Information Technology
Challenges Remain for VA's Sharing of Electronic Health Records with DOD Gao ID: GAO-09-427T March 12, 2009For over a decade, the Department of Veterans Affairs (VA) and the Department of Defense (DOD) have been engaged in efforts to improve their ability to share electronic health information. These efforts are vital for making patient information readily available to health care providers in both departments, reducing medical errors, and streamlining administrative functions. In addition, Congress has mandated that VA and DOD jointly develop and implement, by September 30, 2009, electronic health record systems or capabilities that are fully interoperable and compliant with applicable federal interoperability standards. (Interoperability is the ability of two or more systems or components to exchange information and to use the information that has been exchanged.) The experience of VA and DOD in this area is also relevant to broader efforts to advance the nationwide use of health information technology (IT) in both the public and private health care sectors--a goal of both current and past administrations. In this statement, GAO describes VA's and DOD's achievements and challenges in developing interoperable electronic health records, including brief comments on how these apply to the broader national health IT effort.
Through their long-running electronic health information sharing initiatives, VA and DOD have succeeded in increasing their ability to share and use health information. In particular, they are sharing certain clinical information (pharmacy and drug allergy data) in computable form--that is, in a format that a computer can understand and act on. This permits health information systems to provide alerts to clinicians on drug allergies, an important feature that was given priority by the departments' clinicians. The departments are now exchanging this type of data on over 27,000 shared patients--an increase of about 9,000 patients between June 2008 and January 2009. Sharing computable data is considered the highest level of interoperability, but other levels also have value. That is, data that are only viewable still provide important information to clinicians, and much of the departments' shared information is of this type. However, the departments have more to do: not all electronic health information is yet shared, and although VA's health data are all captured electronically, information is still captured on paper at many DOD medical facilities. To share and use health data has required, among other things, that VA and DOD agree on standards. At the same time, they are participating in federal standards-related initiatives, which is important both because of the experience that the departments bring to the national effort, and also because their involvement helps ensure that their adopted standards are compliant with federal standards. However, these federal standards are still emerging, which could complicate the departments' efforts to maintain compliance. Finally, the departments' efforts face management challenges. Specifically, the effectiveness of the departments' planning for meeting the deadline for fully interoperable electronic health records is reduced because their plans did not consistently identify results-oriented performance goals (i.e., goals that are objective, quantifiable, and measurable) or measures that would permit progress toward the goals to be assessed. Further constraining VA's and DOD's planning effectiveness is their inability to complete all necessary activities to set up the interagency program office, which is intended to be accountable for fulfilling the departments' interoperability plans. Defining goals and ensuring that these are met would be an important part of the task of the program office. Without a fully established office that can manage the effort to meet these goals, the departments increase the risk that they will not be able to share interoperable electronic health information to the extent and in the manner that most effectively serves military service members and veterans. Accordingly, GAO has recommended that the departments give priority to fully establishing the interagency program office and develop results-oriented performance goals and measures to be used as the basis for reporting interoperability progress. The departments concurred with these recommendations.
GAO-09-427T, Information Technology: Challenges Remain for VA's Sharing of Electronic Health Records with DOD
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Testimony:
Before the Subcommittee on Military Construction, Veterans‘ Affairs,
and Related Agencies; House Committee on Appropriations:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Thursday, March 12, 2009:
Information Technology:
Challenges Remain for VA‘s Sharing of Electronic Health Records with
DOD:
Statement of Valerie C. Melvin, Director:
Information Management and Human Capital Issues:
GAO-09-427T:
GAO Highlights:
Highlights of GAO-09-427T, a testimony before the Subcommittee on
Military Construction, Veterans' Affairs, and Related Agencies; House
Committee on Appropriations.
