Veterans Affairs
Health Information System Modernization Far from Complete; Improved Project Planning and Oversight Needed Gao ID: GAO-08-805 June 30, 2008The Department of Veterans Affairs (VA), through its Veterans Health Administration (VHA), provides health care for more than 5 million veterans each year. In 2001, VHA began an initiative, HealtheVet, to modernize its current medical information system. GAO's objectives were to determine the status of the modernization, VA's overall plan for completing it, and how VA is providing oversight to ensure the success of the initiative. To conduct this review, GAO analyzed project documentation and interviewed officials responsible for the development and implementation of the new system.
As of June 2008, the HealtheVet initiative has these eight major software development projects under way. One project is to further develop the Health Data Repository, a database of standardized health data. This database, which is currently operational, is not yet complete; additional types of health data remain to be standardized and added to the repository. Four application projects are currently in development. One application project is in the planning stage. Two projects are being pursued to enhance current systems, prepare them for transition to HealtheVet, and develop new applications. From 2001 through fiscal year 2007, VA reported spending almost $600 million for these eight projects. The time frame for completing the projects and the HealtheVet system as a whole was 2012, but the projected completion date has now been delayed until 2018. The department has a high-level strategy for HealtheVet, in which the remainder of the initiative is to be completed incrementally in phases (referred to as "blocks"), but it does not have a comprehensive project management plan to guide the remaining work. This work is considerable: the department plans to replace the 104 applications in its current medical information system with 67 modernized applications (of which 5 are currently in development, as described), 3 databases, and 10 common services (general software functions, such as messaging and security, on which application software can call as needed). In view of this scope, the importance is increased of developing a comprehensive project management plan that includes, among other things, an integrated schedule that considers all dependencies and defines subtasks to ensure that deadlines are realistic. Another important component of such planning is determining the resources necessary to accomplish tasks throughout the life cycle of the initiative. In April 2008, VA provided an $11 billion cost estimate for completion of HealtheVet; however, it has not yet independently validated this estimate. Having a validated cost estimate is essential to improve the accuracy of cost, schedule, and performance management. Without an integrated plan that includes independently validated cost estimates, VA increases the risk that HealtheVet could incur cost increases and continued schedule slippages and not achieve its intended outcomes. Various levels and types of oversight are currently being provided for the HealtheVet initiative by business owners, developers, and departmental information technology governance boards. However, the business owners have not yet implemented a complete governance structure, several key leadership positions within the developers' organization are either vacant or filled with acting personnel, and the governance boards have not yet scheduled critical reviews of HealtheVet projects. Until all elements of governance and oversight are in place, the risk to the success of the HealtheVet initiative is increased.
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-08-805, Veterans Affairs: Health Information System Modernization Far from Complete; Improved Project Planning and Oversight Needed
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Report to the Chairman, Committee on Veterans' Affairs, House of
Representatives:
United States Government Accountability Office:
GAO:
June 2008:
Veterans Affairs:
Health Information System Modernization Far from Complete; Improved
Project Planning and Oversight Needed:
GAO-08-805:
GAO Highlights:
Highlights of GAO-08-805, a report to the House Committee on Veterans'
Affairs.
Why GAO Did This Study:
The Department of Veterans Affairs (VA), through its Veterans Health
Administration (VHA), provides health care for more than 5 million
veterans each year. In 2001, VHA began an initiative, HealtheVet, to
modernize its current medical information system. GAO‘s objectives were
to determine the status of the modernization, VA‘s overall plan for
completing it, and how VA is providing oversight to ensure the success
of the initiative.
To conduct this review, GAO analyzed project documentation and
interviewed officials responsible for the development and
implementation of the new system.
What GAO Found:
As of June 2008, the HealtheVet initiative has these eight major
software development projects under way.
* One project is to further develop the Health Data Repository, a
database of standardized health data. This database, which is currently
operational, is not yet complete; additional types of health data
remain to be standardized and added to the repository.
* Four application projects are currently in development.
* One application project is in the planning stage.
* Two projects are being pursued to enhance current systems, prepare
them for transition to HealtheVet, and develop new applications.
From 2001 through fiscal year 2007, VA reported spending almost $600
million for these eight projects. The time frame for completing the
projects and the HealtheVet system as a whole was 2012, but the
projected completion date has now been delayed until 2018.
The department has a high-level strategy for HealtheVet, in which the
remainder of the initiative is to be completed incrementally in phases
(referred to as ’blocks“), but it does not have a comprehensive project
management plan to guide the remaining work. This work is considerable:
the department plans to replace the 104 applications in its current
medical information system with 67 modernized applications (of which 5
are currently in development, as described), 3 databases, and 10 common
services (general software functions, such as messaging and security,
on which application software can call as needed). In view of this
scope, the importance is increased of developing a comprehensive
project management plan that includes, among other things, an
integrated schedule that considers all dependencies and defines
subtasks to ensure that deadlines are realistic. Another important
component of such planning is determining the resources necessary to
accomplish tasks throughout the life cycle of the initiative. In April
2008, VA provided an $11 billion cost estimate for completion of
HealtheVet; however, it has not yet independently validated this
estimate. Having a validated cost estimate is essential to improve the
accuracy of cost, schedule, and performance management. Without an
integrated plan that includes independently validated cost estimates,
VA increases the risk that HealtheVet could incur cost increases and
continued schedule slippages and not achieve its intended outcomes.
Various levels and types of oversight are currently being provided for
the HealtheVet initiative by business owners, developers, and
departmental information technology governance boards. However, the
business owners have not yet implemented a complete governance
structure, several key leadership positions within the developers‘
organization are either vacant or filled with acting personnel, and the
governance boards have not yet scheduled critical reviews of HealtheVet
projects. Until all elements of governance and oversight are in place,
the risk to the success of the HealtheVet initiative is increased.
What GAO Recommends:
To better ensure the success of HealtheVet, GAO recommends that VA
develop a project management plan that includes validated cost
estimates and that it implement a complete governance structure, fill
key leadership positions, and schedule and perform critical reviews.
Commenting on a draft of this report, VA concurred with GAO‘s
recommendations and described actions planned or being taken to address
them.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-805]. For more
information, contact Valerie Melvin at (202) 512-6304 or
MelvinV@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
HealtheVet Projects Are Under Way, but Time Frames Have Slipped:
VA Has Developed an Overall Strategy for HealtheVet, but It Lacks a
Project Management Plan:
VA Has Not Fully Established an Oversight Structure for HealtheVet:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: Existing VistA Applications Overview:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Start and Completion Dates for HealtheVet Projects as of 2003:
Table 2: Status of HealtheVet Projects:
Table 3: HealtheVet Project Development Costs:
Table 4: HealtheVet Software Applications and Blocks:
Figures:
Figure 1: Overview of High-Level Strategy for HealtheVet:
Figure 2: Organizational Chart of the Office of Enterprise Development:
Abbreviations:
CIO: chief information officer:
HDR: Health Data Repository:
IT: information technology:
OED: Office of Enterprise Development:
SEI: Software Engineering Institute (of Carnegie Mellon):
VA: Department of Veterans Affairs:
VHA: Veterans Health Administration:
VistA: Veterans Health Information Systems and Technology Architecture:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
June 30, 2008:
The Honorable Bob Filner:
Chairman:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Chairman:
The Department of Veterans Affairs (VA) operates the largest health
care delivery system in America, providing health care to more than 5
million patients in more than 1,000 facilities.[Footnote 1] The
department's health information system--the Veterans Health Information
Systems and Technology Architecture (VistA)--is an essential part of
health care delivery, helping to ensure the quality of health care
received by the nation's veterans and their dependents. The use of
VistA, which includes electronic health records, has been widely
credited with improving health care among VA patients.[Footnote 2]
However, VistA currently consists of numerous applications, some of
which have been in operation for more than 20 years and, according to
VA, have become increasingly difficult and costly to maintain. Further,
these applications contain data that are not standardized across VA's
medical facilities. Standardization is a prerequisite for data to be
computable--that is, acted on by computer applications. Such data can
provide important improvements to health care decision making--for
example, allowing applications to provide alerts to clinicians (for
drug allergies) or plot graphs of changes in vital signs such as blood
pressure.
Accordingly, in 2001, the Veterans Health Administration (VHA) began an
initiative to modernize VistA--the HealtheVet initiative. With
HealtheVet, VA plans to standardize patient data and modernize health
information software applications. In doing so, its goal is to move
from the hospital-centric environment that has long characterized the
department's health care operations to a veteran-centric environment
built on an open, robust systems architecture that will more
efficiently provide both the same functions and benefits of the
existing system and enhanced functions based on computable data. The
development and implementation of HealtheVet is also key to achieving
electronic medical records that are interoperable between VA and the
Department of Defense (DOD).[Footnote 3]
Until the new system is fully implemented, the department continues to
depend on the VistA system, which it intends to maintain concurrently-
-a complex task that requires VA to develop interfaces between
HealtheVet and existing VistA software applications to ensure seamless
delivery of care to veterans. According to the department, HealtheVet-
-the largest investment in the department's information technology
portfolio--is scheduled to be fully implemented by 2018 at a total
estimated cost of about $11 billion.[Footnote 4]
Given the importance of the HealtheVet project to the department's
efforts to deliver high-quality health care to veterans, you requested
that we review the department's continuing efforts to develop and
implement the modernized system. Specifically, our objectives were to
determine (1) the status of the HealtheVet initiative, (2) VA's overall
plan for completing the initiative, and (3) how the department is
providing oversight to ensure the success of the initiative.
To achieve our objectives, we analyzed documentation including project
schedules, development plans, technical approach descriptions, funding,
transition plans, information technology governance plans, and
information technology (IT) governance board charters and meeting
minutes. To supplement our analysis, we interviewed officials
responsible for department information technology and the HealtheVet
initiative, including managers of individual HealtheVet projects. The
information on costs that have been incurred for the HealtheVet
projects were provided by VA officials. We did not audit the reported
costs and thus cannot attest to their accuracy or completeness.
