Veterans Affairs
Posthearing Questions Concerning the Departments of Defense and Veterans Affairs Providing Seamless Health Care Coverage to Transitioning Veterans Gao ID: GAO-04-292R November 24, 2003On October 16, 2003, GAO testified before Congress at a hearing on whether DOD and VA are providing seamless health care coverage to transitioning veterans. This letter responds to a request thst we provide answers to follow-up questions from the hearing.
VA and DOD have been pursuing ways to share data in their health information systems and create electronic records since 1998, when the Government Computer-Based Patient Record (GCPR) project was initiated. GCPR was envisioned as an electronic interface that would allow physicians and other authorized users at VA, DOD, and Indian Health Service (IHS) health facilities to access data from any of the other agencies' health facilities. Since undertaking this mission, however, VA and DOD have faced considerable challenges, leading to repeated changes in the focus of their initiative and the target dates for its accomplishment. The near-term initiative--the Federal Health Information Exchange--was completed in July 2002 and enabled the one-way transfer of data from DOD's existing health care information system to a separate database that VA hospitals could access. This initiative has shown success in allowing clinicians in VA medical centers ready access to information--such as laboratory, pharmacy, and radiology records--on almost 2 million patients. However, the departments' strategy for an envisioned longer-term, two-way exchange of clinical information is farther out on the horizon. This initiative, HealthePeople (Federal), is premised upon the departments' development of a common health information infrastructure and architecture comprising standardized data, communications, security, and high-performance health information systems. VA and DOD anticipated achieving a limited capability for two-way data exchange by the end of 2005. Nonetheless, VA and DOD continue to face significant challenges in realizing this longerterm capability. In addition, critical to the two-way exchange will be completing the standardization of the clinical data that these departments plan to share. Achieving the technical capability to unify VA's and DOD's patient care records in and of itself will not ensure the seamless transition of health care data. Other issues that the departments need to address include (1) reaching consensus on and implementing data standards, (2) capturing complete and accurate medical information on service members, and (3) ensuring privacy and security compliance.
GAO-04-292R, Veterans Affairs: Posthearing Questions Concerning the Departments of Defense and Veterans Affairs Providing Seamless Health Care Coverage to Transitioning Veterans
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United States General Accounting Office:
Washington, DC 20548:
November 24, 2003:
The Honorable Christopher H. Smith:
Chairman:
Committee on Veterans' Affairs:
House of Representatives:
Subject: Veterans Affairs: Posthearing Questions Concerning the
Departments of Defense and Veterans Affairs Providing Seamless Health
Care Coverage to Transitioning Veterans:
Dear Mr. Chairman:
On October 16, 2003, I testified before your Subcommittee at a hearing
on Hand-off or Fumble: Are DOD and VA Providing Seamless Health Care
Coverage to Transitioning Veterans?[Footnote 1] This letter responds to
your request that we provide answers to follow-up questions from the
hearing. Your questions, along with my responses, follow.
1. "GAO, at the request of this Committee, has examined VA's
Information:
Technology (IT) needs a number of times. Also, GAO has studied DOD's IT
infrastructure. VA and DOD have pledged over the years to be working
toward common solutions to their IT challenges, most particularly in
the area of computerized patient care records and the portability of
these records across the several systems involved. Yet, they soldier on
separately. What are the basic problems in the view of GAO, that
prevent or obstruct the accomplishment of this goal of a single patient
care record that can accompany a military servicemember from active
duty to veteran status?":
Answer: VA and DOD have been pursuing ways to share data in their
health information systems and create electronic records since 1998,
when the Government Computer-Based Patient Record (GCPR) project was
initiated. GCPR was envisioned as an electronic interface that would
allow physicians and other authorized users at VA, DOD, and Indian
Health Service (IHS) health facilities to access data from any of the
other agencies' health facilities.[Footnote 2] The interface was
expected to compile requested patient information in a "virtual" record
that could be displayed on a user's computer screen.
Since undertaking this mission, however, VA and DOD have faced
considerable challenges, leading to repeated changes in the focus of
their initiative and the target dates for its accomplishment. Our prior
reports discussing the initiative[Footnote 3] noted disappointing
progress, exacerbated in large part by inadequate accountability and
poor planning and oversight, which raised doubts about the departments'
ability to achieve an electronic interface among their health
information systems. When we reported on the initiative in September
2002,[Footnote 4] VA and DOD had taken some actions aimed at
strengthening their joint efforts. For example, they had clarified key
roles and responsibilities for the initiative and begun executing
revised near-and long-term strategies for achieving the electronic
information exchange capability.
