Information Technology
Opportunities Exist to Improve Management of DOD's Electronic Health Record Initiative
GAO-11-50, Oct 6, 2010
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The Department of Defense (DOD) provides medical care to 9.6 million active duty service members, their families, and other eligible beneficiaries worldwide. DOD's Military Health System has long been engaged in efforts to acquire and deploy an electronic health record system. The latest version of this initiative--the Armed Forces Health Longitudinal Technology Application (AHLTA)--was expected to give health care providers real-time access to individual and military population health information and facilitate clinical support. However, the system's early performance was problematic, and DOD recently stated that it intended to acquire a new electronic health record system. GAO was asked to (1) determine the status of AHLTA, (2) determine DOD's plans for acquiring its new system, and (3) evaluate DOD's acquisition management of the initiative. To do this, GAO reviewed program plans, reports, and other documentation and interviewed DOD officials.
After obligating approximately $2 billion over the 13-year life of its initiative to acquire an electronic health record system, as of September 2010, DOD had delivered various capabilities for outpatient care and dental care documentation. DOD had scaled back other capabilities it had originally planned to deliver, such as replacement of legacy systems and inpatient care management. In addition, users continued to experience significant problems with the performance (speed, usability, and availability) of the portions of the system that have been deployed. DOD has initiated efforts to improve system performance and enhance functionality and plans to continue its efforts to stabilize the AHLTA system through 2015, as a "bridge" to the new electronic health record system it intends to acquire. According to DOD, the planned new electronic health record system--known as the EHR Way Ahead--is to be a comprehensive, real-time health record for service members and their families and beneficiaries. The system is expected to address performance problems, provide unaddressed capabilities such as comprehensive medical documentation, capture and share medical data electronically within DOD, and improve existing information sharing with the Department of Veterans Affairs. As of September 2010, the department had established a planning office, and this office had begun an analysis of alternatives for meeting the new system requirements. Completion of this analysis is currently scheduled for December 2010. Following its completion, DOD expects to select a technical solution for the system and release a delivery schedule. DOD's fiscal year 2011 budget request included $302 million for the EHR Way Ahead initiative. Weaknesses in key acquisition management and planning processes contributed to AHLTA having fewer capabilities than originally expected, experiencing persistent performance problems, and not fully meeting the needs of users. (1) A comprehensive project management plan was not established to guide the department's execution of the system acquisition. (2) A tailored systems engineering plan did not exist to guide the technical development of the system, an effort that was characterized by significant complexity. (3) Requirements were incomplete and did not sufficiently reflect user and operational needs. (4) An effective plan was not used to improve users' satisfaction with the system. DOD has initiated efforts to bring its processes into alignment with industry best practices. However, it has not carried out a planned independent evaluation to ensure it has made these improvements. Until it ensures that these weaknesses are addressed, DOD risks undermining the success of further efforts to acquire electronic health record system capabilities. GAO is recommending that DOD take six actions to help ensure that it has disciplined and effective processes in place to manage the acquisition of further electronic health record system capabilities. In written comments on a draft of this report, DOD concurred with GAO's recommendations and described actions planned to address them.
Status Legend:
Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
- In Process
- Open
- Closed - implemented
- Closed - not implemented
Recommendations for Executive Action
Recommendation: To help guide and ensure the successful completion of the AHLTA stabilization effort, the Secretary of Defense, through the Assistant Secretary of Defense for Health Affairs, should direct the Military Health System's (MHS) Chief Information Officer (CIO) to develop and maintain a comprehensive project plan that includes key elements, such as the project's scope, cost, schedule, and risks and update the plan to provide key information for stakeholders on the project's plans and status; further, to help ensure that the Electronic Health Record (EHR) Way Ahead does not have shortfalls similar to those experienced with AHLTA, this management practice should be implemented as part of the planning for this important initiative.
Agency Affected: Department of Defense
Status: Open
Comments: The program office is still developing capabilities and the appropriate project management plans in accordance with DoD acquisition program guidelines and this recommendation to support the AHLTA/CHCS initiative. An updated project management plan, targeted for completion in the 4th Quarter of FY 2011, is not done yet. Additionally, development of overarching planning and guidance documents is underway between DOD and VA to support health information exchange efforts including the Virtual Lifetime Electronic Record (VLER) and a common approach called the integrated EHR (iEHR). In March 2011, the Secretaries of Defense and VA agreed to implement iEHR as a joint, common EHR platform, purchasing commercially available components for joint use whenever possible and cost effective. While the EHR Way Ahead Planning Office (EHR W A) was posturing for a formal program designation, an integrated master schedule (IMS) was developed to track milestone documentation requirements through completion. EHR W A is currently collaborating with DOD organizations and the VA to continue evolving an integrated master schedule with appropriate milestones. This IMS is primarily focused on the workstreams that are of highest importance to the iEHR; while awaiting the formal establishment of the iEHR organization.
Recommendation: To help guide and ensure the successful completion of the AHLTA stabilization effort, the Secretary of Defense, through the Assistant Secretary of Defense for Health Affairs, should direct the MHS CIO to develop a systems engineering plan in accordance with DOD guidance to address the technical complexities of delivering a worldwide electronic health record system; further, to help ensure that the EHR Way Ahead does not have shortfalls similar to those experienced with AHLTA, this management practice should be implemented as part of the planning for this important initiative.
