Electronic Health Records
DOD and VA Efforts to Achieve Full Interoperability Are Ongoing; Program Office Management Needs Improvement Gao ID: GAO-09-775 July 28, 2009The National Defense Authorization Act for Fiscal Year 2008 required the Department of Defense (DOD) and the Department of Veterans Affairs (VA) to accelerate their exchange of health information and to develop systems or capabilities that allow for interoperability (generally, the ability of systems to exchange data) by September 30, 2009. It also required compliance with federal standards and the establishment of a joint interagency program office to function as a single point of accountability for the effort. Further, the act directed GAO to semiannually report on the progress made in achieving these requirements. For this third report, GAO evaluated (1) the departments' progress and plans toward sharing fully interoperable electronic health information that comply with federal standards and (2) whether the interagency program office is positioned to function as a single point of accountability. To do so, GAO analyzed agency documentation on project status and conducted interviews with agency officials.
DOD and VA have taken steps to meet six objectives that they identifiedforachieving full interoperability in compliance with applicable standards (see table) by September 30, 2009. Specifically, the departments have achieved planned capabilities for three of the objectives--refine social history data, share physical exam data, and demonstrate initial network gateway operation. For the remaining three objectives, the departments have partially achieved planned capabilities, with additional work needed to fully meet the objectives. Regarding the objective to expand questionnaires and self-assessment tools, this additional work is intended to be completed by the deadline. The departments' officials have stated that they intend to meet the objectives to expand DOD's inpatient medical records system and demonstrate initial document scanning; however, additional work will be required beyond September to perform all the activities necessary to meet clinicians' needs for health information. The DOD/VA Interagency Program Office is not yet effectively positioned to function as a single point of accountability for the implementation of fully interoperable electronic health record systems or capabilities between DOD and VA. While the departments have made progress in setting up the office by hiring additional staff, they continue to fill key leadership positions on an interim basis. Further, while the office has begun to demonstrate responsibilities outlined in its charter, it is not yet fulfilling key information technology management responsibilities in the areas of performance measurement (as GAO previously recommended), project planning, and scheduling, which are essential to establishing the office as a single point of accountability for the departments' interoperability efforts.
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-09-775, Electronic Health Records: DOD and VA Efforts to Achieve Full Interoperability Are Ongoing; Program Office Management Needs Improvement
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
July 2009:
Electronic Health Records:
DOD and VA Efforts to Achieve Full Interoperability Are Ongoing;
Program Office Management Needs Improvement:
GAO-09-775:
GAO Highlights:
Highlights of GAO-09-775, a report to congressional committees.
Why GAO Did This Study:
The National Defense Authorization Act for Fiscal Year 2008 required
the Department of Defense (DOD) and the Department of Veterans Affairs
(VA) to accelerate their exchange of health information and to develop
systems or capabilities that allow for interoperability (generally, the
ability of systems to exchange data) by September 30, 2009. It also
required compliance with federal standards and the establishment of a
joint interagency program office to function as a single point of
accountability for the effort.
Further, the act directed GAO to semiannually report on the progress
made in achieving these requirements. For this third report, GAO
evaluated (1) the departments‘ progress and plans toward sharing fully
interoperable electronic health information that comply with federal
standards and (2) whether the interagency program office is positioned
to function as a single point of accountability. To do so, GAO analyzed
agency documentation on project status and conducted interviews with
agency officials.
What GAO Found:
DOD and VA have taken steps to meet six objectives that they identified
for achieving full interoperability in compliance with applicable
standards (see table) by September 30, 2009. Specifically, the
departments have achieved planned capabilities for three of the
objectives”refine social history data, share physical exam data, and
demonstrate initial network gateway operation. For the remaining three
objectives, the departments have partially achieved planned
capabilities, with additional work needed to fully meet the objectives.
Regarding the objective to expand questionnaires and self-assessment
tools, this additional work is intended to be completed by the
deadline. The departments‘ officials have stated that they intend to
meet the objectives to expand DOD‘s inpatient medical records system
and demonstrate initial document scanning; however, additional work
will be required beyond September to perform all the activities
necessary to meet clinicians‘ needs for health information.
Table: Description of DOD and VA Interoperability Objectives:
Objective: Refine social history data; Description: DOD will begin
sharing with VA social history data currently captured in the DOD
electronic health record. Such data describe, for example, patients‘
involvement in hazardous activities and tobacco and alcohol use.
Objective: Share physical exam data; Description: DOD will provide an
initial capability to share with VA its electronic health record
information that supports the physical exam process when a service
member separates from active military duty.
Objective: Demonstrate initial network gateway operation; Description:
DOD and VA will demonstrate the operation of secure network gateways
that provide expanded bandwidth to support information sharing between
DOD and VA healthcare facilities.
Objective: Expand questionnaires and self-assessment tools;
Description: DOD will provide all periodic health assessment data
stored in its electronic health record to VA such that questionnaire
responses are viewable with the questions that elicited them.
Objective: Expand DOD inpatient medical records system; Description:
DOD will expand its inpatient medical records system to at least one
additional site in each military medical department (one Army, one Air
Force, and one Navy for a total of three sites).
Objective: Demonstrate initial document scanning; Description: DOD will
demonstrate an initial capability for scanning service members‘ medical
documents into its electronic health record and sharing the documents
electronically with VA.
Source: GAO based on DOD and VA data.
