Kaiser/VA/DoD partnership piloting a nationwide EHR network

Early testing encouraging; improvements in quality anticipated

It appears that the federal government's vision of a nationwide health IT network is starting to become a reality, with the launch of a pilot program by the Department of Veterans Affairs and Kaiser Permanente — soon to be joined by the Department of Defense — that will allow the exchange of electronic health record information between VA and Kaiser providers (and soon the DoD as well) for veterans who receive care from both entities and agree to participate. The program utilizes the Nationwide Health Information Network created by the Department of Health and Human Services.

"The ability to share critical health information is essential to interoperability," said Secretary of Veterans Affairs Eric K. Shinseki in announcing the program. "Utilizing the NHIN's standards and network will allow organizations like VA and the Department of Defense to partner with private-sector health care providers to promote better, faster, and safer care for veterans."

The pilot program currently connects Kaiser Permanente HealthConnect and the VA's electronic health record system, VistA, two of the largest electronic health record systems in the country. The DoD's ALTA system will be linked to the other two shortly.

Prior to the launch of the pilot program, the VA and Kaiser Permanente sent a joint letter to veterans in the San Diego area who receive care from both institutions, to invite them to participate in the pilot program.

"We've had an excellent response rate to the invitation letters," says John Mattison, MD, chief medical information officer and assistant medical director for Kaiser Permanente. "We sent the letter to 1,200 veterans and received positive responses from well over 30% in the first week." Ultimately, he adds, the partners plan to have an ad hoc process to allow patients to opt in and sign up "right on the spot."

Patient privacy will be ensured, says Mattison. "We are using industry-leading standards for privacy and security throughout the course of this trial," he asserts. "There are industry standards in this space, and we use all of them. We've been through a very elaborate policy discussion to be sure to use every possible security element; we're not taking any shortcuts."

A logical partnership

Mattison says the partnership between these organizations makes a great deal of sense. "What makes these three organizations unique is that we have very large-scale operations and nationwide operations — and, in the case of the Department of Defense, international operations," he explains. "That puts us all in a relatively common position with respect to some of the health information exchange initiatives."

These initiatives were originally launched, he says, with the intention of helping Regional Health Information Organizations (RHIOs) produce mechanisms and policies for exchanging information. "That's great, and we support multiple regional and statewide exchanges, but what we can't afford to carry as overhead for our members is the cost of connecting to every proprietary system," Mattison says. "So, what we've endeavored to do for many years is have a single mechanism and policy framework, so whether the patient is in a small county in Georgia or a large one in California, the same mechanisms will be in place — and that same objective is very near and dear to the strategists at the Department of Defense and the VA."

Solving such a challenge on a small scale is difficult, says Mattison, and on a large scale it is even more difficult. "But we at KP and our counterparts felt it was so important to solve we put up our own money to blaze this trail for the country."

Test results 'encouraging'

Mattison says that prior to the pilot launch, some initial testing was conducted. "I'm excited that we had some very encouraging results with the testing and trial, which was with real patients," he says.

The test, conducted Sept. 30, 2009, involved a single patient in the VA and a single patient in a Kaiser Permanente clinic, both treated on the same day. "When the patient first came to the VA hospital the doctor interviewed him. He said, 'I see you've given permission for us to access information at Kaiser Permanente; may we do that now?'" Mattison shares. "With a single-click request, the doctor instantly retrieved all previous conditions, medications, and allergies out of our system. At the end of the interview, a doctor on the Kaiser side was able to get an updated list from the VA on the same patient." On the same day, a Kaiser patient in San Diego "had an exactly symmetric situation."

The test, he adds, was observed via webinar by the Office of the National Coordinator of the Department of Health and Human Services, which handles health IT. "This is the largest-scale pilot using exactly what the government has prescribed," Mattison explains. "Their offices were intimately involved and engaged in discussions and the planning session."

The test, Mattison continues, demonstrated far more than technological wizardry. "The Kaiser Permanente patient had not been seen by us in a long time, but when we pulled up his VA records, we found two recently reported life-threatening allergies at the VA to extremely common medications," he says. "It would have been quite easy, in the absence of that information, for the KP physician to prescribe a different drug in the same class — one was an anti-hypertensive, the other a cholesterol-lowering drug. So, the doctor could have prescribed that other drug and the patient could have said he had no allergy to it. This is a powerful illustration that something as simple as the exchange of this information could be of immense clinical and patient safety benefit."

Quality is key

The goal of the program, first and foremost, is to improve the quality of patient care by having more comprehensive access to information, says Mattison. "In the past, when that vet came into the Kaiser Permanente clinic and said they had been seen at the VA a couple of months ago, what happened was if the doctor had them sign a release, and if the VA had the time, they would copy some records they thought we might be interested in and they would be sent to our medical records department," he notes. "Some doctor here would then sit at their desk and review the information; that whole process would take weeks to months. We've already shown that in less than a second that whole loop can be closed. This is a profound change."

Mattison continues: "What you don't know about a patient will hurt you in health care; from a physician's perspective it's unnerving to know there are other records somewhere you can't access."

He says the partners have engaged a third party to come in and perform objective measurement of all outcomes. "Because this is a pilot, we're trying to keep participation at a low level until we figure out how best to use it and harden the infrastructure," he explains. "We will evaluate every element and identify the best quality and safety indicators. We have a long list of metrics, and the initial work of this consultant will be to help us narrow them down."

The technological solution

While improved quality and safety are the ultimate goals, "the pilot itself really focused, in addition, on establishing the technical solution so that once we've established that this solution is rock solid, we can fairly easily roll it out to all of KP, the VA can do all of the VA, and the Department of Defense can do the same," says Mattison. "The power of this solution is the way we send and receive information over the wire is the same — the same protocols, the same standards. That is a very powerful demonstration of how when you use open standards programs they can be rolled out very quickly." In addition, he says, "Once we prove this works in one location, we know it will work in any location. We also know that anyone who chooses to join us can do so."

That's because the partners are using internationally accepted standards for how document exchange is handled. "It's not an accident that the pilot site is in San Diego, because the continuity of care document was co-founded here by myself and a good friend of mine 12 years ago, and now it is an international standard — part of the clinical document architecture," says Mattison. (This architecture now includes standards known as HL-7, CDA, and CCD.)

Thus, he continues, "The CDC [Centers for Disease Control and Prevention] is staged to be one of the participants in the future. Other smaller organizations in California have already stood up the same infrastructure; they want to join and will in due time." All that will be needed, he says, is for the participant to be able technologically to interface with the network and to sign a Data Use and Reciprocal Support Agreement.

(For more information, contact:

John Mattison, MD, e-mail: john.mattison@kp.org.)