Electronic Health Records
DOD and VA Should Remove Barriers and Improve Efforts to Meet Their Common System Needs Gao ID: GAO-11-265 February 2, 2011In Process
DOD and VA face barriers in three key IT management areas--strategic planning, enterprise architecture, and investment management--and, as a result, lack mechanisms for identifying and implementing efficient and effective IT solutions to jointly address their common health care system needs. First, the departments have been unable to articulate explicit plans, goals, and timeframes for jointly addressing the health IT requirements common to both departments' electronic health record systems. For example, DOD's and VA's joint strategic plan does not discuss how or when the departments propose to identify and develop joint health IT solutions, and department officials have not yet determined whether the IT capabilities developed for the FHCC can or will be implemented at other DOD and VA medical facilities. Second, although DOD and VA have taken steps toward developing and maintaining artifacts related to a joint health architecture (i.e., a description of business processes and supporting technologies), the architecture is not sufficiently mature to guide the departments' joint health IT modernization efforts. For example, the departments have not defined how they intend to transition from their current architecture to a planned future state. Third, DOD and VA have not established a joint process for selecting IT investments based on criteria that consider cost, benefit, schedule, and risk elements, which would help to ensure that the chosen solution both meets the departments' common health IT needs and provides better value and benefits to the government as a whole. These barriers result in part from DOD's and VA's decision to focus on developing VLER, modernizing their separate electronic health record systems, and developing IT capabilities for the FHCC, rather than determining the most efficient and effective approach to jointly addressing their common requirements. Because DOD and VA continue to pursue their existing health information sharing efforts without fully establishing the key IT management capabilities described above, they may be missing opportunities to successfully deploy joint solutions to address their common health care business needs. DOD's and VA's experiences in developing VLER and IT capabilities for the FHCC offer important lessons that the departments can use to improve their management of these ongoing efforts. Specifically, the departments can improve the likelihood of successfully meeting their goal to implement VLER nationwide by the end of 2012 by developing an approved plan that is consistent with effective IT project management principles. Also, DOD and VA can improve their continuing effort to develop and implement new IT system capabilities for the FHCC by developing a plan that defines the project's scope, estimated cost, and schedule in accordance with established best practices. Unless DOD and VA address these lessons, the departments will jeopardize their ability to deliver expected capabilities to support their joint health IT needs. GAO is recommending that DOD and VA take steps to improve their joint strategic planning, enterprise architecture, and IT investment management to address their common health care business needs. GAO is also recommending that the departments strengthen their joint IT system planning efforts for VLER and the FHCC. Commenting on a draft of this report, DOD, VA, and the DOD/VA Interagency Program Office concurred with GAO's recommendations.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Valerie C. Melvin Team: Government Accountability Office: Information Technology Phone: (202) 512-6304GAO-11-265, Electronic Health Records: DOD and VA Should Remove Barriers and Improve Efforts to Meet Their Common System Needs
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
February 2011:
Electronic Health Records:
DOD and VA Should Remove Barriers and Improve Efforts to Meet Their
Common System Needs:
GAO-11-265:
GAO Highlights:
Highlights of GAO-11-265, a report to congressional committees.
Why GAO Did This Study:
The Department of Defense (DOD) and the Department of Veterans Affairs
(VA) operate two of the nation‘s largest health care systems. To do
so, both departments rely on electronic health record systems to
create, maintain, and manage patient health information. DOD and VA
are currently undertaking initiatives to modernize their respective
systems, jointly establish the Virtual Lifetime Electronic Record
(VLER), and develop joint information technology (IT) capabilities for
the James A. Lovell Federal Health Care Center (FHCC). In light of
these efforts, GAO was asked to (1) identify any barriers that DOD and
VA face in modernizing their electronic health record systems to
jointly address their common health care business needs, and (2)
identify lessons learned from DOD‘s and VA‘s efforts to jointly
develop VLER and to meet the health care information needs for the
FHCC. To do this, GAO analyzed departmental reviews and other
documentation and interviewed DOD and VA officials.
What GAO Found:
DOD and VA face barriers in three key IT management areas”strategic
planning, enterprise architecture, and investment management”and, as a
result, lack mechanisms for identifying and implementing efficient and
effective IT solutions to jointly address their common health care
system needs. First, the departments have been unable to articulate
explicit plans, goals, and timeframes for jointly addressing the
health IT requirements common to both departments‘ electronic health
record systems. For example, DOD‘s and VA‘s joint strategic plan does
not discuss how or when the departments propose to identify and
develop joint health IT solutions, and department officials have not
yet determined whether the IT capabilities developed for the FHCC can
or will be implemented at other DOD and VA medical facilities. Second,
although DOD and VA have taken steps toward developing and maintaining
artifacts related to a joint health architecture (i.e., a description
of business processes and supporting technologies), the architecture
is not sufficiently mature to guide the departments‘ joint health IT
modernization efforts. For example, the departments have not defined
how they intend to transition from their current architecture to a
planned future state. Third, DOD and VA have not established a joint
process for selecting IT investments based on criteria that consider
cost, benefit, schedule, and risk elements, which would help to ensure
that the chosen solution both meets the departments‘ common health IT
needs and provides better value and benefits to the government as a
whole. These barriers result in part from DOD‘s and VA‘s decision to
focus on developing VLER, modernizing their separate electronic health
record systems, and developing IT capabilities for the FHCC, rather
than determining the most efficient and effective approach to jointly
addressing their common requirements. Because DOD and VA continue to
pursue their existing health information sharing efforts without fully
establishing the key IT management capabilities described above, they
may be missing opportunities to successfully deploy joint solutions to
address their common health care business needs.
DOD‘s and VA‘s experiences in developing VLER and IT capabilities for
the FHCC offer important lessons that the departments can use to
improve their management of these ongoing efforts. Specifically, the
departments can improve the likelihood of successfully meeting their
goal to implement VLER nationwide by the end of 2012 by developing an
approved plan that is consistent with effective IT project management
principles. Also, DOD and VA can improve their continuing effort to
develop and implement new IT system capabilities for the FHCC by
developing a plan that defines the project‘s scope, estimated cost,
and schedule in accordance with established best practices. Unless DOD
and VA address these lessons, the departments will jeopardize their
ability to deliver expected capabilities to support their joint health
IT needs.
What GAO Recommends:
GAO is recommending that DOD and VA take steps to improve their joint
strategic planning, enterprise architecture, and IT investment
management to address their common health care business needs. GAO is
also recommending that the departments strengthen their joint IT
system planning efforts for VLER and the FHCC. Commenting on a draft
of this report, DOD, VA, and the DOD/VA Interagency Program Office
concurred with GAO‘s recommendations.
View [hyperlink, http://www.gao.gov/products/GAO-11-265] or key
components. For more information, contact Valerie C. Melvin at (202)
512-6304 or melvinv@gao.gov.
[End of section]
Contents:
Letter:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Briefing for Staff Members of Congressional Committees
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:
Abbreviations:
AHLTA: Armed Forces Health Longitudinal Technology Application:
BHIE: Bidirectional Health Information Exchange:
CHDR: Clinical Data Repository/Health Data Repository:
DOD: Department of Defense:
FHCC: Federal Health Care Center:
FHIE: Federal Health Information Exchange:
IT: information technology:
LDSI: Laboratory Data Sharing Interface:
MHS: Military Health System:
VA: Department of Veterans Affairs:
VistA: Veterans Health Information Systems and Technology Architecture:
VHA: Veterans Health Administration:
VLER: Virtual Lifetime Electronic Record:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
February 2, 2011:
The Honorable Thad Cochran:
The Honorable Daniel Inouye:
United States Senate:
The Honorable C.W. Bill Young:
Chairman:
The Honorable Norman D. Dicks:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
The Department of Defense (DOD) and the Department of Veterans Affairs
(VA) operate two of the nation's largest health care systems,
providing health care to service members and veterans at estimated
annual costs of about $49 billion and $48 billion, respectively. To do
so, both departments rely on electronic health record systems to
create, maintain, and manage patient health information. DOD uses
multiple legacy health systems, including its outpatient system--the
Armed Forces Health Longitudinal Technology Application (AHLTA)--which
are supplemented with paper-based records. VA uses an integrated
medical information system, the Veterans Health Information Systems
and Technology Architecture (VistA), which includes electronic health
records and consists of over 100 separate computer applications.
Congress has long expressed an interest in DOD's and VA's efforts to
improve their health information exchange capabilities, and has urged
the departments to identify common health information technology (IT)
requirements and business processes as they continue to modernize
their health IT systems. As we have previously reported,[Footnote 1]
the departments have increased electronic health record
interoperability[Footnote 2] using a patchwork of initiatives
involving DOD and VA systems. The departments have recognized that,
despite interoperability gains over the last decade, more work is
needed to meet clinicians' evolving needs for exchanging health
information between the systems.
Currently, DOD and VA are engaged in two high-profile collaborative
initiatives that are dependent on their ability to fully share
electronic health information. First, in response to the President's
April 2009 announcement, the departments began planning the Virtual
Lifetime Electronic Record (VLER) initiative which is intended to
streamline the transition of electronic medical, benefits, and
administrative information between DOD and VA and support the
transition of military personnel to veteran status, and throughout
their lives. VLER is further intended to expand the departments'
health information sharing capabilities by enabling access to private
sector health data as well. In addition, the James A. Lovell Federal
Health Care Center (FHCC) in North Chicago, Illinois, is to be the
first DOD/VA medical facility operated under a single line of
authority to manage and deliver medical and dental care for veterans,
new Naval recruits, active duty military personnel, retirees, and
dependents. This new center, including initial supporting IT system
capabilities, became operational in late December 2010, with
additional system capabilities to be implemented through December 2011.
