Information Technology
DOD and VA Have Increased Their Sharing of Health Information, but Further Actions Are Needed Gao ID: GAO-08-1158T September 24, 2008The National Defense Authorization Act for Fiscal Year 2008 required the Department of Defense (DOD) and the Department of Veterans Affairs (VA) to accelerate the exchange of health information between the departments and to develop systems or capabilities that allow for full interoperability (generally, the ability of systems to use data that are exchanged) and that are compliant with federal standards. The act also established an interagency program office to function as a single point of accountability for the effort and whose role is to implement such systems or capabilities by September 30, 2009. Further, the act required that GAO semi-annually report on the progress made in achieving these goals; its first report was issued in July 2008. In that report, GAO described the departments' progress in sharing electronic health information, developing electronic health records that comply with federal standards, and establishing the interagency program office. In this testimony, GAO discusses its July 2008 report and updated information obtained from the departments.
DOD and VA are sharing some, but not all, electronic health information. This includes exchanging some information in computable form, which is the highest level of interoperability. In other cases, data can be viewed only--a lower level of interoperability that still provides clinicians with important information. The departments have undertaken a number of initiatives, resulting in varied sharing capabilities. However, information is still being captured in paper records at many DOD medical facilities, and not all electronic health information is being shared. Further enhancing sharing and interoperability depends on adherence to common standards. The two departments have agreed on numerous common standards and are working with federal groups and each other to ensure adherence to such standards and to align their initiatives with emerging standards. These efforts, led by the Office of the National Coordinator for Health Information Technology (within the Department of Health and Human Services), include identifying relevant existing standards, identifying and addressing overlaps and gaps in the standards, and developing interoperability specifications and certification criteria based on these standards. The departments are also in the process of setting up a new interagency program office that will play a crucial role in accelerating their efforts to achieve electronic health records and capabilities that allow for full interoperability. However, the program office is not expected to be fully operational until the end of the year, which will allow the departments only 9 months to meet the deadline for full interoperability between the departments by September 2009. While DOD and VA have produced a plan for achieving interoperability within this time period, many milestones have yet to be determined. In view of the short timeframe and without a fully established program office and a complete plan with fully established milestones, the departments may be challenged in achieving interoperable electronic health records and capabilities that most effectively serve military service members and veterans.
GAO-08-1158T, Information Technology: DOD and VA Have Increased Their Sharing of Health Information, but Further Actions Are Needed
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United States Government Accountability Office:
GAO:
Testimony:
Before the Senate Committee on Veterans' Affairs:
For Release on Delivery:
Expected at 9:30 a.m. EDT:
Wednesday, September 24, 2008:
Information Technology:
DOD and VA Have Increased Their Sharing of Health Information, but
Further Actions Are Needed:
Statement of Valerie C. Melvin, Director:
Human Capital and Management Information Systems Issues:
GAO-08-1158T:
GAO Highlights:
Highlights of GAO-08-1158T, a testimony before the Senate Committee on
Veterans' Affairs.
Why GAO Did This Study:
The National Defense Authorization Act for Fiscal Year 2008 required
the Department of Defense (DOD) and the Department of Veterans Affairs
(VA) to accelerate the exchange of health information between the
departments and to develop systems or capabilities that allow for full
interoperability (generally, the ability of systems to use data that
are exchanged) and that are compliant with federal standards. The act
also established an interagency program office to function as a single
point of accountability for the effort and whose role is to implement
such systems or capabilities by September 30, 2009.
Further, the act required that GAO semi-annually report on the progress
made in achieving these goals; its first report was issued in July
2008. In that report, GAO described the departments‘ progress in
sharing electronic health information, developing electronic health
records that comply with federal standards, and establishing the
interagency program office. In this testimony, GAO discusses its July
2008 report and updated information obtained from the departments.
What GAO Found:
DOD and VA are sharing some, but not all, electronic health
information. This includes exchanging some information in computable
form, which is the highest level of interoperability. In other cases,
data can be viewed only”a lower level of interoperability that still
provides clinicians with important information. The departments have
undertaken a number of initiatives, resulting in varied sharing
capabilities (see table below). However, information is still being
captured in paper records at many DOD medical facilities, and not all
electronic health information is being shared.
Table: Sharing Capabilities of DOD and VA Initiatives:
Initiative: DOD‘s Clinical Data Repository/VA‘s Health Data Repository
Interface[A];
Sharing Capabilities: Bidirectional (or two-way) real-time exchange of
computable pharmacy and drug allergy data.
Initiative: Bidirectional Health Information Exchange;
Sharing Capabilities: Bidirectional real-time sharing of viewable
health data[B].
Initiative: Federal Health Information Exchange;
Sharing Capabilities: One-way transfer of viewable health data[B] from
DOD to VA.
Initiative: Laboratory Data Sharing Interface;
Sharing Capabilities: Bidirectional sharing of viewable lab tests and
results.
Source: DOD and VA.
[A] Known as CHDR, pronounced ’cheddar,“ this interface combines the
names of the two repositories.
[B] See attachment 1 for a list of the data elements that are made
available and are planned for these initiatives.
[End of table]
Further enhancing sharing and interoperability depends on adherence to
common standards. The two departments have agreed on numerous common
standards and are working with federal groups and each other to ensure
adherence to such standards and to align their initiatives with
emerging standards. These efforts, led by the Office of the National
Coordinator for Health Information Technology (within the Department of
Health and Human Services), include identifying relevant existing
standards, identifying and addressing overlaps and gaps in the
standards, and developing interoperability specifications and
certification criteria based on these standards.