Why GAO Did This Study:
For over a decade, the Department of Veterans Affairs (VA) and the
Department of Defense (DOD) have been engaged in efforts to improve
their ability to share electronic health information. These efforts are
vital for making patient information readily available to health care
providers in both departments, reducing medical errors, and
streamlining administrative functions. In addition, Congress has
mandated that VA and DOD jointly develop and implement, by September
30, 2009, electronic health record systems or capabilities that are
fully interoperable and compliant with applicable federal
interoperability standards. (Interoperability is the ability of two or
more systems or components to exchange information and to use the
information that has been exchanged.)
The experience of VA and DOD in this area is also relevant to broader
efforts to advance the nationwide use of health information technology
(IT) in both the public and private health care sectors”a goal of both
current and past administrations.
In this statement, GAO describes VA‘s and DOD‘s achievements and
challenges in developing interoperable electronic health records,
including brief comments on how these apply to the broader national
health IT effort.
What GAO Found:
Through their long-running electronic health information sharing
initiatives, VA and DOD have succeeded in increasing their ability to
share and use health information. In particular, they are sharing
certain clinical information (pharmacy and drug allergy data) in
computable form”that is, in a format that a computer can understand and
act on. This permits health information systems to provide alerts to
clinicians on drug allergies, an important feature that was given
priority by the departments‘ clinicians. The departments are now
exchanging this type of data on over 27,000 shared patients”an increase
of about 9,000 patients between June 2008 and January 2009. Sharing
computable data is considered the highest level of interoperability,
but other levels also have value. That is, data that are only viewable
still provide important information to clinicians, and much of the
departments‘ shared information is of this type. However, the
departments have more to do: not all electronic health information is
yet shared, and although VA‘s health data are all captured
electronically, information is still captured on paper at many DOD
medical facilities.
To share and use health data has required, among other things, that VA
and DOD agree on standards. At the same time, they are participating in
federal standards-related initiatives, which is important both because
of the experience that the departments bring to the national effort,
and also because their involvement helps ensure that their adopted
standards are compliant with federal standards. However, these federal
standards are still emerging, which could complicate the departments‘
efforts to maintain compliance.
Finally, the departments‘ efforts face management challenges.
Specifically, the effectiveness of the departments‘ planning for
meeting the deadline for fully interoperable electronic health records
is reduced because their plans did not consistently identify results-
oriented performance goals (i.e., goals that are objective,
quantifiable, and measurable) or measures that would permit progress
toward the goals to be assessed. Further constraining VA‘s and DOD‘s
planning effectiveness is their inability to complete all necessary
activities to set up the interagency program office, which is intended
to be accountable for fulfilling the departments‘ interoperability
plans. Defining goals and ensuring that these are met would be an
important part of the task of the program office. Without a fully
established office that can manage the effort to meet these goals, the
departments increase the risk that they will not be able to share
interoperable electronic health information to the extent and in the
manner that most effectively serves military service members and
veterans. Accordingly, GAO has recommended that the departments give
priority to fully establishing the interagency program office and
develop results-oriented performance goals and measures to be used as
the basis for reporting interoperability progress. The departments
concurred with these recommendations.
View [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-427T] or key
components. 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 here today to discuss the efforts of the Department
of Veterans Affairs (VA) to advance the use of health information
technology to achieve interoperable electronic health records with the
Department of Defense (DOD). VA has been working with DOD for over a
decade to pursue initiatives to share data between the two departments'
health information systems. To expedite the departments' efforts, the
National Defense Authorization Act for Fiscal Year 2008[Footnote 1]
included provisions directing VA and DOD to jointly develop and
implement, by September 30, 2009, fully interoperable electronic health
record systems or capabilities that are compliant with applicable
federal interoperability[Footnote 2] standards. Such systems and
capabilities are important for making patient information more readily
available to health care providers in both departments, reducing
medical errors, and streamlining administrative functions.
