Electronic Health Records
DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs to Implement Recommended Improvements Gao ID: GAO-10-332 January 28, 2010The National Defense Authorization Act for Fiscal Year 2008 required the Department of Defense (DOD) and the Department of Veterans Affairs (VA) to accelerate their exchange of health information and to develop capabilities that allow for interoperability (generally, the ability of systems to exchange data) by September 30, 2009. It also required compliance with federal standards and the establishment of a joint interagency program office to function as a single point of accountability for the effort. Further, the act directed GAO to semiannually report on the progress made in achieving these requirements. For this fourth report, GAO determined the extent to which (1) DOD and VA developed and implemented electronic health record systems or capabilities that allowed for full interoperability by September 30, 2009, and (2) the interagency program office established by the act is functioning as a single point of accountability. To do so, GAO analyzed agency documentation on project status and conducted interviews with agency officials.
DOD and VA previously established six objectives that they identified as necessary for achieving full interoperability; they have now met the remaining three interoperability objectives that GAO previously reported as being partially achieved--expand questionnaires and self-assessment tools, expand DOD's inpatient medical records system, and demonstrate initial document scanning. As a result of meeting the six objectives, the departments' officials, including the co-chairs of the group responsible for representing the clinician user community, believe they have satisfied the September 30, 2009, requirement for full interoperability. Nevertheless, DOD and VA are planning additional actions to further increase their interoperable capabilities and address clinicians' evolving needs for interoperable electronic health records. Specifically, (1) DOD and VA plan to meet additional needs that have emerged with respect to social history and physical exam data; (2) DOD plans to further expand the implementation of its inpatient medical records system to sites beyond those achieved as of September 2009; and (3) DOD and VA plan to test the capability to scan documents, in follow-up to their demonstration of an initial document scanning capability. Additionally, in response to a Presidential announcement, the departments are beginning to plan for the development and implementation of a virtual lifetime electronic record, which is intended to further increase their interoperable capabilities. The interagency program office is not yet positioned to function as a single point of accountability for the implementation of interoperable electronic health record systems or capabilities. The departments have made progress in setting up their interagency program office by hiring additional staff, including a permanent director. In addition, consistent with GAO's previous recommendations, the office has begun to demonstrate responsibilities outlined in its charter in the areas of scheduling, planning, and performance measurement. However, the office's effort in these areas does not fully satisfy the recommendations and are incomplete. Specifically, the office does not yet have a schedule that includes information about tasks, resource needs, or relationships between tasks associated with ongoing activities to increase interoperability. Also, key IT management responsibilities in the areas of planning and performance measurement remain incomplete. Among the reasons officials cited for not yet completing a schedule, plan, or performance measures were the office's need to focus on verifying achievement of the six interoperability objectives and participating in the departments' efforts to define the virtual lifetime electronic record. Nonetheless, if the program office does not fulfill key management responsibilities as GAO previously recommended, it may not be positioned to function as a single point of accountability for the delivery of future interoperable capabilities, including the development of the virtual lifetime electronic record.
GAO-10-332, Electronic Health Records: DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs to Implement Recommended Improvements
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
January 2010:
Electronic Health Records:
DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs
to Implement Recommended Improvements:
GAO-10-332:
GAO Highlights:
Highlights of GAO-10-332, a report to congressional committees.
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 their exchange of health information and to develop
capabilities that allow for interoperability (generally, the ability
of systems to exchange data) by September 30, 2009. It also required
compliance with federal standards and the establishment of a joint
interagency program office to function as a single point of
accountability for the effort.
Further, the act directed GAO to semiannually report on the progress
made in achieving these requirements. For this fourth report, GAO
determined the extent to which (1) DOD and VA developed and
implemented electronic health record systems or capabilities that
allowed for full interoperability by September 30, 2009, and (2) the
interagency program office established by the act is functioning as a
single point of accountability. To do so, GAO analyzed agency
documentation on project status and conducted interviews with agency
officials.
What GAO Found:
DOD and VA previously established six objectives that they identified
as necessary for achieving full interoperability; they have now met
the remaining three interoperability objectives that GAO previously
reported as being partially achieved”expand questionnaires and self-
assessment tools, expand DOD‘s inpatient medical records system, and
demonstrate initial document scanning. As a result of meeting the six
objectives, the departments‘ officials, including the co-chairs of the
group responsible for representing the clinician user community,
believe they have satisfied the September 30, 2009, requirement for
full interoperability. Nevertheless, DOD and VA are planning
additional actions to further increase their interoperable
capabilities and address clinicians‘ evolving needs for interoperable
electronic health records. Specifically,
* DOD and VA plan to meet additional needs that have emerged with
respect to social history and physical exam data;
* DOD plans to further expand the implementation of its inpatient
medical records system to sites beyond those achieved as of September
2009; and;
* DOD and VA plan to test the capability to scan documents, in follow-
up to their demonstration of an initial document scanning capability.
Additionally, in response to a Presidential announcement, the
departments are beginning to plan for the development and
implementation of a virtual lifetime electronic record, which is
intended to further increase their interoperable capabilities.