We conducted this performance audit from July 2007 through June 2008 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. For more details on our
objectives, scope, and methodology, see appendix I.
Results in Brief:
As of June 2008, the HealtheVet program has these eight software
development projects under way.
* The Health Data Repository (HDR) database became operational in 2006
with a limited set of health care data; it currently contains
standardized health data in three areas that were given high priority
by clinicians (vital signs, allergies, and outpatient pharmacy). The
development project is currently focused on standardizing and
converting laboratory data so that they can be added to the repository,
with further types of health data (such as inpatient pharmacy data) to
be added as the development of the HealtheVet system continues.
Developing and populating the repository are major goals both for
HealtheVet and for the collaboration between DOD and VA on developing
interoperable health data that are to allow seamless transfer of
information between the two departments.[Footnote 5]
* Four health care applications are under development: Scheduling,
Pharmacy, Laboratory, and Enrollment. The earliest to be deployed is
the Scheduling application, which is planned for initial deployment at
one location in September 2008.
* One software development project (Billing) is in the planning stage;
this is a financial application for HealtheVet.
* Two projects (the VistA application development project and VistA
foundations modernization project) are focused on activities to develop
and implement required enhancements to existing VistA
applications[Footnote 6] and lay the foundation for transitioning the
applications to the modernized HealtheVet system. Among the aims of
these projects is the development of common services--that is,
administrative computer services, such as messaging and security, on
which application software can call as needed.[Footnote 7]
From 2001 through fiscal year 2007, VA reported spending almost $600
million for these eight projects. The time frame for completing the
projects and the HealtheVet system as a whole is 2018; this is an
extension since we first reported in 2003,[Footnote 8] when the
projected completion date was 2012. Department officials acknowledge
that VA has experienced significant delays in developing and
implementing HealtheVet and attribute the delays to various factors,
including loss of experienced contractor staff, changes in technical
and deployment approaches, and lack of management continuity.
Department officials stated that they are working to address the delays
by using an incremental development life-cycle approach; establishing
more realistic time frames; and establishing an integrated product team
composed of information technology, program, and acquisition personnel
to address contracting issues.
Under VA's current strategy for HealtheVet, developed in August 2006,
the department is taking an incremental approach to the remainder of
the initiative, based on six phases (referred to as "blocks") that are
to be completed in 2018. Under this strategy, the department plans to
replace the 104 VistA applications that are currently in use with 67
applications, 3 databases, and 10 common services. Although
considerable work remains to complete the final systems (work has not
begun on 62 of the 67 planned applications), the department does not
yet have a comprehensive project management plan to guide the
development and integration of the many HealtheVet projects. That is,
it does not have a plan that describes, among other factors, the
project's scope, implementation strategy, and lines of responsibility,
and includes an integrated schedule that considers all dependencies and
defines subtasks to ensure that deadlines are realistic. Further, among
the key components of the plan is determining the resources necessary
to accomplish tasks throughout the life cycle of the initiative. In
April 2008, VA provided an $11 billion cost estimate for completion of
HealtheVet; however, it has not yet had the estimate independently
validated. Having a validated cost estimate is essential to improve the
accuracy of cost, schedule, and performance management. Without an
integrated plan that includes independently validated cost estimates,
VA increases the risk that HealtheVet could incur schedule slippages
and cost increases and not achieve its intended outcomes.
Various levels and types of oversight of the HealtheVet initiative are
currently provided by the business owners (the Veterans Health
Administration), the developers (within the organization of the
department's Chief Information Officer), and departmental oversight
boards established to manage IT investments. However, the business
owners do not yet have a fully implemented governance structure for
development projects that was endorsed by the department following a
realignment of IT resources in which IT funding and personnel were
placed under the control of the department's Chief Information Officer
(CIO).) Without a complete HealtheVet governance structure in place,
the business owners' ability to ensure that the HealtheVet projects
meet business needs may be decreased. In addition, several key
leadership positions within the developers' organization are either
vacant or are filled with acting personnel. In the absence of permanent
officials for these positions, the effectiveness of the department's
oversight and management of technical development activities for the
HealtheVet initiative may be reduced. Finally, although the IT
governance boards have begun oversight to ensure, among other things,
that investments align with the department's strategic plan, milestone
reviews of HealtheVet projects have not yet been scheduled. It is
important to hold milestone reviews on projects that are moving from
one phase of development to the next, which at least one of the
HealtheVet projects is scheduled to do in the near future. Without
milestone reviews of project progress, the governance boards cannot
effectively measure progress or determine the necessary funding needed
for HealtheVet.
To better ensure the success of HealtheVet, we are recommending that
the Secretary of Veterans Affairs direct the Chief Information Officer
to develop a project management plan with validated cost estimates for
HealtheVet, fill or permanently staff critical positions, and develop a
schedule for performing milestone reviews of HealtheVet projects. In
addition, to ensure proper oversight of HealtheVet, we are recommending
that the Secretary of Veterans Affairs direct the Veterans Health
Administration Under Secretary to finalize and implement the HealtheVet
governance structure.
In providing written comments on a draft of this report, the Deputy
Secretary of Veterans Affairs concurred with the report's
recommendations. (The department's comments are reproduced in app. II.)
The comments describe actions that begin to address our
recommendations. Among its actions, the department noted that the
Office of Information and Technology is developing a comprehensive
integrated HealtheVet project management plan to be completed by the
end of this year and expects approval of a revised HealtheVet
governance plan this July. If the actions planned or currently under
way are properly implemented, they could help ensure that the system
will be completed successfully.
Background:
The current health information system used by VA clinicians is VistA.
Since the inception of this system in 1983, VHA has made numerous
enhancements to its functionality.[Footnote 9] A significant example
was the release in 1996 of the Computerized Patient Record System,
which enabled the department to provide an individual electronic
medical record for each VA patient. By fiscal year 2007, the
implementation of an imaging capability (VistA Imaging) at all the
department's facilities further enhanced the system by enabling
multimedia data, such as radiology images, to be linked to a patient's
electronic medical record. These collective enhancements to VistA
resulted in a comprehensive, integrated, electronic medical record for
each patient that is viewable by all of the department's clinicians at
all of its health care facilities, thus eliminating the need for paper
medical records.
According to VHA officials, VistA was developed based on close
collaboration between staff in the medical facilities and VHA's IT
personnel, with the intention of providing a system that met the
clinicians' needs. In this regard, clinicians and IT personnel in the
various medical facilities collaborated to define the system's
requirements and, in certain cases, carry out its development and
implementation. For example, development of VistA Imaging resulted from
a clinician building a prototype at home before it was fielded at a
medical facility. Although system enhancements to VistA were
disseminated through a central office, staff at a medical center could
develop and implement applications at the local level to facilitate the
potentially different functions at each location.
According to the department, as a result of VHA's decentralized
development approach, VistA now consists of 104 separate computer
applications. These include 56 health provider applications; 19
management and financial applications; 13 crosscutting applications
such as patient data exchange; 8 registration, enrollment, and
eligibility applications; 5 health data applications; and 3 information
and education applications (app. III contains a complete list of these
applications).
Besides being numerous, these applications have been customized at all
128 VA sites.[Footnote 10] According to VA, this customization
increases the cost of maintaining the system, as it requires that
maintenance also be customized. VA has reported expending significant
resources (approximately $2.5 billion) to maintain the system between
2001 and 2007.
Further, according to the department, limitations in the system need to
be addressed for the system to remain effective. As mentioned, some
VistA applications are more than 20 years old, and VistA does not
standardize data, which is a prerequisite to making data computable. In
addition, according to VA, VistA stores data in an organizational
format based on the location where care is provided, rather than
maintaining a global record for each individual patient, and it is
programmed in a language for which there is a continually decreasing
supply of qualified software developers.[Footnote 11]
Accordingly, in 2001, VHA undertook the HealtheVet initiative in order
to standardize its health care system and eliminate the approximately
128 different systems used by its field locations. As we reported in
2003, it planned to develop or enhance specific areas of system
functionality through six projects, which were to be completed between
2006 and 2012 (shown in table 1).[Footnote 12] These six projects did
not represent all the functionality provided by the 104 VistA
applications; rather, they were high-priority projects that were under
way at the time.
Table 1: Start and Completion Dates for HealtheVet Projects as of 2003:
Project: Health Data Repository;
Project start date: 2001;
Estimated completion date: 2006.
Project: Billing[A];
Project start date: 2002;
Estimated completion date: 2006.
Project: Laboratory;
Project start date: 2003;
Estimated completion date: 2007.
Project: Pharmacy;
Project start date: 2002;
Estimated completion date: 2008.
Project: Imaging;
Project start date: 2002;
Estimated completion date: 2011.
Project: Scheduling[B];
Project start date: 2001;
Estimated completion date: 2012.
Source: GAO analysis of VA data.
[A] Renamed the Patient Financial Services System in 2003.
[B] Originally called the appointment scheduling replacement project.
[End of table]
In 2004, VA contracted with the Software Engineering Institute (SEI)
for a technical review of the HealtheVet program.[Footnote 13] As a
result of this review, SEI concluded, among other things, that VA
needed to improve and integrate the governance of the HealtheVet
program, develop an organizational structure for the program, define
the program's vision, and define the path for transition from VistA to
HealtheVet.
In 2005, VA began to take action on the SEI recommendations. For
example, the department began to develop a HealtheVet organizational
structure, including defining the responsibilities of a project
management office. In addition, it developed an initial draft for
HealtheVet governance that defined decision-making processes,
established guidelines for issue identification and escalation, defined
areas of control and levels of authority, and established
accountability. However, the effort to develop a governance plan and
structure was superseded by a major realignment of the department's
overall IT management structure.