At the same time, DOD and VA have both identified the need to
modernize their electronic health record systems. As they have
undertaken these modernizations, the departments have studied and
reported on the potential to pursue joint solutions to the many health
care system needs that DOD and VA have in common. For example, an
August 2008 study that the departments funded identified alternative
approaches they could use to achieve a high degree of interoperability
by working toward a joint DOD and VA inpatient electronic health
record system. Further, in May 2010, the departments reported to
Congress that they were committed to assessing all possible common
capability development for their next generation of electronic health
record systems.
Because of the importance of comprehensive health information in
providing optimal medical care to service members and veterans, you
requested that we:
* identify any barriers that DOD and VA face in modernizing their
electronic health record systems to jointly address their common
health care business needs, and:
* identify lessons learned from DOD's and VA's efforts to jointly
develop VLER and to meet the health care information needs for the
FHCC.
On December 1, 2010, we provided your offices with briefing slides
that outlined the results of our study. The purpose of this report is
to provide the published briefing slides to you and to officially
transmit our recommendations to the Secretaries of Defense and
Veterans Affairs. The slides, which discuss our scope and methodology,
are included in appendix I.
We conducted our work in support of this performance audit at DOD's
Military Health System offices and VA's headquarters in the
Washington, D.C., metropolitan area and at the departments' medical
facilities in North Chicago, Illinois, from December 2009 to January
2011 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.
In summary, our study highlighted the following:
* Although our prior work has shown that having and using a strategic
plan, enterprise architecture, and IT investment management process
are critical to effectively modernizing major IT systems, DOD and VA
have not sufficiently established these fundamental management
capabilities to guide their joint health IT efforts. In particular,
DOD and VA have not articulated explicit plans, goals, and time frames
for jointly addressing the health IT requirements common to both
departments' electronic health record systems, and the departments'
joint strategic plan does not discuss how or when DOD and VA propose
to identify and develop joint solutions to address their common health
IT needs. In addition, although DOD and VA have taken steps toward
developing and maintaining artifacts related to a joint health
architecture (i.e., a description of business processes and supporting
technologies), the architecture is not sufficiently mature to guide
the departments' joint health IT modernization efforts. For example,
the departments have not defined how they intend to transition from
their current architecture to a planned future state. Furthermore, DOD
and VA have not established a joint process for selecting IT
investments based on criteria that consider cost, benefit, schedule,
and risk elements, which limits their ability to pursue joint health
IT solutions that both meet their needs and provide better value and
benefits to the government as a whole. These barriers can be
attributed to, among other things, the departments' decision to
continue with their existing efforts--VLER, separate electronic health
record modernizations, and developing IT capabilities for the FHCC--
rather than determining the best approach to jointly addressing their
common requirements. Without these key IT management capabilities in
place, the departments will continue to face barriers to identifying
and implementing efficient and effective IT solutions to jointly
address their common health care needs.
* DOD's and VA's experiences in developing VLER and IT capabilities
for the FHCC offer important lessons that the departments can use to
improve their management of these ongoing efforts. Specifically, the
departments can improve the likelihood of successfully meeting their
goal to implement VLER nationwide by the end of 2012 by developing an
approved integrated master schedule, master program plan, and
performance metrics consistent with effective IT project management
principles. Also, DOD and VA can improve their continuing effort to
develop and implement new IT system capabilities for the FHCC by
developing a project plan that defines the scope, estimated cost, and
budget in accordance with established best practices. Unless the
departments address these lessons, their ability to effectively
deliver capabilities to support their joint health IT needs is
uncertain.
Conclusions:
DOD and VA face barriers in three key IT management areas--strategic
planning, enterprise architecture, and IT investment management--that
can be problematic for departments that have undertaken major IT
efforts. First, the departments' joint strategic plan does not discuss
how the departments intend to address their common requirements and
they have not articulated a potential approach or timeline for working
together to meet their common health IT needs. Second, DOD's and VA's
joint health architecture, which could guide the departments in the
identification and development of common IT solutions, is not
sufficiently mature to provide such direction. Third, the departments
have not established a process or criteria for selecting IT
investments that best support their many common electronic health
record requirements. These barriers result in part from the
departments' decision to focus on developing VLER, modernizing their
separate electronic health record systems, and developing IT
capabilities for the FHCC, rather than determining the most efficient
and effective approach to jointly addressing their common
requirements. Because the departments continue to pursue their
existing health information sharing efforts without fully establishing
the key IT management capabilities described above, DOD and VA may be
missing other opportunities to deploy joint solutions to address their
common health care business needs.
DOD's and VA's efforts to jointly develop VLER and the FHCC's IT
capabilities offer important lessons that the departments can use to
improve these endeavors. Specifically, these efforts highlight the
importance of effective project planning to the successful development
and implementation of capabilities needed to care for service members
and veterans as these and the departments' future joint projects move
forward.
Recommendations for Executive Action:
To ensure that DOD and VA efficiently and effectively modernize their
electronic health record systems to jointly address their common
health care business needs, we recommend that the Secretaries of
Defense and Veterans Affairs direct the Joint Executive Council to
take the following three actions:
* Revise the departments' joint strategic plan to include information
discussing their electronic health record system modernization efforts
and how those efforts will address the departments' common health care
business needs.
* Further develop the departments' joint health architecture to
include their planned future (i.e., "to be") state and a sequencing
plan for how they intend to transition from their current state to the
next generation of electronic health record capabilities.
* Define and implement a process, including criteria that considers
costs, benefits, schedule, and risks, for identifying and selecting
joint IT investments to meet the departments' common health care
business needs.
We also recommend that the Secretaries of Defense and Veterans Affairs
strengthen their ongoing efforts to establish VLER and the joint IT
system capabilities for the FHCC by developing plans that include
scope definition, cost and schedule estimation, and project plan
documentation and approval.
Agency Comments and Our Evaluation:
We received written comments on a draft of this report from the
Assistant Secretary of Defense for Health Affairs, the VA Chief of
Staff, and the Director of the DOD/VA Interagency Program Office. In
the comments, DOD concurred with our recommendations; VA generally
agreed with our conclusions and concurred with our recommendations;
and the DOD/VA Interagency Program Office concurred with our overall
findings and recommendations. Additionally, DOD and VA described
actions the departments took subsequent to our December 1, 2010
briefing. Specifically, they stated that the departments' senior
leaders were briefed on the DOD-VA Joint Action Plan towards a common
platform and that the departments established and staffed teams to
investigate and analyze electronic health record system collaboration.
Further, the DOD/VA Interagency Program Office provided information
about ongoing efforts to plan and manage VLER. These efforts include
the departments' development of a concept of operations that is
intended to serve as a master program plan and is to be completed in
February 2011. The Director also stated that the departments have
begun reporting performance metrics for the VLER pilot currently being
conducted in Tidewater, Virginia, and that schedules, project plans,
and performance measures have been developed for the next VLER pilot,
which is to take place in the Spokane area of Washington state. If the
departments fully implement our recommendations, they should be better
positioned to modernize their electronic health record systems to
jointly address their common health care business needs.
DOD, VA, and the DOD/VA Interagency Program Office also provided
technical comments, which we incorporated as appropriate. Comments
from the Departments of Defense and Veterans Affairs, and the DOD/VA
Interagency Program Office are reproduced in appendices II, III, and
IV, respectively.
We are sending copies of this report to the Secretaries of Defense and
Veterans Affairs and other appropriate congressional committees.
Copies of this report will also be available at no charge on GAO's Web
site at [hyperlink, http://www.gao.gov].
Should you or your staffs have any questions about this report, please
contact me at (202) 512-6304 or melvinv@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix V.
Signed by:
Valerie C. Melvin:
Director, Information Management and Human Capital Issues:
[End of section]
Appendix I: Briefing for Staff Members of Congressional Committees:
Electronic Health Records: DOD and VA Should Remove Barriers and
Improve Efforts to Meet Their Common System Needs:
Briefing for Staff Members of Congressional Committees:
December 1, 2010:
Table of Contents:
Introduction:
Objectives:
Scope and Methodology:
Results in Brief:
Background:
Results:
* Barriers to Addressing Common Requirements:
* Lessons Learned:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Congressional Requesters:
[End of section]
Introduction:
The Department of Defense (DOD) and the Department of Veterans Affairs
(VA) operate two of the nation's largest health care systems,
providing health care to service members and veterans at estimated
annual costs of about $49 billion and $48 billion, respectively. To do
so, both departments rely on electronic health record systems to
create, maintain, and manage patient health information.
* DOD's health care operation supports service members at over 700
hospitals, clinics, and other facilities around the world. To provide
access to patient information, DOD uses multiple legacy health
systems, including its outpatient system--the Armed Forces Health
Longitudinal Technology Application (AHLTA); DOD's medical information
systems are supplemented with paper-based records.
* VA's Veterans Health Administration (VHA) has over 1,500 facilities
(e.g., hospitals and clinics) throughout the United States. In
contrast to DOD, VA has one integrated medical information system, the
Veterans Health Information Systems and Technology Architecture
(VistA).