[End of table]
The DOD/VA Interagency Program Office is not yet effectively positioned
to function as a single point of accountability for the implementation
of fully interoperable electronic health record systems or capabilities
between DOD and VA. While the departments have made progress in setting
up the office by hiring additional staff, they continue to fill key
leadership positions on an interim basis. Further, while the office has
begun to demonstrate responsibilities outlined in its charter, it is
not yet fulfilling key information technology management
responsibilities in the areas of performance measurement (as GAO
previously recommended), project planning, and scheduling, which are
essential to establishing the office as a single point of
accountability for the departments‘ interoperability efforts.
What GAO Recommends:
GAO is recommending that the departments improve management of their
interoperability efforts by establishing a project plan and a complete
and detailed integrated master schedule. Commenting on a draft of this
report, DOD, VA, and the interagency program office concurred with GAO‘
s recommendation.
View [hyperlink, http://www.gao.gov/products/GAO-09-775] or key
components. For more information, contact Valerie C. Melvin at (202)
512-6304 or melvinv@gao.gov.
[End of section]
Contents:
Letter:
Background:
DOD and VA Have Taken Steps to Meet their Objectives, but Activities
Are Expected to Remain after the Deadline for Achieving Full
Interoperability:
DOD/VA Interagency Program Office Has Made Progress in Becoming
Operational, but Is Not Fully Functioning as a Single Point of
Accountability:
Conclusions:
Recommendation 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: Comments from the DOD/VA Interagency Program Office:
Appendix V: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Description of DOD and VA Interoperability Objectives:
Table 2: Status of Selected Key Activities to Establish the DOD/VA
Interagency Program Office:
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:
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:
July 28, 2009:
Congressional Committees:
The Department of Defense (DOD) and the Department of Veterans Affairs
(VA) have been working for over a decade on initiatives to share data
between their health information systems. However, while they have
taken important steps, questions have continued to be raised about when
and to what extent the departments' intended electronic sharing
capabilities will be fully achieved. In an effort to expedite the
exchange of electronic health information between the two departments,
the National Defense Authorization Act for Fiscal Year 2008[Footnote 1]
included provisions directing DOD and VA to jointly develop and
implement, by September 30, 2009, fully interoperable[Footnote 2]
electronic health record systems or capabilities that are compliant
with applicable federal interoperability standards. Such systems and
capabilities are important for making patient information more readily
available to health care providers in both departments, reducing
medical errors, and streamlining administrative functions. In addition,
the act established an interagency program office to be a single point
of accountability for the departments' efforts.
Further, the act directed us to assess DOD's and VA's progress in
implementing the electronic health record systems and to report
semiannually our results to the appropriate congressional committees.
Accordingly, on July 28, 2008,[Footnote 3] and January 28, 2009,
[Footnote 4] we issued reports in response to the act. As agreed with
the committees of jurisdiction, our objectives for this third 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 accomplish these objectives, we reviewed our past work in this area;
analyzed current agency documentation (including plans outlining
objectives for achieving interoperability, project status information,
and the interagency program office charter); and conducted interviews
with officials from DOD and VA.
We conducted this performance audit from April 2009 through July 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.
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 5]
As we have previously noted,[Footnote 6] 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 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, do not
provide decision support capabilities, such as automatic alerts about a
particular patient's health, or other advantages of automation.
Interoperability depends on the use of agreed-upon standards to ensure
that information can be shared and used. In the health IT field,
standards may govern areas ranging from technical issues, such as file
types and interchange systems, to content issues, such as medical
terminology. DOD and VA have agreed upon numerous common standards that
allow them to share health data. They have also participated in
numerous standards-setting organizations tasked to reach consensus on
the definition and use of standards. For example, DOD and VA officials
serve as members and are actively working on several committees and
groups within the Healthcare Information Technology Standards Panel.
[Footnote 7] The panel identifies and harmonizes[Footnote 8] competing
standards and develops interoperability specifications that are needed
for implementing the standards.[Footnote 9]
Interoperability can be achieved at different levels.[Footnote 10] 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. According to DOD and VA officials, not all data require the
same level of interoperability, nor is interoperability at the highest
level achievable in all cases. For example, unstructured, viewable data
may be sufficient for such narrative information as clinical notes.
Figure 1 shows the distinction 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: illustration]
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]
DOD and VA Have Been Working to Exchange Health Information for Over a
Decade:
DOD and VA have been working to exchange patient health information
electronically since 1998. We have previously noted[Footnote 11] their
efforts on three key projects:
* The Federal Health Information Exchange (FHIE), begun in 2001 and
enhanced through its completion 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), 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 12] The interface also allows DOD sites to see
previously inaccessible data at other DOD sites.
* The Clinical Data Repository/Health Data Repository (CHDR) [Footnote
13] interface, implemented in September 2006, linked the departments'
separate repositories of standardized data to enable a two-way exchange
of computable health information. These repositories are a part of the
modernized health information systems that the departments have been
developing--DOD's AHLTA[Footnote 14] and VA's HealtheVet.
In their ongoing initiatives to share information, VA uses its
integrated medical information system--the Veterans Health Information
Systems and Technology Architecture (VistA)--which was developed in-
house by VA clinicians and IT personnel.[Footnote 15] All VA medical
facilities have access to all VistA information.
DOD currently relies on its AHLTA, which is comprised of multiple
legacy medical information systems that the department developed from
commercial software products that were customized for specific uses.
