Computer-Based Patient Records
Subcommittee Questions Concerning VA and DOD Efforts to Achieve a Two-Way Exchange of Health Data Gao ID: GAO-04-691R May 14, 2004This letter responds to a request by the Chairman of the Subcommittee on Oversight and Investigations, House Committee on Veterans' Affairs, that we provide answers to questions relating to our March 17, 2004, testimony. At that hearing, we discussed the Department of Veterans Affairs' (VA) and Department of Defense's (DOD) progress toward defining a detailed strategy and developing the capability for a two-way exchange of patient health information.
In the last 10 years we have testified seven times on matters pertaining to VA's and DOD's efforts toward achieving the capability to electronically exchange patient health information. Our statements have highlighted significant challenges that VA and DOD have faced in pursuing ways to share data in their health information systems and create electronic medical records. VA and DOD have taken action on several recommendations that we have made over the past 3 years. These recommendations were aimed at improving the coordination and management of the departments' initial efforts to achieve electronic information sharing via the Government Computer-Based Patient Record (GCPR) project, and furthering DOD's development of its new health information system, the Composite Health Care System II. VA and DOD agreed with and took actions that addressed all of these recommendations. In addition, in September 2002 we reported on DOD's acquisition of the Composite Health Care System II. However, our review of the initiative noted, among other concerns, DOD's limited progress during early stages of the system's development that led to a change in its redesign and development/deployment schedule. We recommended five actions aimed at increasing the project's likelihood of success, three of which have been implemented. DOD is in various stages of implementing the remaining two recommendations. From fiscal year 1998 through fiscal year 2003, the departments reported spending a total of about $670 million on their individual and collective efforts. However, through fiscal year 2003, VA and DOD did not report any costs associated with the critical tasks of defining and developing the electronic interface. In discussing with VA and DOD their actions since last November toward achieving a two-way exchange of patient health information under the HealthePeople (Federal) initiative, officials in both departments expressed their belief that progress was being made. However, as our testimony noted, the departments had not fully defined their approach or requirements for developing and demonstrating the capabilities of the planned prototype. The early stage of the prototype and the uncertainties regarding what capabilities it will demonstrate provided little evidence or assurance as to how or whether this project would contribute to defining the architecture and technological solution. The information collected during our review of the HealthePeople (Federal) initiative suggests that the Subcommittee's scheduled hearing may have provided an incentive for VA and DOD to move forward on this issue. At the time of our testimony, critical project components were absent from VA's and DOD's initiative. The top five priorities that VA and DOD need to address in 2004 to increase the likelihood of a successful outcome are (1) development of an architecture for the electronic interface that articulates system requirements, design specifications, and software descriptions; (2) selection of a lead entity with final decision-making authority for the initiative; (3) establishment of a project management structure to provide day-to-day guidance of and accountability for the investments in and implementation of the electronic interface capability; (4) development and implementation of a comprehensive and coordinated project plan; and (5) implementation of project review milestones and measures to provide the basis for comprehensive management, progressive decision making, and authorization of funding for each step in the development process. Based on our work, we cannot point to any instances in which either department has initiated a major information technology project with a clearly defined architecture and sound project management having been established. We did see evidence that implementing critical project management processes after a project has been undertaken can positively affect its outcome.
GAO-04-691R, Computer-Based Patient Records: Subcommittee Questions Concerning VA and DOD Efforts to Achieve a Two-Way Exchange of Health Data
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May 14, 2004:
The Honorable Steve Buyer:
Chairman, Subcommittee on Oversight and Investigations:
Committee on Veterans' Affairs:
House of Representatives:
Subject: Computer-Based Patient Records: Subcommittee Questions
Concerning VA and DOD Efforts to Achieve a Two-Way Exchange of Health
Data:
Dear Mr. Chairman:
This letter responds to your April 7, 2004, request that we provide
answers to questions relating to our March 17, 2004,
testimony.[Footnote 1] At that hearing, we discussed the Department of
Veterans Affairs' (VA) and Department of Defense's (DOD) progress
toward defining a detailed strategy and developing the capability for a
two-way exchange of patient health information. Your questions, along
with our responses, follow.
1. How many times has the GAO testified on VA-DOD sharing of medical
information in the last 10 years?
In the last 10 years we have testified seven times on matters
pertaining to VA's and DOD's efforts toward achieving the capability to
electronically exchange patient health information. VA and DOD have
been working to achieve this capability since 1998. Our testimony was
delivered between October 2001 and March of this year, and is
summarized in enclosure I.
Our statements at these hearings have highlighted significant
challenges that VA and DOD have faced in pursuing ways to share data in
their health information systems and create electronic medical records.
Although noting the departments' ultimate success in sharing data
through the one-way transfer of health information from DOD to VA
health care facilities, as part of the Federal Health Information
Exchange,[Footnote 2] we also detailed persistent weaknesses in the
departments' actions toward achieving a two-way health data exchange--
the focus of the HealthePeople (Federal) initiative. For example, our
most recent testimony highlighted the limited progress that the
departments had made toward establishing sound project management and
defining a specific architecture and technological solution for
developing the electronic interface that is fundamental to exchanging
data between the individual health information systems that VA and DOD
are developing.
