Computer-Based Patient Records
VA and DOD Made Progress, but Much Work Remains to Fully Share Medical Information Gao ID: GAO-05-1051T September 28, 2005For the past 7 years, the Departments of Veterans Affairs (VA) and Defense (DOD) have been working to exchange patient health information electronically and ultimately to have interoperable electronic medical records. Sharing medical information helps (1) promote the seamless transition of active duty personnel to veteran status and (2) ensure that active duty military personnel and veterans receive high-quality health care and assistance in adjudicating their disability claims. This is especially critical in the face of current military responses to national and foreign crises. In testimony before the Veterans' Affairs Subcommittee on Oversight and Investigations in March and May 2004, GAO discussed the progress being made by the departments in this endeavor. In June 2004, at the Subcommittee's request, GAO reported on its review of the departments' progress toward the goal of an electronic two-way exchange of patient health records. GAO is providing an update on the departments' efforts, focusing on (1) the status of ongoing, near-term initiatives to exchange data between the agencies' existing systems and (2) progress in achieving the longer term goal of exchanging data between the departments' new systems.
In the past year, VA and DOD have begun to implement applications that exchange limited electronic medical information between the departments' existing health information systems. These applications are (1) Bidirectional Health Information Exchange, a project to achieve the two-way exchange of health information on patients who receive care from both VA and DOD, and (2) Laboratory Data Sharing Interface, an application used to electronically transfer laboratory work orders and results between the departments. The Bidirectional Health Information Exchange application has been implemented at five sites, at which it is being used to rapidly exchange information such as pharmacy and allergy data. Also, the Laboratory Data Sharing Interface application has been implemented at six sites, at which it is being used for real-time entry of laboratory orders and retrieval of results. According to the departments, these systems enable lower costs and improved service to patients by saving time and avoiding errors. VA and DOD are continuing with activities to support their longer term goal of sharing health information between their systems, but the goal of two-way electronic exchange of patient records remains far from being realized. Each department is developing its own modern health information system--VA's HealtheVet VistA and DOD's Composite Health Care System II--and they have taken steps to respond to GAO's June 2004 recommendations regarding the program to develop an electronic interface that will enable these systems to share information. That is, they have developed an architecture for the interface, established project accountability, and implemented a joint project management structure. However, they have not yet developed a clearly defined project management plan to guide their efforts, as GAO previously recommended. Further, they have not yet fully populated the repositories that will store the data for their future health systems, and they have experienced delays in their efforts to begin a limited data exchange. Lacking a detailed project management plan increases the risk that the departments will encounter further delays and be unable to deliver the planned capabilities on time and at the cost expected.
GAO-05-1051T, Computer-Based Patient Records: VA and DOD Made Progress, but Much Work Remains to Fully Share Medical Information
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United States Government Accountability Office:
GAO:
Testimony before the Committee on Veterans' Affairs, House of
Representatives:
For Release on Delivery:
Expected at 10:00 a.m. EDT September 28, 2005:
Computer-Based Patient Records:
VA and DOD Made Progress, but Much Work Remains to Fully Share Medical
Information:
Statement of Linda D. Koontz:
Director, Information Management Issues:
GAO-05-1051T:
GAO Highlights:
Highlights of GAO-05-1051T, a testimony before the Committee on
Veterans' Affairs, House of Representatives:
Why GAO Did This Study:
For the past 7 years, the Departments of Veterans Affairs (VA) and
Defense (DOD) have been working to exchange patient health information
electronically and ultimately to have interoperable electronic medical
records. Sharing medical information helps (1) promote the seamless
transition of active duty personnel to veteran status and (2) ensure
that active duty military personnel and veterans receive high-quality
health care and assistance in adjudicating their disability claims.
This is especially critical in the face of current military responses
to national and foreign crises.
In testimony before the Veterans‘ Affairs Subcommittee on Oversight and
Investigations in March and May 2004, GAO discussed the progress being
made by the departments in this endeavor. In June 2004, at the
Subcommittee‘s request, GAO reported on its review of the departments‘
progress toward the goal of an electronic two-way exchange of patient
health records.
GAO is providing an update on the departments‘ efforts, focusing on (1)
the status of ongoing, near-term initiatives to exchange data between
the agencies‘ existing systems and (2) progress in achieving the longer
term goal of exchanging data between the departments‘ new systems.