Because the departments collect, store, and process health information
in different systems, providing seamless, comprehensive access to
information that is necessary to optimally treat patients is a
challenge for DOD and VA, particularly as patients transition from
service member to veteran status. The departments have thus far
attempted to meet this challenge through increasing electronic health
record interoperability--generally the ability of systems to exchange
data--using a patchwork of initiatives between DOD and VA systems. The
departments recognize that, despite interoperability gains over the
last decade, more work is needed to meet clinicians' evolving needs
for exchanging health information between the departments' systems.
Building on DOD's and VA's efforts to increase electronic heath record
interoperability, in April 2009 the President announced that the
departments would work together to define and build the Virtual
Lifetime Electronic Record (VLER) to streamline the transition of
electronic medical, benefits, and administrative information between
the two departments. 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. Further, VLER
is to expand the departments' health information sharing capabilities
by enabling access to private sector health data as well.
In addition, DOD and VA have both identified the need to modernize
their electronic health record systems. As they have undertaken these
modernizations, the departments have studied and reported on the
potential to pursue joint solutions to the many health care system
needs that DOD and VA have in common. For example, an August 2008
study that the departments funded identified alternative approaches
they could use to achieve a high degree of interoperability[Footnote
3] by working toward a joint DOD and VA inpatient electronic heath
record system. Further, in May 2010, the departments reported to
Congress that they were committed to assessing all possible common
capability development for their next generation of electronic health
record systems.[Footnote 4]
Apart from their VLER and electronic health record modernization
efforts, consolidation of the Naval Health Clinic, Great Lakes, and
the North Chicago VA Medical Center to form the James A. Lovell
Federal Health Care Center (FHCC) has prompted the departments to work
toward implementing electronic health record system components to
support the provision of health care to service members and veterans
in a joint setting. This new center is expected to be operational in
late December 2010, with the supporting system capabilities being
implemented between December 2010 and December 2011.
[End of section]
Objectives:
Because of the importance of comprehensive health information in
providing optimal medical care to service members and veterans, the
Chairmen and Ranking Members of the cognizant Senate and House of
Representatives Appropriations Subcommittees requested that we:
* identify any barriers that DOD and VA face in modernizing their
electronic health record systems to jointly address their common
health care business needs, and:
* identify lessons learned from DOD's and VA's efforts to jointly
develop VLER and to meet the health care information needs for the
FHCC.
Appendix I lists the congressional requesters.
[End of section]
Scope and Methodology:
To identify any barriers that DOD and VA face in modernizing their
electronic health record systems, we:
* evaluated reports in which DOD, VA, and a consultant identified the
commonality of the departments' health care missions and supporting
system needs;
* reviewed DOD and VA's joint strategic plan and analyzed the extent
to which the plan and supporting documents discuss common health care
needs and information technology (IT) system solutions to meeting
those needs;
* reviewed the departments' joint health enterprise architecture and
assessed the architecture's content based on accepted definitions of
completeness, as described in our architecture management guide;
[Footnote 5]
* evaluated DOD's and VA's IT investment policies, processes, and
organization charters to determine whether the departments have
established and used criteria for selecting joint IT investments; and:
* discussed the departments' joint health care mission and system
needs, strategic plan, enterprise architecture, and IT investment
management with officials in DOD's Military Health System, VHA, and
the DOD/VA Interagency Program Office.
To identify lessons learned from DOD's and VA's efforts to jointly
develop VLER and to meet the IT system needs for the FHCC, we:
* assessed available project plans and associated documentation such
as a schedule and performance metrics for VLER against effective
project planning practices;
* visited the Naval Health Clinic, Great Lakes, and the North Chicago
VA Medical Center and discussed their missions, operations, systems,
IT needs, and plans for development of the FHCC information technology
system with managers and clinicians;
* compared available project management documentation for the FHCC
initiative, including funding proposals and an integrated master
schedule, with industry standards, effective practices, and
disciplined processes for effective project management; and:
* discussed VLER and the FHCC initiative with DOD and VA officials.
We conducted this performance audit at DOD's Military Health System
offices and VA's headquarters in the Washington, D.C., metropolitan
area and at the departments' medical facilities in North Chicago,
Illinois, from December 2009 to November 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]
Results in Brief:
Although our prior work has shown that having and using a strategic
plan, enterprise architecture, and IT investment management process
are critical to effectively modernizing major IT systems, DOD and VA
have not sufficiently established these fundamental management
capabilities. In particular, the departments lack a specific plan for
when and how they intend to address their common health IT
requirements, do not have a sufficiently mature joint health
enterprise architecture to guide their mutual IT initiatives, and do
not have a joint IT investment management process in place to identify
and pursue common health IT solutions. These weaknesses can be
attributed to, among other things, the departments' decision to
continue with their existing efforts rather than determining the best
approach to jointly addressing their common requirements. Without
having and using these IT management capabilities, the departments are
impeded in identifying and implementing efficient and effective IT
solutions to jointly address their common health care needs.
DOD's and VA's experiences in developing VLER and IT capabilities
offer important lessons that the departments can use to improve their
management of these ongoing efforts. Specifically, the departments can
improve their effort to implement VLER nationwide by the end of 2012
by developing a plan that is consistent with effective IT project
management principles. Also, DOD and VA can improve their continuing
effort to develop and implement new IT system capabilities for the
FHCC by developing a project plan in accordance with established best
practices. Unless the departments address these lessons, their ability
to deliver expected capabilities to support their joint health IT
needs is uncertain.
To ensure that DOD and VA address barriers they face in modernizing
their electronic health record systems to jointly meet their common
health care business needs, we are making recommendations for the
revision of their strategic plan, further developing their joint
enterprise architecture, and defining and executing a joint IT
investment management process. To address lessons learned that we have
identified from DOD's and VA's efforts to develop VLER and joint IT
system capabilities to support the FHCC, we recommend that the
departments address the project management weaknesses identified in
this briefing.
In oral comments on a draft of these briefing slides, DOD and VA
officials including the Military Health System's Director for External
Relationship Management and the Veterans Health Administration's
Deputy Chief Officer for Health Systems generally agreed with our
recommendations and provided additional information and technical
comments, which we incorporated in the briefing as appropriate.
[End of section]
Background:
DOD and VA operate two of the nation's largest health care systems,
providing health care and other services and benefits to active
service members, veterans, and their families and dependents.
DOD's Military Health System (MHS) is responsible for providing
comprehensive medical care during military operations, as well as
responding to natural disasters and humanitarian crises around the
globe. With about 135,000 employees and an annual budget of about $49
billion, MHS provides health care services to 9.6 million active duty
service members, their families, and other eligible beneficiaries.
Within VA, the VHA has about 255,000 employees and, in fiscal year
2010, was appropriated $48 billion to support its medical care and
research mission. VHA provides primary care, specialized care, and
related medical and social support services to the nation's veterans
and their families. VHA provides health care to approximately 6
million patients at 153 VA medical centers and more than 1,300
outpatient clinics and centers nationwide.
VHA's health care centers are organized into Veterans Integrated
Service Networks which oversee the operations of the various medical
centers and treatment facilities within their assigned geographic
areas.
While in military status and later as veterans, many DOD and VA
patients tend to be highly mobile and may have health records residing
at multiple medical facilities within and outside the United States.
Therefore, electronic health records are particularly crucial for
optimizing the health care provided to military personnel and
veterans. 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.
Furthermore, electronic health records are essential to providing
quality care to DOD's and VA's 3.5 million shared patients--that is,
those who receive health care and services from both departments.
Under the departments' policies for providing health care services,
veterans and active duty service members may, for example, receive
outpatient care from VA clinicians and be hospitalized at a military
treatment facility.
Both DOD and VA rely on complex electronic health record systems to
collect, store, and retrieve information on patients in their care.
* DOD currently relies primarily on AHLTA, which makes use of multiple
legacy information systems that the department developed from
commercial software products that were customized for specific uses.
For example, the Composite Health Care System, which was formerly the
department's primary health information system, is used to capture
pharmacy, radiology, and laboratory order management.[Footnote 6] To
provide capabilities not currently supported by AHLTA, the department
also uses additional systems, such as Essentris (formerly called the
Clinical Information System), a commercial product customized to
support inpatient treatment at military medical facilities. According
to a department official, DOD currently uses Essentris to support 83
percent of inpatient beds in its medical facilities.
The department has been modernizing AHLTA and is currently conducting
an analysis of alternatives on its next iteration of the system,
called EHR Way Ahead. For fiscal year 2011, DOD has requested $302
million to pursue the EHR Way Ahead initiative.
* VA relies on VistA, which includes electronic health records and, as
a result of its decentralized development approach, consists of over
100 separate computer applications. These include health provider
applications; management and financial applications; crosscutting
applications such as patient data exchange; registration, enrollment,
and eligibility applications; health data applications; and
information and education applications. These applications have been
further customized at all VA sites where they are deployed and some
are more than 20 years old.
In 2001, VA began an initiative called HealtheVet to modernize VistA.
However, the department experienced problems and delays in delivering
HealtheVet capabilities and in August 2010 reported that it had
stopped the initiative. Nevertheless, VA requested $347 million in
fiscal year 2011 funding to continue with several projects related to
VistA modernization, including a health data repository and an eHealth
portal to enable veterans to manage their personal health information.
Key to making health care information electronically available is the
ability to share that information among health care providers--that
is, interoperability. If electronic health records conform to
interoperability standards, they can be managed and consulted by
authorized clinicians and staff across more than one health care
organization--such as MHS and VHA--thus providing patients and their
caregivers the necessary information required for optimal care.
For more than a decade, DOD and VA have progressed in their efforts to
improve interoperability between the departments' systems to provide
optimal health care to military personnel and veterans.
The departments' efforts to share information among their existing
systems have historically focused on four key projects:
* 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) was established
in 2004 to allow 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 7] The interface also allows DOD sites to see
previously inaccessible data, such as inpatient documentation from
Essentris, at other DOD sites.
* The Clinical Data Repository/Health Data Repository (CHDR)[Footnote
8] interface, implemented in September 2006, linked the departments'
separate repositories of standardized data to enable a two-way
exchange of computable outpatient pharmacy and medication allergy
information.
* The Laboratory Data Sharing Interface (LDSI), a project established
in 2004, allows DOD and VA facilities to share laboratory resources.
This interface allows the departments to communicate orders for lab
tests and their results electronically.
DOD and VA have established a number of executive-level organizations
to define the strategic direction for a range of their health care
collaborative efforts, and to oversee the implementation of these
efforts. In 2002, the departments established the Joint Executive
Council to, among other things, develop a strategic planning process
for the departments' joint efforts, facilitate opportunities to
enhance sharing, and remove barriers that impede collaboration.
[Footnote 9] Through this strategic plan, the Council communicates the
departments' strategic direction for joint initiatives related to
health care and benefits--as well as establishes the priorities and
processes for implementing these initiatives--to the Secretaries of
DOD and VA, and to Congress.
In addition, the Health Executive Council, an interagency council
under the Joint Executive Council, is responsible for formulating VA
and DOD joint policies that relate to health care, facilitating the
exchange of patient information, and ensuring patient safety.[Footnote
10] The Health Executive Council is further comprised of 13 issue-
specific workgroups, including one devoted to information
management/information technology issues.
Both Congress and the Executive Branch have long expressed an interest
in DOD's and VA's efforts to improve their health information exchange
capabilities, and have urged the departments to identify common health
IT requirements and business processes as they continue to modernize
their health IT systems. For example:
* In May 2003, a presidential task force recommended that the
departments identify common health information requirements so they
can work together to reengineer their business processes and systems
to improve interoperability and efficiency.[Footnote 11]
* In July 2007, the Dole-Shalala Commission recommended that DOD and
VA work quickly to make patient data more accessible to clinicians and
health professionals by creating a fully interoperable information
system to meet their long-term needs.[Footnote 12]
* The National Defense Authorization Act for Fiscal Year 2008[Footnote
13] further required that DOD and VA jointly develop and implement
electronic health record systems or capabilities that allow for full
interoperability of personal health care information between the
departments by September 30, 2009. The act required the departments to
establish a joint interagency program office under the Joint Executive
Council to serve as a single point of accountability for their joint
health IT efforts. In January 2009, the departments established such
an office to act as a single point of accountability for DOD's and
VA's joint efforts to develop and implement electronic health record
systems or capabilities to enable full interoperability of the
departments' health care information. Currently, the office is
responsible for integrating DOD's and VA's program management plans
and activities--such as requirements, schedules, costs, and
performance measures--for their joint health IT initiatives.
The departments have also initiated activities to determine how they
might jointly address common health business needs. Specifically:
* In 2007, the Joint Executive Council commissioned a two-phase study
on the feasibility of implementing a joint VA/DOD inpatient electronic
health record system, and potential alternatives for doing so. The
study team reported in January 2008 that a joint inpatient electronic
health record was feasible, based on finding that over 97 percent of
inpatient functional requirements were common to both DOD and VA. The
second phase of the study recommended that the departments commit to a
joint service-oriented architecture[Footnote 14] strategy--including
an ongoing joint investment in a common architecture and a strong
architecture governance structure--and outlined steps the departments
would need to take to move toward this framework. In October 2008, the
departments accepted these recommendations.
* In May 2010, DOD submitted, in coordination with VA, a report to
Congress on the status of their efforts to identify joint health IT
requirements relative to their electronic health record modernization
efforts. In this report, the departments noted that they shared 10 of
13 core health IT requirements and identified 7 high-level
capabilities for potential shared acquisition or development. The
departments also described at a high level how they could move forward
in identifying potential joint IT solutions.
In addition, the departments have been engaged in two high-profile
collaborative initiatives that are dependent on their ability to fully
share electronic health information. The FHCC in North Chicago,
Illinois, is to be the first DOD/VA medical facility operated under a
single line of authority--led by a Director from VA and a Deputy
Director from the Navy--to manage and deliver medical and dental care.
The FHCC is to serve both DOD and VA patient populations, including
veterans, new Naval recruits, active duty military personnel,
retirees, and dependents. DOD and VA are estimating that clinical
operations at the facility will start at the end of December 2010.
Because the ability to share and exchange patient information is
essential to the mission of the FHCC, the departments have been
working together to develop an IT solution with capabilities beyond
those provided by FHIE, BHIE, and CHDR. Based on input from FHCC
stakeholders and clinicians, the departments decided to pursue
development of 3 IT capabilities,[Footnote 15] as summarized in table
1.
Table 1: FHCC IT Capabilities under Development:
Capability: Single patient registration;
Description: Registers, verifies eligibility, and updates basic
patient information in AHLTA and VISTA through a single user interface;
Expected delivery date[A]: December 2010.
Capability: Single sign on with patient context management;
Description: Allows users to use a single credential (e.g., user name
and password, a DOD Common Access Card, or a Homeland Security
Presidential Directive-12 Personal Identity Verification badge) to
access a patient's record in DOD and VA medical applications within
the FHCC;
Expected delivery date[A]: December 2010.
Capability: Orders portability;
Description: Enables clinicians to place and manage various clinical
orders (as noted below) from either AHLTA or VistA, updates the status
in both systems, and returns the results to the original ordering
system;
Capability: Consults/referrals;
Expected delivery date[A]: To be determined[B].
Capability: Pharmacy;
Expected delivery date[A]: December 2011[C].
Capability: Radiology;
Expected delivery date[A]: December 2010.
Capability: Laboratory;
Expected delivery date[A]: December 2010.
Capability: Allergy[D];
Expected delivery date[A]: July 2011.
Source: GAO analysis of DOD and VA data.
[A] Date for full solution implementation, as of November 2010.
[B] DOD and VA are developing business requirements. As a workaround,
the departments will maintain existing AHLTA and VistA processes for
this capability.
[C] An interim business process solution for orders portability--
pharmacy is planned to be delivered in December 2010.
[D] Orders portability--allergy is a required capability identified by
the departments in August 2010 when an issue was found with the
planned orders portability--pharmacy capability.
[End of table]
In addition, the departments have expressed interest in developing
future capabilities for the FHCC, including outpatient appointment
scheduling and workload management.
To fund DOD and VA's joint IT projects for the FHCC, the departments
relied on two grants--totaling $109.5 million--from the DOD/VA Health
Care Sharing Incentive Fund (known to the departments as the Joint
Incentive Fund).[Footnote 16]
* In fiscal year 2008, the departments submitted a proposal to guide
their IT project management and requirements development efforts for
the FHCC, and received an award for a total of $9.5 million.
* In fiscal year 2009, DOD and VA submitted another proposal to
support activities related to developing the IT solution, and received
an award for $100 million.
As of September 2010, the departments estimated that the FHCC joint IT
project will cost approximately $111 million.
In response to the President's April 2009 announcement, the
departments began planning the VLER initiative, which is intended to
enable DOD, VA, and the private sector to share medical, benefits, and
administrative information to support the transition of military
personnel to veteran status. According to the departments, the goal of
VLER is to ultimately enable clinicians to access all electronic
records for service members as they transition from military to
veteran status, and throughout their lives.
To implement initial VLER capabilities, the departments are embarking
on an incremental series of 6-month pilots to deploy a set of health
data exchange capabilities between existing electronic health record
systems at local sites around the country.[Footnote 17] DOD and VA are
both utilizing software that allows AHLTA and VistA to exchange
information through the Department of Health and Human Services'
Nationwide Health Information Network,[Footnote 18] which allows the
departments to share information with each other and private sector
entities capable of information exchange. The first pilot in San
Diego, California, which started in August 2009, resulted in DOD, VA,
and Kaiser Permanente being able to share a limited set of test
patient data.
Since March 2010, DOD and VA have been jointly conducting another
pilot in the Tidewater area of southeastern Virginia. This pilot is
planned to last until January 2011 and is focusing on sharing the same
data as the San Diego pilot plus additional laboratory data. The
departments have stated that additional pilots are planned for the
second quarter of fiscal year 2011. The goal for nationwide deployment
of the VLER initiative is at or before the end of 2012.
The departments have not yet developed cost estimates for the entire
initiative. DOD informed us that it planned to spend $33.6 million in
fiscal year 2010, and $61.9 million in fiscal year 2011. VA stated
that it planned to spend $23.5 million in fiscal year 2010, and has
submitted a budget request of $52 million for fiscal year 2011.
Between July 2008 and January 2010, we issued a series of reports
[Footnote 19] on the departments' efforts to develop fully
interoperable electronic health record systems or capabilities as
required by the Fiscal Year 2008 National Defense Authorization Act.
In those reports, we described their progress and highlighted issues
that the departments needed to address to achieve full electronic
health record interoperability. Specifically, while the departments
reported that they had met six interoperability objectives to further
increase their sharing of electronic health information, we noted that
the interagency program office was not yet positioned to function as a
single point of accountability for the implementation of interoperable
electronic health record systems or capabilities. Our final report, in
January 2010, reiterated that DOD and VA needed to implement our
previous recommendations to establish project plans, schedules, and
performance measures for the interagency program office to effectively
oversee and manage the departments' delivery of interoperable
capabilities, including VLER.[Footnote 20]
We have also reported on the departments' ongoing efforts to modernize
their individual electronic health record systems and found that they
have been met with limited success:
* In June 2008,[Footnote 21] we reported that between 2001 and 2007,
VA spent almost $600 million on its HealtheVet initiative, which at
the time was comprised of eight major software development projects.