2. What recommendations have either VA or DOD implemented independently
or cooperatively?
VA and DOD have taken action on several recommendations that we have
made over the past 3 years. These recommendations were aimed at
improving the coordination and management of the departments' initial
efforts to achieve electronic information sharing via the Government
Computer-Based Patient Record (GCPR) project, and furthering DOD's
development of its new health information system, the Composite Health
Care System II. Our recommendations, along with the departments'
actions to implement them, are summarized in enclosure II.
In particular, our prior reviews of the project to develop a government
computer-based patient record determined that the lack of a lead
entity, clear mission, and detailed planning to achieve that mission
had made it difficult to monitor progress, identify project risks, and
develop appropriate contingency plans. As a result, in reporting on
GCPR in April 2001[Footnote 3] and again in June 2002,[Footnote 4] we
made several recommendations to help strengthen the management and
oversight of this project. VA and DOD agreed with and took actions that
addressed all of these recommendations, including designating VA as the
lead entity for the initiative, reevaluating and revising its original
goals and objectives, and assigning a full-time project manager and
supporting staff to oversee its implementation.
In addition, in September 2002 we reported on DOD's acquisition of the
Composite Health Care System II.[Footnote 5] DOD envisioned achieving a
state-of-the-art automated medical information system that would lead
to improved health-care decisions and lower medical and system costs
through creating computer-based patient records that doctors and other
health service providers would be able to access from any military
treatment facility, irrespective of location. However, our review of
the initiative noted, among other concerns, DOD's limited progress
during early stages of the system's development that led to a change in
its redesign and development/deployment schedule. We recommended five
actions aimed at increasing the project's likelihood of success, three
of which have been implemented. DOD is in various stages of
implementing the remaining two recommendations.
3. What is the total dollars spent by DOD and VA on their individual or
collective efforts on the development of an interoperable medical
record?
From fiscal year 1998, when VA and DOD began pursuing ways to share
data in their health information systems and create electronic records
for active duty personnel and veterans, through fiscal year 2003, the
departments reported spending a total of about $670 million on their
individual and collective efforts. As shown in table 1, this amount is
attributable to the departments' joint actions on the Government
Computer-Based Patient Record (GCPR) project and subsequently the
Federal Health Information Exchange (FHIE) initiative, which have
resulted in the one-way transfer of data from DOD's existing health
information system (the Composite Health Care System) to a separate
database that VA hospitals can access. The amount also includes the
departments' reported expenditures for individual health information
systems--VA's HealtheVet (VistA) and DOD's Composite Health Care System
II--that each is currently developing and anticipates using to support
the two-way exchange of health data as part of the HealthePeople
(Federal) initiative.[Footnote 6] However, through fiscal year 2003, VA
and DOD did not report any costs associated with the critical tasks of
defining and developing the electronic interface that is essential to
achieving the two-way exchange of patient health information between
these systems.
Table 1: Dollars (in millions) Spent by VA and DOD to Develop
Electronic Health Information Systems and Sharing Capabilities through
Fiscal Year 2003:
Agency: VA;
GCPR: $27.8;
FHIE: $20.4;
HealthePeople (Federal): HealtheNet VistA[A]: $120.0;
HeathePeople (Federal): Composite Health Care System II: $0.0 Total:
$168.2.
Agency: DOD;
GCPR: $17.7;
FHIE: $18.8;
HealthePeople (Federal): HealtheNet VistA[A]: $0.0;
HeathePeople (Federal): Composite Health Care System II:
$464.0;
Total: $168.2.
Total;
GCPR: $45.5;
FHIE: $39.2;
HealthePeople (Federal): HealtheNet VistA[A]: $120.0;
HeathePeople (Federal): Composite Health Care System II:
$464.0;
Total: $668.7.
Source: VA and DOD data.
[A] Veterans Health Information Systems and Technology Architecture:
[End of table]
4. GAO testified that there had been very little progress since our
last hearing in November 2003. How did VA and DOD explain this to you?
When Congress scheduled its March 17, 2004, hearing, did GAO get the
sense that this provided an incentive for the two departments to move
forward on this issue?
In discussing with VA and DOD their actions since last November toward
achieving a two-way exchange of patient health information under the
HealthePeople (Federal) initiative, officials in both departments
expressed their belief that progress was being made. In response to our
finding that the departments had not yet defined an architecture to
describe in detail how specific technologies will be used to achieve
the capability to electronically exchange data between their health
information systems--a significant concern that we also raised in our
November testimony--the officials stated that they had recently taken
an important first step toward accomplishing this task.