The experience of VA and DOD in this area is also relevant to broader
efforts to advance the nationwide use of health information technology
(IT) in both the public and private health care sectors --a goal of
both current and past administrations. As you are aware, a nationwide
effort is currently under way to promote the use of health IT to help
improve the efficiency and quality of health care. In April 2004 an
executive order called for widespread adoption of interoperable
electronic health records by 2014,[Footnote 3] and it set up the Office
of the National Coordinator for Health Information Technology within
the Department of Health and Human Services (HHS) to help guide efforts
leading to this goal. Most recently, in February, the American Recovery
and Reinvestment Act of 2009 established the office in law, giving the
National Coordinator responsibility for coordinating health IT policy
and standards, among other things.[Footnote 4]
Since 2001, we have been reviewing aspects of the various federal
efforts undertaken to implement IT for health care and public health
solutions. We have reported on VA's and DOD's electronic health
information sharing initiatives, as well as on HHS's national health IT
initiatives.[Footnote 5] Overall, our studies have recognized progress
made by these departments, but we have also pointed out challenges and
other areas of concern. At your request, in this statement, we will
describe some of VA's and DOD's achievements and challenges in
developing interoperable electronic health records, including brief
comments on how these apply to the broader national health IT effort.
In developing this testimony, we relied largely on our previous work.
We conducted our work in support of this testimony during February 2009
and March 2009, 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.
Background:
The use of 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
6]
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 VA and DOD 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.
VA Has Been Working with DOD to Exchange Health Information for Over a
Decade:
VA and DOD have been working to exchange patient health data
electronically since 1998. As we have previously noted,[Footnote 7]
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.
[Footnote 8] 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 9] In addition, the Clinical Information System (CIS), a
commercial health information system customized for DOD, is used to
support inpatient treatment at military medical facilities.
The departments' short-term initiatives to share information in their
existing systems have included several projects. Most notable are two
information exchange 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 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--veterans may receive
outpatient care from VA clinicians and be hospitalized at a military
treatment facility).[Footnote 10] 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 AHLTA[Footnote 11] 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, in September 2006 the
departments implemented an interface named CHDR[Footnote 12], to link
the two repositories.
Beyond these initiatives, in January 2007, the departments announced
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. In December 2008, the contractor
provided the departments with a recommended strategy for jointly
developing an inpatient solution.
VA and DOD Have Increased Information Sharing, but Continue to Face
Challenges in Developing and Implementing Interoperable Health Records:
VA and DOD have increased their ability to share and use health
information, sharing both computable and viewable data. This
achievement has required years of effort by the two departments,
involving, among other things, agreeing on standards and setting
priorities for the kind of information to be shared and the appropriate
level of interoperability to work toward.
Interoperability--the ability to share data among health care
providers--is key to sharing health care information electronically.
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 13] 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. 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: illustration]
Level move toward having increasingly sophisticated and standardized
data.
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.
Source: GAO analysis of data from the Center for Information TEchnology
Leadership.
[End of figure]
VA and DOD have adopted a classification framework like the one in the
figure to define what level of interoperability they are aiming to
achieve in various information areas. For example, in their initial
efforts to implement computable data, VA and DOD 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. As of January 31, 2009, the
departments were exchanging computable outpatient pharmacy and drug
allergy data through the CHDR interface on over 27,000 shared patients-
-an increase of about 9,000 patients since June 2008.
However, according to VA and DOD officials, not all data require the
same level of interoperability, nor is interoperability at the highest
level achievable in all cases. For example, unstructured, viewable data
may be sufficient for such narrative information as clinical notes.
According to the departments, much of the information being shared
today is currently at the structured, viewable level. For example,
through BHIE, the departments exchange surgical pathology reports,
microbiology results, cytology reports, chemistry and hematology
reports, laboratory orders, vital signs, and other data in structured,
viewable form. Some of this information is from scanned documents that
are viewable but unstructured. With this format, a clinician would have
to find needed or relevant information by scanning uncategorized
information. The value of viewable data is increased if the data are
structured so that information is categorized and easier to find.
