can do with a list of lab results if each hospital in and displays the results differently. This is the difference between a read-only file and data that is searchable, sortable, and able to be organized and utilized.
▶ 0:13:58The quality of the data is just as important as the That is why this committee put a requirement in the Dole Act for the VA to adopt health information interoperability standards for the department and its community care These standards are about data quality and will improve how VA and community care providers exchange data for care and benefits, patient identity matching, and more. Ultimately, improving outcomes for veterans inside and outside the VA.
▶ 0:14:26During this hearing, I hope to hear some preliminary updates on VA's strategy. In addition, I hope to hear about some of VA's recent progress and their plans to bridge the interoperability gaps that still exist. VA recently created the Veterans Interoperability Pledge, which allows private hospitals to instantly confirm whether a patient is a veteran.
▶ 0:14:48There are many health issues that are assumed to be linked to military Simply knowing that a patient is a veteran allows health care providers outside VA's system to give the best care, consider service service-related health issues, and quickly connect them to the right supports where necessary. This is an important leap forward for data exchange between VA and community While it's only in its infancy, I am eager to hear more about its early success and VA's plans to expand to more community care providers.
▶ 0:15:19VA is currently connected over 90% of hospitals in America through health information exchanges. 10 years ago though, VA exchanged less than 100,000 healthcare documents a Now, they're changing millions. While VA is connected to roughly 90% of US hospitals, the last 10% are the hardest to reach. And far less than 90% of physicians' offices are currently exchanging data with the VA.
▶ 0:15:46I'll close by saying that many of the technical challenges around healthcare interoperability are no longer obstacles. What remains is for VA to organize and collaborate with its community care partners to make sure that the provider I mentioned earlier who is seeking who is seeing a veteran for the first time today has all the information they need to provide the best care possible. Thank you again for being here. I look forward to your testimony. With that, I'll yield to the ranking member Buszinski for her opening statement as well. Thank you. Thank Thank you very much, Mr.
▶ 0:16:15Chairman, and thank you as well to the witnesses for being here to discuss this critical topic today. Interoperability is a crucial factor in ensuring safe, effective, and veteran-centric healthcare. It supports the care coordination that is a hallmark of VA healthcare. Unfortunately, VA's interoperability efforts have been hindered for decades by the decentralized nature of its electronic health record.
▶ 0:16:41In fact, one of three major goals of the electronic health record modernization or or EHRM program is to implement an EHR that is interoperable with DoD and community care providers, creating a complete medical record for the life of the A complete medical record allows for better outcomes for veterans as their providers, wherever their wherever they receive care, have all the information they need to make the best, most clinically informed
▶ 0:17:11decisions. I wholeheartedly support this effort. However, getting from where we are today to complete an interoperability is no small undertaking. It requires a combination of efforts from three corners: technology, people, and VA utilizes a multitude of platforms, systems, and frameworks to approach interoperability from a technology standpoint.
▶ 0:17:36From the referral of services with the health share referral manager or eSRM to the standardization of the data EP to the information sharing itself with veteran health information exchange and VA's growing work with TEFCA. VA appears to be throwing everything they have at interoperability.
▶ 0:18:00VA's websites tout a seamless and secure interface for VA and community providers with this infrastructure, but from what I've heard, that doesn't seem to be the case. Despite these systems getting us closer to our interoperability goals, they do not encompass the full picture. VA's legacy EHR does not allow for complete integration of medical records even when they are shared through the health information exchange.
▶ 0:18:27This requires clerks to locate records, download them, and then upload them to the vis to Vista A. Oracle Cerner's EHR has a direct link to the exchange allowing records to be pulled in and integrated in two to three clicks. Though again, these records can only be pulled through if providers are using the veteran health information exchange and if they know and remember to do it.
▶ 0:18:53Without standard use of the exchange, providers continue to rely on sending information via fax or e I'm sorry, or which inevitably results in processing delays and backlogs and risk incomplete records that could have disastrous clinical impacts including putting patient safety at risk. I look forward to hearing from Dr. Greenstone, a former executive director of clinical operations at VA, and Mr.
▶ 0:19:22McGraw from the Michigan Health Information Network on systems that integrate referrals and document management into one workflow. Technology is great, but it is nothing without the people. It takes a highly skilled and impressively dedicated workforce to deliver the world-class health care and benefits the VA is known for. That's why the recent news of the Trump administration's personnel actions is extremely concerning.
▶ 0:19:48Their decisions to terminate over 2,400 probationary employees and its plans to further reduce the VA workforce by at least 15% or 80,000 positions is abhorrent. These actions have already resulted in negative patient outcomes for veterans and will continue to do so. While it's great the VA purports to be exempting doctors and nurses from these cuts, that ignores the fact that there are dozens of other jobs, clinical and non-clinical, that make delivery of health care possible.
▶ 0:20:19For example, scanning and file clerks in the health information management or HIM service were impacted in the secretary's probationary employee purge. Without sufficient HIM scanning and filing clerks, medical records will continue to pile up, not being entered into the veterans files, and further risking quality of care. If we expect world-class care for veterans at VA, we must ensure the VA is resourced and adequately to do so.
▶ 0:20:48Finally, VA's ongoing struggles with its processes have over complica- over complicated what was already a complicated process. Like most of VA's modernization efforts, the move toward interoperability seems to be burdened by training and change management challenges.
▶ 0:21:06Additionally, the variation of VA's clinical workflows makes the data standardization needed for interoperability difficult in the agreements with community care providers and third-party administrators leaves VA with little recourse for accountability. The lack of connectivity depends on the user. Some community care providers are unaware of the health information exchanges and their practices don't possess mature enough systems to utilize it.
▶ 0:21:34Others are not trained adequately to use the tools defaulting to their comfortable workflows like faxes, fax machines, and phone calls. By reverting to these antiquated workflows, providers and veterans may face weeks or even months-long delays in accessing their records due to processing backlogs. Backlogs that will likely only become lengthier with the Trump administration's cuts to the VA workforce and IT contract support.
▶ 0:22:02I look forward to today's discussion, but also think we need to have a bigger conversation with Oracle and the third-party administrators for the community care network in future meetings on their efforts to increase awareness, training, and use of interoperability tools, and how they're going to hold both VA and community care providers accountable.
▶ 0:22:23Ultimately, we must be realistic about what we are expecting VA to do and with that and with what resources, especially when we operate in an environment as we are today with an administration that wants VA to do more with less. I believe this conversation today will be enlightening and I look forward to further work on this topic. Thank you, Mr. Chairman, and I yield back. Thank you. I appreciate that. I'll now introduce our witnesses from the Department of Veteran Affairs. We have Dr.
▶ 0:22:53Jonathan Nebeker, Chief Medical Information Informatics Officer and Executive Director of Clinical Informatics. Did I say that correctly? Very good. Thank you, Doctor. Dr. Lori Protula, right? Deputy Chief Information Officer for the Electronic Health Record Modernization Integration Office. Um also joining us from the great state of Michigan, of course, is Mr.
▶ 0:23:19Rick McGraw, Chief Growth Officer for the University of Michigan Health Information Network Shared Services. And um Dr. Andrew Rosenberg, um Chief uh Information Officer at Michigan Thank you. And finally, we have Dr. Leo Greenstone, Chief Medical Officer at Signature Performance. Um very good. Thank you all again, uh each one of you for being here today.
▶ 0:23:47Um and uh I ask witnesses please stand and raise your right hand. Do you solemnly swear under penalty of perjury that the testimony you are about to provide is the truth, the whole truth, and nothing but the truth? Thank you, and let the record reflect that all witnesses have answered in the And I going in order, Dr. Nebeker, you are now recognized for 5 minutes to deliver your opening statement on behalf of VA.
▶ 0:24:14Good afternoon, Chairman Barrasso, Ranking Member Boozman, and distinguished members of and distinguished members of the subcommittee. Joining me here today is Dr. Laura Protula, Deputy Chief Information Officer of the Electronic Health Record Modernization Integration Office. Thank you for the opportunity to discuss the interoperability between the Department of Veterans Affairs and communities beyond VA. Our efforts to expand veterans access to scare to care both inside and outside VA mean more veterans are using their benefits to seek care.
