Computer-Based Patient Records
VA and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project Management Gao ID: GAO-04-687 June 7, 2004A critical element of the Department of Veterans Affairs' (VA) information technology program is its continuing work with the Department of Defense (DOD) to achieve the ability to exchange patient health care information and create electronic medical records for use by veterans, active-duty military personnel, and their health care providers.
While VA and DOD continue to move forward in agreeing to and adopting standards for clinical data, they have made little progress since last winter toward defining how they intend to achieve an electronic medical record based on the two-way exchange of patient health data. The departments continue to face significant challenges in achieving this capability. VA and DOD lack an explicit architecture--a blueprint--that provides details on what specific technologies will be used to achieve the electronic medical record by the end of 2005. The departments have not fully implemented a project management structure that establishes lead decision-making authority and ensures the necessary day-to-day guidance of and accountability for their investment in and implementation of this project. They are operating without a project management plan describing the specific responsibilities of each department in developing, testing, and deploying the electronic interface. In seeking to provide a two-way exchange of health information between their separate health information systems, VA and DOD have chosen a complex and challenging approach--one that necessitates the highest levels of project discipline. Yet critical project components are currently lacking. As such, the departments risk investing in a capability that could fall short of what is expected and what is needed. Until a clear approach and sound planning are made integral parts of this initiative, concerns about exactly what capabilities VA and DOD will achieve--and when--will remain.
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: Team: Phone:GAO-04-687, Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project Management
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Report to the Chairman, Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs, House of Representatives:
United States General Accounting Office:
GAO:
June 2004:
Computer-Based Patient Records:
VA and DOD Efforts to Exchange Health Data Could Benefit from Improved
Planning and Project Management:
GAO-04-687:
GAO Highlights:
Highlights of GAO-04-687, a report to the Subcommittee on Oversight and
Investigations, House Committee on Veterans' Affairs
Why GAO Did This Study:
A critical element of the Department of Veterans Affairs‘ (VA)
information technology program is its continuing work with the
Department of Defense (DOD) to achieve the ability to exchange patient
health care information and create electronic medical records for use
by veterans, active-duty military personnel, and their health care
providers.
This report provides an assessment of the departments‘ recent progress
toward achieving an electronic two-way exchange of health care data,
along with recommendations based on GAO‘s work.
What GAO Found:
While VA and DOD continue to move forward in agreeing to and adopting
standards for clinical data, they have made little progress since last
winter toward defining how they intend to achieve an electronic
medical record based on the two-way exchange of patient health data.
The departments continue to face significant challenges in achieving
this capability.
* VA and DOD lack an explicit architecture”a blueprint”that provides
details on what specific technologies will be used to achieve the
electronic medical record by the end of 2005.
* The departments have not fully implemented a project management
structure that establishes lead decision-making authority and ensures
the necessary day-to-day guidance of and accountability for their
investment in and implementation of this project.
* They are operating without a project management plan describing the
specific responsibilities of each department in developing, testing,
and deploying the electronic interface.
In seeking to provide a two-way exchange of health information between
their separate health information systems, VA and DOD have chosen a
complex and challenging approach”one that necessitates the highest
levels of project discipline. Yet critical project components are
currently lacking. As such, the departments risk investing in a
capability that could fall short of what is expected and what is
needed. Until a clear approach and sound planning are made integral
parts of this initiative, concerns about exactly what capabilities VA
and DOD will achieve”and when”will remain.
What GAO Recommends:
To help ensure progress by the departments in achieving the two-way
exchange of health information, GAO recommends that the Secretaries of
Veterans Affairs and Defense develop an architecture for the systems‘
electronic interface, establish a project management structure that
designates a lead decision-making entity, and create and implement a
coordinated project plan for developing the interface between the
departments‘ health information systems. In commenting on a draft of
this report, the departments agreed with our recommendations and
identified actions planned or undertaken to address them.