Nonetheless, achieving even a minimal level of electronic
interoperability is valuable for potentially making all relevant
information available to clinicians.
However, the departments have more to do: not all electronic health
information is yet shared. In addition, although VA's health data are
all captured electronically, information is still captured on paper at
many DOD medical facilities.
VA and DOD Have Adopted Standards to Allow Sharing and Are Taking Steps
to Follow Evolving Federal Standards:
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 may govern areas ranging from technical
issues, such as file types and interchange systems, to content issues,
such as medical terminology.
* For example, vocabulary standards provide common definitions and
codes for medical terms and determine how information will be
documented for diagnoses and procedures. These standards are intended
to lead to consistent descriptions of a patient's medical condition by
all practitioners. Without such standards, the terms used to describe
the same diagnoses and procedures may vary (the condition known as
hepatitis, for example, may be described as a liver inflammation). The
use of different terms to indicate the same condition or treatment
complicates retrieval and reduces the reliability and consistency of
data.
* Another example is messaging standards, which establish the order and
sequence of data during transmission and provide for the uniform and
predictable electronic exchange of data. For example, they might
require the first segment to include the patient's name, hospital
number, and birth date. A series of subsequent segments might transmit
the results of a complete blood count, dictating one result (e.g., iron
content) per segment. Messaging standards can be adopted to enable
intelligible communication between organizations via the Internet or
some other communications pathway. Without them, the interoperability
of health IT systems may be limited, reducing the data that can be
shared.
VA and DOD have agreed upon numerous common standards that allow them
to share health data. These are listed in a jointly published common
set of interoperability standards called the Target DOD/VA Health
Standards Profile, updated annually. The profile 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); and
international standards (such as the Systematized Nomenclature of
Medicine Clinical Terms, or SNOMED CT, and security standards
established by the International Organization for Standardization).
For the two kinds of data now being exchanged in computable form
through CHDR (pharmacy and drug allergy data), VA and DOD adopted the
National Library of Medicine data standards for medications and drug
allergies, as well as the SNOMED CT codes for allergy reactions. 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, VA and DOD 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 under the direction of HHS. These
initiatives have included the designation of standards-setting
organizations tasked to reach consensus on the definition and use of
standards. For example, these organizations have been responsible for,
among other things,
* developing use cases,[Footnote 14] which provide the context in which
standards would be applicable;
* identifying competing standards for the use cases and harmonizing the
standards;
* developing interoperability specifications that are needed for
implementing the standards;[Footnote 15] and:
* creating certification criteria to determine whether health IT
systems meet standards accepted or recognized by the Secretary of HHS,
and then certifying systems that meet those criteria.
The involvement of the two departments in these initiatives is
important both because of the experience that the departments can offer
the national effort, and also because their involvement helps ensure
that the standards they adopt are consistent with the emerging federal
standards. DOD and VA have made progress toward adopting health data
interoperability standards that are newly recognized and accepted by
the Secretary of HHS. The departments have identified these new
standards, which relate to three HHS-recognized use cases,[Footnote 16]
in their most recent Target Standards Profile.
Nonetheless, the need to be consistent with the emerging federal
standards adds complexity to the task faced by the two departments of
extending their standards efforts to additional types of health
information. The National Coordinator recognized the importance of
their participation and stated it would not be advisable for VA and DOD
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.
VA and DOD Plans Lack Results-Oriented Performance Goals and Measures,
and Interagency Program Office Is Not Fully Set Up:
Using interoperable health IT to help improve the efficiency and
quality of health care is a complex goal that requires the involvement
of multiple stakeholders in both departments, as well as numerous
activities taking place over an expanse of time. In view of this
complexity, it is important to develop comprehensive plans that cover
the full scope of the activities needed to reach the goal of
interoperable health capabilities or systems. To be effective, these
plans should be grounded in results-oriented goals and performance
measures that allow the results of the activities to be monitored and
assessed, so that the departments can take corrective action if needed.