The near-term initiative--the Federal Health Information Exchange--was
completed in July 2002 and enabled the one-way transfer of data from
DOD's existing health care information system to a separate database
that VA hospitals could access. This initiative has shown success in
allowing clinicians in VA medical centers ready access to information-
-such as laboratory, pharmacy, and radiology records--on almost 2
million patients.
However, the departments' strategy for an envisioned longer-term, two-
way exchange of clinical information is farther out on the horizon.
This initiative, HealthePeople (Federal), is premised upon the
departments' development of a common health information infrastructure
and architecture comprising standardized data, communications,
security, and high-performance health information systems. VA and DOD
anticipated achieving a limited capability for two-way data exchange by
the end of 2005.
Nonetheless, VA and DOD continue to face significant challenges in
realizing this longer-term capability. While the departments have
developed a high-level strategy for the initiative, they face the
challenge of clearly articulating a common health information
infrastructure and architecture to show how they intend to achieve the
data exchange capability or what exactly they will be able to exchange.
Such an architecture is necessary for ensuring that the departments
have defined a level of detail and specificity needed to build the
exchange capability, including requirements and design specifications.
In addition, critical to the two-way exchange will be completing the
standardization of the clinical data that these departments plan to
share. Data standardization is essential to allowing the exchange of
health information from disparate systems and improving decision-making
by providing health information when and where it is needed. Currently,
VA and DOD face an enormous task of standardizing their health data. VA
will have to migrate over 150 variations of clinical and demographic
data to one standard, and DOD will have to migrate over 100 variations
of clinical data to one standard. VA and DOD officials maintain that
their departments, along with the Department of Health and Human
Services, are actively pursuing the development and adoption of data
standards. Nonetheless, they remain uncertain as to when the necessary
standardization will be accomplished. Without standardization, the task
of sharing meaningful data is made more complex and may not prove
successful.
2. "Assuming that VA and DOD actually unify their patient care record
keeping, will this accomplishment solve the "seamless transition"
challenge, or will the records problem be supplanted by some other new
one, such as HIPAA [Health Insurance Portability and Accountability
Act] or another cause, and what are your reasons for this conclusion?":
Answer: Achieving the technical capability to unify VA's and DOD's
patient care records in and of itself will not ensure the seamless
transition of health care data. Other issues that the departments need
to address include the following:
Reaching consensus on and implementing data standards. As we pointed
out in our previous response, an essential aspect of making the data
usable will be establishing data standards. Accomplishing this is
particularly challenging, as consensus must be reached with clinicians
and other health care providers to achieve common acceptance of the
standards.
Capturing complete and accurate medical information on service members.
The departments must establish and closely adhere to a process that
will ensure the complete and accurate capture of medical information of
service members stored in their respective databases.[Footnote 5] As
noted in our testimony, DOD's database does not currently contain
patient health information (such as health assessments and
immunizations) for all service members.
Ensuring privacy and security compliance. The departments will have to
ensure that the exchange of medical information is compliant with
privacy requirements established in the HIPAA. In addition, given the
sensitivity of patient health information, the departments must ensure
that adequate security is an integral feature of the data exchange
capability.
We are sending copies of this letter to the Secretary of Veterans
Affairs and the Secretary of Defense and other interested parties. We
will also make copies available to others upon request. In addition,
this report will be available at no charge on the GAO Web site at
http://www.gao.gov. Should you or your staff have any questions on
matters discussed in this letter, please contact me at (757) 552-8100.
I can also be reached by e-mail at curtinn@gao.gov.
Sincerely yours,
Neal P. Curtin:
Director, Operations and Readiness Issues:
Signed by Neal P. Curtin:
(350472):
FOOTNOTES
[1] U.S. General Accounting Office, Defense Health Care: DOD Needs
to Improve Force Health Protection And Surveillance Processes, GAO-04-
158T (Washington, D.C.: Oct. 16, 2003).
[2] The Indian Health Service became involved in GCPR because of its
expertise in population-based research and its longstanding
relationship with VA in caring for the American Indian veteran
population.
[3] U.S. General Accounting Office, Computer-Based Patient Records:
Better Planning and Oversight by VA, DOD, and IHS [Indian Health
Service] Would Enhance Health Data Sharing, GAO-01-459 (Washington,
D.C.: Apr. 30, 2001); VA Information Technology: Progress Made, but
Continued Management Attention Is Key to Achieving Results, GAO-02-369T
(Washington, D.C.: Mar. 13, 2002); and VA Information Technology:
Management Making Important Progress in Addressing Key Challenges
GAO-02-1054T (Washington, D.C.: Sept. 26, 2002).
[4] GAO-02-1054T.
[5] VA and DOD plan to implement a capability to share patient health
information that will be collected in data repositories that each is
implementing.
