The Department of Veterans Affairs’ (VA) implementation of the Virtual Lifetime Electronic Record (VLER): Findings and lessons learned from Health Information Exchange at 12 sites

https://doi.org/10.1016/j.ijmedinf.2014.04.005Get rights and content

Highlights

  • VLER Health, a pioneer in HIE, made great strides in advancing HIE and standards.

  • Mixed methods approach provided insightful, real-world HIE implementation lessons.

  • Clinicians reported high perceived value, trust, and experience with VLER Health.

  • Veterans reported high perceived value and few barriers/concerns about VLER HIE.

  • Clinicians will sustain VLER Health use as data availability and quality improve.

Abstract

Purpose

We describe the Department of Veterans Affairs’ (VA) Virtual Lifetime Health Electronic Record (VLER) pilot phase in 12 communities to exchange health information with private sector health care organizations and the Department of Defense (DoD), key findings, lessons, and implications for advancing Health Information Exchanges (HIE), nationally.

Methods

A mixed methods approach was used to monitor and evaluate the status of VLER Health Exchange pilot phase implementation from December 2009 through October 2012. Selected accomplishments, contributions, challenges, and early lessons that are relevant to the growth of nationwide HIE are discussed.

Results

Veteran patient and provider acceptance, trust, and perceived value of VLER Health Exchange are found to be high, and usage by providers is steadily growing. Challenges and opportunities to improve provider use are identified, such as better data quality and integration with workflow. Key findings and lessons for advancing HIE are identified.

Conclusions

VLER Health Exchange has made great strides in advancing HIE nationally by addressing important technical and policy issues that have impeded scalability, and by increasing trust and confidence in the value and accuracy of HIE among users. VLER Health Exchange has advanced HIE interoperability standards and patient consent policies nationally. Policy, programmatic, technology, and health Information Technology (IT) standards implications to advance HIE for improved delivery and coordination of health care are discussed. The pilot phase success led to VA-wide deployment of this data sharing capability in 2013.

Introduction

Through the Virtual Lifetime Electronic Record (VLER) Health Exchange program, the United States (U.S.) Department of Veterans Affairs (VA) can electronically share parts of Veteran patients’ health records with providers at the U.S. Department of Defense (DoD), and participating private sector health care organizations (exchange partners). VLER Health Exchange leverages the policies and technical standards of the eHealth Exchange, formerly the Nationwide Health Information Network. Goals include better informed care providers; improved continuity and timeliness of care; enhanced awareness among all parties; and elimination of gaps in a patient's health record. VLER Health Exchange serves as a national catalyst for interoperable health systems and a model for future Health Information Exchange (HIE).

VA engaged in a VLER Health Exchange pilot phase in December, 2009 to identify scalable implementation strategies and to evaluate the early impact of VLER Health Exchange.3 The pilot phase concluded September 30, 2012. VA commissioned a two-year, independent evaluation and performance monitoring of the pilot phase to better understand the impact of VLER Health Exchange and to inform decisions about future directions for the program. The evaluation was guided by an HIE evaluation framework reported elsewhere [1].

This study summarizes major accomplishments and contributions of VLER Health Exchange as well as early lessons gleaned from the implementation and evaluation, including findings related to adoption and perceived value of VLER Health Exchange to Veteran patients and providers.

The adoption of health Information Technology (IT) such as Electronic Health Record (EHR) systems and the opportunity they create for HIE across complex health care environments has been slow and problematic. More recent studies of HIE suggest that factors beyond technology are important to both HIE adoption and implementation [2], [3], [4], [5], [6], [7], [8]. Implementation science suggests that both the technology and the implementation processes and context must be addressed when implementing health IT. Several frameworks to characterize health IT implementation, and the factors that contribute to health IT, including HIE success, have been proposed to identify and advance implementation best practices and address gaps in the health IT implementation body of knowledge [9], [10]. This study sought to add to the body of knowledge about the implementation of HIE.