www.gao.gov/cgi-bin/getrpt?GAO-04-687.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Linda D. Koontz at (202)
512-6240 or koontzl@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
The Two-Way Exchange Could Benefit from Improved Planning and Project
Management:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Comments from the Secretary of Veterans Affairs:
Appendix II: Comments from the Director, Interagency Program
Integration & External Liaison for Health Affairs:
United States General Accounting Office:
Washington, DC 20548:
June 7, 2004:
The Honorable Steve Buyer:
Chairman, Subcommittee on Oversight and Investigations:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Chairman:
As you know, the Departments of Veterans Affairs (VA) and Defense (DOD)
are currently pursuing the ability to exchange patient health care data
and create an electronic medical record for veterans and active-duty
military personnel. While in military status and later as veterans,
many patients tend to be highly mobile and may have health records
residing at multiple medical facilities within and outside of the
United States. Having readily accessible medical data on these
individuals is important to providing high-quality health care to them
and to adjudicating any disability claims that they may have. This goal
of having electronic medical records that display all available
clinical information in each department's health information system is
a positive and necessary step. However, as we have previously
reported,[Footnote 1] the lack of progress the departments have made in
accomplishing this two-way exchange of health care data raises doubts
as to when and to what extent a true electronic medical record will be
achieved.
As requested, our objective was to assess VA's and DOD's recent
progress toward achieving an electronic two-way exchange of health care
data. In conducting our work, we analyzed key documentation supporting
VA's and DOD's strategy for developing and implementing the two-way
electronic exchange of health data. In addition, we reviewed
documentation to identify 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/Federal Health
Information Exchange (GCPR/FHIE) initiatives, DOD's Composite Health
Care System II, and VA's HealtheVet VistA. We did not audit the
reported costs, and thus, cannot attest to their accuracy or
completeness. We supplemented our analyses with interviews of VA and
DOD officials responsible for key decisions and actions on the
initiatives. Our work was performed at VA and DOD offices located in
the Washington, D.C., area in accordance with generally accepted
government auditing standards, from December 2003 to May of this year.
Results in Brief:
While VA and DOD have continued to define data standards that are
essential to facilitating the exchange of data, they have made little
progress toward defining just how they intend to achieve the two-way
exchange of patient health data between their two health information
systems currently under development. Although VA officials recognize
the importance of having an architecture that describes in detail how
they plan to develop an electronic interface between those systems,
they acknowledge that the departments' efforts continue to be guided by
a less specific, high-level strategy that has been in place since
September 2002. Compounding the challenge and uncertainties of
developing the electronic interface is that VA and DOD have not fully
established a project management structure to ensure the necessary day-
to-day guidance of and accountability for the departments' investment
in and implementation of this capability. Although maintaining that
they were collaborating on this initiative through a joint working
group and receiving oversight from executive-level councils, neither
department has the authority to make final project decisions binding on
the other. Further, the departments are operating without a project
management plan describing the specific responsibilities of VA and DOD
in developing, testing, and deploying the interface. In the absence of
an explicit architecture and critical project management, VA and DOD
are progressing slowly in their development of the interface and their
limited progress to date calls into question the departments' ability
to begin exchanging patient health information by their targeted date
of the end of 2005.
Given the implications that readily accessible medical data can have
for improving the quality of health care and disability claims
processing for military members and veterans, we are recommending that
the Secretaries of Veterans Affairs and Defense take a number of
actions to improve the likelihood of successfully achieving the two-way
exchange of medical data.
In commenting on a draft of this report, the Secretary of Veterans
Affairs and DOD's Interagency Program Integration and External Liaison
for Health Affairs agreed with the report's recommendations. In their
comments, they provided information on actions planned or undertaken to
improve program management.
Background:
Since 1998 VA and DOD have been trying to achieve the capability to
share patient health care data electronically. The original effort--the
government computer-based patient record (GCPR) project--included the
Indian Health Service (IHS) and was envisioned as an electronic
interface that would allow physicians and other authorized users at VA,
DOD, and IHS health facilities to access data from any of the other
agencies' health information systems. The interface was expected to
compile requested patient information in a virtual record that could be
displayed on a user's computer screen.