The interagency program office is not yet positioned to function as a
single point of accountability for the implementation of interoperable
electronic health record systems or capabilities. The departments have
made progress in setting up their interagency program office by hiring
additional staff, including a permanent director. In addition,
consistent with GAO‘s previous recommendations, the office has begun
to demonstrate responsibilities outlined in its charter in the areas
of scheduling, planning, and performance measurement. However, the
office‘s effort in these areas does not fully satisfy the
recommendations and are incomplete. Specifically, the office does not
yet have a schedule that includes information about tasks, resource
needs, or relationships between tasks associated with ongoing
activities to increase interoperability. Also, key IT management
responsibilities in the areas of planning and performance measurement
remain incomplete. Among the reasons officials cited for not yet
completing a schedule, plan, or performance measures were the office‘s
need to focus on verifying achievement of the six interoperability
objectives and participating in the departments‘ efforts to define the
virtual lifetime electronic record. Nonetheless, if the program office
does not fulfill key management responsibilities as GAO previously
recommended, it may not be positioned to function as a single point of
accountability for the delivery of future interoperable capabilities,
including the development of the virtual lifetime electronic record.
What GAO Recommends:
GAO is not making further recommendations at this time; DOD and VA
need to implement the recommendations on program planning, scheduling,
and performance measurement that GAO previously made. Commenting on a
draft of this report, DOD, VA, and the interagency program office
concurred with GAO‘s findings.
View [hyperlink, http://www.gao.gov/products/GAO-10-332] or key
components. For more information, contact Joel Willemssen at (202) 512-
6253 or willemssenj@gao.gov.
[End of section]
Contents:
Letter:
Background:
Although DOD and VA Have Met Their Six Interoperability Objectives,
Additional Work Remains to Meet Clinicians' Evolving Needs:
DOD/VA Interagency Program Office Has Made Progress toward Filling
Positions, but Has Not Fully Implemented Recommended Management
Improvements:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: Comments from the DOD/VA Interagency Program Office:
Appendix V: GAO Contact and Staff Acknowledgments:
Table:
Table 1: Description of DOD and VA Interoperability Objectives:
Figure:
Figure 1: Levels of Data Interoperability:
Abbreviations:
AHLTA: Armed Forces Health Longitudinal Technology Application:
BHIE: Bidirectional Health Information Exchange:
CDR: Clinical Data Repository:
CHCS: Composite Health Care System:
CHDR: interface between DOD's CDR and VA's HDR:
DOD: Department of Defense:
FHIE: Federal Health Information Exchange:
HDR: Health Data Repository:
HHS: Department of Health and Human Services:
IT: information technology:
VA: Department of Veterans Affairs:
VistA: Veterans Health Information Systems and Technology Architecture:
VLER: Virtual Lifetime Electronic Record:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
January 28, 2010:
Congressional Committees:
The Department of Defense (DOD) and the Department of Veterans Affairs
(VA) have long-standing efforts to increase sharing of data between
their health information systems. However, while the departments have
progressively increased electronic health information sharing,
questions have been raised about when and to what extent the
departments intend such sharing capabilities to be fully achieved. To
expedite the exchange of electronic health information between the two
departments, 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, fully interoperable
[Footnote 2] electronic health record systems or capabilities that are
compliant with applicable federal interoperability standards. Such
systems and capabilities are important for making patient information
more readily available to health care providers in the departments,
reducing medical errors, and streamlining administrative functions. In
addition, the act established an interagency program office to be a
single point of accountability for the departments' efforts.
Further, the act directed us to assess DOD's and VA's progress in
implementing the electronic health record systems and to semiannually
report our results to the appropriate congressional committees.
Accordingly, we issued reports in July 2008,[Footnote 3] January 2009,
[Footnote 4] and July 2009[Footnote 5] in response to the act. As
agreed with the committees of jurisdiction, our objectives for this
fourth report are to determine the extent to which (1) DOD and VA
developed and implemented electronic health record systems or
capabilities that allowed for full interoperability by the September
30, 2009, deadline and (2) the interagency program office established
by the National Defense Authorization Act for Fiscal Year 2008 is
functioning as a single point of accountability for developing and
implementing electronic health records.
To accomplish these objectives, we reviewed our past work in this
area; analyzed current agency documentation (including the
departments' objectives for achieving interoperability, project status
information, and the interagency program office charter); and
conducted interviews with officials from DOD and VA.
We conducted this performance audit from September 2009 through
January 2010, 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. For more details on our scope and methodology, see
appendix I.
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 important 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]
Interoperability--the ability to share data among health care
providers--is key to making health care information electronically
available. 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. Unlike paper-based health records,
electronic health records can provide decision support capabilities,
such as automatic alerts about a particular patient's health, or other
advantages of automation.
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. DOD and VA have agreed upon numerous common standards
that allow them to share health data. They have also participated in
numerous standards-setting organizations tasked to reach consensus on
the definition and use of standards. For example, DOD and VA officials
serve as members and are actively working on several committees and
groups within the Healthcare Information Technology Standards
Panel.[Footnote 7] The panel identifies and harmonizes[Footnote 8]
competing standards and develops interoperability specifications that
are needed for implementing the standards.[Footnote 9]
Interoperability can be achieved at different levels.[Footnote 10] 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 search through
uncategorized data to find needed or relevant information. Beyond
these, paper records also can be considered interoperable (at the
lowest level) because they allow data to be shared, read, and
interpreted by human beings. According to DOD and VA 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. 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]
This figure is an illustration of levels of data interoperability,
leading to increasingly sophisticated and standardized data, 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).