What GAO Found:
In the past year, VA and DOD have begun to implement applications that
exchange limited electronic medical information between the
departments‘ existing health information systems. These applications
are (1) Bidirectional Health Information Exchange, a project to achieve
the two-way exchange of health information on patients who receive care
from both VA and DOD, and (2) Laboratory Data Sharing Interface, an
application used to electronically transfer laboratory work orders and
results between the departments. The Bidirectional Health Information
Exchange application has been implemented at five sites, at which it is
being used to rapidly exchange information such as pharmacy and allergy
data. Also, the Laboratory Data Sharing Interface application has been
implemented at six sites, at which it is being used for real-time entry
of laboratory orders and retrieval of results. According to the
departments, these systems enable lower costs and improved service to
patients by saving time and avoiding errors.
VA and DOD are continuing with activities to support their longer term
goal of sharing health information between their systems (see figure),
but the goal of two-way electronic exchange of patient records remains
far from being realized. Each department is developing its own modern
health information system”VA‘s HealtheVet VistA and DOD‘s Composite
Health Care System II”and they have taken steps to respond to GAO‘s
June 2004 recommendations regarding the program to develop an
electronic interface that will enable these systems to share
information. That is, they have developed an architecture for the
interface, established project accountability, and implemented a joint
project management structure. However, they have not yet developed a
clearly defined project management plan to guide their efforts, as GAO
previously recommended. Further, they have not yet fully populated the
repositories that will store the data for their future health systems,
and they have experienced delays in their efforts to begin a limited
data exchange. Lacking a detailed project management plan increases the
risk that the departments will encounter further delays and be unable
to deliver the planned capabilities on time and at the cost expected.
History of Selected VA/DOD Efforts on Electronic Medical Records and
Data Sharing:
[See PDF for image]
[End of figure]
www.gao.gov/cgi-bin/getrpt?GAO-05-1051T.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Linda D. Koontz at (202)
512-6240 or koontzl@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to participate in today's discussion on the actions taken
by the Departments of Veterans Affairs (VA) and Defense (DOD) to
promote the seamless transition of active duty personnel to veteran
status. Among the two departments' goals for seamless transition is to
be able to exchange patient health information electronically and
ultimately to have interoperable[Footnote 1] electronic medical
records. Sharing of medical information is an important tool to help
ensure that active duty military personnel and veterans receive high-
quality health care and assistance in adjudicating their disability
claims--goals that, in the face of current military responses to
national and foreign crises, are more essential than ever.
For the past 7 years, VA and DOD have been working to achieve these
capabilities, beginning with a joint project in 1998 to develop a
government computer-based patient record. As we have noted in previous
testimony,[Footnote 2] the departments had achieved a measure of
success in sharing data through the one-way transfer of health
information from DOD to VA health care facilities. However, they have
been severely challenged in their pursuit of the longer term objective-
-providing a virtual medical record in which data are computable. That
is, rather than data being provided as text for viewing only, data
would be in a format that the health information application can act
on: for example, providing alerts to clinicians (of such things as drug
allergies) and plotting graphs of changes in vital signs such as blood
pressure. According to the departments, the use of such computable
medical data contributes significantly to the usefulness of electronic
medical records.
As of June 2004, when we last reported on this topic,[Footnote 3] VA
and DOD were continuing to define the data standards that are essential
both for the exchange of data and for the development of interoperable
electronic medical records. At that time, we identified weaknesses in
the planning and management structure of the departments' program, and
we recommended that the departments take a number of actions to address
these weaknesses.
Also in 2004, in response to a mandate in the Bob Stump National
Defense Authorization Act for Fiscal Year 2003,[Footnote 4] VA and DOD
initiated information technology demonstration projects focusing on
near-term goals: the exchange of electronic medical information between
the departments' existing health information systems. These projects
are to help in the evaluation of the feasibility, advantages, and
disadvantages of measures to improve sharing and coordination of health
care and health care resources. The two demonstration projects
(Bidirectional Health Information Exchange and Laboratory Data Sharing
Interface) are interim initiatives that are separate from the
departments' ongoing long-term efforts in sharing data and developing
health information systems.
At your request, my testimony today will discuss the two departments'
continued efforts to exchange medical information, with a specific
focus on (1) the status of ongoing, near-term initiatives to exchange
data between the agencies' existing systems and (2) progress in
achieving the longer term goal of exchanging data between the
departments' new systems, still in development, which are to be built
around electronic patient health records.