In particular, VA and DOD officials referred to a pharmacy prototype
project, undertaken in response to the Bob Stump National Defense
Authorization Act for Fiscal Year 2003, to develop a real-time
interface, data exchange, and capability to check prescription drug
data for outpatients by October 1, 2004. According to VA's Deputy Chief
Information Officer for Health, the departments hope to determine from
the prototype, planned for completion by September 2004, whether the
interface technology developed to meet this mandate can be used to
facilitate the exchange of data between the health information systems
that VA and DOD are currently developing. However, as our testimony
noted, the departments had not fully defined their approach or
requirements for developing and demonstrating the capabilities of the
planned prototype. Further, since VA and DOD have not yet completed
their new health information systems that are intended to be used under
HealthePeople (Federal), the demonstration may only test the ability to
exchange data in VA's and DOD's existing health systems--the Veterans
Health Information Systems and Technology Architecture (VistA) and the
Composite Health Care System (CHCS), respectively. Consequently, the
early stage of the prototype and the uncertainties regarding what
capabilities it will demonstrate provided little evidence or assurance
as to how or whether this project would contribute to defining the
architecture and technological solution for the two-way exchange of
patient health information.
The information collected during our review of the HealthePeople
(Federal) initiative suggests that the Subcommittee's scheduled hearing
may have provided an incentive for VA and DOD to move forward on this
issue. In conducting our review from December 2003 through March 2004,
we observed that the level of activity undertaken by the departments to
support the initiative increased significantly in the month preceding
the hearing. For example, the departments' officials first informed us
of their intent to rely on the planned pharmacy prototype to determine
the technology interface for the two-way data exchange capability in
early February; a contract for development of the prototype was
finalized on February 27. Beyond these actions, VA and DOD began steps
toward designating a program manager for the pharmacy prototype project
and establishing an overall project plan in the week before the
hearing.
5. GAO stated that success lies with the highest levels of project
discipline, including a well-defined architecture and an established
project management structure. At the present time, these criteria are
absent. Is that correct? Please provide your recommendations on the top
five priorities that need to be addressed in 2004.
At the time of our testimony, these critical project components were
absent from VA's and DOD's initiative to develop a two-way exchange of
patient health information. Specifically, VA and DOD lacked a clearly
defined architecture to describe how they planned to develop the
electronic interface needed to exchange data between their health
information systems. In addition, the departments had not fully
established a project management structure to ensure the necessary day-
to-day guidance of and accountability for their investments in and
implementation of this capability.
Given the implications that an electronic interface can have for
improving the quality of health care and disability claims processing
for military members and veterans, the top five priorities that VA and
DOD need to address in 2004 to increase the likelihood of a successful
outcome are:
* development of an architecture for the electronic interface that
articulates system requirements, design specifications, and software
descriptions;
* selection of a lead entity with final decision-making authority for
the initiative;
* establishment of a project management structure (i.e., project manager
and supporting staff) to provide day-to-day guidance of and
accountability for the investments in and implementation of the
electronic interface capability;
* development and implementation of a comprehensive and coordinated
project plan that defines the technical and managerial processes
necessary to satisfy project requirements and that includes the
authority and responsibility of each organizational unit; a work
breakdown structure and schedule for all of the tasks to be performed
in developing, testing, and deploying the electronic interface; and a
security plan; and:
* implementation of project review milestones and measures to provide
the basis for comprehensive management, progressive decision making,
and authorization of funding for each step in the development process.
VA and DOD officials stated at the conclusion of our review that they
had begun discussions to establish an overall project plan and finalize
roles and responsibilities for managing the joint initiative to develop
an electronic interface.
6. To your knowledge, has any major VA or DOD IT project ever been
initiated with such criteria firmly established from the beginning?
To date, we have evaluated only a small portion of VA's and DOD's
respective portfolios of information technology investments. Based on
our work, we cannot point to any instances in which either department
has initiated a major information technology project with a clearly
defined architecture and sound project management having been
established. At the same time, we are generally aware that DOD has held
out certain projects undertaken by its component organizations as
examples in which well-defined architectures and sound project
management existed. However, we did not participate in, and therefore
cannot comment on, the validity of those representations.
During our reviews of the Government Computer-Based Patient Record
project, we did see evidence that implementing critical project
management processes after a project has been undertaken can positively
affect its outcome. As our testimony noted,[Footnote 7] VA's and DOD's
designation of clear lines of authority and a manager to provide day-
to-day oversight helped strengthen overall project management and
accountability and contributed to successfully achieving the transfer
of patient health information from DOD to VA's medical facilities.
Agency Comments and Our Evaluation:
We received comments orally and via e-mail on a draft of this
correspondence from VA's Assistant Secretary for Information and
Technology and DOD's Interagency Program Integration and External
Liaison for Health Affairs. In commenting on our responses, these
officials offered additional perspectives and suggested
clarifications, which have been incorporated where appropriate. Both
departments' officials disagreed with the way in which our response to
question 4 characterized their progress toward developing a two-way
electronic data exchange capability.