Source: GAO analysis based on data from the Center for Information
Technology Leadership.
[End of figure]
DOD and VA Efforts to Exchange Health Information Are Long-standing:
DOD and VA have been working to exchange patient health information
electronically since 1998. We have previously described their efforts
on three key projects:[Footnote 11]
* The Federal Health Information Exchange (FHIE), begun in 2001 and
enhanced through its completion 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), established in
2004, was aimed at allowing clinicians at both departments viewable
access to health information 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 12] The interface also allows DOD sites
to see previously inaccessible data at other DOD sites.
* The Clinical Data Repository/Health Data Repository (CHDR) [Footnote
13] interface, implemented in September 2006, linked the department's
separate repositories of standardized data to enable a two-way
exchange of computable outpatient pharmacy and medication allergy
information. These repositories are a part of the modernized health
information systems that the departments have been developing--DOD's
AHLTA[Footnote 14] and VA's HealtheVet.
In its ongoing initiatives to share information, VA uses its
integrated medical information system--the Veterans Health Information
Systems and Technology Architecture (VistA)--which was developed in-
house by VA clinicians and IT personnel.[Footnote 15] All VA medical
facilities have access to all VistA information.
DOD currently relies on its AHLTA, which comprises multiple legacy
medical information systems that the department developed from
commercial software products that were 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 order management.[Footnote
16] In addition, the department uses Essentris (also called the
Clinical Information System), a commercial health information system
customized to support inpatient treatment at military medical
facilities. Not all of DOD's medical facilities yet have this
inpatient medical system.
DOD and VA Identified Interoperability Objectives and Formed an
Interagency Program Office:
As previously noted, the National Defense Authorization Act for Fiscal
Year 2008 called for DOD and VA to jointly develop and implement, by
September 30, 2009, electronic health record systems or capabilities
that allow for full interoperability of personal health care
information that are compliant with applicable federal
interoperability standards. To facilitate compliance with the act, the
departments' Interagency Clinical Informatics Board,[Footnote 17] made
up of senior clinical leaders who represent the user community, began
establishing priorities for interoperable health data between DOD and
VA. In this regard, the board is responsible for determining clinical
priorities for electronic data sharing between the departments, as
well as what data should be viewable and what data should be
computable. Based on its work, the board established six
interoperability objectives for meeting the departments' data sharing
needs. According to the former acting director of the interagency
program office, DOD and VA considered achievement of these six
objectives, in conjunction with capabilities previously achieved
(e.g., FHIE, BHIE, and CHDR), to be sufficient to satisfy the
requirement for full interoperability by September 2009. The six
objectives are listed in table 1.
Table 1: Description of DOD and VA Interoperability Objectives:
Objective: Refine social history data;
Description: DOD will begin sharing with VA the social history data
that are currently captured in the DOD electronic health record. Such
data describe, for example, patients' involvement in hazardous
activities and tobacco and alcohol use;
Associated interoperability level: Level 3: Structured, viewable
electronic data.
Objective: Share physical exam data;
Description: DOD will provide an initial capability to share with VA
its electronic health record information that supports the physical
exam process when a service member separates from active military duty;
Associated interoperability level: Level 3: Structured, viewable
electronic data.
Objective: Demonstrate initial network gateway operation;
Description: DOD and VA will demonstrate the operation of the secure
network gateways[A] to support joint DOD-VA health information sharing;
Associated interoperability level: There is no interoperability level
associated with this objective.
Objective: Expand questionnaires and self-assessment tools;
Description: DOD will provide all periodic health assessment data
stored in its electronic health record to VA such that questionnaire
responses are viewable with the questions that elicited them;
Associated interoperability level: Level 3: Structured, viewable
electronic data.
Objective: Expand Essentris in DOD;
Description: DOD will expand its inpatient medical records system
(CliniComp's Essentris product suite) to at least one additional site
in each military medical department (one Army, one Air Force, and one
Navy for a total of three sites);
Associated interoperability level: Level 2: Unstructured, viewable
electronic data.
Objective: Demonstrate initial document scanning;
Description: DOD will demonstrate an initial capability for scanning
service members' medical documents into its electronic health record
and sharing the documents electronically with VA;
Associated interoperability level: Level 2: Unstructured, viewable
electronic data.
Source: GAO based on DOD and VA data.
[A] Secure network gateways provide expanded bandwidth to support
information sharing and ensure secure and reliable data communications
between DOD and VA health care facilities.
[End of table]
Also since April 2008, the departments have been working to set up an
interagency program office to be accountable for their efforts to
implement fully interoperable electronic health record systems or
capabilities by the September deadline. In January 2009, the office
completed its charter, articulating, among other things, its mission
and functions with respect to attaining interoperable electronic
health data. The charter further identified the office's
responsibilities in carrying out its mission, in areas such as
oversight and management, stakeholder communication, and decision
making. Among the specific responsibilities identified in the charter
was the development of a plan, schedule, and performance measures to
guide the departments' electronic health record interoperability
efforts.
