MIDTERM PROPOSAL 3
Introduction: The Health Information Technology (HIT) and Electronic Health Record (EHR)
systems of the United States Department of Defense (DoD) and the Veterans Health
Administration (VHA), respectively, have been lauded as pioneers of Health Information
Technology design and deployment successes. Although certain services are currently linked
between the two health systems, the DoD’s Military Health System (MHS) EHR and the VHA
VistA EHR system had not been previously linked. The development and implementation of a
joint DoD/VHA EHR system would support and improve continuity of care for service members,
veterans, and their families, improve quality and evidence-based care, and continue the legacy of
innovative HIT implementation in these respective health systems. The following sections
outline recommendations for the development and deployment of a joint DoD/VHA joint EHR
system by relevant categories for consideration.
Scope and functions of a joint DoD/VA HER: Both the DoD and VHA EHR systems have
been developed over the past five decades and include many custom and proprietary elements as
artifacts of their development. In a joint EHR the functionalities of these existing systems need
to be combined with additional military-specific clinical functionalities, such as mental health
alerts, increased access to injury rehabilitation resources via EHR systems and referral tracking,
and chronic disease management for aging veteran populations. Additional functionalities that
should be included are those that facilitate continuity of care across the two systems for service
members, veterans, and their families; this may be facilitated through developing a patient portal
in the EHR system. One major challenge of making the two systems interoperable will be to
ensure that functionality and usability are continued across the merge while consolidating the
existing system differences.
System Architecture: The architecture of joint DoD/VHA EHR system must enable patientcentered and quality care, promote integration over interoperability, and reduce health and IT
expenditure for both the DoD and VA. To accomplish these needs, the joint DoD/VHA EHR
architecture must organize and utilize data fields shared by both departments in one enterprise
patient centric data system, characterized by common standards, applications, middleware, and
data centers. The shared data fields ought to relate back to a Master Patient Index and
demographic table to ensure accurate patient specific information can be stored appropriately,
accessed, and retrieved. From this common infrastructure shared and specific applications to the
DoD or VHA can be integrated to the MUMPS database level so that shared data is not repeated.
Additionally, applications can be updated and distributed only on servers in data centers, which
is more efficient than maintaining software and infrastructure in multiple clinic locations.
The VistA EHR system contains the data fields necessary for clinical care across the US
and has achieved HIMSS Stage 7 qualifications. Demonstrated HIMSS Stage 7 qualifications
will allow an iEHR system to easily extend quality clinical data for military personnel and
families into external Health systems through utilization of messaging standards like HL7. The
DoD requires highly specific functionality and potentially top-secret information, which the DoD
should house in its own servers under its own safeguards. This group recommends the iEHR
system model existing and successful VistA architecture.
Software Procurement: We recommend that the DoD and the VHA continue the development
of in-house software through the Open Source Electronic Health Record Agent (OSEHRA).
OSEHRA is a an independent, nonprofit organization that serve as the central governing body of
a new open source EHR between the VA and DOD in creating single electronic health record
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system for service members and Veterans. OSEHRA has deployed an open source model for
software development that creates the infrastructure for efficient and collaborative interactions
between developers, users, vendors, service providers and other stakeholders. In-house software
will allow the flexibility to customize the software to meet unique needs, minimize changes in
agency procedures and policies, meet constraints of existing VistA system and enhance existing
internal resources and capabilities.
Staffing and Project governance: Strong leadership and project governance will be critical to
the implementation of a joint EHR between the DoD and VHA. Continuous input from both
DoD and VHA personnel should be provided to developers, implementers and end users of the
joint systems, for example, via optional surveys offered regularly, to ensure that deployment is
on track and the integrated system has the desired functionality. The VHA has been identified as
the institutional focal point for the implementation of a joint system, and will thus be held
accountable for design and deployment governance and for oversight of the project and of staff.
Successfully tested functionality will have to be loaded into the iEHR data center by
dedicated staff that will be responsible for maintaining and updating the iEHR on data center
servers. Implementation specialists will be needed at care locations to ensure the new
functionality is utilized appropriately, efficiently, and does not interrupt work flow or the quality
of clinical care. Work flow should be studied and considered in the development and
implementation to ensure maximum benefit of the iEHR. Training is also recommended for
clinical and administrative staff at care sites to ensure the iEHR is utilized appropriately.
