Electronic Health Records
DOD's and VA's Sharing of Information Could Benefit from Improved Management Gao ID: GAO-09-268 January 28, 2009Under the National Defense Authorization Act for Fiscal Year 2008, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) are required to accelerate the exchange of health information between the departments and to develop systems or capabilities that allow for interoperability (generally, the ability of systems to exchange data) and that are compliant with federal standards. The Act also established a joint interagency program office to function as a single point of accountability for the effort, which is to implement such systems or capabilities by September 30, 2009. Further, the Act required that GAO semi-annually report on the progress made in achieving these goals. For this second report, GAO evaluates the departments' progress and plans toward sharing electronic health information that comply with federal standards, and whether the interagency program office is positioned to function as a single point of accountability. To do so, GAO reviewed its past work, analyzed agency documentation, and conducted interviews.
DOD and VA continue to increase health information sharing through ongoing initiatives and related activities. Specifically, the departments' are now exchanging pharmacy and drug allergy data on over 21,000 shared patients, an increase of about 2,700 patients between June and October 2008. Further, they recently expanded the number of standards and specifications with which they expect their interoperability initiatives will comply. In addition, DOD reported that it received certification of its electronic health record system. Also, the departments have defined their plans to further increase their sharing of electronic health information. In particular, they have identified the Joint Executive Council Strategic Plan and the DOD/VA Information Interoperability Plan as the key documents defining their planned efforts to provide interoperable health records. These plans identify various objectives and activities that, according to the departments, are aimed at increasing health information sharing and achieving full interoperability, as required by the National Defense Authorization Act for Fiscal Year 2008. However, neither plan identifies results-oriented (i.e., objective, quantifiable, and measurable) performance goals and measures that are characteristic of effective planning and can be used as a basis to track and assess progress toward the delivery of new interoperable capabilities. In the absence of results-oriented goals and performance measures, the departments are not positioned to adequately assess progress toward increasing interoperability. Instead, DOD and VA are limited to assessing progress in terms of activities completed and increases in data exchanged (e.g., the number of patients for which certain types of data are exchanged). The departments have continued to take steps to set up the interagency program office. For example, they have developed descriptions for key positions and agreed with GAO's July 2008 recommendation that they give priority to establishing permanent leadership and hiring staff. Also, the departments developed the program office organization structure document that depicts the office's organization and, in January 2009, the departments approved a program office charter to describe, among other things, the mission and function of the office. Nonetheless, DOD and VA have not yet fully executed their plan to set up the program office. For example, among other activities, they have not yet filled key positions for the Director and Deputy Director, or 22 of 30 other positions identified for the office. In the continued absence of a fully established program office, the departments will remain ineffectively positioned to assure that interoperable electronic health records and capabilities are achieved by the required date.
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
January 2009:
Electronic Health Records:
DOD's and VA's Sharing of Information Could Benefit from Improved
Management:
GAO-09-268:
GAO Highlights:
Highlights of GAO-09-268, a report to congressional committees.
Why GAO Did This Study:
Under the National Defense Authorization Act for Fiscal Year 2008, the
Department of Defense (DOD) and the Department of Veterans Affairs (VA)
are required to accelerate the exchange of health information between
the departments and to develop systems or capabilities that allow for
interoperability (generally, the ability of systems to exchange data)
and that are compliant with federal standards. The Act also established
a joint interagency program office to function as a single point of
accountability for the effort, which is to implement such systems or
capabilities by September 30, 2009.
Further, the Act required that GAO semi-annually report on the progress
made in achieving these goals. For this second report, GAO evaluates
the departments‘ progress and plans toward sharing electronic health
information that comply with federal standards, and whether the
interagency program office is positioned to function as a single point
of accountability. To do so, GAO reviewed its past work, analyzed
agency documentation, and conducted interviews.
What GAO Found:
DOD and VA continue to increase health information sharing through
ongoing initiatives and related activities. Specifically, the
departments‘ are now exchanging pharmacy and drug allergy data on over
21,000 shared patients, an increase of about 2,700 patients between
June and October 2008. Further, they recently expanded the number of
standards and specifications with which they expect their
interoperability initiatives will comply. In addition, DOD reported
that it received certification of its electronic health record system.
Also, the departments have defined their plans to further increase
their sharing of electronic health information. In particular, they
have identified the Joint Executive Council Strategic Plan and the
DOD/VA Information Interoperability Plan as the key documents defining
their planned efforts to provide interoperable health records. These
plans identify various objectives and activities that, according to the
departments, are aimed at increasing health information sharing and
achieving full interoperability, as required by the National Defense
Authorization Act for Fiscal Year 2008. However, neither plan
identifies results-oriented (i.e., objective, quantifiable, and
measurable) performance goals and measures that are characteristic of
effective planning and can be used as a basis to track and assess
progress toward the delivery of new interoperable capabilities. In the
absence of results-oriented goals and performance measures, the
departments are not positioned to adequately assess progress toward
increasing interoperability. Instead, DOD and VA are limited to
assessing progress in terms of activities completed and increases in
data exchanged (e.g., the number of patients for which certain types of
data are exchanged).
The departments have continued to take steps to set up the interagency
program office. For example, they have developed descriptions for key
positions and agreed with GAO‘s July 2008 recommendation that they give
priority to establishing permanent leadership and hiring staff. Also,
the departments developed the program office organization structure
document that depicts the office‘s organization and, in January 2009,
the departments approved a program office charter to describe, among
other things, the mission and function of the office. Nonetheless, DOD
and VA have not yet fully executed their plan to set up the program
office. For example, among other activities, they have not yet filled
key positions for the Director and Deputy Director, or 22 of 30 other
positions identified for the office. In the continued absence of a
fully established program office, the departments will remain
ineffectively positioned to assure that interoperable electronic health
records and capabilities are achieved by the required date.
What GAO Recommends:
GAO is recommending that the departments develop results-oriented
performance goals and measures to be used as the basis for reporting
interoperability progress. Commenting on a draft of this report, DOD
and VA concurred with GAO‘s recommendations.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-268]. For more
information, contact Valerie Melvin at (202) 512-6304 or
melvinv@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
DOD and VA Report Continued Progress toward Increased Interoperability;
however, Plans Lack Results-Oriented Performance Goals and Measures:
Steps Have Been Taken to Set Up the DOD/VA Interagency Program Office,
but It Is Not Positioned to Function as a Single Point of
Accountability:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Table:
Table 1: Status of Selected Key Activities to Establish the DOD/VA
Interagency Program Office, as of January 2009:
Figure:
Figure 1: Levels of Data Interoperability:
Abbreviations:
AHLTA: Armed Forces Health Longitudinal Technology Application:
BHIE: Bidirectional Health Information Exchange:
CDR: Clinical Data Repository:
CHCS: Composite Health Care System:
CHDR: interface between DOD's CDR and VA's HDR:
CIS: Clinical Information System:
DOD: Department of Defense:
FHIE: Federal Health Information Exchange:
HDR: Health Data Repository:
HHS: Department of Health and Human Services:
IT: information technology:
VA: Department of Veterans Affairs:
VistA: Veterans Health Information Systems and Technology Architecture:
[End of section]
United States Government Accountability Office: Washington, DC 20548:
January 28, 2009:
Congressional Committees:
As you are aware, the Department of Defense (DOD) and the Department of
Veterans Affairs (VA) have, for over a decade, pursued initiatives to
share data between their health information systems. The departments'
efforts have included working toward a long-term vision of a single
"comprehensive, lifelong medical record"[Footnote 1] that would enable
each service member to transition seamlessly between the two
departments, as well as more short-term efforts focused on meeting
immediate needs to share health information, including responding to
current military crises.