Subsequent to an April 2009 Presidential announcement, the departments
approved a new version of the interagency program office's charter in
September to expand the office's responsibilities to include
coordination and oversight of the development of a Virtual Lifetime
Electronic Record (VLER).[Footnote 18] Still in the planning stages,
VLER is intended to enable access to all electronic records for
service members as they transition from military to veteran status,
and throughout their lives. According to the Director of the DOD/VA
Interagency Program Office, VLER is to expand the departments'
existing electronic health record capabilities by enabling access to
private sector health data as well. The revised charter describes that
the office is responsible for developing and maintaining a master
plan, integrated master schedule, and performance metrics for the VLER
initiative.
GAO Reports Have Identified the Need for DOD and VA to Improve Their
Efforts to Share Health Information:
Our prior reports on DOD's and VA's efforts to develop fully
interoperable electronic health record systems or capabilities noted
their progress and highlighted issues that the departments needed to
address to achieve electronic health record interoperability.
Specifically, our July 2008 report[Footnote 19] noted that the
departments were sharing some, but not all, electronic health
information at different levels of interoperability. At that time the
departments' efforts to set up the interagency program office were in
the early stages. Leadership positions in the office were not
permanently filled, staffing was not complete, and facilities to house
the office had not been designated. Accordingly, we recommended that
the Secretaries of Defense and Veterans Affairs expedite efforts to
put in place permanent leadership, staff, and facilities for the
program office. The departments agreed with this recommendation and
have taken actions to address it.
Our January 2009 report[Footnote 20] noted that the departments had
defined plans to further increase their sharing of electronic health
information; however, the plans did not contain results-oriented
(i.e., objective, quantifiable, and measurable) performance goals and
measures that could be used as a basis to track and assess progress.
We recommended the departments develop and document such goals and
performance measures for the six interoperability objectives, to use
as the basis for future assessments and reporting of interoperability
progress. DOD and VA agreed with our recommendation and stated that
the departments intended to include results-oriented goals in their
future plans.
We also reported and testified in July 2009[Footnote 21] that the
departments were continuing to take steps toward achieving full
interoperability by the September 2009 deadline. Specifically, we
noted that they had identified six interoperability objectives and had
fulfilled three of the six. For the remaining three objectives, DOD
and VA had partially achieved planned capabilities but additional work
was needed to meet the objectives. Moreover, our report and testimony
also noted that the departments' interagency program office was not
effectively positioned to function as a single point of accountability
for achievement of full interoperability because it did not yet have
fundamental IT management capabilities and was not fulfilling key
responsibilities, including establishment of performance measures, a
project plan, or a detailed schedule. As a result, we recommended that
the departments improve management of their interoperability efforts
by establishing a project plan and a complete and detailed integrated
master schedule.
Although DOD and VA Have Met Their Six Interoperability Objectives,
Additional Work Remains to Meet Clinicians' Evolving Needs:
DOD and VA have achieved planned capabilities for the three remaining
objectives (expand questionnaires and self-assessment tools, expand
Essentris in DOD, and demonstrate initial document scanning). Having
now met all six of their interoperability objectives, the departments'
officials, including the co-chairs of the group responsible for
representing the clinician user community, believe they have satisfied
the September 30, 2009, requirement for developing and implementing
systems or capabilities that allow for full interoperability.
Nevertheless, the departments are planning additional actions to
further increase their interoperable capabilities, recognizing that
clinicians' needs for interoperable electronic health records are
evolving.
The following describes the departments' activities with respect to
the three remaining objectives.
Expand questionnaires and self-assessment tools: The departments
intended to provide all periodic health assessment data stored in the
DOD electronic health record to VA in a format that associates
questions with responses. Health assessment data are collected from
two sources: questionnaires administered at military treatment
facilities and a DOD health assessment reporting tool that enables
patients to answer questions about their health. Questions relate to a
wide range of personal health information, such as dietary habits,
physical exercise, and tobacco and alcohol use. While the departments
had established the capability for VA to view questions and answers
from the questionnaires collected by DOD at military treatment
facilities, they had not yet achieved the capability for VA to view
information from the second source--DOD's health assessment reporting
tool. Since our last review, the departments have established this
capability and have therefore met their objective.
Expand Essentris in DOD: DOD intended to expand Essentris to at least
one additional site for each military service and to increase the
percentage of inpatient discharge summaries that it shares
electronically with VA. While the departments had previously expanded
the system to two Army sites, they had not yet expanded to the
remaining two military departments (Air Force and Navy). Since we last
reported, the departments have met this objective by successfully
deploying Essentris to an additional Air Force and Navy site. In
addition, the departments expanded the system to two more Army sites
and are sharing inpatient discharge summaries from 59 percent of DOD
inpatient beds.[Footnote 22]
Demonstrate initial document scanning: The departments intended to
demonstrate an initial capability to scan service members' medical
documents into the DOD electronic health record and share the
documents electronically with VA. Since our last review, the
departments have met this objective by successfully demonstrating the
capability in a joint test environment. Specifically, DOD has
demonstrated the capability to scan a medical document, associate the
document with a test patient, and save the document into the patient's
electronic health record; and VA demonstrated the capability to search
and retrieve the scanned document associated with that patient.