▶ 0:24:45Recently enacted laws like the Compact and Mission Acts empower veterans to seek care from the community providers when it's in the best interest or for veteran best interest for the the or when VA care is unavailable. As a result, the need for care coordination and exchange of health information among VA and community providers has surged.
▶ 0:25:06The exchange and use of health care data are essential for ensuring the veterans have better access, better health, and reduced out-of-pocket In 2009, VA and DoD began allowing clinicians to view shared data to reduce reliance on paper records. Launched in 2014, the Joint Longitudinal Viewer or JLV provided a more reliable and user-friendly solution.
▶ 0:25:32In January 2025 now, over 110,000 VA employees accessed and opened 2.2 million community care documents in JLV. User surveys show JLV improved patient outcomes, saved time, and reduced duplicative testing. The Joint Health Information Exchange, commonly referred to as JE, established by VA and DoD in 2020, has significantly improved federal EHR interoperability.
▶ 0:26:02It connects connects well over 100,000 provider sites through two national exchanges, eHealth Exchange and In January 2025 alone, JE exchanged over 360 million documents for 18 million patient matches. The Trusted Exchange Framework and Common Agreement, also known as TEFCA, is a nation nationwide framework for health information sharing.
▶ 0:26:26VA aims to participate in TEFCA, contract with a qualified health information network provider, and be fully functional and tested for purposes of treatment by early December 2025. Key considerations include accurate patient matching and cost. The deployment of the federal electronic health record will also advance its interoperability agenda.
▶ 0:26:48Despite the significant process progress, VA continues to address connectivity gaps, especially with small provider organizations not using a top five EHR system. While about 80% of veterans actively enrolled in VA care list visit at least one, sorry, when while 80% of veterans actively enrolled in VA care visit at least one provider connected to national exchange, only 30% of providers billing VA for community care are connected to eHealth Exchange or CommonWell.
▶ 0:27:19Connectivity to state or metropolitan exchanges via regional health information organizations or REOs may help close this gap. Moreover, REOs enhance care coordination by offering unique services like longitudinal viewers and push notifications that national exchanges currently do not. VA is collaborating with industry partners to improve data quality gaps, which impact clinical decision support, quality measurement, population health, and benefits adjudication.
▶ 0:27:47Examples of challenges include incorrect weights, missing serum sodium values, incomprehensible codes, and misclassified allergies. Stakeholders are developing open-source technologies to objectively code data quality and provide improvement The Veteran Interoperability Pledge demonstrates a cost-effective approach to interoperability, yielding significant vet benefits for veterans.
▶ 0:28:09Launched in 2023 with 13 high-quality healthcare systems, VIP addresses goals beyond TEFCA, including identifying veterans, connecting them with VA and community resources, and ensuring reliable care Our partners have already identified over 200,000 veterans that may benefit from the COMPACT and PACT Acts.
▶ 0:28:32VA plans to expand VIP membership to more healthcare systems, payers, and technology companies, prioritizing automation of benefits determination and care coordination. These efforts will ensure that VA can connect veterans to federal, state, and donated benefits. VA remains committed to putting veterans at the center of its operations, focusing on customer service and convenience, which interoperability makes easier.
▶ 0:28:56We appreciate the subcommittee's commitment and oversight to ensure VA serves veterans with excellence, and we look forward to responding to any questions you may have. Thank you, Doc. Appreciate it. The written statement of Dr. Nebeker will be entered into the hearing record. And um I think we're moving next to Mr. McGraw. Is that correct? Um Dr.
▶ 0:29:25Pertulla, do you have separate Okay, very good. And then, Doc, I'll get back to you in just a moment. Um but uh I think we're going next to Mr. McGraw for your remarks. Um for 5 minutes. Thank you. Thank you. Thank you for the opportunity to testify today about the vital role that health information exchanges play in the operability of our overall health care Today, I will concentrate my testimony on the over 10 million residents of Michigan with over 461,000 veterans of our military services.
▶ 0:29:54Michigan Health Information Network is our statewide HIE. MiHIN was formed in 2010 as a public-private partnership with the Health Information Technology Commission housed in the Department of Health and Human Services. MiHIN was designed to play a pivotal role in advancing health care interoperability by facilitating seamless information sharing across Michigan's health care ecosystem.
▶ 0:30:16Since MiHIN's inception in 2010, we have interfaced with nearly 80 individual electronic health record systems and two national networks that only represent a limited number of use cases. A use case is a unique instance of sharing specific information regarding patients and their MiHIN, however, operates over 50 use cases for our clients, ranging from hospitals, primary care facilities, payers, community mental health facilities, skilled nursing facilities, and local city and county health departments to name a few.
▶ 0:30:44From the 5,300 plus healthcare facilities connected to myhin, we have routed over 8.3 billion messages to enhance care coordination and vital data delivery across the state. For example, 97% of all state admission, discharge, and transfer summaries pass through Myhin's direct interfaces with local healthcare facilities EHRs provides instantaneous record submissions immediately following an encounter with a patient.
▶ 0:31:09In less than 4 minutes, that information is received, verified, and routed to our portal where the patient's longitudinal record is updated with their latest information. Our most recent use case is collaborating with a mobile technology company to route real-time data from ambulances en route to emergency rooms. Emergency medical technicians en route will have access to a patient's electronic medical records while also transmitting current vitals to the receiving emergency department.
▶ 0:31:34Alerts sent to the ED will notify them that the patient en route so they have access to the patient's longitudinal record from The best quality healthcare is not only local, but it is in near real time. For security and privacy considerations, myhin is a business associate to the largest health and government systems in Michigan, provides security and privacy of healthcare data while ensuring it is interoperable and accessible. Myhin and our major technology vendors are certified under HITRUST r2 certification.
▶ 0:32:01This industry-leading certification requires external penetration testing, security and an operations, and security during the development of custom applications, ultimately ensuring best practices across all our systems and services. Myhin designed our active care relationship service model, which allows real-time association of patients with their providers using the information found in the data ingested by myhin. This service restricts patient data access to only those providers that actively care for that patient.
▶ 0:32:30With all of this in mind, let's consider a veteran's healthcare journey. If a veteran goes to their primary care doctor that uses one EHR, but also goes to a community mental health facility that uses a different EHR, and also sees a specialist on a third EHR, without an HIE like MyHIN, these providers wouldn't be able to access critical patient information from those those other encounters. Because of MyHIN's broad network of connectivity, MyHIN has all interactions from all three facilities available in that patient's longitudinal record to improve overall care coordination.
▶ 0:33:01Today, however, in Michigan, the VA and DoD are a blind spot to a veteran's overall health care. The VA does not only not submit data through the network, but cannot access its patient's records from encounters outside of the VA. From a provider perspective, HIEs bring critical value. A 2024 survey of primary care physicians found that 81% spend less time with their patients than they 57% write prescriptions or refer patients out due to time constraints.
▶ 0:33:2846% report a lack of adequate time with patients as a top stressor, and almost 2/3 feel their work is more transactional rather than relational. Accessing patient information within an HIE's longitudinal record has shown that a provider can save up to 15 minutes per patient per visit, while the cost of this access is nominal. Today, the VA does not comprehensively see interactions outside of its facilities, and like the patient journey example I gave you, community care facilities cannot see veterans interactions with the VA hospital, either.
▶ 0:33:58There is no such thing as a lifetime record of a veteran's health care residing in one EHR system. It simply does not exist. There's also no such no such thing as a national exchange with a handful of EHRs that can replace the infrastructure we have spent the last 14 years perfecting. We can and we must do better to provide higher quality care to our veterans in Michigan. There is always potential for improvement, and I believe we can achieve it with the right strategy, support, and collaboration. Thank you for the time and attention to this important issue. Your support and understanding is greatly appreciated.