The departments are also in the process of setting up a new interagency
program office that will play a crucial role in accelerating their
efforts to achieve electronic health records and capabilities that
allow for full interoperability. However, the program office is not
expected to be fully operational until the end of the year, which will
allow the departments only 9 months to meet the deadline for full
interoperability between the departments by September 2009. While DOD
and VA have produced a plan for achieving interoperability within this
time period, many milestones have yet to be determined. In view of the
short timeframe and without a fully established program office and a
complete plan with fully established milestones, the departments may be
challenged in achieving interoperable electronic health records and
capabilities that most effectively serve military service members and
veterans.
What GAO Recommends:
In the report covered by this testimony, GAO made recommendations that
the departments give priority to fully establishing the interagency
program office and finalizing the implementation plan. DOD and VA
concurred with GAO‘s recommendations.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-1158T]. For more
information, contact Valerie Melvin at (202) 512-6304 or
melvinv@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to participate in today‘s hearing on the exchange of
electronic medical information between the Department of Defense (DOD)
and the Department of Veterans Affairs (VA). As you know, the two
departments have been pursuing initiatives to share data between their
health information systems for the last decade. However, while progress
has been made, questions have remained concerning when and to what
extent the intended electronic sharing capabilities will be fully
achieved.
To expedite the departments‘ efforts to exchange electronic medical
information, the National Defense Authorization Act for Fiscal Year
2008[Footnote 1] included provisions directing DOD and VA to jointly
develop and implement, by September 30, 2009, electronic health record
systems or capabilities. The act required that these systems or
capabilities be compliant with applicable interoperability[Footnote 2]
standards, and it established an interagency program office to be a
single point of accountability for the departments‘ efforts.
Further, the act directed GAO to assess DOD‘s and VA‘s progress in
implementing the electronic health record systems and to report semi-
annually its results to the appropriate congressional committees.
Accordingly, on July 28, 2008, we issued the first of our reports in
response to the act, in which we highlighted the departments‘ progress
in (1) sharing electronic health information, (2) developing electronic
records that comply with national standards, and (3) establishing the
interagency program office. [Footnote 3] At your request, my testimony
today summarizes our findings in these three areas, as presented in
that report.
In developing this testimony, we relied largely on our previous work
supporting the July 2008 report. Where available, we also obtained and
analyzed updated information about the departments‘ exchange
activities. We conducted our work in support of this testimony during
August 2008 and September 2008, in Washington, D.C. All work on which
this testimony is based was performed in accordance with generally
accepted government auditing standards. Those standards require that we
plan and perform the audit to obtain sufficient, appropriate evidence
to provide a reasonable basis for our findings and conclusions based on
our audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
Results in Brief:
DOD and VA are sharing some, but not all, electronic health information
at different levels of interoperability. Specifically, pharmacy and
drug allergy data on almost 19,000 shared patients are exchanged at the
highest level of interoperability”that is, in computable form; at this
level, the data are in a standardized format that a computer
application can act on. In other cases, data can be viewed only”a lower
level of interoperability that still provides clinicians with important
information. However not all health information is shared
electronically; information is still being captured in paper records at
many DOD medical facilities. According to the departments, the
September 2008 DOD/VA Information Interoperability Plan is intended to
address these and other issues and define tasks required to guide the
development and implementation of an interoperable electronic health
record capability. If properly executed, the plan could help the
departments fully achieve the goal of seamless sharing of health
information.
Further enhancing interoperability depends on adherence to common
standards. The two departments have agreed upon numerous standards that
allow them to share health data and are participating in initiatives
led by the Office of the National Coordinator for Health Information
Technology (within the Department of Health and Human Services) that
are aimed at promoting the adoption of federal standards and broader
use of electronic health records. The involvement of the departments in
the federal initiatives is an important mechanism for aligning their
electronic health records with emerging federal standards.
Once fully established, a new interagency program office is expected to
play a crucial role in accelerating the departments‘ efforts to develop
and implement electronic health records and capabilities that allow for
full interoperability. However, the program office is not expected to
be fully operational until the end of the year, after which only 9
months will remain to meet the deadline for full interoperability
between the departments by September 2009. The program office‘s plan
for achieving interoperability within this time period includes
milestones that are yet to be determined. In view of the short
timeframe, without a fully established program office and a complete
plan with established milestones, the departments may be challenged in
meeting the required date for achieving interoperable electronic health
records and capabilities.
To better ensure the successful attainment of interoperable electronic
health record systems or capabilities, we recommended that the
departments give priority to fully establishing the interagency program
office and finalizing their implementation plan. The departments
concurred with our recommendations.
Background:
The use of information technology (IT) to electronically collect,
store, retrieve, and transfer clinical, administrative, and financial
health information has great potential to help improve the quality and
efficiency of health care and is critical to improving the performance
of the U.S. health care system. Historically, patient health
information has been scattered across paper records kept by many
different caregivers in many different locations, making it difficult
for a clinician to access all of a patient‘s health information at the
time of care. Lacking access to these critical data, a clinician may be
challenged to make the most informed decisions on treatment options,
potentially putting the patient‘s health at greater risk. The use of
electronic health records can help provide this access and improve
clinical decisions.[Footnote 4]
Electronic health records are particularly crucial for optimizing the
health care provided to military personnel and veterans. While in
military status and later as veterans, many DOD and VA patients tend to
be highly mobile and may have health records residing at multiple
medical facilities within and outside the United States. Making such
records electronic can help ensure that complete health care
information is available for most military service members and veterans
at the time and place of care, no matter where it originates.