In the course of their health IT efforts, VA and DOD have faced
considerable challenges in project planning and management. As far back
as 2001 and 2002, we reported management weaknesses, such as inadequate
accountability and poor planning and oversight, and recommended that
the departments apply principles of sound project management.[Footnote
17] The departments' efforts to meet the recent requirements of the
National Defense Authorization Act for Fiscal Year 2008 provide
additional examples of such challenges, raising concerns regarding
their ability to most effectively meet the September 2009 deadline for
developing and implementing interoperable electronic health record
systems or capabilities.
The departments have identified key documents as defining their planned
efforts to meet this deadline: the November 2007 VA/DOD Joint Executive
Council Strategic Plan for Fiscal Years 2008-2010 (known as the VA/DOD
Joint Strategic Plan) and the September 2008 DOD/VA Information
Interoperability Plan (Version 1.0). These plans identify various
objectives and activities that, according to the departments, are aimed
at increasing health information sharing and achieving full
interoperability. However, of the 45 objectives and activities
identified in their plans, we previously reported that only 4 were
documented with results-oriented (i.e., objective, quantifiable, and
measurable) performance goals and measures that are characteristic of
effective planning.[Footnote 18]
* An example of an objective, quantifiable, and measurable performance
goal is DOD's objective of increasing the percentage for inpatient
discharge summaries that it shares with VA from 51 percent as of March
2009, to 70 percent by September 30, 2009.
* However, other goals in the plans are not measurable: For example,
one objective is the development of a plan for interagency sharing of
essential health images. Another objective is to review national health
IT standards. In neither case are tangible deliverables described that
would permit the departments to determine progress in achieving these
goals.
In view of the complexity and scale of the tasks required for the two
departments to develop interoperable electronic health records, the
lack of documented results-oriented performance goals and measures
hinder their ability to measure and report their progress toward
delivering new capabilities. Both departments agreed with our January
2009 recommendation that they develop results-oriented goals and
associated performance measures to help them manage this effort.
[Footnote 19] Until they develop these goals and measures, the
departments will be challenged to effectively assess their progress.
In addition, we previously reported that the departments had not fully
set up the interagency program office that was established in the
National Defense Authorization Act for Fiscal Year 2008. According to
department officials, this office will play a crucial role in
coordinating the departments' efforts to accelerate their
interoperability efforts. These officials stated that having a
centralized office to take on this role will be a primary benefit.
Further, defining results-oriented performance goals and ensuring that
these are met would be an important part of the task of the program
office. However, the effort to set up the program office was still in
its early stages. The departments had taken steps to set up the program
office, such as developing descriptions for key positions and beginning
to hire personnel, but they had not completed all necessary activities
to meet their December 2008 deadline for the office to be fully
operational. Both departments agreed with our July 2008 recommendation
that the departments give priority to fully establishing the
interagency program office.[Footnote 20] Since we last reported, the
departments have continued their efforts to hire staff for the office
with 18 of 30 positions filled as of March 5, 2009, but the positions
of Director and Deputy Director are not yet filled with permanent
hires.
Until the departments complete key activities to set up the program
office, it will not be positioned to be fully functional, or
accountable for fulfilling the departments' interoperability plans.
Coupled with the lack of results-oriented plans that establish program
commitments in measurable terms, the absence of a fully operational
interagency program office leaves VA and DOD without a clearly
established approach for ensuring that their actions will achieve the
desired purpose of the act.
In closing, Mr. Chairman, VA and DOD have made important progress in
achieving electronic health records that are interoperable, but the
departments continue to face challenges in managing the activities
required to achieve this inherently complex goal. These include the
need to continue to agree on standards for their own systems while
ensuring that they maintain compliance with federal standards, which
are still emerging as part of the effort to promote the nationwide
adoption of health IT. In addition, the departments' efforts face
managerial challenges in defining goals and measures and setting up the
interagency program office. Until these challenges are addressed, the
risk is increased that the departments will not achieve the ability to
share interoperable electronic health information to the extent and in
the manner that most effectively serves military service members and
veterans.
This concludes my statement. I would be pleased to respond to any
questions that you or other members of the subcommittee may have.
Contacts and Acknowledgements:
If you have any questions on matters discussed in this testimony,
please contact Valerie C. Melvin, Director, Information Management and
Human Capital 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; J.
Michael Resser; Kelly Shaw; and Eric Trout.
[End of section]
Footnotes:
[1] The National Defense Authorization Act for Fiscal Year 2008, Pub.
L. No. 110-181, Section 1635 (Jan. 28, 2008).
[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] 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).
[4] Health Information Technology for Economic and Clinical Health
(HITECH) Act, sec. 13101, Title XIII of the American Recovery and
Reinvestment Act of 2009, Pub. L. No. 111-5, Feb. 17, 2009, adding sec.
3001 to the Public Health Service Act, 42 U.S.C. sec. 300jj-11.
[5] GAO, Computer-Based Patient Records: Better Planning and Oversight
by VA, DOD, and IHS Would Enhance Health Data Sharing, [hyperlink,
http://www.gao.gov/products/GAO-01-459] (Washington, D.C.: Apr. 30,
2001); Computer-Based Patient Records: VA and DOD Efforts to Exchange
Health Data Could Benefit from Improved Planning and Project
Management, [hyperlink, http://www.gao.gov/products/GAO-04-687]
(Washington, D.C.: June 7, 2004); Health Information Technology: HHS Is
Continuing Efforts to Define its National Strategy, [hyperlink,
http://www.gao.gov/products/GAO-06-1071T] (Washington, D.C.: Sept. 1,
2006); Information Technology: DOD and VA Have Increased Their Sharing
of Health Information, but More Work Remains, [hyperlink,
http://www.gao.gov/products/GAO-08-954] (Washington, D.C.: July 28,
2008); and Electronic Health Records: DOD's and VA's Sharing of
Information Could Benefit from Improved Management, [hyperlink,
http://www.gao.gov/products/GAO-09-268] (Washington, D.C.: Jan. 28,
2009).
[6] An electronic health record is a 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.
[7] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[8] VistA began operation in 1983 as the Decentralized Hospital
Computer Program. In 1996, the name of the system was changed to the
Veterans Health Information Systems and Technology Architecture.
[9] According to DOD, CHCS applications are now accessed through its
modernized health information system, AHLTA.
[10] 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.
[11] The department considers AHLTA the official name of the system.
(It was formerly an abbreviation for Armed Forces Health Longitudinal
Technology Application). Previously, AHLTA was known as CHCS II.
[12] The name CHDR, pronounced "cheddar," combines the names of the two
repositories.
[13] 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 VA
and DOD, the different levels of interoperability have been accepted
for use by the Office of the National Coordinator for Health
Information Technology.
[14] 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 related to specific health care areas
of high priority, such as standards harmonization, architecture
specification, certification consideration, and detailed policy
discussions to advance the national health IT agenda.
[15] An interoperability specification codifies detailed implementation
guidance that includes references to the identified standards or parts
of standards and explains how they should be applied to specific health
care topic areas.
[16] Specifically, the profile now includes the use cases for
Electronic Health Records Laboratory Results Reporting,
Biosurveillance, and Consumer Empowerment.
[17] GAO, Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results, [hyperlink,
http://www.gao.gov/products/GAO-02-703] (Washington, D.C.: June 12,
2002) and [hyperlink, http://www.gao.gov/products/GAO-01-459].
[18] [hyperlink, http://www.gao.gov/products/GAO-09-268].
[19] [hyperlink, http://www.gao.gov/products/GAO-09-268].
[20] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[End of section]
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