Among other things, we found that the department lacked a
comprehensive project management plan to guide the substantial amount
of work remaining on HealtheVet, including an integrated schedule and
an independent cost estimate, and recommended the department take
action to address these issues to reduce the risk to the HealtheVet
initiative.
* In May 2010,[Footnote 22] we reported on VA's efforts to replace
VistA's scheduling system, which was to be the first application
completed as part of the HealtheVet initiative. The department had
decided to terminate the scheduling replacement project in 2009, after
9 years of planning and spending an estimated $127 million, with the
intention of starting over. We found that the project was hindered by
ineffective oversight and weaknesses in key project management areas,
including acquisition planning, requirements development, and risk
management. We recommended that VA take six actions to improve its
project management processes prior to another attempt at replacing its
scheduling system. VA generally agreed with our recommendations.
* DOD has faced challenges in its efforts to modernize its current
medical information system, AHLTA. In October 2010,[Footnote 23] we
reported that the department's 13-year, $2 billion initiative to
modernize AHLTA had failed to include key planned system capabilities
and had not met users' expectations for system usability,
availability, and speed. We noted that weaknesses in the department's
acquisition management and planning processes--including lack of
comprehensive plans to guide both system acquisition and engineering,
and incomplete requirements--contributed to AHLTA having fewer
capabilities than originally expected, experiencing persistent
performance problems, and not fully meeting the needs of users. DOD is
working to address these issues through planned system performance
improvements and functionality enhancements to stabilize AHLTA through
2015 and serve as a bridge to the new electronic health record system
the department intends to acquire. Given that DOD is now pursuing a
new electronic health record system, we recommended that the
department take a number actions to help ensure that it has
disciplined and effective processes in place to manage the acquisition
of further electronic health record system capabilities.
[End of section]
Results: Barriers to Addressing Common Requirements:
DOD and VA Face Barriers in Addressing Common Health Care System Needs:
Our prior work has shown that success in modernizing major IT systems
depends on having and using a set of IT management capabilities,
including strategic planning, the use of an enterprise architecture,
and IT investment management. However, DOD and VA lack specific plans
for when and how they intend to address their common health IT
requirements, do not have a joint health enterprise architecture to
guide their joint IT initiatives, and do not have joint IT investment
management processes in place to identify and pursue common health IT
solutions. These weaknesses result in part from the departments'
decision to focus on (1) VLER, (2) their separate electronic health
record system modernizations, and (3) development of IT capabilities
for the FHCC rather than determining the best approach to jointly
addressing their common requirements. Without key IT management
capabilities in place, the departments are impeded in identifying and
implementing efficient and effective IT solutions to jointly address
their common needs.
DOD and VA Have Not Yet Formulated Specific Plans for When and How the
Departments Intend to Address Their Joint Electronic Health Record
System Needs:
We have previously reported on the importance of strategic planning to
guide major IT initiatives and modernization efforts. In addition to
outlining an organization's mission, key business processes, IT
challenges, and guiding principles, a strategic plan serves as a
single voice for communicating goals and objectives to stakeholders.
DOD's and VA's success in identifying and implementing joint IT
solutions has been hindered by an inability to articulate explicit
plans, goals, and time frames for meeting their common health IT
needs. For example:
* In April 2010, the Joint Executive Council released its joint
strategic plan for fiscal years 2010-2012, which is intended to
describe the departments' strategic direction for joint efforts
related to health care, including IT.[Footnote 24] The plan states
that the departments have directed their information-sharing efforts
toward planning for and developing VLER[Footnote 25] and that they
intend to maintain the status quo of their current interoperability
initiatives until VLER is sufficiently mature. However, the plan does
not discuss either when or how DOD and VA propose to identify and
develop joint solutions to address the health IT requirements common
to both departments' electronic health record systems.
* In May 2010, the departments submitted a report to Congress in which
they stated that they recognized the economic and strategic benefits
of working together to meet their common health IT needs. The
departments stated that they intended to identify opportunities for
joint IT development or acquisition--through, for example, DOD's
analysis of alternatives process--as they continued to develop their
individual plans for electronic health record modernization. Although
the report affirms the departments' intention to work together to meet
their common health IT needs, it does not provide insight or specific
details on the departments' agreed-upon plans or time frames for
pursuing joint IT solutions. Furthermore, DOD and VA officials have
stated that the departments intend to acquire or develop common
components for their respective electronic health record "where it
makes sense," though they have not articulated when and how such
activities would occur.
* DOD and VA officials have not yet determined whether the IT
capabilities developed for the FHCC can or will be implemented at the
departments' other medical facilities. Specifically, department
officials have noted that the IT effort to establish interoperability
capabilities between the departments' electronic health record systems
at the FHCC is a pilot project.[Footnote 26] After 5 years, the
departments intend to evaluate whether the FHCC's IT solution can be
applied to other sites, or if VLER is sufficiently mature to fulfill
the departments' needs for sharing medical information. Thus, the
departments have delayed determining whether the FHCC IT solution has
the potential to address the departments' common health IT needs,
beyond those that are specific to the FHCC.
DOD and VA have not yet formulated specific plans to address their
joint electronic health record system requirements because they have
placed priority on addressing their immediate needs including VLER,
separate electronic health record system modernizations, and
development of IT capabilities for the FHCC. However, until DOD and VA
define a specific plan for how they intend to address their common
electronic health record system requirements, they are not positioned
to identify and develop joint solutions to meet their common needs. In
addition, until DOD and VA develop specific plans, stakeholders will
be left with an incomplete view of how the departments intend to meet
their common health IT needs in an efficient and effective manner.
DOD and VA's Joint Health Architecture Is Not Sufficiently Mature to
Guide Identification and Development of Common IT Solutions:
An enterprise architecture is a blueprint for organizational change
defined in models that describe in both business and technology terms
how an entity operates today (i.e., "as is") and how it intends to
operate in the future (i.e., "to be"); it also includes a plan for
transitioning to this future state. Specifically, an enterprise
architecture describes an organization's interrelated business
processes and business rules, information needs and flows, work
locations and users, as well as the technologies--the hardware,
software, data, communications, and security attributes--needed to
support its business.
We have long promoted the use of architectures to guide systems
modernization efforts, in part because an architecture can greatly
increase the chances that organizations' operational and IT
environments will be configured to fully support their missions.
Similarly, Congress, the Office of Management and Budget, and the
federal Chief Information Officers Council have also stressed the
importance of an architecture-centric approach to IT modernization
through legislation and guidance.[Footnote 27]
Recognizing the importance of enterprise architecture in addressing
the challenges associated with implementing joint health IT
initiatives, DOD and VA established the Health Architecture
Interagency Group--an advisory subgroup within the Health Executive
Council--in 2005. The group serves as the architectural governance
body for joint DOD and VA health IT initiatives, and is responsible
for overseeing the departments' efforts to develop a joint health
architecture strategy. Among other things, the group works to identify
opportunities for joint IT procurement and development and is to
perform architecture reviews of joint DOD/VA health IT initiatives.
Although VA and DOD are engaged in health-related enterprise
architecture activities and have established an interagency governance
body to manage the development of a joint health architecture, they
have not yet established a joint health architecture to guide their
efforts to address their common health care needs.
As we have previously reported,[Footnote 28] DOD and VA each have
ongoing enterprise architecture efforts. These include activities to
define and develop architectures for their respective health business
areas. For example, DOD continues to develop an architecture for MHS
which describes its activities, business processes, and data. VA has
begun documenting its health business processes and has drafted
architecture-related tools such as a health business reference model.
In addition to their individual enterprise architecture efforts, the
departments have taken steps to improve their collaboration on
enterprise architecture sharing initiatives related to health care.
Specifically, DOD's and VA's Health Architecture Interagency Group has
created several artifacts related to a joint health architecture,
including:
* a DOD/VA Target Health Standards Profile, a collection of annually
updated technical, data, and security standards that DOD and VA are
required to comply with as they develop joint health IT solutions;
* a matrix that identifies current DOD and VA health information
exchanges, as well as the policies, data, and standards governing
these exchanges; and:
* a document intended to provide an overview of the departments' joint
health architecture, including a governance framework, standards, and
the "as is" and "to be" architectures required to help the departments
realize their shared health IT goals.
Although the departments have taken steps toward developing and
maintaining artifacts related to a joint health architecture, the
artifacts themselves do not comprise an architecture capable of
guiding the departments' joint health IT modernization efforts. For
example, the joint health architecture overview document describes the
governance organizations established to promote DOD/VA health efforts,
yet it does not identify which of these organizations is ultimately
responsible and accountable for the departments' joint health
architecture. In addition, although the document outlines at a high
level the "as is" architecture in terms of business and technical
attributes of current DOD/VA interoperability efforts, the "to be"
architecture does not describe the departments' planned future state
relative to their business or technical needs. The document describes
the departments' "to be" architecture only in terms of the status of
DOD and VA's six interoperability objectives, which the departments
report they have already met, and states their intentions to pursue
VLER and participate in the Nationwide Health Information Network.
Furthermore, the document lacks information on how the departments
intend to transition from their current architecture to a planned
future state--a key component of an enterprise architecture.
