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"Closing the Data Gap: Improving Interoperability Between VA and Community Providers"

House Veterans Affairs Committee, Technology Modernization Subcommittee Hearing

March 24, 2025 (recording here)

HEARING INFORMATION

Witnesses & Written Testimony (linked):

• Dr. Jonathan Nebeker, M.D.: Chief Medical Informatics Officer & Executive Director of Clinical Informatics, U.S. Department of Veterans Affairs

• Dr. Laura Prietula: Deputy Chief Information Officer, U.S. Department of Veterans Affairs

• Mr. Rick McGraw: Chief Growth Officer, Michigan Health Information Network Shared Services

• Dr. Andrew Rosenberg, M.D.: Chief Information Officer, Michigan Medicine

• Dr. Leo Greenstone, M.D.: Chief Medical Officer, Signature Performance

Keywords mentioned:

• Interoperability, Electronic Health Record Modernization (EHRM), Trusted Exchange Framework and Common Agreement (TEFCA), Qualified Health Information Network (QHIN), community care, data quality

IN THEIR WORDS

OPENING STATEMENTS FROM THE SUBCOMMITTEE

• Chairman Tom Barrett opened the hearing with a note underscoring the importance of timely submission of testimonies, particularly from the VA, to allow the Subcommittee staff adequate preparation time. He then explained the critical role of healthcare data interoperability in ensuring that veterans receive high-quality care regardless of the provider or facility. He outlined both progress made and existing gaps, especially with smaller providers, and called for standardized, interoperable data to fulfill the VA’s commitment to veterans.

• Ranking Member Nikki Budzinski stressed that interoperability is essential for effective, veteran-centered care and supports seamless care coordination. She claimed that the VA's decentralized electronic health record (EHR) system has long hindered these efforts, and while recent modernization initiatives are commendable, they still fall short. The Ranking Member then criticized the Trump administration’s workforce cuts at the VA, warning of worsening delays and diminished care quality. She advocated for improved training, greater accountability among community care providers, and a broader conversation with vendors and administrators about expanding and enforcing interoperability tools.

SUMMARY OF KEY POINTS

• Dr. Jonathan Nebeker detailed the VA’s advancements in data interoperability, including the implementation of tools like the Joint Longitudinal Viewer (JLV) and joint Health Information Exchange (HIE), which have significantly improved access to shared medical data. He noted that while progress has been made, especially with large healthcare systems, connectivity with smaller providers remains limited. He mentioned the VA’s work with national frameworks like the Trusted Exchange Framework and Common Agreement (TEFCA) and initiatives like the Veterans Interoperability Pledge, aimed at improving patient identification and care coordination. Dr. Nebeker emphasized the importance of continued collaboration and standardization to enhance data quality and ensure comprehensive care for veterans.

• Mr. Rick McGraw explained how the Michigan Health Information Network (MiHIN) has facilitated healthcare interoperability statewide by connecting over 5,300 healthcare facilities and processing more than 8.3 billion data messages. He described how real-time data sharing, including ambulance-to-hospital transfers, has greatly improved patient care. Mr. McGraw said that the VA and Department of Defense (DoD) currently represent a blind spot in Michigan’s health data network, creating significant gaps in veteran care. He argued that existing national exchanges are insufficient substitutes for robust, state-level health information exchanges and asked for better integration of VA data into systems like MiHIN.

• Dr. Andrew Rosenberg spoke on the ethical and practical necessity of health information exchange, calling it a common-sense expectation for both providers and patients. He noted dramatic improvements over the past decade, with Michigan Medicine now exchanging over 220,000 records daily, including thousands with the VA. He credited standardized frameworks and government regulations for this progress but acknowledged that providers face challenges navigating numerous digital systems. Dr. Rosenberg concluded that while current tools are significantly better than past systems, further improvements are needed to streamline workflows and reduce provider burden.