While the departments have met the remaining three objectives and
believe they have met the September 30, 2009, deadline for achieving
full interoperability as required by the act, they are planning
additional work to further increase their interoperable capabilities.
These actions reflect the departments' recognition that clinicians'
needs for interoperable electronic health records are not static.
Currently, the departments are focusing their efforts to meet
clinicians' evolving needs for interoperable capabilities in the
following areas.
Clinicians have identified additional needs with respect to social
history and physical exam data that have emerged since existing
capabilities were made available in those areas. To meet these needs,
the departments are planning additional efforts to provide, for
example, the capabilities to search, sort, and filter patient social
history and physical exam data based on criteria such as date,
location of care, and type of document.
DOD plans to further expand the implementation of Essentris to sites
beyond those achieved as of September 2009. In this regard, the
department has established a goal of making the inpatient system
operational for 90 percent of its inpatient beds by January 31, 2011.
In December 2009, DOD began limited user testing of the document
scanning capability that was demonstrated in September 2009. According
to department officials, this testing entails use of test data by a
limited number of users at nine sites and is expected to be completed
in March 2010. After that, further testing of the document scanning
capability using actual data is expected at sites and dates that are
to be determined.
Beyond these ongoing efforts to meet their clinicians' evolving
interoperability needs, the departments have begun planning their
efforts to define and build VLER. For example, in mid-December 2009,
VA and a private health care provider in San Diego, California, began
a pilot project to demonstrate that clinical information such as
patient demographic, allergy, and active medication information can be
securely sent and received. DOD plans to be added to this pilot on
January 31, 2010. Further, the departments are working in cooperation
with the interagency program office and the Interagency Clinical
Informatics Board to define additional clinical information to be
exchanged, additional functionality, and additional geographic areas
of interest for future VLER deployment.
DOD/VA Interagency Program Office Has Made Progress toward Filling
Positions, but Has Not Fully Implemented Recommended Management
Improvements:
The interagency program office is not yet positioned to function as a
single point of accountability for the implementation of interoperable
electronic health record systems or capabilities. Since we last
reported, the departments have made progress in setting up the office
by hiring additional staff, including a permanent director. In
addition, consistent with our prior recommendations, the office has
begun to demonstrate responsibilities outlined in its charter in the
areas of scheduling, planning, and performance measurement. However,
the office's efforts to develop its capabilities in these areas are
incomplete.
Staffing of the Interagency Program Office Is Nearly Completed:
Among the activities the departments identified in the September 2008
DOD/VA Information Interoperability Plan as necessary for setting up
the interagency program office were appointing a permanent director
and deputy director, as well as recruiting and hiring staff. Since we
last reported in July 2009,[Footnote 23] DOD appointed a permanent
director to lead the office, effective October 27, 2009. Also, VA
filled the permanent deputy director position, effective January 17,
2010.[Footnote 24]
According to the former acting deputy director, the departments have
also filled 13 of 14 government staff positions, an increase of 3
staff since our last report.[Footnote 25] Additionally, this official
stated the departments have taken steps to fill the remaining senior
health program analyst position. He reported that a selection had been
made to fill this remaining position, but a date for when this
position would be filled remained to be determined.
Interagency Program Office Has Not Fully Established a Schedule, Plan,
or Performance Measures:
As previously noted, DOD, VA, and the interagency program office
developed a new version of the office's charter in September 2009.
Consistent with the office's original charter, the new version
describes the office's responsibilities in carrying out its mission
and function associated with attaining interoperable electronic data.
For example, it identifies the office's responsibilities to develop an
integrated master schedule, plan, and performance metrics to monitor
the departments' performance against interoperability goals. Since we
last reported, the office has taken steps toward developing, but has
not yet fully established, these management tools.
We previously recommended in July 2009 that the program office
establish a complete and detailed master schedule to improve its
management of the departments' efforts to achieve fully interoperable
electronic health record systems.[Footnote 26] In response to our
recommendation, the office has begun to develop an integrated master
schedule that includes information about its ongoing interoperability
activities, including VLER. For example, the schedule identifies the
limited user testing of the document scanning capability that DOD
plans between December 2009 and March 2010. However, the schedule does
not include information about the tasks, resource needs, or
relationships between tasks for the testing activity. The office's
acting deputy director stated that the program office is currently
working to improve the schedule by including task dependencies to help
in identifying the critical path for the office's interoperability
activities.[Footnote 27]
Similarly, we recommended that the program office establish a project
plan, which is an important tool for effective IT program management.
The program office has concurred with the recommendation and has
reported that it is developing a master program plan.[Footnote 28] In
January 2010, department officials stated that this plan is undergoing
review by the departments and is expected to be approved in February
2010.
In January 2009 we recommended that DOD and VA take action to complete
results-oriented (i.e., objective, quantifiable, and measurable) goals
and performance measures to be used as a basis for the office to
provide meaningful information on the status of the departments'
interoperability initiatives. In November 2009, program office
officials stated that such goals and measures would be included in the
next version of the VA/DOD Joint Executive Council Joint Strategic
Plan (known as the joint strategic plan), which the office expects to
be approved in February 2010.[Footnote 29]
While the departments have agreed with our past recommendations and
have indicated that they are working toward addressing them, officials
stated that other priorities have prevented full implementation of our
recommendations. Specifically, the office has been focused on
verifying achievement of the six interoperability objectives.
