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James Gfrerer discusses the VA’s migration to Cerner and how being a patient in the system helps him make health-tech decisions.
Veterans often face health issues following service, but it is difficult for that population to get the appropriate care. Through technology efforts varying from telehealth services to digital health apps that allow veterans access to their full medical record, the U.S. Department of Veterans Affairs (VA) aims to improve the health outcomes of those who have served.
James Gfrerer is the assistant secretary for information and technology (IT) and chief information officer at VA. A former Marine Corps Officer, Gfrerer is also a patient within the VA system. Gfrerer leverages being a patient to make technological decisions to improve veteran satisfaction and outcomes.
A graduate of the U.S. Naval Academy, Gfrerer served in the Marine Corps for 28 years.
I spoke with Gfrerer about how the VA is using technology to benefit veterans, the agency’s electronic health record (EHR) migration to Cerner and the innovations in the VA’s pipeline.
Editor’s note: This interview has been lightly edited for length, style and clarity.
James Gfrerer: I want to start off by saying that even 10 years ago, people in any industry were still referring to technology and IT as an enabler. I think we know that in the healthcare sector, just as in probably any other sector, IT and technology now are critical requirements. That's the phrase I keep saying. Healthcare systems and clinics really can't do their job without technology — it's so intertwined and part of the atmosphere, all the way from the medical devices to the administration to the broader ecosystem of partners and vendors. Technology is a critical requirement and it's a part of everything that our health system does.
This is probably not unique to veterans, but it’s certainly an attribute: roughly 40% of our population is in a rural environment. And so that's a particular kind of factoid that also shows how technology is enabling and critically supporting the delivery of healthcare services. We have a very mature telehealth program across our VA Video Connect system. There's a recent partnership that was announced with Philips where we're going to be putting these pods at veteran service organizations and areas to facilitate veterans’ access across that telehealth system, so that they can get their care where they are, as opposed to traveling several hours.
James Gfrerer: We have an existing suite of applications that support all lines of business. I come in every day, as the Chief Information Officer for VA and I'm also a patient within the veterans’ healthcare system, so I come with the mindset of a patient and a user of the system every day.
Specifically, around the applications, we have a number of platforms around scheduling and accessing your records and around a whole suite services all the way from pharmacy to weight loss to mental health counseling — just a whole raft of applications that veterans want to use.
It’s imperative for us to maintain and expand that portfolio and support the Veterans Health Administration (VHA).
James Gfrerer: You’ve probably heard the saying before, “It's not personal, it’s just business.” I kind of turn that around and say, “It's not just business, it's also personal.”
In other words, it's personal, not necessarily just because I get my care within the VA, but also because I've known so many veterans personally that get their care there — people I've served with, people I know and people that I share a common background with.
So, the first thing that I think any executive has to do is understand the core business. And because I use the network, I understand what the average veteran has to go through in terms of scheduling, medications, using the pharmacy and getting specialty referrals.
I think it positively influences me because I'm an active user. I understand what the requirements and challenges are.
James Gfrerer: The biggest thing is around our Lighthouse API program interface. As we move to further the electronic access of one's medical records, it's important for us to make sure that we don't just have the applications that we develop in-house, but we help patients to access their data across all commercially viable applications.
One main example of a strategy we're building out is on an iPhone. If you go into the Apple Health application on your iPhone, the VA medical system is one of the medical networks that a veteran can use the Health app on their mobile device to access their record.
Sometimes I will pull it up and show people how I can access my records. And where that’s important is that the veteran as the patient owns their data. They want real-time electronic access to it. There are a lot of philosophical and practical reasons why they want to have it.
With the passing and implementation of the Mission Act this past June, we have a greater percentage of our veterans who are now qualified to receive their care in the community as opposed to the VA if they want.
So, if I'm a veteran, I go out to a community-based healthcare provider for an appointment if I meet the criteria in terms of wait time and drive time — it's not automatic. If I'm sitting out there and my civilian provider asked me a question, I might want to have access to it. The provider might want to pull some labs and I can go into that application and pull up my blood work that I just had done. I could literally hold the phone up to the clinician and he can see my latest labs.
That’s a practical use case of why this open API strategy would help out. It not only gives the veteran access to their data, but it gives them access at their fingertips.
We’re going to continue to build out our API strategy and this is where the commercial market space can come in and develop applications. We’ll let the marketplace and the veterans determine which applications can plug into our system with the right security requirements to help the veteran access their data and enable better health outcomes.
James Gfrerer: It’s kind of independent of any particular application. I use My HealtheVet and just last week had to go on and send a secure message to my provider to follow up on a prescription.