▶ 0:34:28Thank you, Mr. McGraw. Written statement of Mr. McGraw will be entered into the hearing record. Dr. Rosenberg, you are now recognized for 5 minutes to deliver your opening statement on behalf of Michigan Well, good afternoon, and uh I want to use my time to emphasize three areas in my statement. I want to take the uh perspective of a in particular, but also with an organization that's providing the care in the communities that we've discussed.
▶ 0:34:56Um exchanging the information that we're talking about is not controversial. This is common sense. It is a common expectation that we as providers have, uh our nurses, our doctors, our administrators is the common expectation of patients and their families. So, this is a good discussion for us to be having. Uh and I would also uh say it's really an ethical responsibility. So, the providers feel very, very strongly to do this and to do it well, as you've already mentioned.
▶ 0:35:25The reality is when I think about some of us, Dr. Nebeker, Dr. Greenstone, and I, when we were training, we did health information exchange a few times a day at best. And usually it was a packet of papers in an envelope, and occasionally, later on, a CD that we would hand walk down and try to get the images loaded. And the reality is these are at very, very good places, really only 10 years ago. And now, as you've already mentioned, we're doing a lot of health information exchange.
▶ 0:35:53At Michigan Medicine alone, across our large health system, and our somewhat unique role in the state, within our electronic medical record, we're exchanging over 220,000 records a day.
▶ 0:36:07With our excellent state HIE, we're exchanging tens of thousands of records and results, particularly admission, discharge, and transfer notices that are critical in that infrastructure to make this work for a community doctor or others to know when a veteran has been seen or not.
▶ 0:36:26Uh, within our, VA itself, although somewhat new, we're exchanging almost 3,000 records a day and especially as we, Michigan Medicine, sign on to the QHIN via our EHR, and with, uh, the VA already involved in e-health exchange, those numbers are going to go up more and more and more. So, from where we were to where we are now is a very good news story. we want to do better.
▶ 0:36:55So, why is that I was recently in the UK. I was lecturing at some very good health systems and they were challenged exchanging information even within their own health system. Whereas for us, because of the networks we have, CommonWell, Care Equality, and especially now TEFCA, uh, the frameworks and the networks themselves, e-health exchange, and I would argue that the direct EHR to EHR and EHR into these nodes is the way that
▶ 0:37:25we're expanding the use of this. We have good to very good government regulations. We have agreed upon open standards, HL7 CCDA, the FHIR standard. We have a very good set of agreed upon data elements and categories with USCDI. We have a number of tools that are currently working to give us those numbers that I've just mentioned and even more that are in my statement that we can focus on.
▶ 0:37:53So, then the third element, uh, this is then what are our Well, within health information exchange, one of the challenges that all providers right now are having as we get more digital are the digital systems themselves. We have an enormous amount of data that we can look up, whereas before we couldn't. We have an enormous, uh, need to document these not just for patient care, but for quality care and deficiency and improvements in health information exchange is no different from that.
▶ 0:38:22We want to do it, and yet at the same time we're also overwhelmed with all of the other work that our doctors, nurses, and others have to do. And also, we know that with all these options, we have to choose. Which do we use? How do we sign up? How long does it take to sign up for one versus another? So, these are things that we can continue to improve upon because as I said, in the end we're so much better but the reality is we know that we can still do better. So, Well, I'll yield the rest of my time, but hopefully that's helpful.
▶ 0:38:54Thank you, Doc. Appreciate your We will enter that your written statement will be entered into the hearing record. And Dr. Greenstone, you're now recognized for 5 minutes to deliver your opening statement on behalf of Signature Performance, and thank you as well for being here today. Thank you, Chairman Barrett. Ranking Member Wexton, it's a pleasure to to be here to talk to you about interoperability between the VA and the community.
▶ 0:39:20I come to you as a former VA physician for over 18 years, primary care doctor, as well as an executive at the local Ann Arbor VA for 11 years, and a senior executive in the Office of Community Care for 6 and 1/2 years, and now working in the private sector for Signature Performance, where we're focused on decreasing administrative cost burden within So, there is no question that we absolutely agree that interoperability is so important and so necessary,
▶ 0:39:51and it's also we have to recognize it's been really really hard. People have been working at this for a couple of decades now, and you can hear the incredible progress that has in fact been made over the years. One of the things that I think is critically important to to recognize is I'm going to give you a perspective from the Veteran Community Care Program, and I care deeply about, is that we absolutely have to, as the ranking member mentioned, uh focus not just on technology,
▶ 0:40:21but on people and processes because the technology will not be fully adopted un- unless we have pretty much ubiquitous and and reliable tools. And that's why within healthcare today we still have a lot of use of those tools, telephones and fax machines. And a lot of that is used today within VA to actually get records back and forth. And we want to get rid of that. I'd love to to sunset fax machines, but boy are they still, you know, pretty pretty active today.
▶ 0:40:51And, you know, one of the things that I think is critical as well is that VA really needs to stay, and they've been really good at doing this, but staying in lockstep with HHS, in lockstep with industry, understanding what's happening with the EHR vendors, what's happening with in the community, and staying very close with their colleagues at the integrated veteran care office within VA so that we can ensure that VA staff as well as community care network providers
▶ 0:41:22are working very closely together to try and ensure that there are workflows that utilize a lot of the technologies that we've been hearing about, and workflows that really support the work that individual folks are doing.
▶ 0:41:35So, we have to have thoughtful change management for the implementation of these great technologies that we've been talking Within the veteran community care program, we not only have to make sure that providers in the community are receiving appropriate clinical information about the veterans they have have been referred to them, but those providers also need an authorization. So, the way things stand now within the veteran community care program, it requires an authorization.
▶ 0:42:01And so, that means that the provider in the community needs to know what the VA is authorizing, what the VA will be paying for, what VA how long is that referral for, and for some services, how many visits are available? That referral and authorization is not available in the exchange today, but perhaps it could be and that may be a And so when we look at the solutions going forward, there are a couple of things that I think are being valuable to think about in the short term and perhaps even a little longer.
▶ 0:42:32So one is let the VA take advantage of the DOLL Act where there is incentive to actually have TPAs in the community care network and their providers work together because all of the TPAs, Optum, Serve, TriWest, they have VIZN based provider groups that go out and can in fact work with providers in the in the CCN network and those providers who get a fair number of referrals,
▶ 0:43:02but they can ensure that those providers are connected to an exchange, that's connected to a QHN, that that information will be available for VA providers to be able to see and best care for for veterans. And that that information can be made available to VA providers and other staff within the PPMS. This is the provider profile management system. It is the directory for the Veteran Community Care Program of all those providers.
▶ 0:43:28And so then VA has opportunity to send referrals to those providers who actually are connected to exchange. And that means I may want to do that because I know I can actually get access to the data that I need to care for veterans. The other thing to consider is and you know, they they have this closed-loop referral data transfer process that is something that's worth further investigating.
▶ 0:43:53So what I mean is this, is that when a VA provider writes an order and that veteran opts to go to the community, the authorization and associated medical documentation is passed through the infrastructure of the exchange into the EHR of the receiving provider. And then when that veteran is seen, that provider's information that they generate is passed on into VA's EHR.
▶ 0:44:18And therefore you have this closed loop referral and medical documentation system that is in play today in some places, and it's something that the VA may want to consider. So thank you for your time and look forward to further questions. Thank you, Dr. The written statement Dr. Greenstone will be entered into the hearing record. Uh with the opening statements complete, we'll now proceed to questioning and I will now recognize myself for 5 minutes.
▶ 0:44:44Um and again, thank you all for for being here and for the time and attention you put toward this. Um a few questions I had just jotted down based on um some of your opening Um Dr. Rosenberg, maybe you can answer this and Dr. Greenstone, too.
▶ 0:45:03Do you know of examples where we have duplicated procedures, whether it's testing or other um uh you know, procedures, diagnoses, tools that you have, things like that, where we've duplicated that because of a lack of transferability of medical records or the cumbersome nature of it or the lack of interoperability that would apply. And I'll I'll let both of you answer that question separately.