Moreover, according to the former interim director, the office was
focused on providing briefings and status information on activities
the office has undertaken to achieve interoperability, in addition to
participating in the departments' efforts to define VLER. In addition,
the office director told us that it has taken the departments longer
than anticipated to provide the detailed information that is needed by
the office to prepare a schedule for joint interagency data sharing
goals.
While the interagency program office is nearly fully staffed and has
begun to establish important management tools, it has not yet
completed an integrated schedule, project plan, and results-oriented
goals and measures. As a result, the interagency program office's
ability to effectively provide oversight and management, including
meaningful progress reporting on the delivery of interoperable
capabilities, is jeopardized. If the departments fully implement our
recommendations, they will have the comprehensive picture that they
need for effectively defining and managing progress toward meeting
their interoperability objectives and goals, including VLER.
Furthermore, implementation of our recommendations will also better
position the office to function as a single point of accountability
for the delivery of interoperable electronic health records, which are
intended to improve service members' and veterans' health care.
Agency Comments and Our Evaluation:
In written comments on a draft of this report, the DOD official who is
performing the duties of the Assistant Secretary of Defense (Health
Affairs), the VA Chief of Staff, and the Director of the DOD/VA
Interagency Program Office concurred with our findings. Beyond its
concurrence with our findings, the VA Chief of Staff provided
information regarding the department's efforts to address
recommendations from our prior reports.[Footnote 30] For example, in
response to our previous recommendation that the departments use
results-oriented performance goals and measures as the basis for
future assessments and reporting of interoperability progress, the
Chief of Staff stated that the departments have prepared draft goals
and measures for their joint strategic plan, which is to be finalized
in February 2010. Additionally, in response to our prior
recommendation that the departments establish a project plan and a
compete and detailed integrated master schedule to improve management
of their interoperability efforts, the Chief of Staff asserted that
the interagency program office expects to have a draft project plan by
the end of January 2010 and that VA meets monthly with DOD and the
program office to coordinate input into an integrated master schedule.
If the departments continue to implement our recommendations, they
should be better positioned to effectively manage their ongoing
efforts to increase their interoperable electronic health record
capabilities. DOD and the interagency program office also provided
technical comments on the draft report, which we incorporated as
appropriate. Comments from the Departments of Defense and Veterans
Affairs, and the DOD/VA Interagency Program Office are reproduced in
appendixes II, III, and IV, respectively.
We are sending copies of this report to the Secretaries of Defense and
Veterans Affairs, appropriate congressional committees, and other
interested parties. In addition, the report is available at no charge
on the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staffs have questions about this report, please contact
me at (202) 512-6253 or willemssenj@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. Key contributors to this report are
listed in appendix V.
Signed by:
Joel C. Willemssen:
Managing Director, Information Technology:
List of Congressional Committees:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Daniel K. Akaka:
Chairman:
The Honorable Richard M. Burr:
Ranking Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Daniel K. Inouye:
Chairman:
The Honorable Thad Cochran:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Tim Johnson:
Chairman:
The Honorable Kay Bailey Hutchison:
Ranking Member:
Subcommittee on Military Construction, Veterans' Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Ike Skelton:
Chairman:
The Honorable Howard P. "Buck" McKeon:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Bob Filner:
Chairman:
The Honorable Steve Buyer:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable John P. Murtha:
Chairman:
The Honorable C.W. Bill Young:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
United States House of Representatives:
The Honorable Chet Edwards:
Chairman:
The Honorable Zach Wamp:
Ranking Member:
Subcommittee on Military Construction, Veterans' Affairs, and Related
Agencies:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
To determine the extent to which the Department of Defense (DOD) and
the Department of Veterans Affairs (VA) developed and implemented
electronic health record systems or capabilities that allowed for full
interoperability by the September 30, 2009, deadline, we reviewed our
previous work on DOD and VA efforts to develop health information
systems, interoperable health records, and interoperability standards
to be implemented in federal health care programs. We obtained and
analyzed agency documentation and interviewed program officials to
determine the departments' progress toward achieving full
interoperability by September 30, 2009, as required by the National
Defense Authorization Act for Fiscal Year 2008. Specifically, we
compared the departments' interoperability plans, objectives, and
requirements with the reported status of efforts to achieve full
interoperability, corroborating officials' statements about progress
through analyses of available documentation including test results and
status reports. In addition, we analyzed agency plans and interviewed
cognizant DOD and VA officials to determine the work required to meet
additional clinician requirements and increase interoperability of
electronic health information beyond September 30, 2009.
To determine whether the interagency program office was functioning as
a single point of accountability for developing and implementing
electronic health records, we obtained and reviewed program office
documentation, including its new charter and its integrated master
schedule. We compared the responsibilities identified in the charter
with actions taken by the office to exercise the responsibilities.