Regarding our response to question 1, VA and DOD officials commented
that they have now designated a single manager for the electronic
interface initiative. They have not yet, however, provided for our
analysis any documentation on the project management structure and the
manager's and supporting staff's roles and responsibilities for
overseeing and ensuring accountability for this initiative.
Regarding our response to question 2, VA and DOD officials stated that
both departments have cooperatively implemented our recommendations.
Our response has been clarified to reflect that VA and DOD took actions
that addressed all of our recommendations for improving management of
the Government Computer-Based Patient Record project, and to reflect
that DOD has implemented three of five recommendations that we made to
improve its CHCS II project.
In commenting on our response to question 3, which addressed the total
dollars spent by VA and DOD on developing an electronic medical record
through fiscal year 2003 (the latest time frame for which we had
complete information reported by the departments), both VA and DOD
referred to initiatives other than GCPR, FHIE, and their individual
health information systems, which they believed reflected work on
developing the electronic data exchange capability. For example, both
departments identified the pharmacy prototype as a critical effort
toward developing an electronic interface for which resources were
being expended. Our testimony, as well as this correspondence,
acknowledges that the departments had taken action related to the
pharmacy prototype. However, this initiative was not undertaken until
late February of this year, which was outside of the time frame of the
reported costs reflected in our response to the question. We have
revised our response to more clearly reflect our use of cost
information reported through fiscal year 2003.
Beyond the pharmacy prototype, VA stated that a number of other
initiatives had also demonstrated progress toward achieving an
electronic interface. It stated, for example, that the departments had
contributed "in-kind" resources to efforts supporting the Consolidated
Health Informatics initiative and internal standards boards within each
department. However, VA did not provide any specific cost information
for these actions.
Finally, in commenting on the reported costs, DOD suggested that we
clarify the title of our table identifying the departments'
expenditures, to better reflect that not all costs reported through
fiscal year 2003 were directly attributable to achieving the two-way
electronic health data exchange. We have revised the table to more
clearly reflect the reported expenditures for GCPR, FHIE, and the
departments' individual health information system initiatives.
Regarding our response to question 4, VA and DOD stated that they did
not agree with our assessment that the departments' progress since
November 2003 had been limited, or that most progress had been apparent
just before the March hearing. Both departments cited their work
related to the pharmacy prototype project as evidence of their progress
toward developing the electronic interface. For example, DOD stated
that although the departments may not have informed us, before last
February, of their intent to rely on the pharmacy prototype to
determine the technology for the electronic interface, a memorandum
discussing the pharmacy data exchange strategy had been signed in
October 2003. However, we were not provided with copies of any such
documentation, and without information on such an activity, we cannot
offer an assessment of any actions taken by VA and DOD on the pharmacy
prototype earlier than February 2004--the point at which we were made
aware that this prototype would be used to help define the electronic
interface. Further, in its comments, VA said it continued to anticipate
that the prototype would assist in determining an appropriate
architecture for the electronic interface. Given the stage of the
pharmacy project and the supporting documentation available to us when
our review ended, our analysis determined that the departments lacked
evidence as to how or whether the project would contribute to defining
the architecture and technological solution for a two-way exchange of
patient health information.
Beyond the pharmacy prototype, VA cited numerous other initiatives
involving the departments' existing health information systems (VistA
and CHCS) and infrastructure that it considered to be evidence of
progress. These included a project aimed at automatically sending to VA
relevant electronic health information for patients sent to DOD for VA-
paid care as veterans; and a data-sharing interface project, involving
the use of VA's and DOD's existing health information systems to
produce real-time, bidirectional exchange of clinically relevant data,
including outpatient pharmacy, allergy, and patient demographic
information at VA and DOD locations with medical sharing agreements.
During our review, VA and DOD did not offer information on these
initiatives or identify them as being part of the HealthePeople
(Federal) strategy for an electronic two-way data exchange capability.
Therefore, we are unable to make an assessment of these initiatives or
how they relate to VA's and DOD's progress toward achieving the
intended capability to electronically exchange patient data between the
new health information systems--HealtheVet (VistA) and CHCS II--that
the departments are developing.
In commenting on the response to question 5, the departments identified
various actions that, in their views, addressed our identified
priorities for disciplined project management. Regarding the
development of an architecture to define the electronic interface, the
departments anticipated that the pharmacy prototype would assist them
in determining the appropriate architecture and emphasized their
continued work on developing standards that will affect the interface
requirements. Our testimony acknowledged the departments' actions on
developing data standards, and also noted their plans for using the
pharmacy prototype to determine the architecture for the electronic
interface. As we pointed out, however, the early stage of the prototype
and the uncertainties regarding what capabilities it would demonstrate
provided little evidence or assurance as to how or whether the project
would contribute to defining the architecture and technological
solution for a two-way exchange of patient health information.