Agency Affected: Department of Defense
Status: Open
Comments: DoD development and use of project plans is performed in accordance with applicable guidance. including DoD Instruction 5000.02, Operation of the Defense Acquisition System, December 8, 2008, and the Joint Capabilities Integration and Development System (JCIDS) Instruction 3170.01G. The System Engineering Management Plan Vl.O, November 7,2003, guided the AHLTA program through its initial worldwide deployment. Upon completion of AHLTA Block 1 deployment in November 2006, the program entered the life cycle sustainment effort of the Block 1 operations and support phase.Based on DoD Instruction 5000.02, a System Engineering Plan is required to support Milestones A, B and C. Since Block 1 is in the operations and support phase (post-Milestone C), the program office does not plan to modify the existing plan. Development of key project plans is underway for the next generation EHR system. The Departments have committed to jointly addressing the need to modernize their EHRs, and are currently working together to synchronize planning activities and implement a common approach known as the iEHR.In March 2011, the Secretaries of Defense and VA agreed to implement a joint, common EHR platform, purchasing commercially available components for joint use whenever possible and cost effective. In June 2011, the Secretaries approved plans to implement this iEHR and a governance structure to oversee the effort, and also appointed a near term Program Executive to oversee day to day execution efforts. As a best business practice, the EHR Way Ahead Program Office has developed a DRAFT SEP for the iEHR. The DRAFT SEP will be routed internally not later than September 30, 2011. It should be noted that the iEHR has been designated a Defense Business System (DBS) and is subject to the documentation requirements of the Business Capability Lifecycle (BCL) model which does not require a SEP.(On November 15, 2010, AT&L issued the Interim Acquisition Guidance for DBS, requiring the use of the BCL model as appropriate.)
Recommendation: To help guide and ensure the successful completion of the AHLTA stabilization effort, the Secretary of Defense, through the Assistant Secretary of Defense for Health Affairs, should direct the MHS CIO to ensure that its requirements development process involves system users throughout the development process, to obtain an understanding of what will satisfy their needs; further, to help ensure that the EHR Way Ahead does not have shortfalls similar to those experienced with AHLTA, this management practice should be implemented as part of the planning for this important initiative.
Agency Affected: Department of Defense
Status: Closed - Not Implemented
Comments: According to DOD officials, this recommendation is closed and no further actions are planned. DOD indicated that they ensure that the requirements development process involves system users throughout the development process to obtain an understanding of what will satisfy their needs. No information was provided by DOD as to how "ensurance" will be achieved. They believe current processes are adequate.
Recommendation: To help guide and ensure the successful completion of the AHLTA stabilization effort, the Secretary of Defense, through the Assistant Secretary of Defense for Health Affairs, should direct the MHS CIO to ensure the establishment of bidirectional traceability for all system requirements; further, to help ensure that the EHR Way Ahead does not have shortfalls similar to those experienced with AHLTA, this management practice should be implemented as part of the planning for this important initiative.
Agency Affected: Department of Defense
Status: Open
Comments: To address the need for bidirectional traceability across the Departments, DoD and the VA have agreed to leverage DoD's Program Management Accountability Tool (PMA T) which both Departments have acquired as "Software as a Service" (SaaS). This tool will enable requirements to be tracked against planned and actual execution of dollars; and include associated risks, schedule, and lessons learned at the product leveL. This effort within the Electronic Heath Record Way Ahead initiative is in Phase 2 of implementation which focuses on the "Financial" requirements that arecurrently in user acceptance testing. The acquisition and implementation of this capability is anticipated during the 1st Quarter of FY 2012.
Recommendation: To help guide and ensure the successful completion of the AHLTA stabilization effort, the Secretary of Defense, through the Assistant Secretary of Defense for Health Affairs, should direct the MHS CIO to develop and document a plan for improving user satisfaction that prioritizes improvement projects; identifies needed resources; includes schedules for improvement efforts, including future user feedback surveys; and links efforts to measurable outcomes and specific user needs; further, to help ensure that the EHR Way Ahead does not have shortfalls similar to those experienced with AHLTA, this management practice should be implemented as part of the planning for this important initiative.
Agency Affected: Department of Defense
Status: Open
Comments: DHIMS intends to measure end-user satisfaction with AHLTA and services following completion of the deployment of capabilities that result in a significant change in the software baseline. Also, efforts to improve user satisfaction are included in planning for the next generation EHR system and the iEHR. However, at this time these efforts have not been completed.
Recommendation: To help guide and ensure the successful completion of the AHLTA stabilization effort, the Secretary of Defense, through the Assistant Secretary of Defense for Health Affairs, should direct the MHS CIO to establish acquisition management processes in accordance with industry best practices, including identifying milestones and a completion date for the external evaluation that MHS's processes are at maturity level 2 of the Capability Maturity Model Integration for Acquisition; further, to help ensure that the EHR Way Ahead does not have shortfalls similar to those experienced with AHLTA, this management practice should be implemented as part of the planning for this important initiative.
Agency Affected: Department of Defense
Status: Open
Comments: As the Department plans for its next generation Electonic Health Record (EHR), steps are being taken to enhance acquisition management capabilities and processes in accordance with best practices. For example, the Department is ensuring that program office personnel are knowledgeable acquisition professionals with the appropriate level of acquisition certification. Specifically, the Electronic Health Record Way Ahead (EHRW A) initiative is committed to ensuring all program office personnel achieve a minimum of Level III acquisition certification, as appropriate. Additionally, in the past year, EHRWA has been implementing rigorous processes and procedures that are typical of a Major Automated Information System (MAIS) program. These actions, however, are in process and incomplete and no milestones for completion have been generated.