Our prior reviews of the GCPR project determined that the lack of a
lead entity, clear mission, and detailed planning to achieve that
mission made it difficult to monitor progress, identify project risks,
and develop appropriate contingency plans. Accordingly, reporting on
this project[Footnote 2] in April 2001 and again in June 2002, we made
several recommendations to help strengthen the management and oversight
of GCPR. Specifically, in 2001 we recommended that the participating
agencies (1) designate a lead entity with final decision-making
authority and establish a clear line of authority for the GCPR project,
and (2) create comprehensive and coordinated plans that included an
agreed-upon mission and clear goals, objectives, and performance
measures, to ensure that the agencies could share comprehensive,
meaningful, accurate, and secure patient health care data. In 2002, we
recommended that the participating agencies revise the original goals
and objectives of the project to align with their current strategy,
commit the executive support necessary to adequately manage the
project, and ensure that it followed sound project management
principles. VA and DOD took specific measures in response to our
recommendations for enhancing overall management and accountability of
the project.
By July 2002, VA and DOD had revised their strategy and had made some
progress toward electronically sharing patient health data. The two
departments had renamed the project the Federal Health Information
Exchange (FHIE) program and, consistent with our prior recommendation,
had finalized a memorandum of agreement designating VA as the lead
entity for implementing the program. This agreement also established
FHIE as a joint effort that would allow the exchange of health care
information in two phases. The first phase, completed in mid-July 2002,
enabled the one-way transfer of data from DOD's existing health
information system to a separate database that VA clinicians could
access. A second phase, finalized this past March, completed VA's and
DOD's efforts to add to the base of patient health information
available to VA clinicians via this one-way sharing capability. The
departments reported total GCPR/FHIE costs of about $85 million through
fiscal year 2003.
The revised strategy also envisioned the pursuit of a longer term, two-
way exchange of health information between DOD and VA.[Footnote 3]
Known as HealthePeople (Federal), this initiative is premised upon the
departments' development of a common health information architecture
comprising standardized data, communications, security, and high-
performance health information systems. The joint effort is expected to
result in the secured sharing of health data required by VA's and DOD's
health care providers between systems that each department is currently
developing--DOD's Composite Health Care System (CHCS) II and VA's
HealtheVet VistA.
DOD began developing CHCS II in 1997 and has completed the development
of its associated clinical data repository--a key component for the
planned electronic interface. The department expects to complete
deployment of all of its major system capabilities by September
2008.[Footnote 4] It reported expenditures of about $464 million for
the system through fiscal year 2003. VA began work on HealtheVet VistA
and its associated health data repository in 2001, and expects to
complete all six initiatives comprising this system in 2012.[Footnote
5] VA reported spending about $120 million on HealtheVet VistA through
fiscal year 2003.
Under the HealthePeople (Federal) initiative, VA and DOD envision that,
upon entering military service, a health record for the service member
will be created and stored in DOD's CHCS II clinical data repository.
The record will be updated as the service member receives medical care.
When the individual separates from active duty and, if eligible, seeks
medical care at a VA facility, VA will then create a medical record for
the individual, which will be stored in its health data repository.
Upon viewing the medical record, the VA clinician would be alerted and
provided access to the individual's clinical information residing in
DOD's repository. In the same manner, when a veteran seeks medical care
at a military treatment facility, the attending DOD clinician would be
alerted and provided with access to the health information in VA's
repository. According to the departments, this planned approach would
make virtual medical records displaying all available patient health
information from the two repositories accessible to both departments'
clinicians. VA officials have stated that they anticipate being able to
exchange some degree of health information through an interface of
their health data repository with DOD's clinical data repository by the
end of calendar year 2005.
The Two-Way Exchange Could Benefit from Improved Planning and Project
Management:
While VA and DOD are making progress in agreeing to and adopting
standards for clinical data,[Footnote 6] they continue to face
significant challenges in providing a virtual medical record based on
the two-way exchange of data as part of their HealthePeople (Federal)
initiative. Specifically, VA and DOD do not have:
* an explicit architecture that provides details on what specific
technologies they will use to achieve the exchange capability;
* a fully established project management structure that will ensure the
necessary day-to-day guidance of and accountability for the
departments' investment in and implementation of the exchange; and:
* a project management plan describing the specific responsibilities of
each department in developing, testing, and deploying the interface and
addressing security requirements.