Regarding the selection of a lead entity with final decision-making
authority for the electronic interface initiative, the departments
stated that the VA/DOD Health Executive Council was serving in this
capacity. VA added that this council provides a fully integrated body
in which decisions are made and accountability for progress is provided
for both departments. We agree that the Health Executive Council plays
an important role in helping to ensure full accountability for the
HealthePeople (Federal) initiative. Nonetheless, as established, this
council meets on a bimonthly basis and is composed of senior VA and DOD
leaders who work from a high-level, departmentwide perspective, to
institutionalize all of VA's and DOD's sharing and collaboration on
health services and resources. As our testimony noted, there is no one
entity dedicated to making binding decisions for the HealthePeople
(Federal) project. Our prior work on GCPR noted the importance of a
lead entity to exercise final authority over the project, and VA and
DOD demonstrated improvements in managing GCPR as a result of
implementing our recommendation that it establish such an entity.
On establishing a project manager and supporting staff to provide day-
to-day guidance for the electronic interface initiative, VA and DOD
cited their designation of a single manager with accountability and
day-to-day responsibility for project implementation. However, as
discussed, the departments have not yet provided documentation of the
management structure that they have implemented, including information
on the roles and responsibilities that the manager and supporting staff
will have for the joint electronic interface initiative.
Regarding the development and implementation of a comprehensive and
coordinated project plan for the electronic interface initiative, the
departments stated that a project management plan had been developed
for the pharmacy prototype. We agree that such a plan is necessary for
the pharmacy prototype. However, it is also essential that the
departments have a project management plan for the electronic interface
initiative to define the technical and managerial processes needed to
satisfy project requirements, and assign responsibilities, tasks, and
schedules associated with developing, testing, and deploying the
electronic interface between the new health information systems that VA
and DOD are developing.
Further, regarding the implementation of project review milestones and
measures for the electronic interface initiative, VA and DOD stated
that the departments provide updates to the Health Executive Council
and the Joint Executive Council. VA added that performance measures for
interoperability are built into the joint strategic plan managed by the
Joint Executive Council. As our March testimony noted, the Health
Executive Council meets bimonthly to institutionalize sharing and
collaboration of health services and resources, and the Joint Executive
Council meets quarterly to recommend strategic direction of joint
coordination and sharing efforts. VA and DOD did not provide any
evidence to explain the levels of update being provided to these
councils or how the councils' reviews address critical milestones and
measures of the initiative's progress. In addition, our review of the
joint strategic plan found that this high-level strategy established
broad time frames and a general approach for achieving a health data
exchange between VA and DOD, but did not articulate specific details
regarding the incremental design and development of the electronic
interface capability. For example, the strategy lacked specific
milestones or measures that would enable the departments to track the
status of their actions toward developing the interface at critical
intervals in the project's life cycle.
Finally, in commenting on our response to question 6, VA officials
stated that the department has implemented all of its major health
information initiatives under the Veterans Health Information Systems
and Technology Architecture. For its part, DOD stated that it is guided
by a rigorous project management system, and cited our September 2002
report[Footnote 8] in which we stated that the CHCS II initiative was
generally aligned with the Military Health System's (MHS) enterprise
architecture. As noted, our evaluations have not identified any major
initiatives that VA and DOD have begun with both a clearly defined
architecture and sound project management already established. While
our report on DOD's CHCS II noted that this system and the MHS
architecture were generally aligned, it also highlighted deficiencies
in the project's management during its early years. For example,
performance-based contracting methods were not used to ensure
contractor accountability.
In responding to these questions, we relied on past work related to our
review of VA's and DOD's actions since last November toward defining a
detailed strategy and developing the capability for a two-way exchange
of patient health information. We reviewed our prior analyses of key
documentation supporting the departments' strategy, including
deployment and conversion plans, project schedules, and status reports
for their individual health information systems. In addition, we
reviewed documentation identifying the costs incurred by VA and DOD in
developing technology to support the sharing of health data, including
costs for the Government Computer-Based Patient Record and Federal
Health Information Exchange initiatives, and with their ongoing
projects to develop new health information systems. We did not audit
the reported costs, and thus cannot attest to their accuracy or
completeness. We conducted our work in accordance with generally
accepted government auditing standards, during April 2004.
We are sending copies of this letter to the Secretaries of Veterans
Affairs and Defense, and to other interested parties. Copies will also
be available at no charge at our Web site at www.gao.gov.
Should you or your office have any questions on matters discussed in
this letter, please contact me at (202) 512-6240 or Valerie Melvin,
Assistant Director, at (202) 512-6304. We can also be reached by e-mail
at koontzl@gao.gov and melvinv@gao.gov, respectively. Key contributors
to this correspondence include Barbara S. Oliver, J. Michael Resser,
and Eric Trout.
