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Office of Public and Intergovernmental Affairs

Remarks by Former Deputy Secretary W. Scott Gould

CONNECT Seminar '09
Washington, DC
June 30, 2009

On behalf of Secretary Shinseki, the Department of Veterans Affairs, and the 23 million Veterans we serve, I would like to thank Dr. David Blumenthal [National Coordinator for Health Information Technology], Vish Şankaran [Program Director, Federal Health Architecture], Ginger Price [Program Director, Nationwide Health Information Network], and the staff at the Office of the National Coordinator for the opportunity to offer a VA perspective on the nationwide exchange of health information.

As many of you know, VA operates the largest integrated healthcare system in the country. Over a third of the nation’s Veterans are enrolled in the VA system — about 8 million out of 23 million. Last year alone, five and half million Veteran-patients walked through our doors. We operate more than 1,400 points of care, where nearly 18,000 VA doctors, 49,000 VA nurses, and an army of clinical and support staff provide some of the best care anywhere. It wasn’t always that way, but it is today — thanks in part to VA’s investment in health information technology.

VA is not only the largest health-care system in the country. It’s also a leader in the development and use of electronic health records, and the largest health-care system in the country to provide EHR’s for 100% of its patients.

When VA adopted EHR’s system-wide in the 1990’s, it wasn’t easy getting everyone to go along. In 1998, a VA physician in South Texas surveyed his colleagues on their willingness to adopt EHR's. One third said they were "willing" to do it, another third said they would "wait for it to go away," and the final third said they would "never do it" and that VA would just have to wait for them to retire.

Since then, the hold-outs have either retired or changed their mind, and I’m pleased to report that every single VA health-care provider is now using the Veterans Health Information Systems and Technology Architecture — known as VistA — VA’s celebrated electronic health record system.

VistA is one of the most comprehensive and sophisticated electronic records systems in use anywhere. It brings together in one place all elements of a patient’s health history — medications, lab results, diagnoses, progress notes, medical images, and more. It’s all there, anytime and anywhere it’s needed, which as you know often isn’t the case with paper records. In the mid-1990’s, when a Veteran came to one of our hospitals, the all-important patient record was available only 60% of the time. Today, the records of the millions of patients we see each year are available any time and every time, at any of our fourteen-hundred-plus points of care. 

When a Veteran from New York snowbirds in Florida, his records are there for him. When a 73-year-old diabetic Veteran in New Orleans was evacuated upstate after Hurricane Katrina, his records were there for him, too. It’s estimated that over a million medical records were destroyed by Katrina — but not even one belonging to America’s Veterans, because they were all saved electronically in VistA.

VistA has largely eliminated errors stemming from lost or incomplete health records. VistA saves patients and providers time and trouble. It lowers costs and improves care by cutting down on redundant tests. It warns providers of drug allergies and drug interactions. It provides Veterans with much better care for lower cost.

These achievements are just a preview of things to come. Now the challenge for VA and the Department of Defense is to ensure the seamless transition of service members from active duty to Veteran status. When Veterans enroll in the VA system after leaving the military, it takes time to verify their eligibility and obtain their military health records. Care delayed is care denied, so to eliminate the delay, President Obama in April charged Secretary Shinseki and Defense Secretary Gates with building an integrated record system that would provide each member of our armed forces with a single lifetime electronic health record — called VLER — to stay with them from the day they put on the uniform to the day they are laid to rest.

Such a system would be a big step toward transforming VA into the high-performing 21st century organization envisioned by the President. But there are different ways to achieve that transformation, and some are more forward-looking than others.

One way would be for VA and DOD to construct their own point-to-point system, linking their electronic health records together through special portals and customized protocols. In fact, today, VA and DOD are nearing completion of just such a one-to-one integration. This is a tremendous achievement, of course, and will be of great benefit to Veterans.

But such a system is far from ideal. Many Veterans also receive care outside the VA system. In fact, DOD and VA spend about half of their combined health-care budget purchasing care in the private sector. When Veterans do come to VA for care, we need access — with their permission, of course — to the notes and records of that outside care, to ensure that the care they are getting is seamless and safe. For the same reason, private-sector providers need secure, reliable, and Veteran-authorized access to our patient records as well. It must be a two-way street.