In conducting this work, we reviewed the departments' documentation
describing the two demonstration projects, including business plans,
budget summaries, and project status reports. We also reviewed
documentation identifying the costs that the departments have incurred
in developing technology to support the sharing of health data,
including costs associated with achieving the one-way transfer of data
from DOD to VA health care facilities, and ongoing projects to develop
new health information systems. We did not audit the reported costs and
thus cannot attest to their accuracy or completeness. We reviewed draft
system requirements, design specifications, and software descriptions
for the electronic interface between the departments' new health
systems. We supplemented our analyses of the agencies' documentation
with interviews of VA and DOD officials responsible for key decisions
and actions on the health data-sharing initiatives. In addition, to
observe the Bidirectional Health Information Exchange and Laboratory
Data Sharing Interface capabilities, we conducted site visits to
military treatment facilities and VA medical centers in El Paso and San
Antonio, Texas, and Puget Sound, Washington. We conducted our work from
June through September 2005, in accordance with generally accepted
government auditing standards.
Results in Brief:
In the past year, VA and DOD have begun to implement applications that
exchange limited electronic medical information between the
departments' existing health information systems. These applications
were developed through two information technology demonstration
projects: (1) Bidirectional Health Information Exchange is a project to
achieve the two-way exchange of health information on shared
patients,[Footnote 5] and (2) Laboratory Data Sharing Interface is an
application used to facilitate the electronic transfer/sharing of
orders for laboratory work and the results of the work. The departments
have implemented the Bidirectional Health Information Exchange
application at five sites, at which it is being used for the rapid
exchange of specific types of information (pharmacy data, drug and food
allergy information, patient demographics, and laboratory
results[Footnote 6] on shared patients). Also, the Laboratory Data
Sharing Interface application has been implemented at six sites, at
which it is being used for real-time entry of laboratory orders and
retrieval of laboratory results. Although the data exchanged by these
demonstration projects are in text form only (that is, they are not
computable), the systems have significant benefits, according to the
two departments, because they enable lower costs and improved service
to patients by saving time and avoiding errors.
Since our last report on the departments' efforts to achieve a virtual
medical record, VA and DOD have taken several actions, but the
departments continue to be far from achieving the two-way electronic
data exchange capability originally envisioned. The departments have
implemented three recommendations that we made in June 2004: They have
developed an architecture for the electronic interface between DOD's
Clinical Data Repository and VA's Health Data Repository; they have
established the VA/DOD Health Executive Council[Footnote 7] as the lead
entity for the project; and they have established a joint project
management structure to provide day-to-day guidance for this
initiative. Additionally, the Health Executive Council established
working groups to provide programmatic oversight and to facilitate
interagency collaboration on sharing initiatives between DOD and VA.
However, VA and DOD have not yet developed a clearly defined project
management plan that gives a detailed description of the technical and
managerial processes necessary to satisfy project requirements, as we
previously recommended. Moreover, the departments have experienced
delays in their efforts to begin exchanging computable patient health
data; they have not yet fully populated the data repositories that are
to store the medical data for their future health systems. As a result,
much work remains before the departments achieve their ultimate goal--
interoperable electronic health records and two-way electronic exchange
of computable patient health information.
Background:
In 1998, following a presidential call for VA and DOD to start
developing a "comprehensive, life-long medical record for each service
member," the two departments began a joint course of action aimed at
achieving the capability to share patient health information for active
duty military personnel and veterans.[Footnote 8] Their first
initiative, undertaken in that year, was the Government Computer-Based
Patient Record (GCPR) project, whose goal was an electronic interface
that would allow physicians and other authorized users at VA and DOD
health facilities to access data from any of the other agency's health
information systems. The interface was expected to compile requested
patient information in a virtual record that could be displayed on a
user's computer screen.
In our reviews of the GCPR project, we determined that the lack of a
lead entity, clear mission, and detailed planning to achieve that
mission made it difficult to monitor progress, identify project risks,
and develop appropriate contingency plans. In April 2001 and in June
2002,[Footnote 9] we made recommendations to help strengthen the
management and oversight of the project. In 2001, we recommended that
the participating agencies (1) designate a lead entity with final
decision-making authority and establish a clear line of authority for
the GCPR project and (2) create comprehensive and coordinated plans
that included an agreed-upon mission and clear goals, objectives, and
performance measures, to ensure that the agencies could share
comprehensive, meaningful, accurate, and secure patient health care
data. In 2002, we recommended that the participating agencies revise
the original goals and objectives of the project to align with their
current strategy, commit the executive support necessary to adequately
manage the project, and ensure that it followed sound project
management principles.
VA and DOD took specific measures in response to our recommendations
for enhancing overall management and accountability of the project. By
July 2002, VA and DOD had revised their strategy and had made progress
toward being able to electronically share patient health data. The two
departments had refocused the project and named it the Federal Health
Information Exchange (FHIE) program and, consistent with our prior
recommendation, had finalized a memorandum of agreement designating VA
as the lead entity for implementing the program. This agreement also
established FHIE as a joint activity that would allow the exchange of
health care information in two phases.
* The first phase, completed in mid-July 2002, enabled the one-way
transfer of data from DOD's existing health information system (the
Composite Health Care System, CHCS) to a separate database that VA
clinicians could access.
* A second phase, finalized in March 2004, completed VA's and DOD's
efforts to add to the base of patient health information available to
VA clinicians via this one-way sharing capability.
According to the December 2004 VA/DOD Joint Executive Council[Footnote
10] Annual Report, FHIE was fully operational, and VA providers at all
VA medical centers and clinics nationwide had access to data on
separated service members. According to the report, the FHIE data
repository at that time contained historical clinical health data on
2.3 million unique patients from 1989 on, and the repository made a
significant contribution to the delivery and continuity of care and
adjudication of disability claims of separated service members as they
transitioned to veteran status. The departments reported total
GCPR/FHIE costs of about $85 million through fiscal year 2003.
In addition, officials stated that in December 2004, the departments
began to use the FHIE framework to transfer pre-and postdeployment
health assessment data from DOD to VA. According to these officials, VA
has now received about 400,000 of these records.
However, not all DOD medical information is captured in CHCS. For
example, according to DOD officials, as of September 6, 2005, 1.7
million patient stay records were stored in the Clinical Information
System (a commercial product customized for DOD). In addition, many Air
Force facilities use a system called the Integrated Clinical Database
for their medical information.
The revised DOD/VA strategy also envisioned achieving a longer term,
two-way exchange of health information between DOD and VA, which may
also address systems outside of CHCS. Known as HealthePeople (Federal),
this initiative is premised on the departments' development of a common
health information architecture comprising standardized data,
communications, security, and high-performance health information
systems. The joint effort is expected to result in the secured sharing
of health data between the new systems that each department is
currently developing and beginning to implement--VA's HealtheVet VistA
and DOD's CHCS II.
* DOD began developing CHCS II in 1997 and had completed a key
component for the planned electronic interface--its Clinical Data
Repository. When we last reported in June 2004, the department expected
to complete deployment of all of its major system capabilities by
September 2008.[Footnote 11] DOD reported expenditures of about $600
million for the system through fiscal year 2004.[Footnote 12]
* VA began work on HealtheVet VistA and its associated Health Data
Repository in 2001 and expected to complete all six initiatives
comprising this system in 2012. VA reported spending about $270 million
on initiatives that comprise HealtheVet VistA through fiscal year
2004.[Footnote 13]
Under the HealthePeople (Federal) initiative, VA and DOD envision that,
on entering military service, a health record for the service member
would be created and stored in DOD's Clinical Data Repository. The
record would be updated as the service member receives medical care.
When the individual separated from active duty and, if eligible, sought
medical care at a VA facility, VA would then create a medical record
for the individual, which would be stored in its Health Data
Repository. On viewing the medical record, the VA clinician would be
alerted and provided with access to the individual's clinical
information residing in DOD's repository. In the same manner, when a
veteran sought medical care at a military treatment facility, the
attending DOD clinician would be alerted and provided with access to
the health information in VA's repository. According to the
departments, this planned approach would make virtual medical records
displaying all available patient health information from the two
repositories accessible to both departments' clinicians.
To achieve this goal requires the departments to be able to exchange
computable health information between the data repositories for their
future health systems: that is, VA's Health Data Repository (a
component of HealtheVet VistA) and DOD's Clinical Data Repository (a
component of CHCS II). In March 2004, the departments began an effort
to develop an interface linking these two repositories, known as CHDR
(a name derived from the abbreviations for DOD's Clinical Data
Repository--CDR--and VA's Health Data Repository--HDR). According to
the departments,[Footnote 14] they planned to be able to exchange
selected health information through CHDR by October 2005. Developing
the two repositories, populating them with data, and linking them
through the CHDR interface would be important steps toward the two
departments' long-term goals as envisioned in HealthePeople (Federal).
Achieving these goals would then depend on completing the development
and deployment of the associated health information systems--HealtheVet
VistA and CHCS II.
In our most recent review of the CHDR program, issued in June
2004[Footnote 15], we reported that the efforts of DOD and VA in this
area demonstrated a number of management weaknesses. Among these were
the lack of a well-defined architecture for describing the interface
for a common health information exchange; an established project
management lead entity and structure to guide the investment in the
interface and its implementation; and a project management plan
defining the technical and managerial processes necessary to satisfy
project requirements. With these critical components missing, VA and
DOD increased the risk that they would not achieve their goals.
