Information Technology
VA and DOD Continue to Expand Sharing of Medical Information, but Still Lack Comprehensive Electronic Medical Records Gao ID: GAO-08-207T October 24, 2007The Department of Veterans Affairs (VA) and the Department of Defense (DOD) are engaged in ongoing efforts to share medical information, which is important in helping to ensure high-quality health care for active-duty military personnel and veterans. These efforts include a long-term program to develop modernized health information systems based on computable data: that is, data in a format that a computer application can act on--for example, to provide alerts to clinicians of drug allergies. In addition, the departments are engaged in short-term initiatives involving existing systems. GAO was asked to testify on the history and current status of the departments' efforts to share health information. To develop this testimony, GAO reviewed its previous work, analyzed documents about current status and future plans and interviewed VA and DOD officials.
For almost a decade, VA and DOD have been pursuing ways to share health information and to create comprehensive electronic medical records. However, they have faced considerable challenges in these efforts, leading to repeated changes in the focus of their initiatives and target completion dates. Currently, the two departments are pursuing both long- and short-term initiatives to share health information. Under their long-term initiative, the modern health information systems being developed by each department are to share standardized computable data through an interface between data repositories associated with each system. The repositories have now been developed, and the departments have begun to populate them with limited types of health information. In addition, the interface between the repositories has been implemented at seven VA and DOD sites, allowing computable outpatient pharmacy and drug allergy data to be exchanged. Implementing this interface is a milestone toward the departments' long-term goal, but more remains to be done. Besides extending the current capability throughout VA and DOD, the departments must still agree to standards for the remaining categories of medical information, populate the data repositories with this information, complete the development of the two modernized health information systems, and transition from their existing systems. While pursuing their long-term effort to develop modernized systems, the two departments have also been working to share information in their existing systems. Among various short-term initiatives are a completed effort to allow the one-way transfer of health information from DOD to VA when service members leave the military, as well as ongoing demonstration projects to exchange limited data at selected sites. One of these projects, which builds on the one-way transfer capability, developed an interface between certain existing systems that allows a two-way view of current data on patients receiving care from both departments. VA and DOD are now expanding the sharing of additional medical information by using this interface to link other systems and databases. The departments have also established ad hoc processes to meet the immediate need to provide data on severely wounded service members to VA's polytrauma centers, which specialize in treating such patients. These processes include manual workarounds (such as scanning paper records) that are generally feasible only because the number of polytrauma patients is small. While these multiple initiatives and ad hoc processes have facilitated degrees of data sharing, they nonetheless highlight the need for continued efforts to integrate information systems and automate information exchange. At present, it is not clear how all the initiatives are to be incorporated into an overall strategy focused on achieving the departments' goal of comprehensive, seamless exchange of health information.
GAO-08-207T, Information Technology: VA and DOD Continue to Expand Sharing of Medical Information, but Still Lack Comprehensive Electronic Medical Records
This is the accessible text file for GAO report number GAO-08-207T
entitled 'Information Technology: VA and DOD Continue to Expand Sharing
of Medical Information, but Still Lack Comprehensive Electronic Medical
Records' which was released on October 24, 2007.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Testimony:
Before the Subcommittee on Oversight and Investigations, Committee on
Veterans' Affairs, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 10:00 a.m. EDT:
Wednesday, October 24, 2007:
Information Technology:
VA and DOD Continue to Expand Sharing of Medical Information, but Still
Lack Comprehensive Electronic Medical Records:
Statement of Valerie C. Melvin, Director Human Capital and Management
Information Systems Issues:
GAO-08-207T:
GAO Highlights:
Highlights of GAO-08-207T, a testimony before the Subcommittee on
Oversight and Investigations, Committee on Veterans‘ Affairs, House of
Representatives.
Why GAO Did This Study:
The Department of Veterans Affairs (VA) and the Department of Defense
(DOD) are engaged in ongoing efforts to share medical information,
which is important in helping to ensure high-quality health care for
active-duty military personnel and veterans. These efforts include a
long-term program to develop modernized health information systems
based on computable data: that is, data in a format that a computer
application can act on”for example, to provide alerts to clinicians of
drug allergies. In addition, the departments are engaged in short-term
initiatives involving existing systems.
GAO was asked to testify on the history and current status of the
departments‘ efforts to share health information. To develop this
testimony, GAO reviewed its previous work, analyzed documents about
current status and future plans and interviewed VA and DOD officials.
What GAO Found:
For almost a decade, VA and DOD have been pursuing ways to share health
information and to create comprehensive electronic medical records.
However, they have faced considerable challenges in these efforts,
leading to repeated changes in the focus of their initiatives and
target completion dates. Currently, the two departments are pursuing
both long- and short-term initiatives to share health information.
Under their long-term initiative, the modern health information systems
being developed by each department are to share standardized computable
data through an interface between data repositories associated with
each system. The repositories have now been developed, and the
departments have begun to populate them with limited types of health
information. In addition, the interface between the repositories has
been implemented at seven VA and DOD sites, allowing computable
outpatient pharmacy and drug allergy data to be exchanged. Implementing
this interface is a milestone toward the departments‘ long-term goal,
but more remains to be done. Besides extending the current capability
throughout VA and DOD, the departments must still agree to standards
for the remaining categories of medical information, populate the data
repositories with this information, complete the development of the two
modernized health information systems, and transition from their
existing systems.
While pursuing their long-term effort to develop modernized systems,
the two departments have also been working to share information in
their existing systems. Among various short-term initiatives are a
completed effort to allow the one-way transfer of health information
from DOD to VA when service members leave the military, as well as
ongoing demonstration projects to exchange limited data at selected
sites. One of these projects, which builds on the one-way transfer
capability, developed an interface between certain existing systems
that allows a two-way view of current data on patients receiving care
from both departments. VA and DOD are now expanding the sharing of
additional medical information by using this interface to link other
systems and databases. The departments have also established ad hoc
processes to meet the immediate need to provide data on severely
wounded service members to VA‘s polytrauma centers, which specialize in
treating such patients. These processes include manual workarounds
(such as scanning paper records) that are generally feasible only
because the number of polytrauma patients is small. While these
multiple initiatives and ad hoc processes have facilitated degrees of
data sharing, they nonetheless highlight the need for continued efforts
to integrate information systems and automate information exchange. At
present, it is not clear how all the initiatives are to be incorporated
into an overall strategy focused on achieving the departments‘ goal of
comprehensive, seamless exchange of health information.
What GAO Recommends:
GAO has previously made several recommendations on this topic,
including that VA and DOD develop a detailed project management plan to
guide their efforts to share patient health data. While the departments
agreed with these recommendations, a comprehensive overall strategy
that incorporates all of the ongoing activities still needs to be
implemented.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-207T].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Valerie Melvin at (202)
512-6304 or melvinv@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be a part of today's continuing dialogue on efforts by
the Department of Veterans Affairs (VA) and the Department of Defense
(DOD) to share electronic medical information. Over most of the past
decade, the departments have been pursuing initiatives to share
electronic medical information to help ensure that active-duty military
personnel and veterans receive high-quality health care. The
departments' efforts have included working towards a long-term vision
of a single "comprehensive, lifelong medical record"[Footnote 1] that
would allow each service member to transition seamlessly between the
two departments, as well as more short-term efforts focused on meeting
immediate needs to exchange health information, including responding to
current military crises.
Since 2001, we have reported or testified numerous times on the various
initiatives undertaken by the departments to develop the capability to
share health information. Our last testimony before this Subcommittee
on May 8, 2007, highlighted key projects that the departments have
pursued in this regard and the progress of their activities.[Footnote
2] At your request, my statement today further discusses the history
and current status of the departments' efforts.
The information in my testimony is based largely on our previous work
in this area. To describe the history and current status of the
departments' efforts to exchange patient health information, we
reviewed our previous work, analyzed documents on various health
initiatives, and interviewed VA and DOD officials about current status
and future plans. We conducted our work in support of this testimony
during October 2007 in the Washington, D.C., area. Information on costs
that have been incurred for the various projects was provided by
responsible officials at each department. We did not audit the reported
costs and thus cannot attest to their accuracy or completeness. All
work on which this testimony is based was conducted in accordance with
generally accepted government auditing standards.
Results in Brief:
VA and DOD have been pursuing initiatives to share data between their
health information systems and create comprehensive electronic medical
records since 1998, following a call for the development of a
comprehensive, integrated system to allow the two departments to share
patient health information. However, the departments have faced
considerable challenges in project planning and management, leading to
repeated changes in the focus of their initiatives and target
completion dates. In prior reviews of their efforts, we noted
management weaknesses such as inadequate accountability and poor
planning and oversight and made recommendations for improvement,
including the development of a comprehensive and coordinated project
management plan that defines the technical and managerial processes
necessary to satisfy project requirements and to guide their
activities. In response, by July 2002, VA and DOD revised their
strategy, refocusing the project and dividing it into long-term and
short-term initiatives. For the long term, both departments are
modernizing their health information systems to replace their existing
(legacy) systems and enable the new systems to share data and,
ultimately, to have interoperable[Footnote 3] electronic medical
records. Unlike the legacy systems, the modernized systems are to be
based on computable data--data that can be automatically processed in a
healthcare system to, for example, provide alerts to clinicians on drug
allergies, or to plot graphs of changes in vital signs such as blood
pressure. For the short-term initiative, the departments focused on
sharing information in existing systems.
