Veterans Affairs Committee on March 23rd, 2009

[Kirsty Duncan, Liberal, Etobicoke North, ON]

What are you trying to do to increase the percentage of use?

[Gail Graham]

We have the personal health record. My HealtheVet coordinators in each of the medical centres do a great deal of education. We use public service announcements. We work through the veterans service organizations to educate the veterans. The mobile units that I talked about earlier for the vet centres, and the mobile clinics, are all set up so that the veteran can access their personal health record from those locales. We do quite a bit of marketing to inform veterans that this service is available to them. But what really brings them in is when a feature is added that is of interest to them.

[The Chair, Conservative, David Sweet]

Thank you very much, Madam Graham and Ms. Duncan.

I did give you an extra question at 5 minutes and 10 seconds. It's okay, because it was a good follow-up question you needed to get in. No problem.

Mr. Gaudet, for five minutes.

[Roger Gaudet, Bloc, Montcalm, QC]

Thank you, Mr. Chair.

Good day, Madam.

Surely there is a downside to this system. What might that be? Based on what you're telling us, it appears to be a sound system that relies on the Internet and the like, but surely there are some disadvantages for veterans, especially for those living in more remote regions.

[Gail Graham]

Did you want me to explore the negative aspects?

[Roger Gaudet, Bloc, Montcalm, QC]

Yes. It's important that we not make the same mistakes that you did.

[Gail Graham]

Sir, I certainly understand that. There have been large and published electronic health record implementation problems around the country. They've been in the newspapers and the trade magazines.

With VA, I think we started very small and very slowly. We started at one of our smaller, less complicated facilities when we went down the road of a true electronic health record, with the clinicians actually ordering through the electronic health record. I think that was an advantage.

It was also important not only that the nurses and doctors adopted this, but that administrators recognized that, for example, when we implemented the electronic health record in a medical centre or clinic, many times that required that the appointment time be extended from 20 minutes to 30 minutes, for example, because it took longer for the clinician to interact with the system, especially during the learning time.

We talked about these preventative reminders. All of those reminders come with some time impact to the clinician. We believe that impact is positive, that it maybe avoids illness or patients returning unnecessarily. So certainly that recognition that it requires time for the clinicians to adapt to this technology and that it may require longer time permanently is important. Many of our clinics still run 30-minute instead of 20-minute clinic appointments.

We had some pretty widely publicized problems a few months ago with the latest release of our electronic health record system--problems that were not found during testing. For example, we had a flaw in the latest release that changed the viewing of the discontinuation of medication orders, and nine patients received IV infusions and infusion heparin for hours after the physician discontinued the order. We identified the problem. We have mechanisms in place for the medical centres and the physicians and the nurses and the clinical application coordinators to report suspected problems immediately so we can research them.

Certainly you have to put in an infrastructure that allows providers to report problems with the system. For us, it created a whole new occupation called clinical application coordinators, who are available to help clinicians should they have problems with the system. I think that's absolutely necessary. We can anticipate that's going to be one of the challenges as electronic health records go into small physician offices that really can't afford full-time support.

We've had lessons learned in deploying slowly, giving time for clinicians to be trained and use the system, taking care and testing the system thoroughly, and making sure when we develop systems that we take heed that clinical practice is not uniform at every medical centre and clinic. It all requires that we do our due diligence and that we be good stewards of this technology. It's a tool, but it's just a tool, and it is still required to work well within the flow of clinical practice.

[Roger Gaudet, Bloc, Montcalm, QC]

Are new service members automatically signed up for this service?

[Gail Graham]

New recruits who come into the military are immediately entered into the Department of Defense system. VA has knowledge of them if they seek our services, but we could not access their records if they did not seek our services. There are some VA benefits available to service members before they become veterans. These may be non-health care benefits in the area of veterans' benefits administration--for example, there are some housing modifications they might be eligible for when they're still on active duty.

We have a new secretary--Secretary Shinseki. He has made a proposal that we do become informed of that service member upon entering the military. But at this time, unless they sought our services, we would not know about them.

[Roger Gaudet, Bloc, Montcalm, QC]

I have one last quick question for you.

When a service member retires, is his file forwarded to the Department of Veterans Affairs? I would appreciate an answer.

[Gail Graham]

Actually, there's still a fair amount of paper in the Department of Defense. VA is the custodian of the Department of Defense's paper records for those who are either separated or retired from the military. Those are sent to a place in St. Louis, Missouri, where if the veteran applies for a benefits claim or seeks health benefits from VA, those records are available to either be sent to Veterans Health Administration Benefits or to the veteran themselves. If that military person seeks care from us, then we can access those records, but if they do not seek care, we cannot access the records.