The knowledge gained through VA and exchange partners’ efforts will be useful for organizations seeking to connect to the eHealth Exchange. Further, VA's experience with VLER Health Exchange has policy, technical, health IT, interoperability standards, and other implications for initiatives that advance HIE to improve health care and coordination of care. These initiatives include the Meaningful Use of EHRs [11] and health care financing and delivery models that benefit from health IT and HIE.

Communication breakdown often occurs when patients transition between health care organizations and during episodes of shared care. This fragmentation can result in decreased quality of care and inefficiencies in the delivery of health care [12], [13], [14], [15].

HIE can improve care coordination by providing providers with more complete health record information at the point of care. HIE has been shown to improve access to test results [16], reduce rates of diagnostic imaging tests in the Emergency Department (ED) [17], [18], [19], and improve communication with primary care providers following an episode of urgent care [20]. Patient-centered medical homes, which have information exchange as a core component, have been shown to improve quality of care for patients with chronic medical conditions [21], [22].

Veterans who receive health care from VA usually transition between DoD and VA health care systems, and many receive care from both systems. HIE has been an integral part of both VA's and DoD's health care delivery strategy for over a decade. Further, an estimated seven of ten Veterans who receive health care from VA also receive a portion of their health care from the private sector [23], [24], [25]. Thus, Veteran patients can benefit from increased HIE.

Twelve pilot sites were the focus of this evaluation study. VA selected sites with a strong business case for HIE and sought a diversity of characteristics, such as geographic factors (i.e., rural, urban), populations served, the maturity of the HIE organization, and their sustainability models. Four pilot sites participated in a three-way exchange between VA, DoD, and the private sector, and eight sites participated in two-way exchange between VA and the private sector.

VA implementation of VLER Health Exchange is overseen by a central leadership group and local implementation teams. Members of the local VA teams include, but are not limited to, VA medical center leadership and representatives from the Privacy, Health Information Management, and Release of Information departments, and clinician champions from throughout the VA health care system. During the pilot phase, VA community coordinators managed local troubleshooting, helped establish Veteran education and consent processes, supported provider training, and acted as the local liaison between VA and the partner organizations.

eHealth Exchange uses a “pull” model where trusted partners can query and retrieve information from each other's system, after proper authentication and purpose of use is authorized by the patient and the organizational policies. Query/retrieve refers to a messaging pattern in which a query is initiated from one eHealth Exchange partner to another, requesting a list of available documents meeting the given query parameters for a particular patient.

To implement the VLER Health Exchange standard-based solution, each organization needs to implement two basic components: a Gateway and an Adapter. The Gateway communicates with other Gateways securely over the Internet. VA VLER uses the publicly available CONNECT gateway available at http://www.connectopensource.org/. The Adapter translates between the Gateway and the organization back-end system or EHR. The VA provider user interface is through VA's EHR system, called the Veterans Health Information Systems and Technology Architecture (VistA). A portal called VistAWeb from the VA's EHR initiates secure data queries over the eHealth Exchange to all exchange partners for which the patient has authorized access. These partners respond by sending their health summary records, which VistAWeb then displays to the requesting provider. Conversely, when an exchange partner queries VA, the Adapter accesses VA patient databases (VistA) and packages the data into standardized health record documents (i.e., Continuity of Care Document (CCD)) before replying to the partner query. The Master Veteran Index (MVI)4 enables patient identification matching to ensure the requestor and responders are communicating about the same patient.

The VLER Health Exchange Program developed an automated service to record Veterans’ preferences to share information, called the Veterans Authorization Preferences (VAP) System. VAP records and enforces patient consent directives using a policy decision engine. VAP also audits transactions in order to meet confidentiality obligations for the accounting of disclosures of patient individually identifiable health information (Fig. 1).