▶ 0:45:30Sure, I can certainly start with that, Chairman Barrett. I'll give you an example. I was in clinic at the VA last summer. I saw a veteran who said, "Hey doc, um I passed out about 2 weeks ago and went to an outside hospital." I'm like, "Oh my goodness." Um and and and so I looked to see if that was a that was care that was actually authorized by VA, and it was. I went into our systems to look to see whether a fax had come in, and it hadn't. I then went to the joint longitudinal viewer to ping the exchange.
▶ 0:45:59And look, I saw um a record from the ER from where he was. When I opened it, I was excited cuz I thought I was going to see everything I needed and all I saw was a problem list, meds, and allergies. And at the top of the problem list, it said syncope, which means he passed out. That's what he already told me. So then I had asked my clerk to try and call over to get the information faxed.
▶ 0:46:21And so then I have this veteran in front of me who I have to start from square one to order tests to figure out what the heck was going on with him, do his exam, his history, and I probably was ordering things that may have already been done. Right? But I had to do all that I had what I had available, as you mentioned before. Hey, good docs, we do what we have to do, but I I will bet you that I ended up doing things that may have already been done, but I didn't have access to do that. But I had to come up with a treatment plan. Thank you.
▶ 0:46:49Do you think a um And that to me is not based upon the ability to send data back and forth. It's based on the the perhaps data protocols of how we organize these things so that you're able to access it and read what it says and and and interface with it in a usable way. Is that Am I understanding that correctly? Even when providers within my great state of Michigan are connected, not all the information is readily available, right? So we talked about quality of data and we talked about all the data like notes.
▶ 0:47:18Very often office notes aren't there. Procedure notes may not be available. And so question is, why aren't all those things available when folks have connections and therefore some information is available. We need better information to be able to make clinical decisions. Sure. Okay. Dr. Osmar. Quantifying your excellent question is a bit difficult, but I'll give you my impression. It's probably somewhere in the thirds. And it depends on the situation.
▶ 0:47:43So a patient arriving in an emergency department where you know nothing about them, we're going to be repeating or we're going to be drawing and sending labs and imaging no matter what we find. Uh sometimes would be helpful to know what pre-existing conditions or data, labs, imaging existed before.
▶ 0:48:07But, it's usually not that we're going to either rely on those data, rely on what might be old data for the Another third would be where we have some data, but we need more complete data or different. It'll depend on if we're primary care or we're quaternary care itself.
▶ 0:48:27I think the area that you're focusing on that's especially important is when the data are more expensive and difficult to get, a biopsy, for example. Uh, uh, an expensive or difficult radiologic study that we would normally not get or that we would want to compare to. Those are still elements where depending on the system, the proximity, the closeness, we will either have those data or we won't.
▶ 0:48:56And so, I think where efficiency would be gained is that, as I've mentioned before, the common elements of medications, of basic labs, of conditions and documentation where you can frequently find the results of data, even if it's not a discrete variable, will help some of that gap. And I would argue that for those things that really are difficult to get and expensive, those would be interesting and good targets.
▶ 0:49:26For example, Myhin fits into that in the ability to act as a broker of where a biopsy result is from another element that we can commonly get to, where we sometimes close those gaps. But, to quantify that, I think it'd be difficult. Sure, thank you. I I do appreciate that. I know, um, my first round of questions have just run out of time. But, I want to recognize the ranking member for for your questions. Sure, thank you, Chairman.
▶ 0:49:52And actually, to kind of build on your um, initial question, wanted to ask Dr. Nebeker from the VA because in your testimony, you talked about how the federal system is 90% interoperable with hospitals today. I think the question after we've heard from, you know, both Dr. Greenstone and Dr.
▶ 0:50:13Rosenberg and those experiences, you know, how how are you measuring And how are you certifying that? I just I find it hard to believe that where that 90% is coming from based on at least Dr. Greenstone's story. Yes, so thanks for the question.
▶ 0:50:35The that number comes from eHealth Exchange that has looked at who are connected to and knows a number of hospitals that are in each connect in each healthcare organization that we're connecting to. So, that's where that 90% comes from. And do you know how they gauge that? So, I could speculate, but I'm I'm not sure. I mean, there each organization has a website that has, you know, usually states the number of hospitals that they have.
▶ 0:51:03The American Hospital Association also has similar information on it. So, I imagine it's, again, speculation, but I imagine that's how they arrived at that number. Okay. And can I ask you continuing just about community care providers? What what is the requirement for community care providers to return records to the um so, you So, I'm I might want to ask you to clarify the question.
▶ 0:51:32For So, for my practice, for example, most of the documents that I'm looking for are actually not paid for by VA. Just happens to be the way my patients are in the Salt Lake City area is. And and so, there are no requirements, you know, obviously for those people when they go out and use their own health insurance to get a specialty appointment or they're seeing even sometimes a primary care physician. I practice primary care geriatrics.
▶ 0:52:00Then there's the community care documents that there is a requirement to return documentation on and that's as far as I can go cuz I'm not you know, overseeing the IVC community care network contract. Mhm. So So it's possible basically you're seeing a veteran and that their complete record might not be completely captured is what you're saying cuz it's not all required to be passed back to the VA.
▶ 0:52:28Yes, and so as Dr. Greenstone was stating the So I mean I saw a guy who had really healthy 88-year-old guy last Friday. And I said how's everything going? No problems at all, doc. I'm doing great. And so then I open up the you know, click on the button up comes these records and I see, oh, well, you were in the hospital 2 months ago a urinary tract infection.
▶ 0:52:54And so that actually prevented me from ordering a whole raft of lab tests and everything that I was thinking about ordering at the time. But more often than not the kind of the That was an emergency room visit. So those are usually in there, not always. It's kind of a mystery to us of so why, you know, we deal with primarily with HCA with Intermountain Healthcare, you know, that currently has Oracle and University of Utah that has Epic.
▶ 0:53:19And from all of those institutions I'm often missing inexplicably data that I would expect from a hospitalization not so much from hospitalizations, but from emergency room visits and also doctor's office visits are rarely there. And so the you know, what Dr. Greenstone was talking about of getting and and also Mr. McCormick about using getting the office visits.
▶ 0:53:42That's kind of really valuable data and and so and because of the the way that people craft their continuity of care documents, it's often not driven by office visits, but more by emergency room visits and And so there is a bit of a gap in recent hospital visits.
▶ 0:54:01Sometimes if there's an emergency room visit or hospitalization the uh pri- the a a consult, you know, especially care visit, then we'll see the those information, but not for recent uh specialty care visits.
▶ 0:54:15Again, not paid for by the the VA network uh and we can take for the record and get back to you what the um what the requirement is on the VA That would be I would be very interested in that and like what the the timeliness is of community care providers as well to provide that information back to the Um you know, and then what recourse the VA has if you're running into community care providers that just aren't providing that type of timely information
▶ 0:54:46because to me interoperability would be if it's successful, it's capturing the full picture for the veteran patient. Um not just some and we're eliminating those gaps. So um I'll I'll yield back to the Sure, thank you very much. Just following up on that, Dr.
▶ 0:55:03Nebeker, is missing data that you're talking about is the reason for that because that record doesn't exist or because it's not being displayed, because you can't access it, because it's not you know, sent through the through the system? What's What do you attribute most of that to? So we're not getting those records because they're not being sent uh from the system.
▶ 0:55:26So remember, it's a query system that we use typically from these uh exchanges, and the And so we send the query out, say, "Hey, give us your documents." And they say, "Okay, here are the documents and then the the you know, excellent portal the gateway the doctor Bertolan Oracle and others have worked on to provide for us collates all those documents and gives them to us. But a lot of those data just aren't getting there in the first place. And that's where is the the pinch point in that?
▶ 0:55:55Like what is is it the system that collates it the system that you're querying? I mean if if you were look up my name and my date of birth and social security number it'd probably give you all my medical records is my assumption and it sounds like what you're saying is some of that might be Yes.
▶ 0:56:15And so the so there's there's um the EHRs do really well at what the EHRs were designed for which is trying you know, storing records and transactions for our lab tests and radiology tests and that sort of thing. But it's um they could use some work on getting those data into their you know, external gateway and then pushing those out in response to a query. Okay.