VA and DOD have made progress in both their long-term and short-term
initiatives, but much work remains to achieve the goal of interoperable
electronic medical records and a seamless transition between the two
departments. In the long-term project to develop modernized health
information systems, the departments have begun to implement the first
release of the interface between their modernized data repositories,
and computable outpatient pharmacy and drug allergy data are being
exchanged at seven VA and DOD sites. However, significant work remains,
including agreeing to standards for the remaining categories of medical
information and populating the data repositories with all this
information. Regarding their short-term projects to share information
in existing systems, the departments completed the Federal Health
Information Exchange in 2004, and as of this month reported
transferring clinical data on more than 4 million veterans. In
addition, they have made progress on two demonstration projects: (1)
the Laboratory Data Sharing Interface, deployed at 9 localities, allows
the departments to communicate orders for lab tests and their results
electronically and (2) the Bidirectional Health Information Exchange
allows a real-time, two-way view of certain outpatient health data from
existing systems[Footnote 4] at all VA and DOD sites, and certain
inpatient discharge summary data[Footnote 5] at all VA sites and 13
large DOD sites. Further, the two departments have undertaken ad hoc
activities to accelerate the transmission of health information on
severely wounded patients from DOD to VA's four polytrauma centers,
which care for veterans and service members with severe traumatic brain
injuries or disabling injuries to more than one physical region or
organ system. These ad hoc processes include manual workarounds, such
as scanning paper records and individually transmitting radiological
images, which are generally feasible only because the number of
polytrauma patients is small (according to VA officials, about 460 with
traumatic brain injuries to date).
Through all of these efforts, VA and DOD are exchanging health
information. However, these exchanges have been limited, and it is not
yet clear how they are to be integrated into an overall strategy to
reach the departments' long-term goal of a comprehensive, seamless
exchange of health information. Accordingly, as we have previously
recommended, it remains critical for the departments to develop a
comprehensive project plan that can guide their efforts to completion.
Background:
In their efforts to modernize their health information systems and
share medical information, VA and DOD start from different positions.
As shown in table 1, VA has one integrated medical information system-
-the Veterans Health Information Systems and Technology Architecture
(VistA)--which uses all electronic records. All 128 VA medical sites
thus have access to all VistA information.[Footnote 6] (Table 1 also
shows, for completeness, VA's planned modernized system and its
associated data repository.)
Table 1: VA Medical Information Systems and Data Base:
System name: Legacy systems: VistA Veterans Health Information Systems
and Technology Architecture;
Description: Existing integrated health information system.
System name: Modernized system and repository: HealtheVet VistA;
Description: Modernized health information system based on computable
data.
System name: Modernized system and repository: HDR Health Data
Repository;
Description: Data repository associated with modernized system.
Source: GAO analysis of VA data.
[End of table]
In contrast, DOD has multiple medical information systems (table 2
illustrates certain selected systems). DOD's various systems are not
integrated, and its 138 sites do not necessarily communicate with each
other. In addition, not all of DOD's medical information is electronic:
some records are paper-based.
Table 2: Selected DOD Medical Information Systems and Data Bases:
System name: Legacy systems: CHCS: Composite Health Care System;
Description: Primary existing DOD health information system.
System name: Legacy systems: CIS: Clinical Information System;
Description: Commercial health information system customized for DOD;
used by some DOD facilities for inpatients.
System name: Legacy systems: ICDB: Integrated Clinical Database;
Description: Health information system used by many Air Force
facilities.
System name: Legacy systems: TMDS: Theater Medical Data Store;
Description: Database to collect electronic medical information in
combat theater for both outpatient care and serious injuries.
System name: Legacy systems: JPTA: Joint Patient Tracking Application;
Description: Web-based application primarily used to track the movement
of patients as they are transferred from location to location, but may
include text-based medical information.
System name: Modernized system and repository: AHLTA: Armed Forces
Health Longitudinal Technology Application[A];
Description: Modernized health information system, integrated and based
on computable data.
System name: Modernized system and repository: CDR: Clinical Data
Repository;
Description: Data repository associated with modernized system.
Source: GAO analysis of DOD data.
[A] Formerly CHCS II.
[End of table]
VA and DOD Have Been Working to Exchange Health Information Since 1998:
For nearly a decade, VA and DOD have been undertaking initiatives to
exchange data between their health information systems and create
comprehensive electronic records.[Footnote 7] However, the departments
have faced considerable challenges in project planning and management,
leading to repeated changes in the focus and target completion dates of
the initiatives.
As shown in figure 1, the departments' efforts have involved both long-
term initiatives to modernize their health information systems[Footnote
8] and short-term initiatives to respond to more immediate information-
sharing needs.
Figure 1: Timeline of Selected VA/DOD Electronic Medical Records and
Data Sharing Efforts:
This figure is a chart showing a timeline of selected VA/DOD electronic
medical records and data sharing efforts.
[See PDF for image]
Source: GAO analysis of VA and DOD data.
[End of figure]
The departments' first initiative was the Government Computer-Based
Patient Record (GCPR) project, which aimed to develop an electronic
interface that would allow physicians and other authorized users at VA
and DOD health facilities to access data from each other's health
information systems. The interface was expected to compile requested
patient information in a virtual record (that is, electronic as opposed
to paper) that could be displayed on a user's computer screen.
We reviewed the GCPR project in 2001 and 2002, noting disappointing
progress exacerbated in large part by inadequate accountability and
poor planning and oversight, which raised questions about the
departments' abilities to achieve a virtual medical record. 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.[Footnote 9] In both years, we recommended that the departments
enhance the project's overall management and accountability. In
particular, we recommended that the departments designate a lead entity
and a clear line of authority for the project; create comprehensive and
coordinated plans that include an agreed-upon mission and clear goals,
objectives, and performance measures; revise the project's original
goals and objectives to align with the current strategy; commit the
executive support necessary to adequately manage the project; and
ensure that it followed sound project management principles.
In response, by July 2002, the two departments had revised their
strategy, refocusing the project and dividing it into two initiatives.
A short-term initiative, the Federal Health Information Exchange
(FHIE), was to enable DOD to electronically transfer service members'
health information to VA when the members left active duty. VA was
designated as the lead entity for implementing FHIE, which was
completed in 2004. A longer-term initiative was to develop a common
health information architecture that would allow a two-way exchange of
health information. The common architecture is to include standardized,
computable data, communications, security, and high-performance health
information systems (these systems, DOD's Composite Health Care System
II and VA's HealtheVet VistA, were already in development, as shown in
the figure).[Footnote 10] The departments' modernized systems are to
store information (in standardized, computable form) in separate data
repositories: DOD's Clinical Data Repository (CDR) and VA's Health Data
Repository (HDR). The two repositories are to exchange information
through an interface named CHDR.[Footnote 11]
In March 2004, the departments began to develop the CHDR interface.
They planned to begin implementation by October 2005;[Footnote 12]
however, implementation of the first release of the interface (at one
site) occurred in September 2006, almost a year beyond the target date.
In a report in June 2004,[Footnote 13] we identified a number of
management weaknesses that could have contributed to this delay and
made a number of recommendations, including creation of a comprehensive
and coordinated project management plan. The departments agreed with
our recommendations and took steps to improve the management of the
CHDR initiative, designating a lead entity with final decision-making
authority and establishing a project management structure. However, as
we noted in subsequent testimony,[Footnote 14] the initiative did not
have a detailed project management plan that described the technical
and managerial processes necessary to satisfy project requirements
(including a work breakdown structure and schedule for all development,
testing, and implementation tasks), as we had recommended.
In October 2004, responding to a congressional mandate,[Footnote 15]
the departments established two more short-term initiatives: the
Laboratory Data Sharing Interface, aimed at allowing VA and DOD
facilities to share laboratory resources, and the Bidirectional Health
Information Exchange (BHIE), aimed at giving both departments'
clinicians access to records on shared patients (that is, those who
receive care from both departments).[Footnote 16] As demonstration
projects, these initiatives were limited in scope, with the intention
of providing interim solutions to the departments' needs for more
immediate health information sharing. However, because BHIE provided
access to up-to-date information, the departments' clinicians expressed
strong interest in expanding its use. As a result, the departments
began planning to broaden this capability and expand its implementation
considerably. Extending BHIE connectivity could provide each department
with access to most data in the other's legacy systems, until such time
as the departments' modernized systems are fully developed and
implemented. According to a VA/DOD annual report[Footnote 17] and
program officials, the departments now consider BHIE an interim step in
their overall strategy to create a two-way exchange of electronic
medical records.
The departments' reported costs for the various sharing initiatives and
the modernization of their health information systems through fiscal
year 2007 are shown in table 3.
Table 3: Reported Costs of VA and DOD Initiatives since inception:
Project: HealtheVet VistA;
VA expenditure: $681.7 million;
through FY 2006;
DOD expenditure: [Empty].
Project: AHLTA;
VA expenditure: [Empty];
DOD expenditure: $954.3 million through FY 2007 (estimated).
Project: Joint Initiatives: CHDR;
VA expenditure: 4.1 million;
DOD expenditure: DOD does not account for these projects separately.
Project: Joint Initiatives: FHIE;
VA expenditure: 65.5 million;
DOD expenditure: DOD does not account for these projects separately.
Project: LDSI;
VA expenditure: 2.8 million;
DOD expenditure: DOD does not account for these projects separately.
Project: BHIE;
VA expenditure: 6.3 million;
DOD expenditure: DOD does not account for these projects separately.
Project: Total;
VA expenditure: $78.7 million;
DOD expenditure: $89.7 million though FY 2007.
Source: VA and DOD data.
[End of table]
Beyond these initiatives, in January 2007, the departments announced a
further change to their information-sharing strategy: their intention
to jointly develop a new inpatient medical record system. On July 31,
2007, they awarded a contract for a feasibility study.[Footnote 18]
According to the departments, adopting this joint solution is expected
to facilitate the seamless transition of active-duty service members to
veteran status, and make inpatient health care data on shared patients
immediately accessible to both DOD and VA. In addition, the departments
believe that a joint development effort could enable them to realize
significant cost savings. We have not evaluated the departments' plans
or strategy for this new system.
Other Evaluations Have Recommended Strengthening the Management and
Planning of the Departments' Health Information Initiatives:
Throughout the history of these initiatives, evaluations besides our
own have found deficiencies in the departments' efforts, especially
with regard to the lack of comprehensive planning. For example, a
recent presidential task force identified the need for VA and DOD to
improve their long-term planning.[Footnote 19] This task force,
reporting on gaps in services provided to returning veterans, noted
problems in sharing information on wounded service members, including
the inability of VA providers to access paper DOD inpatient health
records. The task force stated that although significant progress has
been made towards sharing electronic information, more needs to be
done, and recommended that VA and DOD continue to identify long-term
initiatives and define the scope and elements of a joint inpatient
electronic health record. In addition, in fiscal year 2006, Congress
did not provide all the funding requested for HealtheVet VistA because
it did not consider that the funding had been adequately justified.
VA and DOD Are Exchanging Limited Medical Information, but a Seamlessly
Shared Medical Record Will Require Much More Work:
VA and DOD have made progress in both their long-term and short-term
initiatives to share health information. In the long-term project to
modernize their health information systems, the departments have begun,
among other things, to implement the first release of the interface
between their modernized data repositories. The departments have also
made progress in their short-term projects to share information in
existing systems, having completed two initiatives, and are making
important progress on another. In addition, the departments have
undertaken ad hoc activities to accelerate the transmission of health
information on severely wounded patients from DOD to VA's four
polytrauma centers. However, despite the progress made and the sharing
achieved, the tasks remaining to reach the goal of a shared electronic
medical record are substantial.
VA and DOD Have Begun Deployment of a Modernized Data Interface:
In their long-term effort to share health information, VA and DOD have
completed the development of their modernized data repositories, agreed
on standards for various types of data, and begun to populate the
repositories with these data.[Footnote 20] In addition, they have now
implemented the first release of the CHDR interface. According to the
departments' officials, all DOD sites can now access the interface, and
it is expected to be available across VA when necessary software
updates are released. (Currently 103 of 128 VA sites have received
these updates.)[Footnote 21] At 7 sites, VA and DOD are now exchanging
limited medical information for shared patients: specifically,
computable outpatient pharmacy and drug allergy information.
CHDR is the conduit for exchanging computable medical information
between the departments. Data transmitted via the interface are
permanently stored in each department's new data repository, CDR, and
HDR. Once in the repositories, these computable data can be used by DOD
and VA at all sites through their existing systems. CHDR also provides
terminology mediation (translation of one agency's terminology into the
other's). The departments' plans call for further developing the
capability to exchange computable laboratory results data through the
interface during fiscal year 2008.
Although implementing this interface is an important accomplishment,
the departments are still a long way from completing the modernized
health information systems and comprehensive longitudinal health
records. While DOD and VA had originally projected completion dates of
2011 and 2012, respectively, for their modernized systems, the
departments' officials told us that there is currently no scheduled
completion date for either system. VA is evaluating a proposal that
would result in completion of its system in 2015; DOD is evaluating the
impact of the new study on a joint inpatient medical record and has not
indicated a new completion date.
Further, both departments have still to identify the next types of data
to be stored in the repositories. The departments will then have to
populate the repositories with the standardized data. This involves
different tasks for each department. Specifically, while VA's medical
records are already electronic, it must still convert them into the
interoperable format appropriate for its repository. DOD, in addition
to converting current records from its multiple systems, must also
address medical records that are not automated. As pointed out by a
recent Army Inspector General's report, some DOD facilities are having
problems with hard copy records.[Footnote 22] The report also
identified inaccurate and incomplete health data as a problem to be
addressed. Before the departments can achieve the long-term goal of
seamless sharing of medical information, all of these tasks and
challenges will have to be addressed. Accordingly, it is essential that
the departments develop a comprehensive project plan to guide these
efforts to completion, as we have previously recommended.
Short-Term Projects Are Allowing VA and DOD to Exchange Limited Health
Information:
In addition to the long-term effort previously described, the two
departments have made some progress in meeting immediate needs to share
information in their respective legacy systems through short-term
projects which, as mentioned earlier, are in various stages of
completion. They have also set up special processes to transfer data
from DOD facilities to VA's polytrauma centers in a further effort to
more effectively treat traumatic brain injuries and other especially
severe injuries.
One-Way Transfer Capability Is Operational:
DOD has been using FHIE to transfer information to VA since 2002.
According to DOD officials, 194 million clinical messages on more than
4 million veterans had been transferred to the FHIE data repository as
of September 2007, including laboratory results, radiology results,
outpatient pharmacy data, allergy information, consultation reports,
elements of the standard ambulatory data record, and demographic data.
Further, since July 2005, FHIE has been used to transfer pre-and post-
deployment health assessment and reassessment data; as of September
2007, VA had access to data for more than 793,000 separated service
members and demobilized Reserve and National Guard members who had been
deployed. Transfers are done in batches once a month, or weekly for
veterans who have been referred to VA treatment facilities. According
to a joint VA/DOD report,[Footnote 23] FHIE has made a significant
contribution to the delivery and continuity of care of separated
service members as they transition to veteran status, as well as to the
adjudication of disability claims.
Laboratory Interface Initiative Allows VA and DOD to Share Lab
Resources:
One of the departments' demonstration projects--the Laboratory Data
Sharing Interface (LDSI)--is now fully operational and is deployed when
local agencies have a business case for its use and sign an agreement.
It requires customization for each locality and is currently deployed
at nine locations. LDSI currently supports a variety of chemistry and
hematology tests, and, at one of the nine locations, anatomic pathology
and microbiology tests.
Once LDSI is implemented at a facility, the only nonautomated action
needed for a laboratory test is transporting the specimens. If a test
is not performed at a VA or DOD doctor's home facility, the doctor can
order the test, the order is transmitted electronically to the
appropriate lab (the other department's facility or in some cases a
local commercial lab), and the results are returned electronically.
Among the benefits of the LDSI interface, according to VA and DOD, are
increased speed in receiving laboratory results and decreased errors
from manual entry of orders. The LDSI project manager in San Antonio
stated that another benefit of the project is 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 no longer has to contract out some of its
laboratory work to private companies, but instead uses the DOD
laboratory.
Two-Way Interface Allows Real-Time Viewing of Text Information:
Developed under a second demonstration project, the BHIE interface
permits a medical care provider to query selected health information on
patients from all VA and DOD sites and to view that data onscreen
almost immediately. It not only allows the two departments to view each
other's information, but it also allows DOD sites to see previously
inaccessible data at other DOD sites.
VA and DOD have been making progress on expanding the BHIE interface.
As initially developed, the interface provided access to information in
VA's VistA and DOD's Composite Health Care System, but it is currently
being expanded to query data in other DOD systems and databases. In
particular, the interface has been expanded to DOD's:
* Modernized data repository, CDR, which has enabled department-wide
access to outpatient data for pharmacy and inpatient and outpatient
allergy, radiology, chemistry, and hematology data since July 2007, and
to microbiology data since September 2007.
* Clinical Information System (CIS), an inpatient system used by some
DOD facilities; the interface enables bidirectional views of discharge
summaries and is currently deployed at 13 large DOD sites.
* Theater Medical Data Store, which became operational in October 2007,
enabling access to inpatient and outpatient clinical information from
combat theaters.
The departments are also taking steps to make more data elements
available through BHIE. VA and DOD staff told us that by the end of the
first quarter of fiscal year 2008, they plan to add provider notes,
procedures, and problem lists. Later in fiscal year 2008, they plan to
add vital signs, scanned images and documents, family history, social
history, and other history questionnaires. In addition, a VA/DOD
demonstration site in El Paso began sharing radiological images between
the VA and DOD facilities in September 2007 using the BHIE/FHIE
infrastructure.[Footnote 24]
Types of Data Shared by DOD and VA Are Growing but Remain Limited:
Although VA and DOD are sharing various types of health data, the type
of data being shared has been limited and significant work remains to
expand the data shared and integrate the various initiatives. Table 4
summarizes the types of health data currently shared via the long-and
short-term initiatives we have described, as well as additional types
of data that are currently planned for sharing. While this gives some
indication of the scale of the tasks involved in sharing medical
information, it does not depict the full extent of information that is
currently being captured in the health information systems at VA and
DOD.
Table 4: Data Elements Made Available and Planned by DOD-VA
Initiatives:
Initiative: CHDR;
Data elements: Available:
Outpatient pharmacy:
Drug allergy;
Data elements: Planned: Laboratory data;
Comments: Computable data are exchanged between one department's data
repository and the other's.
Initiative: FHIE;
Data elements: Available:
Patient demographics:
Laboratory results:
Radiology reports:
Outpatient pharmacy information:
Admission discharge transfer data:
Discharge summaries:
Consult reports:
Allergies:
Data from the DOD Standard Ambulatory Data Record:
Pre-and post-deployment assessments:
Data elements: Planned: None;
Comments: One-way batch transfer of text data from DOD to VA occurs
weekly if discharged patient has been referred to VA for treatment;
otherwise monthly.
Initiative: LDSI;
Data elements: Available:
Laboratory orders:
Laboratory results (chemistry, hematology and microbiology at 2
localities);
Data elements: Planned:
Microbiology:
Anatomic pathology;
Comments: Noncomputable text data are transferred.
Initiative: BHIE;
Data elements: Available:
Outpatient pharmacy data:
Drug and food allergy information:
Surgical pathology reports:
Microbiology results:
Cytology reports:
Chemistry and hematology reports:
Laboratory orders:
Radiology text reports:
Inpatient discharge summaries and/or emergency room notes from CIS at
13 DOD and all VA sites:
Data elements: Planned:
Provider notes:
Procedures:
Problem lists:
Vital signs:
Scanned images and documents:
Family history:
Social history:
Other history questionnaires:
Radiology images:
Comments: Data are not transferred but can be viewed.
Source: GAO analysis of VA and DOD data.
