1. February 7, 2006 Greg W. Donham BHIE/FHIE Interagency Project Director Federal Health Information Exchange (FHIE) & Bidirectional Health Information Exchange (BHIE)

2. Indian Health Service Brief January 8, 2006 Interagency Presentation Agenda Program Overview Technical Overview Back-up Slides

3. Indian Health Service Brief January 8, 2006 Interagency Project Background Break-through information technology effort between the Departments of Veterans Affairs and Defense –Award winning interagency product in 2005 and 2006 –Based up design and analysis work that the Indian Health Service provided from 1998-2000 Approved OMB Exhibit 300 project, proceeding through FY2012 –Part of President’s Management Agenda, Initiative #14 –Among highest scoring VA Exhibits examined by OMB Affordability achieved through re-use of existing processes and joint, interagency infrastructure –DoD pays 50% of annual operating costs –IHS start-up costs would be manageable Embraces high performance project management and continuous improvement

4. Indian Health Service Brief January 8, 2006 FHIE/BHIE contributes to Interoperability Operate a joint system for perpetual one-way transfer and two-way exchange of electronic health information between DoD and VA Provide on-demand electronic DoD health information to assist in the compensation process Demonstrate compliance with HIPAA regulations by creating an interagency environment for storing very sensitive information Use a patient-focused information technology familiar to authorized VA and DoD (and IHS?) users

5. Indian Health Service Brief January 8, 2006 Federal Health Information Exchange (FHIE) Federal Health Information Exchange (FHIE) provides clinically relevant DoD health information about separated and retired members of the Uniformed Services FHIE Interagency Capabilities: Provides historical views, from 1987 forward, of DoD laboratory results, radiology reports, outpatient pharmacy, PDTS, allergy information, patient demographics, consult reports, DoD’s Standard Ambulatory Data Records, and discharge summaries Updated monthly, averaging 9,000 additional patients Receives daily clinical data about VA beneficiaries (DoD’s PATCAT – K61), shortly after they receive care at DoD MTFs Initial Operating Capability (IOC) with CHCS and VistA achieved Memorial Day, 2002 First VHA system to be Re-certified and Re-accredited December 2005 –NIST independently scored was 100 ! Quick performance---average response time <30 seconds with over 5,300 weekly queries

6. Indian Health Service Brief January 8, 2006 3.3 million unique patients with clinical data** Correlated Patients 2.4 million unique patients registered in the VA with DoD clinical data DMDC Data 4.1 million records* *Due to the incremental deployment of CHCS in the early 1990s, many of those who separated during that period had no entries within CHCS, therefore this number will not match the data extraction number from DMDC. FHIE Repository Statistics: Access by IHS ? Separated Service Members (As of February 3, 2006)

7. Indian Health Service Brief January 8, 2006 Bidirectional Health Information Exchange (BHIE) Supports effective, quality care at Joint Venture, medical sharing locations and, if approved, any Interagency entity Provides both Veteran’s Health Administration (VHA) and authorized physicians access to clinical data for a patient, regardless of the location of the data Bidirectional Health Information Exchange (BHIE) allows physicians of Federal Departments to view in real time laboratory results, radiology text results, outpatient medication profiles and allergy information –Plus, displays any historical information from FHIE CHCS/VistA bidirectional, real-time enhancements

8. Indian Health Service Brief January 8, 2006 Clinical Displays: VA and DoD

9. Indian Health Service Brief January 8, 2006 CPRS Interface – DoD Cytology Report

10. Indian Health Service Brief January 8, 2006 BHIE Functionality: Current and Future Incremental Clinical Functionality delivered within budget and on time in October 2004:  Patient Identity Management and Correlation  Bidirectional transmittal and display of Outpatient Pharmacy and Allergy data  Incremental Clinical Functionality delivered within budget and on time in May 2005:  Bidirectional transmittal and display of Surgical Pathology reports, Cytology, Microbiology data, Chemistry and Hematology results, Laboratory Order information, and Radiology text reports  Incremental Clinical Functionality delivered within budget in January 2006:  Prototype of displaying non-CHCS Discharge Summaries from Madigan’s Essentris system  Work underway for an enterprise solution, based upon experience building the prototype  Incremental Clinical Functionality to be delivered in 2006  Interface with DoD’s Armed Forces Health Longitudinal Technology Application (AHLTA) --- compliments CHDR work  Additional DoD Inpatient documentation (e.g. Progress Notes, Operative Notes, etc.), pending project review

