Electronic Health Records:

VA and DOD Need to Support Cost and Schedule Claims, Develop Interoperability Plans, and Improve Collaboration

GAO-14-302: Published: Feb 27, 2014. Publicly Released: Feb 27, 2014.

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What GAO Found

The Departments of Veterans Affairs (VA) and Defense (DOD) abandoned their plans to develop an integrated electronic health record (iEHR) system and are instead pursuing separate efforts to modernize or replace their existing systems in an attempt to create an interoperable electronic health record. Specifically, in February 2013, the secretaries cited challenges in the cost and schedule for developing the single, integrated system and announced that each department would focus instead on either building or acquiring similar core sets of electronic health record capabilities, then ensuring interoperability between them. However, VA and DOD have not substantiated their claims that the current approach will be less expensive and more timely than the single-system approach. Major investment decisions—including terminating or significantly restructuring an ongoing program—should be justified using analyses that compare the costs and schedules of alternative proposals. Yet, the departments have not developed revised cost and schedule estimates for their new modernization efforts and any additional efforts needed to achieve interoperability between the new systems, and compared them with the relevant estimates for their former approach. In the absence of such a comparison, VA and DOD lack assurance that they are pursuing the most cost-effective and timely course of action for delivering the fully interoperable electronic health record the departments have long pursued to provide the best possible care for service members and veterans.

The departments have initiated their separate system efforts. VA intends to deploy clinical capabilities of its new system at two locations by September 2014, and DOD has set a goal of beginning deployment of its new system by the end of fiscal year 2016. However, the departments have yet to update their joint strategic plan to reflect the new approach or to disclose what the interoperable electronic health record will consist of, as well as how, when, and at what cost it will be achieved. Without plans that include the scope, lines of responsibility, resource requirements, and an estimated schedule for achieving an interoperable health record, VA, DOD, and their stakeholders may not have a shared understanding of how the departments intend to address their common health care business needs.

VA and DOD have not addressed management barriers to effective collaboration on their joint health information technology (IT) efforts. As GAO previously reported, the departments faced barriers to effective collaboration in the areas of enterprise architecture and IT investment management, among others. However, they have yet to address these barriers by, for example, developing a joint health care architecture or a joint IT investment management process to guide their collaboration. Further, the Interagency Program Office (IPO), established by law to act as a single point of accountability for the departments' development of interoperable health records, was to better position the departments to collaborate; but the departments have not implemented the IPO in a manner consistent with effective collaboration. For example, the IPO lacks effective control over essential resources such as funding and staffing. In addition, recent decisions by the departments have diffused responsibility for achieving integrated health records, potentially undermining the IPO's intended role as the point of accountability. Providing the IPO with control over essential resources and clearer lines of authority would better position it for effective collaboration.

Why GAO Did This Study

VA and DOD operate two of the nation's largest health care systems, serving approximately 16 million veterans and active duty service members, and their beneficiaries, at total annual costs of over $100 billion. The departments have recognized the importance of developing capabilities for sharing electronic patient health information and have worked since 1998 to develop such capabilities. In February 2011, VA and DOD initiated a program to develop a single, common electronic health record system—iEHR—to replace their existing health record systems. This program was to be managed by the IPO and implemented by 2017. However, the departments made significant changes to the program in 2013. GAO was asked to review the iEHR program. This report (1) describes changes to the program and evaluates the departments' current plans and (2) determines whether the departments are effectively collaborating on management of the program. GAO reviewed relevant program documents and interviewed agency officials.

What GAO Recommends

GAO recommends that VA and DOD develop and compare the estimated cost and schedule of their current and previous approaches to creating an interoperable electronic health record and, if applicable, provide a rationale for pursuing a more costly or time-consuming approach. GAO also recommends that the departments develop plans for interoperability and ensure the IPO has control over needed resources and clearer lines of authority. VA and DOD concurred with GAO's recommendations.