[End of table]
Special Procedures Provide Information to VA Polytrauma Centers:
In addition to the information technology initiatives described, DOD
and VA have set up special procedures to transfer medical information
to VA's four polytrauma centers, which treat active duty service
members and veterans severely wounded in combat.[Footnote 25] Some
examples of polytrauma include traumatic brain injury, amputations, and
loss of hearing or vision.[Footnote 26]
When service members are seriously injured in a combat theater
overseas, they are first treated locally. They are then generally
evacuated to Landstuhl Medical Center in Germany, after which they are
transferred to a military treatment facility in the United States,
usually Walter Reed Army Medical Center in Washington, D.C; the
National Naval Medical Center in Bethesda, Maryland; or Brooke Army
Medical Center, at Fort Sam Houston, Texas. From these facilities,
service members suffering from polytrauma may be transferred to one of
VA's four polytrauma centers for treatment.[Footnote 27]
At each of these locations, the injured service members will accumulate
medical records, in addition to medical records already in existence
before they were injured. According to DOD officials, when patients are
referred to VA for care, DOD sends copies of medical records
documenting treatment provided by the referring DOD facility along with
them. The DOD medical information is currently collected in several
different systems:
1. In the combat theater, electronic medical information may be
collected for a variety of reasons, including routine outpatient care,
as well as serious injuries. These data are stored in the Theater
Medical Data Store. As mentioned earlier, the BHIE interface to this
database became operational in October.
2. At Landstuhl, inpatient medical records are paper-based (except for
discharge summaries). The paper records are sent with a patient as the
individual is transferred for treatment in the United States. DOD
officials told us that the paper record is the official DOD medical
record, although AHLTA is used extensively to provide outpatient
encounter information for medical records purposes.
3. At the DOD treatment facility (Walter Reed, Bethesda, or Brooke),
additional inpatient information is recorded in CIS and outpatient
pharmacy and drug information are stored in CDR; other health
information continues to be stored in local CHCS databases.
When service members are transferred to a VA polytrauma center, VA and
DOD have several ad hoc processes in place to electronically transfer
the patients' medical information:
* DOD has set up secure links to enable a limited number of clinicians
at the polytrauma centers to log directly into CIS at Walter Reed and
Bethesda Naval Hospital to access patient data.
* Staff at Walter Reed, Brooke, and Bethesda medical centers collect
paper records, print records from CIS, scan all these, and transmit the
scanned data to the four polytrauma centers. DOD staff pointed out that
this laborious process is feasible only because the number of
polytrauma patients is small. According to VA officials, 460 severe
traumatic brain injury patients had been treated at the polytrauma
centers through fiscal year 2007. According to DOD officials, the
medical records for 81 patients planned for transfer or already at a VA
polytrauma center were scanned and provided to VA between April 1 and
October 11 of this year. Digital radiology images were also provided
for 48 patients.
* Staff at Walter Reed and Bethesda are transmitting radiology images
electronically to the four polytrauma centers. Access to radiology
images is a high priority for polytrauma center doctors, but like
scanning paper records, transmitting these images requires manual
intervention: when each image is received at VA, it must be
individually uploaded to VistA's imagery viewing capability. This
process would not be practical for large volumes of images.
* VA has access to outpatient data (via BHIE) from all DOD sites,
including Landstuhl.
These special efforts to transfer medical information on seriously
wounded patients represent important additional steps to facilitate the
sharing of information that is vital to providing polytrauma patients
with quality health care.
In summary, VA and DOD are exchanging health information via their long-
and short-term initiatives and continue to expand sharing of medical
information via BHIE. However, these exchanges have been limited, and
significant work remains to fully achieve the goal of exchanging
interoperable, computable data. Work still to be done includes agreeing
to standards for the remaining categories of medical information;
populating the data repositories with all this information; completing
the development of HealtheVet VistA, and AHLTA; and transitioning from
the legacy systems. To complete this work and achieve the departments'
ultimate goal of a maintaining a lifelong electronic medical record
that will follow service members as they transition from active to
veteran status, a comprehensive and coordinated project management plan
that defines the technical and managerial processes necessary to
satisfy project requirements and to guide their activities continues to
be of vital importance. We have previously recommended that the
departments develop such a plan and that it include a work breakdown
structure and schedule for all development, testing, and implementation
tasks. Without such a detailed plan, VA and DOD increase the risk that
the long-term project will not deliver the planned capabilities in the
time and at the cost expected. Further, it is not clear how all the
initiatives we have described today are to be incorporated into an
overall strategy toward achieving the departments' goal of a
comprehensive, seamless exchange of health information.
This concludes my statement. I would be pleased to respond to any
questions that you may have.
Contacts and Acknowledgments:
If you have any questions concerning this testimony, please contact
Valerie C. Melvin, Director, Human Capital and Management Information
Systems Issues, at (202) 512-6304 or melvinv@gao.gov. Other individuals
who made key contributions to this testimony are Barbara Oliver
(Assistant Director), Nancy Glover, Glenn Spiegel, and Amos Tevelow.
[End of section]
Related GAO Products:
Computer-Based Patient Records: Better Planning and Oversight by VA,
DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459. Washington,
D.C.: April 30, 2001.
Veterans Affairs: Sustained Management Attention Is Key to Achieving
Information Technology Results. GAO-02-703. Washington, D.C.: June 12,
2002.
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.: November 19, 2003.
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.: March 17, 2004.
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.