11. Indian Health Service Brief January 8, 2006 BHIE Sites: Current and Future with IHS ? BHIE operational BHIE implementations planned during FY2006 NCA Brooke AMC LRMC Mike O’Callaghan Federal Hospital David Grant FMC Bassett ACH Elmendorf AFB Madigan AMC NH Great Lakes Eisenhower AMC NH Charleston 7 DoD host sites = 7 DoD Medical Centers, 5 DoD Hospitals & 50 DoD Clinics (Access to over 880,000 correlated patients) Tripler AMC William Beaumont AMC NMC San Diego NH Camp Pendleton NH Camp Lejeune Womak AMC NH Pensacola Darnall ACH

12. Indian Health Service Brief January 8, 2006 Further use of the Interagency framework VA-DoD Pre- and Post Deployment Health Assessments (PPDHA) –Milestone achieved: Two new progress notes are available for displaying (a) Pre- and (b) Post-Deployment Health Assessment (PPDHA) data in CPRS from DoD’s Defense Medical Surveillance System (DMSS)  PPDHA information delivered on schedule and within budget via CPRS Remote Data View (RDV) on December 7, 2005  From service members deployed for IOF/OEF --- over 475,000 currently available (DoD Forms 2795 and 2796)  Monthly updates provided to VA from DMSS  Re-used BHIE architecture --- proving its extensibility  Analysis underway for delivery of DoD Form 2900 (Post Deployment Health Reassessment) in the same manner, pending availability of funding

13. Indian Health Service Brief January 8, 2006 TECHNICAL OVERVIEW

14. Indian Health Service Brief January 8, 2006 FHIE/BHIE Framework Jointly owned and operated by VA and DoD --- non-proprietary, standards-based and open-systems compliant –Principles that DoD, IHS, and VA agreed to in 1998 Built-on notion of logical domains Domains collaborate with other domains Extensible architecture –Used by the Office of Information’s HSD&D to build the HDR-IMS –Interfaced with CAPRI to share same DoD data with VBA –CHDR will use BHIE’s secure network infrastructure for operations –Demonstrating interoperability with EPIC, IBM and ALLScripts @ HIMSS 2006 –Explore with the Indian Health Service ? VHIM compliant with Reference Information Models (RIM) Standards employed

15. Indian Health Service Brief January 8, 2006 BHIE/FHIE Services & Standard Interfaces IIOP/ CORBA HTTPS IIOP/ CORBA HTTP PIDS Adapter SOAP/ XML COAS Adapter HL7 V3 (Future) PIDS Adapter HL7 V2.2 Adapter SQL Adapter WS Beans IIOP CHCS ftp ODBC SOAP/ XML  Patient Identity Management  Information Location/Collection  Security and Privacy  Terminology  Data Normalization (RIM) FHIE/BHIE Framework Services Connectors Adapters MPI Client Access EI/DS HL7 FHIE Repository Electronic Health Record Work Station

16. Indian Health Service Brief January 8, 2006 Vitria IE High-Level FHIE/BHIE Architectural Components DoDFHIE/BHIE FrameworkVA Legacy EHR Sharing Facility MHS Data Repository FHIE Framework FHIE Repository  Patient Identity Service  Information Locator  Security  Optimization  Adapter/Connector VistA VA Host (Station 200) VistA Local VAMC CPRS VA MPI DoD Web Server DoD GUI HL7 Messages WS/XML CACHE’ WS/XML HL7/ADT Query Access VistALINK RDV PIDS/Correlation

17. Indian Health Service Brief January 8, 2006 FHIE Repository FHIE Framework Patient data delivered to Physician Authorized Inquiry Requests for Records Records Returned VA Facility or DoD Facility DoD Military Treatment Facilities with BHIE All VA Facilities Index of where patients have records Temporary aggregate clinical record BHIE Data Flow and Access