For example, CHCS, which was formerly DOD's primary health information
system, is still in use to capture pharmacy, radiology, and laboratory
order management.[Footnote 16] In addition, the department uses
Essentris (also called the Clinical Information System), a commercial
health information system customized to support inpatient treatment at
military medical facilities. Not all of DOD's medical facilities yet
have this inpatient medical system.
DOD and VA Have Identified Interoperability Objectives:
To facilitate compliance with the act, the Interagency Clinical
Informatics Board,[Footnote 17] made up of senior clinical leaders from
both departments who represent the user community, began establishing
priorities for interoperable health data between DOD and VA. In this
regard, the board is responsible for determining clinical priorities
for electronic data sharing between the departments, as well as what
data should be viewable and what data should be computable. Based on
its work, the board established six interoperability objectives for
meeting the departments' data sharing needs. According to the former
acting director of the interagency program office, DOD and VA consider
achievement of these six objectives, in conjunction with capabilities
previously achieved (e.g., FHIE, BHIE, CHDR), to be sufficient to
satisfy the requirement for full interoperability by September 2009.
The six objectives are listed in table 1.
Table 1: Description of DOD and VA Interoperability Objectives:
Objective: Refine social history data;
Description: DOD will begin sharing with VA the social history data
that are currently captured in the DOD electronic health record. Such
data describe, for example, patients' involvement in hazardous
activities and tobacco and alcohol use;
Associated interoperability level: Level 3: Structured, viewable
electronic data.
Objective: Share physical exam data;
Description: DOD will provide an initial capability to share with VA
its electronic health record information that supports the physical
exam process when a service member separates from active military duty;
Associated interoperability level: Level 3: Structured, viewable
electronic data.
Objective: Demonstrate initial network gateway operation;
Description: DOD and VA will demonstrate the operation of the secure
network gateways[A] to support joint DOD-VA health information sharing;
Associated interoperability level: There is no interoperability level
associated with this objective.
Objective: Expand questionnaires and self-assessment tools;
Description: DOD will provide all periodic health assessment data
stored in its electronic health record to VA such that questionnaire
responses are viewable with the questions that elicited them;
Associated interoperability level: Level 3: Structured, viewable
electronic data.
Objective: Expand Essentris in DOD;
Description: DOD will expand its inpatient medical records system
(CliniComp's Essentris product suite) to at least one additional site
in each military medical department (one Army, one Air Force, and one
Navy for a total of three sites);
Associated interoperability level: Level 2: Unstructured, viewable
electronic data.
Objective: Demonstrate initial document scanning;
Description: DOD will demonstrate an initial capability for scanning
service members' medical documents into its electronic health record
and sharing the documents electronically with VA;
Associated interoperability level: Level 2: Unstructured, viewable
electronic data.
Source: GAO based on DOD and VA data.
[A] Secure network gateways provide expanded bandwidth to support
information sharing and ensure secure and reliable data communications
between DOD and VA health care facilities.
[End of table]
GAO Reports Have Highlighted the Need for DOD and VA to Address Issues
in Their Efforts to Share Health Information:
Our prior reports on DOD's and VA's efforts to develop fully
interoperable electronic health records noted their progress and
highlighted issues that they needed to address to achieve electronic
health record interoperability. Specifically, our July 2008[Footnote
18] report noted that the departments were sharing some, but not all,
electronic health information at different levels of interoperability.
At that time the departments' efforts to set up the interagency program
office were in the early stages. Leadership positions in the office
were not permanently filled, staffing was not complete, and facilities
to house the office had not been designated. Accordingly, we
recommended that the Secretaries of Defense and Veterans Affairs
expedite efforts to put in place permanent leadership, staff, and
facilities for the program office. The departments agreed with our
recommendations and stated that they would take actions to address
them.
Our January 2009 report[Footnote 19] noted that the departments had
defined plans to further increase their sharing of electronic health
information; however, the plans did not contain results-oriented (i.e.,
objective, quantifiable, and measurable) performance goals and measures
that could be used as a basis to track and assess progress. We
recommended the departments develop and document such goals and
performance measures for the six interoperability objectives, to use as
the basis for future assessments and reporting of interoperability
progress. DOD and VA agreed with our recommendation and stated that the
departments intended to include results-oriented goals in their future
plans.
DOD and VA Have Taken Steps to Meet their Objectives, but Activities
Are Expected to Remain after the Deadline for Achieving Full
Interoperability:
DOD and VA continue to take steps toward achieving full
interoperability in compliance with applicable standards by September
30, 2009. In this regard, the departments have achieved planned
capabilities for three of the interoperability objectives--refine
social history data, share physical exam data, and demonstrate initial
network gateway operation. The following information further explains
DOD's and VA's activities with respect to these three objectives.
Refine social history data: The departments established this objective
to enable DOD to share social history data captured in its electronic
health record with VA. These data describe, for example, patients'
involvement in hazardous activities and tobacco and alcohol use. Our
review of DOD and VA project documentation confirmed that the
departments have achieved sharing of viewable social history data, thus
providing VA with additional clinical information on shared patients
that clinicians could not previously view.
Share physical exam data: The departments established this objective to
implement an initial capability for DOD to share with VA the electronic
health record information that supports the physical exam process when
a service member separates from active military duty. To this end, the
departments achieved the capability for VA to view DOD's medical exam
data through the BHIE interface, allowing VA to view outpatient
treatment records, pre-and post-deployment health assessments, and post-
deployment health reassessments, which are compiled for the DOD
physical exam.