Accordingly, we recommended that the departments:
* develop an architecture for the electronic interface between their
health systems that includes system requirements, design
specifications, and software descriptions;
* select a lead entity with final decision-making authority for the
initiative;
* establish a project management structure to provide day-to-day
guidance of and accountability for their investments in and
implementation of the interface capability; and:
* create and implement a comprehensive and coordinated project
management plan for the electronic interface that defines the technical
and managerial processes necessary to satisfy project requirements and
includes (1) the authority and responsibility of each organizational
unit; (2) a work breakdown structure for all of the tasks to be
performed in developing, testing, and implementing the software, along
with schedules associated with the tasks; and (3) a security policy.
Besides pursuing their long-term goals for future systems through the
HealthePeople (Federal) strategy, the departments are working on two
demonstration projects that focus on exchanging information between
existing systems: (1) Bidirectional Health Information Exchange, a
project to exchange health information on shared patients, and (2)
Laboratory Data Sharing Interface, an application used to transfer
laboratory work orders and results. These demonstration projects were
planned in response to provisions of the Bob Stump National Defense
Authorization Act of 2003, which mandated that VA and DOD conduct
demonstration projects that included medical information and
information technology systems to be used as a test for evaluating the
feasibility, advantages, and disadvantages of measures and programs
designed to improve the sharing and coordination of health care and
health care resources between the departments.
Figure 1 is a time line showing initiation points for the VA and DOD
efforts discussed here, including strategies, major programs, and the
recent demonstration projects.
Figure 1: History of Selected VA/DOD Electronic Medical Records and
Data Sharing Efforts:
[See PDF for image]
[End of figure]
VA and DOD Are Exchanging Limited Medical Information between Existing
Health Systems:
VA and DOD have begun to implement applications developed under two
demonstration projects that focus on the exchange of electronic medical
information. The first--the Bidirectional Health Information Exchange-
-has been implemented at five VA/DOD locations and the second--
Laboratory Data Sharing Interface--has been implemented at six VA/DOD
locations.
Bidirectional Health Information Exchange:
According to a VA/DOD annual report and program officials,
Bidirectional Health Information Exchange (BHIE) is an interim step in
the departments' overall strategy to create a two-way exchange of
electronic medical records. BHIE builds on the architecture and
framework of FHIE, the current application used to transfer health data
on separated service members from DOD to VA. As discussed earlier, FHIE
provides an interface between VA's and DOD's current health information
systems that allows one-way transfers only, which do not occur in real
time: VA clinicians do not have access to transferred information until
about 6 weeks after separation. In contrast, BHIE focuses on the two-
way, near-real-time exchange of information (text only) on shared
patients (such as those at sites jointly occupied by VA and DOD
facilities). This application exchanges data between VA's VistA system
and DOD's CHCS system (and CHCS II where implemented). To date, the
departments reported having spent $2.6 million on BHIE.
The primary benefit of BHIE is the near-real-time access to patient
medical information for both VA and DOD, which is not available through
FHIE. During a site visit to a VA and DOD location in Puget Sound, we
viewed a demonstration of this capability and were told by a VA
clinician that the near-real-time access to medical information has
been very beneficial in treating shared patients.
As of August 2005, BHIE was tested and deployed at VA and DOD
facilities in Puget Sound, Washington, and El Paso, Texas, where the
exchange of demographic, outpatient pharmacy, radiology, laboratory,
and allergy data (text only) has been achieved. The application has
also been deployed to three other locations this month (see table 1).
According to the program manager, a plan to export BHIE to additional
locations has been approved. The additional locations were selected
based on a number of factors, including the number and types of VA and
DOD medical facilities in the area, FHIE usage, and retiree population
at the locations. The program manager stated that implementation of
BHIE requires training of staff from both departments. In addition,
implementation at DOD facilities requires installation of a server;
implementation at VA facilities requires installation of a software
patch (downloaded from a VA computer center), but no additional
equipment. As shown in table 1, five additional implementations are
scheduled for the first quarter of fiscal year 2006.
Table 1: Scheduled Rollout of BHIE at Selected DOD Facilities:
Facility: Madigan Army Medical Center, Washington;
Implementation date: October 2004.
Facility: William Beaumont Army Medical Center, Texas;
Implementation date: October 2004.
Facility: Eisenhower Army Medical Center, Georgia;
Implementation date: September 2005.
Facility: Naval Hospital Great Lakes, Illinois;
Implementation date: September 2005.