• Dr. Leo Greenstone brought a dual perspective as a former VA physician and administrator, illustrating the complexity of achieving interoperability despite decades of effort. He stressed the importance of integrating technology with people and processes, advocating for better workflows and change management to reduce reliance on outdated methods like fax machines. Dr. Greenstone proposed leveraging tools like the Provider Profile Management System (PPMS) and establishing a closed-loop referral and documentation process to ensure VA and community providers share comprehensive data. He also recommended aligning the VA closely with the Department of Health and Human Services (HHS) and EHR vendors to improve coordination and data exchange across the healthcare continuum.

• Chairman Barrett asked whether duplicated procedures occurred due to a lack of data transfer or interoperability. Dr. Greenstone shared a personal example of a veteran whose recent emergency room visit data was not accessible, leading him to potentially reorder redundant tests. Dr. Rosenberg estimated that about a third of such cases involved duplicated or unnecessary procedures, particularly when accessing pre-existing data was difficult or incomplete. Both stated that incomplete or poor-quality data—especially notes and specialty visit records—created gaps in clinical decision-making despite technical connectivity.

• Chairman Barrett followed up by asking whether the issue was the ability to send data or how the data was organized and displayed. Dr. Greenstone responded that even connected providers often lacked critical information like office notes or procedural summaries, revealing a gap in data completeness. Dr. Rosenberg added that better quality and more accessible data would particularly help avoid redundant expensive procedures like biopsies or specialized imaging.

• Ranking Member Budzinski questioned Dr. Nebeker about the VA’s claim of 90% interoperability with U.S. hospitals. Dr. Nebeker explained that the figure was based on the number of hospitals connected via the eHealth Exchange, but he admitted he could only speculate on the exact calculation method.

• The Ranking Member then asked about requirements for community care providers to return records to the VA. Dr. Nebeker responded that documentation requirements applied only to VA-authorized care, and many other visits remained unrecorded in VA systems. He acknowledged gaps in receiving emergency room and office visit data, particularly from community providers not integrated into the VA’s exchange.

• Chairman Barrett asked if missing data was due to transmission failure or access restrictions. Dr. Nebeker explained that the VA’s systems query partner EHRs for documents, but some providers simply do not send certain data elements, leading to missing information. 

• The Chairman questioned why only partial data would be sent, to which Dr. Nebeker clarified that it was likely unintentional and could result from how external systems organize and export their records. They also briefly discussed the Veteran Interoperability Pledge and its limitations around veteran status, which is defined by Title 38 and confirmed through DoD records.

• Chairman Barrett asked how MiHIN handled out-of-state care, such as for “snowbirds.” Mr. McGraw explained that MiHIN paid for access to national exchanges and could retrieve out-of-state records for patients when requested. Chairman Barrett then clarified that MiHIN stored health records in cloud-based servers and maintained a longitudinal record accessible via its portal, which could be used by providers even if they did not contribute data. Mr. McGraw confirmed this, stating that 79 EHR systems were connected to MiHIN, and participating providers could view patient histories regardless of their specific EHR.

• Ranking Member Budzinski revisited the issue of full bi-directional interoperability between VA and community care. Dr. Rosenberg said that there were not necessarily “disconnects,” but rather evolving gaps due to administrative burdens in setting up data exchange systems, especially for smaller institutions. Mr. McGraw identified cost and time constraints as primary barriers to interoperability for local facilities, noting that financial incentives helped drive participation in MiHIN’s push-based data model. Dr. Greenstone added that many small or rural providers lacked awareness or resources to connect and that third-party administrators could play a larger role in facilitating these integrations.

• Chairman Barrett asked if MiHIN subscribers must join additional networks to access out-of-state data. Mr. McGraw said no, as MiHIN manages those national exchange connections on their behalf. He then clarified that MiHIN stores data in cloud servers and updates the longitudinal patient record within four minutes of a new entry. Providers can access this data through MiHIN’s portal, even if they do not submit data themselves.