This realignment, initiated in October 2005, was undertaken with the
goal of providing greater authority and accountability over VA
resources by centralizing IT management under the department's CIO; an
additional goal was to standardize operations and systems development
across the department using new management processes based on industry
best practices.[Footnote 14] Under the department's realigned
structure, the Assistant Secretary for Information and Technology
serves as VA's CIO. [Footnote 15] The CIO is assisted by one Principal
Deputy Assistant Secretary and five Deputy CIOs. In particular, the
Deputy CIO [Footnote 16] for Enterprise Development serves as the chief
advisor to the CIO for all enterprise applications development
activities, including HealtheVet; this official heads the Office for
Enterprise Development, which is responsible for performing enterprise
applications development.
Before the realignment, funding and approval of IT was controlled by
each medical center director, this enabled local IT personnel to make
changes to VistA applications that were specific to the local medical
facility.[Footnote 17] As a result of the realignment, the funding for
all IT development projects, including both VistA and HealtheVet
projects, was moved under the control of the department's CIO. The
business owners (that is, VHA for VistA and HealtheVet) retain
responsibility for development and prioritization of requirements and
program oversight, while staff in the Office of Enterprise Development
are responsible for planning and execution of information technology
development projects.
HealtheVet Projects Are Under Way, but Time Frames Have Slipped:
As of June 2008, the HealtheVet program has eight major software
development projects under way.[Footnote 18] One of these is to
continue development and population of an operational database that
currently contains health data. Five are applications development
projects, of which four are health care applications currently in
development and one is a financial application in the planning stage.
The remaining two projects are to enhance current VistA systems,
prepare them for transition to HealtheVet, and develop new
applications. However, since 2003, the time frames for completing the
projects and the HealtheVet system as a whole have been extended from
2012 to 2018. Department officials acknowledge that VA has experienced
significant delays in developing and implementing HealtheVet and
attribute the delays to various factors, and stated that they are
working to address the delays by using an incremental development life-
cycle approach and establishing more realistic time frames, among other
things.
Of the eight projects in progress, one is currently operational though
not yet completed. The Health Data Repository (HDR) database, which
became operational in 2006, currently contains standardized health data
in three areas: vital signs, allergies, and outpatient pharmacy. These
data were addressed first because they were given high priority by
clinicians. As we have previously reported,[Footnote 19] the department
is currently using HDR to help achieve interoperability with DOD to
support the exchange of computable electronic patient information. The
HDR project is currently standardizing and converting laboratory data
so that they can be added to the repository next, with further types of
health data (for example, inpatient pharmacy, dental, and
ophthalmology) to be added as the development of the HealtheVet system
continues.
Four projects are developing health care information applications:
[Footnote 20]
* The Scheduling application is planned for initial deployment at one
site (a VA medical center in Muskogee, Oklahoma) in September 2008
(full deployment to all medical facilities is planned for 2011).
* For the Pharmacy project, final testing of one function (order
checking) is scheduled to begin in September 2008, and new drug file
and pharmacy data management systems are scheduled to be implemented in
January 2009. Remaining system functions to be developed include
inventory, order entry and clinical monitoring, medication dispensing,
and medication administration. Further development of the Pharmacy
application depends on the results of an ongoing analysis and
evaluation of the costs of building and deploying these functions. This
analysis, for which a contract was issued in February 2008, is due July
2008.
* The new Laboratory system is scheduled for independent verification
and validation[Footnote 21] in October 2008. National deployment is
planned to begin in 2010, with a phased implementation across the
department expected to take place over the next 5 years.
* The initial implementation of the Enrollment application is scheduled
for August 2008. This project is to provide an enrollment workflow for
use at VA's Health Eligibility Center. An enhancement is scheduled for
implementation by July 2009 for communicating to veterans and providing
operational efficiencies for VA staff at the Health Eligibility Center
and medical centers to coordinate changes in veterans' eligibility.
Finally, in December 2011, the department expects to complete a
modernized registration capability.
A fifth project (Billing) is for a new financial system, which is in
the planning stage. The current Billing project is a second attempt to
modernize the billing system. Under the first attempt, VA awarded a
contract in July 2003 to implement a commercial product to provide an
updated billing capability for the department (called at that time the
Patient Financial Services System); however, after about $107 million
was spent on this effort, the contract was terminated in September 2006
by mutual agreement between the department and the contractor. The
department expects to complete national deployment of the current
project (called the Revenue Improvements and System Enhancement
project) at the end of fiscal year 2015.
Finally, the program has two ongoing projects that are focused on
activities to develop and implement required enhancements to existing
VistA applications and lay the foundation for transitioning these
applications to HealtheVet:
* The focus of the VistA application development project in the near
term is to develop the critical enhancements and fixes to the VistA
system that are necessary to ensure compliance with changes to patient
enrollment and billing requirements and accomplish other critical data
updates. In fiscal year 2010, the emphasis for this initiative will
shift from fixes and enhancements to new development work aimed at the
transition to HealtheVet. The initiative will then encompass building
many of the replacement systems within HealtheVet.
* The VistA foundations modernization project includes work on
architecture and testing services, including a comprehensive testing
suite and strategy for all VistA and HealtheVet applications. In fiscal
year 2009, several common services--the deployment toolkit, business
rules engine, and workflow engine--are expected to be delivered, along
with new testing services capabilities and updates to the overall
architecture. This work is expected to be ongoing until the completion
of the HealtheVet initiative.
Table 2 summarizes the status of these projects.
Table 2: Status of HealtheVet Projects:
Project: Health Data Repository;
Current status: Operational;
Next steps: National rollout;
Date: Fiscal year 2009;
Planned completion date: 2018.
Project: Enrollment;
Current status: In development;
Next steps: Initial implementation of workflow;
Date: August 2008;
Planned completion date: 2011.
Next steps: Enhancement for communicating to veterans and coordinating
eligibility information;
Date: July 2009;
Planned completion date: [Empty].
Next steps: Modernized registration capability;
Date: December 2011;
Planned completion date: [Empty].
Project: Scheduling;
Current status: In development;
Next steps: Planned initial deployment at one site;
Date: September 2008;
Planned completion date: 2011.
Project: Pharmacy;
Current status: In development;
Next steps: Beginning of final testing of new and enhanced order
checking;
Date: September 2008;
Planned completion date: 2011.
Next steps: Replacement of national drug file and pharmacy data
management systems;
Date: January 2009;
Planned completion date: [Empty].
Project: Billing;
Current status: In planning;
Next steps: [Empty];
Date: [Empty];
Planned completion date: 2015.
Project: Laboratory;
Current status: In development;
Next steps: Independent verification and validation;
Date: October 2008;
Planned completion date: 2015.
Next steps: Initial field testing;
Date: April 2009;
Planned completion date: [Empty].
Next steps: Beginning of national deployment;
Date: 2010;
Planned completion date: [Empty].
Project: VistA Application Development;
Current status: In development;
Next steps: Enhancements and fixes of VistA;
Date: Ongoing;
Planned completion date: 2018.
Next steps: New development for HealtheVet;
Date: 2010;
Planned completion date: [Empty].
Project: VistA Foundations Modernization;
Current status: In development;
Next steps: Delivery of a comprehensive testing suite for all
HealtheVet applications development;
Date: Fiscal year 2008;
Planned completion date: 2018.
Next steps: Additional common services and tools;
Date: Fiscal year 2009;
Planned completion date: [Empty].
Source: GAO analysis of VA data.
Note: The plan as of 2003 (see table 1) also included the Imaging
project; work on the HealtheVet version of this system has not yet
begun.
[End of table]
From the inception of the initiative in 2001 through fiscal year 2007,
VA reported spending almost $600 million for the development of these
eight projects. The department estimates that it will incur additional
development costs of approximately $535 million for the initiative
during fiscal years 2008 and 2009, with the estimated total development
cost of HealtheVet being $11 billion when completed in 2018. Table 3
shows the reported development costs through fiscal year 2007 and
estimated development costs for fiscal years 2008 and 2009.
Table 3: HealtheVet Project Development Costs (Dollars in millions):
Project: Health Data Repository;
Reported development cost through FY 2007: $136;
Estimated development cost for FY 2008 and 2009: $50.
Project: Scheduling;
Reported development cost through FY 2007: $85;
Estimated development cost for FY 2008 and 2009: $50.
Project: Pharmacy;
Reported development cost through FY 2007: $56;
Estimated development cost for FY 2008 and 2009: $27.
Project: Billing;
Reported development cost through FY 2007: $107;
Estimated development cost for FY 2008 and 2009: $1.
Project: Laboratory;
Reported development cost through FY 2007: $16;
Estimated development cost for FY 2008 and 2009: $36.
Project: Enrollment;
Reported development cost through FY 2007: $47;
Estimated development cost for FY 2008 and 2009: $29.
Project: VistA application development;
Reported development cost through FY 2007: $58;
Estimated development cost for FY 2008 and 2009: $181.
Project: VistA foundations modernization;
Reported development cost through FY 2007: $93;
Estimated development cost for FY 2008 and 2009: $161.
Project: Total;
Reported development cost through FY 2007: $598;
Estimated development cost for FY 2008 and 2009: $535.
Source: GAO analysis of data provided by VA.
[End of table]
In addition, the time frames for completing the projects and the
HealtheVet system as a whole have been extended since the inception of
the HealtheVet initiative. As shown in table 1, the time frames as of
2003 envisioned completion by 2012. Current time frames extend the
completion date to 2018.
Officials from VA's Office of Information and Technology acknowledged
that VA had experienced significant delays in developing and
implementing HealtheVet. These officials attribute the delays to
various factors, including changes in technical and deployment
approaches, lack of management continuity, and loss of experienced
contractor staff.
For example, changes in technical and deployment approaches delayed the
development of the Scheduling, Health Data Repository, Pharmacy,
Laboratory, and Enrollment projects. In particular, for Scheduling,
Health Data Repository, Laboratory, and Enrollment, VHA has alternated
between developing the systems in-house and using a commercial off-the-
shelf product. In addition, programming languages for the Scheduling
and Enrollment projects changed. Finally, VHA changed the deployment
approach for Pharmacy annually between 2003 and 2007.