18. Indian Health Service Brief January 8, 2006 Security Architecture WAN Management Responsibilities Gateway Firewall operation Gateway-to-Gateway VPN VISN Routing and Security RAS Server Operation User Identification User Authentication Privacy Disclosure Controls Privacy Act / HIPAA Training System Access Control VistA and CPRS Responsibilities Off Site Data Storage Intrusion Detection Vulnerability Scanning VPN (Remote Administration) AAC Host Site ResponsibilitiesOperations and Maintenance Contractor Responsibilities Cisco PIX Firewall Configuration Network Configuration and Operation Secure Host Configuration Data Backup and Recovery Framework Responsibilities Data Access Control Local I & A (SysAdmins) Event Logging & Auditing Privacy Disclosure Records PowerChannel Decryption, decompression RAS Client Operation DOD Responsibilities Data Filtering Record Release Approval DOD Firewall Operation Gateway-to-Gateway VPN operation PowerChannel Encryption and Compression

19. Indian Health Service Brief January 8, 2006 Standards Support Framework services are available to external clients through standard interfaces HL7 (2.x) CORBAMed (COAS, PIDS) WebServices SOAP XML NCPDP Java JMS Service also supports non-standard data interchanges (custom adapters)

20. Indian Health Service Brief January 8, 2006 Local Domain Analogous to Local Healthcare Information Infrastructure Master Patient Index Cache Medical Records System Radiology System Registration System Laboratory System Information Locator Index Query Access Interface External Provider Client Clinical Data Repositories Information Collector DoD Data Adapters FHIE/BHIE Framework

21. Indian Health Service Brief January 8, 2006 Current Domain Infrastructure DoD SQL MPI DoD Data Adapters DoD Data Repositories CHCS System 1 CHCS System 2 CHCS System 3 PDTS System SADR System DoD Person Subsystem SQL Person Graph Collection X Cache Subsystem: Cache Graph Collection VA Person Subsystem: Pids Person Graph Collection VA Cache VA Framework COAS Adapter: Query Access Impl VA Cache Subsystem: Cache Graph Collection X Person Subsystem: Sql Person Graph Collection X SQL MPI VA Non-Captive PIDS Adapter :CPRS System A: VISTA System :VISTA Primary Host Austin VA PIDS Server: VA_MPI DoD Cache Subsystem: Cache Graph Collection VA 0 Local DomainCross DomainDoD 0 Local Domain DoD B/DS Message Consolidator

22. Indian Health Service Brief January 8, 2006 BACKUP SLIDES

23. Indian Health Service Brief January 8, 2006 Path to Interoperability BHIE Bidirectional Health Information Exchange FHIE Federal Health Information Exchange CHDR Clinical Data Repository/ Health Data Repository One-way Enterprise exchange Historical access Text data Bidirectional Enterprise exchange Real-time access Text data Bidirectional Enterprise exchange Real-time access Computable data Path to Interoperability

24. Indian Health Service Brief January 8, 2006 High-Level FHIE Architectural Components Legacy EHR MHS Data Repository FHIE Framework FHIE Repository VistA VA Host (Station 200) VistA Local VAMC CPRS VA MPI DoDFHIE FrameworkVA HL7 Messages Query Access RDV PIDS/Correlation  Patient Identity Service  Information Locator  Security  Optimization  Adapter/Connector

25. Indian Health Service Brief January 8, 2006 MDR VistA Local VAMC VistA Local VAMC VistA Local VAMC CPRS VA MPI RE-Use -Correlation -Information Locator -Security -Optimization -Adapter/Connector Data Securely Pulled From EIDS via PowerChannel VistA VA Host (station 200) E FHIE Framework Reuse High-Level FHIE/BHIE Architectural Components CHCS MTF CHCS MTF HL7 PDTS SADR K61 FHIE Repository QueryAccess/ VistaLink RDV DoD GUI/Share CHCS Sharing Facility DOD Web Server Vitria IE Web services/SOAP Query/Response real time HL7/ADT HL7 ADT WebServices MEDs and Allergies RAD, LAB Cache’ WS/XML HL7/ADT HL7 PDTS SADR K61 HL7/ADT HL7 PDTS SADR K61 WS/XML HL7/ADT PIDS 104 DoD MTFs 174 VA MTFs

26. Indian Health Service Brief January 8, 2006 Sample of a transmitted HL7 Message from DoD to the FHIE Framework Example of DoD HL7 Message: