DEPARTMENT OF HEALTH AND HUMAN SERVICES

STATEMENT OF RANDY E. GRINNELL

DEPUTY DIRECTOR

INDIAN HEALTH SERVICE

BEFORE THE

SENATE COMMITTEE ON VETERANS’AFFAIRS

November 5, 2009

STATEMENT OF THE INDIAN HEALTH SERVICE

Mr. Chairman and Members of the Committee:

Good afternoon.  I am Randy E. Grinnell, the Deputy Director of the Indian Health Service (IHS).  I am accompanied by Theresa Cullen, M.D., Director, Office of Information Technology.  I am pleased to have the opportunity to testify on the Indian Health Service - Veterans’ Administration (VA) collaboration. 

As you know, the Indian Health Service plays a unique role in the Department of Health and Human Services because it is a health care system that was established to meet the federal trust responsibility to provide health care to American Indians and Alaska Natives.  The mission of the Indian Health Service is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.  The IHS provides high-quality, comprehensive primary care and public health services through a system of IHS, Tribal, and Urban operated facilities and programs based on treaties, judicial determinations, and acts of Congress.  This Indian health system provides services to nearly 1.5 million American Indians and Alaska Natives through hospitals, health centers, and clinics located in 35 States, often representing the only source of health care for many American Indian and Alaska Native individuals, especially for those who live in the most remote and poverty-stricken areas of the United States.  The purchase of health care from private providers through the Contract Health Services program is also an integral component of the health system for services unavailable in IHS and Tribal facilities or, in some cases, in lieu of IHS or Tribal health care programs.  IHS accomplishes a wide array of clinical, preventive, and public health activities, operations, and program elements within a single system for American Indians and Alaska Natives.

American Indian/Alaska Native Veterans’ Dual Use of IHS and VHA
In 2006, a joint VHA-IHS study was initiated to review dual use of the two systems by American Indians.  The findings of this study indicate that American Indians and Alaska Natives using the VHA are demographically similar to other VHA users with similar medical conditions, such as Post Traumatic Stress Syndrome (PSTD), hypertension, and diabetes.  To date, the review has found that dual-users are more likely to receive primary care from IHS, and diagnostic and mental health care from the VHA.  They are likely to be receiving complex care from VA and IHS. 

Many American Indians and Alaska Natives are eligible for healthcare services from both Indian Health Service and Veterans Health Administration.  IHS has an estimated 45,000 Indian beneficiaries registered as veterans in the agency’s patient registration system.  Some American Indian and Alaska Native Veterans who live in urban locations do not have geographic access to care in IHS facilities on or near reservations and must use the local systems of care or urban Indian clinics where they are available.  In some of these locations Urban Indian Health Programs provide limited direct care and assist these patients in accessing VA and other services in the local area.  Indian veterans residing on reservations in some cases are not easily able to access VA health facilities and services, as well.

IHS recognizes that the complexity of IHS Contract Health Services and VA eligibility requirements may discourage Indian Veterans from accessing care.   IHS pays for the care referred outside of IHS for American Indians and Alaska Natives including veterans if all rules and regulations governing the CHS program are met.  For the Indian veteran, the VHA is an alternate resource along with Medicare, Medicaid and private insurance under the CHS regulations.  Other requirements include membership in a Federally-recognized Indian tribe, residence on the reservation or within an IHS Contract Health Service Delivery Area (CHSDA), meeting the CHS medical priority of care, exhaustion of alternative resources of coverage, and compliance with the timelines for notification of IHS.  If the Indian Veteran patient is eligible for Contract Heath Services and requires services outside the IHS facility, i.e. specialty inpatient and outpatient services, she or he may be approved for care pending relevant medical priority level on same basis as any other American Indian and Alaska Native.   

HHS/Indian Health Service – VA/Veterans’ Health Administration Memorandum of Understanding
A Memorandum of Understanding (MOU) between the HHS/IHS and the Department of Veterans Affairs (VA)/Veterans Health Administration (VHA) was signed in 2003 to encourage cooperation and resource sharing between the two Departments.  It outlines joint goals and objectives for ongoing collaboration between VA and HHS to be implemented primarily by IHS and VHA.   The MOU advances our common goal of delivering quality health care services to and improving the health of the 189,000 veterans who are American Indian and Alaska Native as of 9/30/08.  The HHS and the VA entered into this MOU to further their respective missions, in particular, to serve American Indian and Alaska Native veterans who comprise a segment of the larger beneficiary population for which they are individually responsible. 