• The Chairman then asked about safeguards to prevent unauthorized access to health records. Mr. McGraw explained that MiHIN uses an Active Care Relationship Service (ACRS) to restrict access to providers with legitimate relationships with a patient. He also noted that a “common key” service ensures consistency across systems using varying patient identifiers. Dr. Rosenberg added that some EHRs include internal safeguards like “break-the-glass” alerts when accessing sensitive data, and he called for continued refinement to balance access and privacy.

• Ranking Member Budzinski questioned witnesses on the impact of recent mass terminations of VA staff, particularly Health Information Management (HIM) personnel critical to data uploads and interoperability. Dr. Nebeker stated he did not have the data on how many staff were affected but committed to following up with the Committee. The Ranking Member questioned how the VA planned to meet its goal of full Qualified Health Information Network (QHIN) participation by December 2025 without these critical staff. Dr. Nebeker responded that the necessary staff for QHIN integration were located at the central office and, to his knowledge, staffing there was sufficient for implementation.

• Ranking Member Budzinski asked how many contracts related to the Electronic Health Record Modernization (EHRM) program had been canceled since January 2025. Dr. Laura Prietula reported that her office was still reviewing requests for information and would provide details once the review was complete. She was not aware of specific contract cancellations.

• Chairman Barrett asked whether VA facilities typically participate in regional joint HIEs. Dr. Nebeker replied that the VA was not currently a member of any regional joint HIEs but aimed to gain connectivity through TEFCA by joining a QHIN that connects with regional exchanges.

• The Chairman inquired about the Indian Health Service's (IHS) status with QHINs. Dr. Nebeker confirmed that IHS was the only federal agency connected, using a variant of the VA’s legacy VistA EHR system. Chairman Barrett also asked whether Oracle was building its own QHIN, which Dr. Nebeker confirmed, though he said it was premature to assume that the VA would use it.

• Chairman Barrett followed up with questions about how TEFCA might address the VA’s interoperability gaps. Dr. Nebeker explained that TEFCA provided the legal and technical framework for trust and connectivity, though it did not address data quality. He underscored the importance of computable, standardized data, citing studies showing that the VA could determine colonoscopy needs from shared data only 35% of the time.

• Ranking Member Budzinski asked about the utilization rate of tools like JLV and HealthShare Referral Manager (HSRM) among community providers. Dr. Greenstone explained that approximately 130,000 providers in the Community Care Network were provisioned to use HSRM, especially those receiving multiple referrals. He noted that utilization was high among high-volume users (75–100%) but lower in facilities still using outdated methods like faxes due to local VA center preferences or limitations.

• The Ranking Member then asked how the VA planned to reduce reliance on fax machines and increase the use of interoperable tools. Dr. Nebeker said that a key barrier was the lack of standardized workflows across providers and that the VA needed to align its systems with those used in the broader healthcare community. He highlighted the Elizabeth Dole Act’s provision for collaboration with HHS as a positive step in this direction. Dr. Prietula added that the VA had been working on interoperability for over 20 years and was exploring alternatives to faxing, such as secure messaging. She pushed for semantic interoperability and praised the role of open-source collaboration in improving standards alignment.

• Chairman Barrett asked Dr. Nebeker to clarify whether his earlier comments on data quality referred to technical format or physician documentation. Dr. Nebeker responded that he was referring to the technical side—how data is transmitted from EHRs to external systems and whether it arrives intact and usable. He provided an example of data being scrambled during transfer, such as incorrect units or implausible values, which undermines clinical usefulness.

• Ranking Member Budzinski stated that seamless interoperability was essential for veterans and that recent personnel actions risked undermining those efforts. She claimed that staffing, not just technology, was crucial for success and that a complete medical record was necessary for proper veteran care.

• Chairman Barrett echoed the importance of interoperability in connecting the VA with the other 97% of hospitals in the U.S. He underlined that community care would always be a major part of veterans' healthcare and urged the VA to lead in interoperability efforts, expand its partnerships, and deliver better outcomes.

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