DOD and VA officials recognize that their joint health architecture is
not sufficiently mature to guide the identification and development of
common IT solutions. The Health Architecture Interagency Group co-
chair characterized the joint health architecture as a large-scale,
strategic effort that the departments plan to refine in the future.
Further, the departments' joint health architecture overview states
that DOD and VA plan to improve their architecture to include
information about health information sharing initiatives.
Nevertheless, until DOD and VA have an understanding of the common
business processes and technologies that a joint health architecture
could provide, the departments will continue to lack an essential tool
for jointly addressing their common health IT needs.
The Absence of Processes to Identify Joint IT System Investments
Limits DOD's and VA's Ability to Pursue Common Health IT Solutions:
IT investment management is a process for linking IT investment
decisions to an organization's strategic objectives and business plans
that focuses on selecting, controlling, and evaluating investments in
a manner that minimizes risks while maximizing the return on
investment. Among other things, GAO's IT investment management
guidance[Footnote 29] states that agencies should establish a
structured project selection process that includes cost, benefit,
schedule, and risk elements, and qualitative measures for comparing
and prioritizing alternative information systems investment projects;
and that identifies and addresses possible IT investments and
proposals that are conflicting, strategically unlinked, or redundant.
Although DOD and VA have a number of organizations with
responsibilities that relate to identifying and managing joint
efforts--including IT--the departments lack joint IT investment
management processes to help these organizations effectively fulfill
their responsibilities.
The Joint Executive Council and its subgroups have various
responsibilities for managing joint IT initiatives. Specifically, the
Council's responsibilities include:
* identifying and overseeing implementation of changes in policies,
procedures, and practices that promote mutually beneficial
coordination or sharing of services and resources between the two
departments; and:
* identifying and assessing other opportunities for the coordination
and sharing of services and resources between the departments that
would provide improved delivery of services for DOD and VA
beneficiaries.
Additionally, the Health Executive Council is responsible for
identifying opportunities (policy, operations, and capital planning)
to enhance mutually beneficial coordination, and has established
workgroups that are responsible for identifying and developing joint
VA/DOD IT initiatives. In particular, the Information Management/
Information Technology workgroup is responsible for developing
interfaces and implementing standards to improve the exchange of
health data between DOD and VA. Additionally, the departments' Health
Architecture Interagency Group has responsibility to seek "joint
procurements and/or building of applications, where appropriate" and
to "explore convergence of DOD and VA health information technology
applications."
Even though the establishment of these groups partially addresses the
Joint Executive Council's responsibilities to manage DOD's and VA's
joint IT initiatives, the Council has not taken the additional step to
establish a joint process for selecting IT investments based on
criteria that consider cost, benefit, schedule, and risk elements.
Without establishing and using a process for selecting joint IT
solutions, DOD and VA are impeded in identifying and selecting
solutions that both meet their common health IT needs and provide
better value and benefits to the government as a whole.
Results: Lessons Learned:
Lessons Learned Provide Opportunities for DOD and VA to Improve
Ongoing Collaborative Efforts:
DOD's and VA's experiences in developing VLER and IT system
capabilities for the FHCC offer important lessons that the departments
can use to improve their management of these efforts. First, the
departments can improve their effort to implement VLER nationwide by
the end of 2012 by developing a plan to guide the endeavor. Second,
DOD and VA can improve their continuing effort to develop and
implement new IT system capabilities for the FHCC by developing a
project plan in accordance with established best practices. Unless the
departments address these lessons, their ability to deliver expected
capabilities to support their joint health IT needs is uncertain.
VLER Is Proceeding without a Comprehensive Plan for Achieving
Nationwide Implementation:
Effective project planning is dependent on completing a number of key
activities, including defining the scope of the project, establishing
a schedule, and--based on these inputs--developing a project plan.
Recognizing the importance of planning and oversight of the VLER
initiative, the departments designated the Interagency Program Office
as the single point of accountability for the coordination and
oversight of VLER in September 2009.[Footnote 30] To fulfill this
role, the office is responsible for activities such as developing and
maintaining an integrated master schedule, a master program plan, and
performance metrics for VLER, in coordination with DOD and VA.
Although DOD and VA have identified a high-level approach for
implementing VLER and designated the Interagency Program Office as the
single point of accountability for the effort, they have yet to
develop a comprehensive plan to guide the nationwide implementation of
VLER as the stated deadline for achieving nationwide implementation by
the end of 2012 approaches. Moreover, the departments have completed
one VLER pilot project and the initial phase of another without
attending to key planning activities that are necessary to guide the
overall initiative.
Shortly after VLER was announced in April 2009, DOD, VA, and the
Interagency Program Office began working to define and plan for the
initiative. In June 2009, the departments adopted a phased
implementation strategy for VLER consisting of a series of 6-month
pilot projects to exchange clinical health data, which began in August
2009.[Footnote 31] Each VLER pilot project is intended to build upon
the technical capabilities of its predecessor, resulting in a set of
baseline capabilities to inform project planning and guide the
implementation of VLER nationwide. However, the departments have not
completed a plan that identifies the target set of capabilities that
they intend to demonstrate in the pilot projects and then implement on
a nationwide basis at all domestic DOD and VA sites by the end of 2012.
In addition, the Interagency Program Office has not developed an
approved integrated master schedule, master program plan, or
performance metrics for the VLER initiative, as outlined in the
office's charter. In November 2010, department officials asserted that
the Interagency Program Office was in the process of developing a
master program plan, which is expected to be approved in late 2011.
Recently, Interagency Program Office officials stated that they have
been focusing on developing individual schedules, project plans, and
performance measures for each pilot effort. The office has developed a
schedule and a project plan for the VLER pilot currently being
conducted in Tidewater, Virginia, although it did not establish
approved performance metrics before the pilot became operational. In
addition, the office has not yet established a schedule, project plan,
and performance measures for the next pilot project, which is
scheduled to begin in January 2011.
Unless DOD, VA, and the Interagency Program Office complete a project
plan for VLER, the departments jeopardize the implementation of the
capabilities they need to effectively share medical information with
each other and the private sector by the end of 2012.
Project Planning for the FHCC IT System Was Not Complete:
Industry best practices and IT project management principles stress
the importance of sound planning for any project, particularly an
effort of the magnitude and complexity of the FHCC.[Footnote 32] Among
other things, planning activities should include (1) defining project
scope using a work breakdown structure, (2) estimating project cost
based on the work breakdown structure, and (3) establishing a budget
for project resources and schedule for project tasks. The above
activities should be followed by documenting their results in a
project plan that is approved by those responsible for implementing
the plan. Carrying out these activities helps to ensure that projects
deliver planned capabilities.
Although DOD and VA performed various planning activities for the FHCC
IT system, these activities were generally not completed in accordance
with effective practices and do not help the departments effectively
meet the FHCC's IT needs.
* Defining scope: The departments did not define the project's scope
using a work breakdown structure that identified the detailed
activities that need to be completed to develop and implement the FHCC
IT system. DOD and VA officials stated that the Joint Incentive Fund
[Footnote 33] proposals described the scope of the project; however,
the proposals provide only a high-level description of the project.
Without developing a project scope definition that identified all
detailed activities, the departments were not positioned to reliably
estimate the project's cost and schedule.
* Estimating cost: The project cost was not estimated using a work
breakdown structure. DOD and VA estimated that the FHCC IT system
would cost $100 million over 3 years. Officials from the departments
characterized this estimate as "high-level" and stated that it was
based on their experiences with previous development efforts. However,
by not basing their estimate on a work breakdown structure, DOD and VA
may not have reliably determined the total cost of the FHCC IT system.
* Establishing a budget and schedule: A budget for requesting
necessary project resources and for tracking project tasks based on
the cost estimate was not created. A joint baseline schedule that
could be used to track performance of the project was not created
until 1 month after the departments began development work. Without
timely development of a budget and schedule, DOD and VA did not have a
basis for reliably determining their progress toward delivering
planned IT capabilities.
DOD and VA recognized the importance of having a project plan and
included a funding request to develop such a plan, along with a
request for money to perform requirements development, in their
December 2007 proposal to obtain support from the Joint Incentive
Fund. However, the departments used the funds they received in June
2008 only for requirements development to the exclusion of project
planning. In lieu of preparing a project plan based on the effective
practices described above, the departments, according to DOD and VA
officials, are using a collection of documents that they asserted
constitute their project plan. Specifically, DOD officials stated that
they use project documentation (such as design reviews and project
status briefings) to guide its portion of the effort while VA uses a
project plan that describes its portion of the IT development effort.
However, this approach does not provide an integrated and
comprehensive plan that documents DOD's and VA's commitments to
completing development of IT system capabilities for the FHCC.
Without performing effective project planning, DOD and VA have not
formalized their shared project commitments and have jeopardized the
departments' ability to fully and timely provide the IT system
capabilities the FHCC needs.
[End of section]
Conclusions:
DOD and VA face barriers in three key IT management areas--strategic
planning, enterprise architecture, and IT investment management--that
can be problematic for departments that have undertaken major IT
efforts. First, the departments' joint strategic plan does not discuss
how the departments intend to address their common requirements and
they have not articulated a potential approach or timeline for working
together to meet their common health IT needs. Second, DOD's and VA's
joint health architecture, which could guide the departments in the
identification and development of common IT solutions, is not
sufficiently mature to provide such direction. Third, the departments
have not established a process or criteria for selecting IT
investments that best support their many common electronic health
record requirements. These barriers result in part from the
departments' decision to focus on developing a Virtual Lifetime
Electronic Record, modernizing their separate electronic health record
systems, and developing IT capabilities for the Federal Health Care
Center, rather than determining the most efficient and effective
approach to jointly addressing their common requirements. Because the
departments continue to pursue their existing health information-
sharing efforts without fully establishing the key IT management
capabilities described above, DOD and VA may be missing other
opportunities to deploy joint solutions to address their common health
care business needs.