However, while important steps have been taken, questions have remained
concerning when and to what extent the intended electronic sharing
capabilities of the two departments will be fully achieved, prompting
continuing calls for progress in the sharing of essential health
information. Among these, a presidential task force recommended in May
2003 that DOD and VA develop and deploy bidirectional electronic health
records by fiscal year 2005. Further, in July 2007, the President's
Commission on Care for America's Returning Wounded Warriors reported
that the departments had continued to develop independent, stand-alone
systems and recommended that DOD and VA move rapidly to make all
essential health information available to clinicians.[Footnote 2]
More recently, to expedite the departments' efforts to exchange
electronic health information, the National Defense Authorization Act
for Fiscal Year 2008[Footnote 3] included provisions directing DOD and
VA to jointly develop and implement, by September 30, 2009, fully
interoperable electronic health record systems or capabilities. The Act
required that these systems or capabilities be compliant with
applicable interoperability[Footnote 4] standards of the federal
government, and it established an interagency program office to be a
single point of accountability for the departments' efforts.
In addition, the Act directed GAO to assess DOD's and VA's progress in
implementing the electronic health record systems and to report
semiannually its results to the appropriate congressional committees.
Accordingly, on July 28, 2008, we issued the first of our reports in
response to the Act.[Footnote 5] Further, we subsequently testified on
this report in September 2008.[Footnote 6] As agreed with the
committees of jurisdiction, our objectives for this second report are
to (1) evaluate the departments' progress and plans toward developing
electronic health record systems or capabilities that allow for full
interoperability and comply with applicable federal interoperability
standards and (2) determine whether the interagency program office
established by the National Defense Authorization Act for Fiscal Year
2008 is positioned to function as a single point of accountability for
developing and implementing electronic health records.
To carry out these objectives, we reviewed our past work in this area;
[Footnote 7] analyzed current agency documentation (including plans for
achieving interoperability, actions accomplished or planned to
establish the interagency program office, and program documentation for
interoperability standards); and conducted interviews with officials
from DOD, VA, and the Department of Health and Human Services' Office
of the National Coordinator for Health Information Technology.
We conducted this performance audit from August 2008 through January
2009, 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 scope and methodology, see appendix I.
Results in Brief:
DOD and VA continue to increase sharing of their electronic health
information. For example, the departments stated that they are
exchanging computable pharmacy and drug allergy data on over 21,000
shared patients, an increase of about 2,700 patients between June and
October 2008.[Footnote 8] The departments also recently expanded the
number of standards and specifications with which they expect their
interoperability initiatives will comply, and DOD reported that it has
received certification of its electronic health record system. In
addition, the departments have continued to define their plans to
further increase their sharing of electronic health information. In
particular, they have identified the November 2007 Joint Executive
Council Strategic Plan for Fiscal Years 2008-2010 and the September
2008 DOD/VA Information Interoperability Plan (Version 1.0) as the key
documents defining their planned efforts to provide interoperable
health records. These plans identify various objectives and activities
that are aimed at increasing health information sharing and achieving
full interoperability, as required by the Act. For example, the
Information Interoperability Plan identifies six objectives that are
intended to be met by September 30, 2009, including an expanded
capability to increase the sharing of inpatient discharge summaries at
additional DOD sites. However, while the plans discussed objectives and
activities to increase information sharing, neither included results-
oriented goals and performance measures that are characteristic of
effective planning and can be used as a basis to track and measure
progress toward the delivery of the interoperable capabilities the
departments plan to establish by September 30, 2009. In the absence of
results-oriented goals and performance measures, the departments are
not positioned to adequately assess progress toward achieving increased
interoperability and can only report the completion of activities and
indicate increases in data exchanged. In discussing the absence of
results-oriented performance goals and measures, DOD and VA officials
stated that their plans represent their initial efforts to articulate
interoperability goals. Until the departments establish results-
oriented goals and performance measures, they will be limited in their
ability to assess their progress and ensure that they are taking the
necessary steps to achieve their interoperability goals.
The Act called for the establishment of an interagency program office
to be accountable for implementing electronic health record systems or
capabilities that allow for full interoperability of personal health
care information between DOD and VA. As we previously reported,
[Footnote 9] the departments had planned to set up this office by
December 2008. The departments have continued to take steps to set up
the office. For example, they have developed descriptions for key
positions and agreed with our July 2008 recommendation that they give
priority to establishing permanent leadership and hiring staff. Also,
the departments developed the program office organization structure
document that depicts the office's organization and, in January 2009,
the departments approved a program office charter to describe, among
other things, the mission and function of the office. However, they
have not yet fully executed their plan for doing so. For example, among
other activities, they have not yet filled key positions for the
Director and Deputy Director, or 22 of 30 other positions identified
for the office. In the continued absence of a fully established program
office, the departments will remain ineffectively positioned to ensure
that interoperable electronic health records and capabilities are
achieved by the required date.
To better ensure the successful attainment of interoperable electronic
health record systems or capabilities, we are recommending that the
Secretaries of Defense and Veterans Affairs develop and document
results-oriented goals and performance measures for the departments'
interoperability plans and that they use such plans as the basis for
measuring and reporting progress.
The Assistant Secretary of Defense and the Secretary of Veterans
Affairs provided written comments on a draft of this report, which are
reproduced in app. II and app. III, respectively. In the comments, the
departments concurred with the report's recommendations. DOD and VA
stated that high priority will be given to the establishment and use of
results-oriented (i.e., objective, quantifiable, and measurable) goals
and associated performance measures for the departments'
interoperability objectives and documentation of these goals in
interoperability plans. If the recommendations are properly
implemented, they should better position DOD and VA to effectively
measure and report progress in achieving interoperability.
Background:
The use of information technology (IT) to electronically collect,
store, retrieve, and transfer clinical, administrative, and financial
health information has great potential to help improve the quality and
efficiency of health care and is important to improving the performance
of the U.S. health care system. Historically, patient health
information has been scattered across paper records kept by many
different caregivers in many different locations, making it difficult
for a clinician to access all of a patient's health information at the
time of care. Lacking access to these critical data, a clinician may be
challenged to make the most informed decisions on treatment options,
potentially putting the patient's health at greater risk. The use of
electronic health records can help provide this access and improve
clinical decisions.[Footnote 10]
Electronic health records are particularly crucial for optimizing the
health care provided to military personnel and veterans. While in
military status and later as veterans, many DOD and VA patients tend to
be highly mobile and may have health records residing at multiple
medical facilities within and outside the United States. Making such
records electronic can help ensure that complete health care
information is available for most military service members and veterans
at the time and place of care, no matter where it originates.
