The Department of Defense (DoD) and the Department of Veterans Affairs (VA) plan to expand their virtual lifetime electronic record (VLER) pilot, which began a year ago in 11 sites across the country. The purpose of the pilot is to demonstrate the feasibility and the value of exchanging health information between DoD and VA clinicians and private sector clinicians who care for the same veterans.

The expansion will be gradual, and no new sites have yet been selected, said Tim Cromwell, RN, VLER health program manager for the DoD/VA Interagency Program Office (IPO). IPO will choose additional sites, he said, based on the maturity and success of local health information exchanges (HIEs), as well their ability to increase adoption by veterans and give the DoD/VA "some real clear data."

To date, more than 56,000 veterans have signed forms authorizing the use of their personal health information in what used to be called the Nationwide Health Information Exchange (NwHIN) and is now termed the eHealth Exchange (EHE). About 5,000 data exchanges have occurred between private sector providers and DoD and VA clinicians, Cromwell said.

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The EHE, which began as a government project, recently became a public-private consortium operated by a private-sector entity known as Healtheway. DoD and VA, which belong to EHE, see a great opportunity in this transition, said Cromwell, because of the new testing and certification procedures for HIEs and electronic health record vendors that want to participate in EHE.

Healtheway has partnered with the Interoperability Work Group (IWE), a consortium of states, HIEs and vendors, to implement standards that make it easier to exchange information. Healtheway and IWE have appointed the Certification Commission on Health IT (CCHIT) to test systems to ensure they can exchange specified content using a specified transport mechanism. The goal is to create plug-and-play connectivity within and between HIEs, lessening the need for interfaces.

Cromwell said his office is very excited about this approach. In the future, he said, only HIEs and vendors that are certified to join the EHE will be considered as partners for the VLER Health exchange.

Not all the veterans who have signed authorization forms live in the areas where VLER Health pilots are running, Cromwell noted; some have given their permission in the expectation that the program will go nationwide. But VLER Health has matched about half of the enrolled veterans with the master patient indexes of participating HIEs. As a result, if a VA clinician, for example, wants test results on a patient who has had a test done at a private sector hospital, he can retrieve that information from the HIE if the hospital participates in the exchange.

The data is sent in the form of an HL7 message containing a summary of care record known as the C-32 (an advanced version of the Continuity of Care Document, or CCD). The VLER Health user interface parses the XML-tagged elements in that clinical summary so that VA clinicians can go to a secure website and see components such as medication lists, allergy lists and so on. But VLER Health has not invested in the technology that would be required to send the data elements into the VA VistA EHR, Cromwell said.

Another part of the pilot is related to direct messaging, which is being used to transmit referrals to specialists and to send consultant reports back to primary care doctors. While the Direct protocol is compatible with EHE, it's not being used for any other purposes, with one exception: veterans in the VLER pilot who download their personal health records via the Blue Button can use Direct to send those summaries to their providers. Cromwell noted that this is useful because many clinicians in the pilot areas don't participate in local HIEs.

The VLER Health exchange currently involves VA and DoD sites in the following regions: Southern California; Northern Virginia; Indianapolis; Grand Junction, Colo.; Asheville, N.C.; Buffalo, N.Y.; Charleston, S.C.; Minneapolis; Spokane, Wash., and the Puget Sound area in Washington State.

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