Several projects experienced management turnover. For example, the
Enrollment project has had multiple program managers since it began,
and the VistA application development and VistA foundations
modernization projects have seen more than one change in program
management.
Finally, the Scheduling, Health Data Repository, Laboratory, Vista
Application Development, and Vista Foundations Modernization projects
were delayed by the loss of experienced contractor staff. These
initiatives were supported by an overall contract for HealtheVet. When
this contract expired in September 2006, it was renewed on a monthly
basis to ensure continuity of work until a new contract was awarded.
However, task orders from the new contract, which was signed in
November 2006, were not issued until June, July, and September 2007.
According to department officials, as a result of these delays, the
experienced contractor staff who supported the initiatives had moved to
other work, corporate knowledge for these initiatives was lost, and new
contractor staff had to be hired and educated.
Department officials stated that they are working to address the delays
experienced by using an incremental, development life-cycle approach
and establishing more realistic time frames for the effort. In
addition, to address future contracting issues, the department is
establishing an integrated product team composed of IT, program, and
acquisition personnel.
VA Has Developed an Overall Strategy for HealtheVet, but It Lacks a
Project Management Plan:
Under VA's current strategy for HealtheVet, developed in August 2006,
the department is taking an incremental approach to the remainder of
the initiative, based on six phases (referred to as "blocks") that are
to be completed in 2018. Under this strategy, the department plans to
replace the 104 VistA applications that are currently in use (see app.
III) with 67 applications, 3 databases,[Footnote 22] and 10 common
services.[Footnote 23] Figure 1 provides a high-level overview of the
strategy, and table 4 lists all the planned software development
applications by block.
Figure 1: Overview of High-Level Strategy for HealtheVet:
[See PDF for image]
This figure is an illustration of an overview of high-level strategy
for HealtheVet, as follows:
5 applications:
* Block One:
- Scheduling;
- Enrollment;
* Block Two:
- Laboratory;
- Pharmacy;
- one application not yet in planning or development.
62 applications:
* Block Three:
- Billing;
- 16 applications not yet in planning or development;
* Block Four:
- 19 applications not yet in planning or development;
* Block Five:
- 15 applications not yet in planning or development;
* Block Six:
- 11 applications not yet in planning or development.
Activities to be developed and implemented through all six blocks
include data repositories, common services, VistA application
development, and VistA foundations modernization.
Source: VA.
[End of figure]
Table 4: HealtheVet Software Applications and Blocks:
Block 1:
* Scheduling;
* Enrollment.
Block 2:
* Laboratory;
* Pharmacy;
* Bar code expansion project.
Block 3:
* Implant management;
* Health care acquired infection and influenza surveillance;
* Emergency room;
* Clinical decision support;
* Home telehealth;
* Oncology;
* Mental health;
* Fee basis;
* Compensation and pension records interchange;
* MyHealtheVet (online access application);
* Joint inpatient electronic health record;
* Enhanced VA/DOD seamless care;
* Billing (renamed revenue improvements system enhancement);
* Prosthetics;
* Report writer;
* Patient information management system;
* Workload management.
Block 4:
* Discharge summary;
* Consult/request tracking;
* Clinical reminders;
* Automated information collection system;
* Authorization/subscription utility;
* Adverse reaction tracking;
* Women's health;
* Vitals/measurements;
* Text integration utilities;
* Remote order entry system;
* Progress notes;
* Problem list;
* Outpatient clinical care;
* Order entry/results reporting;
* Order check expert;
* Intake/output.
Block 5:
* Clinical procedures;
* Clinical device connectivity;
* Clinical case registries;
* Care management;
* Ophthalmology;
* Nutrition and food service;
* Nursing service;
* Imaging system[A];
* Home-based primary care;
* Employee health record;
* Dental record manager;
* Social work;
* Release of information;
* Radiology/nuclear medicine;
* Quality audiology and speech analysis and reporting.
Block 6:
* Health summary;
* Library;
* Incident reporting;
* Blind rehabilitation;
* Beneficiary travel automated safety incident surveillance tracking
system;
* Voluntary service system;
* Veterans' personal finance system;
* Spinal cord dysfunction;
* Police and security;
* Patient advocate tracking system.
Source: GAO analysis of VA information.
Note: The projects under way are in bold.
[A] Although included in the initial plan (see table 1), work on the
imaging system has not begun.
[End of table]
As table 4 shows, work has not yet been initiated on many applications
that are planned for the final system. Further, although the department
has established interim dates for completing projects that are under
way, as of mid-June 2008, the department had not developed a detailed
schedule or approach for completing the HealtheVet initiative,
including the remaining 62 software applications, other than to state
that it intends to complete all six blocks of the initiative by 2018.
Industry best practices and IT project management principles[Footnote
24] stress the importance of accountability and sound planning for any
project, particularly an effort of the magnitude and complexity of
HealtheVet. Inherent in such planning is the development and use of a
project management plan that describes, among other factors, the
project's scope, implementation strategy, lines of responsibility,
security requirements, resources, and estimated schedule for
development and implementation. Specifically, an effective project
management plan incorporates all the critical areas of system
development and is to be used as a means of determining what needs to
be done and when, and should measure progress. Such a plan also
includes an integrated schedule that considers all dependencies and
includes subtasks so that deadlines are realistic, and it incorporates
reviews to allow oversight and approval by high-level managers.
A key component of planning is determining the resources necessary to
accomplish the myriad tasks needed throughout the life cycle of the
initiative. In April 2008, VA provided an $11 billion cost estimate to
complete HealtheVet; however, it has not yet independently validated
these estimates. We stress in our Cost Assessment Guide[Footnote 25]
that having a validated cost estimate is essential to improve the
accuracy of cost, schedule, and performance management. Validated cost
estimates are also important to facilitate program approval and
determine the necessary funding needed for HealtheVet.
Without an integrated plan that includes independently validated cost
estimates, VA increases the risk that HealtheVet could incur schedule
slippages and cost increases and not achieve what it intends to
achieve.
VA Has Not Fully Established an Oversight Structure for HealtheVet:
In the wake of the realignment of IT resources under central,
department-level control, VA leadership endorsed an approach to the
oversight and governance of IT development projects that is based on
ensuring the involvement of senior management from both the user and
the developer organizations.[Footnote 26] Under this approach, business
owners establish IT requirements, business benefits, and priorities and
oversee full life-cycle execution of IT programs. The department's CIO
organization provides the developers who devise technology solutions
for the users. In addition, CIO officials chair a set of IT governance
boards that review progress and recommend funding for IT projects;
these boards include executive-level representation from business
owners.
For the HealtheVet initiative, various levels and types of oversight
are currently provided by the business owner (the Veterans Health
Administration), the developers (the Office of Enterprise Development
within the department's CIO organization), and departmental IT
governance boards. However, the business unit has not yet finalized a
governance plan or implemented a complete governance structure, several
key leadership positions within the developers' organization are either
vacant or filled with acting personnel, and the IT governance boards
have not yet scheduled critical reviews of HealtheVet projects. Until
all elements of governance and oversight are in place, the risk is
increased that the HealtheVet initiative may experience cost overruns
and continued schedule slippages and may not achieve what it intends to
achieve.
VHA Has Not Fully Implemented a HealtheVet Governance Structure:
VHA has not yet established a governance structure for HealtheVet in
accordance with the approach endorsed by the department. Under this
approach, business unit governance for IT initiatives is provided at
several levels. An Executive Steering Committee, chaired by the head of
the business unit, provides executive oversight. Reporting to the
Executive Steering Committee is an Oversight Board that is responsible
for ensuring that all stakeholders are represented in defining
requirements, monitoring progress, and determining that the initiative
is meeting their needs. Finally, a Program Director is responsible for
day-to-day oversight activities to ensure that the technical solution
provided by the developers meets business needs (such as requirements
development and testing) and for coordinating with the developers'
program office.
According to senior management officials, VHA has not yet established a
governance structure for HealtheVet in accordance with this approach,
but it has developed a plan to do so. According to these officials,
they worked with the departmental CIO organization to develop this
plan. Officials told us that the plan had been approved by the Under
Secretary for Health and was under review and awaiting approval by the
Secretary of Veterans Affairs (we anticipate reviewing the plan upon
its approval by the Secretary). VHA officials expect the plan to be
approved next month. However, the officials did not provide a schedule
for finalizing the plan and implementing the structure.
Until the governance structure is implemented, VHA is providing
oversight of the HealtheVet initiative through various means. For
example, according to officials, the former VHA CIO (now the Chief
Officer of VHA's Office of Information) briefs the VHA head (the Under
Secretary for Health) twice weekly. In addition, the Office of
Information holds formal meetings every two weeks with the developers
(the Office of Enterprise Development in the department's CIO
organization) on three or four IT projects (which may include
HealtheVet projects). Further, VHA's Office of Information holds
meetings with VHA managers who act as business liaisons between VHA and
the departmental CIO organization. VHA also has an Information Data
Management Committee that establishes priorities for VHA IT investments
(including HealtheVet) and makes funding recommendations to the Under
Secretary. This committee includes major VHA stakeholders, including
headquarters and regional executives, as well as the Chief Officer, who
co-chairs the council.
These means fulfill some of the functions of the governance model
endorsed by the department. That is, the Information Data Management
Committee performs some of the oversight functions of an Oversight
Board, and the Chief Officer coordinates with the developers' program
office. However, there is currently no equivalent to an Executive
Steering Committee, and there is no Program Director. If the draft
governance plan follows the model endorsed by the department, its
approval and implementation would include these elements.
Without a complete governance structure in place, the business owners'
ability to perform appropriate oversight of the HealtheVet projects may
be decreased.
Key Positions within the Office of Enterprise Development Are Vacant:
The Office of Enterprise Development within the departmental CIO
organization is responsible for development of the HealtheVet projects.
This office provides day-to-day oversight and management of the
technical development activities. However, currently several key
leadership positions within the Office of Enterprise Development are
either vacant or are filled with acting personnel. That is, positions
within Program Management and Software Development are vacant, and the
Assistant Deputy CIO for Software Engineering is acting (see fig. 2 for
an organizational chart showing these positions).