Key to making health care information electronically available is
interoperability”that is, the ability to share data among health care
providers. Interoperability enables different information systems or
components to exchange information and to use the information that has
been exchanged. This capability is important because it allows
patients‘ electronic health information to move with them from provider
to provider, regardless of where the information originated. If
electronic health records conform to interoperability standards, they
can be created, managed, and consulted by authorized clinicians and
staff across more than one health care organization, thus providing
patients and their caregivers the necessary information required for
optimal care. (Paper-based health records”if available”also provide
necessary information, but unlike electronic health records, do not
provide decision support capabilities, such as automatic alerts about a
particular patient‘s health, or other advantages of automation.)
Interoperability can be achieved at different levels.[Footnote 5] At
the highest level, electronic data are computable (that is, in a format
that a computer can understand and act on to, for example, provide
alerts to clinicians on drug allergies). At a lower level, electronic
data are structured and viewable, but not computable. The value of data
at this level is that they are structured so that data of interest to
users are easier to find. At still a lower level, electronic data are
unstructured and viewable, but not computable. With unstructured
electronic data, a user would have to find needed or relevant
information by searching uncategorized data. Beyond these, paper
records can also be considered interoperable (at the lowest level)
because they allow data to be shared, read, and interpreted by human
beings. However, my discussion today focuses only on the three levels
of electronic interoperability. Figure 1 shows the distinction between
the various levels of interoperability and examples of the types of
data that can be shared at each level.
Figure 1: Levels of Data Interoperability:
[Refer to PDF for image]
This figure is an illustration of the levels of data interoperability,
as follows:
Level 1: Nonelectronic data (i.e., paper forms);
Level 2: Unstructured, viewable electronic data (i.e., scans of paper
forms);
Level 3: Structured, viewable electronic data (i.e., electronically
entered data that cannot be computed by other systems);
Level 4: Computable electronic data (i.e., electronically entered data
that can be computed by other systems.
Level 4 leads to increasingly sophisticated and standardized data.
Source: GAO analysis based on data for the Center for Information
Technology Leadership.
[End of figure]
It is important to note that not all data require the same level of
interoperability. For example, in their initial efforts to implement
computable data, DOD and VA focused on outpatient pharmacy and drug
allergy data because clinicians gave priority to the need for automated
alerts to help medical personnel avoid administering inappropriate
drugs to patients. On the other hand, for such narrative data as
clinical notes, unstructured, viewable data may be sufficient.
Achieving even a minimal level of electronic interoperability is
valuable for potentially making all relevant information available to
clinicians.
Efforts to Adopt and Implement Federal Interoperability Standards Are
Ongoing:
Any level of interoperability depends on the use of agreed-upon
standards to ensure that information can be shared and used. In the
health IT field, standards govern areas ranging from technical issues,
such as file types and interchange systems, to content issues, such as
medical terminology. Developing, coordinating, and agreeing on
standards are only part of the processes involved in achieving
interoperability for electronic health records systems or capabilities.
In addition, specifications are needed for implementing the standards,
as well as criteria and a process for verifying compliance with the
standards.
The President‘s executive order of April 2004 that called for
widespread adoption of interoperable electronic health records by
2014,[Footnote 6] established the Office of the National Coordinator
for Health Information Technology within the Department of Health and
Human Services (HHS) to, among other things, develop, maintain, and
direct the implementation of a strategic plan to guide the nationwide
implementation of interoperable health IT in both the public and
private health care sectors. Under the direction of HHS (through the
Office of the National Coordinator), three primary organizations were
designated to play major roles in expanding the implementation of
health IT:
* The American Health Information Community was created by the
Secretary of Health and Human Services as a federal advisory body to
make recommendations on how to accelerate the development and adoption
of health IT, including advancing interoperability, identifying health
IT standards, advancing nationwide health information exchange, and
protecting personal health information. Formed in September 2005, the
community is made up of representatives from both the public and
private sectors, including high-level DOD and VA officials. The
community determines specific health care areas of high priority and
develops ’use cases“[Footnote 7] for these areas, which provide the
context in which standards would be applicable. The use cases convey
how health care professionals would use such records and what standards
would apply.
* The Healthcare Information Technology Standards Panel, sponsored by
the American National Standards Institute[Footnote 8] and funded by the
Office of the National Coordinator, was established in October 2005 as
a public-private partnership to identify competing standards for the
use cases being developed by the American Health Information Community
and to ’harmonize“[Footnote 9] the standards. The panel also develops
the interoperability specifications that are needed for implementing
the standards. Interoperability specifications were developed for each
of the seven use cases developed by the American Health Information
Community in 2006 and 2007.[Footnote 10] The community is also
developing six use cases for 2008 for which interoperability
specifications have not yet been released.[Footnote 11] The Healthcare
Information Technology Standards Panel is made up of representatives
from both the public and private sectors, including DOD and VA
officials who serve as members and are actively working on several
committees and groups within the panel. This panel is the successor to
the Consolidated Health Informatics[Footnote 12] initiative, which was
dissolved and absorbed into the panel on September 30, 2006.
* The Certification Commission for Healthcare Information Technology is
an independent, nonprofit organization that certifies health IT
products. HHS entered into a contract with the commission in October
2005 to develop and evaluate the certification criteria and inspection
process for electronic health records. According to HHS, certification
is to be the process by which the IT systems of federal health
contractors are established to meet federal interoperability standards.