System Architecture Not Developed:
VA's and DOD's ability to exchange data between their separate health
information systems is crucial to achieving the goals of HealthePeople
(Federal). Yet, successfully sharing health data between the
departments via a secure electronic interface between each of their
data repositories can be complex and challenging, and depends
significantly on the departments' having a clearly articulated
architecture, or blueprint, defining how specific technologies will be
used to achieve the interface. Developing, maintaining, and using an
architecture is a best practice in engineering information systems and
other technological solutions. An architecture would articulate, for
example, the system requirements and design specifications, database
descriptions, and software descriptions that define the manner in which
the departments will electronically store, update, and transmit their
data.
VA and DOD lack an explicit architecture that provides details on what
specific technologies they will use to achieve the exchange capability,
or just what they will be able to exchange by the end of 2005--their
projected date for having this capability operational. While VA
officials stated that they recognize the importance of a clearly
defined architecture, they acknowledged that the departments' actions
were continuing to be driven by the less specific, high-level strategy
that has been in place since September 2002.
Officials in both departments stated that a planned pharmacy prototype
initiative, begun this past March in response to requirements of the
National Defense Authorization Act of 2003,[Footnote 7] would assist
them in defining the electronic interface technology needed to exchange
patient health information. The act mandated that VA and DOD develop a
real-time interface, data exchange, and capability to check
prescription drug data for outpatients by October 1, 2004. In late
February, VA hired a contractor to develop the planned prototype but
the departments had not yet fully determined the approach or
requirements for it. DOD officials stated that the contractor was
expected to more fully define the technical requirements for the
prototype. In late April, the departments reported approval of the
contractor's requirements and technical design for the prototype.
While the pharmacy prototype may help define a technical solution for
the two-way exchange of health information between the two departments'
existing systems, there is no assurance that this same solution can be
used to interface the new systems under development. Because the
departments' new health information systems--major components of
HealthePeople (Federal)--are scheduled for completion over the next 4
to 9 years, the prototype may only test the ability to exchange data in
VA's and DOD's existing health systems. Thus, given the uncertainties
regarding what capabilities the pharmacy prototype will demonstrate, it
is difficult to predict how or whether the prototype initiative will
contribute to defining the architecture and technological solution for
the two-way exchange of patient health information for the
HealthePeople (Federal) initiative.
Fully Established Project Management Structure Not in Place:
Industry best practices and information technology project management
principles stress the importance of accountability and sound planning
for any project, particularly an interagency effort of the magnitude
and complexity of HealthePeople (Federal). Based on our past work, we
have found that a project management structure should establish
relationships between managing entities with each entity's roles and
responsibilities clearly articulated.[Footnote 8] Further, it is
important to establish final decision-making authority with one entity.
However, VA and DOD have not fully established a project management
structure that will ensure the necessary day-to-day guidance of and
accountability for the departments' investment in and implementation of
the two-way capability. According to officials in both departments a
joint working group and oversight by the Joint Executive Council and
VA/DOD Health Executive Council has provided the collaboration
necessary for HealthePeople (Federal).[Footnote 9] However, this
oversight by the executive councils is at a very high level, occurs
either bimonthly or quarterly, and encompasses all of the joint
coordination and sharing efforts for health services and resources.
Since a lead entity has not been designated, neither department has had
the authority to make final project decisions binding on the other.
Further, the roles and responsibilities for each department have not
been clearly articulated. Without a clearly defined project management
structure, accountability and a means to monitor progress are difficult
to establish.
In early March, VA officials stated that the departments had designated
a program manager for the planned pharmacy prototype and were
establishing roles and responsibilities for managing the joint
initiative to develop an electronic interface. Just this month,
officials from both departments told us that this individual would be
the program manager for the electronic interface. However, they had not
yet designated a lead entity or provided documentation for the project
management structure or their roles and responsibilities for the
HealthePeople (Federal) initiative.
Project Management Plan Lacking:
An equally important component necessary for guiding the development of
the electronic interface is a project management plan. Information
technology project management principles and industry best
practices[Footnote 10] emphasize that a project management plan is
needed to define the technical and managerial processes necessary to
satisfy project requirements. Specifically, the plan should include,
among other things, the authority and responsibility of each
organizational unit; a work breakdown structure for all of the tasks to
be performed in developing, testing, and deploying the software, along
with schedules associated with the tasks; and a security policy.
