Virtual lifetime electronic hospital

By Peter Buxbaum
02:37 PM

Oct. 1, 2010, was opening day in North Chicago, Ill. That's when, well north of Wrigley Field, the Captain James A. Lovell Federal Health Care Center was inaugurated.

This first-of-its-kind partnership between the U.S. Department of Veterans Affairs and the Department of Defense merges systems and services from the North Chicago VA Medical Center and the Naval Health Clinic Great Lakes into a single mammoth health care facility with a joint VA and Navy mission.

The integrated facility, named in honor of Lovell, the Apollo 13 astronaut, retired U.S. Naval officer and Illinois resident, will have an annual budget of $250 million and serve a regional population of 140,000 naval personnel and veterans.

The unprecedented merger of the two facilities was the brain child of financial necessity and medical practicality. But it is also spawning innovations in medical care: DoD and VA are integrating their electronic health records in a way that is likely to serve as a model for national efforts. North Chicago is also the site where a potential merger of two departmental biosurveillance systems is being piloted.

Much like many mergers in the private sector, saving money was one impetus for the North Chicago venture. The Naval Hospital Great Lakes, a 450,000 square foot, 850-bed facility dedicated in 1960, was becoming obsolete and needed to be replaced or revamped. It is also located short mile from the VA facility.

Meanwhile, the North Chicago Veterans Administration Medical Center, established in 1926, with 1.4 million square feet and 550 beds, had excess capacity. With the Navy footing the bill for an expansion of the VA facility, DoD was able to save the $8 million it would have cost to rehabilitate the old Navy hospital and the federal government will save around $4 million annually in ongoing operating expenses.

The two facilities began sharing resources even before the merger was complete. "The naval hospital [now the Naval Health Clinic Great Lakes] realized that its facility was becoming old and a lot the infrastructure was becoming too expensive to maintain," said Capt. Dr. Norm Lee, Director of Health Services at the clinic. "DoD was already renting out space from the VA for a blood bank. That was an initial way of leveraging the proximity of the two centers."

The medical staffs of the two facilities also complemented each other nicely, said Dr. Frank Maldonado, Lovell's Associate Chief of Medical Services. "This project was initiated and driven by clinicians," he said. "DoD is strong on surgical services and VA is very strong on medical services. We recognized each other's strengths because we have been exchanging services for 20 or 30 years. Merging the two facilities and staffs was good for patients."

Early on, planners of the merged facility realized it would make little sense to operate an integrated facility if providers had to access separate DoD and VA medical records. The two departments run different and disparate electronic health records systems, DoD's AHLTA and VA's VistA. What started out as a plan to provide integrated accessibility to the two systems to health providers has become the cutting edge of the project to create a joint lifetime electronic record for service members and veterans.

DoD and VA have been working on integrating their medical records systems incrementally for some years. In November 2008, DoD and VA announced they would be seeking to enhance the interoperability of their electronic patient clinical data by migrating their respective electronic health records systems to a service-oriented architecture. And in 2009, the Obama administration announced an initiative called the virtual lifetime electronic record, or VLER, a system that will include lifetime administrative and medical information for armed services members and veterans.

Pillars of integration
Service-oriented architectures develop software capabilities through the integration of loosely coupled, reusable components, as opposed to point-to- point integration between standalone systems. Key to creating this interoperability involves the creation of an enterprise service bus or service broker that is able to extract data from one application and present it in another.

Features of Lovell's service-oriented architecture are being phased in, beginning on opening day of Oct. 1, with some elements having been tested at the VA facility in advance of that. The coupling of the VA and DoD electronic health records depended on meeting five objectives, said Dr. Doug Rosendale, a manager in the Veterans Health Administration Office of Health Information.

First, patients needed to be registered in both applications. "Joint registration means that registration in one system means registration in both," said Rosendale. The joint registration service transfers all relevant demographic information between one system and the other, he said. Other pertinent medical information is transferred between the systems as necessary.

Providers also need to be able to access data in both systems. "That's why we needed a single log-in," said Rosendale, "so providers can sign on in one application and have access to patient information from the other application."

The third integration pillar involved "order portability," so that laboratory requests or radiology orders entered in one system would be reflected in both. "This will allow clinicians to use one system and the order and results will be reflected in both systems," said Maldonado.

The fourth involves workload reconciliation between the two systems. "This is especially important for determining the operational readiness of sailors," Rosendale explained. "We have to make sure that all medical issues are addressed before they are sent back to their ship." The fifth element is a joint scheduling capability for the two systems.

As of opening day, joint registration, single sign on and order portability were ready to go. Those features are expected to be fully operational by the end of November. Single sign on has already been successfully tested in some Lovell wards. "The others will be worked on at some future date," said Rosendale.

Internet windows
The ultimate vision is for a provider to access any number of applications after signing in once. "It will be like opening up several windows on the Internet," said Rosendale. "If you're looking at data on Mr. Smith, every new application that you open will be displaying Mr. Smith's data."

The North Chicago experience offers lessons for national projects, including VLER, to create singular electronic health records. "This is what everyone wants," said Rosendale, "the ability to share relevant information across two or more government agencies, two separate hospitals, between the public and private sectors. The VLER project is pursuing this fluidity of standardized data along a patient's entire lifetime."

Simultaneous access to DoD and VA systems is already making a difference in how clinicians practice medicine in North Chicago, according to some of the facility's biggest customers.

"It has been helpful getting information from the Navy when we see service people and their dependents," said Dr. Robert Sorensen, acting chief of Lovell's emergency department. "It keeps us from prescribing medications that may interact with others the patient is taking and from duplicating services. It also won't be necessary to order an x-ray when the naval clinic took one six hours ago and we have access to it."

"We have the opportunity to demonstrate a huge improvement in patient care," said Rosendale, "by reducing redundant testing and just simply having access to all of the information that we need to help us manage patients."

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