The first value proposition is independent of what the application is, and that is that you get better speed, better scalability and then from a cost standpoint, it's better cost transparency from the cloud providers. When we have stuff in the on-premise environment, sometimes we have excess capacity and capability, whereas the cloud provider will provide us exactly what we need when we need it. If the demand increases, they can spin up and provision additional servers and capacity to meet that demand.
In this case, for My HealtheVet, I think the cloud also provides better reliability.
We had a different application that had 70% availability and reliability in the on-premise environment. When we moved it to the cloud environment with all of its benefits to include that geographic fail-over — if one location fails, it will pick up on another regional server, and we improved that one application to over 99% availability.
So, I think those are the benefits of a cloud strategy.
James Gfrerer: We have the Office of EHR Modernization within the VA and it's led by John Windom and his team. They're ultimately the program owner and responsible for our EHR migration and modernization efforts. But two other important stakeholders in that environment are Dr. Richard Stone from VHA and myself within the Office of IT.
The decision was made a few years ago to go with the Cerner Millennium solution. I think largely that was to achieve some commonality with the U.S. Department of Defense (DOD) and Defense Health Agency who had chosen a similar solution with Cerner as the vendor.
The goal ultimately, is to create this longitudinal record.
So, in the most extreme case, say you're a military dependent, born into a military family in a military treatment facility, and then receive your care there over the next 18 years of your life. Then let's say that same young man or woman enlists or is commissioned into one of the military services and serves for another 20 years and has their own career. Now maybe they’re 42 years old and retire from the military and transition to the VA system. From the time they're 42 years old for as long as they live, they have their record across those three lifespans with the new Cerner system. With the longitudinal record, all the data will be in the same enclave.
The same longitudinal record can be accessed at any VA facility, any outpatient clinic and any military treatment facility, along with our commercial providers as well.
Ultimately, the value is creating that longitudinal record and ensuring that seamless transition for the individual from the time that they depart the military. All that medical data will remain in the joint enclave that will be shared by DOD and VA and the doctor at the VA can pick up right from there with all the medical history and continue the patient’s care for the rest of the time they're in the VA system.
James Gfrerer: VistA was homegrown and one of the nation’s first EHRs in the early 90s. It was created independent of any development within DOD. The DOD has its systems and there's a number of them that the agency consolidated down to. But those are separate systems that were developed independently by their own departments and agencies, so you don't have that common data format. You certainly don't have direct interoperability.
The big innovation within the past decade was the Joint Legacy Viewer. All that did was provide a physician or a provider within either DOD or the VA access to the other department’s healthcare system. Providers would get a read-only view of some of their patient’s information.
The system had much less capability as compared to this longitudinal record — this one record system that we're going to end up going to.
James Gfrerer: For now, the largest challenge really resides in that transition period. When an active duty member leaves the military and then migrates to the VA system, they apply and are granted status.
When I retired four years ago, the VA was still capturing paper records and I had to submit my large paper medical record, which had to be sent to the VA and scanned. That's how the data were migrated over. We all know how suboptimal that is from a data or awareness standpoint.
I'm comparing it to the future state capability, which will be the same record but electronic, and there will really be nothing for the veteran to have to do. All of a patient’s treatment and medical history that they incurred in service will be immediately visible as they transition to VA, but it would be immediately visible if they were to visit a VA facility. If for some reason an active duty service member is out somewhere, we have a number of arrangements and informal opportunities for active duty to be seen in a VA facility. That brings great value because the provider could go in and look at that information right away and see the latest labs and blood work and medical history.
James Gfrerer: Being the nation’s — if not the world's — largest integrated health system, the private sector looks to the VA for leadership around innovation, research and development and standardization.
With this increasingly critical dependency on technology, we in the Office of IT are looking for ways that we are accelerating and partnering with VHA around innovations.
We’re focused on telehealth and have the One Million Veteran program, which is basically a database of almost one million veterans — veterans are still enrolling. So, we have a partnership with the U.S. Department of Energy, which is super competitive with using its supercomputers to do analyses on those data for research and development purposes. Through that, we are looking for insights around veteran conditions, diseases and causality.
James Gfrerer: IT and technology are critical partners in the healthcare sector. If we're going to enable business success, then it's important for IT and healthcare executives to work together very deliberately to develop and enable the right technology to produce the future health outcomes that our society wants and needs.
I think the challenge comes when IT is not seen as a business partner in terms of developing these capabilities — that's where the problems creep in. Business success in the healthcare sector, in terms of delivering these health outcomes, will be even more increasingly dependent on technology and IT to deliver those.
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