Published on February 14, 2008
LDSI: Laboratory Data Sharing & Interoperability: LDSI: Laboratory Data Sharing & Interoperability State of the MHS 2006 Annual Conference LDSI Presenters: LDSI Presenters Senior Project Manager Health Information Technology Sharing Veterans Health Administration Health Systems Design & Development Project Officer, AHLTA Imaging, DoD/VA IM/IT Sharing Initiatives DoD Military Health System Clinical Information Technology Program Office Laboratory Information Manager Veterans Health Administration North Chicago VA Medical Center LDSI Agenda: LDSI Agenda Background & Overview Communications Functionality LDSI In Action Background Set-Up Test Example: NCH VAMC - NHGL Experience Benefits & Lessons Learned Q & A LDSI: Background & Overview: LDSI: Background & Overview Presented by Senior Project Manager, Health IT Sharing VHA Office of Information LDSI: Background: LDSI: Background The VA and DoD Health Resources Sharing and Emergency Operations Act of 05/04/1982 initiated sharing activities between VA and DoD In 1997 the VA and DoD formed the DoD/VA Health Executive Council (HEC) to guide sharing activities The National Defense Authorization Act (NDAA) for FY2000 authorized joint IT demonstration projects for healthcare The NDAA for FY2003 directed VA/DoD to conduct sharing projects at no fewer than three sites and provided funding for the same through FY2007 LDSI Background: VA LEDI Story: LDSI Background: VA LEDI Story LEDI – 1997 - VA developed LEDI software (Laboratory Electronic Data Interchange) for VA to VA use for Chemistry & Hematology testing LEDI II – 2002 - VA enhanced the software to allow VA to electronically send orders to and receive results from commercial reference laboratories LEDI III – 2004 - LEDI further enhanced to allow VA and DoD facilities to utilize each other as reference laboratories. Additional development allowed for bidirectional sending/receiving of orders/results (LDSI Phase 1) LEDI IV – 2006 – Currently additional LEDI enhancements are under development by the VA, in concert with DoD, to allow electronic ordering and resulting for Anatomic Pathology and Microbiology testing (LDSI Phase 2) LDSI Overview: LDSI Overview LDSI is a VA/DoD joint venture project which provides a bidirectional software interface between the DoD’s CHCS and VA’s VistA/CPRS health care systems which supports sharing secure encrypted laboratory orders and results between the two agencies Currently, enables the real-time electronic order entry and results retrieval capability for clinical chemistry, hematology, toxicology and serology assays (Chemistry subscript tests) Software enables either the VA or DoD facility to act as the reference or performing laboratory (local sharing sites need to examine their business processes to determine whether it makes sense to use the other agency as a reference lab) Deployed throughout the VA and DoD in 2004 and is currently available to all hospitals and clinics Eliminates much of the current manual reentry of orders and results into either system which may contribute to medical errors LDSI Overview: Current Deployment: LDSI Overview: Current Deployment North Chicago VA Medical Center - Naval Hospital Great Lakes VA Spark M Matsunaga Medical Center (Hawaii) - Tripler Army Medical Center New Mexico VA Health Care System (Albuquerque) - Kirtland Air Force Base (377th Medical Group) - Brooks Air Force Base VA San Diego Healthcare System - Naval Medical Center San Diego El Paso VA Health Care System - William Beaumont Army Medical Center South Texas Veterans Health Care System - Brooke Army Medical Center, Wilford Hall Medical Center Alaska VA Healthcare System - Bassett Army Community Hospital testing network connectivity Mike O’Callaghan Federal Hospital - Nellis Air Force Base establishing network connectivity Miami VA Medical Center - Jacksonville Naval Hospital, Naval Air Station Key West pending MOU VA Boston Healthcare System - Naval Ambulatory Care Center Groton pending MOU VA Northern California Healthcare System- Davis Grant Medical Center (Travis AFB) discussing feasibility LDSI Overview: Business Flowchart: LDSI Overview: Business Flowchart LDSI: Communications: LDSI: Communications Presented by Project Officer, AHLTA Imaging