Electronic Health Records:

DOD's and VA's Sharing of Information Could Benefit from Improved Management

GAO-09-268: Published: Jan 28, 2009. Publicly Released: Jan 28, 2009.

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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.

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.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To better ensure that DOD and VA achieve interoperable electronic health record systems or capabilities, the Secretaries of Defense and Veterans Affairs should 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.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: In January 2010, DOD and VA reported that they had achieved their objectives for electronic health record interoperability, though they had not developed and documented results-oriented goals and associated performance measures as the basis for reporting achievement of their objectives. However, in April 2010, the VA/DOD Joint Executive Council released its joint strategic plan for fiscal years 2010-2012, which describes the departments' strategic direction for joint efforts related to health care, including interoperability of IT systems. The joint strategic plan articulates seven performance-based objectives related to health systems interoperability and establishes corresponding activities, milestones, and performance measures intended to assist the departments in meeting their stated goals. For example, one objective is to support continuity of patient care by increasing the type and amount of electronic image data shared between VA and DOD. The departments intend to report to an executive-level work group on the status of technical solutions to increase their ability to access to scanned records; develop testing schedules for technical solutions by a set deadline; and implement technical solutions on a limited scale by a set deadline. Their performance metric is completion of 75 percent of their stated activities and milestones.

    Recommendation: To better ensure that DOD and VA achieve interoperable electronic health record systems or capabilities, the Secretaries of Defense and Veterans Affairs should use results-oriented performance goals and measures as the basis for future assessments and reporting of interoperability progress.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: VA agreed with our recommendation and in January 2010 the department stated that it intended to include results-oriented goals in its future plans. In April 2010, the VA/DOD Joint Executive Council released its joint strategic plan for fiscal years 2010-2012, which describes the departments' strategic direction for joint efforts related to health care, including interoperability of IT systems. The joint strategic plan articulates seven performance-based objectives related to health systems interoperability and establishes corresponding activities, milestones, and performance measures intended to assist the departments in meeting their stated goals. The establishment and use of these results-oriented goals and associated performance measures is an important step for the departments, given that they have ongoing interoperability initiatives including development of a Virtual Lifetime Electronic Record.

    Recommendation: To better ensure that DOD and VA achieve interoperable electronic health record systems or capabilities, the Secretaries of Defense and Veterans Affairs should 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.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: In January 2010, DOD and VA reported that they had achieved their objectives for electronic health record interoperability, though they had not developed and documented results-oriented goals and associated performance measures as the basis for reporting achievement of their objectives. However, in April 2010, the VA/DOD Joint Executive Council released its joint strategic plan for fiscal years 2010-2012, which describes the departments' strategic direction for joint efforts related to health care, including interoperability of IT systems. The joint strategic plan articulates seven performance-based objectives related to health systems interoperability and establishes corresponding activities, milestones, and performance measures intended to assist the departments in meeting their stated goals. For example, one objective is to support continuity of patient care by increasing the type and amount of electronic image data shared between VA and DOD. The departments intend to report to an executive-level work group on the status of technical solutions to increase their ability to access to scanned records; develop testing schedules for technical solutions by a set deadline; and implement technical solutions on a limited scale by a set deadline. Their performance metric is completion of 75 percent of their stated activities and milestones.

    Recommendation: To better ensure that DOD and VA achieve interoperable electronic health record systems or capabilities, the Secretaries of Defense and Veterans Affairs should use results-oriented performance goals and measures as the basis for future assessments and reporting of interoperability progress.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: DOD agreed with our recommendation and in January 2010 the department stated that it intended to include results-oriented goals in its future plans. In April 2010, the VA/DOD Joint Executive Council released its joint strategic plan for fiscal years 2010-2012, which describes the departments' strategic direction for joint efforts related to health care, including interoperability of IT systems. The joint strategic plan articulates seven performance-based objectives related to health systems interoperability and establishes corresponding activities, milestones, and performance measures intended to assist the departments in meeting their stated goals. The establishment and use of these results-oriented goals and associated performance measures is an important step for the departments, given that they have ongoing interoperability initiatives including development of a Virtual Lifetime Electronic Record.

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