Deployment Strategy and Schedule: Identified leadership within the DoD and VHA will
initially determine the core components and primary functionality for development into the
iEHR. These priorities must then be distributed to the Open Source Electronic Health Record
Agent (OSEHRA) for community development. New functionality should then be tested by both
VHA and DoD developers to test the functions. Data definitions will also require
standardization and the system architecture will need to be developed. When the data standards
and system architecture are completed, system testing will be started on system functionality and
vocabulary. Sample patients will be passed through with an extensive number of data points
relative to the general patient population. When validation is complete then open deployment
will be launched.
The development stage should be allowed the most time since proper design should
minimize the issues in the testing phase. 8 months will be allocated for design and vocabulary
standardization. Concurrently testing scenarios will be developed, as the VHA is aware of which
data elements should be populated prior to design. Testing will be allocated 2 months with a 2
month flex time for beta testing and any needed repairs
Process for EHR maintenance and ongoing enhancements: A committee dedicated to system
maintenance for ongoing enhancements will be formed of clinical and executive DoD and VHA
health system administrators. Additionally, staff for sub-committees should be identified to
address maintenance and ongoing issues with design and deployment. These committees will
meet frequently following iEHR system deployment for timely identification and response to
issues that arise in the deployment process. Teams or sub-committee members will need to be
from geographically diverse areas to promote maintenance and enhancement needs system-wide.
The executive committee dedicated to maintenance and ongoing assessments should consider the
following issues when assessing and addressing the joint iEHR system: strategic budget for longterm software and hardware needs; ongoing evaluation of appropriate data sets and system use;
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staff training and support; the need for adaptation of modules; processes to support efficiency;
continual checks that iEHR functions support performance management and quality
improvement objectives; and review of legislation that may support or impair the ability for
iEHR to operate optimally.
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Works Cited
Baker GR, MacIntosh-Murray A, Porcellato C, Dionne L, Stelmacovich K, Born, K. High
Performing Healthcare Systems. Toronto, Canada: Longwoods Publishing Corporation;
2008.
Berrios, Wilbert. Briefing to the Department of Defense Task Force on the Care, Management,
and Transition of Recovering Wounded, Ill, and Injured Members of the Armed Forces.
Presentation on 19 May 2011.http://dtf.defense.gov/rwtf/m04/m04pa09.pdf. Accessed
November 23, 2011.
Brown, Steven H. VistA U.S. Department of Veterans Affairs National-scale HIS. International
Journal of Medical Informatics. (2003;69:135-56.
http://distance.jhsph.edu/fileDepot/onlineLibrary/258/VistA%20US%20Dept%20of%20
Veterans%20Affairs%20National%20scale%20HIS%20by%20Brown%20Lincoln%20Gr
oen%20and%20Kolodner_copy-1.pdf.Accessed 30 Nov. 2011.
Government Information Group. Towards a single military HER. Insights: Health IT Custom
Report. http://www.defensesystems.com/Microsites/2011/Insights-Health-IT/02-DODVA-EHRs.aspx. Accessed November 23, 2011.
MHS. IM/IT Strategic Plan 2010-2015. January 2010.
http://www.health.mil/Libraries/OCIO_Documents/MHS_IM-IT_Strategic_Plan_20102015__January_2010.pdf. Accessed November29 2011.
US Department of Veterans Affairs. Department of Veterans Affairs, VA Launches Open Source
Custodian – Media Release, August 30, 2011.
http://www.businesswire.com/news/home/20110830006887/en/VA-Launches-OpenSource-Custodian. Accessed on November 25, 2011.
MIDTERM PROPOSAL 4: Recommendation to the US Departments of Defense and Veterans
Affairs: Merging and Maintenance of a Joint Electronic Health Record System
Introduction
The pursuit of a common electronic health record (EHR) system by two of the largest and most complex healthcare systems in the
country is nothing short of daunting. The Department of Defense (DOD), through its Military Health System (MHS), operates 59
hospitals and 364 outpatient clinics and provides healthcare to more than 9 million healthcare beneficiaries. It serves a highly
transient population, both patients and providers, worldwide. The Department of Veterans Affairs (VA) serves over 8 million
veterans annually through over 1400 points of care. Although the organizations have significantly different missions and each
interacts at different times in a service member’s life, the DOD and the VA share responsibility for the health of United States service
members. A unified, patient-centric, longitudinal, EHR that is available to medical providers in both systems could serve to improve
the quality and delivery of healthcare.