Clinical Information Technology Program Office LDSI Communications: Connectivity : LDSI Communications: Connectivity LDSI Data for all VA sites is sent via a single VPN located at the Austin Automation Center (AAC) Hardware Server to Server (not User to Server) Connects the VA Wide Area Network (WAN) to the DoD WAN over a TCP/IP connection Utilizes existing firewalls, gateways, & security measures LDSI Communications: Data: LDSI Communications: Data All exchanged data is encrypted Information sent via HL7 messaging (Health Level 7 – A national standard for healthcare- specific data exchange between computer applications) LOINC (Logical Observation Identifier Names and Codes) and SNOMED CT (Systemized Nomenclature of Medicine Clinical Terminology) utilized for standardized communication – industry standard code sets LDSI Communications: Data Transfer Detail: LDSI Communications: Data Transfer Detail CHCS, VistA/CPRS and the commercial reference laboratories exchange data using HL7 version 2.2 messages that are transmitted when triggering events occur Computer connectivity between CHCS, VistA/CPRS and the commercial reference laboratories is via a transient TCP/IP connection Two TCP sockets on each system provide communications between the two systems. VistA/CPRS electronic messaging uses one HL7 server listening on a TCP/IP port and socket, and a non-persistent HL7 client connecting over a TCP/IP port and socket Within the context of each TCP socket, VistA/CPRS and the commercial reference laboratories are the server or the client to which multiple CHCS sites may connect as a client or a server Lower level connectivity is provided via HL7 Minimal Lower Layer Protocol Slide15: VA or EpiLab Reference Lab Server Lab Interoperability LDSI Communications: Network View (2) LDSI: Functionality: LDSI: Functionality Presented by Project Officer, AHLTA Imaging Clinical Information Technology Program Office LDSI Functionality: Definitions: LDSI Functionality: Definitions Reference Facility (Host) – Laboratory performing the tests Collection Facility (Submitting) – Laboratory sending the specimen to be tested LEDI – VA name for Interoperability software LDSI – VA/DoD name for NDAA enhancements to Laboratory Interoperability software LDSI Functionality: At a Glance: LDSI Functionality: At a Glance At Collection Facility Build Electronic Orders Create Shipping Manifests Close and Send Shipping Manifests Transport Specimens to Reference Lab At Reference Lab Accept Electronic Manifest – Minimal keystroke log-in order into Ref. Lab computer system, process test, and verify result Result returned electronically to Collection Facility At Collection Facility Verify/Release Transmitted Result Results available to clinicians LDSI: Workflow: LDSI: Workflow LDSI Functionality: In Detail: LDSI Functionality: In Detail Collection Facility using the VA LEDI or CHCS Lab Interop software creates an HL7-formatted electronic order message. The order message contains the patient’s demographics (patient’s name, social security number, patient’s location, and ordering physician) as well as the test requested information to enable quick and easy ordering at the Reference Facility. The Collection Facility software (LEDI or Lab Interop) hands the HL7-formatted message via WAN/VPN to the Reference Facility HL7 server. The Reference HL7 server processes the Collection site’s order message. The Reference Lab orders the test using the electronically received data, performs the analytical test procedures and the test results are verified/released by authorized lab personnel. LDSI Functionality: In Detail (cont.): LDSI Functionality: In Detail (cont.) The Reference Lab software creates an HL7-formatted message containing result information, and sends the message via WAN/VPN back to the Collection Lab’s HL7 server. The Collection Lab’s HL7 server accepts and processes the HL7 message, and then passes the message to the LEDI or LDSI software for further processing. The electronic result message is stored at the collection facility and the collection lab technicians/technologists review the results on the screen for completeness and clinical credibility. If the results are acceptable, the collection lab personnel will certify them and record