For more information, contact Valerie C. Melvin at (202) 512-6304 or melvinv@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: The Department of Defense has made limited progress in addressing this recommendation. The department asserted that the current approach to achieving an interoperable electronic health record, whereby it plans to modernize its own system separate from the Department of Veterans Affairs, would cost less than the single-system approach both departments had been pursuing together. However, DOD has provided only limited documentation that would allow us to assess the reliability of this assertion. Specifically, DOD reported that it had developed a cost estimate of $10.5 billion for the DOD Healthcare Management System Modernization (DHMSM) program. In addition, the DHMSM Program Executive Officer stated that the Office of Cost Assessment and Program Evaluation had developed an independent cost estimate. Yet, the department has not provided documentation of this estimate to GAO. In addition, DOD (in conjunction with VA) has not provided a comparison of the estimated costs of the current and previous (i.e., single-system) approaches. Further, with respect to the assertion that the current approach to achieving an interoperable health record will take less time than the 2017 planned completion date for the previous single-system approach, both departments have developed schedules which indicate that their separate modernizations are not planned to be completed until after 2017. Moreover, the DHMSM Program Executive Officer has stated that the departments' previous plan to complete the single system by 2017 was not a valid point of comparison because that schedule was not realistic and had not been baselined. Without a documented comparison of the current and previous approaches, the departments cannot provide assurances to stakeholders, including Congress, that they are pursuing the most cost-effective and timely course of action for delivering the fully interoperable electronic health record.

    Recommendation: To bring transparency and credibility to the Secretaries of Veterans Affairs and Defense's assertion that VA and DOD's current approach to achieving an interoperable electronic health record will cost less and take less time than the previous single-system approach, the secretaries should (1) develop a cost and schedule estimate for their current approach, from the perspective of both departments, that includes the estimated cost and schedule of VA's VistA Evolution program, DOD's DOD Healthcare Management System Modernization (DHMSM) program, and the departments' joint efforts to achieve interoperability between the two systems; then, (2) compare the cost and schedule estimates of the departments' current and previous (i.e., single-system) approaches. If the results of the comparison indicate that the departments' current approach is estimated to cost more and/or take longer than the single-system approach, the secretaries should (1) provide a rationale for pursuing the current approach despite its higher cost and/or longer schedule and (2) report the cost and schedule estimates of the current and previous approaches, results of the comparison of the estimates, and reasons (if applicable) for pursuing a more costly or time-consuming approach to VA's and DOD's congressional authorizing and appropriations committees.

    Agency Affected: Department of Defense

  2. Status: Open

    Comments: VA has made limited progress in addressing this recommendation. The department asserted that the current approach to achieving an interoperable electronic health record, whereby it plans to modernize its own system separate from the Department of Defense, would cost less than the single-system approach both departments had been pursuing together. Further, the department developed a cost estimate for the modernization effort-the Veterans Health Information Systems and Technology Architecture (VistA) 4 solution-and provided documentation to support this estimate; it also reported that it is updating the estimate to include information based on actual expenditures and refinement of near-term requirements. However, VA (in conjunction with DOD) has not provided a comparison of the estimated costs of the current and previous (i.e., single-system) approaches. Further, with respect to the assertion that the current approach to achieving an interoperable health record will take less time than the 2017 planned completion date for the previous single-system approach, both departments have developed schedules which indicate that their separate modernizations are not planned to be completed until after 2017. VA also asserted that the department's experience to date supports earlier statements indicating that an interoperable health record would be delivered more quickly and economically by leveraging and evolving existing infrastructure and capabilities. However, without a documented comparison of the current and previous approaches, the departments cannot provide assurances to stakeholders, including Congress, that they are pursuing the most cost-effective and timely course of action for delivering the fully interoperable electronic health record.

    Recommendation: To bring transparency and credibility to the Secretaries of Veterans Affairs and Defense's assertion that VA and DOD's current approach to achieving an interoperable electronic health record will cost less and take less time than the previous single-system approach, the secretaries should (1) develop a cost and schedule estimate for their current approach, from the perspective of both departments, that includes the estimated cost and schedule of VA's VistA Evolution program, DOD's DOD Healthcare Management System Modernization (DHMSM) program, and the departments' joint efforts to achieve interoperability between the two systems; then, (2) compare the cost and schedule estimates of the departments' current and previous (i.e., single-system) approaches. If the results of the comparison indicate that the departments' current approach is estimated to cost more and/or take longer than the single-system approach, the secretaries should (1) provide a rationale for pursuing the current approach despite its higher cost and/or longer schedule and (2) report the cost and schedule estimates of the current and previous approaches, results of the comparison of the estimates, and reasons (if applicable) for pursuing a more costly or time-consuming approach to VA's and DOD's congressional authorizing and appropriations committees.

    Agency Affected: Department of Veterans Affairs

  3. Status: Open

    Comments: DOD has taken steps toward addressing this recommendation, but additional action is needed. While DOD (in conjunction with VA) has developed a Joint Interoperability Plan that is intended to better position the departments to achieve an interoperable electronic health record, this plan, together with related and supporting documentation, partially addresses the specific elements of our recommendation. Specifically, the Joint Interoperability Plan refers to the Interagency Program Office's Healthcare Information Interoperability Technical Package, which identifies a list of clinical domains that are to be included in the interoperable electronic health record. Further, together with the Health Data Interoperability Management Plan, the plan describes the organizations within DOD and VA that are involved in acquiring, developing, and implementing the electronic health record. The plan also identifies high-level risks that may challenge the departments' effort to promote interoperability and the departments have established risk management processes for their respective modernization and acquisition efforts. Additionally, although not referenced in the plan, DOD and VA have performed multiple iterations of cost estimates for their respective system acquisition and modernization efforts. However, while the Joint Interoperability Plan also includes expected dates for key interoperability activities, as well as expected time frames for infrastructure and electronic health record modernization efforts, it does not include a schedule for implementing the interoperable record at each DOD and VA location. Further, the plan identifies high-level descriptions of monitoring and performance testing, but it lacks specific goals and metrics related to defining, measuring, tracking and reporting progress toward achieving expected performance of the interoperable record. It is important for DOD and VA to provide detailed information on all aspects of the departments' plans for achieving an interoperable health record, including when the record will be implemented at each location and how results will be measured and reported, to ensure that stakeholders have a shared understanding of how the departments intend to address their common health care business needs.

    Recommendation: To better position VA and DOD to achieve an interoperable electronic health record, the Secretaries of Veterans Affairs and Defense should develop a plan that, at a minimum, describes (1) the clinical domains that the interoperable electronic health record will address; (2) a schedule for implementing the interoperable record at each VA and DOD location; (3) the estimated cost of each major component (i.e., VistA Evolution, DHMSM, etc.) and the total cost of the departments' interoperability efforts; (4) the organizations within VA and DOD that are involved in acquiring, developing, and implementing the record, as well as the roles and responsibilities of these organizations; (5) major risks to the departments' interoperability efforts and mitigation plans for those risks; and (6) the departments' approach to defining, measuring, tracking, and reporting progress toward achieving expected performance (i.e., benefits and results) of the interoperable record.

    Agency Affected: Department of Defense

  4. Status: Open

    Comments: VA has taken steps toward addressing this recommendation, but additional action is needed. While VA (in conjunction with DOD) has developed a Joint Interoperability Plan that is intended to better position the departments to achieve an interoperable electronic health record, this plan, together with related and supporting documentation, partially addresses the specific elements of our recommendation. Specifically, the Joint Interoperability Plan refers to the Interagency Program Office's Healthcare Information Interoperability Technical Package, which identifies a list of clinical domains that are to be included in the interoperable electronic health record. Further, together with the Health Data Interoperability Management Plan, the plan describes the organizations within VA and DOD that are involved in acquiring, developing, and implementing the electronic health record. The plan also identifies high-level risks that may challenge the departments' effort to promote interoperability and the departments have established risk management processes for their respective modernization and acquisition efforts. Additionally, although not referenced in the plan, VA and DOD have performed multiple iterations of cost estimates for their respective system modernization and acquisition efforts. However, while the Joint Interoperability Plan also includes expected dates for key interoperability activities, as well as expected time frames for infrastructure and electronic health record modernization efforts, it does not include a schedule for implementing the interoperable record at each VA and DOD location. Further, the plan identifies high-level descriptions of monitoring and performance testing, but it lacks specific goals and metrics related to defining, measuring, tracking and reporting progress toward achieving expected performance of the interoperable record. It is important for VA and DOD to provide detailed information on all aspects of the departments' plans for achieving an interoperable health record, including when the record will be implemented at each location and how results will be measured and reported, to ensure that stakeholders have a shared understanding of how the departments intend to address their common health care business needs.