Certification helps assure purchasers and other users of health IT
systems that the systems will provide needed capabilities (including
ensuring security and confidentiality) and will work with other systems
without reprogramming. Certification also encourages adoption of health
IT by assuring providers that their systems can participate in
nationwide health information exchange in the future. In 2006, the
commission certified the first 37 ambulatory”or clinician office-
based”electronic health record products as meeting baseline criteria
for functionality, security, and interoperability. In 2007, the
commission expanded certification to inpatient”or hospital”electronic
health record products, which could significantly increase patients‘
and providers‘ access to the health information generated during a
hospitalization. To date, the commission has certified over 100
electronic health record products.
DOD and VA Have Been Pursuing Efforts to Exchange Health Information
for a Decade:
DOD and VA have been working to electronically exchange patient health
data since 1998. As we have reported previously,[Footnote 13] their
efforts have included both short-term initiatives to share information
in existing (legacy) systems, as well as a long-term initiative to
develop modernized health information systems”replacing their legacy
systems”that would be able to share data and, ultimately, use
interoperable electronic health records.
In their short-term initiatives to share information from existing
systems, the departments began from different positions. VA has one
integrated medical information system”the Veterans Health Information
Systems and Technology Architecture (VistA)”which uses all electronic
records and was developed in-house by VA clinicians and IT personnel.
All VA medical facilities have access to all VistA information.
In contrast, DOD uses multiple legacy medical information systems, all
of which are commercial software products that are customized for
specific uses. For example, the Composite Health Care System (CHCS)
which was formerly DOD‘s primary health information system is still in
use to capture pharmacy, radiology, and laboratory information.
[Footnote 14] In addition, the Clinical Information System (CIS), a
commercial health information system customized for DOD, is used by
some facilities for inpatients. The departments‘ short-term initiatives
to share information in their existing systems have included several
projects:
* The Federal Health Information Exchange (FHIE), completed in 2004,
enables DOD to electronically transfer service members‘ electronic
health information to VA when the members leave active duty.
* The Laboratory Data Sharing Interface (LDSI), a project established
in 2004, allows DOD and VA facilities to share laboratory resources.
This interface, now deployed at nine locations, allows the departments
to communicate orders for lab tests and their results electronically.
* The Bidirectional Health Information Exchange (BHIE), also
established in 2004, was aimed at allowing clinicians at both
departments viewable access to records on shared patients (that is,
those who receive care from both departments”for example, veterans may
receive outpatient care from VA clinicians and be hospitalized at a
military treatment facility).[Footnote 15] The interface also allows
DOD sites to see previously inaccessible data at other DOD sites.
As part of the long-term initiative, each of the departments aims to
develop a modernized system in the context of 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: DOD‘s Armed Forces Health Longitudinal Technology
Application (AHLTA)[Footnote 16] and VA‘s HealtheVet. 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). For the two-way
exchange of health information, the two repositories are to be linked
through an interface named CHDR,[Footnote 17] which the departments
began developing in March 2004 (with implementation beginning in
September 2006).
Beyond these initiatives, in January 2007, the departments announced an
addition to their information-sharing strategy: their intention to
jointly determine an approach for inpatient health records. On July 31,
2007, they awarded a contract for a feasibility study and exploration
of alternatives.[Footnote 18] According to the departments, one of the
options would be adopting a joint solution, which would be expected to
facilitate the seamless transition of active-duty service members to
veteran status, and make inpatient health care data on shared patients
more readily accessible to both DOD and VA. In addition, the
departments believe that a joint development effort could enable them
to realize cost savings. However, no decision on a joint inpatient
health records system has yet been made. The departments‘ officials
stated that they received recommendations from the contractor on the
possible approaches for the joint inpatient electronic health record in
August, but added that they would not be prepared to release the
findings from the study until senior leadership has fully reviewed and
considered the recommendations”a step for which no date was provided.
We have previously pointed out that the many tasks and challenges
associated with the departments‘ long-term goal of seamless sharing of
health information made it essential that the departments develop a
comprehensive project plan to guide these efforts to completion.
Therefore, in 2004, we recommended that the departments develop such a
plan for the CHDR interface and that it include a work breakdown
structure and schedule for all development, testing, and implementation
tasks.[Footnote 19] Further, as the departments undertook work on their
short-term initiatives, we raised concerns regarding how all of these
initiatives were to be incorporated into an overall strategy toward
achieving the departments‘ goal of a comprehensive, seamless exchange
of health information. In response to our concerns, the departments
began developing a comprehensive plan, which they called the DOD/VA
Information Interoperability Plan. To provide input to the plan and
determine priorities, in December 2007, the departments established the
Joint Clinical Information Board, made up of senior clinical leaders
from both departments. The board is responsible for establishing
clinical priorities for electronic data sharing between the
departments, determining essential health information to be shared, and
further identifying and prioritizing data that should be viewable and
data that should be computable.
The departments produced the DOD/VA Information Interoperability Plan
(Version 1.0) this month. While the scope of the plan includes health
information interoperability, it also addresses interoperability of
personnel and benefits information. According to the plan, it describes
the scope and milestones necessary to achieve and measure progress
toward interoperability goals. To this end, the plan identifies over 20
initiatives, including, for example, enhancing health information
exchange between clinical information systems. The plan also
incorporates information intended to address requirements in the
National Defense Authorization Act for Fiscal Year 2008 that require
schedules for establishing the interagency program office; establishing
requirements for electronic health record systems; and acquiring,
testing, and implementing electronic health record systems.
DOD and VA Are Sharing Some, but Not All, Health Information at
Different Levels of Interoperability:
DOD and VA are electronically sharing health information as a result of
their long- and short-term initiatives to achieve interoperability;
some of this information is exchanged in computable form, while other
information is viewable only. However, not all electronic health
information is yet shared. Further, although VA‘s health information is
all captured electronically, not all health data collected by DOD are
electronic”many DOD medical facilities use paper-based health records.
Long-Term Initiative Provides Computable Data:
Data in computable form are exchanged as a result of the departments‘
long-term initiative to develop the CHDR interface, which links the
modernized health data repositories for the new systems that each
department is developing. Implementing the interface required the
departments to agree on standards for various types of data, put the
data into the agreed standard formats, and populate the repositories
with the standardized data.[Footnote 20] Currently, the types of
computable health data being exchanged are limited to outpatient
pharmacy and drug allergy data. According to the departments, the next
type of data to be standardized, included in the repositories, and
exchanged in computable form is laboratory data (i.e., chemistry and
hematology laboratory results).[Footnote 21] However, DOD and VA
officials told us that this data exchange is expected to be achieved by
October 31, 2009.
Currently, these computable data are not shared for all patients”rather
only for those who are seen at both DOD and VA medical facilities,
identified as shared patients, and then ’activated.“[Footnote 22] Once
a patient is activated, all DOD and VA sites can access information on
that patient and receive alerts on allergies and drug interactions for
that patient. According to DOD and VA officials, outpatient pharmacy
and drug allergy data were being exchanged on almost 19,000 shared
patients as of July 31, 2008; however, officials stated that they are
unable to track the number of shared patients currently receiving care
from both departments, so the number of patients for whom data could
potentially be shared is unknown.
Short-Term Initiatives Provide Viewable Data:
Data in viewable form are shared as a result of the various short-term
initiatives previously mentioned. Through BHIE, clinicians can query
selected health information on patients from all DOD and VA sites and
view current data onscreen almost immediately. Because the BHIE
interface provides access to up-to-date information, clinicians at both
departments have expressed strong interest in expanding its use, and
DOD and VA have taken steps in this regard. For example, the
departments completed a BHIE interface with DOD‘s Clinical Data
Repository in July 2007, and they began sharing viewable patient vital
signs information through BHIE in June 2008. Extending BHIE
connectivity could provide both departments with the ability to view
additional data in DOD‘s legacy systems, until such time as the
departments‘ modernized systems are fully developed and implemented.
According to a DOD/VA annual report[Footnote 23] and program officials,
the departments now consider BHIE an interim step in their overall
strategy to create a two-way exchange of electronic health records.
DOD has been using another short-term initiative, FHIE, to transfer
information to VA since 2002, allowing VA clinicians to view service
members‘ electronic health information when the members leave active
duty. Among the data elements transferred are laboratory results,
radiology results, outpatient pharmacy data, allergy information,
consultation reports, and demographic data. Further, since July 2005,
FHIE has been used to transfer pre- and post-deployment health
assessment and reassessment data. Transfers are done in batches once a
month, or weekly for veterans who have been referred to VA treatment
facilities.
Another initiative that provides viewable data, LDSI, is deployed when
local agencies have a business case for its use and sign an agreement
to share laboratory resources. LDSI currently supports a variety of
chemistry, hematology, toxicology, and serology laboratory results. If
a test is not performed at a DOD or VA 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 LDSI, according to DOD and VA, are increased
speed in receiving laboratory results and decreased errors from manual
entry of orders.
Attachment 1 summarizes the types of health data currently shared via
the DOD and VA initiatives, as well as additional types of data that
are currently planned for sharing via these initiatives.
While DOD and VA are sharing or plan to share a wide range of health
information, questions nonetheless exist regarding when and to what
extent electronic sharing capabilities will be fully achieved. Beyond
the initiatives and types of data already discussed, the electronic
sharing of health information between the departments has not been
fully addressed. Although VA‘s health information is all captured
electronically, many DOD medical facilities continue to rely on paper
records. Also, clinical encounters for those enrolled in the military‘s
TRICARE health care program[Footnote 24] are not captured in DOD‘s
electronic health system unless care is received at a military
treatment facility.[Footnote 25] Addressing these conditions will be
important to determining the outcome of the departments‘ joint efforts.
DOD and VA Have Adopted Standards to Allow Sharing and Are Engaged in
Efforts to Establish Standards:
As previously discussed, interoperability standards are an essential
element in the exchange of electronic health information. In this
regard, DOD and VA have agreed upon numerous common standards that
allow them to share health data, which include standards that are part
of current and emerging federal interoperability specifications. The
foundation built by this collaborative process has allowed the two
departments to begin sharing computable health data (the highest level
of interoperability).
The standards agreed to by the two departments are listed in a jointly
published common set of interoperability standards called the Target
DOD/VA Health Standards Profile.[Footnote 26] The current version of
the profile, dated September 2007, includes federal standards (such as
data standards established by the Food and Drug Administration and
security standards established by the National Institute of Standards
and Technology); industry standards (such as wireless communications
standards established by the Institute of Electrical and Electronics
Engineers and Web file sharing standards established by the American
National Standards Institute); international standards (such as the
Systematized Nomenclature of Medicine Clinical Terms, or SNOMED CT, and
security standards established by the International Organization for
Standardization). According to the departments, they anticipate
continued updates and revisions to the profile as additional federal
standards emerge.
For the two kinds of data now being exchanged in computable form
through CHDR (pharmacy and drug allergy data), DOD and VA adopted the
National Library of Medicine data standards for medications and drug
allergies,[Footnote 27] as well as the SNOMED CT codes for allergy
reactions.[Footnote 28] This standardization was a prerequisite for
exchanging computable medical information”an accomplishment that,
according to the Department of Health and Human Services‘ National
Coordinator for Health IT, has not been widely achieved.
Further, DOD and VA are continuing their historical involvement in
efforts to agree upon standards for the electronic exchange of clinical
health information by participating in ongoing initiatives led by the
Office of the National Coordinator that are aimed at promoting the
adoption of federal standards and broader use of electronic health
records. Health officials from both departments participate as members
of the American Health Information Community and the Healthcare
Information Technology Standards Panel. For example, high-level
representatives of the 18-member Community include the Assistant
Secretary of Defense for Health Affairs and the Director, Health Data
and Informatics, Veterans Health Administration. DOD and VA are also
members of the Healthcare Information Technology Standards Panel Board
and are actively working on several committees and groups, including
the Provider Perspective Technical Committee; Population Perspective
Technical Committee; and Security, Privacy and Infrastructure Domain
Technical Committee. The National Coordinator indicated that such
participation is important and stated it would not be advisable for DOD
and VA to move significantly ahead of the national standards
initiative; if they did, the departments might have to change the way
their systems share information by adjusting them to the national
standards later, as the standards continue to evolve.
In addition, according to DOD officials, their department is taking
steps to ensure that the electronic health records produced by its
modernized health information system, AHLTA (which is a customized
commercial software application), are compliant with standards by
arranging for certification through the Certification Commission for
Healthcare Information Technology. AHLTA version 3.3 has been installed
at three DOD locations[Footnote 29] for beta testing and has met
specific functionality, interoperability, and security requirements.
However, the officials stated that the commission cannot fully certify
this version of AHLTA until it has verified that the system has been in
operational use at a medical site.
The departments‘ efforts to share data and to be involved in
standardization activities are important mechanisms for ensuring that
their electronic health records are both interoperable and aligned with
emerging standards.
Further Actions Needed to Fully Establish the Interagency Program
Office:
To accelerate the departments‘ ongoing interoperability efforts,
Congress included in the National Defense Authorization Act for Fiscal
Year 2008 provisions establishing an interagency program office. Under
the act, the Secretary of Defense and the Secretary of Veterans Affairs
were required to jointly develop schedules and benchmarks for setting
up the DOD/VA Interagency Program Office, and for other activities to
achieve interoperable health information (that is, establishing system
requirements, acquisition and testing, and implementation of
interoperable electronic health records or capabilities). The schedules
and benchmarks were due 30 days after passage of the act, or the end of
February 2008.
The departments did not meet the February 2008 date; however, just this
month they produced the DOD/VA Information Interoperability Plan, which
incorporates fiscal year 2008 and 2009 schedules and milestones that
DOD and VA previously referred to in a draft implementation plan.
Further, in an effort to set up the program office, the departments
appointed an Acting Director from DOD and an Acting Deputy Director
from VA.[Footnote 30] According to the Acting Director, the departments
also have detailed staff and provided temporary space and equipment to
a transition team. The official stated that, through the efforts of the
transition team, the departments are currently developing a charter for
the office, defining and approving an organizational structure, and
preparing to begin recruiting permanent staff for the office, which is
expected to number about 30. According to the plan, the departments
expect to appoint a permanent Director and Deputy Director and begin
recruiting staff by October 2008. The Acting Director added that
program staff are expected to be in place, and the office is expected
to be fully operational by December 2008. To fund the office, the
departments have reported requesting $4.94 million for fiscal year 2008
and $6.94 million for fiscal year 2009.
Within the plan, milestones and schedules have been included for
achieving interoperable health information in two stages. The first
stage”Interoperability I” is to be completed this month and is to make
available those health data most commonly required by health care
providers, as validated by the Joint Clinical Information Board,
[Footnote 31] which sets the clinical priorities for what electronic
health information should be shared. The first milestone for this
stage, sharing vital signs information, was already achieved this past
June as part of the BHIE initiative. According to department officials,
the remaining milestones related to sharing questionnaires and forms,
family history, social history, and other history are all due during
this month.
The second stage”Interoperability II” is to be completed by September
2009, and is to address additional health information enhancements.
Department officials stated that the information to be covered by these
enhancements is being defined, and that validation of the requirements
for the enhancements by the Joint Clinical Information Board was
completed in July 2008.
Nevertheless, milestones for this stage have not been fully
established. Specifically, of 52 activities identified for
Interoperability II, 11 do not yet have defined milestones. For
example, milestones have not been identified for completing
requirements validation, acquisition, and testing for the scanning of
service members‘ paper medical records into DOD‘s electronic health
record system in order to share these records electronically with VA; a
capability expected to be implemented by September 30, 2009. Department
officials stated that decisions on these milestones will depend on
clinical priorities, technical considerations, and policy decisions.
Further, according to the plan, it is intended to serve as a ’living
document“ that will be updated and refined as more detailed information
becomes known on planned fiscal year 2008 and fiscal year 2009
initiatives, and as health care information needs change. However,
although the plan (as a planning tool) is a living document, it is
nonetheless important to complete the planning and make the decisions
needed to finalize the plan, particularly in view of the fast
approaching September 2009 deadline.