them in the patient’s electronic clinical record. LDSI: In Action: LDSI: In Action Lab Data Sharing Between North Chicago VA Medical Center and Naval Hospital Great Lakes Presented by Laboratory Information Manager North Chicago VAMC VISN 12 of 21 Veterans Integrated Service Networks: VISN 12 of 21 Veterans Integrated Service Networks Slide24: Sault Ste. Marie Appleton Rhinelander Marquette Houghton/ Hancock Iron Mt. Union Grove Hines Westside Lakeside North Chicago Chicago Metro VAs Rockford Crown Point Cleveland VISN 12 Hospitals & Clinics LaSalle Chippewa Falls Madison Tomah Milwaukee Oak Park Evanston Waukegan Elgin Aurora Wausau Menomonie Loyal Joliet Chicago Heights Manteno Woodlawn LEDI Used Since 1997:VISN 12 Distance Schematic: LEDI Used Since 1997: VISN 12 Distance Schematic Madison, WI Iron Mountain, MI Tomah, WI North Chicago, IL Milwaukee, WI Hines Lakeside Westside 92 mi 220 mi 56 mi 40 mi 3 mi 7 mi 78 mi Chicago VAMC Facilities Proximity of NCH VA and NHGL: Proximity of NCH VA and NHGL LDSI: Setup: LDSI: Setup Presented by Laboratory Information Manager North Chicago VAMC & DoD Slides Prepared by Laboratory Department Naval Hospital Great Lakes, IL LDSI Set-Up: LDSI Set-Up One-Time Set-Up Activities Do It Once, Then Use It Forever Obtain Signed Sharing Agreement Activate the Electronic Interface Secure Connection to the National VPN Set Up Lab Send-out Tests Utilizing Standard Names and Test Codes Map/Link Tests Using Standardized Codes from both VA and DoD computer databases Validate electronic ordering and resulting using a test patient LDSI Setup: File Info Required: LDSI Setup: File Info Required VA and DoD must share certain file entries in order to map/link tests between facilities Required Information for each test: Test Name Test Order Code – for automatic electronic ordering Test Result Code – to send result electronically Specimen/Sample Name Specimen/Sample Numeric Code LDSI Set-Up: VA File Setup for VA to DoD: LDSI Set-Up: VA File Setup for VA to DoD Select SHIPPING CONFIGURATION: Are you editing this entry as the: 1 Collecting facility COLLECTING FACILITY: NORTH CHICAGO VAMC// HOST FACILITY: NH GREAT LAKES// LAB MESSAGING LINK: LA7V HOST 0056// Select TEST/PROFILE: NAVY TROPONIN I// ACCESSION AREA: NC/NAVY// NON-NLT TEST ORDER CODE: 7634// DoD Standard Test Code NON-NLT TEST ORDER NAME: TROPONIN I CARDIAC// DoD Name NON-HL7 SPECIMEN CODE: 72// DoD and VA Specimen Code NON-HL7 SPECIMEN NAME: SERUM// DoD and VA Spec. Name COLLECTION SAMPLE CODE: 99// DoD Sample Code COLLECTION SAMPLE NAME: BLOOD// DoD Sample Name LDSI Set-Up: VA File Setup for DoD to VA: LDSI Set-Up: VA File Setup for DoD to VA Select SHIPPING CONFIGURATION: NAVY from NAVY to VA N.Chicago Are you editing this entry as the: 2 Host facility COLLECTING FACILITY: NH GREAT LAKES// COLLECTING FACILITY'S SYSTEM: NH GREAT LAKES// HOST FACILITY: NORTH CHICAGO VAMC// HOST FACILITY'S SYSTEM: NORTH CHICAGO VAMC// Select TEST/PROFILE: TEST/PROFILE: BNP Brain Natriuretic Peptide // VA Test Name HOST COLLECTION SAMPLE: BLOOD LAVENDER// VA Name NON-HL7 SPECIMEN CODE: 73// VA Specimen Code # NON-HL7 SPECIMEN NAME: PLASMA// VA Specimen Name LDSI Set-Up: VA File Info Given to DoD for Set-up: LDSI Set-Up: VA File Info Given to DoD for Set-up BNP (Brain Natriuretic Peptide) Test Name NUMERIC - TYPE A # BETWEEN 0 AND 9999 Collection Tube: BLOOD LAVENDER Sample Name Site/Specimen: PLASMA Specimen Name LEDI HL7:Plasma Reference Low: 0 Reference High: 100 Units: pg/mL LOINC Code: 30934-4 Interpretation: BNP INTERPRETATION: <= 100 pg/ml Negative > 100 pg/ml Positive > 200 pg/ml High correlation with left heart failure NLT Code: 82021.0000 Natriuretic Peptide Brain Order Code NLT Result Code: 82021.0000 Natriuretic Peptide Brain Result Code LDSI Set-Up DOD: 1st Add Each Test in the Reference Lab File: LDSI Set-Up DOD: 1st Add Each Test in the Reference Lab File LDSI Set-Up DOD: Entry of VA Order Code for Test Set-up: LDSI Set-Up DOD: Entry of VA Order Code for Test Set-up LDSI Set-Up DOD: Test Must Be a Standard DoD Test: LDSI Set-Up DOD: Test Must Be a Standard DoD Test LDSI Set-Up DOD: Collection Sample Type & Lab Method: LDSI Set-Up DOD: Collection Sample Type & Lab Method LDSI Set-Up DOD: Instructions for Lab Techs: LDSI Set-Up DOD: Instructions for Lab Techs LDSI Set-Up: Additional File Entries – Method and Specimen: LDSI Set-Up: Additional File Entries – Method and Specimen LDSI Set-Up DOD: More Set-Up For Tests to Send Out to VA: LDSI Set-Up DOD: More Set-Up For Tests to Send Out to VA LDSI Set-Up DOD: Enter Reference (Performing) Lab Identifier: LDSI Set-Up DOD: Enter Reference (Performing) Lab Identifier LDSI Set-up: Result Code from VA for DoD Set-up: LDSI Set-up: Result Code from VA for DoD Set-up BNP Brain Natriuretic Peptide NUMERIC TYPE A NUMBER BETWEEN 0 AND 9999 Collection Tube: BLOOD LAVENDER MIN VOL (in mls.): 3 Site/Specimen: PLASMA LEDI HL7:Plasma Reference Low: 0 Reference High: 100 Units: pg/mL LOINC Code: 30934-4 Interpretation: BNP INTERPRETATION: <= 100 pg/ml Negative > 100 pg/ml Positive > 200 pg/ml High correlation with left heart failure At this time there is insufficient evidence to suggest that BNP levels have added value in terms of guiding heart failure management over and above information that is recommended by current heart failure guidelines. NLT Code: 82021.0000 Natriuretic Peptide Brain NLT Result Code: 82021.0000 Natriuretic Peptide Brain Result Code LDSI Set-Up DOD: Enter VA Result Codes and Lab Method: LDSI Set-Up DOD: Enter VA Result Codes and Lab Method LDSI: Test Example: LDSI: Test Example Test Sent to North Chicago VAMC (Reference Lab) from Naval Hospital Great Lakes (Collection Lab) Test Example: Sending Testwith VA as Reference Lab: Test Example: Sending Test with VA as Reference Lab Place Orders Orders are entered through existing clinical and laboratory pathways utilizing existing functional practice Accession Orders in Lab (Log-in Specimens) Orders are accessioned (Log-in Specimens ) through existing laboratory pathways utilizing existing functional practice Test Example: Sending Test VA as Reference Lab (cont’d): Test Example: Sending Test VA as Reference Lab (cont’d) Generate and Send Shipping Lists Options RVA: Review Accession Pool - Lists accession pool by selected or all Performing Labs GSL: Generate Shipping List Batch - Automatically generates a shipping list by accession or performing lab and allows sending of the shipping list MSL: Manually Create Shipping List Batch - Generates a shipping list with user specified accessions and allows sending of the shipping list PSB: Process Shipping List Batch - Allows user manipulation and sending of an existing shipping list. PBL: Print Shipping List Batch - Prints shipping list batches, sent and received Test Example: Sending Test VA as Reference Lab (cont’d): Test Example: Sending Test VA as Reference Lab (cont’d) Generate and Send Shipping Lists (cont.) Statuses Logged-in to the Laboratory (AWAITING SHIPMENT) On a shipping list batch (ON SHIPPING LIST) Shipping list batch has been sent (IN SHIPPING TRANSIT) Specimens accepted at performing lab (AT PEFORMING LAB ACCEPTED) Specimens rejected at performing lab (AT PERFORMING LAB REJECTED) Test Example: Generate Electronic Shipping List at DoD: Test Example: Generate Electronic Shipping List at DoD Test Example: Add Test to Shipping List and Send via LDSI: Test Example: Add Test to Shipping List and Send via LDSI Test Example: Print Shipping List By Batch Number at DoD: Test Example: Print Shipping List By Batch Number at DoD Test Example: Alerts Sent to Reference Lab: Test Example: Alerts Sent to Reference Lab Notification immediately sent to VA - manifest received message You have PENDING ALERTS Enter "VA to jump to VIEW ALERTS option VA View Alerts 1.I Lab Messaging - Manifest# 556-N00211-412 received from LA7V COLLECTION 0056 (Great Lakes Naval Hospital) Test Example: Reference Lab (Continued): Test Example: Reference Lab (Continued) Receive Shipping List / Manifest ACK: Acknowledge Receipt of Specimens Allow user to Accept or Reject Specimens Allow user to enter Condition of specimen Reason for rejection is required for rejected specimens Auto Register Patients (Mail-in Register Patients) Auto generate Orders Accession Orders (Log-in Specimens) Test Example: InfoContained in Shipping List: Test Example: Info Contained in Shipping List Illustration of data electronically embedded in the Shipping List sent from the Navy Shipping Manifest: 556-N00211-412 Page: 1 to Site: NORTH