[The Chair, Conservative, David Sweet]

Thank you very much, Mr. Gaudet.

Thank you very much, Madam Graham.

I put us out of rotation again, so I apologize. It will appear a little lopsided here because I missed a Conservative.

So, Mr. Clarke, for five minutes.

[Rob Clarke, Conservative, Desnethé—Missinippi—Churchill River, SK]

Thank you, Mr. Chair, and thank you, Ms. Graham.

I'm going to follow up on the question in regard to the electronic system that Mr. Kerr brought up here. You mentioned earlier Google and Microsoft. With the electronic system, in my personal experience when the Royal Bank--our banking system--shuts down, we don't have access to our records. Do you experience the same problems with your electronic system with the veterans right now?

[Gail Graham]

Sure. We've become very reliant on the electronic system, and if it's down for any length of time, while we have contingencies in place, it's still a very debilitating impact to our organization. Some of the contingencies we have, for example, are that we do a backup of patients' information for patients who are in the hospital, or for patients who have clinic appointments. Sites are set on routinely backing up a summary of information on those patients, but when the systems are down, our contingency plans are centred around paper and it's very problematic if they're down for any length of time. But we do have contingencies in place.

[Rob Clarke, Conservative, Desnethé—Missinippi—Churchill River, SK]

Is there another way to access the files when the system is down?

[Gail Graham]

There is. There are two things that happen.

One of them is that every day the system backs up summary information on in-patients and those who have appointments the next day. That information is kept separate from the mainframe of the hospital, for example, so that it can be accessed independently of the system being up.

We also have a read-only version of CPRS that can allow providers to look at information even if their local system is down for any length of time, but for it to carry on current work, it reverts back to a paper process of ordering laboratory, ordering radiology, in a manual process. We do have contingencies for looking up information should the systems be down, but it's a struggle. I'm not going to pretend that it's not.

[Rob Clarke, Conservative, Desnethé—Missinippi—Churchill River, SK]

With veterans and with the systems going down, sometimes information is lost, especially on veterans. Have you had any experiences where veterans have been lost due to system failure?

[Gail Graham]

We have not.

Actually, we've had the opposite. For example, during Hurricane Katrina when our hospital in New Orleans was evacuated, we took the backup tapes from the computer system and, within 24 hours, moved them to the Houston facility and had that information back up and online available for those veterans wherever they showed up. If they had a dialysis treatment on Monday, by Wednesday they were back online and their information was available. That has been our experience.

We had an experience about a year and a half ago where we had 17 systems on the same regional data processing system that went down. Providers did have access to read-only information, but they were down for about 17 hours, and there have been contingencies put in place since then that after five hours of downtime they would actually be reverted to a backup system. We're putting a lot of redundancy in place to make sure we don't have single points of failure for these systems.

[Rob Clarke, Conservative, Desnethé—Missinippi—Churchill River, SK]

When there are a lot of veterans going through the system on a daily basis, how many times a day or week is the system upgraded?

[Gail Graham]

Upgraded as a whole? We send out about 400 patches a year that upgrade some part of the system. Most of the upgrades currently, though, don't require that you take the system completely down. Those that do require the system being down are done off-hours and on weekends.

[Rob Clarke, Conservative, Desnethé—Missinippi—Churchill River, SK]

With the veterans and this electronic system, if they're sitting at home or are anywhere in the world, at the side of a lake or something like that, do they have access to review their own personal records to make sure they are up to date and well kept?

[Gail Graham]

If they're registered for the My HealtheVet personal health record and if they have authenticated in person, then parts of their medical record are available through My HealtheVet. That's the only electronic means by which the veteran can access their records. But that would be available regardless of where they were physically, as long as they were on the Internet.

For providers, it has been a tool that we've used. For example, we have a shortage of radiologists in this country. We have a central reading centre in California that, either as a contingency or a matter of routine because they can't hire a radiologist, does readings for different hospitals throughout the country. The electronic technology enables us to actually take the exam locally and communicate it to those radiologists, where they do the reading and transmit it back to the medical centre.

So there are other business reasons why it has been important to us to have this system.

[The Chair, Conservative, David Sweet]

Thank you very much, Madam Graham and Mr. Clarke.

Mr. Lobb, for five minutes.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thank you.

It's been very interesting so far, Ms. Graham, that's for sure.

I noticed from your slide deck that there are 153 medical centres, 747 outpatient clinics, many long-term care and home-based programs, as well as 107 academic health systems that also participate with Veterans Affairs. Is your software system implemented in all those locations?

[Gail Graham]

It's not implemented in the academic affiliates, but it's implemented in all the VA locations, yes.