Key to making health care information electronically available is
interoperability--that is, the ability to share data among health care
providers. Interoperability enables different information systems or
components to exchange information and to use the information that has
been exchanged. This capability is important because it allows
patients' electronic health information to move with them from provider
to provider, regardless of where the information originated. If
electronic health records conform to interoperability standards, they
can be created, managed, and consulted by authorized clinicians and
staff across more than one health care organization, thus providing
patients and their caregivers the necessary information required for
optimal care. (Paper-based health records--if available--also provide
necessary information, but unlike electronic health records, paper
records do not provide decision support capabilities, such as automatic
alerts about a particular patient's health, or other advantages of
automation.)
Interoperability can be achieved at different levels.[Footnote 11] At
the highest level, electronic data are computable (that is, in a format
that a computer can understand and act on to, for example, provide
alerts to clinicians on drug allergies). At a lower level, electronic
data are structured and viewable, but not computable. The value of data
at this level is that they are structured so that data of interest to
users are easier to find. At still a lower level, electronic data are
unstructured and viewable, but not computable. With unstructured
electronic data, a user would have to find needed or relevant
information by searching uncategorized data. Beyond these, paper
records also can be considered interoperable (at the lowest level)
because they allow data to be shared, read, and interpreted by human
beings. Figure 1 shows the distinctions between the various levels of
interoperability and examples of the types of data that can be shared
at each level.
Figure 1: Levels of Data Interoperability:
[Refer to PDF for image]
This figure is an illustration of levels of data interoperability,
leading to increasingly sophisticated and standardized data, as
follows:
Level 1: Nonelectronic data(i.e., paper forms);
Level 2: Unstructured, viewable electronic data(i.e., scans of paper
forms);
Level 3: Structured, viewable electronic data(i.e., electronically
entered data that cannot be computed by other systems);
Level 4: Computable electronic data(i.e., electronically entered data
that can be computed by other systems).
Source: GAO analysis based on data from the Center for Information
Technology Leadership.
[End of figure]
According to DOD and VA officials, not all data require the same level
of interoperability. For example, in their initial efforts to implement
computable data, DOD and VA focused on outpatient pharmacy and drug
allergy data because clinicians gave priority to the need for automated
alerts to help medical personnel avoid administering inappropriate
drugs to patients. On the other hand, for such narrative data as
clinical notes, unstructured, viewable data may be sufficient.
Achieving even a minimal level of electronic interoperability is
valuable for potentially making all relevant information available to
clinicians.
Efforts to Adopt and Implement Federal Interoperability Standards Are
Ongoing:
Interoperability depends on adherence to common standards to promote
the exchange of health information between participating agencies and
with nonfederal entities in supporting quality and efficient health
care. In the health IT field, standards govern areas ranging from
technical issues, such as file types and interchange systems, to
content issues, such as medical terminology. Developing, coordinating,
and agreeing on standards are only part of the processes involved in
achieving interoperability for electronic health record systems or
capabilities. In addition, specifications are needed for implementing
the standards, as well as criteria and a process for verifying
compliance with the standards.
In April 2004, the President called for widespread adoption of
interoperable electronic health records by 2014.[Footnote 12] The
executive order established the Office of the National Coordinator for
Health Information Technology within the Department of Health and Human
Services (HHS). This office has been tasked to, among other things,
develop, maintain, and direct the implementation of a strategic plan to
guide the nationwide implementation of interoperable health IT in both
the public and private health care sectors. Under the direction of HHS
(through the Office of the National Coordinator), three primary
organizations were designated to play major roles in expanding the
implementation of health IT:
* The American Health Information Community was created by the
Secretary of HHS as a federal advisory body to make recommendations on
how to accelerate the development and adoption of health IT, including
advancing interoperability, identifying health IT standards, advancing
a nationwide health information exchange, and protecting personal
health information. Formed in September 2005, the community is made up
of representatives from both the public and private sectors, including
high-level DOD and VA officials. The community determines specific
health care areas of high priority and develops "use cases"[Footnote
13] for these areas, which provide the context in which standards would
be applicable. The use cases convey how health care professionals would
use such records and what standards would apply.
* The Healthcare Information Technology Standards Panel, sponsored by
the American National Standards Institute[Footnote 14] and funded by
the Office of the National Coordinator, was established in October 2005
as a public-private partnership to identify competing standards for the
use cases being developed by the American Health Information Community
and to "harmonize"[Footnote 15] the standards. The panel also develops
the interoperability specifications that are needed for implementing
the standards. Interoperability specifications were developed for each
of the seven use cases developed by the American Health Information
Community in 2006 and 2007.[Footnote 16] The community also developed
six use cases for 2008.[Footnote 17] The Healthcare Information
Technology Standards Panel is made up of representatives from both the
public and private sectors, including DOD and VA officials who serve as
members and are actively working on several committees and groups
within the panel.
* The Certification Commission for Healthcare Information Technology is
an independent, nonprofit organization that creates certification
criteria to determine whether health IT systems meet standards accepted
or recognized by the Secretary of HHS, and then certifies systems that
meet those criteria. HHS entered into a contract with the commission in
October 2005 to develop and evaluate the certification criteria and
inspection process for electronic health records. Certification helps
assure purchasers and other users of health IT systems that the systems
will provide needed capabilities (including ensuring security and
confidentiality) and will work with other systems without
reprogramming. Certification also encourages adoption of health IT by
assuring providers that their systems can participate in a nationwide
health information exchange in the future.
DOD and VA Have Been Pursuing Efforts to Exchange Health Information
for Over a Decade:
DOD and VA have been working to exchange patient health data
electronically since 1998. As we have previously noted,[Footnote 18]
their efforts have included both short-term initiatives to share
information in existing (legacy) systems, as well as a long-term
initiative to develop modernized health information systems--replacing
their legacy systems--that would be able to share data and, ultimately,
use interoperable electronic health records.
In their short-term initiatives to share information from existing
systems, the departments began from different positions. VA has one
integrated medical information system--the Veterans Health Information
Systems and Technology Architecture (VistA)--which uses all electronic
records and was developed in-house by VA clinicians and IT personnel.
All VA medical facilities have access to all VistA information.
In contrast, DOD uses multiple legacy medical information systems, all
of which are commercial software products that are customized for
specific uses. For example, the Composite Health Care System (CHCS),
which was formerly DOD's primary health information system, is still in
use to capture pharmacy, radiology, and laboratory information.
[Footnote 19] In addition, the Clinical Information System (CIS), a
commercial health information system customized for DOD, is used to
support inpatient treatment at military medical facilities.