Sincerely yours,
Signed by:
Linda D. Koontz:
Director, Information Management Issues:
Enclosure I: GAO Testimony on VA-DOD Sharing of Patient Health
Information:
Testimony date/number; March 17, 2004; GAO-04-402T;
Summary of results: VA and DOD had made little progress since November
2003 toward defining how they intended to achieve the two-way exchange
of patient health information under the HealthePeople (Federal)
initiative. While VA officials recognized the importance of an
architecture to describe in detail how the departments would
electronically interface their health systems, they continued to rely
on a less-specific, high-level strategy--in place since September 2002
--to guide the development and implementation of this capability. The
departments intended to rely on a pharmacy prototype project undertaken
in March 2004 to better define the electronic interface needed to
exchange patient health data, but had not fully determined the approach
or requirements for this undertaking. Thus, there was little evidence
of how this project would contribute to defining a specific
architecture and technological solution for achieving a two-way
exchange of patient health information. These uncertainties were
further complicated by the absence of sound project management to guide
the departments' actions on the HealthePeople (Federal) initiative.
Although progress toward defining data standards continued, delays had
occurred in VA's and DOD's development and deployment of their
individual health information systems, critical for achieving the
electronic interface.
Testimony date/number; November 19, 2003; GAO-04-271T;
Summary of results: The one-way transfer of health information
resulting from VA's and DOD's near-term solution--the Federal Health
Information Exchange (FHIE)--represented a positive undertaking and had
enabled electronic health data from separated (retired or discharged)
service members contained in DOD's Military Health System Composite
Health Care System to be transmitted monthly to a VA FHIE repository,
giving VA clinicians more ready access to DOD health data, such as
laboratory, pharmacy, and radiology records, on almost 2 million
patients. The departments' longer term strategy to enable electronic,
two-way information sharing--HealthePeople (Federal)--was farther out
on the horizon, and VA and DOD faced significant challenges in
implementing a full data exchange capability. Although a high-level
strategy existed, the departments had not clearly articulated a common
health information infrastructure and architecture to show how they
intended to achieve the data exchange capability or what they would be
able to exchange by the end of 2005. Critical to achieving the two-way
exchange was completing the standardization of the clinical data that
the departments planned to share.
Testimony date/number; September 26, 2002; GAO-02-1054T;
Summary of results: VA and DOD reported some progress in achieving the
capability to share patient health care data under the Government
Computer-Based Patient Record (GCPR) initiative. The agencies had,
since March 2002, formally renamed the initiative the Federal Health
Information Exchange and begun implementing a more narrowly defined
strategy involving the one-way transfer of patient health data from DOD
to VA;
a two-way exchange was planned by 2005.
Testimony date/number; March 13, 2002; GAO-02-369T;
VA had achieved limited progress in its joint efforts with DOD and the
Indian Health Service to create an interface for sharing data in their
health information systems, as part of GCPR. Strategies for
implementing the project continued to be revised, its scope had been
substantially narrowed from its original objectives, and it continued
to operate without clear lines of authority or comprehensive,
coordinated plans. Consequently, the future success of this project
remained uncertain, raising questions as to whether it would ever fully
achieve its original objective of allowing health care professionals to
share clinical information via a comprehensive, lifelong medical
record.
Testimony date/number; February 27, 2002; GAO-02-478T;
Summary of results: DOD's and VA's numerous databases and electronic
systems for capturing mission-critical data, including health
information, were not linked, and information could not be readily
shared. DOD had several initiatives under way to link many of its
information systems--some with VA. For example, to create a
comprehensive, lifelong medical record for service members and veterans
and to allow health care professionals to share clinical information,
the departments, along with the Indian Health Service, initiated the
Government Computer-Based Patient Record (GCPR) project in 1998.
However, several factors, including planning weaknesses, competing
priorities, and inadequate accountability, made it unlikely that they
would achieve a GCPR or realize its benefits in the near future. To
strengthen management and oversight of the project, we recommended
designating a lead entity with clear lines of authority for the project
and the creation of comprehensive and coordinated plans for sharing
meaningful, accurate, and secure patient health data. For the near
term, DOD and VA had decided to reconsider their approach to GCPR and
focus on allowing VA to access selected service members' health data
captured by DOD, such as laboratory and radiology results, outpatient
pharmacy data, and patient demographic information. However, GCPR would
not provide VA with access to information on the health status of
personnel when they entered military service; on medical care provided
to Reservists while not on active duty; or on the care military
personnel received from providers outside DOD, including those from
TRICARE.[A].
Testimony date/number; January 24, 2002; GAO-02-377T;
Summary of results: DOD improved its medical surveillance system under
Operation Joint Endeavor. However, system problems included lack of a
single, comprehensive electronic system to document and access medical
surveillance data. Some DOD initiatives to improve information
technology capability were several years away from full implementation.
The ability of VA to fulfill its role in serving veterans and providing
backup to DOD in times of war was to be enhanced as DOD increased its
medical surveillance capability. GCPR was a joint DOD/VA initiative in
conjunction with the Indian Health Service to link information systems.
However, because of planning weaknesses, competing priorities, and
inadequate accountability, it was unlikely that the departments would
accomplish GCPR or realize its benefits in the near future. To
strengthen management and oversight of the initiative, we again
recommended designating a lead entity with clear lines of authority for
the project and the creation of comprehensive and coordinated plans for
sharing meaningful, accurate, and secure patient health data.