We can achieve this better solution with a plug-and-socket-like capability, that would not only make the interoperability between VA and DOD easier and more complete, but would also enable any properly secured and authenticated system — public or private — to "attach" to the network. Indeed, this is the purpose of your meetings yesterday and today.

In other words, what we need is not a stand-alone, point-to-point VA-DOD system, but the capability for interoperability throughout the health-care community, based on open architectures governed by common standards. This is, of course, the approach that made possible the explosive growth of personal computers and the Internet. It can do the same for electronic health information.

And so we have taken these principles and developed a new strategy for the joint DOD-VA VLER project. This open-architecture design philosophy is a crucial step in delivering on the President’s vision of a secure, reliable, accessible, and — here comes the punch line — scalable system that leverages DOD health and benefit information, and lays the groundwork for sensible public/private interoperability. In fact, just last Friday, with the support of the White House, the DOD-VA Joint Executive Committee, co-chaired by DOD Deputy Secretary Lynn and myself, formally adopted this strategy as the go-forward plan of record.

The open approach focuses resources not on building big, costly, high-risk, enterprise-class systems, but on making new and existing systems interoperable. In web development, this is done through the use of application programming interfaces — or API’s.

API’s make the development of applications quicker, easier, and more cost-effective. They are budget friendly. Many require no upfront fee and no subscription commitment, which eliminates the need for major capItal investment. Portions of the system costs become an operating expense instead of a capItal, or development, expense. The lower cost lowers the risk of investment and speeds implementation. New features can be added in hours because they don’t have to be developed from scratch. And because API’s are based on common standards, the hard task of infrastructure scalability can be outsourced to others.

This is the approach we are taking for health IT As you well know, the Federal Government has already taken serious steps towards laying a solid foundation. We have promoted the Nationwide Health Information Network, to create a truly integrated system. Soon, we will connect — with permission and on-demand — not just to other federal and other public-sector agencies, but to private health systems as well. This is the beauty and the opportunity of open, standards-based, architectures.

The IT industry is replete with examples of exactly this kind of innovation-igniting approach. The best example is the Internet itself.

The Federal Government’s role in the creation of the Internet was largely limited to leadership. It provided the vision of what could be built, it helped specify the standards by which things should be built, and then it let smart folks like you do everything else. It’s a role the Federal Government does well.

In health IT, we have enabled the development of standards for interoperability, through the work of the Office of the National Coordinator and a broad and inclusive spectrum of federal, state, and private-sector stakeholders. We have drawn our own agencies into a national health network and are making it possible for non-federal systems to connect.

We are not mandating participation by anyone; participation is entirely voluntary. But the smart money is on those who join in this approach.

The expectation is that voluntary participation in an open-architecture network of networks, based on national standards, will spur private-sector innovation. Unleashing those forces will create better choice, greater flexibility, and lower cost. The health-care community will want to move away from paper-based, innovation-resistant, legacy systems, and move towards an interoperable future.

And the Department of Veterans Affairs will continue to be out in front — walking point, as Secretary Shinseki likes to say. We have a well-tested and much admired EHR platform. We have the most comprehensive collection of outcome data available. And we have a responsibility to share what we have and what we know with others, for the greater good of the nation.

We also have a responsibility to protect the privacy of our Veterans and to maintain the security and integrity of their health records. This is a responsibility we at VA take very seriously. You probably know we had some non-health-system–related challenges years ago and are vigilant about cyber security. Indeed, cyber security is an important design criteria that needs to be reflected in the national standards that govern open, interoperable health IT systems.

Interoperability is the key. If we have learned anything from the evolution of information systems, it is that we can all do a lot more when we work together on open architectures according to established standards. That’s the path to the future of health IT That’s the change needed to provide the best care anywhere.

And finally, we must not forget why this work is important and compelling. It’s to provide treatment for our Veterans like Sarah Wade’s husband. You will recall that Sarah spoke compellingly yesterday about her husband, who suffered TBI from an IED while serving in Iraq. Keep Sarah and her husband in mind while you’re here. Helping us as a nation provide the care we promised and that they need is what interoperability is all about.

We at VA look forward to working closely with you to make it happen soon. Thank you.