The departments' short-term initiatives to share information in their
existing systems have included the following projects:
* The Federal Health Information Exchange (FHIE), completed in 2004,
enables DOD to electronically transfer service members' electronic
health information to VA when the members leave active duty.
* The Bidirectional Health Information Exchange (BHIE), also
established in 2004, was aimed at allowing clinicians at both
departments viewable access to records on shared patients (that is,
those who receive care from both departments--for example, veterans may
receive outpatient care from VA clinicians and be hospitalized at a
military treatment facility).[Footnote 20] The interface also allows
DOD sites to see previously inaccessible data at other DOD sites.
As part of the long-term initiative, each of the departments aims to
develop a modernized system in the context of a common health
information architecture that would allow a two-way exchange of health
information. The common architecture is to include standardized,
computable data; communications; security; and high-performance health
information systems: DOD's Armed Forces Health Longitudinal Technology
Application (AHLTA)[Footnote 21] and VA's HealtheVet. The departments'
modernized systems are to store information (in standardized,
computable form) in separate data repositories: DOD's Clinical Data
Repository (CDR) and VA's Health Data Repository (HDR). For the two-way
exchange of health information, in September 2006 the departments
implemented an interface named CHDR[Footnote 22], to link the two
repositories.
Beyond these initiatives, in January 2007, the departments announced
their intention to jointly determine an approach for inpatient health
records. On July 31, 2007, they awarded a contract for a feasibility
study and exploration of alternatives. In December 2008, the contractor
provided the departments with a recommended strategy for jointly
developing an inpatient solution.
GAO's Recent Report Highlighted DOD's and VA's Efforts to Share Health
Information and Identified the Need to Set Up the Program Office and
Finalize the Implementation Plan:
In reporting on the departments' progress toward developing fully
interoperable electronic health records in July 2008,[Footnote 23] we
highlighted several findings:
* DOD and VA had established and implemented mechanisms to achieve
sharing of electronic health information at different levels of
interoperability. As of June 2008, pharmacy and drug allergy data on
about 18,300 shared patients were being exchanged at the highest level
of interoperability--that is, in computable form, a standardized format
that a computer application can act on (for example, to provide alerts
to clinicians of drug allergies). Viewable data also were being shared
including, among other types, outpatient pharmacy data, allergy
information, procedures, problem lists, vital signs, microbiology
results, cytology reports, and chemistry and hematology reports.
However, the departments were not sharing all electronic health data,
including for example, immunization records and history, data on
exposure to health hazards, and psychological health treatment and care
records. Finally, although VA's health information was all captured
electronically, not all health data collected by DOD were electronic--
many DOD medical facilities used paper-based health records.
* DOD and VA were participating in a number of initiatives led by the
Office of the National Coordinator for Health Information Technology
(within HHS), aimed at promoting the adoption of federal standards and
broader use of electronic health records. The involvement of the
departments in these initiatives was an important mechanism for
aligning their electronic health records with emerging standards. The
departments also had jointly published a common (agreed to) set of
interoperability standards called the Target DOD/VA Health Standards
Profile. Updated annually, the profile was used for reviewing joint
DOD/VA initiatives to ensure standards compliance. The departments
anticipate such updates and revisions to the profile as additional
federal standards emerge and are recognized and accepted by HHS. In
addition, according to DOD officials, the department was taking steps
to ensure that its modernized health information system, AHLTA, was
compliant with standards by arranging for certification through the
Certification Commission for Healthcare Information Technology.
Specifically, version 3.3 of AHLTA was conditionally certified in April
2007 against 2006 outpatient electronic health record criteria
established by the commission. DOD officials stated that AHLTA version
3.3 was installed at three DOD locations.[Footnote 24]
* The departments' efforts to set up the DOD/VA Interagency Program
Office were still in their early stages. Leadership positions in the
office had not been permanently filled, staffing was not complete, and
facilities to house the office had not been designated. According to
the Acting Director, DOD and VA had begun developing a charter for the
office, but had not yet completed the document. Further, the
implementation plan was in draft, and although it included schedules,
milestones for several activities were not determined (such as
implementing a capability to share immunization records), even though
all capabilities were to be achieved by September 2009. We pointed out
that without a fully established program office and a finalized
implementation plan with set milestones, the departments might be
challenged in meeting the September 2009 date for achieving
interoperable electronic health records and capabilities. As a result,
we recommended that the Secretaries of Defense and Veterans Affairs
give priority to fully establishing the interagency program office and
finalizing the draft implementation plan. Both DOD and VA agreed with
these recommendations.
DOD and VA Report Continued Progress toward Increased Interoperability;
however, Plans Lack Results-Oriented Performance Goals and Measures:
Since our July 2008 report and September 2008 testimony, DOD and VA
have continued to make progress toward increased interoperability
through ongoing initiatives and activities documented in their plans
related to increasing information sharing efforts. Also, the
departments recently expanded the number of standards and
specifications with which they expect their interoperability
initiatives will comply. However, the departments' plans lack results-
oriented (i.e., objective, quantifiable, and measurable) performance
goals and measures that are characteristic of effective planning. As a
result, the extent to which the departments' progress can be assessed
and reported in terms of results achieved is largely limited to
reporting on activities completed and increases in interoperability
over time. Consequently, it is unclear what health information sharing
capabilities will be delivered by September 2009.
With regard to their ongoing initiatives, DOD and VA reported increases
in data exchanged between the departments for their long-term
initiative (CHDR) and their short-term initiative (BHIE). For example,
between June and October 2008, the departments increased the number of
shared patients for which computable outpatient pharmacy and drug
allergy data were being exchanged through the CHDR initiative by about
2,700 (from about 18,300 to over 21,000). For the BHIE initiative, the
departments continued to expand their information exchange by sharing
viewable patient vital signs information in June 2008, and demonstrated
the capability to exchange family history, social history, other
history, and questionnaires data in September 2008.
Since we last reported,[Footnote 25] DOD and VA also have made progress
toward adopting additional health data interoperability standards that
are newly recognized and accepted by the Secretary of HHS. The
departments have identified these new standards, which relate to three
use cases in the updated September 2008 Target Standards Profile.
Specifically, the profile now includes Electronic Health Records
Laboratory Results Reporting, Biosurveillance, and Consumer Empowerment
use cases. According to DOD and VA officials, the adoption of
recognized standards is a goal of both departments in order to comply
with the provisions set forth in the National Defense Authorization Act
for Fiscal Year 2008. In addition, DOD has reported progress toward
certification of its health IT system in adhering to applicable
standards. Department officials stated that AHLTA version 3.3 is now
fully operational and certified at five DOD locations,[Footnote 26]
having met certification criteria, including specific functionality,
interoperability, and security requirements. According to DOD
officials, this version of AHLTA is expected to be installed at the
remaining locations by September 30, 2009.