Additionally, we interviewed interagency program office officials to
determine the status of filling leadership and staffing positions
within the office and to examine the level to which the departments
have addressed our prior recommendations to develop needed management
tools including results-oriented (i.e., objective, quantifiable, and
measurable) goals and performance measures, a complete and detailed
master schedule, and a project plan.
We conducted this performance audit at DOD offices and the DOD/VA
Interagency Program Office in the greater Washington, D.C.,
metropolitan area from September 2009 through January 2010, 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.
[End of section]
Appendix II: Comments from the Department of Defense:
Office Of The Assistant Secretary Of Defense:
Health Affairs:
Washington, DC 20301-1200:
January 22, 2010:
Mr. Joel C. Willemssen:
Managing Director, Information Technology:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Mr. Willemssen:
This is the Department of Defense's (DoD) response to the Government
Accountability Office (GAO) Draft Report, GAO-10-332, "Electronic
Health Records: DoD and VA Interoperability Efforts Are Ongoing;
Program Office Needs to Implement Recommended Improvement," January
12, 2010, (Engagement Code 310945).
DoD acknowledges receipt of the draft audit report and concurs with
the overall findings. We have provided suggested technical corrections
in the enclosed formal response.
Thank you for the opportunity to review and comment on the draft
report. The points of contact for additional information are Ms. Lois
Kellett, Lois.Kellett@tma.osd.mil, or (703) 681-8836, and Mr Gunther
Zimmerman, Gunther.Zimmerman@tma.osd.mil, or (703) 681-4360.
Sincerely,
Signed by: [Illegible], for:
Ellen P. Embrey:
Deputy Assistant Secretary of Defense (Force Health Protection and
Readiness):
Performing the Duties of the Assistant Secretary of Defense (Health
Affairs):
Attachments: As stated:
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
January 22, 2010:
Mr. Joel C. Willemssen:
Managing Director, Information Technology:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Willemssen:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, Electronic Health Records:
DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs
to Implement Recommended Improvements (GAO-10-332), and concurs with
GAO's findings.
Enhancing health information sharing between VA and the Department of
Defense (DoD) is a key step towards achieving seamless health care for
our Nation's Veterans. The report accurately states that, even though
VA and DoD have now met the six objectives necessary for achieving
full interoperability, the Departments are planning further actions to
increase interoperable capability.
The enclosure provides a status update on recommendations from
previous related reports: (1) Electronic Health Records: DoD and VA
Sharing of Information Could Benefit from Improved Management (GA0-09-
268); and (2) Electronic Health Records: DoD and VA Efforts to Achieve
Full Interoperability Are Ongoing; Program Office Management Needs
Improvement (GAO-09-775).
VA appreciates the opportunity to comment on your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of letter]
Enclosure:
The Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report:
Electronic Health Records: DOD and VA Interoperability Efforts Are
Ongoing; Program Office Needs to Implement Recommended Improvements
(GA0-10-332):
Outstanding Recommendations from GAO Report, Electronic Health
Records: DOD's and VA's Sharing of Information Could Benefit from
Improved Management (GAO-09-268).
GAO Recommendation: To better ensure that DOD and VA achieve
interoperable electronic health record systems or capabilities, GAO
recommends that the Secretaries of Defense and VA take the following
actions:
Recommendation 1: Develop results-oriented (i.e., objective,
quantifiable, and measurable) goals and associated performance
measures for the Departments' interoperability objectives and document
these goals and measures in their interoperability plans.
VA Status Update January 2010: By agreement of VA and DOD, and as
verified by the DoD and VA Interagency Program Office, the Departments
successfully achieved the interoperability objectives contained in the
fiscal year 2008 National Defense Authorization Act (NDAA). The NDAA
required the Departments to implement systems allowing for full
interoperability by September 2009.
Recommendation 2: Use results-oriented performance goals and measures
as the basis for future assessments and reporting of interoperability
progress.
VA Status Update January 2010: VA and DoD have prepared draft results-
oriented goals and performance measures related to future
interoperability objectives for the DoD and VA Joint Strategic Plan
(JSP) for 2010-2012. The Departments anticipate that the JSP will be
finalized and signed by departmental leadership in February 2010.
Outstanding Recommendation from GAO Report, Electronic Health Records:
DOD's and VA's Efforts to Achieve Full Interoperability Are Ongoing;
Program Office Management Needs Improvement (GAO-09-775).
Recommendation 1: To better improve management of VA's and DOD's
efforts to achieve fully interoperable electronic health records
systems, including satisfaction of the departments' interoperability
objectives, GAO recommends that the Secretaries of Defense and VA
direct the Director of the Interagency Program Office to establish a
project plan and a complete and detailed integrated master schedule.
VA Status Update January 2010: The Interagency Program Office (IPO)
has developed an integrated master schedule and the Veterans Health
Administration's Office of Health Information continues to work
closely with VA's Office of Information Technology, the lead office,
to continue to enhance the schedule. VA, DoD, and the !PO now meet at
least once a month to coordinate interagency input. The IPO reports
that it is on target to provide a draft project plan by the end of
January 2010.
