IOM joins chorus pushing VA, Defense on interoperable records

The Institute of Medicine has added one more voice to what has been a chorus of critics, advisers and federal officials calling for improved interoperability between the record-keeping systems of the medical services of the departments of Defense and Veterans Affairs.

In its recommendations, the IOM adroitly sidestepped a fundamental and hugely expensive decision that has roiled the two departments for more than a decade: how to best achieve that interoperability, either by interfacing their disparate electronic health-record systems, or forcing the two departments to settle on one common EHR.

For fiscal 2008, Congress, as part of the National Defense Authorization Act, required the secretaries of Defense and Veterans Affairs to contract with the National Academies, which delegated the task to the IOM, to study “the physical-health, mental-health, and other readjustment needs of members and former members of the armed forces” deployed in the wars in Afghanistan and Iraq.

The final report of that 29-member study group, the 794-page “Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families,” was released this week.

More than 2.2 million military personnel have been deployed in the two wars since U.S. troops first invaded Afghanistan in 2001 as “Operation Enduring Freedom” and then Iraq in 2003 as “Operation Iraqi Freedom,” which was renamed in 2010 “Operation New Dawn.”

According to the IOM, there have been 2,222 U.S. fatalities and more than 16,000 wounded in Afghanistan, with that occupation still ongoing, and 4,422 killed and more than 32,000 wounded in the Iraq war between its commencement March 20, 2003, and Sept. 1, 2010, when the name change occurred and the IOM study period ended.

In addition to the known dead and wounded, “the operations have unforeseen consequences that are yet to be fully understood,” the IOM said. A significant part of the IOM report was devoted to recommendations on studies and analyses that would count or estimate, and make public, many of those unforeseen present and future costs and consequences. It addressed a wide array of issues, with health IT impacting on several, but mainly secondarily, in that IT systems will be needed to provide the data to do the long-range studies and monitoring programs the committee recommended.

Those studies range from the measurement of the clinical effectiveness of mental health and other programs for the treatment of veterans diagnosed with post-traumatic stress disorder, to the continuing supervision and analysis of programs to train clinicians in evidence-based treatments, and once trained, to periodically evaluate the clinicians on their adherence to established care protocols.

The IOM also called on the VA to beef up its existing, but limited, forecasts of health and disability spending, since “long-term planning for veterans' care requires public, long-term cost forecasts in the same way that Social Security and Medicare require them, and that these forecasts should take a similar form and be internally and externally useful.”

Other IOM recommendations had little to do with healthcare, including a call to “develop policies to eliminate military sexual trauma,” and another to assess the educational attainment levels of veterans and eligible family members under benefits provided by the Post-9/11 GI Bill.

But in a shot at the two departments' healthcare operations, the IOM also pointed to the historic difficulties between them with interoperability.

The IOM report cites the “numerous difficulties” Iraq and Afghanistan war veterans have had “navigating services” because of the complexity of both the Defense Department and Veterans Affairs healthcare systems. Although both the VA and DoD “are making administrative changes to alleviate some of the problems, information sharing between the two agencies remains a problem,” the IOM said.

The IOM recommended “improved coordination of care and services” between the medical treatment facilities of the two departments, “including the completion of an interoperable or single combined electronic health record for all care that begins with entry into military service and continues throughout care in the Department of Veterans Affairs system after transition.”

From the General Accountability Office, to members of Congress, to the leadership of the departments themselves, improving healthcare interoperability between the two healthcare systems has long been a topic of discussion and criticism. Only last month, the Defense and Veterans Affairs secretaries scrapped as too costly at an estimated $8 billion to $12 billion, a five-year effort to build from scratch and off-the-shelf commercial parts a unified EHR for the VA and DoD.

The good news, according to the IOM, is that many of the issues examined in its report “can be addressed through analyses of data already maintained in numerous federal agencies.” The bad news is the IOM's own researchers “tried to gain access to the data files so that it could begin such analyses, but it faced numerous obstacles” trying to access them.

The IOM recommended access to the data could be improved by both departments posting on their websites data dictionaries for these databases and “all the requirements” to accessing them on websites accessible to researchers.