DOD and VA have also reported progress relative to two plans that
contain objectives, initiatives, and activities related to further
increasing health information sharing. Specifically, the departments
have identified the November 2007 VA/DOD Joint Executive Council
Strategic Plan for Fiscal Years 2008-2010 (known as the VA/DOD Joint
Strategic Plan) and the September 2008 DOD/VA Information
Interoperability Plan (Version 1.0) as defining their efforts to
provide interoperable health records. The Joint Strategic Plan
identified 39 activities related to information sharing that the
departments planned to complete by September 30, 2008. The Information
Interoperability Plan describes six objectives to be met by September
30, 2009.
The departments reported that the 39 information sharing activities
identified in the Joint Strategic Plan were completed on or ahead of
schedule. For example, the departments completed a report on the
analysis of alternatives and recommendations for the development of the
joint inpatient electronic health record,[Footnote 27] and briefed the
recommendations to the Health Executive Council and the Joint Executive
Council.[Footnote 28] However, only 3 of the 39 activities in the Joint
Strategic Plan were described in results-oriented (i.e., objective,
quantifiable, and measurable) terms that are characteristic of
effective planning and can be used as a basis to track and measure
progress toward the delivery of new interoperable capabilities. For
example, among these three, one of the activities called for the
departments to share viewable vital signs data in real-time and
bidirectional for shared patients among all sites by June 30, 2008. In
contrast, 36 activities lacked results-oriented performance measures,
limiting the extent to which progress can be reported in terms of
results achieved. For example, one activity calls for the development
of a plan for interagency sharing of essential health images, but does
not provide details on measurable achievement of additional
interoperable capabilities. Another activity calls for the review of
national health IT standards, but does not provide a tangible
deliverable to determine progress in achieving the goal.
According to department officials, DOD and VA have activities underway
to address the six interoperability objectives included in the
Information Interoperability Plan. Among these objectives, one calls
for DOD to deploy its inpatient solution at additional medical sites to
expand sharing of inpatient discharge summaries. Department officials
indicated that, as of December 2008, DOD is sharing patient discharge
summaries at 50 percent of inpatient beds compared to their goal of 70
percent by September 30, 2009. However, this is the only one of six
objectives in the Information Interoperability Plan with an associated
results-oriented performance measure. None of the remaining five
objectives are documented in terms that could allow the departments to
measure and report their progress toward delivering new capabilities.
Specifically, the objective for scanning medical documents calls for
providing an initial capability. However, "initial capability" is not
defined in quantifiable terms. As such, this objective cannot be used
as a basis to effectively measure results-oriented performance.
According to DOD and VA officials, their plans are relatively new and
represent their initial efforts to articulate interoperability goals.
However, while the departments' plans identify interoperable
capabilities to be implemented, the plans do not establish the results-
oriented (i.e., objective, quantifiable, and measurable) goals and
associated performance measures that are a necessary basis for
effective management. Without establishing plans that include results-
oriented goals, then reporting progress using measures relative to the
plans, the departments and their stakeholders do not have the
comprehensive information that they need to effectively manage their
progress toward achieving increased interoperability.
Steps Have Been Taken to Set Up the DOD/VA Interagency Program Office,
but It Is Not Positioned to Function as a Single Point of
Accountability:
The National Defense Authorization Act for Fiscal Year 2008 called for
the establishment of an interagency program office and for the office
to be accountable for implementing electronic health record systems or
capabilities that allow for full interoperability of personal health
care information between DOD and VA. Since we last reported, the
departments have continued taking steps to set up the program office,
although they have not yet fully executed their plan for doing so. As a
result, the office is not yet in a position to be accountable for
accelerating the departments' efforts to achieve interoperability by
the September 30, 2009 deadline.
To address the requirements set forth in the Act, the departments
identified in the September 2008 DOD/VA Information Interoperability
Plan a schedule for standing up the interagency program office.
Consistent with the plan, the departments have taken steps, such as
developing descriptions for key positions, including those of the
Director and Deputy Director. Further, the departments have begun to
hire personnel for program staff positions. Specifically, out of 30
total program office positions, they have hired staff for 2 of 14
government positions, 6 of 16 contractor positions, and have actions
underway to fill the remaining 22 positions. Also, since we reported in
July 2008, the departments developed the program office organization
structure document that depicts the program office's organization.
Further, in December 2008, DOD issued a Delegation of Authority
Memorandum, signed by the Deputy Secretary of Defense that formally
recognizes the program office. In January 2009, the departments
approved a program office charter to describe, among other things, the
mission and function of the office.
Nonetheless, even with the actions taken, four of eight selected key
activities that the departments identified in their plan to set up the
program office remain incomplete, including filling the remaining 22
positions, in addition to those of the Director and Deputy Director (as
shown in table 1).
Table 1: Status of Selected Key Activities to Establish the DOD/VA
Interagency Program Office, as of January 2009:
Interagency program office activities: Appoint interim Acting Director
and Acting Deputy Director;
Due date: April 2008;
Status: Complete.
Interagency program office activities: Provide interim detailed staff,
temporary space, and equipment;
Due date: May 2008;
Status: Complete.
Interagency program office activities: Develop and approve the program
office organization structure document to include mission, function,
manpower, internal governance, accountability, and authority;
Due date: June 2008;
Status: Complete.
Interagency program office activities: Develop and approve program
office charter or interagency agreement;
Due date: July 2008;
Status: Complete.
Interagency program office activities: Complete resource management
plan to include budget, space, equipment, and human resources;
Due date: July 2008;
Status: Not yet complete.
Interagency program office activities: Complete personnel position
descriptions and rating schemes;
Due date: August 2008;
Status: Not yet complete.
Interagency program office activities: Appoint permanent Director and
Deputy Director;
Due date: October 2008;
Status: Not yet complete.
Interagency program office activities: Advertise and recruit program
staff;
Due date: October 2008;
Status: Not yet complete.
Source: GAO analysis of DOD and VA data.
[End of table]
DOD and VA officials stated that the reason the departments have not
completed the execution of their plan to fully set up an interagency
program office is the longer than anticipated time needed to obtain
approval from multiple DOD and VA offices for key program office
documentation (for example, the delegation of authority memorandum and
charter). They stated that this was because the departments' leadership
broadened the program office's scope to include the sharing of
personnel and benefits data in addition to health information.
Our July 2008 report recommended that the departments give priority to
establishing the program office by establishing permanent leadership
and hiring staff.[Footnote 29] Without completion of these and other
key activities to set up the program office, the office is not yet
positioned to be fully functional, or accountable, for fulfilling the
departments' interoperability plans. Coupled with the lack of results-
oriented plans that establish program commitments in measurable terms,
the absence of a fully operational interagency program office leaves
DOD and VA without a clearly established approach for ensuring that
their actions will achieve the desired purpose of the Act.
Conclusions:
In the more than 10 years since DOD and VA began collaborating to
electronically share health information, the two departments have
increased interoperability. Nevertheless, while the departments
continue to make progress, the manner in which they report progress--by
reporting increases in interoperability over time--has limitations.