Demonstrate initial network gateway operation: DOD and VA want to
demonstrate the operation of secure network gateways to support health
information sharing between the departments. These gateways are to
support health record data exchange, thus facilitating future growth in
data sharing. As of early July 2009, the departments reported that five
network gateways were operational and that data migration to two of the
operational gateways had begun.[Footnote 20] The departments believed
these five gateways satisfy the intent of the objective and will
provide sufficient capacity to support health information sharing
between DOD and VA as of September 2009. The officials stated, however,
that they anticipate needing up to four additional gateways to support
future growth in information sharing between the departments at
locations and dates that are to be determined.
For the remaining three objectives, the departments have partially
achieved planned capabilities, with additional work needed to fully
meet the objectives. Regarding the objective to expand questionnaires
and self-assessment tools, this additional work is intended to be
completed by September 2009. With respect to the objectives to expand
Essentris and demonstrate initial document scanning, department
officials stated that they also intend to meet these objectives;
however, additional work will be required beyond September to perform
all the activities necessary to meet clinicians' needs for health
information. The following information further explains the
departments' activities with respect to these objectives.
Expand questionnaires and self-assessment tools: The departments intend
to provide all periodic health assessment data stored in the DOD
electronic health record to VA in a format that associates questions
with responses. Health assessment data are collected from two sources:
questionnaires administered at military treatment facilities and a DOD
health assessment reporting tool that enables patients to answer
questions about their health upon entry into the military. Questions
relate to a wide range of personal health information, such as dietary
habits, physical exercise, and tobacco and alcohol use. Our review of
the departments' project documentation determined that they have
established the capability for VA to view questions and answers from
the questionnaires collected by DOD at military treatment facilities;
however, they have not yet established the capability for VA to view
information from DOD's health assessment reporting tool. Department
officials stated that they intend to establish this additional
capability by September 2009.
Expand Essentris in DOD: By September 30, 2009, DOD intends to expand
Essentris to at least one additional site for each military service and
to increase the percentage of inpatient discharge summaries that it
shares electronically with VA to 63 percent.[Footnote 21] According to
the acting director of the interagency program office, as of late June
2009, the departments had expanded the system to two Army sites (but
not yet to an Air Force or Navy site) and were sharing 58 percent of
inpatient discharge summaries. The acting director stated that the
departments expect to meet their goal of sharing 63 percent of
inpatient discharge summaries and expand the system to an Air Force and
a Navy site by the September deadline. Nonetheless, the official stated
that to better meet clinicians' needs, DOD plans to further expand the
inpatient medical records system. In this regard, the department has
established a revised goal of making the inpatient system operational
for 92 percent of DOD's inpatient beds by September 2010.
Demonstrate initial document scanning: The departments intend to
demonstrate an initial capability to scan service members' medical
documents into the DOD electronic health record and share the documents
electronically with VA by September 2009. According to the program
office acting director, the departments were in the process of setting
up an interagency test environment to test the initial capability to
query medical documents associated with specific patients as of late
June 2009. He stated that the departments expect to begin user testing
at up to nine sites by September 2009. According to this official,
these activities are expected to demonstrate initial document scanning
capability. However, after September, the departments anticipate
performing additional work to expand their initial document scanning
capability (e.g., completion of user testing and deployment of the
scanning capability at all DOD sites).
DOD/VA Interagency Program Office Has Made Progress in Becoming
Operational, but Is Not Fully Functioning as a Single Point of
Accountability:
The DOD/VA Interagency Program Office is not yet effectively positioned
to serve as a single point of accountability for the implementation of
fully interoperable electronic health record systems or capabilities.
Since we last reported in January 2009, the departments have made
progress in setting up the office by hiring additional staff, although
they continue to fill key leadership positions on an interim basis. In
addition, the office has begun to demonstrate responsibilities outlined
in its charter, but is not yet fulfilling key IT management
responsibilities in the areas of performance measurement, scheduling,
and project planning.
Progress Made in Staffing Interagency Program Office:
To address the requirements set forth in the act, the departments
identified in the September 2008 DOD/VA Information Interoperability
Plan a schedule and key activities for setting up the interagency
program office. Since we last reported in January 2009,[Footnote 22]
the departments have completed all but one of the activities identified
in their schedule. For example, they have completed personnel
descriptions for the office's staff and have continued efforts to
recruit and hire staff for both government and contractor positions. As
of early July 2009, the departments had selected staff members for 10
of 14 government positions, an increase of 8 staff since our last
report. The acting director of the office reported that recruitment
efforts were underway to fill the remaining 4 positions by late
September 2009. Further, all 16 contractor positions had been filled,
an increase of 10 contractor staff since we last reported. Table 2
provides the status of selected key activities to establish the
interagency program office.
Table 2: Status of Selected Key Activities to Establish the DOD/VA
Interagency Program Office:
Interagency program office activities: Appoint interim acting director
and acting deputy director;
Due date: April 2008;
Status as of July 2009: Complete.
Interagency program office activities: Provide interim detailed staff,
temporary space, and equipment;
Due date: May 2008;
Status as of July 2009: 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 as of July 2009: Complete.
Interagency program office activities: Develop and approve program
office charter or interagency agreement;
Due date: July 2008;
Status as of July 2009: Complete.
Interagency program office activities: Complete resource management
plan to include budget, space, equipment, and human resources;
Due date: July 2008;
Status as of July 2009: Complete.