CHICAGO VAMC Printed: Jan 04, 2006@11:13 from Site: NH GREAT LAKES Status: Electronic Manifest Ship via: Electronic manifest Patient Name Patient ID Accession Date of Birth Sex Specimen UID Requested By Collect Date/Time ------------------------------------------------------------------------------- Item: 1 PATIENT,NAME SSN XXX-XX-XXX Dec 04, 1957 Female 060104 VA 7 REF:0056 Jan 04, 2006@09:48 Host test status: Specimen in process ------------------------------- BRAIN NATRIURETIC PEPTIDE PLASMA VA NLT code [Name]: 82021.0000 [Natriuretic Peptide Brain (B Type)] Host site UID: 1160040119 Test Example: VA Bar-coded Shipping List / Manifest Example: Test Example: VA Bar-coded Shipping List / Manifest Example Bar-code with Submitting Lab Info Bar-code contains pt. info and requested tests for #1 Patient #2 Patient #3 Patient #4 Test Example: VA Bar-coded Manifest for Single Pt. Demo Test: Test Example: VA Bar-coded Manifest for Single Pt. Demo Test Test Example: Ordering Tests at VA (Reference Lab): Test Example: Ordering Tests at VA (Reference Lab) Option: referral Patient Multi-purpose Accessioning (Can use bar-coded manifest or manual entry of List # and DoD Lab Accn # ) Are you using a barcode reader? YES// Scan Remote Site Barcode (SM): SITE^0056^^556-N00211-413^116 Select ACCN TEST GROUP: NAVY - TO/FROM GREAT LAKES Scan Patient/Accession Barcode (PD): PD^xxxxxxxxx^0056^ 060104 VA 8 ^3060104.1133^116 You have just selected the following tests for ZZMO,TEST xxx-xx-xxxx entry no. Test Sample 1 BNP Brain Natriuretic Peptide BLOOD LAVENDER PLASMA All satisfactory? Yes// (Yes) LAB Order number: 1121 Print labels on: LABLABEL// C80 ACCESSION: CH 0104 135 <1160040135> BNP Brain Natriuretic Peptide BLOOD LAVENDER PLASMA Scan Patient/Accession Barcode (PD): More patients could be scanned Test Example: Processing VA as Reference Lab (cont’d): Test Example: Processing VA as Reference Lab (cont’d) Perform Test Analysis Enter Results Results are entered through existing laboratory pathways utilizing existing functional practice. Results Returned Electronically to Submitting Lab via LDSI Test Example: Result Entry and Verification at VA: Test Example: Result Entry and Verification at VA Lab Option: Enter/verify data (auto instrument) ZZMO,TEST SSN: xxx-xx-xxxx Pat Info: Sex: MALE Age: 12yr as of Jan 04, 2006 ACCESSION: CH 0104 135 1/4 11:33d BNP Brain Natriuretic Peptide 258 H pg/mL SELECT ('E' to Edit, 'C' for Comments, 'W' Workload): Approve for release by entering your initials: SMH Result immediately transmitted electronically to CHCS. Test Example: Alert Sent to Collecting Lab: Test Example: Alert Sent to Collecting Lab Alert is electronically sent to Navy when the result is available for release in CHCS Naval Hospital Great Lakes Department of Pathology Select Lab System Menu Option: Results awaiting local verification have been received. Test Example: Notification of Results in CHCS Upon Log-On: Test Example: Notification of Results in CHCS Upon Log-On Test Example: Test Available for Resulting: Test Example: Test Available for Resulting Test Example: CHCS Verification as the Collection Lab: Test Example: CHCS Verification as the Collection Lab Note - Reference Range, Units, & Interp. transmitted from VA Test Example: CHCS Verification as the Collection Lab : Test Example: CHCS Verification as the Collection Lab Verify Results VRR: Verify Reference Lab Results New accession status of “PENDING LOCAL VERIFICATION” Allows a user to verify (verification causes a result to be certified and available outside of the laboratory) Verified results are broadcast to offboard systems such as CEIS and CIW Allows a user to reject with a comment Reports New Accession Statuses will be listed on appropriate reports Accession status of “PENDING LOCAL VERIFICATION” will not appear in PLI, PLI will display “PENDING” Full performing lab disclosure will be displayed on the Daily and Discharge Cumulative Reports. Test Example: Other Alerts/Mail Msgs Available: Test Example: Other Alerts/Mail Msgs Available Other meaningful alerts/mail bulletins that might be generated when processing LEDI HL7 messages LA7 ABNORMAL RESULTS RECEIVED - Mail bulletin created by Lab package when processing a LEDI interface type HL7 result (ORU) message