VLER Health Exchange is enabled by eHealth Exchange standards, services, and policies and is governed by a Data Use and Reciprocal Service Agreement (DURSA). The eHealth Exchange DURSA includes various legal requirements that participating organizations are already subject to and describes the mutual responsibilities, obligations and expectations of all participants under the agreement. All of these responsibilities, obligations and expectations create a framework for safe and secure HIE, and are designed to promote trust among participants and protect the privacy, confidentiality and security of the health data that is shared. The DURSA is based upon the existing body of law (federal, state, local) applicable to the privacy and security of health information and is supportive of the current policy framework for HIE. The DURSA is intended to be a legally enforceable contract that represents a framework for broad-based information exchange among a set of trusted entities [26].

eHealth Exchange is based on a federated model with organizational control of the health care record. Exchange partners own their data, thus there is no central repository of patient information.

Many of the pilot sites initially targeted education efforts to Veterans who receive care from both VA and from an exchange provider (“shared” patients); however, any Veteran patient could participate even if not currently a shared patient [27]. Participation by non-shared patients can impact the ability to match patients, since these patients may not be known to existing HIE partners, as discussed below. Over time as more health care providers participate in HIE, there is a greater likelihood that the Veterans will be shared patients, and that their information will be available via VLER Health Exchange. Participation is optional, and Veterans can opt-out at any time. Veterans complete a VLER Health Exchange authorization form that is valid for five years. The pilot sites use a variety of approaches to educate Veterans about VLER Health Exchange including mailings, the media, social media, and VA medical center outreach activities. In some sites dual authorization is required from both VA and the private sector HIE partner.

In order for VA to exchange Veteran health information with a partner health care organization, VA must match the Veteran patient's EHR to a record at the partner organization. As previously discussed, VA, DoD and exchange partners each maintain independent patient databases and Master Patient Index (MPI) systems. After a patient is enrolled and the signed authorization is recorded in VAP, the system automatically announces the patient's identity to all VLER partners in an attempt to determine where the patient is known and the location of other records. Demographic traits are exchanged during this “Patient Discovery” exchange and each partner responds with either a positive match from their matching algorithm, or ‘empty’ reply, if there is no match or the patient is not known. A positive match by the VA is stored in the MVI.

The DURSA signed by all exchange partners allows for a “no risk” model, where both the exchange partner and VA's systems perform independent tests that confirm the positive match. As such, each exchange partner uses an independent matching algorithm that considers various demographic traits, including SSN. The matching algorithmic rules and standards used by VA for a positive match of patient traits are strict; VA chose to only record a match when both systems achieve a match.

A Veteran's record may not match, due to a number of factors including but not limited to: the inability to match on the partner equivalent information (e.g., name, gender, date of birth, Social Security Number (SSN), address, phone number); technical problems (e.g., system timeouts); and strict algorithmic rules (e.g., deterministic match). It is also possible that the Veteran may not be a current patient of an exchange partner or additional consents required have not been obtained by exchange partners.

VLER Health Exchange data are sent as Extensible Markup Language or XML-structured Health Level 7 (HL7) [28] messages containing a summary of care record known as the Health Information Technology Standards Panel (HITSP) C32 – a constrained version profile of the HL7 Continuity of Care Document, or CCD. Exchange information is typically accessed through a web portal. The VA portal is called VistAWeb and is integrated with VA's EHR system. VA providers receive notifications if a patient has data available via eHealth Exchange. VistAWeb parses partners’ C32 data, and displays them as a whole or by section views, including ‘foundational data’ – medications, health problems, allergies, and laboratory test results. While VLER Health Exchange partners do not share all health record information, and what is exchanged varies by each partner, more information is being exchanged as the program matures, including immunizations, encounters, procedures and vital signs. In 2012, exchange of clinical notes began including consultation notes, discharge summaries, history and physical notes, results of diagnostic procedures, and radiology and surgery reports.

There is significant variability among the software applications, which allow VA and partner users to access and view information from the eHealth Exchange. None of the applications during the pilot phase incorporated the health information within their EHR. All relied on a “pull” model where the user initiated the query and retrieval of information for viewing only.