Interagency program office activities: Complete personnel position
descriptions and rating schemes;
Due date: August 2008;
Status as of July 2009: Complete.
Interagency program office activities: Appoint permanent director and
deputy director;
Due date: October 2008;
Status as of July 2009: Not yet complete.
Interagency program office activities: Advertise and recruit program
staff;
Due date: October 2008;
Status as of July 2009: Complete.
Source: GAO analysis of DOD and VA data.
[End of table]
However, while the departments have taken action toward hiring a full-
time permanent director and a deputy director to lead the office, these
positions continue to be filled on an interim basis. As of early July,
DOD had selected a candidate for the director position, VA had
concurred with the selection, and the candidate's application had been
sent to the Office of Personnel Management for approval. In the
meantime, the departments requested and received an extension of the
current acting director's appointment until September 30, 2009, or
until a permanent official is hired. Further, as of late June 2009,
interagency program officials stated that actions were underway to fill
the deputy director position and that VA was interviewing candidates
for this position. According to the acting director, the departments
anticipate making a selection for the deputy director position by the
end of July 2009.
Interagency Program Office Has Not Fulfilled Key Management
Responsibilities Identified in Its Charter:
The January 2009 interagency program office charter describes, among
other things, the mission and function of the office associated with
attaining interoperable electronic data. The charter further identifies
responsibilities of the office in carrying out its mission, in areas
such as oversight and management, stakeholder communication, and
decision making.
The office has taken steps toward fulfilling certain responsibilities
described in its charter. For example, the office submitted its first
annual report to Congress that summarized the departments' efforts
toward achieving full interoperability and the status of key activities
completed to set up the office. Further, the office developed 11
standard operating procedures in areas such as program management
oversight, strategic communications, and process improvement.
However, the office has yet to carry out other key responsibilities
identified in its charter that are fundamental to effective IT program
management and that would be essential to effectively serving as the
single point of accountability. For example, the office has not yet
established results-oriented (i.e., objective, quantifiable, and
measurable) goals and performance measures for all six interoperability
objectives--an action that we previously recommended that DOD and VA
undertake.
Using results-oriented metrics to measure progress is an important IT
program management activity because they can serve as a basis to
provide meaningful information on the status of a program. As noted
earlier, DOD and VA agreed with our recommendation calling for the
establishment of results-oriented performance goals and measures.
Further, the program office charter identifies the development of
metrics to monitor the departments' performance against
interoperability goals as a responsibility of the office. Nonetheless,
the office has only developed such a goal for one interoperability
objective--expand Essentris in DOD. It has not developed results-
oriented goals and measures for the other five objectives, instead
stating that such goals and measures will be included in the next
version of the DOD/VA Joint Executive Council Joint Strategic Plan
(known as the joint strategic plan), which the office expects to
complete by December 2009. If the departments complete the development
of results-oriented performance goals and measures for their
interoperability objectives, they will be better positioned to gauge
their progress toward achieving fully interoperable capabilities and
improving veterans' health care.
Development of an integrated master schedule is also a key IT program
management activity, especially given the complexity of the
departments' efforts to achieve full interoperability. According to DOD
guidance,[Footnote 23] an integrated master schedule should identify
detailed project tasks and the associated start, completion, and
interim milestone dates; resource needs; and relationships (e.g.,
sequence and dependencies) between tasks.
While the program office has begun to develop an integrated master
schedule as required by its charter, the current version does not
include the attributes of an effective schedule. For example, the
schedule included limited information for three of the six
interoperability objectives (i.e., refine social history data, share
physical exam data, and expand questionnaires and self-assessment
tools). Specifically, the schedule included the name of each objective
and a completion date of September 30, 2009. However, the schedule
contained no information on tasks to be performed to meet the
objectives. Further, the schedule did not reflect start dates, resource
needs, or relationships between tasks for any of the six
interoperability objectives. Without a complete and detailed integrated
master schedule, the departments are missing another key activity that
could be useful in determining their progress towards achieving full
interoperability.
Similarly, development of a project plan is an important activity for
IT program management. Industry best practices and IT project
management principles stress the importance of sound planning for any
project. Inherent in such planning is the development and use of a
project management plan that describes, among other factors, the
project's scope, resources, and key milestones. The interagency program
office charter identifies the need to develop a project plan, but, as
of late June 2009, the office had not yet done so. Without a project
plan, the departments lack a key tool that could be used to guide their
efforts in achieving full interoperability.
In discussing these activities, the program office's acting director
and former acting director cited three reasons for why performance
measurement, scheduling, and project planning responsibilities had not
been accomplished. First, they stated that because it has taken longer
than anticipated to hire staff, the office has not been able to perform
all of its responsibilities. Second, the office's interim leadership
and staff have focused their efforts on providing to interested parties
(e.g., federal agencies and military organizations) briefings,
presentations, and status information on activities the office is
undertaking to achieve interoperability, in addition to participating
in efforts to develop a strategy for implementation of the Virtual
Lifetime Electronic Record, which the President announced in April
2009. Finally, according to the officials, the office waited until June
2009 to begin the process of developing metrics so that they could do
so in conjunction with the departments' annual update to the joint
strategic plan that is scheduled for completion in late 2009. However,
without metrics to monitor progress, a complete integrated master
schedule, and a project plan, the interagency program office's ability
to effectively provide oversight and management, including meaningful
progress reporting on the delivery of interoperable capabilities, is
jeopardized. Moreover, in the absence of these critical activities, the
office is not effectively positioned to function as the single point of
accountability for achieving full interoperability.