The MOU identifies 5 mutual goals to (1) improve beneficiary access to healthcare and services; (2) improve communication among the VA, American Indian and Alaska Native veterans and Tribal governments with IHS assistance; (3) encourage partnerships and sharing agreements among VHA, IHS, and Tribal governments in support of American Indian and Alaska Native veterans; (4) ensure the availability of appropriate support for programs serving American Indian and Alaska Native veterans; and (5) improve access to health promotion and disease prevention services for American Indian and Alaska Native veterans. 

Indian Health Service – Veterans Health Administration Collaborations
The principal focus of the interagency communication and cooperation is to provide optimal health care for the American Indian and Alaska Native veterans who rely on the IHS and/or VHA for their medical needs.   Together we strive to achieve multiple goals outlined by the MOU by developing projects that, for example, improve access to VHA services by allowing VHA staff to utilize Indian health facilities for providing health care to Indian veterans while the joint working relationship expands opportunities for professional development of clinical skills by IHS providers.  IHS experience with the use of traditional healing in its system became a model for the VHA when it began incorporating traditional approaches to healing for Indian veterans.  VA’s development and use of the tribal veterans’ representative (TVR) program has been and is critical to addressing issues related to communicating about and reducing barriers to VA services and to the IHS CHS program for Indian veterans through the coordinated training on benefits and eligibility issues for each of the two programs. 

Other collaborations that meet the goals of the MOU range from expansion of access to VHA home based primary care for Indian veterans through the use of IHS and Tribal health facilities to the improvement of interagency partnership on health information and use of tele-health modalities.  The home based primary care program expansion will increase availability of services for Indian veterans with complex chronic disease and disability through 14 collaborative projects located in states including New York, North Carolina, Oklahoma, Oregon, New Mexico, South Dakota, California, Mississippi, and Minnesota.  In Arizona, the IHS -VHA are working together to increase mental health services by locating VHA social workers in IHS health facilities on the Navajo and Hopi reservations. 

In Montana, the Billings Area IHS and the VA Montana Healthcare System (VAMHCS) have on-going collaborative efforts such as tele-psych established at each service unit to facilitate providing VA mental health services for American Indian and Alaska Native veterans.  Because of the geographic remoteness and difficulty in accessing transportation to a VA facility, this service greatly benefits the American Indian and Alaska Native veterans.  The Billings Area IHS and VAMHCS have formalized a PTSD protocol that is utilized by the service units and Fort Harrison.  Among the protocol elements, the VA has created a position designated as a Tribal Outreach Worker (TOW) who works on-site to actively seek and educate veterans who may benefit from the services provided through tele-psyche clinics.  Each service unit has a designated VA liaison to help the American Indian and Alaska Native veterans needing medical services as well as working with the TOW and local Tribal Veteran Representative.  As the primary IHS contact, they can provide information, assistance, and guidance on VA services and health benefits to American Indian and Alaska Native veterans.  These collaborative efforts are reviewed on an on-going basis in efforts to address patient related issues, improved services, outreach, rural initiatives, and to assist American Indian and Alaska Native veterans to utilize both IHS/VHA systems.

The IHS and VHA have a long history of working jointly on health information technology (HIT).  Since the mid-1980s when the two agencies both successfully fielded the Decentralized Hospital Computer Program (DHCP) software, the VHA and IHS have sought opportunities to collaborate in the sharing of HIT.  The Resource and Patient Management System (RPMS) is the IHS’ comprehensive health information system created to support the delivery of high quality health care to American Indians and Alaska Natives at several hundred Federal and Tribal hospitals and clinics nationwide.  The RPMS is a government-developed and owned system that evolved alongside the Veteran’s Health Administration’s (VHA) acclaimed VistA system.