These limitations are rooted in the departments' plans, which identify
interoperable capabilities to be implemented, but lack the results-
oriented (i.e., objective, quantifiable, and measurable) goals and
associated performance measures that are a necessary basis for
effective management. Without establishing results-oriented goals, then
reporting progress using measures relative to the established goals,
the departments and their stakeholders do not have the comprehensive
picture that they need to effectively manage their progress toward
achieving increased interoperability. Further constraining the
departments' management effectiveness is their slow pace in addressing
our July 2008 recommendation related to setting up the interagency
program office that Congress called for to function as a single point
of accountability in the development and implementation of electronic
health record capabilities.
Recommendations for Executive Action:
To better ensure that DOD and VA achieve interoperable electronic
health record systems or capabilities, we recommend that the
Secretaries of Defense and Veterans Affairs take the following two
actions:
* Develop results-oriented (i.e., objective, quantifiable, and
measurable) goals and associated performance measures for the
departments' interoperability objectives and document these goals and
measures in their interoperability plans.
* Use results-oriented performance goals and measures as the basis for
future assessments and reporting of interoperability progress.
Agency Comments and Our Evaluation:
In providing written comments on a draft of this report in a January
22, 2009 letter, the Assistant Secretary of Defense for Health Affairs
concurred with our recommendations. In a January 17, 2009 letter, the
Secretary of Veterans Affairs also concurred with our recommendations.
(The departments' comments are reproduced in app. II and app. III,
respectively.) DOD and VA stated that high priority will be given to
the establishment and use of results-oriented (i.e., objective,
quantifiable, and measurable) goals and associated performance measures
for the departments' interoperability objectives. If the
recommendations are properly implemented, they should better position
DOD and VA to effectively measure and report progress in achieving full
interoperability. The departments also provided technical comments on
the draft report, which we incorporated as appropriate.
We are sending copies of this report to the Secretaries of Defense and
Veterans Affairs, appropriate congressional committees, and other
interested parties. In addition, the report is available at no charge
on the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staffs have questions about this report, please contact
me at (202) 512-6304 or melvinv@gao.gov. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. Key contributors to this report are listed in
appendix II.
Signed by:
Valerie C. Melvin:
Director, Human Capital and Management Information Systems Issues:
List of Congressional Committees:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Daniel K. Akaka:
Chairman:
The Honorable Richard M. Burr:
Ranking Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Daniel K. Inouye:
Chairman:
The Honorable Thad Cochran:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Tim Johnson:
Chairman:
The Honorable Kay Bailey Hutchison:
Ranking Member:
Subcommittee on Military Construction, Veterans' Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Ike Skelton:
Chairman:
The Honorable John M. McHugh:
Ranking Member:
Committee on Armed Services:
United States House of Representatives:
The Honorable Bob Filner:
Chairman:
The Honorable Steve Buyer:
Ranking Member:
Committee on Veterans' Affairs:
United States House of Representatives:
The Honorable John P. Murtha:
Chairman:
The Honorable C.W. Bill Young:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
United States House of Representatives:
The Honorable Chet Edwards:
Chairman:
The Honorable Zach Wamp:
Ranking Member:
Subcommittee on Military Construction, Veterans' Affairs, and Related
Agencies:
Committee on Appropriations:
United States House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
To evaluate the Department of Defense's (DOD) and the Department of
Veterans Affairs' (VA) progress toward developing electronic health
record systems or capabilities that allow for full interoperability of
personal health care information, we reviewed our previous work on DOD
and VA efforts to develop health information systems, interoperable
health records, and interoperability standards to be implemented in
federal health care programs. To describe the departments' efforts to
ensure that their health records comply with applicable
interoperability standards, we analyzed information gathered from DOD
and VA documentation and interviews pertaining to the interoperability
standards that the two departments have agreed to for exchanging health
information via their health care information systems. We reviewed
documentation and interviewed agency officials from the Department of
Health and Human Services' Office of the National Coordinator for
Health Information Technology to obtain information regarding the
defined federal interoperability standards, implementation
specifications, and certification criteria. Further, we interviewed
responsible officials to obtain information regarding the steps taken
by the departments to certify their electronic health record products.
To evaluate DOD and VA plans toward developing electronic health record
systems or capabilities, we obtained information from agency
documentation and interviews with cognizant DOD and VA officials
pertaining to the November 2007 VA/DOD Joint Executive Council
Strategic Plan for Fiscal Years 2008-2010, and the September 2008 DOD/
VA Information Interoperability Plan (Version 1.0) which together
constitute the departments' overall plans for achieving full
interoperability of electronic health information. Additionally, we
reviewed information gathered from agency documentation to identify
interoperability objectives, milestones, and target dates. Further, we
analyzed objectives and activities from their plans to determine if DOD
and VA had established results-oriented performance measures that
enable the departments to assess progress toward achieving increased
sharing capabilities and functionality of their electronic health
information systems.
To determine whether the interagency program office is fully
operational and positioned to function as a single point of
accountability for developing and implementing electronic health
records, we analyzed DOD and VA documentation, including the schedule
for setting up the office identified in the DOD/VA Information
Interoperability Plan. Additionally, we interviewed responsible
officials to determine the departments' progress to date in setting up
the interagency program office. Further, we reviewed documentation and
interviewed DOD and VA officials to determine the extent to which the
departments have positioned the office to function as a single point of
accountability for developing electronic health records.
We conducted this performance audit at DOD sites and also the
Department of Heath and Human Services' Office of the National
Coordinator for Health Information Technology in the greater
Washington, D.C., metropolitan area from August 2008 through January
2009 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 Defense:
The Assistant Secretary Of Defense:
Health Affairs:
1200 Defense Pentagon:
Washington, DC 20301-1200:
The Honorable Valerie C. Melvin:
Director, Human Capital and Management Information Systems Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
January 22, 2009:
Dear Ms. Melvin:
The enclosed Department of Defense (DoD) response addresses
recommendations from the Government Accountability Office (GAO) Draft
Report, GAO-09-268, "Electronic Health Records: DoD's and VA's Sharing
of Information Could Benefit from Improved Management," dated January
8, 2009 (GAO Code 310928).
The Department acknowledges receipt of the draft audit report and
concurs with the overall findings and recommendations. We have provided
several suggested technical corrections in the enclosed document. '
Thank you for the opportunity to review and comment on the draft
report. My points of contact for additional information are Ms. Lois
Kellett, Lois.Kellett@tma.osd.mil or (703) 681-9530, and Mr. Gunther
Zimmerman, Gunther.Zimmmerman@tma.osd.mil or (703) 681-4360.
Sincerely,
Signed by:
S. Ward Casscells, MD:
Enclosures: As stated:
Government Accountability Office (GAO) Draft Report-Dated January 8,
2009:
GAO 09-268 (GAO Code 310928):
"Electronic Health Records: DOD'S And VA'S Sharing Of Information Could
Benefit From Improved Management"
Department Of Defense Comments To GAO Recommendations:
Recommendation 1: GAO recommended that the Secretary of Defense and
Veterans Affairs develop results-oriented (i.e., objective,
quantifiable, and measurable) goals and associated performance measures
for the departments' interoperability objectives and document these
goals and measures in their interoperability plans.