Facility: Naval Medical Center, California;
Implementation date: September 2005.
Facility: Brooke Army Medical Center, Texas;
Implementation date: First quarter, fiscal year 2006.
Facility: Landstuhl Regional Medical Center, Germany;
Implementation date: First quarter, fiscal year 2006.
Facility: Bassett Army Community Hospital, Alaska;
Implementation date: First quarter, fiscal year 2006.
Facility: Walter Reed Army Medical Center, Maryland;
Implementation date: First quarter, fiscal year 2006.
Facility: Bethesda Naval Medical Center, Maryland;
Implementation date: First quarter, fiscal year 2006.
Sources: VA and DOD.
Note: VA facilities are sited near all the DOD facilities shown.
[End of table]
Additionally, because DOD stores electronic medical information in
systems other than CHCS (such as the Clinical Information System and
the Integrated Clinical Database), work is currently under way to allow
BHIE to have the ability to exchange information with those systems.
The Puget Sound Demonstration site is also working on sharing
consultation reports stored in the VA and DOD systems.
Laboratory Data Sharing Interface:
The Laboratory Data Sharing Interface (LDSI) initiative enables the two
departments to share laboratory resources. Through LDSI, a VA provider
can use VA's health information system to write an order for laboratory
tests, and that order is electronically transferred to DOD, which
performs the test. The results of the laboratory tests are
electronically transferred back to VA and included in the patient's
medical record. Similarly, a DOD provider can choose to use a VA lab
for testing and receive the results electronically. Once LDSI is fully
implemented at a facility, the only nonautomated action in performing
laboratory tests is the transport of the specimens.
Among the benefits of LDSI is increased speed in receiving laboratory
results and decreased errors from multiple entry of orders. However,
according to the LDSI project manager in San Antonio, a primary benefit
of the project will be the time saved by eliminating the need to rekey
orders at processing labs to input the information into the
laboratories' systems. Additionally, the San Antonio VA facility will
no longer have to contract out some of its laboratory work to private
companies, but instead use the DOD laboratory. To date, the departments
reported having spent about $3.3 million on LDSI.
An early version of what is now LDSI was originally tested and
implemented at a joint VA and DOD medical facility in Hawaii in May
2003. The demonstration project built on this application and enhanced
it; the resulting application was tested in San Antonio and El Paso. It
has now been deployed to six sites in all. According to the
departments, a plan to export LDSI to additional locations has been
approved. Table 2 shows the locations at which it has been or is to be
implemented.
Table 2: VA/DOD Facilities with LDSI Implementations:
Facility: Tripler Army Medical Center and VA Spark M. Matsunaga Medical
Center, Hawaii;
Implementation Date: May 2003.
Facility: Kirtland Air Force Base and Albuquerque VA Medical Center,
New Mexico;
Implementation Date: May 2003.
Facility: Naval Medical Center and San Diego VA Health Care System,
California;
Implementation Date: July 2004.
Facility: Great Lakes Naval Hospital and VA Medical Center, Illinois;
Implementation Date: October 2004.
Facility: William Beaumont Army Medical Center, El Paso, Texas;
Implementation Date: October 2004.
Facility: Brooke Army Medical Center, San Antonio, Texas;
Implementation Date: August 2005.
Facility: Bassett Army Community Hospital, Alaska;
Implementation Date: Pre-implementation.
Facility: Nellis Air Force Base, Nevada;
Implementation Date: Pre-implementation.
Sources: VA and DOD.
[End of table]
VA and DOD Are Taking Actions to Achieve a Virtual Medical Record, but
Much Work Remains:
Besides the near-term initiatives just discussed, VA and DOD continue
their efforts on the longer term goal: to achieve a virtual medical
record based on the two-way exchange of computable data between the
health information systems that each is currently developing. The
cornerstone for this exchange is CHDR, the planned electronic interface
between the data repositories for the new systems.
The departments have taken important actions on the CHDR initiative. In
September 2004 they successfully completed Phase I of CHDR by
demonstrating the two-way exchange of pharmacy information with a
prototype in a controlled laboratory environment.[Footnote 16]
According to department officials, the pharmacy prototype provided
invaluable insight into each other's data repository systems,
architecture, and the work that is necessary to support the exchange of
computable information. These officials stated that lessons learned
from the development of the prototype were documented and are being
applied to Phase II of CHDR, the production phase, which is to
implement the two-way exchange of patient health records between the
departments' data repositories. Further, the same DOD and VA teams that
developed the prototype are now developing the production version.