Conclusions:
DOD and VA have continued to increase electronic health information
interoperability. In particular, the departments have taken steps to
meet their six interoperability objectives by September 30, 2009.
However, for two of the six interoperability objectives, the
departments subsequently plan to perform significant additional
activities that are necessary to meet clinicians' needs. Further, the
departments' lack of progress in establishing fundamental IT management
capabilities that are specific responsibilities of the interagency
program office contributes to uncertainty about the extent to which the
departments will progress toward achievement of full interoperability
by the deadline. While the departments have generally made progress
toward making the program office operational, the office has not yet
completed a project plan or a detailed integrated master schedule.
Without these important tools, the office is limited in its ability to
effectively manage and provide meaningful progress reporting on the
delivery of interoperable capabilities that are intended to improve the
quality of health care provided to our nation's veterans.
Recommendation for Executive Action:
To better improve management of DOD's and VA's efforts to achieve fully
interoperable electronic health record systems, including satisfaction
of the departments' interoperability objectives, we recommend that the
Secretaries of Defense and Veterans Affairs direct the Director of the
DOD/VA Interagency Program Office to establish a project plan and a
complete and detailed integrated master schedule.
Agency Comments and Our Evaluation:
In written comments on a draft of this report, the DOD official who is
performing the duties of the Assistant Secretary of Defense (Health
Affairs) and the Acting Director of the DOD/VA Interagency Program
Office concurred with our findings and recommendation. The VA Chief of
Staff also provided written comments, in which the department concurred
with our recommendation. In this regard, DOD and VA stated that they
will provide the necessary information for the DOD/VA Interagency
Program Office to establish a project plan and to complete a detailed
integrated master schedule. If the recommendation is properly
implemented, it should better position DOD and VA to effectively
measure and report progress in achieving full interoperability.
Beyond its concurrence with the recommendation, the VA Chief of Staff
stated that the department disagreed with the report's characterization
of the six interoperability objectives and expressed concern about the
report projecting that the objective to demonstrate initial document
scanning would not be completed by the September 30, 2009 deadline.
Specifically, VA stated that our report portrayed the six
interoperability objectives as the necessary steps to achieving full
interoperability, even though the departments consider the objectives
to be just one component of achieving full interoperability, along with
existing data exchange capabilities. However, in discussing the
objectives, we stated that according to the former acting director of
the interagency program office, the departments consider achievement of
the six objectives, in conjunction with capabilities previously
achieved (e.g., FHIE, BHIE, CHDR), to be sufficient to satisfy the
requirement for full interoperability by September 2009.
With respect to the objective to demonstrate initial document scanning,
the Chief of Staff stated that our report projects that the objective
will not be met by the September deadline. However, while our report
states that according to the acting program office director, additional
work will be required beyond September to perform all the activities
necessary to meet clinicians' needs related to document scanning, we
did not report that the departments would not meet this objective by
the September deadline. In fact, our report noted that according to
this official the departments expect to begin user testing at up to
nine sites by September 2009, and that these activities are expected to
demonstrate initial document scanning capability. Nonetheless, we
revised our report as appropriate, in an attempt to more clearly
reflect the departments' intent with regard to this objective.
DOD, VA, and the interagency program office also provided technical
comments on the draft report, which we incorporated as appropriate. The
departments and the DOD/VA Interagency Program Office comments are
reproduced in app. II, app. III, and app. IV, respectively.
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 V.
Signed by:
Valerie C. Melvin:
Director, Information Management and Human Capital Issues:
List of 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 Howard P. "Buck" McKeon:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Bob Filner:
Chairman:
The Honorable Steve Buyer:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable John P. Murtha:
Chairman:
The Honorable C.W. Bill Young:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
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:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
To evaluate the Department of Defense's (DOD) and 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. We obtained and analyzed agency documentation and interviewed
program officials to determine DOD's and VA's progress towards
achieving full interoperability by September 30, 2009, as required by
the National Defense Authorization Act for Fiscal Year 2008. We also
analyzed information gathered from agency documentation to identify
interoperability objectives, milestones, and target dates for ongoing
and planned interoperability initiatives whose target dates extend
beyond September 30, 2009. In addition, through interviews with
cognizant DOD and VA officials, we obtained and assessed information
regarding the departments' plans for achieving full interoperability of
electronic health information.
To determine whether the interagency program office is positioned to
serve as a single point of accountability for developing and
implementing electronic health records, we obtained and reviewed
program office documentation, including its charter and standard
operating procedures. We compared the responsibilities identified in
the charter with actions taken by the office to exercise the
responsibilities. Additionally, we interviewed interagency program
office officials to determine the status of filling leadership and
staffing positions within the office.
We conducted this performance audit at DOD and VA locations in the
greater Washington, D.C., metropolitan area from April through July
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:
Office Of The Assistant Secretary Of Defense:
Health Affairs:
Washington, DC 20301-1200:
Ms. Valerie C. Melvin:
Director, Information Management and Human Capital Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, D.C. 20548:
Dear Ms. Melvin:
This is the Department of Defense (DoD) response to the GAO Draft
Report, "GAO-09775, `Electronic Health Records: DoD and VA Efforts to
Achieve Full Interoperability Are Ongoing; Program Office Management
Needs Improvement,' dated July 9, 2009 (GAO Code 310935)."