DoD Response: Concur. Department of Defense (DoD) will give high
priority to the establishment of results-oriented (i.e., objective,
quantifiable, and measurable) goals and associated performance measures
for the departments' interoperability objectives and document these
goals and measures in interoperability plans.
Recommendation 2: The GAO recommended that the Secretary of Defense and
Veteran Affairs use results-oriented performance goals and measures as
the basis for future assessments and reporting of interoperability
progress.
DoD Response: Concur. DoD will give high priority to the use of results-
oriented performance goals and measures as the basis for future
assessments and reporting of interoperability progress.
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
January 17, 2009:
Ms. Valerie C. Melvin:
Director:
Human Capital and Management Information Systems Issues:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Melvin:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, Electronic Health Records:
DOD's and VA's Sharing of Information Could Benefit from Improved
Management (GAO-09-268). We agree with your findings and concur with
your recommendations.
GAO's observations have been very beneficial to us and will form the
basis of discussion and action. The enclosure provides our response to
your recommendations and technical comments suggested to provide
clarification for the overall report's accuracy.
Sincerely yours,
Signed by:
James B. Peake, M.D.
Enclosure:
Department of Veterans Affairs:
Comments to Government Accountability Office (GAO) Draft Report:
Electronic Health Records: DOD's and VA's Sharing of Information Could
Benefit from Improved Management (GAO-09-268):
GAO Recommendations:
To better ensure that DOD and VA achieve interoperable electronic
health record systems or capabilities, GAO recommends that the
Secretaries of Defense and Veterans Affairs take the following actions:
Recommendation 1: Develop results-oriented (i.e., objective,
quantifiable, and measurable) goals and associated performance measures
for the Departments' interoperability objectives and document these
goals and measures in their interoperability plans.
Response: Concur. VA and DoD will give high priority to the
establishment of results-oriented (i.e., objective, quantifiable, and
measurable) goals and associated performance measures for the
Departments' interoperability objectives and document these goals and
measures in interoperability plans.
Recommendation 2: Use results-oriented performance goals and measures
as the basis for future assessments and reporting of interoperability
progress.
Response: Concur. VA and DoD will give high priority to the use of
results-oriented performance goals and measures as the basis for future
assessments and reporting of interoperability progress.
[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 Mark Bird, Assistant Director; Neil Doherty;
Rebecca LaPaze; J. Michael Resser; Kelly Shaw; and Eric Trout.
[End of section]
Related GAO Products:
Information Technology: DOD and VA Have Increased Their Sharing of
Health Information, but Further Actions Are Needed. [hyperlink,
http://www.gao.gov/products/GAO-08-1158T]. Washington, D.C.: September
24, 2008.
Electronic Health Records: DOD and VA Have Increased Their Sharing of
Health Information, but More Work Remains. [hyperlink,
http://www.gao.gov/products/GAO-08-954]. Washington, D.C.: July 28,
2008.
VA and DOD Health Care: Progress Made on Implementation of 2003
President's Task Force Recommendations on Collaboration and
Coordination, but More Remains to Be Done. [hyperlink,
http://www.gao.gov/products/GAO-08-495R]. Washington, D.C.: April 30,
2008.
Health Information Technology: HHS Is Pursuing Efforts to Advance
Nationwide Implementation, but Has Not Yet Completed a National
Strategy. [hyperlink, http://www.gao.gov/products/GAO-08-499T].
Washington, D.C.: February 14, 2008.
Information Technology: VA and DOD Continue to Expand Sharing of
Medical Information, but Still Lack Comprehensive Electronic Medical
Records. [hyperlink, http://www.gao.gov/products/GAO-08-207T].
Washington, D.C.: October 24, 2007.
Veterans Affairs: Progress Made in Centralizing Information Technology
Management, but Challenges Persist. [hyperlink,
http://www.gao.gov/products/GAO-07-1246T]. Washington, D.C.: September
19, 2007.
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/products/GAO-07-1108T]. Washington, D.C.: July 18,
2007.
Health Information Technology: Efforts Continue but Comprehensive
Privacy Approach Needed for National Strategy. [hyperlink,
http://www.gao.gov/products/GAO-07-988T]. Washington, D.C.: June 19,
2007.
Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Are Far from Comprehensive Electronic Medical
Records. [hyperlink, http://www.gao.gov/products/GAO-07-852T].
Washington, D.C.: May 8, 2007.
DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for
Some Shared Patients, but Additional Steps Could Facilitate Exchanging
These Data for All Shared Patients. [hyperlink,
http://www.gao.gov/products/GAO-07-554R]. Washington, D.C.: April 30,
2007.
Health Information Technology: Early Efforts Initiated but
Comprehensive Privacy Approach Needed for National Strategy.
[hyperlink, http://www.gao.gov/products/GAO-07-400T]. Washington, D.C.:
February 1, 2007.
Health Information Technology: Early Efforts Initiated, but
Comprehensive Privacy Approach Needed for National Strategy.
[hyperlink, http://www.gao.gov/products/GAO-07-238]. Washington, D.C.:
January 10, 2007.
Health Information Technology: HHS is Continuing Efforts to Define Its
National Strategy. [hyperlink,
http://www.gao.gov/products/GAO-06-1071T]. Washington, D.C.: September
1, 2006.
Information Technology: VA and DOD Face Challenges in Completing Key
Efforts. [hyperlink, http://www.gao.gov/products/GAO-06-905T].
Washington, D.C.: June 22, 2006.
Health Information Technology: HHS Is Continuing Efforts to Define a
National Strategy. [hyperlink,
http://www.gao.gov/products/GAO-06-346T]. Washington, D.C.: March 15,
2006.
Computer-Based Patient Records: VA and DOD Made Progress, but Much Work
Remains to Fully Share Medical Information. [hyperlink,
http://www.gao.gov/products/GAO-05-1051T]. Washington, D.C.: September
28, 2005.
Health Information Technology: HHS Is Taking Steps to Develop a
National Strategy. [hyperlink, http://www.gao.gov/products/GAO-05-628].
Washington, D.C.: May 27, 2005.
Computer-Based Patient Records: VA and DOD Efforts to Exchange Health
Data Could Benefit from Improved Planning and Project Management.
[hyperlink, http://www.gao.gov/products/GAO-04-687]. Washington, D.C.:
June 7, 2004.
Computer-Based Patient Records: Improved Planning and Project
Management Are Critical to Achieving Two-Way VA-DOD Health Data
Exchange. [hyperlink, http://www.gao.gov/products/GAO-04-811T].
Washington, D.C.: May 19, 2004.
Computer-Based Patient Records: Sound Planning and Project Management
Are Needed to Achieve a Two-Way Exchange of VA and DOD Health Data.
[hyperlink, http://www.gao.gov/products/GAO-04-402T]. Washington, D.C.:
March 17, 2004.
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/products/GAO-04-271T].
Washington, D.C.: November 19, 2003.