However, the departments are currently operating without a project
management plan for HealthePeople (Federal) that describes the specific
responsibilities of each department in developing, testing, and
deploying the interface and addressing security requirements. This
month, officials from both departments stated that a pharmacy prototype
project management plan that includes a work breakdown structure and
schedule was developed in mid-March. They further stated that a work
group that reports to the integrated project team has been given
responsibility for the development of security and information
assurance provisions. While these actions should prove useful in
guiding the development of the prototype, they do not address the
larger issue of how the departments will develop and implement an
interface to exchange health care information between their systems by
2005.
Without a project management plan, VA and DOD lack assurance that they
can successfully develop and implement an electronic interface and the
associated capability for exchanging health information within the time
frames that they have established. VA and DOD officials stated that
they have begun discussions to establish an overall project plan.
Conclusions:
Achieving an electronic interface that will enable VA and DOD to
exchange patient medical records is an important goal, with substantial
implications for improving the quality of health care and disability
claims processing for the nation's military members and veterans. In
seeking a virtual medical record based on the two-way exchange of data
between their separate health information systems, VA and DOD have
chosen a complex and challenging approach that necessitates the highest
levels of project discipline, including a well-defined architecture for
describing the interface for a common health information exchange; an
established project management structure to guide the investment in and
implementation of this electronic capability; and a project management
plan that defines the technical and managerial processes necessary to
satisfy project requirements. These critical components are currently
lacking; thus, the departments risk investing in a capability that
could fall short of expectations. The continued absence of these
components elevates concerns about exactly what capabilities VA and DOD
will achieve--and when.
Recommendations for Executive Action:
To encourage significant progress on achieving the two-way exchange of
health information, we recommend that the Secretaries of Veterans
Affairs and Defense instruct the Acting Chief Information Officer for
Health and the Chief Information Officer for the Military Health
System, respectively, to:
* develop an architecture for the electronic interface between their
health systems that includes system requirements, design
specifications, and software descriptions;
* select a lead entity with final decision-making authority for the
initiative;
* establish a project management structure to provide day-to-day
guidance of and accountability for their investments in and
implementation of the interface capability; and:
* create and implement a comprehensive and coordinated project
management plan for the electronic interface that defines the technical
and managerial processes necessary to satisfy project requirements and
includes (1) the authority and responsibility of each organizational
unit; (2) a work breakdown structure for all of the tasks to be
performed in developing, testing, and implementing the software, along
with schedules associated with the tasks; and (3) a security policy.
Agency Comments:
The Secretary of Veterans Affairs provided written comments on a draft
of this report and we received comments via e-mail from DOD's
Interagency Program Integration and External Liaison for Health
Affairs; both concurred with the recommendations. Each department's
comments are reprinted in their entirety as appendixes I and II,
respectively. In their comments, the officials also provided
information on actions taken or underway that, in their view, address
our recommendations.
We are sending copies of this report to the Secretaries of Veterans
Affairs and Defense and to the Director, Office of Management and
Budget. Copies will also be available at no charge on GAO's Web site at
www.gao.gov.
Should you have any question on matters contained in this report,
please contact me at (202) 512-6240, or Barbara Oliver, Assistant
Director, at (202) 512-9396. We can also be reached by e-mail at
koontzl@gao.gov and oliverb@gao.gov, respectively. Other key
contributors to this report were Michael P. Fruitman, Valerie C.
Melvin, J. Michael Resser, and Eric L. Trout.
Sincerely yours,
Signed by:
Linda D. Koontz:
Director, Information Management Issues:
[End of section]
Appendix I: Comments from the Secretary of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS
WASHINGTON:
May 28, 2004:
Ms. Linda Koontz:
Director:
Information Technology Team:
U. S. General Accounting Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Koontz:
The Department of Veterans Affairs (VA) has reviewed your draft report
COMPUTER-BASED PATIENT RECORDS: VA and DOD Efforts to Exchange Health
Data Could Benefit from Improved Planning and Project Management, (GAO-
04-687) and agrees with your conclusions and concurs with your
recommendations. As outlined in the enclosure, VA and the Department of
Defense (DoD) are actively engaged in a number of endeavors that
address the intent of each recommendation.
