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

House Veterans Affairs Committee, Technology Modernization Subcommittee

March 24, 2025 (recording linked here)

HEARING INFORMATION

Witnesses and Written Testimony:

• 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

HEARING HIGHLIGHTS

IN THEIR WORDS

SUMMARY OF OPENING STATEMENTS FROM THE COMMITTEE AND SUBCOMMITTEE

• Chairman Barrett emphasized the critical importance of interoperability, stating veterans regularly visit new healthcare providers without accessible medical records, potentially compromising care quality. Barrett acknowledged substantial progress over two decades but noted gaps, particularly in VA's data exchange with smaller hospitals and private physician offices. He highlighted the need for standardized, high-quality data exchange, as mandated by the Dole Act, to improve healthcare delivery to veterans. Barrett concluded by urging VA to collaborate closely with community care partners to ensure comprehensive patient data availability for optimal veteran care.

• Ranking Member Budzinski outlined how VA’s decentralized electronic health records historically hindered interoperability, noting the ongoing modernization efforts aimed at addressing this issue. Budzinski highlighted existing technological systems used by VA, such as the Health Information Exchange, but criticized their incomplete integration, reliance on outdated processes like fax machines, and resulting clinical risks. She expressed deep concern over workforce reductions implemented by the previous administration, arguing these personnel cuts threatened interoperability progress and patient safety. Budzinski called for improved accountability, better training, and more realistic resource allocation for VA to achieve complete interoperability.

SUMMARY OF WITNESS STATEMENT

• Dr. 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. 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. 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.

• Mr. 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.

SUMMARY OF KEY Q&A

• 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 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.

  Ranking Member Budzinski 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. 

  Chairman Barrett 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.

  Chairman Barrett 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.

  Ranking Member Budzinski 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.

  Chairman Barrett inquired about the Indian Health Service's (IHS) status with QHINs and whether Oracle was building its own. Dr. Nebeker confirmed that IHS was the only federal agency connected, using a variant of the VA’s legacy VistA EHR system. He also confirmed that Oracle was building its own QHIN, though 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.

  Ranking Member Budzinski 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.

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