DOD's and VA's efforts to jointly develop VLER and the FHCC's IT
capabilities offer important lessons that the departments can use to
improve these endeavors. Specifically, these efforts highlight the
importance of effective project planning to the successful development
and implementation of capabilities needed to care for service members
and veterans as these and the departments' future joint projects move
forward.
[End of section]
Recommendations for Executive Action:
To ensure that DOD and VA efficiently and effectively modernize their
electronic health record systems to jointly address their common
health care business needs, we recommend that the Secretaries of
Defense and Veterans Affairs direct the Joint Executive Council to
take the following actions:
* Revise the departments' joint strategic plan to include information
discussing their electronic health record system modernization efforts
and how those efforts will address the departments' common health care
business needs.
* Further develop the departments' joint health architecture to
include their planned future (i.e., "to be") state and a sequencing
plan for how they intend to transition from their current state to the
next generation of electronic health record capabilities.
* Define and implement a process, including criteria that considers
costs, benefits, schedule, and risks, for identifying and selecting
joint IT investments to meet the departments' common health care
business needs.
We recommend that the Secretaries of Defense and Veterans Affairs
strengthen their ongoing efforts to establish the Virtual Lifetime
Electronic Record and the joint IT system capabilities for the Federal
Health Care Center, by developing plans that include scope definition,
cost and schedule estimation, and project plan documentation and
approval.
[End of section]
Agency Comments and Our Evaluation:
In oral comments on a draft of these briefing slides, DOD and VA
officials, including the Military Health System's Director for
External Relationship Management and the Veterans Health
Administration's Deputy Chief Officer for Health Systems, generally
agreed with our recommendations. The officials stated that the
departments are focused on addressing their common health care system
needs while also performing the departments' unique missions. In
addition, the departments provided technical comments, which we
incorporated in the briefing as appropriate.
[End of section]
Appendix I: Congressional Requesters:
The Honorable Daniel Inouye:
Chairman:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Tim Johnson:
Chairman:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Norman D. Dicks:
Chairman:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
The Honorable Thad Cochran:
Vice Chairman:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Kay Bailey Hutchison:
Ranking Member:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable C.W. Bill Young:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
[End of section]
[End of Briefing slides]
Appendix II: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
January 10, 2011:
Ms. Valerie C. Melvin:
Director:
Information Management and Human Capital Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Ms. Melvin:
This is the Department of Defense's (DoD) response to the
recommendations in the Government Accountability Office (GAO) Draft
Report GA0-11-265, "DoD and VA Should Remove Barriers and Improve
Efforts to Meet their Common System Needs," December 2010, (Engagement
Code 310960). DoD acknowledges receipt of the draft report and will
address each of the recommendations and ensure appropriate measures
are carried out effectively. Enclosed are suggested technical comments
and corrections to GAO's draft report. Please note that since the
closing date of GAO's discovery phase for this report, the Departments
have made significant collaborative progress in electronic health
record (EHR) planning.
On December 4, 2010, the Principal Advisor, EHR, to the Assistant
Secretary of Defense, Health Affairs, and the Senior Advisor to the
Secretary and Chief Technology Officer, Department of Veterans Affairs
(VA), briefed the DoD-VA Joint Action Plan towards a common platform
to the Vice Chairman of the Joint Chiefs of Staff and the Departments'
Deputy Secretaries. Subsequently, the DoD-VA EHR Senior Coordinating
Group established and staffed a collaborative structure for
investigating and analyzing key objectives for the EHR planning
efforts. Six teams were identified: Enterprise Architecture Team; Data
Interoperability Team; Business Process Team; Systems Capabilities
Team; Presentation Layer Team; and Mission Requirements & Performance
Outcomes Team. The DoD-VA EHR Senior Coordinating Group intends to
report collective team findings in early 2011.
Thank you for the opportunity to review and comment on the draft
report. The points of contact for additional information are Ms. Lois
Kellett and Mr. Gunther Zimmerman. Ms. Kellett may be reached at
Lois.Kellett@tma.osd.mil, or (703) 681-8836. Mr. Zimmerman may be
reached at Gunther.Zimmerman@tma.osd.mil, or (703) 681-4360.
Sincerely,
Signed by:
Jonathan Woodson, M.D.
Enclosure: As stated:
GAO Draft Report Dated December 2010:
GA0-11-265 (Engagement Code 310960):
"DoD and VA Should Remove Barriers and Improve Efforts to Meet their
Common System Needs"
Department of Defense Comments to GAO Recommendations:
Recommendation: Revise the Departments' Joint Strategic Plan (JSP) to
include information discussing their electronic health record (EHR)
system modernization efforts, and how those efforts will address the
Departments' common health care business needs.
Department of Defense (DoD) Response: Concur. DoD, in collaboration
with the Department of Veterans Affairs (VA), will revise the VA/DoD
Joint Executive Council (JEC) JSP for Fiscal Year (FY) 2011-2013 to
reflect EHR system modernization efforts.
Recommendation: Further develop the Departments' joint health
architecture to include their planned future (i.e., "to 14") state and
a sequencing plan for how they intend to transition from their current
state to the next generation of EHRs.
DoD Response: Concur. DoD, in collaboration with VA, will update the
DoD/VA Shared Health Architecture to include the "to be" state and
explain how the departments intend to transition from the current
state to the next generation of EHRs.
Recommendation: Define and implement a process, including criteria
that considers costs, benefits, schedule, and risks, for identifying
and selecting joint information technology (IT) investments to meet
the Departments' common health care business needs.
DoD Response: Concur. DoD, in collaboration with VA, will define and
implement a process for identifying and selecting joint IT investments
to meet the Departments' common health care business needs.
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
Department Of Veterans Affairs:
Washington DC 20420:
January 20, 2011:
Ms. Valerie Melvin:
Director:
Information Management and Human Capital Issues:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Melvin:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "Electronic Health
Records: DOD and VA Should Remove Barriers and Improve Efforts to Meet
their Common System Needs" (GAO-11-265), and generally agrees with
GAO's conclusions and concurs with GAO's recommendations to the
Department.
The enclosure specifically addresses GAO's recommendations and
provides technical comments to the draft report. VA appreciates the
opportunity to comment on your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of letter]
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report: Electronic Health Records:
DOD and VA Should Remove Barriers and Improve Efforts to Meet their
Common Needs (GA0-11-265):
GAO recommendation: To ensure that DOD and VA efficiently and
effectively modernize their electronic health record systems to
jointly address their common health care business needs, we recommend
that the Secretaries of Defense and Veterans Affairs direct the Joint
Executive Council to take the following actions:
Recommendation 1: Revise the departments' joint strategic plan to
include information discussing their electronic health record system
modernization efforts and how those efforts will address the
department's common health care business needs.
VA Response: Concur. VA is revising its Electronic Health Record (EHR)
modernization plan to focus on business drivers that require a
modernized EHR along with the functional requirements of the provider
and information requirements of the consumers to allow them to be more
involved in their care. In the process of designing the new plan, VA
is working collaboratively with the Department of Defense (DoD) to
identify joint solutions. VA, in collaboration with DoD, will revise
the VA/DoD Joint Executive Council Joint Strategic Plan for fiscal
year (FY) 2011”2013 to reflect EHR system modernization efforts.
Target Completion Date: to be determined upon further discussion with
DoD.
Recommendation 2: Further develop the departments' joint health
architecture to include their planned future (i.e., "to be") state and
a sequencing plan for how they intend to transition from their current
state to the next generation of electronic health record capabilities.
VA Response: Concur. VA and DoD have identified similarities in our
future planned architectures and are currently working together at the
business process, enterprise architecture, system capabilities and
data model levels to identify opportunities for joint solutions. VA,
in collaboration with DoD, will update the DOD/VA Shared Health
Architecture to include the "to be" state and explain how the
Departments intend to transition from the current state to the next
generation EHR.
Target Completion Date: to be determined upon further discussion with
DoD.
Recommendation 3: Define and implement a process, including criteria
that considers costs, benefits, scheduled, and risks, for identifying
and selecting joint IT investments to meet the departments' common
health care business needs.
VA Response: Concur. As VA and DoD complete the analysis of the scope
of a common EHR way forward, a rough estimate of costs and schedule is
planned for completion. VA, in collaboration with DoD, will define and
implement a process for identifying and selecting joint IT investments
to meet the departments' common health care business needs.
Target Completion Date: to be determined upon further discussion with
DoD.
Recommendation 4: Strengthen their on-going efforts to establish VLER
and the Joint IT system capabilities for the FHCC by developing plans
that include scope definition, costs and schedule estimation, and
project plan documentation and approval.
VA Response: Concur. VA considers the Federal Health Care Center
project plan, including scope definition, to be very detailed and well
documented. As the project moves forward, these plans will be extended
and strengthened. The VA cost estimate to date is on target and within
budget. It is reported to the Veterans Health Administration and the
Assistant Secretary for Information Technology and others at least
every two months or upon request. Project documentation, software
development processes, networks, security, and deployment follow all
VA Office of Information and Technology (OIT) Program Management
Accountability System requirements and are fully documented. At the
time of the interviews for this report, OIT considers the VLER plan as
in the development process. The VA VLER Enterprise Program Management
Office (EMPO) has conducted many interdisciplinary and interagency
meetings to determine and finalize the scope and timing of releases.