Scope and Function
The scope of this joint EHR must address continuity of care, the continuum of care interoperability, and shareable data and
processes. It must include the functionality to seamlessly integrate ambulatory, inpatient, primary and specialized care, clinical
decision support, pharmacy, laboratory, radiographic, multimedia, outside consultation/referral management, scheduling, and
billing, as well as support needs that are unique to each organization, i.e. home care for VA and in-theater care for DOD. The
function of this comprehensive patient record should allow clinicians to take care of a patient in any setting, at any time, across the
health care continuum.
Purpose
The current DOD and VA EHR systems, AHLTA and VistA respectively, are limited regarding interoperability and data sharing, partly
due to lack of standardization of data. Although both programs arose from the same programming language, the internallydeveloped or acquired applications were designed to fulfill different objectives at the time. This has led to development of systems
that are unable to contribute to patient care continuity and quality. With the health information technology (HIT) available today, a
joint EHR system can support the requirements of both systems by drawing on both AHLTA and VistA functionality.
System Architecture
The system architecture should be a more modern framework, such as a service-oriented architecture
(SOA) versus a component-based architecture. “SOA aims to allow users to string together fairly large chunks of functionality to
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form ad hoc applications that are built almost entirely from existing software services.” Once the components are identified and
mapped, a centralized platform of services and applications managed by a common service broker would be able to extract data
from one application and present it in another. The common service broker, “provides the interconnections among various
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applications and services and enables internal and external systems to exchange information.” Another advantage of SOA is that
Department specific services can be plugged in to this broker and replace current components as technology advances or medical
practice changes.
This centralized approach, utilizing a web-based EHR with a single, integrated clinical data repository in which there would be a
single (one-to-one), complete record for each patient, would reduce fragmented records and patient mis-identification, improve
verification of patient eligibility and scheduling, ensure availability of the complete medical record across the spectrum of care, and
enable aggregation of health data for population management and system performance/improvement functions. Centralized
oversight of the EHR system would also enable a centralized maintenance function that could efficiently provide system updates,
security patches, integrate current DOD/VA CPGs in CDS functionality, and ensure all sites across the globe are functioning on the
same version of the EHR.
As seen with the implementation and evolution of VistA, this open-source approach allows for rapid development, improvement,
and user satisfaction and ownership which is not often achievable; for the joint system, expanding on the VA process for requiring
standardization of data and elements would allow for the centralized data storage and a single patient record while supporting the
benefits reaped from the open-source communal development. While centralized data and maintenance may provide efficiency and
standardization for both systems, the user interface and selection of functionality should be locally modifiable by users/leadership to
enable localized workflow integration, continued innovation for continuous improvement, and support user acceptance.
Software development
When available, the joint EHR should leverage existing open-source or purchase existing systems and functionality modules that can
be integrated with minimal vendor dysfunction. In-house development of a de novo system would be costly, time-prohibitive, and a
waste of tax dollars. The existing, competitive EHR systems have all been in existence for many years and have decades of
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MIDTERM PROPOSAL 4: Recommendation to the US Departments of Defense and Veterans
Affairs: Merging and Maintenance of a Joint Electronic Health Record System
experience and lessons learned which should not be reproduced by a government in-house development team. The VA has several
years of experience in successful evolution and improvement of the VistA system to bring to the joint EHR system. With the recent
creation of OSEHRA, an open source agent for the VA, along with participation from the DOD, innovation in the private sector and
collaboration between Departments can be leveraged to potentially upgrade or replace large chunks of each system. This
“morphing” approach will minimize the impact to patient care, eliminate redundancies, increase clinician buy-in, and allow the best
of each system to surface.
Project Governance
The VA and DOD have decades of experience working together since Public Law 97-174 mandated that they share healthcare
resources. However, a venture of this size and complexity requires a reassessment of the current management environment. A joint
strategic plan should be either created or updated annually and serve as a guide for this project. For a single EHR to support the
diverse missions of both organizations without evolving into two distinct systems from local development, the governance of the
joint EHR would require representation from both the DOD and the VA. First, an Executive Council should provide leadership,
support, and stakeholder collaboration. Then, a Governing Board, comprised of clinical, business, and IT leaders, should be held
accountable for the implementation and success of the project. Lastly, a comprehensive Project Management model should be
developed for all the functions as determined by the Governing Board. Throughout this entire process, it is important that
healthcare provider and patient contributions be solicited and valued as these particular stakeholders offer crucial insight to
ensuring that patient care is not compromised.