Figure 2: Organizational Chart of the Office of Enterprise Development:
[See PDF for image]
This figure is an illustration of the Organizational Chart of the
Office of Enterprise Development, as follows:
Top level:
* Enterprise Development:
- Deputy CIO.
Second level:
*Program Management:
- Assistant Deputy CIO (vacant).
* Software Engineering:
- Assistant Deputy CIO (acting).
* Software Development:
- Assistant Deputy CIO (vacant).
Source: GAO analysis of VA data.
[End of figure]
The position of Assistant Deputy CIO for Program Management is
currently vacant; this position is responsible for activities such as
managing a program's portfolio of IT applications during its entire
life cycle, as well as for developing and managing project plans and
schedules and managing risk. In addition, the position of head of
Software Engineering is filled by an acting Assistant Deputy CIO; this
position has responsibility for overseeing the architecture of an
application's technical solution. Another Assistant Deputy CIO position
(head of Software Development) is vacant; this position is responsible
for ensuring that software deliverables meet their expected
requirements. In commenting on a draft of this report, the department
noted that a vacancy announcement for the Assistant Deputy CIO for
Program Management position has been posted with a closing date of July
7, 2008. Until these key leadership positions are permanently staffed,
the risk is increased that the department's management and control of
the HealtheVet initiative will not be efficient and effective.
IT Governance Boards Have Been Established, but No Milestone Reviews
Have Been Scheduled:
In 2007, three VA governance boards for IT investment projects were
established; they have the following general responsibilities:
* The Business Needs and Investment Board (chaired by the Principal
Deputy Assistant Secretary) is to evaluate whether proposed IT
investment projects meet business needs.
* The Planning, Architecture, Technology, and Services Board (chaired
by a Deputy CIO)[Footnote 27] determines whether IT projects meet
technical standards by, among other things, performing milestone
reviews.
* The Information Technology Leadership Board (chaired by the CIO) uses
input from the two other boards to make recommendations to the
department's Strategic Management Council for funding the major
categories of IT projects.
Although the boards are chaired by officials in the CIO's office, they
all include high-level executives from the user organizations. For
example, the VHA representative on the Information Technology
Leadership Board is the head of VHA--the Under Secretary for Health.
Since being established, the three governance boards have begun
providing oversight to ensure that investments align with the
department's strategic plan and that business and budget requirements
for ongoing and new initiatives meet user demands. In 2007, the three
boards evaluated the HealtheVet projects that were proposed for fiscal
year 2009, and the Information Technology Leadership Board made funding
recommendations to the department's Strategic Management Council. As a
result of these deliberations, the department requested about $330
million for HealtheVet development projects for fiscal year 2009.
However, there is one oversight function that has not yet been
exercised for the HealtheVet projects: milestone reviews. Milestone
reviews, which are a responsibility of the Planning, Architecture,
Technology, and Services Board, afford an opportunity for progressive
decision making about the program under review and are coupled with
authorization for funding. The VA milestone review process includes
concept definition, requirements development, system design and
prototype, system development and testing, system deployment, and
operations and maintenance. Each step in the process has specific and
organizationally required exit criteria that must be satisfied before
the program can proceed to the next stage.
The Planning, Architecture, Technology, and Services Board has
performed one milestone review since being established (this was a
system design and prototype review for another IT development project).
[Footnote 28] However, the board has not yet developed a schedule for
any milestone reviews for HealtheVet projects. In particular, although
the Enrollment project is scheduled for initial implementation in
August 2008, no system deployment milestone review has been scheduled.
According to the chair of this board, although no HealtheVet milestone
reviews have been scheduled, the board has scheduled an operational
test readiness review for another HealtheVet project (the Scheduling
project) in June 2008 to verify that the application functions as
designed are ready for initial deployment. Doing such a review should
provide the board with useful information for oversight of this
project. Nonetheless, it is important to hold milestone reviews on all
projects that are moving from one phase of development to the next.
Without milestone reviews of project progress, the governance boards
cannot effectively measure progress or determine the funding needed for
HealtheVet.
Conclusions:
Although VA has made progress on its $11 billion HealtheVet initiative,
it has also experienced significant delays, and none of the associated
development projects have been completed. Moreover, VA is proceeding
with this complex initiative without a project management plan and
validated cost estimates to coordinate and guide the effort.
At the same time, a governance structure for HealtheVet has not yet
been established, and key leadership positions that are responsible for
providing day-to-day oversight have not been permanently staffed.
Further, several IT governance boards with oversight responsibility for
HealtheVet have not yet performed essential reviews of HealtheVet
projects to gauge progress and funding requirements and the department
lacks a time frame for doing so. Until the department takes the
necessary actions to fully address these matters, it will face the risk
that HealtheVet may experience cost overruns and continued schedule
slippages, and may not achieve the outcome it intends to achieve.
Recommendations for Executive Action:
To better ensure the success of HealtheVet, we recommend that the
Secretary of Veterans Affairs direct the Chief Information Officer to
take the following four actions:
* Develop a project management plan that encompasses all six blocks of
HealtheVet.
* Validate cost estimates for all six blocks of HealtheVet.
* Expedite efforts to permanently staff the position of the Director of
the Program Management office and fill other critical leadership
positions in the Office of Enterprise Development.
* Develop a schedule for and conduct milestone reviews of the
HealtheVet projects.
In addition, to ensure proper oversight of HealtheVet, we recommend
that the Secretary of Veterans Affairs direct the Veterans Health
Administration Under Secretary to take the following action:
* Finalize and implement the plan to establish the HealtheVet
governance structure.
Agency Comments and Our Evaluation:
In providing written comments on a draft of this report, the Deputy
Secretary of Veterans Affairs agreed with our conclusions and concurred
with our recommendations. (The department's comments are reproduced in
app. II.) The comments described actions planned or being taken that
respond to our recommendations. For example, according to the
department, the Office of Information and Technology is developing a
comprehensive, integrated HealtheVet project management plan to be
completed within 6 months that is to reflect dependencies between
resources and establish a single schedule for all VA medical
information technology projects. As part of this plan, the department
noted that it will include the format and schedule for conducting
milestone reviews for HealtheVet projects. In addition, the department
stated that it has hired a contractor to conduct an independent
financial validation of the HealtheVet preliminary cost estimate that
includes three phases and is to be completed by February 2009. To
address staffing within the Office of Enterprise Development, the
department stated that it had posted a vacancy announcement to fill the
leadership position for the Program Management Office. Lastly, the
department said it expects final review and approval of the HealtheVet
governance plan by July 2008. If the actions that the department has
planned or undertaken are properly implemented, they should help ensure
success with the development and implementation of HealtheVet. The
department also provided technical comments on the draft report, which
we have incorporated as appropriate.
As agreed, unless you publicly announce the contents of this report
earlier, we plan no further distribution until 30 days from the report
date. At that time, we are sending copies of this report to interested
congressional committees and the Secretary of Veterans Affairs. Copies
of this report will also be made available to other interested parties
on request. This report will also be available at no charge on our Web
site at [hyperlink, http://www.gao.gov].
Should you or your staffs have any questions on matters discussed in
this report, please contact me at (202) 512-6304 or melvinv@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. GAO staff who
made major contributions to this report are listed in appendix IV.
Sincerely,
Signed by:
Valerie C. Melvin:
Director, Human Capital and Management Information Systems Issues:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
As requested, the objectives of our review were to determine (1) the
status of the HealtheVet initiative, (2) VA's overall plan for
completing the initiative, and (3) how VA is providing oversight to
ensure the success of the initiative. We conducted our review by
reviewing relevant HealtheVet project and budget documentation and
validated our analyses through interviews with knowledgeable VA
officials.
To determine the status of the HealtheVet initiative, we reviewed
individual HealtheVet documents on system operation and development,
time frames, and activities planned. Additionally, we researched the
department's expenditures on HealtheVet initiatives through fiscal year
2007 and the department's current estimate of how much it plans to
spend in fiscal years 2008 and 2009. We did not assess the accuracy of
the cost data provided to us. We supplemented our analyses with
interviews of VA personnel involved in the initiative. We also observed
demonstrations of scheduling and enrollment prototypes to better
understand how HealtheVet initiatives could provide enhanced service to
patients and better support VA's medical care providers. Finally, to
gain user perspective on moving from VistA to HealtheVet, we visited
the VA Medical Center in Salem, Virginia, because it had recently
installed customized enhancements to VistA.
To determine VA's plan for completing HealtheVet, we reviewed the
department's strategy and transition plan. We supplemented this review
with responsible officials at the Office of Information and Technology,
including the Deputy CIO for Enterprise Development and the Acting
Deputy Director of the Program Management Office within the Office of
Enterprise Development, to identify the department's current strategy
for the completion of HealtheVet. We summarized information obtained
through interviews and reviews of HealtheVet documents to illustrate
VA's approach to completing the initiative.
To determine how VA is providing oversight for HealtheVet, we reviewed
department information technology (IT) governance documents, including
the IT Governance Plan, as well as the charters of the three VA IT
governance boards, to determine the boards' roles and responsibilities
for oversight of VA IT initiatives such as HealtheVet. In addition, we
reviewed minutes of the three VA IT governance boards to determine the
extent of their oversight of HealtheVet to date. We interviewed the
chairman of the Planning, Architecture, Technology, and Services Board
to determine that board's plans for conducting future milestone reviews
for HealtheVet. We also reviewed the Office of Enterprise Development
organizational structure and responsibilities. We interviewed the Chief
Officer of VHA's Office of Information and members of his staff to
obtain information on the plan under development to provide governance
for HealtheVet.