In addition, the departments developed an architecture for the CHDR
electronic interface, as we recommended in June 2004. The architecture
for CHDR includes major elements required in a complete architecture.
For example, it defines system requirements and allows these to be
traced to the functional requirements, it includes the design and
control specifications for the interface design, and it includes design
descriptions for the software.
Also in response to our recommendations, the departments have
established project accountability and implemented a joint project
management structure. Specifically, the Health Executive Council has
been established as the lead entity for the project. The joint project
management structure consists of a Program Manager from VA and a Deputy
Program Manager from DOD to provide day-to-day guidance for this
initiative. Additionally, the Health Executive Council established the
DOD/VA Information Management/Information Technology Working Group and
the DOD/VA Health Architecture Interagency Group, to provide
programmatic oversight and to facilitate interagency collaboration on
sharing initiatives between DOD and VA.
To build on these actions and successfully carry out the CHDR
initiative, however, the departments still have a number of challenges
to overcome. The success of CHDR will depend on the departments'
instituting a highly disciplined approach to the project's management.
Industry best practices and information technology project management
principles stress the importance of accountability and sound planning
for any project, particularly an interagency effort of the magnitude
and complexity of this one. We recommended in 2004 that the departments
develop a clearly defined project management plan that describes the
technical and managerial processes necessary to satisfy project
requirements and includes (1) the authority and responsibility of each
organizational unit; (2) a work breakdown structure for all of the
tasks to be performed in developing, testing, and implementing the
software, along with schedules associated with the tasks; and (3) a
security policy. Currently, the departments have an interagency project
management plan that provides the program management principles and
procedures to be followed by the project. However, the plan does not
specify the authority and responsibility of organizational units for
particular tasks; the work breakdown structure is at a high level and
lacks detail on specific tasks and time frames; and security policy is
still being drafted. Without a plan of sufficient detail, VA and DOD
increase the risk that the CHDR project will not deliver the planned
capabilities in the time and at the cost expected.
In addition, officials now acknowledge that they will not meet a
previously established milestone: by October 2005, the departments had
planned to be able to exchange outpatient pharmacy data, laboratory
results, allergy information, and patient demographic information on a
limited basis. However, according to officials, the work required to
implement standards for pharmacy and medication allergy data was more
complex than originally anticipated and led to the delay. They stated
that the schedule for CHDR is presently being revised. Development and
data quality testing must be completed and the results reviewed. The
new target date for medication allergy, outpatient pharmacy, and
patient demographic data exchange is now February 2006.
Finally, the health information currently in the data repositories has
various limitations.
* Although DOD's Clinical Data Repository includes data in the
categories that were to be exchanged at the missed milestone described
above: outpatient pharmacy data, laboratory results, allergy
information, and patient demographic information, these data are not
yet complete. First, the information in the Clinical Data Repository is
limited to those locations that have implemented the first increment of
CHCS II, DOD's new health information system. As of September 9, 2005,
according to DOD officials, 64 of 139 medical treatment facilities
worldwide have implemented this increment. Second, at present, health
information in systems other than CHCS (such as the Clinical
Information System and the Integrated Clinical Database) is not yet
being captured in the Clinical Data Repository. For example, according
to DOD officials, as of September 9, 2005, the Clinical Information
System contained 1.7 million patient stay records.
* The information in VA's Health Data Repository is also limited:
although all VA medical records are currently electronic, VA has to
convert these into the interoperable format appropriate for the Health
Data Repository. So far, the data in the Health Data Repository consist
of patient demographics and vital signs records for the 6 million
veterans who have electronic medical records in VA's current system,
VistA (this system contains all the department's medical records in
electronic form). VA officials told us that they plan next to
sequentially convert allergy information, outpatient pharmacy data, and
lab results for the limited exchange that is now planned for February
2006.
In summary, developing an electronic interface that will enable VA and
DOD to exchange computable patient medical records is a highly complex
undertaking that could lead to substantial benefits--improving the
quality of health care and disability claims processing for the
nation's military members and veterans. VA and DOD have made progress
in the electronic sharing of patient health data in their limited, near-
term demonstration projects, and have taken an important step toward
their long-term goals by improving the management of the CHDR program.
However, the departments face considerable work and significant
challenges before they can achieve these long-term goals. While the
departments have made progress in developing a project management plan
defining the technical and managerial processes necessary to satisfy
project requirements, this plan does not specify the authority and
responsibility of organizational units for particular tasks, the work
breakdown structure lacks detail on specific tasks and time frames, and
security policy has not yet been finalized. Without a project
management plan of sufficient specificity, the departments risk further
delays in their schedule and continuing to invest in a capability that
could fall short of expectations.
