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.

Additional Materials:

Contact:

Valerie C. Melvin
(202) 512-6304
melvinv@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

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: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    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

  2. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    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

  3. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    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

  4. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    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

  5. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    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

  6. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    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

 

Explore the full database of GAO's Open Recommendations »

Sep 18, 2014

Sep 16, 2014

Sep 8, 2014

Sep 2, 2014

Aug 22, 2014

Aug 13, 2014

Aug 11, 2014

Jul 30, 2014

Jul 29, 2014

Looking for more? Browse all our products here