which contains laboratory testing results that are flagged as critical. LA7 AMENDED RESULTS RECEIVED - Mail bulletin created by Laboratory package when processing a LEDI interface type HL7 result (ORU) message which contains laboratory testing results that are flagged as amended. LA7 ORDER STATUS CHANGED – Order cancelled or Test Added LDSI: Benefits : LDSI: Benefits Before & After Benefits Lessons Learned Before LDSI: Lab Result Process: Before LDSI: Lab Result Process Submitting Lab mails specimens to Performing Lab for processing Performing Lab tech manually registers patient, enters order, accessions specimen, enters results and sends results to Submitting Lab (e-mail, phone, fax, etc.) Results are manually entered into CHCS at the Submitting Lab Submitting Lab user must configure a Lab Method in the Lab Method file to store the Units of Measure, Alerts, Reference Ranges, and Interpretations reported by the Performing Lab. If the Submitting lab does not configure a Lab Method in the Lab Method file, results entered from the Performing Lab report will be displayed correctly, however, it is possible that Units, Alerts, Reference Ranges and Interpretations will be incorrect. Submitting Lab tech certifies the result which triggers the broadcast of the certified result to interfaced systems such as EI/DS and CHCS II. Units, Alerts, References Ranges, and Interpretations stored in the Lab Method are included in the broadcast message but may not be correct for that result. After LDSI: Lab Result Process: After LDSI: Lab Result Process Submitting Lab mails specimens to Performing Lab for processing Submitting Lab electronically transmits patient, order and accession information to the Performing Lab in an HL7 Standard interface message Performing Laboratory acknowledges the electronic order. Using information provided in the HL7 message: Performs an interactive mail-in registration The Order and Accession is automatically created Results are entered through existing result entry pathways and certified. Certified result is automatically transmitted to the Submitting Lab and filed in the Lab Result file. Submitting Lab Supervisor is not required to configure a Lab Method to maintain the Performing Lab’s Units of Measure, Alerts, Reference Ranges and Interpretations Values received from the Performing Lab are stored in the Lab Result file and will be displayed to the clinical users with the correct Units, Alerts, Reference Ranges and Interpretations as transmitted from Performing Lab Submitting Lab tech verifies the result which triggers the broadcast of the certified result to interfaced systems such as EI/DS and CHCS II. Units, Alerts, References Ranges, and Interpretations received from the Performing Lab are included in the broadcast message and are not derived from the Lab Method. LDSI Benefits: LDSI Benefits Regional laboratories operate as a unified system Improved DOD/VA resource sharing Eliminates extra file setup required to store reference ranges, units, etc. of test results from Reference Labs. Reduces the labor required for duplicate patient registration, lab order entry, accessioning, result entry, and reporting. Eliminates need to call submitting Lab for pt. info such as SSN, DOB Eliminates possible data transcription errors during patient registration, lab test ordering, and result entry Improves turnaround-time (TAT) Eliminates calling and faxing of results Accountability through electronic date/time stamps for each step LDSI: Lessons Learned: LDSI: Lessons Learned Focused Effort for Initial Implementation – First interfaced test set-up requires a significant time investment for data input and testing. Subsequent added tests can be set up in minutes and can be validated in 30-60 minutes Implementation Commitment – Once the site goes electronic, it cannot revert to a manual process without creating duplicate work Contact Names – Retain a current list of contacts in both agencies for connectivity issues. When you have the right names, you can quickly resolve communication problems Training Critical – The constant movement of personnel, particularly in the DoD, requires a sustained training effort and protocol LDSI: Q&A: LDSI: Q&A Questions?
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