The VA VLER EPMO is currently actively collaborating with DoD and the
Interagency Program Office to finalize the VLER Concept of Operations.
Target Completion Date: to be determined upon further discussion with
DoD.
[End of section]
Appendix IV: Comments from the DOD/VA Interagency Program Office:
Dod/VA Interagency Program Office:
1700 North Moore Street:
Arlington, Va 22209:
January 24, 2011:
10:42 A.M.
Ms. Valerie C. Melvin:
Director:
Information Management & Human Capital Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, D.C. 20548:
Dear Ms. Melvin:
This is the DoD/VA Interagency Program Office's (IPO) response to the
recommendations enclosed in the Government Accountability Office (GAO)
Draft Report, "Electronic Health Records: DoD and VA Should Remove
Barriers and Improve Efforts to Meet their Common System Needs,"
(Project No. GA0-11-265, GAO Code 310960).
IPO acknowledges receipt of the draft audit report and concurs with
the overall findings and recommendations. We have provided several
suggested technical corrections in the enclosed formal response.
Thank you for the opportunity to review and comment on the draft
report. My point of contact for additional information is Mr. Ryan
Cool, Ryan.Cool@osd.mil, 703-696-3636.
Sincerely,
Signed by:
Debra M. Filippi:
Director:
DoD/VA Interagency Program Office:
Enclosures: As stated:
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Valerie C. Melvin, (202) 512-6304 or melvinv@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Mark T. Bird (Assistant
Director), Bradley Becker, Jeremy Brodsky, Heather A. Collins, Rebecca
Eyler, Jacqueline Mai, Lee McCracken, Sylvia Shanks, and Adam Vodraska
made key contributions to this report.
[End of section]
Footnotes:
[1] 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); 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); Electronic Health Records: Program Office Improvements Needed
to Strengthen Management of VA and DOD Efforts to Achieve Full
Interoperability, [hyperlink, http://www.gao.gov/products/GAO-09-895T]
(Washington, D.C.: July 14, 2009); 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); and Electronic Health Records: DOD and VA Interoperability
Efforts Are Ongoing; Program Office Needs to Implement Recommended
Improvements, [hyperlink, http://www.gao.gov/products/GAO-10-332]
(Washington, D.C.: January 28, 2010).
[2] Interoperability is the ability for different information systems
or components to exchange information and to use the information that
has been exchanged.
[3] Interoperability is the ability for different information systems
or components to exchange information and to use the information that
has been exchanged.
[4] Joint Executive Council and Health Executive Council, Report to
Congress on Department of Defense and Department of Veterans Affairs
Medical Information Technology (Washington, D.C., May 21, 2010).
[5] GAO, Organizational Transformation: A Framework for Assessing and
Improving Enterprise Architecture Management (Version 2.0),
[hyperlink, http://www.gao.gov/products/GAO-10-846G] (Washington,
D.C.: August 2010).
[6] According to DOD, Composite Health Care System applications are
now accessed through its modernized health information system, AHLTA.
[7] 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.
[8] The name CHDR, pronounced "cheddar," combines the names of these
two repositories.
[9] The Joint Executive Council is comprised of the Deputy Secretary
of Veterans Affairs; the Under Secretary of Defense for Personnel and
Readiness; and the co-chairs of joint councils on health, benefits,
and capital planning. The council meets on a quarterly basis.
[10] The Health Executive Council is co-chaired by VA's Under Secretary
for Health and DOD's Assistant Secretary of Defense for Health
Affairs. DOD membership also includes the surgeons general for the
military services. The council meets bimonthly.
[11] President's Task Force to Improve Health Care Delivery for Our
Nation's Veterans (May 26, 2003).
[12] Serve, Support, Simplify: Report of the President's Commission on
Care for America's Returning Wounded Warriors (July 30, 2007).
[13] Pub. L. No. 110-181, Sec. 1635 (2008).
[14] A service-oriented architecture approach is intended to identify
and promote the shared use of common business capabilities across the
enterprise, reduce redundancy, increase integration, and enable
organizations to respond quickly to new business requirements. Under
this approach, business functions and applications are defined and
designed as discrete and reusable capabilities or services that may be
under the control of different organizations.
[15] According to department officials, DOD and VA decided to develop
these capabilities in parallel, where each departments' IT
organization creates, tests, and deploys enterprise quality software
in their respective department, then jointly tests and deploys the
software at the FHCC.
[16] The DOD/VA Health Care Sharing Incentive Fund was authorized by
Congress in the Bob Stump National Defense Authorization Act of 2003,
Pub. L. No. 107-314, Sec. 721 (38 U.S.C. Sec. 8111(d)). The purpose of
this fund is to provide seed money for creative sharing initiatives at
facility, regional, and national levels to facilitate the mutually
beneficial coordination, use, or exchange of health care resources,
with the goal of improving the access to, and quality and cost-
effectiveness of, the health care provided to beneficiaries of both
departments.
[17] Currently, the departments are focusing on the exchange of health
information for the pilots, and not benefits and administrative data.
[18] The Nationwide Health Information Network is defined as a set of
standards, services, and policies that enable the secure exchange of
health information over the Internet.
[19] 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); 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); Electronic Health Records: Program Office Improvements Needed
to Strengthen Management of VA and DOD Efforts to Achieve Full
Interoperability, [hyperlink, http://www.gao.gov/products/GAO-09-895T]
(Washington, D.C.: July 14, 2009); 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); and Electronic Health Records: DOD and VA Interoperability
Efforts are Ongoing; Program Office Needs to Implement Recommended
Improvements, [hyperlink, http://www.gao.gov/products/GAO-10-332]
(Washington, D.C.: January 28, 2010).
[20] [hyperlink, http://www.gao.gov/products/GAO-10-332].
[21] GAO, Veterans Affairs: Health Information System Modernization
Far from Complete; Improved Project Planning and Oversight Needed,
[hyperlink, http://www.gao.gov/products/GAO-08-805] (Washington, D.C.:
June 30, 2008).
[22] GAO, Information Technology: Management Improvements Are
Essential to VA's Second Effort to Replace Its Outpatient Scheduling
System, [hyperlink, http://www.gao.gov/products/GAO-10-579]
(Washington, D.C.: May 27, 2010).
[23] GAO, Information Technology: Opportunities Exist to Improve
Management of DOD's Electronic Health Record Initiative, [hyperlink,
http://www.gao.gov/products/GAO-11-50] (Washington, D.C.: October 6,
2010).
[24] The joint strategic plan describes the integrated information
sharing goal as enabling the exchange of health and benefits data
using secure and interoperable IT systems. Note that interoperability
is the ability of two or more systems or components to exchange
information and use the information that has been exchanged.
[25] As previously mentioned, VLER's ultimate goal is to enable DOD,
VA, and the private sector to exchange health, benefits, and
administrative information using the Nationwide Health Information
Network. Department officials have stated that VLER is intended to
eventually replace some of the departments' current interoperability
capabilities, such as BHIE.
[26] The departments consider the entire FHCC effort--including the
integrated governance structure and health business operations, as
well as the IT--a pilot project.
[27] See, for example, 40 U.S.C. §11315; the E-Government Act of 2002,
44 U.S.C. §3602; and the Chief Information Officers Council, A
Practical Guide to Federal Enterprise Architecture, Version 1.0
(February 2001).
[28] See, for example, GAO, DOD Business Systems Modernization:
Military Departments Need to Strengthen Management of Enterprise
Architecture Programs, [hyperlink,
http://www.gao.gov/products/GAO-08-519] (Washington, D.C.: May 12,
2008); Enterprise Architecture: Leadership Remains Key to Establishing
and Leveraging Architectures for Organizational Transformation,
[hyperlink, http://www.gao.gov/products/GAO-06-831] (Washington, D.C.:
August 14, 2006); DOD Business Systems Modernization: Long-standing
Weaknesses in Enterprise Architecture Development Need to Be
Addressed, [hyperlink, http://www.gao.gov/products/GAO-05-702]
(Washington, D.C.: July 22, 2005); Information Technology: Leadership
Remains Key to Agencies Making Progress on Enterprise Architecture
Efforts, [hyperlink, http://www.gao.gov/products/GAO-04-40]
(Washington, D.C.: November 17, 2003).
[29] GAO, Information Technology Investment Management: A Framework
for Assessing and Improving Process Maturity, [hyperlink,
http://www.gao.gov/products/GAO-04-394G] (Washington, D.C.: March
2004).
[30] The Interagency Program Office's mission is to serve as the
single point of accountability for the coordination and oversight of
Joint Executive Council-approved IT projects, data, and information
sharing activities--including the VLER.
[31] The Joint Executive Council approved this phased strategy for
VLER in June 2009.
[32] See Institute of Electrical and Electronics Engineers (IEEE),
IEEE/EIA Guide for Information Technology, IEEE/EIA 12207.1-1997
(April 1998) and Carnegie Mellon Software Engineering Institute,
Capability Maturity Model Integration for Acquisition, Version 1.2
(November 2007).
[33] As mentioned previously, the Joint Incentive Fund is used by the
departments to provide seed money for creative sharing initiatives at
facility, regional, and national levels to facilitate the mutually
beneficial coordination, use, or exchange of health care resources.
[End of section]
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