[End of section]
Appendix IV: Comments from the DOD/VA Interagency Program Office:
Department of Defense:
Department of Veterans Affairs:
Mr. Joel C. Willemssen:
Managing Director, Information Technology:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Willemssen:
This is the DOD/VA Interagency Program Office's (IPO) response to the
Government Accountability Office (GAO) Draft Report GAO-10-332,
"Electronic Health Records: DOD and VA Interoperability Efforts Are
Ongoing; Program Office Needs to Implement Recommended Improvements,"
January 12, 2010, (Engagement Code 310945).
IPO acknowledges receipt of the draft audit report and concurs with
the overall findings. We have provided suggested technical corrections
in the enclosed formal response.
Thanks you for the opportunity to review and comment on the draft
report. The points of contact for additional information are Mr. Ryan
Cool, Ryan.Cool@osd.mil or (703)696-3636, and Mr. Kevin Tewes,
Kevin.Tewes@osd.mil or (703)696-2856.
Sincerely,
Signed by:
Debra M. Filippi:
Director:
DID/VA Interagency Program Office:
Attachments: As stated:
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Joel C. Willemssen, (202) 512-6253 or willemssenj@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, key contributions to this
report were made by Mark Bird, Assistant Director; Rebecca Eyler; J.
Michael Resser; and Kelly Shaw.
[End of section]
Footnotes:
[1] Pub. L. No. 110-181, § 1635 (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.
[3] See GAO, Electronic Health Records: 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). In this report, we highlighted the departments'
progress in sharing electronic health information, developing
electronic records that comply with national standards, and setting up
the interagency program office.
[4] See GAO, 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). In this report, we noted that DOD and VA have increased their
sharing of health information, and defined plans to further increase
their sharing of electronic health information. However, the plans did
not identify results-oriented (i.e., objective, quantifiable, and
measurable) performance goals and measures that are characteristic of
effective planning.
[5] See GAO, Electronic Health Records: DOD and VA Efforts to Achieve
Full Interoperability Are Ongoing; Program Office Management Needs
Improvement, [hyperlink, http://www.gao.gov/products/GAO-09-775]
(Washington, D.C.: July 28, 2009). In this report, we found that DOD
and VA had taken steps to meet six objectives that they identified for
achieving full interoperability by September 30, 2009, but had
additional work planned to fully meet the objectives. In addition, we
noted that the DOD/VA Interagency Program Office was not effectively
positioned to function as the single point of accountability for the
implementation of fully interoperable electronic health records.
[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] The panel was established in October 2005 as a public-private
partnership funded by the Office of the National Coordinator. This
panel is sponsored by the American National Standards Institute, which
is a private, nonprofit organization whose mission is to promote and
facilitate voluntary consensus standards and ensure their integrity.
[8] Harmonization is the process of identifying overlaps and gaps in
relevant standards and developing recommendations to address these
overlaps and gaps.
[9] 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. 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.
[10] 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, the different levels of interoperability have been
accepted for use by the Office of the National Coordinator for Health
Information Technology.
[11] [hyperlink, http://www.gao.gov/products/GAO-09-775].
[12] 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.
[13] The name CHDR, pronounced "cheddar," combines the names of these
two repositories.
[14] 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.
[15] 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.
[16] According to DOD, CHCS applications are now accessed through its
modernized health information system, AHLTA.
[17] This board was originally named the Joint Clinical Information
Board.
[18] On April 9, 2009, the President announced that DOD and VA will
work together to define and build a Virtual Lifetime Electronic Record
capability to streamline the transition of electronic records between
the two departments.
[19] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[20] [hyperlink, http://www.gao.gov/products/GAO-09-268].
[21] GAO, Electronic Health Records: Program Office Improvements
Needed to Strengthen Management of VA and DOD Efforts to Achieve Full
Interoperability, GAO-09-895T (Washington, D.C.: July 14, 2009) and
[hyperlink, http://www.gao.gov/products/GAO-09-775].
[22] The Army sites are Reynolds Army Community Hospital at Fort Sill,
Okla.; Moncrief Army Community Hospital at Fort Jackson, S.C.; the
United States Army Hospital in Seoul, Korea; and Fort Leonard Wood
Army Community Hospital at Fort Leonard Wood, Mo. The Navy site is the
Naval Hospital Bremerton in Bremerton, Wash. The Air Force site is the
David Grant United States Air Force Medical Center at Travis Air Force
Base, Calif.
[23] [hyperlink, http://www.gao.gov/products/GAO-09-775].
[24] The director is a DOD employee and the deputy director is a VA
employee.
[25] The office staff include both government and contractor personnel.
[26] [hyperlink, http://www.gao.gov/products/GAO-09-775].
[27] The critical path is the single longest path of activities
through a project's schedule. Each day of delay in the critical path
could delay the completion of the entire project.
[28] The plan was originally considered a project plan in the previous
charter, but the name was changed to a program plan, which according
to the former interim director of the program office, represents a
higher level of oversight that is required of the interagency program
office.
[29] In July, we reported that the office had expected to complete the
joint strategic plan by December 2009, but in interviews with program
office officials, we were told that the plan would not be released
until February 2010 as part of the presidential budget submission.
[30] [hyperlink, http://www.gao.gov/products/GAO-09-268] and
[hyperlink, http://www.gao.gov/products/GAO-09-775].
[End of section]
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