▶ 0:56:38Um and I I I might need some more um guidance around if they have the information and they're sending some of it why aren't they sending all of it? Like it seems to me like it would be an equal amount of work to send all and maybe even harder to only send some of it because you're stopping part of that. think it's intentional, right?
▶ 0:57:01that information and and so I think you know, that would be a nice experiment to you know, talk with some of our partners in the VIP pledge for example. Why you know, are you getting everything there consistently? And then um the uh that that veteran information pledge am I saying that correctly? Is that the name of that program? The instant interoperability pledge. Yes. Yes.
▶ 0:57:25Um one question I had about that is um I know some veterans are not eligible for VA care because of the status of their um discharge. Does that account for that in that system or not? So, the veteran interoperability pledge, the first piece of work we did was around the veteran confirmation API. This is also known as the Dick's Sporting Good API.
▶ 0:57:49So, this what this does is use draws on uh DOD records and you know, that are stored at the VA and uses the Title 38 definition of a veteran. So, whatever that definition is at the time, demographic information are are sent to the our you know, the API, the application program interface on our side, and we send back a simple confirmed or not confirmed answer.
▶ 0:58:12Okay, so that would be um determined by the definition within that, not necessarily all of the protocols like a a general discharge, So, so that goes into that Title 38, but it's a legal definition created by Okay. All right. Um okay. Thank you. Um and uh Mr. McGraw, I know that um My Hen has quite a bit of market share throughout Michigan.
▶ 0:58:40Most most network or most systems providers and other things through Michigan are included within that. Um can you I guess explain if you have records outside of Michigan or we have, you know, snowbirds who go down to Florida for example and then come back to Michigan and spend a predominant share of their time outside of the state. Are what is the process by which their records would be able to transfer back and forth or is that still a coverage gap that exists?
▶ 0:59:10Um we do have uh we pay uh um a certain amount of money, several hundred thousand dollars a year for access to the three national exchanges. So, we don't just keep the records within the state of Michigan. Um so, if they do snowbird down to Florida and we know that they snowbird down to Florida and they come back. We will ping those exchanges to get that data from the national exchanges. All of our clients can access those national networks through an aggregated volume that we have purchased from those exchanges.
▶ 0:59:39So, they don't have to go one-on-one. The whole state of Michigan can come through us. We we connect to those exchanges to to fill in those Okay. And is the are the VA facilities in Michigan part of My Health Today they are not. Okay. Um Dr. Rosenberg with the amount of time I have left um if you can tell I know that um Michigan Medicine in the Ann Arbor VA just as a anecdotal example have quite an arrangement between the two of them together.
▶ 1:00:08How is that information shared without using My Health? Like what is the functional way in which that uh patient information is shared across both sides? Well, for geographically nearly co-located and very tightly managed academic veteran affairs uh where if not all most of the faculty who work at the Veteran Affairs Hospital are less than a mile away from the campus as you saw recently.
▶ 1:00:37Uh so, right now I would say more of the exchanges from interpersonal discussions with each other in the fact that the care delivery are frequently similar teams. That of course doesn't scale rural America or uh even within the state of Michigan. The more uh contemporary digital methods as I've mentioned now are the beginning of our use of uh Care Equality and then TEFCA to start exchanging those core records.
▶ 1:01:06And one thing I wanted to mention from the previous conversation, I think it's helpful for us to talk about core records. Medications, allergies, From more complex uh uh a primary care visit would be part of a core record. Basic labs. But for example, as a cardiac anesthesiologist intensivist, the kind of data that I need to do very special critical care or even anesthesiology are not typically in core medical records.
▶ 1:01:35And that's where the expanded use of the data, the data elements within TEFCA will improve the further exchange of those kinds of records. And then final point, there is very importantly very privileged, very confidential data that we want to be careful about, that we uh make sure that the patient and their consent is allowing that data to be sent very, very specifically.
▶ 1:02:02Mental health, um substance use and things like that. So, when we talk about the records that we're sharing, I do think it'll be helpful for us to to to stage out what we mean by those specific um Thank you, doctor. Um thank you, member Brzezinski. Do you have further questions? I do. Um I actually just kind of wanted to go back to what Dr.
▶ 1:02:27Rosenberg brought us back to, which is this bidirectional Community Care VA complete interoperability record. Um and I I wanted to ask both Dr. Greenstone, Mr. McGraw, and Dr. Rosenberg a little bit more about where you believe that disconnect um is and and if you could speak, I guess the three of you could each speak to where you think that disconnect could be. But I think from Dr.
▶ 1:02:51Rosenberg, what you were saying though is are you're not suggesting though that like a complete, like the mental health record or substance, that should all still be encompassed within a record of a veteran. Absolutely. It's I think appropriate like some other confidential data frequently behind extra levels of protection, but it's absolutely part of the medical record. What I'd say I would say there's not so much of disconnect right now. In my my opening statements, I really mean that.
▶ 1:03:18I think it's a evolution and maturity. For us, for example, and I'll use Michigan Medicine, it might not be as indicative of across the country, but it it probably is. It takes a certain administrative workload to procure, contract, and administratively set up these systems. That is not a um that's not a criticism of the network or the exchanges or the frameworks, but it is a reality.
▶ 1:03:49For us, Epic to Epic works extremely well, and that's one reason why Epic has such a large exchange of information among itself. I suspect as Oracle Cerner continues to roll out, we'll enjoy those benefits of contemporary EHRs connecting to each other as well and or, I should say probably through the QHINs as part of TEFCA. I also think that while query-based, as Dr.
▶ 1:04:16Nebeker pointed out, is still perhaps the predominant method of getting that data, there are also mechanisms now for push, as Dr. Nebeker mentioned. And as push starts to occur and as expanded data within this framework occurs, those disconnects, which are really not disconnects but those gaps, will narrow from the common data to the more sophisticated to the more nuanced data. Okay. Mr. McGraw, would you be willing to add anything?
▶ 1:04:47Yeah, a lot of the disconnects we see in the state of Michigan is around connectivity to the local facilities' EHR systems. Uh the two impediments that we see the most is really a time constraint. Sometimes the implementation of that connectivity could be up to 6 months. Uh sometimes it's a fiscal constraint. So, the EHR companies, you know, they're not charity organizations, they're for-profit companies, so they'll charge thousands of dollars to just connect and then an annual maintenance fee.
▶ 1:05:17So, um you know, is the the facilities will ask, you know, is the juice worth the squeeze? And the juice in the state of Michigan is we really work well with our payer partners, and they put incentives together. Uh those incentives incentivize facilities to submit data. And what My Hand does is we get that data that comes in. It is a push, so the second that record is saved, as I mentioned in my testimony, it is pushed to us within 4 minutes, it's available in the longitudinal record.
▶ 1:05:47So, that push comes to us, and the incentives are there's a lot of information in an admission, discharge, and transfer document. So, today 27 of those elements are incentivized. Uh we have position organizations that do transition of care that say, "This is not enough for us to do transitions of care. Can you go back to the payers, and can they incent the facilities to provide more?" So, those incentives are financial incentives. So, the conformance comes through us.
▶ 1:06:14We look if 95% of what they submit to us has all columns uh filled in, and then we check the box, and we tell the payer they are eligible for the incentive program. I think the mention before was someone mentioned something about quality. Today it's a quantity thing, but at My Hand we're really ahead of of of of other HIEs in the country, and our next phase the data that you're coming in meets the quality standard point, but is the data quality? Is it usable?
▶ 1:06:42Or is there just stuff in a particular um area of the the data? Or is it Can we use it for gaps in care, population health management? So, we're moving away from quantity and getting into the quality, but that is how we incent people, and those are the impediments I see today. It's not enough incentives. There's no interoperability issue. There's an incentive misalignment. May I add something about the incentive? It's not so much for us to do the work as I mentioned before, but as Mr. McGraw said, it's around the quality.