Staffing and Maintenance
With a centralized, functioning governance body representing DOD and VA that ensures integration through use of standards while
allowing local modification and adaptability, a central maintenance function providing system-wide updates and bringing locally
developed improvements and innovations to the system as necessary, and the utilization of existing open-source and vendors with
years of experience, the local staffing required would be IT personnel to ensure connectivity/security and training personnel to
provide local user support. Centralized staffing would include help desk staff; IT personnel to maintain connectivity, hardware and
database maintenance; a team to evaluate and test innovations prior to delivering system wide; and contracting personnel to
manage vendors in various spaces of EHR development, CDS, and system integration.
Implementation
Phased implementation of the joint system should be overseen by the governance body and would be dependent on the situation in
both organizations (i.e. operational tempo), but should involve sites in both the DOD and VA to enable early joint successes,
demonstrate cooperation, and to identify barriers in each organization to be addressed in subsequent implementation phases. The
schedule of initial implementation should be rapid enough to allow a single version to be operating and centralized processes testing
and improved prior to pushing enhanced versions. Implementation of innovations and improvements derived from both the user
community and the centralized oversight function could be as a system roll-out or a phased approach depending upon the
anticipated impact on workflow and barriers to user acceptance.
Summary
The development of a longitudinal, comprehensive EHR that supports the geographical and diverse requirements of two large health
systems that provide comprehensive healthcare for a complex patient population is a challenge. The DoD and the VA can ensure a
successful representative joint healthcare record by collectively applying the following: leveraging decades of vendor experience and
open-source community knowledge; addressing the needs for modular functionality that seamlessly integrates primary and
specialized care, inpatient, ambulatory, and ancillary care, and supports administrative functions such as scheduling and billings;
developing and enforcing standards that allow for local modification of user interface as well as the development and maintenance
of a centralized data repository to support a single life-time record for each patient, aggregation of data for population
management, performance improvement, and creation of a learning system to advance medical evidence; implementation of a
collegiate and functioning governance body which ensures both organizations’ requirements are met; and, developing an efficient
centralized oversight function that both provides standardization for integration across the system. It is our recommendation that
these activities will create a healthcare technology environment that will improve the quality of care provided to those who defend
the United States of America.
References
1.
2.
http://en.wikipedia.org/wiki/Service-oriented_architecture. Accessed on 11/25/2011
http://govhealthit.com/. Accessed on 11/25/2011
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MIDTERM PROPOSAL 5
Recommendations for Implementing and Maintaining
The Joint DOD/VA Electronic Health Record System
Scope and Functions
The Veteran's Administration (VA) and Department of Defense (DoD) represent a continuum of
care for soldiers, sailors, airmen, and marines which should be reflected by a joint, interoperable
electronic health record (EHR). Each department has developed respective systems over the
years, more recently successfully implementing some levels of health information exchange (1).
Yet, military medical healthcare delivery itself does not function as a fully integrated system, and
aging devices limit complete capture of in theatre data acquisition. A comprehensive, seamlessly
interoperable system is now more achievable. Demographic data can be captured via common
access cards rather than entered manually, and tablet devices may be used to access systems
rather than older Motorola devices to access the army's in theatre medical record system,
AHLTA-T (2). Improvements in healthcare delivery to the theatre, including forward surgical
care, have improved survival, so that the ratio of injured to killed in action is now 17 to 1 rather
than a historical ratio in the single digits. In addition, the asynchronous warfare of the last decade
has produced many survivors with unique psychosocial and neurologic deficits as well as
amputees. This "success" means a larger burden of care with specific needs. These healthcare
recipients are also more technologically savvy. An ideal joint, interoperable DoD/VA system
would allow for the unique needs of the current recipients and adapt to fluctuating level of troop
active duty and reserve forces, adjusted to meet budget constraints and new threats. Current
levels of HIE will need to be expanded to insure key past medical history summaries and surgical
care is included. Special needs populations may require specific surveillances and clinical
decision support. Registries of specific diagnoses and/or injuries are likely to be key sources of
secondary use data, particularly for case-control studies of rare health outcomes of interest. As
those veterans age, optimization of interoperability with Medicare databases should be
considered, both to coordinate primary care of the patient, and insure quality of secondary use
data (to make sure patients are double counted in different databases) (3).