DoD 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 formal response.
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.Zimmerman@tma.osd.mil or (703) 681-4360.
Sincerely,
Signed by:
[Illegible], for:
Ellen P. Embrey:
Performing the Duties of the Assistant Secretary of Defense (Health
Affairs):
Enclosures: As stated:
[End of letter]
GAO Draft Report-Dated July 9, 2009:
GAO 09-775 (GAO Code 310935):
"Electronic Health Records: DoD and VA Efforts to Achieve Full
Interoperability Are Ongoing; Program Office Management Needs
Improvement:
Department of Defense Comments to GAO Recommendations:
Recommendation: To better improve management of DOD's and VA's efforts
to achieve fully interoperable electronic health record systems,
including satisfaction of the departments' interoperability objectives,
we recommend that the Secretaries of Defense and Veterans Affairs
direct the Director of the Interagency Program Office to establish a
project plan and a complete and detailed integrated master schedule.
DoD Response: Concur. DoD will provide the necessary information for
the DoD/VA Interagency Program Office to establish a project plan and
to complete a detailed integrated master schedule.
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
Department of Veterans Affairs:
Office of the Secretary:
July 22, 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 and VA Efforts to Achieve Full Interoperability Are Ongoing;
Program Office Management Needs Improvement (GAO-09-775) and concurs
with the recommendation. Enhancing health information sharing between
VA and the Department of Defense (DoD) is a key step towards achieving
seamless health care for our Nation's Veterans. Fully interoperable
electronic health data exchange will enable patient information to be
more readily available to health care providers in both departments,
reduce medical errors, and streamline administrative functions.
However, I disagree with the report's portrayal of the six
interoperability objectives established by the DoD/VA Interagency
Clinical Informatics Board (ICIB) for meeting the Departments' data
sharing needs. The report characterizes these objectives as the
necessary steps to "achieve full interoperability" by the September
2009 deadline required by Section 1635 of the Fiscal Year 2008 National
Defense Authorization Act. Rather, VA and DoD have described the six
interoperability objectives as just one component of achieving full
interoperability. Furthermore, VA and DoD have already achieved a
significant level of interoperability through existing data exchanges.
Using the Federal and Bidirectional Health Information Exchange, VA and
DoD already share nearly all essential health information that is
available in electronic form. The ICIB identified the six
interoperability objectives as additional activities that could
leverage the existing data and interagency infrastructure already in
existence between the Departments. The six objectives are the initial
clinical priorities that should be in place by the September 2009
legislative target, and taken alone, do not comprise "full
interoperability."
I also disagree with the report's projection that the objective to
demonstrate an initial capability for scanning service members' medical
documents into its electronic health record and sharing the documents
electronically with VA will not be completed by the September 30, 2009
deadline.
Although VA and DoD have indicated that the Departments will perform
additional work beyond September 2009, the Departments are on target to
achieve all six interoperability objectives as defined by the ICIB by
September 2009. Specifically, while the Departments will continue work
to expand document-scanning capability beyond the initial test site,
the completion by VA of a query and retrieval of a DoD scanned document
in an interagency test environment will complete the interoperability
objective as defined by the ICIB.
Beyond September 2009, VA will work with DoD to identify additional
electronic health information that should be shared. The Departments'
future work will be based on the clinical priorities identified by the
ICIB. Additionally, the Departments continue active participation on
the national effort led by the National Coordinator for Health
Information Technology. This work will ensure that VA and DoD's
interoperable electronic health record systems remain aligned with the
national strategy for interoperability.
The enclosure addresses GAO's recommendation and provides additional
comments to the draft report. VA appreciates the opportunity to comment
on your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of letter]
Enclosure:
Department of Veterans Affairs (VA):
Comments on Government Accountability Office (GAO) Draft Report:
Electronic Health Records: DOD and VA Efforts to Achieve Full
Interoperability Are Ongoing; Program Office Management Needs
Improvement (GAO-09-775):
GAO Recommendation: To better improve management of DOD's and VA's
efforts to achieve fully interoperable electronic health records
systems, including satisfaction of the departments' interoperability
objectives, [GAO] recommends that the Secretaries of Defense and
Veterans Affairs direct the Director of the Interagency Program Office
to establish a project plan and a complete and detailed integrated
master schedule.
Response: Concur. VA and DoD are coordinating on an integrated master
schedule and more detailed joint project plan that will permit the
Interagency Program Office (IPO) to carry out the functions identified
in its charter. The project plan will include the level of information
that is agreed to by VA and DoD. VA will work with the IPO and DoD to
provide a copy of the project plan, including key information
concerning interoperability project dependencies and risks, to GAO upon
completion of an internal review by appropriate information technology
and management execution offices.
Additional comments:
Throughout the Draft Report (e.g., page 1 summary paragraph; pages 13-
14), GAO projects that the Departments will not be able to complete the
following objective by the September 30, 2009, deadline: DoD
demonstrate an initial capability for scanning service members' medical
documents into its electronic health record and sharing the documents
electronically with VA.
VA Comment: Although VA and DoD have indicated that the Departments
will perform additional work beyond September 2009, the Departments are
on target to achieve all six interoperability objectives as defined by
the ICIB by September 2009.
VA does not concur with the finding on page 14 that the Departments
will need to perform additional work to expand their initial document
scanning capability to all DoD sites in order to meet the
interoperability objective. VA recommends that GAO edit the paragraph
to state: "Although the Departments will continue work to expand
document scanning capability beyond the initial test site, the
completion by VA of a query and retrieval of a DoD scanned document in
an interagency test environment will complete the interoperability
objective as defined by the ICIB."