In addition, the model for the RPMS Electronic Health Record (EHR) is the Veterans Health Administration (VHA) electronic medical record, the Computerized Patient Record System (CPRS).  CPRS has been successfully deployed across the VHA hospital network over half a decade ago.  The EHR utilizes a technical infrastructure originally developed for the VHA that displays various clinical functions in a graphical user interface (GUI) format.

Consolidated Mail Outpatient Pharmacy (CMOP)
The IHS and VHA will soon begin a pilot-test using VA’s CMOP to process IHS outpatient prescriptions, based upon the electronic dispensing data provided from the IHS facilities.  Through the IHS use of the CMOP facilities, prescription filling can be centralized while providing more efficient prescription delivery and increased pharmacy billing collections.  It will also provide facilities with the capability to fill prescriptions for more than 30-day refills.  The VA’s CMOP programs offer an attractive technology for dispensing refills within the IHS because it offers the possibility of decreasing capitalization costs, reduction of outdated medications, and freeing up significant IHS pharmacist time for patient counseling, adverse drug event prevention, and primary care.  The IHS has been able to successfully transmit prescriptions from an IHS RPMS test system to a CMOP test system and transmit appropriate prescription information back to the RPMS test system. The VA’s CMOP is currently in beta testing at Haskell Indian Health Center in Lawrence, Kansas; at the Phoenix, AZ Indian Medical Center; and at the Indian health facility in Rapid City, South Dakota.

VistA Imaging
A Memorandum of Understanding between the IHS and the VHA has enabled telemedicine program coordinators from both Departments to identify key areas for cooperation and possible shared resource development.  An example is the implementation of the VA’s VistA Imaging System (VI) in IHS, which is now up to approximately 45 RPMS systems nationwide.  VistA Imaging provides the multimedia component of the VHA’s Computerized Patient Record System (CPRS) and is also offered as a multimedia tool to complement the IHS RPMS- EHR. The VI is an extension to the RPMS hospital information system. The RPMS Health Information System and Radiology Information System provide extensive support for imaging and contain a full image management infrastructure. VistA Imaging provides clinicians with access to all images and text data in an integrated manner that facilitates the clinician's task of correlating the data and making patient care decisions in a timely and accurate way. Through this agreement, the VHA also provides the IHS with on-site VI installation and training support. 

Alaska Area IHS – VA HIT Collaborations
The Alaska Area IHS has partnered with the VA since 1995 via the Alaska Federal Health Care Partnership (AFHCP) which includes IHS/tribal, VA, Army, Air Force and Coast Guard partners.  The Alaska Federal Health Care Partnership office’s primary responsibility is to coordinate initiatives between the partners that result in increased quality and access to federal beneficiaries, or an overall cost savings to the federal government.  Current initiatives in the Alaska Area include: joint training offerings, a neurosurgery contract services agreement, a perinatology contract services agreement, tele-radiology, sleep studies, home tele-health monitoring, partner staffing needs assessment, emergency planning and preparedness, and tele-behavioral health.

Past projects of AFHCP include Alaska Tribal Health System Wide Area Network (ATHSAN) Telemedicine and the development of the Wide Area Network.  The AFHCP frequently shares workload data during its investigations of possible joint services analyses; a recent example is a study for joint-agency tele-dermatology and tele-rheumatology contracts.  One of the AFHCP committees is the Partnership Telehealth & Technology Committee (PT&T) which brings together information technology staff to discuss partner organization needs, identify potential telehealth and technology applications to meet those needs, and find avenues for shared technology resources. PT&T members and their clinical champions will monitor patient results and gather feedback on the use of new technologies to improve clinical outcomes and access to care.

Future Opportunities of Partnership
Local IHS – VHA efforts to improve access and develop formal partnerships have increased since 2003 but IHS acknowledges that our joint efforts on issues related to access to health care for Indian veterans need to continue.  We are committed to working on these issues, within the Indian Health system, as well as with the Department of Veterans Affairs and the Veterans Health Administrations.   Indian communities have always honored their Indian veterans and we are committed to improving the health services they utilize and the quality of their lives.  

Mr. Chairman, this concludes my testimony.  I appreciate the opportunity to appear before you to discuss the collaboration between the Department of Health and Human Services through the Indian Health Service and the Department of Veterans Affairs I will be happy to answer any questions that you may have.  Thank you.