Developing the technology to provide the ability to exchange patient
health care data and the creation of an electronic medical record for
both veterans and active duty personnel remains a priority for VA. The
Department believes the plan VA and DoD are pursuing, although
challenging and complex, will provide the necessary flexibility while
achieving the desired interface between VA and DoD.
Attached are specific actions VA is taking and planning on each
recommendation. Due to the limited comment period the General
Accounting Office (GAO) has provided for responding to this report, the
Department is unable to develop extensive information on these
activities at this time. VA will provide additional information as well
as updates on planned actions in its response to your final report.
The Department appreciates the opportunity to comment on your draft
report.
Sincerely yours,
Signed by:
Anthony J. Principi:
Enclosure:
Enclosure:
The Department of Veterans Affairs (VA) Comments on the General
Accounting Office's (GAO) Draft Report: COMPUTER-BASED PATIENT RECORDS:
VA and DOD Efforts to Exchange Health Data Could Benefit from Improved
Planning and Project Management (GAO-04-687):
GAO recommends that the Secretaries of Veterans Affairs and Defense
instruct the Acting Chief Information Officer for Health and the Chief
Information Officer for the Military Health System respectively to:
* Develop an architecture for the electronic interface between their
health systems that includes system requirements, design
specifications, and software descriptions.
Concur-The Departments are actively engaged in several activities that
relate to development of a final architecture for the electronic
interface between the agencies' health information systems. VA and DoD
expect to have developed the final architecture by the 1STQuarter, FY
2005. The Departments anticipate that the current work to develop a
pharmacy prototype to demonstrate the bi-directional exchange of
pharmacy data will provide important technical information, and have
significant impact on the final definition of an architecture.
* Select a lead entity with final decision-making authority for the
initiative.
Concur-The Veterans Health Administration (VHA) Acting Under Secretary
for Health and DoD's Assistant Secretary of Defense for Health Affairs,
have agreed that the VA/DoD Health Executive Council (HEC) will
continue to serve as the lead entity with final decision-making
authority for the initiative. Co-chaired by the Assistant Secretary of
Defense Health Affairs and the Under Secretary for Health the HEC is an
executive body that provides single and final decision making authority
for the initiative.
* Establish a project management structure to provide day-to-day
guidance of and accountability for their investments in and
implementation of the interface capability.
Concur - The Departments have implemented a joint project management
structure that includes a single Program Manager from VA and a single
Deputy Program Manager from DoD. This structure ensures joint
accountability and day-to-day responsibility for project
implementation. VA provided formal documentation of this project
management structure and the appointments as part of its response to
GAO's document request on May 14, 2004.
* Create and implement a comprehensive and coordinated project
management plan for the electronic interface that defines the technical
and managerial processes necessary to satisfy project requirements and
includes (1) the authority and responsibility of each organizational
unit; (2) a work breakdown structure for all of the tasks to be
performed in developing, testing, and implementing the software, along
with schedules associated with the tasks; and (3) a security policy.
Concur -The Departments have developed a comprehensive draft "DoDNA
Joint Electronic Medical Records (JEMR) Interoperability Program
Management Plan" that updates the previously provided project
management plan. This draft document is in coordination between the
Departments. VA anticipates approval of this plan in June 2004. As part
of its response to GAO's document request and in earlier responses, VA
provided GAO with an initial project management plan and GANTT chart/
work breakdown structure for the high-level tasks that comprise the
work to achieve interoperability. A final security policy will be
completed once the final technical architecture is identified. It is
current practice to ensure that all patient data exchanges are done in
compliance with all regulatory and congressional privacy and security
mandates, including the Privacy Act and the Privacy Regulations
contained within the Health Insurance Portability and Accountability
Act.
[End of section]
Appendix II: Comments from the Director, Interagency Program
Integration & External Liaison for Health Affairs:
Comments on the General Accounting Office (GAO) draft report GAO-04-
687, COMPUTER-BASED PATIENT RECORDS: "VA and DoD Efforts to Exchange
Health Data Could Benefit from Improved Planning and Project
Management", dated June 2004, (GAO Code 310710):
The GAO recommended that the Under Secretary for Health for the
Veterans Health Administration and Assistant Secretary of Defense,
Health Affairs instruct the Acting Chief Information Officer for Health
and the Chief Information Officer for the Military Health System
respectively, to:
* GAO Recommendation 1: Develop an architecture for the electronic
interface between their health systems that includes system
requirements, design specifications, and software descriptions;
* DoD Response to 1: Concur: The Departments are refining the
appropriate architecture to be used for the electronic exchange of data
between DoD's Clinical Data Repository and VA's Health Data Repository.