On page 8, the paragraph concerning FHIE should reflect that VA and DoD
first developed data sharing in 2001 and enhanced the FHIE one-way data
exchange through 2004 when BHIE was first implemented.
On pages 14-19, GAO raises issues regarding key management
responsibilities of the IPO.
VA comment: the IPO charter will be revised to address GAO's concerns
about identifying specific IPO management responsibilities.
[End of section]
Appendix IV: Comments from the DOD/VA Interagency Program Office:
DoD/VA Interagency Program Office:
1700 North Moore Street:
Rosslyn, VA 22209:
July 16, 2009:
Ms. Valerie C. Melvin:
Director, Information Management & Human Capital Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, D.C. 20548:
Dear Ms. Melvin:
This is the DoD/VA Interagency Program Office's (IPO) response to the
recommendations enclosed in the Government Accountability Office (GAO)
Draft Report, "Electronic Health Records: DoD and VA Efforts to Achieve
Full Interoperability Are Ongoing; Program Office Management Needs
Improvement," July 9, 2009, (Project No. GAO-09-775, GAO Code 310935).
IPO 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 formal response.
Thank you for the opportunity to review and comment on the draft
report. My points of contact for additional information are Mr. Cliff
Freeman at Cliff.Freeman@va.gov, 703-696-0216; Mr. Kevin Tewes,
Kevin.Tewes@osd.mil, 703696-2856; and Mr. Ryan Cool, Rvan.Cool@osd.mil,
703-696-3636.
Sincerely,
Signed by:
Gregory Timberlake:
RADM, SHCE, USN:
Director, DoD/VA Interagency Program Office:
Enclosures: As stated:
[End of letter]
GAO Draft Report-Dated July 9, 2009:
GAO 09-775 (GAO Code 310935):
"Electronic Health Records: DoD and VA Efforts to Achieve Full
Interoperability Are Ongoing; Program Office Management Needs
Improvement"
IPO Comments to GAO Recommendations:
GAO Recommendation: "To better improve management of DOD's and VA's
efforts to achieve fully interoperable electronic health record
systems, including satisfaction of the departments' interoperability
objectives, we recommend that the Secretaries of Defense and Veterans
Affairs direct the Director of the Interagency Program Office to
establish a project plan and a complete and detailed integrated master
schedule."
IPO Response: Concur. The IPO will establish a project plan and
complete a detailed integrated master schedule. DoD and VA should
provide the IPO with the information that it requires to accomplish
these tasks.
[End of section]
Appendix V: 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; Rebecca Eyler; Lee
McCracken; Michael Redfern; J. Michael Resser; Kelly Shaw; Eric Trout;
and Merry Woo.
[End of section]
Footnotes:
[1] Pub. L. No. 110-181, § 1635 (2008).
[2] Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
[3] 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.
[4] See GAO, Electronic Health Records: DOD's and VA's Sharing of
Information Could Benefit from Improved Management, [hyperlink,
http://www.gao.gov/products/GAO-09-268] (Washington, D.C.: Jan. 28,
2009). In this report, we noted that DOD and VA have increased their
sharing of health information, and defined plans to further increase
their sharing of electronic health information. However, the plans did
not identify results-oriented (i.e., objective, quantifiable, and
measurable) performance goals and measures that are characteristic of
effective planning.
[5] 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.
[6] [hyperlink, http://www.gao.gov/products/GAO-09-268].
[7] The panel was established in October 2005 as a public-private
partnership funded by the Office of the National Coordinator. This
panel is sponsored by the American National Standards Institute, which
is a private, nonprofit organization whose mission is to promote and
facilitate voluntary consensus standards and ensure their integrity.
[8] Harmonization is the process of identifying overlaps and gaps in
relevant standards and developing recommendations to address these
overlaps and gaps.
[9] Developing, coordinating, and agreeing on standards are only part
of the processes involved in achieving interoperability for electronic
health records 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. An
interoperability specification codifies detailed implementation
guidance that includes references to the identified standards or parts
of standards and explains how they should be applied to specific health
care topic areas.
[10] 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.
[11] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[12] 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.
[13] The name CHDR, pronounced "cheddar," combines the names of the two
repositories.
[14] The department considers AHLTA the official name of the system.
(It was formerly an abbreviation for Armed Forces Health Longitudinal
Technology Application.) Previously, AHLTA was known as the Composite
Health Care System II (or CHCS II).
[15] 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.
[16] According to DOD, CHCS applications are now accessed through its
modernized health information system, AHLTA.
[17] This board was originally named the Joint Clinical Information
Board.
[18] [hyperlink, http://www.gao.gov/products/GAO-08-954].
[19] [hyperlink, http://www.gao.gov/products/GAO-09-268].
[20] The five operational gateways are located in Dallas, Texas;
Reston, Virginia; Kansas City, Missouri; North Chicago, Illinois; and
Santa Clara, California.
[21] DOD and VA previously reported this goal at 70 percent, but in
comments to our report, stated a revised goal of 63 percent.
[22] [hyperlink, http://www.gao.gov/products/GAO-09-268].
[23] DOD Integrated Master Plan and Integrated Master Schedule
Preparation and Use Guide, Version 0.9, October 21, 2005.
[End of section]
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Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