VA Information Technology: Management Making Important Progress in
Addressing Key Challenges. [hyperlink,
http://www.gao.gov/products/GAO-02-1054T]. Washington, D.C.: September
26, 2002.
Veterans Affairs: Sustained Management Attention Is Key to Achieving
Information Technology Results. [hyperlink,
http://www.gao.gov/products/GAO-02-703]. Washington, D.C.: June 12,
2002.
VA Information Technology: Progress Made, but Continued Management
Attention Is Key to Achieving Results. [hyperlink,
http://www.gao.gov/products/GAO-02-369T]. Washington, D.C.: March 13,
2002.
VA and Defense Health Care: Military Medical Surveillance Policies in
Place, but Implementation Challenges Remain. [hyperlink,
http://www.gao.gov/products/GAO-02-478T]. Washington, D.C.: February
27, 2002.
VA and Defense Health Care: Progress Made, but DOD Continues to Face
Military Medical Surveillance System Challenges. [hyperlink,
http://www.gao.gov/products/GAO-02-377T]. Washington, D.C.: January 24,
2002.
VA and Defense Health Care: Progress and Challenges DOD Faces in
Executing a Military Medical Surveillance System. [hyperlink,
http://www.gao.gov/products/GAO-02-173T]. Washington, D.C.: October 16,
2001.
Computer-Based Patient Records: Better Planning and Oversight by VA,
DOD, and IHS Would Enhance Health Data Sharing. [hyperlink,
http://www.gao.gov/products/GAO-01-459]. Washington, D.C.: April 30,
2001.
[End of section]
Footnotes:
[1] In 1996, the Presidential Advisory Committee on Gulf War Veterans'
Illnesses reported on many deficiencies in VA's and DOD's data
capabilities for handling service members' health information. In
November 1997, the President called for the two agencies to start
developing a "comprehensive, lifelong medical record for each service
member," and in August 1998 issued a directive requiring VA and DOD to
develop a "computer-based patient record system that will accurately
and efficiently exchange information."
[2] The commission recommended that DOD and VA work toward a "fully
interoperable information system that will meet the long-term
administrative and clinical needs of all military personnel over time."
[3] The National Defense Authorization Act for Fiscal Year 2008, Pub.
L. No. 110-181, Section 1635 (Jan. 28, 2008).
[4] Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged. Further discussion of levels of interoperability is
provided later in this report.
[5] See GAO, Electronic Health Records: DOD and VA Have Increased Their
Sharing of Health Information, but More Work Remains, [hyperlink,
http://www.gao.gov/products/GAO-08-954] (Washington, D.C.: July 28,
2008). In this report, we highlighted the departments' progress in
sharing electronic health information, developing electronic records
that comply with national standards, and setting up the interagency
program office.
[6] See GAO, Information Technology: DOD and VA Have Increased Their
Sharing of Health Information, but Further Actions Are Needed,
[hyperlink, http://www.gao.gov/products/GAO-08-1158T] (Washington,
D.C.: Sept. 24, 2008). In this testimony, we noted that DOD and VA have
increased their sharing of health information, but still face
significant work to plan and implement new capabilities that could
further increase electronic health information sharing between the
departments and to determine the desired level of data
interoperability.
[7] See Related GAO Products at the end of this report for previous GAO
reports and testimonies on DOD/VA health information sharing and
national health information technology issues.
[8] In our July 2008 report, we noted that the departments were
exchanging pharmacy and drug allergy data on more than 18,300 shared
patients as of June 2008.
[9] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[10] An electronic health record is a collection of information about
the health of an individual or the care provided, such as patient
demographics, progress notes, problems, medications, vital signs, past
medical history, immunizations, laboratory data, and radiology reports.
[11] These levels were identified by the Center for Information
Technology Leadership, which was chartered in 2002 as a research
organization established to help guide the health care community in
making more informed strategic IT investment decisions. According to
DOD and VA, the different levels of interoperability have been accepted
for use by the Office of the National Coordinator for Health
Information Technology.
[12] Executive Order 13335, Incentives for the Use of Health
Information Technology and Establishing the Position of the National
Health Information Technology Coordinator (Washington, D.C.: Apr. 27,
2004).
[13] Use cases are descriptions of events that detail what a system (or
systems) needs to do to achieve a specific mission or goal; they convey
how individuals and organizations (actors) interact with the systems.
For health IT, use cases strive to provide enough detail and context
for follow-up activities to occur, such as standards harmonization,
architecture specification, certification consideration, and detailed
policy discussions to advance the national health IT agenda.
[14] The American National Standards Institute is a private, nonprofit
organization whose mission is to promote and facilitate voluntary
consensus standards and ensure their integrity.
[15] Harmonization is the process of identifying overlaps and gaps in
relevant standards and developing recommendations to address these
overlaps and gaps.
[16] The seven use cases are Emergency Responder; Consumer Empowerment;
Medication Management; Quality; Registration and Medication History;
Laboratory Results Reporting; and Visit, Utilization, and Lab Result
Data.
[17] The six use cases are Remote Monitoring, Patient-Provider Secure
Messaging, Personalized Healthcare, Consultation and Transfers of Care,
Public Health Case Reporting, and Immunizations and Response
Management.
[18] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[19] According to DOD, CHCS applications are now accessed through its
modernized health information system, Armed Forces Health Longitudinal
Technology Application (AHLTA). The department no longer considers
AHLTA as an acronym but as the official name of the system.
[20] To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project. Unlike FHIE, which provides a one-way transfer of information
to VA when a service member separates from the military, the two-way
interface allows clinicians in both departments to view, in real time,
limited health data (in text form) from the departments' existing
health information systems.
[21] AHLTA was formerly known as CHCS II.
[22] The name CHDR, pronounced "cheddar," combines the names of the two
repositories.
[23] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[24] These sites are the Naval Medical Center in Portsmouth, Va.;
Eisenhower Army Medical Center in Fort Gordon, Ga.; and Goodfellow Air
Force Base in San Angelo, Tex.
[25] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[26] These locations are the Naval Medical Center in Portsmouth, Va.;
Goodfellow Air Force Base in San Angelo, Tex; U.S. Naval Hospital,
Naples, Italy; Wright Patterson Air Force Base in Dayton, Ohio; and
U.S. Army Installation Management Command at Fort Huachuca, Ariz.
[27] A contractor, tasked to study the issue, recommended that the
departments should invest in a common services strategy for jointly
developing an inpatient solution. 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.
[28] The Joint Executive Council is comprised of the Deputy Secretary
of Veterans Affairs; the Under Secretary of Defense for Personnel and
Readiness; and the cochairs of joint councils on health, benefits, and
capital planning. The council meets on a quarterly basis to recommend
strategic direction of joint coordination and sharing efforts. The VA/
DOD Health Executive Council is comprised of senior leaders from VA and
DOD, who work to institutionalize sharing and collaboration of health
services and resources. The council is cochaired by the VA Under
Secretary for Health and DOD Assistant Secretary of Defense for Health
Affairs, and meets on a bimonthly basis.
[29] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[End of section]
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