We conducted this performance audit at the Department of Veterans
Affairs headquarters in Washington, D.C., and the VA medical center in
Salem, Virginia, from July 2007 through June 2008, in accordance with
generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
The Deputy Secretary Of Veterans Affairs:
Washington:
June 24, 2008:
Ms. Valerie C. Melvin:
Director:
Human Capital and Management Information Systems:
U.S. Government Accounting Office:
441 G. Street NW:
Washington, DC 204548:
Dear Ms. Melvin:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, Veterans Affairs: Health
Information System Modernization Far from Complete; Improved Project
Planning and Oversight Needed (GAO-08-805). The report validates all
the efforts that are in the process of being finalized or are presently
underway. As examples, the over arching governance structure is in
final coordination and will be finalized by the end of this month, the
life-cycle cost estimate recently developed is presently undergoing an
independent validation, a draft comprehensive project plan detailing
all the steps necessary to develop and implement the replacement system
was completed and is undergoing extensive validation and review.
In the past year, with the consolidation of all information technology
activities into a single organization, we have been able to transform
how the department approaches the management of large information
technology development programs. These efforts are not one time
activities and require constant attention and focus which we are
committed to providing. The enclosure describes the efforts that are
presently underway that align with each of GAO's recommendations in
detail.
VA appreciates the opportunity to comment on your draft report.
Sincerely yours,
Signed by:
Gordon H. Mansfield:
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) draft report, Veterans Affairs: Health
Information System Modernization Far from Complete; Improved Project
Planning and Oversight Needed (GAO-08-805):
To better ensure the success of HealtheVet, GAO recommends that the
Secretary of Veterans Affairs direct the Chief Information Officer to
take the following five (sic) actions:
* Develop a project management plan that encompasses all six blocks of
HealtheVet.
Concur - The Office of Information and Technology (OI&T) is developing
a comprehensive integrated HealtheVet project management plan. Features
of the integrated plan include:
* Establishing a single schedule for all VA medical information
technology (IT).
* Enabling key decisions for sustaining the VistA-HealtheVet
environment VA is operating and planning, to include Replacement
Scheduling Application (RSA) and 80 other HealtheVet modules, as well
as more than 60 VistA applications.
* Depicting dependencies between resources to eliminate "stack-ups" or
disconnects in programs/projects, activities, and locations.
* Providing a visual tool for understanding scheduled activities, and
measuring objective progress against the schedule.
* Providing ability to forecast the impact and consequences of changes
or problems with the schedule (both positively and negatively).
VA estimates completing this plan within 6 months and will include it
in the bimonthly briefings to Congress.
* Validate cost estimates for all six blocks of HealtheVet.
Concur - OI&T has developed a preliminary cost estimate (included in
the report). In May 2008, the Space and Naval Warfare Systems Center
Charleston (SPAWAR) was tasked with conducting an independent financial
validation of the 10 year life cycle costs for the HealtheVet suite of
applications. This review will have three phases, which include:
* Phase 1 - Quick-look Sufficiency Review: Review relevant artifacts;
interview appropriate parties and formulate an opinion on the
sufficiency of the VA budget preparation process for the HealtheVet 10
year life-cycle cost estimate submitted to Congress and the Office of
Management and Budget. Estimated completion date: July 2008.
* Phase 2 - Risk Analysis: Define and perform an uncertainty analysis
(risk) of current cost estimate of the HealtheVet 10 year life-cycle
cost estimate. SPAWAR will develop an initial cost risk model to
characterize the probability distributions of the key cost elements
associated with the VA-developed HealtheVet cost estimate and review
and iterate the cost model to develop statistical estimates of the
overall cost estimate uncertainty. Estimated completion date: September
2008.
* Phase 3 - Independent Cost Estimate: Develop an independent cost
estimate of the HealtheVet 10 year life-cycle. Using the
information/data collected during the first two phases and the initial
period of this phase, SPAWAR shall apply government best practices to
develop an independent life cycle cost model. Estimated completion
date: February 2009.
* Expedite efforts to permanently staff the position of the Director of
the Program Management office and fill other critical leadership
positions in the Office of Enterprise Development.
Concur - The Director of the Program Management position is a Senior
Executive Service position (Assistant Deputy CIO, Enterprise
Development Program Management). The Secretary approved this position
on October 23, 2007. The vacancy announcement has been posted with a
closing date of July 7, 2008. OI&T maintains a staffing plan that
depicts critical fills, and is actively recruiting to fill these
positions. In addition, an interagency agreement has been put in place
with SPAWAR, which provides for the assignment of SPAWAR government
staff to OI&T positions.
* Develop a schedule for and conduct milestone reviews of the
HealtheVet projects.
Concur - OI&T is working with the IT strategic planning division in
order to determine appropriate formats and schedules for milestone
reviews. Milestone reviews involve a number of stakeholders to ensure
comprehensive program review. The review format and schedule will be
included in the project management plan and will, therefore, be
published within 6 months.
In addition, to ensure proper oversight of HealtheVet, GAO recommends
that the Secretary of Veterans Affairs direct the Veterans Health
Administration Under Secretary to take the following action:
* Finalize and implement the plan to establish the HealtheVet
governance structure.
Concur - As stated in GAO's draft report, in 2004, VA contracted with
the Software Engineering Institute (SEI) for the technical review of
the HealtheVet program effort. As a result of this review, SEI
concluded, among other things, that VA needed to improve and integrate
the governance of the HealtheVet program. In 2005, VA began to take
action on the SEI recommendations by beginning to develop an initial
draft for HealtheVet governance that defined decision-making processes,
established guidelines for issue identification and escalation, defined
areas of control and levels of authority, and established
accountability. However, the effort to develop a governance plan and
structure was superseded by a major realignment of the Department's
overall IT management structure.
Following the realignment, a major effort was undertaken by the
Veterans Health Administration's (VHA) Office of Information to develop
a governance structure for HealtheVet in accordance with the approach
endorsed by the Department and in alignment with previously approved
governance structures for Financial and Logistics Integrated Technology
Enterprise (FLITE) and Veterans Services Network (VETSNET). Under this
approach, HealtheVet governance for IT initiatives is provided at
several levels. An Executive Steering Committee, chaired by VHA's Under
Secretary for Health provides executive oversight. Reporting to the
Executive Steering Committee is an Oversight Board, which is chaired by
the Deputy Under Secretary for Health with responsibility for ensuring
that all stakeholders are represented in defining requirements,
monitoring progress, and determining that the HealtheVet program is
meeting their needs. Finally, a program director has been established
with responsibility for day-to-day oversight activities to ensure that
the technical solution provided by the developers meets business needs
and that the integrated HealtheVet program is performing on-scope, on-
cost, and on-schedule.
On March 27, 2008, VHA's Under Secretary for Health formally approved
the proposed HealtheVet governance structure. Subsequently, VHA revised
the governance document based upon comments from departmental offices.
Final review and approval of the document by VA's Secretary is targeted
by July 2008.
[End of section]
Appendix III: Existing VistA Applications Overview:
According to VA, all of the functionality delivered by the VistA
applications described below will be either rehosted or replaced as
part of HealtheVet.
[End of section]
Health Provider Applications:
Application name: Care Management;
Description: Offers a convenient way for healthcare providers to view
information about multiple patients on a single screen. Users can see
at a glance multiple patients for whom they have items that require
attention.
Application name: Clinical Procedures;
Description: Passes final patient results between vendor clinical
information systems and VistA.
Application name: Computerized Patient Record System;
Description: Enables clinicians to enter, review, and continuously
update all order-related information connected with any patient.
Application name: CPRS: Adverse Reaction Tracking;
Description: Provides a common and consistent data structure for
adverse reaction data.
Application name: CPRS: Authorization/Subscription Utility;
Description: Provides a method for identifying who is authorized to
perform various actions on clinical documents.
Application name: CPRS: Clinical Reminders;
Description: Assists clinical decision-making and educate providers
about appropriate care. The primary goal is to provide relevant
information to providers at the point of care, for improving care for
veterans.
Application name: CPRS: Consult/Request Tracking;
Description: Provides an efficient way for clinicians to order
consultations and procedures from other providers or services within
the hospital site, at their own facility or another facility.
Application name: CPRS: Health Summary;
Description: A clinically oriented, structured report that extracts
many kinds of data from VistA and displays it in a standard format.
Application name: CPRS: Problem List;
Description: Provides the clinician with a current and historical view
of the patient's health care problems across clinical specialties and
allows each identified problem to be traceable through the VistA system
in terms of treatment, test results, and outcome.
Application name: CPRS: Text Integration Utilities;
Description: Simplifies the use and management of clinical documents
for both clinical and administrative medical facility personnel.
Application name: Dentistry;
Description: A menu-based system incorporating features necessary for
the maintenance of medical center dental records.
Application name: Hepatitis C Case Registry;
Description: Contains important demographic and clinical data on VHA
patients identified with Hepatitis C infection.
Application name: Home Based Primary Care;
Description: Designed to allow for the local entry and verification of
patient-related data at an individual medical center.
Application name: Immunology Case Registry;
Description: Contains important demographic and clinical data on VHA
patients identified with Human Immunodeficiency Virus infection.
Application name: Intake and Output;
Description: Designed to store, in the patient's electronic medical
record, all patient intake and output information associated with a
hospital stay or outpatient visit.
Application name: Laboratory;
Description: Supports General Laboratory, Microbiology, Histology,
Cytology, Surgical Pathology, Electron Microscopy, Blood Donors, and
Blood Bank for managing and automating the workload and reporting
process.
Application name: Laboratory: Anatomic Pathology;
Description: Automates record keeping and reporting for all areas of
Anatomic Pathology.
Application name: Laboratory: Blood Bank;
Description: Uses data that can be tied primarily to a donor, a
patient, or a unit of blood/blood component.
Application name: Laboratory: Electronic Data Interchange;
Description: Reduces or eliminates the need for manual ordering and
reporting of laboratory results to interface laboratories.
Application name: Medicine;
Description: Allows entry, edit, and viewing of data for many medical
tests and procedures.
Application name: Mental Health;
Description: Provides computer support for both clinical and
administrative patient care activities associated with mental health
care.