Computer-Based Patient Records: VA and DOD Made Progress, but Much Work
Remains to Fully Share Medical Information. GAO-05-1051T. Washington,
D.C.: September 28, 2005.
Information Technology: VA and DOD Face Challenges in Completing Key
Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
DOD and VA Exchange of Computable Pharmacy Data. GAO-07-554R.
Washington, D.C.: April 30, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Are Far from Comprehensive Electronic Medical
Records, GAO-07-852T. Washington, D.C.: May 8, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Remain Far from Having Comprehensive
Electronic Medical Records, GAO-07-1108T. Washington, D.C.: July 18,
2007.
[End of section]
Footnotes:
[1] In 1996, the Presidential Advisory Committee on Gulf War Veterans'
Illnesses reported on many deficiencies in VA's and DOD's data
capabilities for handling service members' health information. In
November 1997, the President called for the two agencies to start
developing a "comprehensive, lifelong medical record for each service
member," and in 1998 issued a directive requiring VA and DOD to develop
a "computer-based patient record system that will accurately and
efficiently exchange information."
[2] GAO, Information Technology: VA and DOD Are Making Progress in
Sharing Medical Information, but Are Far from Comprehensive Electronic
Medical Records, GAO-07-852T (Washington, D.C.: May 8, 2007).
[3] Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
[4] DOD's Composite Health Care System (CHCS) and VA's VistA (Veterans
Health Information Systems and Technology Architecture).
[5] Specifically, inpatient discharge summary data stored in VA's VistA
and DOD's Clinical Information System (CIS), a commercial health
information system customized for DOD.
[6] A site represents one or more facilities--medical centers,
hospitals, or outpatient clinics--that store their electronic health
data in a single database.
[7] Initially, the Indian Health Service (IHS) was also a party to this
effort, having been included because of its population-based research
expertise and its longstanding relationship with VA. However, IHS was
not included in a later revised strategy for electronically sharing
patient health information.
[8] DOD began efforts to modernize its existing health information
system (CHCS) in 1997 and VA began efforts to modernize its existing
health information system (VistA) in 2001.
[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] DOD's existing Composite Health Care System (CHCS) was being
modernized as CHCS II, now renamed AHLTA (Armed Forces Health
Longitudinal Technology Application). VA's existing VistA system was
being modernized as HealtheVet VistA.
[11] The name CHDR, pronounced "cheddar," combines the names of the two
repositories.
[12] December 2004 VA and DOD Joint Strategic Plan.
[13] 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).
[14] GAO, Computer-Based Patient Records: VA and DOD Made Progress, but
Much Work Remains to Fully Share Medical Information, GAO-05-1051T
(Washington, D.C.: Sept. 28, 2005) and Information Technology: VA and
DOD Face Challenges in Completing Key Efforts, GAO-06-905T (Washington,
D.C.: June 22, 2006).
[15] The Bob Stump National Defense Authorization Act for Fiscal Year
2003 (Pub. L. No.107-314, § 721, Dec. 2, 2002) mandated that the
departments conduct demonstration projects to test 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.
[16] To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project. Unlike FHIE, which provides a one-way transfer of information
to VA when a service member separates from the military, the two-way
system allows clinicians in both departments to view, in real time,
limited health data (in text form) from the departments' current health
information systems.
[17] December 2004 VA and DOD Joint Strategic Plan.
[18] The contract is for a 6-month base period, with a follow-on 6-
month option period. The cost for the 6-month base period is about $2
million.
[19] Task Force on Returning Global War on Terror Heroes, Report to the
President (Apr. 19, 2007).
[20] DOD has populated CDR with information for outpatient encounters,
drug allergies, and order entries and results for outpatient pharmacy/
lab orders. VA has populated HDR with patient demographics, vital signs
records, allergy data, and outpatient pharmacy data; in July, the
department added chemistry and hematology, and in September,
microbiology.
[21] The Remote Data Interoperability software upgrade provides the
capability for the automated checks and alerts allowed by computable
data.
[22] Inspector General, Army, Army Physical Disability Evaluation
System Inspection (March 2007).
[23] December 2004,VA and DOD Joint Strategic Plan.
[24] To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project.
[25] In particular, clinicians require access to discharge notices,
which describe the treatment given at previous medical facilities and
the status of patients when they left those facilities.
[26] Polytrauma centers care for veterans and returning service members
with injuries to more than one physical region or organ system, one of
which may be life threatening, and which result in physical, cognitive,
psychological, or psychosocial impairments and functional disability.
[27] The four Polytrauma Rehabilitation Centers are in Richmond:
Virginia; Tampa, Florida; Minneapolis, Minnesota; and Palo Alto,
California.
GAO's Mission:
The Government Accountability Office, the audit, evaluation, and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office:
441 G Street NW, Room LM:
Washington, DC 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, DC 20548:
Public Affairs:
Susan Becker, Acting Manager, BeckerS@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, DC 20548:
he four Polytrauma Rehabilitation Centers are in Richmond, Virginia;
Tampa, Florida; Minneapolis, Minnesota; and Palo Alto, California.