* GAO Recommendation 2: Select a lead entity with final decision-making
authority for the initiative.
* DoD Response to 2 : Concur: The DoD/VA Health Executive Council serves
as the lead entity with final decision-making authority for the
initiative.
* GAO Recommendation 3: Establish a project management structure to
provide day-to-day guidance of and accountability for their investments
in and implementation of the interface capability; and:
* DoD Response to 3: Concur: The Departments have implemented a joint
project management structure that includes a single Program Manager and
a single Deputy Program Manager with joint accountability and day-to-
day responsibility for project implementation.
* Recommendation 4 : Create and implement a comprehensive and
coordinated project management plan for the electronic interface that
defines the technical and management plan for the electronic interface
that defines the technical and managerial processes necessary to
satisfy project requirements and includes (1) the authority and
responsibility of each organizational unit; (2) a work breakdown
structure for all of the tasks to be performed in developing, testing,
and implementing the software, along with schedules associated with the
tasks; and (3) a security policy.
* DoD Response to 4: Concur: A comprehensive draft "DoD/VA Joint
Electronic Medical Records Interoperability Program Management Plan"
has been prepared and is currently in coordination.
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.:
March 17, 2004) and Computer-Based Patient Records: Short-Term Progress
Made, but Much Work Remains to Achieve a Two-Way Data Exchange Between
VA and DOD Health Systems, GAO-04-271T (Washington, D.C.: November 19,
2003).
[2] 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) and Computer-
Based Patient Records: Better Planning and Oversight By VA, DOD, and
IHS Would Enhance Health Data Sharing, GAO-01-459 (Washington, D.C.:
April 30, 2001).
[3] IHS, was not included in FHIE, but was expected to assume a role in
the longer-term project--HealthePeople (Federal).
[4] DOD's CHCS II capabilities are being deployed in blocks. Block 1
provides a graphical user interface for clinical outpatient processes;
block 2 supports general dentistry; block 3 provides pharmacy,
laboratory, radiology, and immunizations capabilities; block 4 provides
inpatient and scheduling capabilities; and block 5 will provide
additional capabilities as defined.
[5] The six initiatives that make up HealtheVet VistA are health data
repository, billing replacement, laboratory, pharmacy, imaging, and
appointment scheduling replacement.
[6] Standardized clinical data is important for exchanging health
information between disparate systems. The Institute of Medicine's
Committee on Data Standards for Patient Safety has reported the lack of
common data standards as a key factor preventing information sharing
within the health care industry. VA and DOD, along with the Department
of Health and Human Services, have been active participants in the
Consolidated Health Informatics initiative. As part of this initiative,
the Secretary of Health and Human Services announced in early May the
adoption of 15 new standards to enable the exchange of health
information.
[7] Sec. 724 of the act mandates that the Secretaries of Veterans
Affairs and Defense seek to ensure that, on or before October 1, 2004,
the two departments' pharmacy data systems are interoperable for VA and
DOD beneficiaries by achieving real-time interface, data exchange, and
checking of prescription drug data of outpatients, and using national
standards for the exchange of outpatient medication information. The
act further states that if the specified interoperability is not
achieved by that date, the Secretary of Veterans Affairs shall adopt
DOD's Pharmacy Data Transaction System for VA's use.
[8] GAO-01-459.
[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 cochairs of joint councils on health, benefits, and
capital planning. The council meets on a quarterly basis to recommend
strategic direction of joint coordination and sharing efforts. The VA/
DOD Health Executive Council is comprised of senior leaders from VA and
DOD, who work to institutionalize sharing and collaboration of health
services and resources. The council is cochaired by the VA Under
Secretary for Health and DOD Assistant Secretary of Defense for Health
Affairs, and meets on a bimonthly basis.
[10] Institute of Electrical and Electronics Engineers, IEEE/EIA Guide
for Information Technology (IEEE/EIA 12207.1 - 1997), April 1998.
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