Some VA pilot sites have implemented reminders in VistA which notify a provider when a Veteran patient is a VLER Health Exchange participant. eHealth Exchange partners use very different processes to retrieve VLER Health Exchange data based on the software available to them. During the pilot phase, three partner sites provided a notification to the provider, making it clear that Veteran data would be available, if the provider tried to retrieve it. Without notifications, providers may not realize that outside information is available and consequently may not query for it, or, if they query for it systematically, they may experience a large number of failed searches because there is no external data for the patient. Three partners provided access to VA data through their EHR software. Providers at the remaining eight partner sites had to navigate outside of their EHR and open a separate portal to retrieve VA data. These providers were required to enter login credentials through a separate sign-on, which was reported by providers and other stakeholders to inhibit use.

One of the more mature VLER Health exchange partners, Indiana HIE (IHIE) in Indianapolis, implemented a system to automatically retrieve and print VLER Health Exchange data when the Veteran checks-in at patient registration at selected IHIE participating hospitals, thus “pushing” information to the provider systematically.

Each pilot site trained providers using a variety of VLER Health Exchange training methods including clinical champions recruitment, email or electronic messaging, provider group training for basic education on this program, large group formal user training (e.g., by specialty), VistAWeb training, individual provider training, distribution of written VLER Health Program materials and aids (including pocket cards), and video presentations. The most common training methods reported were email/electronic messaging, group training of providers with basic education/orientation and formal user training.

Section snippets

Methods

A mixed methods approach was used to monitor and evaluate the status of VLER Health Exchange pilot implementation from December 2009 through October 2012. The evaluation incorporated: (1) quantitative data on Veteran participation and provider usage of VLER Health Exchange; and (2) qualitative data from in-depth interviews with providers and Veterans, and from summaries of VLER Health Exchange stakeholder meetings and communications.

Veterans accept, trust, and perceive high value of VLER Health Exchange

Veteran acceptance for VLER Health Exchange is high, consistent with studies showing that Veterans are accepting of sharing their electronic health record information if done in a secure manner [29], [30]. A high proportion of interviewed Veterans (90%) reported that initial reactions to VLER Health Exchange were highly positive. Most (63%) reported no specific concerns or hesitations about participating. Of those who did have concerns (37%), privacy and security were noted as the reasons; most

Discussion

VLER Health Exchange has made great strides in advancing HIE nationally by addressing important technical and policy issues that have impeded scalability, and by increasing trust and confidence in the value and accuracy of HIE among users. The findings and lessons learned from monitoring and evaluating VLER Health Exchange have led to an advanced, incremental approach to expanding VLER Health Exchange to address a number of program improvements that are critical to national expansion and

Author contributions

All of the authors helped to conceptualize this manuscript, and contributed to the writing, carefully reviewed, and revised the paper. All of the authors informed and helped to design the clinician and Veteran interviews. Authors Byrne, Olinger, Pan, Botts, Mercincavage, and Banty developed and implemented the data collection and analysis plan for the evaluation discussed in the paper, which was one source of information. Authors Botts, Mercincavage, and Banty managed and conducted the

Conflict of interest

None declared.

Summary points

What was already known on this topic:

  • Health Information Exchange is supported by policymakers because of its potential to improve healthcare quality and efficiency; however, HIE requires substantial policy, technical, and standards intervention to become widespread and successful.

  • Few studies have assessed the impact and success of HIE, including the clinician and patient acceptance and experience with HIE, usage trends, and impact on patient care.

What this study has

Acknowledgements

We wish to acknowledge the contribution and assistance from LeAnn Roling, Dr. Katherine Gianola, Dr. David Haggstrom, Dr. Michael Weiner, and all VLER Health pilot site Community Coordinators. They helped to support and strengthen this evaluation and provided valuable insights about the VLER Health Program.

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    Mr. Banty no longer employed by Westat. His Current address is Medford, MA, USA.

    2

    Dr. Cromwell is no longer employed by the Department of Veterans Affairs. His Current address is Salt Lake City, UT, USA.

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