Specific next steps to achieve validated problem lists are complex and may require a multiphase
timeline utilizing multiple approaches. While administrative databases could be used to generate
lists of potential diagnoses assigned to a given patient over time, the positive predictive value of
any code may vary considerably depending on the database used. Similarly, natural language
processing of free text has shown promise but can stumble over syntactic expressions of multiple
types and requires a similar, clinical validation. Likely both the patient and physician will need
to be engaged to ensure that a final, validated set of diagnoses are assigned for each patient. This
may be conceptualized similarly to what is currently done in emergency rooms for medication
reconciliation. Likewise the next steps for development of advanced clinical decision support for
special needs populations will require the development of a pathway for the flow of information
from disease registries through replication studies (possibly controlled clinical trials),
incorporation into consensus guidelines, comparison with controlled vocabularies/terminology
services, and ultimately deployed in advanced clinical decision support applications. While the
VA may not have as much of a vested interest in reimbursement for various procedure and
diagnostic codes, attention to reimbursement may affect the adoption of specific codes by
Page 1 of 5
external facilities and subsequently affecting VA patients. Thus, a high degree of semantic
interoperability will be a goal for the next wave of Vista development (1).
Architecture
The three independent EHR systems are interoperable with a Joint Patient Tracking system
(illustrated in Appendix I) (1), which assigns a unique identifier for single individuals. The
tracking system is connected and interoperable with the compensation and pension system, a data
warehouse for long term storage and analysis, and an active clinical data repository. The latter
collects computable data from all systems into a single patient record that drives the clinical
decision support functions of each system. It is also connected to external Pharmacy Benefit
Managements (PBMs) and health information exchanges.
Buy or Build
The decision to buy, build, or outsource health information systems is based on a variety of
project-specific factors as well as cost, suitability, and time-to-deployment for new or modified
IT systems. Buying off-the-shelf products may have lower initial costs and quick deployment
time, and there is already support and access to training materials. However, these off-the-shelf
products often do not fit the needs of the organization. On the other end of the extreme, internal
development requires substantial technical skill but allows for a tailor-made IT solution to fit the
organization's needs. Challenges with this approach may include a longer time frame for
development and deployment, difficulty in estimating time and cost requirements, and challenges
with ongoing maintenance and support. A compromise between the two is to outsource the
project, and doing so with a third-party developer reduces risks and permits an aggressive
timeline for a custom product.
Given the need to merge two existing systems with unique software needs, an off-the-shelf
product is unlikely to be sufficient. As the VA has recently pledged to make VistA open source,
the joint VA/DoD endeavor would build off of VA’s evolving system. Outsourcing is the
recommended solution for software development. The VA/DoD venture should tap into market
competition for the optimal product, and given the size of the market share for a join VA/DoD
electronic health record system, vendor solicitation would spur competition and accelerated
development. A Blanket Purchase Agreement (BPA) Contract will be awarded to winning
vendors for their products and services.
Project Governance (4)
The VA and DoD will work collaboratively to implement the joint EHR system via two levels of
governance.
1. The top level of governance is by the DoD Assistant Secretary for Health Affairs and the VA
Secretary for Health, who direct the interagency efforts as the senior oversight and approval
authority.
2. The second level of governance is the Executive Council staffed by the Chief Information
Officers (CIOs) from the Military Health System (MHS) and the Veterans Health
Administration (VHA) or other high level Program Directors from DoD, MHS, and VHA.
The committee is responsible for the day-to-day oversight of the system development and
deployment and they are assisted by multi-disciplinary staff from the Program Management
Office.
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Staffing (4)
A jointly staffed federal health information exchange Program Management Office will be
established to accomplish the agreed upon goals and objectives. The Program Management
Office will be directly overseen by the Program Directors, and will be staffed by functional
managers from DoD, MHS, and VHA. They are responsible for achieving approved goals and
objectives of the joint effort through interagency teamwork.
The functional managers will be assisted by a support team represented by project managers,
technical specialists, and domain/clinical experts from the three agencies, field hospitals and
clinics. These staff may form workgroups to execute specific tasks and provide deliverables, for
example workgroups for system architecture design, system deployment coordination, program
evaluation improvement, etc.