Testimony date/number; October 16, 2001; GAO-02-173T;
Summary of results: DOD and VA were establishing a medical surveillance
system for the health care needs of military personnel and veterans.
The system was to collect and analyze uniform information on
deployments, environmental health threats, disease monitoring, medical
assessments, and medical encounters. We identified weaknesses in DOD's
medical surveillance capability and performance in the Gulf War and
Operation Joint Endeavor, and uncovered deficiencies in its ability to
collect, maintain, and transfer accurate data. The department had
several initiatives under way to improve the reliability of deployment
information and to enhance its information technology capabilities,
although some initiatives were several years away from full
implementation. VA's ability to serve veterans and provide backup to
DOD in times of war was to be enhanced as DOD increased its medical
surveillance capability. GCPR was one initiative to link the
departments' information systems. However, because of planning
weaknesses, competing priorities, and inadequate accountability, it was
unlikely that they would accomplish GCPR or realize its benefits in the
near future. To strengthen management and oversight of the initiative,
we recommended designating a lead entity with clear lines of authority
for the project and the creation of comprehensive and coordinated plans
for sharing meaningful, accurate, and secure patient health data.
[A] TRICARE is the Department of Defense's worldwide health care
program for active duty and retired uniformed services members and
their families.
Source: GAO.
[End of table]
Enclosure II: Actions Taken by VA and DOD on GAO Recommendations:
Report date/number: June 12, 2002; GAO-02-703;
Recommendations: The Secretary of Veterans Affairs, to make significant
progress beyond the current strategy for the government computer-based
patient record, should instruct the Veterans Health Administration
(VHA) undersecretary and VHA chief information officer, in cooperation
with DOD and the Indian Health Service (IHS), to revisit the original
goals and objectives of the Government Computer-Based Patient Record
(GCPR) initiative to determine if they remain valid, and where
necessary, revise the goals and objectives to be aligned with the
current strategy and direction of the project;
Actions taken by VA and/or DOD: The Department of Veterans Affairs
(VA), in conjunction with DOD, implemented this recommendation. The
departments reevaluated and revised the original goals and objectives
of the GCPR initiative. A May 3, 2002, memorandum of agreement between
VA and DOD established the Federal Health Information Exchange (FHIE),
which replaced the GCPR initiative. As of mid-July 2002, all VA medical
centers had access to FHIE data on over 1 million service personnel who
separated between 1987 and 2001.
Report date/number: June 12, 2002; GAO-02-703;
Recommendations: The Secretary of Veterans Affairs, to make significant
progress beyond the current strategy for GCPR, should instruct the VHA
undersecretary and VHA chief information officer, in cooperation with
DOD and IHS, to commit the executive support necessary for adequately
managing the project, and ensure that sound project management
principles are followed in carrying out the initiative;
Actions taken by VA and/or DOD: VA, in conjunction with DOD,
implemented this recommendation. The departments committed the
executive support necessary for adequately managing the GCPR project.
They also ensured that project management principles were followed in
carrying out the initiative. Specifically, in May 2002 VA and DOD
signed a memorandum of agreement that designated VA as the lead entity
in implementing the project (formally renamed FHIE). VA committed
executive support for the project by way of monthly updates, given by
the FHIE program manager, to the VA chief information officer, as well
as quarterly updates to the joint VA/DOD Executive Council. In
addition, VA procured and implemented project management software to
better track the assignment and status of project tasks and
initiatives.
Report date/number: September 26, 2002; GAO-02-345;
Recommendations: The Secretary of Defense, through the Assistant
Secretary of Health Affairs, should direct the Military Health System
(MHS) chief information officer to give expanded use of best practices
in managing CHCS II the attention and priority it deserves. At a
minimum, the Assistant Secretary should direct the MHS chief
information officer to, as part of the CHCS II deployment decisions,
consider the aggregate impact on defense health affairs mission
performance caused by the workarounds needed to compensate for all
unresolved defects affecting the system's operational efficiency;
Actions taken by VA and/or DOD: DOD implemented this recommendation. In
late 2002, the program office produced a maintenance release for CHCS
II that corrected many of the remaining bugs that required workarounds,
and the limited deployment sites have that version. In addition, MHS
has put a standard operating procedure in place to evaluate the effect
of all workarounds required for new systems/versions before
implementation. The standard operating procedure is part of the
configuration control board procedures and the service components have
agreed to these procedures. Finally, a test and evaluation master plan
that addresses the aggregate impact of workarounds has been completed
for the CHCS II release of functionality supporting general dentistry,
and will be used as a template for future plans.
Report date/number: September 26, 2002; GAO-02-345;
Recommendations: The Assistant Secretary of Health Affairs should
direct the MHS chief information officer to verify that the CHCS II
inventory of risks is complete and correct, and report this to the
Assistant Secretary for Health Affairs every 6 months, along with a
report on the status of all top priority risks, including each risk's
probability of occurrence and impact on mission;
Actions taken by VA and/or DOD: DOD implemented this recommendation.