    Recommendation: To better position VA and DOD to achieve an interoperable electronic health record, the Secretaries of Veterans Affairs and Defense should develop a plan that, at a minimum, describes (1) the clinical domains that the interoperable electronic health record will address; (2) a schedule for implementing the interoperable record at each VA and DOD location; (3) the estimated cost of each major component (i.e., VistA Evolution, DHMSM, etc.) and the total cost of the departments' interoperability efforts; (4) the organizations within VA and DOD that are involved in acquiring, developing, and implementing the record, as well as the roles and responsibilities of these organizations; (5) major risks to the departments' interoperability efforts and mitigation plans for those risks; and (6) the departments' approach to defining, measuring, tracking, and reporting progress toward achieving expected performance (i.e., benefits and results) of the interoperable record.

    Agency Affected: Department of Veterans Affairs

  5. Status: Open

    Comments: DOD concurred with this recommendation and asserted that the Interagency Program Office (IPO), which was re-chartered in December 2013, remained the single point of accountability for achieving interoperability between the departments' electronic health record systems. Further, we recognize that the revised IPO charter states that the office acts as the single point of accountability for developing and implementing electronic health records systems or capabilities that allow for full interoperability of health care information between DOD and VA. However, since we made our recommendation in February 2014, the departments have pursued separate approaches to modernizing their respective electronic health record systems and have established governance structures that are independent of the IPO to manage their efforts. Specifically, DOD has established a Program Executive Office for Defense Health Management Systems, which manages multiple programs related to the department's interoperability efforts, including DOD's acquisition of a new electronic health record system. (VA has established the Executive Triad of VA officials under the Chief Information Officer to oversee modernizing its electronic health record system, which is managed jointly by the Office of Information and Technology and the Veterans Health Administration.) For its part, the IPO is tasked with identifying interoperability standards and coordinating activities to increase the sharing of health information between DOD's and VA's separate systems. However, while the IPO has developed guidance that describes a technical approach for standardizing health data, the office acts as one of multiple organizations that are accountable for actions taken to achieve electronic health record interoperability between DOD's and VA's separate systems. Thus, as currently positioned, the IPO may be limited in its ability to promote effective collaboration.

    Recommendation: To better position the Interagency Program Office for effective collaboration between VA and DOD and to efficiently and effectively fulfill the office's stated purpose of functioning as the single point of accountability for achieving interoperability between the departments' electronic health record systems, the Secretaries of Veterans Affairs and Defense should ensure that the IPO has authority (1) over dedicated resources (e.g., budget and staff), (2) to develop interagency processes, and (3) to make decisions over the departments' interoperability efforts.

    Agency Affected: Department of Defense

  6. Status: Open

    Comments: VA concurred with this recommendation and asserted that the Interagency Program Office (IPO), which was re-chartered in December 2013, remained the single point of accountability for achieving interoperability between the departments' electronic health record systems. Further, we recognize that the revised IPO charter states that the office acts as the single point of accountability for developing and implementing electronic health records systems or capabilities that allow for full interoperability of health care information between VA and DOD. However, since we made our recommendation in February 2014, the departments have pursued separate approaches to modernizing their respective electronic health record systems and have established governance structures that are independent of the IPO to manage their efforts. Specifically, VA has established the Executive Triad of VA officials under the Chief Information Officer to oversee modernizing its electronic health record system, which is managed jointly by the Office of Information and Technology and the Veterans Health Administration. (DOD has established a Program Executive Office for Defense Health Management Systems, which manages multiple programs related to the department's interoperability efforts, including DOD's acquisition of a new electronic health record system.) For its part, the IPO is tasked with identifying interoperability standards and coordinating activities to increase the sharing of health information between VA's and DOD's separate systems. However, while the IPO has developed guidance that describes a technical approach for standardizing health data, the office acts as one of multiple organizations that are accountable for actions taken to achieve electronic health record interoperability between VA's and DOD's systems. Thus, as currently positioned, the IPO may be limited in its ability to promote effective collaboration.

    Recommendation: To better position the Interagency Program Office for effective collaboration between VA and DOD and to efficiently and effectively fulfill the office's stated purpose of functioning as the single point of accountability for achieving interoperability between the departments' electronic health record systems, the Secretaries of Veterans Affairs and Defense should ensure that the IPO has authority (1) over dedicated resources (e.g., budget and staff), (2) to develop interagency processes, and (3) to make decisions over the departments' interoperability efforts.

    Agency Affected: Department of Veterans Affairs

 

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