In addition, according to department officials, the interagency program
office will play a crucial role in coordinating the departments‘
efforts to accelerate their interoperability efforts. An important
aspect of this coordination will be managing implementation of the
DOD/VA Information Interoperability Plan, which the departments
recently finalized. According to these officials, having a centralized
office to take on this role will be a primary benefit. However, the
effort to set up the program office is still in its early stages. As
has been noted, the positions of Director and Deputy Director are not
yet permanently filled, permanent staff have not yet been hired, and
facilities have not yet been designated for housing the office. In
addition, the departments have not completed an interagency program
office charter because the departments‘ leadership broadened its scope
to include sharing of personnel and benefits data instead of only
health information. Until the program office is fully established, it
will not be able to play this crucial role effectively. Thus, it
remains vital that the Secretaries of Defense and Veterans Affairs
fully establish the Interagency Program Office by expediting efforts to
put in place permanent leadership, staff, and facilities.
To better ensure that the effort by DOD and VA to achieve fully
interoperable electronic health record systems or capabilities is
accelerated, our July report included recommendations that the
departments give priority to fully establishing the interagency program
office and finalizing the implementation plan. Prompt action by the
departments to address these recommendations is critical to developing
and implementing electronic health record systems or capabilities that
allow for full interoperability of personal health care information by
September 30, 2009, as specified in the National Defense Authorization
Act for Fiscal Year 2008. In their comments on our report, both
departments concurred with these recommendations.
In summary, through numerous efforts, DOD and VA are sharing electronic
health information at different levels of interoperability. Moreover,
as a result of their efforts, the departments are sharing more data
than ever before. However, significant work remains to plan and
implement new capabilities that could further increase the sharing of
electronic health information between the departments and to determine
the desired level of data interoperability. Recognizing the importance
of timely implementation of such capabilities, Congress established a
requirement for an interagency program office as a single point of
accountability, and a deadline of about one year from now to achieve
full interoperability of personal health care information between the
departments. In view of this short timeframe and as we have
recommended, a fully functioning program office and a finalized plan
with set milestones are critical steps toward achieving interoperable
electronic health records and capabilities. Although completion of the
DOD/VA Information Interoperability Plan is an important and positive
accomplishment, without permanent program office leadership, staff, and
facilities or fully established milestones, the departments may
nonetheless remain challenged in achieving interoperable electronic
health information to the extent and in the manner that most
effectively serves military service members and veterans.
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.
Contacts and Acknowledgements:
If you have any questions on matters discussed in 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 Mark Bird, Assistant Director; Barbara Collier; Neil
Doherty; Rebecca LaPaze; Lee McCracken; Barbara Oliver; Kelly Shaw;
Eric Trout; and Robert Williams, Jr.
[End of section]
Attachment 1: Current and Planned Health Data Sharing:
Table 1 summarizes the types of health data currently shared through
the long- and short-term initiatives we have described, as well as
types of data that are currently planned for addition.
Table 1: Data Elements Made Available and Planned by DOD/VA
Initiatives:
Initiative: CHDR;
Data elements: Available: Outpatient pharmacy; Drug allergy;
Data elements: Planned: Laboratory data;
Interoperability level: Computable data;
Comments: Data are exchanged between one department‘s data repository
and the other‘s. As of July 31, 2008, computable pharmacy and
medication allergy data were being exchanged on almost 19,000 shared
patients. The departments are prioritizing their current needs to
determine what, if any, additional data elements need to be exchanged
at the computable data level.
Initiative: BHIE, Bidirectional Health Information Exchange;
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, emergency room
notes, inpatient consultation, operative reports, and history and
physical reports from CIS at 17 DOD sites (about 40% of inpatient beds)
and all VA sites; Provider notes; Procedures; Problem lists; Vital
signs;
Data elements: Planned: Scanned images and documents; Family history;
Social history; Other history questionnaires; Radiology images;
Psychological health treatment and care records; Rollout of CIS at
additional DOD sites; expansion to include additional CIS
documentation: initial evaluation notes, procedure notes, evaluation
and management notes, preoperative and postoperative evaluation notes;
Interoperability level: Structured, viewable data; Unstructured,
viewable data from scanned documents;
Comments: Data are not transferred but can be viewed. Limitations:
Inpatient data are available only from a portion of DOD inpatient
hospitals, not all military hospitals.
Initiative: FHIE, Federal Health Information Exchange;
Data elements: Available: Patient demographics; Laboratory results
;Radiology reports; Outpatient pharmacy information; Admission
discharge transfer data; Discharge summaries from CHCS; Consult
reports; Allergies; Data from the DOD Standard Ambulatory Data Record;
Pre- and postdeployment health assessments; Postdeployment health
reassessments;
Data elements: Planned: None;
Interoperability level: Structured, viewable data;
Comments: Noncomputable text data are transferred to VA and stored in
VA‘s FHIE database, making it accessible to all VA clinicians. 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.
Limitations: Discharge summaries from CHCS only[A] are transferred, not
from other DOD systems.
Initiative: LDSI, Laboratory Data Sharing Interface;
Data element: Available: Laboratory orders; Laboratory results
(chemistry, hematology, toxicology, and serology at all LDSI sites;
anatomic pathology and microbiology at two localities);
Data element: Planned: Additional sites as business need arises;
Interoperability level: Structured, viewable data;
Comments: Noncomputable text data are transferred and captured in the
individual‘s health record.
Source: GAO analysis of DOD and VA data.
[A] According to department officials, the discharge summary module of
CHCS is used at a limited number of sites.