▶ 1:07:14It is expensive. It takes people with expertise and the time explicitly to make sure the data quality, the data entry, the data mapping work, and we audit to make sure it works well. And My our HIE, our EHR provider, and I would argue really this broader TEFCA goal is to incentivize organizations to be able to have the resources to do that quality and that ongoing quality
▶ 1:07:44check. Cuz we get some of those data wrong, it is amplified, it is copied, and it could be very difficult. No, do you mind if I ask Dr. Greenstone? Dr. Greenstone, do you want to add anything as well, please? Well, I will will say that everything you've heard is things that we've absolutely seen and experienced. In my organization, we work very closely with numerous critical access hospitals, where they don't have big IT departments.
▶ 1:08:12And so some of them are have the ability to connect, but there may not be knowledge of how to do it. They may not have the funding to be able to do it. They don't fully understand it. As I was talking to Mr. McGraw until until 2 years ago, he was unfamiliar with the exchanges, right? It's like so they and he wasn't alone and still, you know, when I you know, look at where veterans are seen in a lot of these rural places, these small hospitals and health systems, you know, are not sort of connected. They don't know, they don't understand.
▶ 1:08:38And that's where this opportunity for, you know, our TPAs to go out there. If they if they are seeing veterans, let's go out there and help them actually get connected and find ways to do that and use incentives to help them in that way. Um I'd also say that it's been wonderful in the last sort of year that when in practicing, when I have veterans who go to Michigan Medicine, I can find almost everything I need when I actually ping the exchange for queries. So, I think that it, you know, before that I'd be so frustrated. They're across the street.
▶ 1:09:08They're our friends. I have to call somebody as opposed to in my workflow being able to find it. But now we can, and I think that's what we want to see everywhere in all states and territories where veterans are, and when they are traveling like the chairman mentioned, they go down, you know, to Florida and not to Arizona, we need to be able to ping the exchange and be able to see the records when those veterans are are in the community out there, and then be able to use JLTV to see when they're seeing another VA medical center. Thank you. That's very helpful. Thank you. I yield back.
▶ 1:09:38Thank you, and um the more discussion we have the more questions I end up writing down. Um so, um I'll start just from ones I haven't written down so I don't forget them first. Mr. McGraw, you were mentioning um for those people that aren't within your network of, you know, within Michigan for example and transferring data back and forth that you're part of a broader, bigger network to, you know, switch to other regional areas, things like that.
▶ 1:10:02Um it does that then is that part of the service that you offer to the um to the subscribers within your networks so that they're not having to subscribe to a separate network in order to do Correct. So, we have obviously all the information in the state of Michigan, and then we work with those national exchanges.
▶ 1:10:24We buy in bulk the ability to ping those national exchanges, several million pings a month for our clients, and then they can all go through us to those national exchanges so that they don't have to work directly with thousands of individual clients. Sure. And then you were saying the whole longitudinal record and pushing record forward and, you know, few minutes only to kind of update that record. Um forgive my ignorance, but my hand, you're not storing the actual patient information, right?
▶ 1:10:54You're merely transferring it to the EHR that is actually storing that record. So, All that data in the state of Michigan is stored in our cloud-based servers. So, we do store all that information. And the longitudinal record that we're talking about as access is my hands portal. So, we do store for HIPAA rules all that uh Okay.
▶ 1:11:16So, a individual with a their principal record to their network that they're a part of Oracle, Epic, whichever it is, they're not actually storing that information. They're logging into your server. They're bouncing signal to your server that has that patient's record stored there. That way if they go somewhere else, the idea being that it would automatically update so the next time they go to their local doctor's office, it already has the urgent care emergency care visit that they had 6 weeks ago or something like that.
▶ 1:11:45Yeah, it's in both. So, as soon as they save that record, it's always going to be in the EHR system for 7 years or more. The second that they save it, then a copy of that is sent to us within seconds. And then within 4 minutes, it's on our longitudinal record. Okay. So, then if they go across town to somewhere else, that provider should be able to see it in there as well.
▶ 1:12:06But you actually to our network, even if they're not attached to the network, let's say they're not submitting data to us, they still have access through our portal to see that patient's interaction everywhere outside of them. So, there are people that use our portal to see the longitudinal record of a patient for all their interactions, they may not have started submitting data to us yet. So, they can see that.
▶ 1:12:29And as I mentioned in my testimony, we're we have connected to I say nearly 80 for dramatic effect, but it's 79 EHR systems that we've connected to in our 14-year Okay. And then um Dr. Rosenberg, I think it was you that mentioned the sensitive nature of some records that we want to make sure we're you know, keeping as secured and and um stored safely as possible.
▶ 1:12:56Um some number of years ago I worked for the state treasurer, and this was an issue we had with people's tax information. We didn't want people the governor's tax returns or something like that. Is there a similar mechanism uh through My Hint to make sure that somebody like would it Is there a mechanism by which you could tell if somebody was trying to open a patient's record when they didn't need access to it for that nefarious purpose?
▶ 1:13:25Like even if they're a a licensed provider, right? Like you hear about this occasionally with um law enforcement officers, you know, looking up, you know, somebody's record who they don't actually have a reason to, and then that violates the the protocol for the record management. Yeah, that's our active care relationship service, uh ACRES, and that means that you have to have an interaction with that patient in order to view their record. Um and one of the things we also have is what we call uh we call common key services.
▶ 1:13:54So sometimes a patient might have their name spelled different ways in different EHR systems. Uh and then we commonize that and give them one unique identifier. Think of it as a social security number for your medical history in the state of Michigan. And then only providers that have interactions with that patient in their EMRs are allowed to see that patient's record. So you couldn't just log in to our system and look up anybody's health care information.
▶ 1:14:20It is extremely you have access, you don't have like it's not just once you're in the door, you can just go start rooting around or There are um several avenues to do this. Uh One, as you've mentioned, is to assure that the people asking for the data are appropriate. And that changes.
▶ 1:14:43That's again to the previous comment of the expense it takes to maintain those records and make sure that they're Epic has a concept of break the glass uh either for accessing data or accessing data within the record itself. If I remember when I was doing tele-critical care for the VA there was within Vista a similar way to identify when some data you may be wanting to look at uh was bit a bit more privileged, a bit more protected.
▶ 1:15:15But then there's also indirect methods. You know, the reality is if I look at a problem a medication list and I see a an antidepressant on the medication list, I don't have to have access to the problem list to potentially see that a patient may have a a mental health condition. That's important for all of us to know.
▶ 1:15:36So, there are layers and then there are matrices almost of where these data come together and I think part of the part of those gaps as we mentioned is to try to do it properly. And if anything, we're probably a bit conservative to start with. And that's one reason of many why we might not be as fast in some areas. All right, thank you. Ranking Member Bozinski. Thank you, Chairman.
▶ 1:16:04Um I know we've talked a lot about or somewhat about people and the importance of people as it relates to Um but we've also can acknowledge that a lot of the functionality is still happening manually through facts um or Um and with these systems, clerks and health information management or HIM staff must manually upload documents to the VA's EHRs. Um so, Mr. Dr.
▶ 1:16:33Nebeker, um I'd like to know how many individuals in this workforce have been impacted by the mass terminations carried out since January 20th of 2025. Thanks for that question. I just don't have the answer for that. Sorry. Would you be able to get us the answer? We'll take it back. Yes, ma'am. Okay, so we'll be able to. Okay.
▶ 1:16:57Cuz I was I was obviously very relieved when Judge Allsup came back and said that those probationary employees that were terminated need to be rehired, but then the administration immediately put those same 2400 employees on administrative leave. Do you know why the VA decided to put those 2400 employees on administrative leave? I'm sorry. I I really do not know.
▶ 1:17:24Would you be able to follow up with the committee on the rationale behind that? My esteemed colleagues will help with that. Yes. Okay, thank you. Are individuals in this workforce Um well, let me say this. Have any of the HIM staff, do you know, taken the fork in the road? Again, I don't have that information, but we can take it back. Okay, great.
▶ 1:17:53Um and what are VA's plans to make VA fully operational with QHIN participation by December 2025 without many of these critical skilled staff that are needed to carry out this work? How are you looking at that with these uh folks off? So, I think I can answer that one. And so, really the the people that do that work are in central office for connecting the QHIN.