Deployment Strategy and Schedule
1. Establish an advisory committee to provide sponsorship for the project. Advisory committee
will be composed of stakeholders from VA and DoD administrations, other federal agencies
(CDC, etc.), and consumers (physicians, nurses, pharmacists, and patients, etc.). They will
provide general guidelines for the project and ensure the progress of the project. (Completion
Date: October 31, 2012)
2. Establish the workgroup for the joint system. The workgroup will be appointed by
administrators of VA and DoD, under assistance of the advisory committee. The group should
meet bi-weekly during the first year of the project and monthly thereafter, to discuss and solve
issues arose during the progress. (Completion Date: December 31, 2012)
3. The work group will build the joint system under guidance of the advisory committee.
(Completion Date: June 30, 2013)
4. Obtain advice and recommendations from advisory committee and users’ group, and make
revisions. At least 3 users’ group meetings should be held to ensure the system is fully
reviewed. (Completion Date: September 30, 2013)
5. Test the joint system at 5-7 selected sites. The testing sites should be representative of VA and
DoD centers across the country. Two or three of the sites can be selected from centers that
more experienced in HIE, such as El Paso Veterans Affairs Healthcare System and South
Texas VA Healthcare System. (Completion Date: September 30, 2014)
6. Debug the system based on test results. (Completion Date: September 30, 2015)
7. Implement the system at all VA and DoD medical centers. (Complete Date: December 31,
2015)
8. Assign maintenance team to provide continuous technical support. The advisory committee
will select key personnel from the workgroup and establish the maintenance team. (Complete
Date: December 31, 2015)
Maintenance and Enhancement
EHR Maintenance and ongoing enhancement will be overseen by a project technical committee
(PTC) comprising of at least a managerial level –informatician, doctor, nurse, lab scientist,
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pharmacist, radiologist and an IT/developer (VHA & DoD will provide one person each for all
the roles).
At the facility level there will be a support/continuous quality improvement team made up of:
1. IT/Technical staff (who carry out day to day system maintenance, and provide 24 hour
support personnel in the facility),
2. Developers (responsible for writing code for enhancements)
3. Clinical staff (end users of the software –one each from radiology, pharmacy, nursing, lab and
an MD)
Systemic maintenance will be scheduled once a month at weekends; while ongoing
enhancements will be structured in such a way that feedback will be from end users:
1. On a real time basis using a feedback button within the software
2. During weekly meetings for the first four weeks in which the support team members meet
with end users; and thereafter bi-weekly meetings for the next three months
3. Thereafter Quarterly email “Requests For Comments”
4. These comments will be collated every two weeks, reviewed by the support team who decide
if the feedback is something that should be recommended to the PTC or not, or if it is
something that can be implemented locally e.g. staff workflow modifications. The PTC will
meet monthly to review all recommendations from facilities and decide which should be
implemented immediately or kept for future implementation or shelved. Decisions will then
be communicated to end users who provided the initial comment, while work will start
immediately on those that are to be implemented.
References
(1) Department of Veterans Affairs Office of Enterprise Development. VistA-HealtheVet
Monograph 2008-2009. 2008; Available at:
http://www.va.gov/VISTA_MONOGRAPH/docs/2008_2009_VistAHealtheVet_Monograph_FC
_0309.pdf. Accessed 11/20, 2011.
(2) Johnson NB. Army to field test tablets to manage medical records on battlefield. 2011;
Available at: http://www.federaltimes.com/article/20110812/IT03/108120303/. Accessed 11/20,
2011.
(3) Department of Defense. Task Force on the Future of Military Health Care Final Report. 2007;
Available at: http://www.naus.org/documents/MilHealthCareTaskForceFINALREPORT1207.pdf.pdf. Accessed 11/20, 2011.
(4) Department of Defense. Memorandum of Agreement for Federal Health Information
Exchange. 2002; Available at: http://www.defense.gov/news/May2002/d20020503moa.pdf.
Accessed 11/20, 2011.
Page 4 of 5
Appendix I Architecture of the Joint Patient Tacking System
Public HIE
Public Rx
Clinical Health
Data Repository
(Rx, Allergies,
Lab-LSRI)
Data Warehouse
• Storage
• Registries (TBI,
Trauma, Other)
Comp &
Pension
System
Joint Patient Tracking System
Theater Medical
Record System
DoD Medical
Record System
Contains
Viewable Data
Sets
Rad Reports
Rad Images
Consults
ADT
Coding
Pre Assessment
Post-Assessment
Problem List
Amb Visits
Contains
Viewable Data
Sets
Rad Reports
Rad Images
Consults
ADT
Coding
Pre Assessment
Post-Assessment
Problem List
Amb Visits
Page 5 of 5
VistA (VHA)
Medical
Record
Contains
Viewable Data
Sets
Rad Reports
Rad Images
Consults
ADT
Coding
Pre Assessment
Post-Assessment
Problem List
Amb Visits
Purchase answer to see full
attachment