[End of table]
[End of section]
Footnotes:
[1] The National Defense Authorization Act for Fiscal Year 2008, Pub.
L. No. 110-181, Section 1635, required ’Fully Interoperable Electronic
Personal Health Information for the Department of Defense and the
Department of Veterans Affairs.“
[2] Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged. Further discussion of levels of interoperability is
provided later in this testimony.
[3] GAO, Electronic Health Records: DOD and VA Have Increased Their
Sharing of Health Information, but More Work Remains, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-08-954] (Washington, D.C.: July
28, 2008).
[4] An electronic health record is a longitudinal collection of
information about the health of an individual or the care provided,
such as patient demographics, progress notes, problems, medications,
vital signs, past medical history, immunizations, laboratory data, and
radiology reports.
[5] These levels were identified by the Center for Information
Technology Leadership, which was chartered in 2002 as a research
organization established to help guide the health care community in
making more informed strategic IT investment decisions. According to
DOD and VA officials, the different levels of interoperability have
been accepted for use by the Office of the National Coordinator for
Health Information Technology.
[6] Executive Order 13335, Incentives for the Use of Health Information
Technology and Establishing the Position of the National Health
Information Technology Coordinator (Washington, D.C.: Apr. 27, 2004).
[7] Use cases are descriptions of events that detail what a system (or
systems) needs to do to achieve a specific mission or goal; they convey
how individuals and organizations (actors) interact with the systems.
For health IT, use cases strive to provide enough detail and context
for follow-up activities to occur, such as standards harmonization,
architecture specification, certification consideration, and detailed
policy discussions to advance the national health IT agenda.
[8] The American National Standards Institute is a private, nonprofit
organization whose mission is to promote and facilitate voluntary
consensus standards and ensure their integrity.
[9] Harmonization is the process of identifying overlaps and gaps in
relevant standards and developing recommendations to address these
overlaps and gaps.
[10] The seven use cases are Emergency Responder, Consumer Empowerment,
Medication Management, Quality, Registration and Medication History,
Laboratory Results Reporting, and Visit, Utilization, and Lab Result
Data.
[11] The six use cases are Remote Monitoring, Patient-Provider Secure
Messaging, Personalized Healthcare, Consultation and Transfers of Care,
Public Health Case Reporting, and Immunizations & Response Management.
[12] In December 2001, the Consolidated Health Informatics was
initiated to enable federal agencies to build interoperable health data
systems. This project was a collaborative agreement among federal
agencies, including DOD and VA, to adopt a common set of health
information standards for the electronic exchange of clinical health
information.
[13] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-954].
[14] According to DOD, CHCS applications are now accessed through its
modernized health information system, Armed Forces Health Longitudinal
Technology Application (AHLTA). The department no longer considers
AHLTA as an acronym but as the official name of the system.
[15] 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
interface allows clinicians in both departments to view, in real time,
limited health data (in text form) from the departments‘ existing
health information systems.
[16] AHLTA was formerly known as CHCS II.
[17] The name CHDR, pronounced ’cheddar,“ combines the names of the two
repositories.
[18] The contract for this study is still ongoing; according to DOD and
VA officials, a contract option period was exercised and began in July
2008 and will conclude in December 2008.
[19] GAO, Computer-Based Patient Records: DOD and VA Efforts to
Exchange Health Data Could Benefit from Improved Planning and Project
Management, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-687]
(Washington, D.C.: June 7, 2004).
[20] DOD has populated CDR with information for outpatient encounters,
drug allergies, and order entries and results for outpatient pharmacy
and lab orders. VA has populated HDR with patient demographics, vital
signs records, allergy data, and outpatient pharmacy data; in July
2007, the department added chemistry and hematology, and in September
2007, added microbiology.
[21] Standardizing the data involves different tasks for each
department. That is, although VA‘s health records are already
electronic, it must still convert them into the standardized format
appropriate for its repository. DOD must convert and standardize
current records from its multiple systems, but it must also address
health records that are not automated.
[22] That is, they are matched on certain identifiers”first name, last
name, date of birth, Social Security number”in both agencies‘ health
information systems and established as ’active“ shared patients.
[23] December 2004 DOD and VA Joint Strategic Plan.
[24] Those eligible are active-duty service members, National Guard and
Reserve members, retirees, their families, survivors and certain former
spouses.
[25] According to DOD officials, about 7.29 million individuals are
enrolled in TRICARE. These people can seek care in both the direct care
system (military medical facilities) and the purchased care system
(nonmilitary medical facilities).
[26] First developed in 2004, this profile resulted from an effort in
which the two departments compared their individual standards profiles
for compatibility and began converging them. The Target Standards
Profile is updated annually and is used for reviewing joint DOD/VA
initiatives to ensure standards compliance.
[27] These data standards are known as RxNorm and Unified Medical
Language System (UMLS) for medications and drug allergies.
[28] SNOMED CT, a comprehensive health and clinical terminology, was
established by the International Health Terminology Standards
Development Organisation, a not-for-profit association that develops
and promotes use of SNOMED CT so as to support safe and effective
health information exchange.
[29] These locations are the Naval Medical Center in Portsmouth, Va.;
Eisenhower Army Medical Center in Fort Gordon, Ga.; and Goodfellow Air
Force Base in San Angelo, Tex.
[30] Before these appointments, both the officials had been involved in
the planning and implementation of the departments‘ current sharing
capabilities.
[31] These data were defined in response to the recommendation by the
President‘s Commission on Care for America‘s Returning Wounded
Warriors.
[End of section]
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