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Although the VHA is a large integrated health care delivery system, no system of health care is closed. Many patients receive care or undergo procedures
not only in the VA but in other medical institutions, such as academic medical centers, community-based hospital systems, free-standing clinics,
laboratories, and pharmacies. In 2009, 50 percent of Veterans with Medicare Advantage received both VA and Medicare Advantage services. What happens when
providers need information about care received by their patients in other institutions?
Health information exchange (HIE) enables information about patients to flow among a network of institutions with trust agreements and standards about how
to share data. Under the Centers for Medicare & Medicaid Services (CMS) Stage 2 meaningful use requirements, eligible providers and hospitals must
electronically transmit care summaries for at least 10 percent of their patient transfers or referrals. Providers may use standardized document formats,
such as a Continuity of Care Document, to summarize a patient's status. Allergies, medications, plans of care, procedures, immunizations, notes, discharge
summaries, and advance directives can all be exchanged using the eHealth Exchange, which is a set of national standards, services, and policies that enable
secure HIE via the Internet. Health information organizations, which operate mostly at regional levels, oversee HIE, facilitate systems' interoperability
and security, and ensure authorized purpose of use among those who access information. In 2009, the United States had about 88 operational health
In 2009, President Obama announced the Virtual Lifetime Electronic Record (VLER) project, to aid the transition of patients and their administrative and
medical records, starting with military service. VLER Health works with community partners in pursuing the interoperability of health information systems,
including VA and DoD systems. More than a dozen VA medical centers have participated in a VLER HIE pilot that allows bi-directional exchange of health
information about Veterans between the VA and its community partners in those cases when a patient is receiving care from both. Initial program sites
include San Diego, Hampton, Puget Sound, Spokane, Altoona, Asheville, Buffalo, Charleston, Grand Junction, Indianapolis, Minneapolis, Richmond, and Salt
Lake City; several of these pilot sites encompass both VA and DoD facilities. Through its graphical user interface, VistA Web makes information from the
local VAMC, remote VA facilities, and partnering community-based facilities available to VA clinicians, for those Veterans who have consented to
participate in this program. More than 68,000 Veterans have already authorized the VA to share their health information among VA and non-VA facilities. In
some cases, the HIE partner requires its own additional consent from patients.
What do we know about the impact of HIE on care? A study of 32,468 emergency encounters in Indiana showed that charges decreased by up to $26 per
encounter.1 Another study of 25,952 patients in Tennessee showed that a city-based HIE could save more than $1 million in a year, primarily due to a reduction in
hospital admissions.2 Many patients are supportive of HIE: a 2012 New York survey showed that two-thirds are comfortable with automatic central data
storage, and more than 90 percent indicated that a primary care doctor should have emergency access to records without permission.3 We also know that the
usability of computer systems that display and manipulate HIE data for clinicians is likely linked with adoption and satisfaction with these systems.
Through an HSR&D IIR grant, investigators at the Richard L. Roudebush VA Medical Center are working with its facility's administration and the region's
health information organization, the Indiana Health Information Exchange, to study outcomes of the VLER Health Initiative pilot in Indianapolis. This study
aims to assess the proportion and predictors of health care received by Veterans outside the VA, to assess the impact of HIE upon quality of care received
by Veterans, and to explore whether HIE is reducing health care costs for Veterans. Potential outcomes of HIE include improvements in the quality of
ambulatory care, reductions in admission rates for ambulatory care-sensitive conditions, and reductions in other types of avoidable services.
HIE is technically achievable, and incremental implementation is recommended. HIE has shown early promise in improving important measures of health care,
and the VA's program is now being studied. Care delivered across institutions is the reality in our mobile society. As the scope of HIE's activity grows
nationwide, health services researchers should consider how to expand the evidence base to understand more fully how HIE can increase the value of health
care delivered to Veterans.
Overhage, J.M. et al. "A Randomized, Controlled Trial of Clinical Information Shared from Another Institution,"
Annals of Emergency Medicine
Frisse, M.E. et al. "The Financial Impact of Health Information Exchange on Emergency Department Care,"
Journal of the American Medical Informatics Association
Dhopeshwarkar, R.V. et al. "Health Care Consumers'
Preferences Around Health Information Exchange," The
Annals of Family Medicine 2012; 10(5):428-34.