Application name: Nursing;
Description: Generates management reports on employees; accumulates
daily statistics on the number of patients treated; generates reports
on patients by bed section and ward; allows users to enter vital signs,
height, and weight for patients; and allows users to generate intake
and output reports.
Application name: Nutrition and Food Service;
Description: Integrates the automation of many Clinical Nutrition, Food
Management, and Management Reports functions.
Application name: Oncology;
Description: Automates the tumor registry and supports tumor registrars
in abstracting cancer cases, following up on cancer patients and
producing the Hospital Annual Report.
Application name: Pharmacy: Automatic Replenishment/Ward Stock;
Description: Provides a method to track drug distribution and inventory
management within a medical center.
Application name: Pharmacy: Bar Code Medication Administration;
Description: Provides a real-time, point-of-care solution for
validating the administration of Unit Dose and intravenous medications
to inpatients in medical centers.
Application name: Pharmacy: Consolidated Mail Outpatient Pharmacy;
Description: Provides a regional system resource to expedite the
distribution of mail-out prescriptions to veteran patients.
Application name: Pharmacy: Controlled Substances;
Description: Provides functionality to monitor and track the receipt,
inventory, and dispensing of all controlled substances.
Application name: Pharmacy: Drug Accountability/Inventory Interface;
Description: Works toward perpetual inventory for each VA medical
facility pharmacy by tracking all drugs through pharmacy locations.
Application name: Pharmacy: Electronic Claims Management Engine;
Description: Provides the ability to create and distribute electronic
Outpatient Pharmacy claims to insurance companies on behalf of VHA
pharmacy prescription beneficiaries in a real-time environment.
Application name: Pharmacy: Inpatient Medications;
Description: Integrates functions from the Intravenous and Unit Dose
modules to provide a comprehensive record of medications utilized
during hospitalization of the veteran.
Application name: Pharmacy: Inpatient Medications - Intravenous;
Description: Provides pharmacists and their staff with IV labels,
manufacturing worksheets, ward lists for order updates, and management
report.
Application name: Pharmacy: Inpatient Medications -Unit Dose;
Description: Provides a standard computerized system for dispensing and
managing inpatient medications.
Application name: Pharmacy: National Drug File;
Description: Provides standardization of the local drug files in all VA
medical facilities.
Application name: Pharmacy: Outpatient Pharmacy;
Description: Provides a way to manage the medication regimen of
veterans seen in outpatient clinics and to monitor and manage the
workload and costs in the Outpatient Pharmacy.
Application name: Pharmacy: Pharmacy Benefits Management;
Description: Makes data extraction reports available at the medical
centers and allows local management to use the data to project local
drug usage and identify potential drug accountability problem areas.
Application name: Pharmacy: Pharmacy Data Management;
Description: Provides tools for managing site configurable data in
pharmacy files.
Application name: Pharmacy: Pharmacy Prescription Practices;
Description: Provides medical centers with the ability to determine
whether a patient has been seen at other VA facilities and to request
current pharmacy information from those facilities prior to the patient
appearing for a scheduled outpatient visit.
Application name: Primary Care Management Module;
Description: In the outpatient setting, patients are assigned a primary
care team and provider who are responsible for delivering essential
health care, coordinating all health care services, and serving as the
point of access for specialty care. This application allows a user to
create, set up, and define teams; create and assign positions to the
team; assign staff to the positions; assign patients to the team; and
assign patient to providers' positions.
Application name: Prosthetics;
Description: Automates purchasing, provides control and auditing of
expenditures, and generates management reports.
Application name: Quality: Audiology and Speech Analysis and Reporting;
Description: Used to enter, edit, and retrieve data for each episode of
care.
Application name: Radiology/Nuclear Medicine;
Description: Automates the entire range of diagnostic functions
performed in imaging departments, including order entry of requests,
registration of patients for exams, processing of exams, recording of
reports/results, verification of reports on-line, displaying/printing
results for clinical staff, automatic tracking of
requests/exams/reports, and generation of management
statistics/reports, both recurring and ad hoc.
Application name: Remote Order Entry System;
Description: Used by clinicians to place orders for certain types of
medical products and services that are maintained under contract by the
Denver Distribution Center. The most substantial product line is custom
hearing aids.
Application name: Scheduling;
Description: Automates all aspects of the outpatient appointment
process.
Application name: Social Work;
Description: Is designed to facilitate the Social Work Service
functions within a medical facility and is composed of Case Management,
Clinical Assessment, and Community Resources.
Application name: Spinal Cord Dysfunction;
Description: Permits the identification and tracking of patients with a
spinal cord dysfunction due to trauma or disease and the medical
resources utilized during their treatment.
Application name: Surgery;
Description: Integrates scheduling surgical cases and tracking clinical
patient data to provide a variety of administrative and clinical
reports.
Application name: Surgery: Risk Assessment;
Description: Provides medical facilities a mechanism to track
information relating to both surgical risk and operative mortality.
Application name: VistA Imaging System;
Description: Facilitates medical decision-making by delivering complete
multimedia patient information to the clinician's desktop in an
integrated manner.
Application name: VistA Imaging: Core Infrastructure;
Description: Includes the components used to capture, store, and
display all types of images.
Application name: VistA Imaging: Document Imaging;
Description: Allows scanned and electronically generated documents to
be associated with the online patient record and displayed on clinical
workstations.
Application name: VistA Imaging: Filmless Radiology;
Description: Allows radiology departments to operate without generating
X-ray film.
Application name: VistA Imaging: Imaging Ancillary Systems;
Description: Captures, stores, and displays images for a particular
service or specialty.
Application name: Visual Impairment Service Team;
Description: Enables the Visual Impairment Service Team to easily
manage and track activities and services provided to blinded veterans
in their service areas.
Application name: Vitals/Measurements;
Description: Designed to store, in the patient's electronic medical
record, all vital signs and various measurements associated with a
patient's hospital stay or outpatient clinic visit.
Application name: Women's Health;
Description: To establish a computerized tracking system that generates
aggregate data at the facility level. It would assist in the assessment
of various aspects of care provided to women veterans.
Management and Financial Systems:
Application name: Accounts Receivable;
Description: Automates the debt collection process and a billing module
is available to create non-medical care debts.
Application name: Automated Information Collection System;
Description: Creates and prints encounter forms that display relevant
clinical information, and provides for the entry of clinical encounter
data for local and national needs.
Application name: Beneficiary Travel;
Description: Provides the ability to perform the functions involved in
issuing beneficiary travel pay.
Application name: Compensation and Pension Records Interchange;
Description: Provides on-line access to medical data to Veterans
Benefits Administration Rating Veteran Service Representatives and
Decision Review Officers. It also creates a more efficient means of
requesting compensation and pension examinations.
Application name: Current Procedural Terminology;
Description: CPT codes are used for reporting medical services and
procedures performed by physicians. The software includes all CPT codes
to code outpatient services for reimbursement and workload purposes.
Application name: Decision Support System Extracts;
Description: Provides a means of exporting data from selected VistA
applications and transmitting it to a Decision Support System at the
Austin Automation Center.
Application name: Diagnostic Related Group Grouper;
Description: Is based on the Medicare Grouper requirements as defined
by the Health Care Financing Administration. Each DRG represents a
class of patients who are deemed medically comparable and who require
approximately equal amounts of health care resources.
Application name: Engineering;
Description: Facilitates the management of information needed to
effectively discharge key operations responsibilities normally assigned
to VA engineering organizations.
Application name: Equipment/Turn-in Request;
Description: Provides additional functionality within the Integrated
Funds Distribution, Control Point Activity, Accounting and Procurement
package.
Application name: Event Capture;
Description: Provides a mechanism to track and account for procedures
and delivered services that are not handled in any other VistA package.
Application name: Fee Basis;
Description: Supports VHA's Fee for Service program, which is care
authorized for veterans who are legally eligible and are in need of
care that cannot feasibly be provided by a VA facility.
Application name: Generic Code Sheet;
Description: Allows code sheet data to be entered and transmitted
electronically from the medical facility service level to the national
database.
Application name: Incomplete Records Tracking;
Description: Provides the medical center the ability to monitor
incomplete records, interim summaries, discharge summaries, and both
inpatient and outpatient operation reports.
Application name: Integrated Funds Distribution, Control Point
Activity, Accounting and Procurement;
Description: Automates a spectrum of VA financial activities. Provides
users the capability to manage budgets, order goods and services,
maintain records of available funds, determine the status of a request,
compare vendors and items to determine the best purchase, record the
receipt of items into the warehouse, and pay vendors.
Application name: Integrated Patient Funds;
Description: Automates the mini-banking system that VA provides for
patients to manage their personal funds while hospitalized in a VA
medical facility.
Application name: Integrated Billing;
Description: Contains all the features necessary to create bills for
patients and third party insurance carriers.
Application name: Patient Care Encounter;
Description: Captures clinical data resulting from ambulatory care
patient encounters.
Application name: Personnel and Accounting Integrated Data;
Description: Automates time and attendance for employees, timekeepers,
payroll, and supervisors.
Application name: Voluntary Service System;
Description: A national-level application replacing the site-based
Voluntary Timekeeping System that tracks and manages the hours of
service contributed by volunteers and volunteer organizations.
Cross-Cutting Monographs:
Application name: Duplicate Record Merge;
Description: Enhances the ability to associate appropriate data with a
single patient identifier. It provides the tools necessary to
automatically identify patient records identified as being duplicates.
Application name: Health Level Seven;
Description: This package enables M-based VistA applications running on
core facility computer systems to exchange health care information with
other computer systems. It provides messaging services and a single
toolset for M-based VistA applications to create, send, receive, and
process HL7 messages.
Application name: Kernel;
Description: A portability layer between the underlying operating
system and application code. This enables the VistA system to be
portable among different computers, operating systems, and M
implementations.
Application name: Kernel Toolkit;
Description: Provides Development and Quality Assessment Tools,
Capacity Planning Tools, and System Management Utilities.