▶ 1:18:23And I'm not aware that we have any problem with the current federal staff to meet the needs of connecting to the QHIN and rolling that out to the local Um my next question is for um Dr. Perreault. The subcommittee has heard reports of several canceled contracts that support the EHRM project.
▶ 1:18:48How many contracts or other or other support services have been cut by DoD since January 20th of 2025? So, we have received the request for information for all this contract and the the office is currently reviewing those and I am sure that as soon as that's completed, we will be providing it to this committee. Okay. Um at least one of these terminated contracts we know focuses on supporting interoperability across VA DoD and community providers.
▶ 1:19:16While some of these have been reinstated, the contractor stated that the smaller workload quote probably isn't enough for them to keep doing business with the VA in the long term, end quote. Um what would be the impact of losing such a such a contractor's support for the EHRM I'm not aware of the contract that you're talking about, so we can take it back to the record and see what the impact would be on that one.
▶ 1:19:42Um I just want to say I think it's extremely concerning that the VA's witnesses today do not have answers to these important questions around staffing and contract support. Without this information, the committee is significantly inhibited in its requirement um to perform oversight of the department's activities. I look forward to receiving this information from VA in a timely manner and working with Chairman Barr to continue oversight of this program. Um I have another question for Dr. Nebeker.
▶ 1:20:13Um has VA performed any audits of providers where veterans may seek care in the community to see if they are connected to the exchange? So, yes. And so, the we are right now, as I mentioned earlier, going through all of the academic affiliates to make sure that they're connected. Um the University of Michigan just recently connected uh with us on that on that matter.
▶ 1:20:37So, now we're going to go systematically through all the academic In addition to um people that aren't yet connected, we also have a data quality monitoring program and by which we look at all the messages that are coming across. Those are saved in an Oracle location and um right now we have um a bit of a contract Oz trying to get those data back to the VA, but we expect that to be resolved shortly. Dr. Perdue's team is doing a great job with that.
▶ 1:21:07And then we we actually sample the data to look for data quality problems and we do uh based on various scenarios for what care coordination of what is is a quality sufficient and then we go back to the healthcare systems and help them improve the quality of data that they're sending us. Okay. Thank you and I yield back to Chairman Barrett. Thank you. Um Dr.
▶ 1:21:32Nebeker, just briefly, is it um I know that uh in in Michigan we learned that VA is not part of the, you know, local or regional health information exchange. Is it common or unusual for VA facilities to members of the regional HIEs? So, we uh are not members of any of the regional HIEs. We um we have been in discussions on this topic for, I don't know, 10 years about how do we participate or not.
▶ 1:22:03I wasn't involved in most of those discussions Neither was I. Only been here 2 months. What we what we are looking for now, so right now there are 50 over 50 regional health information networks that are connected to eHealth Exchange. Eight of those are connected to a QHIN. So, the eHealth Exchange QHIN, the rest are in the traditional network.
▶ 1:22:29So, our strategy is we will join a a QHN and the many of the REOs and we're in discussions with some of those are planning as all the those that we've talked to are planning on joining a QHN. And so, we will then be get connectivity to those regional health information networks through TEFCA. Okay.
▶ 1:22:54And then um I know the Indian Health Services currently is the only federal agency that's connected to a QHN right now. Is that the case? given that the other of the federal Right. I see you're saying there's only two, correct? Uh to my knowledge, yes. Um do you know which EHR they use? So, uh Indian Health Services uses a variant of VistA, but a lot of it's based on VistA and they have it's called RPMS, CPRS RPMS.
▶ 1:23:24It's a similar shared technology, but a little bit different. Okay. So, they don't have one of I guess the more mainline modernized uh EHRs that VA is currently going through the process of upgrading. Correct. They're they have contracted with Oracle to provide that, but not get ready. And yeah, I have of course a lot of friends, you know, in that organization, but they are just starting their journey towards their implementation.
▶ 1:23:53Um and then uh VA is not um sure yet which of the um Now, is it true that Oracle is trying to create their own QHN? Is that also So, right now VA and it's the reason we have to do this is taking a little bit of time as we have to do it with DoD. And so, the firm is hosting some of those discussions and Dr.
▶ 1:24:17Patula's team is really doing a lot of the heavy lifting as far as the you know, the technical approach and we should have a decision on that fairly soon. And sorry the the second part of your question? uh Oracle is creating their own and then would it be natural to assume that that will follow the VA and DoD will follow into that? So, um I I wouldn't make any assumptions. Uh I don't make assumptions on this category. It's it's logical uh that that might happen.
▶ 1:24:47There are um there are uh testing and certification requirements that take about a year to uh to get through after there's an establishment of a QHIN. And so, um you have to talk to Oracle about how they're meeting those timelines. But but I would add that the barriers for switching for entry and switching among QHINs are extremely low.
▶ 1:25:12And so, if Oracle comes up with a great product and it's better than you know, what else we're seeing, the price is right, it would be logical for us to switch to an Oracle solution. Thank you. And then, um could you explain also through TEFCA, which will establish these uh kind of framework for these QHINs with quality of information and everything else, how is that or how can that address VA's interoperability gaps that exist in some of the
▶ 1:25:42examples we heard about today? So, so TEFCA is primarily about the trust framework, about what can we, you know, exchange, you know, the legal framework for trusting each other to exchange information, and then about the pipes, you know, that's the QHIN part, the qualified, not quality, but qualified health information network that So, we're using the same technology to exchange the data.
▶ 1:26:05So, QHIN we believe will solve a large with active REO help, I mean, really need uh the help from the REOs, will solve a lot of the connectivity problem. But there's still the data quality program that this does not uh it's pretty much silent on data quality. Okay. Are there uh discussions in place around that standardization, if you will, and and and where do those go in this process?
▶ 1:26:32Yeah, I I got to say I really appreciate your your interest in these questions in such a nerdy topic. Uh But um so right now, is leading a coalition around data quality. It involves CMS, uh uh used to involve CDC, they're replacing um a member there. And then uh payers, some of the Blues are participating. Also, uh other data exchange and quality organizations, NCQA is participating.
▶ 1:27:00And so the the goal of this uh collaborative is to do to address exactly the data quality problem because all of us want to be able to provide better decision support, better quality management of the care, you know, better population health, etc. We need data we can compute on. So, for example, our studies have shown that only 35% of our uh people can we decide can we tell from the information exchange over the HIEs whether they need a colonoscopy for screening or not.
▶ 1:27:30So, it's very poor data that we're currently getting. It's not, you know, it's not 100% bad, but big gaps. And so, um there's a lot of progress on this uh and I see that you know, we're over time a little bit, but uh there's a vendor that stepped up to donate and will provide through open source some of their technology to provide really objective scoring of data. And that's also accompanied with uh hey, this is what you might be doing wrong if because the data came out this way.
▶ 1:27:57So, it's uh it's going to be really powerful initiative. And we're hoping that insurance companies, like MyHin, uh has a you know, type partnership with their payers, they recognize the value of this interoperability. Not only the connectivity, but also the quality of the data. We hope that they'll be writing in their contracts data quality provisions to really incentivize for us, you know, this change of high-quality data, not just data. Thank you. Remember Brazinski. Thank you, Chairman.
▶ 1:28:28Um Dr. Greenstone, uh can you share what is the utilization rate of these tools that VA utilizes like EHSRM, JLV, and the Veterans Health Information Exchange among community care providers? Sure, I can clearly speak to EHSRM, which I was a product owner for for many years. Um and an EHSRM um is the referral authorization system for VA.
▶ 1:28:56Um and what it creates is the true authorization that providers in the community need to have so they know what VA is authorizing and there's a referral number that has to be associated with the claims that are actually submitted.
▶ 1:29:10There are approximately 130,000 providers in the community in the community care network who are provisioned to use EHSRM as the means by which they receive their referrals, as well as having access in one click to the entire veteran medical record in an organized way. Um the challenge, however, is that it's only for veterans who are seen in the 165 sort of medical centers that are still on our legacy VistA system.