Mr. Chairman, this concludes my statement. I would be pleased to
respond to any questions that you or other members of the Committee may
have at this time.
Contacts and Acknowledgments:
For information about this testimony, please contact Linda D. Koontz,
Director, Information Management Issues, at (202) 512-6240 or at
koontzl@gao.gov. Other individuals making key contributions to this
testimony include Nabajyoti Barkakati, Barbara S. Collier, Nancy E.
Glover, James T. MacAulay, Barbara S. Oliver, J. Michael Resser, and
Eric L. Trout.
FOOTNOTES
[1] Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
[2] GAO,Computer-Based Patient Records: Improved Planning and Project
Management Are Critical to Achieving Two-Way VA-DOD Health Data
Exchange, GAO-04-811T (Washington, D.C.: May 19, 2004); Computer-Based
Patient Records: Sound Planning and Project Management Are Needed to
Achieve a Two-Way Exchange of VA and DOD Health Data, GAO-04-402T
(Washington, D.C.: Mar. 17, 2004); and Computer-Based Patient Records:
Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way
Data Exchange Between VA and DOD Health Systems, GAO-04-271T
(Washington, D.C.: Nov. 19, 2003).
[3] GAO, Computer-Based Patient Records: VA and DOD Efforts to Exchange
Health Data Could Benefit from Improved Planning and Project
Management, GAO-04-687 (Washington, D.C.: June 7, 2004).
[4] Pub. L. No. 107-314, §721 (a)(1), 116 Stat. 2589,2595 (2002). To
further encourage on-going collaboration, section 721 directed the
Secretary of Defense and the Secretary of Veterans Affairs to establish
a joint program to identify and provide incentives to implement, fund,
and evaluate creative health care coordination and sharing initiatives
between DOD and VA.
[5] Shared patients receive care from both VA and DOD clinicians. For
example, veterans may receive outpatient care from VA clinicians and be
hospitalized at a military treatment facility.
[6] These data are text files providing surgical, pathology, cytology,
microbiology, chemistry, and hematology test results and descriptions
of radiology results.
[7] The VA/DOD Health Executive Council is composed of senior leaders
from VA and DOD, who work to institutionalize sharing and collaboration
of health services and resources. The council is cochaired by the VA
Undersecretary for Health and DOD Assistant Secretary of Defense for
Health Affairs, and meets every 2 months.
[8] Initially, the Indian Health Service (IHS) also was a party to this
effort, having been included because of its population-based research
expertise and its long-standing relationship with VA. However, IHS was
not included in a later revised strategy for electronically sharing
patient health information.
[9] GAO, Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results, GAO-02-703 (Washington, D.C.:
June 12, 2002); and Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-01-
459 (Washington, D.C.: Apr. 30, 2001).
[10] The Joint Executive Council is composed of the Deputy Secretary of
Veterans Affairs, the Undersecretary of Defense for Personnel and
Readiness, and the cochairs of joint councils on health, benefits, and
capital planning. The council meets on a quarterly basis to recommend
strategic direction of joint coordination and sharing efforts.
[11] DOD's CHCS II capabilities are being deployed in five increments.
The first provides a graphical user interface for clinical outpatient
processes, thus providing an electronic medical record capability; the
second supports general dentistry; the third provides pharmacy,
laboratory, radiology, and immunizations capabilities; the fourth
provides inpatient and scheduling capabilities; and the fifth will
provide additional capabilities as defined. According to DOD, the first
increment has been deployed to 64 of the 139 DOD health facilities,
representing over 6.9 million beneficiaries, or about 75 percent of the
total 9.2 million beneficiaries.
[12] These expenditures represent acquisition costs for software
development, test and evaluation, hardware acquisition, system
implementation, and associated contractor personnel costs. They do not
include government personnel or operations and maintenance costs.
[13] The six initiatives that make up HealtheVet VistA are the Health
Data Repository, billing replacement, laboratory, pharmacy, imaging,
and appointment scheduling replacement. This amount includes
investments in these six initiatives by VA as reported in their
submission to the Office of Management and Budget for fiscal year 2004.
[14] December 2004 VA and DOD Joint Strategic Plan.
[15] GAO, Computer-Based Patient Records: VA and DOD Efforts to
Exchange Health Data Could Benefit from Improved Planning and Project
Management, GAO-04-687 (Washington, D.C.: June 7, 2004).
[16] The completion of the pharmacy prototype project satisfied a
mandate of the 2003 Bob Stump National Defense Authorization Act, Pub.
L. 107-314, sec. 724 (2002).