The program office updated the risk management plan to require
continuous risk management database updates and monthly risk reports.
An initial 6-month report was provided to the Assistant Secretary in
April 2003 that included the status of all program risks, with details
on priority 1 risks, including probability of occurrence and impact on
mission.
Report date/number: September 26, 2002; GAO-02-345;
Recommendations: The Secretary of Defense should direct the Assistant
Secretary of Defense for Command, Control, Communications, and
Intelligence, who is the designated approval authority for CHCS II, to
monitor the project's use of best practices, including implementation
of each of the above recommendations, and use this information to
oversee the project's movement through its acquisition cycle. To this
end, the Assistant Secretary, or other designated CHCS II approval
authority, should not grant any request for deployment approval of any
CHCS II release that is not justified by reliable analysis of the
release's costs, benefits, and risks;
Actions taken by VA and/or DOD: DOD implemented this recommendation.
The program office updated its cost- benefit analysis in September
2002, and the Naval Center for Cost Analysis validated the cost
estimate. This was used to approve the limited deployment of a
graphical user interface for clinical outpatient processes in January
2003, and is available for use by the milestone decision authority for
the full deployment decision.
Report date/number: September 26, 2002; GAO-02-345;
Recommendations: The Secretary of Defense, through the Assistant
Secretary of Health Affairs, should direct the MHS CIO to give expanded
use of best practices in managing CHCS II the attention and priority
they deserve. At a minimum, the Assistant Secretary should direct the
MHS CIO to define and implement incremental investment management
processes to include
(1) modifying the CHCS II investment strategy to define how this
approach will be implemented;
(2) justifying investment in each system release before beginning
detailed design and development of the release;
(3) requiring that such justification be based on reliable estimates of
costs, benefits, and risks;
(4) measuring whether actual return-on-investment for each deployed
release is in line with justification forecasts;
and (5) using actual return-on investment results in deciding whether
to begin detailed design and development of the next system release;
Actions taken by VA and/or DOD: Actions to implement this
recommendation are ongoing. MHS has contracted with the Army Test and
Evaluation Command and a private contractor to assess limited
deployment sites and obtain data on initial benefits to support return-
on-investment analyses. Deployments of the initial version of the
system were delayed until fiscal year 2004; it is therefore unlikely
that this recommendation will be fully addressed before the end of the
fiscal year.
Report date/number: September 26, 2002; GAO-02-345;
Recommendations: The Secretary of Defense, through the Assistant
Secretary of Health Affairs, should direct the MHS CIO to give expanded
use of best practices in managing CHCS II the attention and priority
they deserve. At a minimum, the Assistant Secretary should direct the
MHS CIO to employ performance-based contracting practices on all future
CHCS II delivery orders to the maximum extent possible, including (1)
defining performance standards against which deliverables can be
judged, (2) developing and using quality assurance plans that describe
how contractor performance against the standards will be measured, and
(3) defining and using contractor incentives and penalties tied to the
quality plan;
Actions taken by VA and/or DOD: Actions to implement this
recommendation are ongoing. The program office received approval to
begin acquiring commercial off- the-shelf software packages to develop
prototype pharmacy/laboratory/ radiology capabilities, and plans to
conduct full and open competition contracts for these packages. A
performance-based, firm fixed-price integration contract, with
incentives, is being prepared and is expected to be awarded in the 3rd
quarter of fiscal year 2004. As the program office re-negotiates the
contracts for a graphical user interface for clinical outpatient
processes and general dentistry, they will also be moved to this
performance-based type of contract.
Source: GAO.
[End of table]
(310712):
FOOTNOTES
[1] U.S. General Accounting Office, Computer-Based Patient Records:
Sound Planning and Project Management Are Needed to Achieve a Two-Way
Exchange of VA and DOD Health Data, GAO-04-402T (Washington, D.C.: Mar.
17, 2004).
[2] When undertaken in 1998, the initiative to share patient health
care information was called the Government Computer-Based Patient
Record project. The project was renamed the Federal Health Information
Exchange in 2002.
[3] U.S. General Accounting Office, Computer-Based Patient Records:
Better Planning and Oversight by VA, DOD, and IHS Would Enhance Health
Data Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001).
[4] U.S. General Accounting Office, Veterans Affairs: Sustained
Management Attention Is Key to Achieving Information Technology
Results, GAO-02-703 (Washington, D.C.: June 12, 2002).
[5] U.S. General Accounting Office, Information Technology: Greater Use
of Best Practices Can Reduce Risks in Acquiring Defense Health Care
System, GAO-02-345 (Washington, D.C.: Sept. 26, 2002).
[6] DOD began developing CHCS II in 1997 and has completed its
associated clinical data repository that is key to achieving the
electronic interface. DOD expects to complete deployment of all of its
major system capabilities by September 2008. VA began work on
HealtheVet (VistA) and its associated health data repository in 2001,
and expects to complete the six initiatives that make up this system in
2012.
[7] GAO-04-402T.
[8] GAO-02-345.