Application name: List Manager;
Description: Provides an efficient way for applications to present a
list of items to the user for action.
Application name: MailMan;
Description: An electronic messaging system that transmits messages,
computer programs, data dictionaries, and data between users and
applications located at the same or at different facilities.
Application name: Master Patient Index and Master Patient Index/Patient
Demographics;
Description: This is a suite of applications that provides the ability
to uniquely identify a patient and the facilities where that patient
receives care. It is a foundation for the CPRS Remote Data Views that
allows the clinician to retrieve clinical information from wherever the
patient has received care.
Application name: My HealtheVet;
Description: Is a Web-based application that creates a new, on-line
environment where veterans, family, and clinicians may come together to
optimize veterans' health care.
Application name: Network Health Exchange;
Description: Provides clinicians quick and easy access to patients'
information from any VA medical facility where a patient has received
care.
Application name: Patient Data Exchange;
Description: Electronically requests and receives patient demographics,
episodes of care, medications, and diagnostic evaluations from other VA
facilities.
Application name: Remote Procedure Call Broker;
Description: Provides functionality so that graphical user interface
developers can establish a connection from a client workstation to a
VistA Server; fun remote procedure calls on the VistA M Server; and
return data to the client workstation.
Application name: VA FileMan;
Description: The majority of VHA clinical data is stored in VA FileMan
files and is retrieved and accessed through VA FileMan Application
Programmer Interfaces and user interfaces.
Application name: VistALink;
Description: Provides a synchronous communication mechanism between M
applications and rehosted applications, supporting VHA's ongoing
transition to HealtheVet.
Registration, Enrollment, and Eligibility Systems:
Application name: Admission, Discharge, Transfer/Registration;
Description: Provides a comprehensive range of software dedicated to
the support of administrative functions related to patient admission,
discharge, transfer, and registration.
Application name: Clinical Monitoring System;
Description: Allows the user to design monitors that capture patient
data in support of quality management efforts.
Application name: Enrollment Application System;
Description: Facilitates the processing of an application for health
benefits, which has been transmitted to the VHA site from the web-based
software.
Application name: Hospital Inquiry;
Description: Provides the capability to request and obtain veteran
eligibility data via the VA national telecommunications network.
Application name: Income Verification Match;
Description: Extracts patient-reported Means Test data and transmit it
to the Health Eligibility Center.
Application name: Record Tracking;
Description: Provides for the maintenance and control of medical
records and x-ray films to facilitate availability to a variety of
users.
Application name: Resident Assessment Instrument/Minimum Data Set;
Description: Provides a standardized assessment tool supporting the
completion of a comprehensive accurate and reproducible patient
assessment, and serves as the basis for developing the patient's plan
of care.
Application name: Veteran Identification Card;
Description: Replaces the embossed data card as a means of identifying
veteran patients entitled to care and service at VA health care
facilities.
Health Data Systems:
Application name: Automated Medical Information Exchange;
Description: Facilitates the electronic interchange of veteran
information between Veteran Benefits Administration Regional Offices
and VA medical facilities.
Application name: Incident Reporting;
Description: Supports VHA policy by compiling data on patient
incidents.
Application name: Lexicon Utility;
Description: Used to express diagnostic clinical problems in easy-to-
understand terminology and associate these terms to coding systems such
as ICD, DSM, NANDA.
Application name: Occurrence Screen;
Description: Supports VHA policy by providing for the identification of
events requiring follow-up review.
Application name: Patient Representative;
Description: Tracks and trends compliments and complaints and measures
the facility's types of complaints as they relate to the Customer
Services Standards and the National Patient Satisfaction Survey.
Information and Education Systems:
Application name: Automated Safety Incident Surveillance Tracking
System;
Description: Designed to manage the data from all employee accidents,
create a Report of Accident, and produce the Office of Worker's
Compensation Programs Form CA-1 and the Federal Employee's Notice of
Occupational Disease and Claim for Compensation Form CA-2.
Application name: Library;
Description: Automates the entire serials management process in VA
Library Services.
Application name: Police and Security;
Description: Supports the VA Police in their responsibilities of crime
prevention, preliminary investigation of crimes, apprehension, legally
correct handling of suspected offenders, and the transfer of suspected
offenders to appropriate authorities.
Source: VA.
[End of table]
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Valerie C. Melvin, (202) 512-6304, or melvinv@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, key contributions to this
report were made by Barbara Oliver (Assistant Director), Barbara
Collier, Neil Doherty, Nancy Glover, Michele Mackin, J. Michael Resser,
Amos Tevelow, Eric Trout, and Charles Youman.
[End of section]
Footnotes:
[1] The number of patients is the projection for fiscal year 2008
reported in VA's 2009 budget request. According to the department, VA
facilities include hospitals, nursing homes, domiciliary residential
rehabilitation and treatment facilities, community-based outpatient
clinics, independent outpatient clinics, and mobile outpatient clinics.
[2] For example, in 2006, VistA received the Innovations in American
Government Award from Harvard University's Ash Institute for Democratic
Governance and Innovation because it has led to reduced errors and
provided cost savings in VA's delivery of health care.
[3] We define interoperability as the ability of two or more systems or
components to exchange information and to use the information
exchanged.
[4] This total includes the almost $600 million spent on HealtheVet
through fiscal year 2007.
[5] GAO, Information Technology: VA and DOD Are Making Progress in
Sharing Medical Information, but Remain Far from Having Comprehensive
Electronic Medical Records, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-1108T] (Washington, D.C.: July 18, 2007).
[6] For example, certain enhancements and fixes are necessary to ensure
compliance with changes to patient enrollment and billing requirements.
[7] Common services are important to the development of a service-
oriented architecture--that is, an architecture in which application
software locates, selects, and uses separately-provided software
services that it needs to perform its intended function. The use of a
service-oriented architecture is intended to provide the department
more flexibility in making system changes and conform to the Federal
Enterprise Architecture. The Federal Enterprise Architecture is
intended to facilitate the coordination of common business processes,
technology insertion, information flows, and system investments among
federal agencies.
[8] GAO, 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, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-
271T] (Washington, D.C.: Nov. 19, 2003).
[9] VistA began operation in 1983 as the Decentralized Hospital
Computer Program. In 1996, the name of the system was changed to the
Veterans Health Information Systems and Technology Architecture.
[10] A site includes one or more facilities--medical centers,
hospitals, or outpatient clinics--that store their electronic health
data in a single database.
[11] This programming language, the Massachusetts General Hospital
Utility Multi-Programming System, is now referred to as M or MUMPS.
[12] GAO, 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, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-
271T] (Washington, D.C.: Nov. 19, 2003).
[13] SEI is a federally-funded research and development center operated
by Carnegie Mellon University. Its mission is to advance software
engineering and related disciplines to ensure the development and
operation of systems with predictable and improved cost, schedule, and
quality.
[14] We had previously reported that a contributing factor to VA's
challenges in managing IT projects was the department's decentralized
management structure, in which its administrations and headquarters
offices controlled a majority of the department's IT budget. GAO,
Veterans Affairs: The Role of the Chief Information Officer in
Effectively Managing Information Technology, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-201T] (Washington, D.C.: Oct.
20, 2005); and Veterans Affairs: The Critical Role of the Chief
Information Officer Position in Effective Information Technology
Management, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-1017T]
(Washington, D.C.: Sept. 14, 2005).
[15] In establishing the Office of Information and Technology, during
fiscal year 2007, VA transferred over 6000 full-time information
technology employees to the CIO. This is to enable the oversight of all
projects and resources, which will be funded through the separate
appropriation account for VA IT, established by Congress in fiscal year
2006.
[16] The department is awaiting congressional approval for three of
these positions to be designated Senior Executive Service Deputy
Assistant Secretary.
[17] GAO, Information Technology: VA Has Taken Important Steps to
Centralize Control of Its Resources, but Effectiveness Depends on
Additional Planned Actions, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-449T] (Washington, D.C.: Feb. 13, 2008).
[18] Major software development projects are those major IT investments
for which the department has submitted a Capital Asset Plan and
Business Case to the Office of Management and Budget to justify
resource requests. This justification, called an Exhibit 300, contains
information such as an investment's historical and future costs,
performance measures and goals, cost-benefit analysis, acquisition
strategy, risk assessment, and security issues.
[19] GAO, Information Technology: VA and DOD Are Making Progress in
Sharing Medical Information, but Remain Far from Having Comprehensive
Electronic Medical Records, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-1108T] (Washington, D.C.: July 18, 2007).
[20] One project (Imaging) that was part of the original development
strategy is now to be implemented at a later, undetermined date.
[21] The purpose of independent verification and validation is to
provide an independent review of system processes and products to
ensure that quality standards are being met.
[22] One of these--the Health Data Repository--has already been
discussed. The two other planned databases are an administrative data
repository and a clinical data warehouse.
[23] Common services are administrative computer services, such as
messaging and security, on which application software can call as
needed. Such services are used in service-oriented architectures, in
which application software locates, selects, and uses separately
provided software services that it needs to perform its intended
function. The 10 common services are security, personal service/ID
management, organizational service/ID management, messaging/enterprise
service bus, deployment toolkit, audit, archive, business rules engine,
workflow engine, and standardization and terminology.
[24] Institute of Electrical and Electronics Engineers, IEEE/EIA Guide
for Information Technology, IEEE/EIA 12207.1-1997 (April 1998).
[25] GAO, Cost Estimate Guide: Best Practices for Estimating and
Managing Program Costs, Exposure Draft, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-1134SP] (Washington, D.C.:
July 2007).
[26] This governance structure has been put in place on another VA
initiative--the Financial and Logistics Integrated Technology
Enterprise.
[27] The Deputy CIO for IT Enterprise Strategy, Policy, Plans, and
Programs.
[28] This project--the Financial and Logistics Integrated Technology
Enterprise project--will replace VA's existing core financial
management and logistics systems and many of the legacy stovepipe
systems interfacing them with an integrated, commercial off-the-shelf
package.
[End of section]
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