▶ 1:29:41So, those five facilities that are on Oracle Cerner have not um had that data in Oracle moved over to um our middleware VDEF that actually EHSRM actually uh uh uses to show the data. So, that we know that let's say if you receive as a provider in the community more than two referrals a day, about 75% of those providers are using EHSRM to receive their referrals and to and to upload medical documents, right?
▶ 1:30:10And if you receive more than 10, we're talking 95% to 100% of providers. So, if those providers who get a lot of referrals want to organize their data and their their referrals, and they do that within HSRM, so that's why they log in. That's why they see the entire veteran medical record, and that's why many of them will then upload data. Right? Some of them are in challenge because some VA medical centers is like, "Hey, our back-end people are using faxes and phone calls and scanning all day long. We don't want to use HSRM.
▶ 1:30:37Send us faxes." And and that that's a problem that that still exists today when VA medical centers are telling folks to fax and not utilize a system that providers want to use cuz it makes it easy for them to actually do their And that that's a great point, and fax machines have come up a few times, I think, today. So, I I would like to ask Dr.
▶ 1:30:56Nebeker, you know, when we're talking about interoperability and things like fax machines are coming up, you know, what are what is the VA's plan to address this reliance and push people to utilize more interoperable tools like HSRM or the exchange? So, thanks for that.
▶ 1:31:17So, back when I was starting out as a young faculty member at the University of Utah, I had what then seemed to be a very large contract with Medicaid, and we were providing really great decision support on drugs when people were prescribing drugs together that they should never prescribe together like Viagra and nitrates, for example. The The providers loved it. When we went out and we asked them, you know, what do you think about these these, you know, forms we're mailing to you back in those And they said, "They're great.
▶ 1:31:48We love them, but I just take them, I throw them in the garbage." And I said, "Why?" "Because 3% of their patient volume is Medicaid, and they can't create workflows in their office to deal with 3% of their volume." And so, the So, my answer is we got to join the rest of the community. Dr. You know, Greenstone was really emphasizing this in his world in his opening comments. We've got to do things the same way as the rest of the community.
▶ 1:32:14And then And then thankfully, I mean, the Elizabeth Dole Act was really a gift in the Section 108 was a gift in this matter because directing the the Secretary of VA to work with the Secretary of HHS cuz it's that teamwork, right? So, we Here we are as the largest health care um integrated health care provider in the country and we're not part of that health community, right? So, um So, really to bring together to have a more cohesive policy making, I think it's really going to be important to address that. And if you have any further technical questions about that, Dr.
▶ 1:32:44Pertula could cover those. Would you like to add anything, Dr. Yeah, we've been working on interoperability, as you all said, probably about 20 years, whether it's health care or otherwise. And we will continue to do that consistently Uh whether it is e-faxing and turning them into something else. Uh we have plans as well for bringing some of that uh interoperability more into rural communities um and helping them.
▶ 1:33:11We have secure messaging as well that they can use, so that instead of faxing, they can well, email if they don't if they if they have that ability, so that then we start having also some more computable information. But But uh as Dr. Newberry and the rest of the panel here has said, you know, we really need to get into everybody really working towards semantic interoperability, right? Making sure that our data models are similar if not the same.
▶ 1:33:35Opening open source this is a great way for us to start really looking into what do others do that can help us uh so that it's not a closed door or behind the door kind of uh discussion around interoperability. Thank you. I yield back. Thank you. Um I know I got to go to closing remarks because um unfortunately, we have to uh move on to other activities. Um, but, um, Dr.
▶ 1:34:00Navakar, just, and I can follow up with you later, but when you talked about quality of record and everything else, I don't know if that means the data itself through the system or like how a physician describes a certain thing.
▶ 1:34:16I'll give you an example, when I was in Ann Arbor last week, a few days ago, they said that carpal carpal tunnel condition, you know, procedure could be categorized one of several different ways by the physician, and the next physician looking it up may not look at it this through the same lens, perhaps. Um, and uh, I just would be curious, I mean, we spent a lot of time making sure we had standardized language in the Army for the things that we did there. I assume that's probably a goal in in medicine as well.
▶ 1:34:46Um, but, uh, happy to have to ask you some of those follow-ups offline unless you've got some brief comments you want to make. very briefly. So, the the kind of the nuance classification diseases is what we, um, think about more for internal interoperability when we're generating the data.
▶ 1:35:03The kinds of quality that I was talking about before is about getting those data that are in the EHR and that are great in the EHR across that divide to where they're actually going out in a way that can be read. And so, that's ones and zeros, not human interfaces. So, are they getting the right information in the right slot? Is it are the units for blood pressure, you know, millimoles per liter instead of milligram, you know, millimeters of mercury, which is very different? Are are they plausible values?
▶ 1:35:34Is it blood pressure, you know, 500? Uh, you know, we're we're seeing these data quality programs when they're going from the EHR to the being pushed out to the exchanges, the data's getting scrambled. It's how you crash a lunar module when you have one guy measuring meters and the other guy measuring feet. So, okay. All right. Thank you. Really appreciate all of your uh testimony each of you for being here Um definitely um learned quite a bit from your testimony.
▶ 1:36:04I I'm only slightly more confused than when I started, so that shows that we're making progress. VA is the largest healthcare system in the nation, um but it only represents Oh, I'm sorry. Remember Ms. Zinsky. Go ahead. You can do your statement first. Sure. Thank you, Mr. Chairman. Um I'll get this right over the next time. Yes, okay. We're in it together. Um I appreciate the testimony and answers from our witnesses this afternoon.
▶ 1:36:29Having a truly seamless and secure interoperability program is crucial for our veterans to be able to seek the care they need. There have been a series of active interoperability efforts, but there are still major issues that need to be addressed about the sharing of information between the VA and the non-VA providers. I'm glad to see that the VA is actively taking steps to figure out how to securely exchange information so veterans can continue to receive care inside and outside of the VA.
▶ 1:36:59While these efforts are on the right track, I would be remiss to not acknowledge the impact of the recent personnel actions on VA's ability to ensure that veterans have a complete medical record. It's critical that VA have sufficient staffing in OIT and EHRM, as well as the clinical settings to ensure that VA can participate in the information exchange processes. Otherwise, our veterans are the ones that will suffer.
▶ 1:37:27Relying on only technology alone is not going to work for a seamless exchange of information. We need to work together to figure out how to produce complete medical records for our veterans so they can receive the care that they so rightfully deserve. Thank you so much, Mr. Mr. and I yield back. Thank you, and I want to thank the ranking member for participating and being here for the entire committee hearing today. Thank you.
▶ 1:37:53Um and I want to thank our witnesses, and as I um was beginning to say, the VA is the largest healthcare system in the nation. Of course, has more medical records perhaps than any other system out there. Um but still only represents about 3% of all US hospitals. So, while it is the largest, it is still not the majority by any stretch.
▶ 1:38:14Uh veterans are people at the end of the day, and the other 97% of hospitals will always play a role in veterans As I said in my opening remarks, roughly 1/3 of VA care is currently gone through the community. The healthcare data in the community care network will always form a large part of the complete picture of a vet- veterans medical history. Republicans on this committee have prioritized making sure that veterans have access to community care when they're eligible for it and are given the opportunity to choose what is best for them in placing them in the driver's seat.
▶ 1:38:44Part of how we make VA stronger and deliver better outcomes for veterans is to continue moving the ball forward on interoperability, so there is that seamless ability and no coverage gap exists. This includes VA producing a thorough actionable plan on healthcare information interoperability standards spanning the VA interoperability the veterans interoperability pledge and fostering more direct information exchange with community partners.
▶ 1:39:09Building stronger partnerships with providers like Michigan Medicine, as well as health information exchanges like MyHealth that we learned a lot from today and appreciate that. Participating in TEFCA to bridge the data exchange gaps with community care providers that still exist. I urge the VA to be a leader in interoperability and build on the progress of recent years. Americans veterans have much to gain from your work. And I thank you all again for participating in today's hearing.
▶ 1:39:35I ask you men unanimous consent that all members have five legislative days to revise and extend their remarks and include extraneous material without objection, so ordered. And with that, we are adjourned.