Electronic Health Records:

Outcome-Oriented Metrics and Goals Needed to Gauge DOD's and VA's Progress in Achieving Interoperability

GAO-15-530: Published: Aug 13, 2015. Publicly Released: Aug 13, 2015.

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What GAO Found

The Departments of Defense (DOD) and Veterans Affairs (VA), with guidance from the Interagency Program Office (IPO) that is tasked with facilitating the departments' efforts to share health information, have taken actions to increase interoperability between their electronic health record systems. Among other things, DOD and VA have initiated work focused on near-term objectives, including standardizing their existing health data and making them viewable by both departments' clinicians in an integrated format. The departments also have developed longer-term plans to modernize their respective electronic health record systems. For its part, the IPO has issued guidance outlining the technical approach for achieving interoperability between the departments' systems.

Even with the actions taken, DOD and VA did not, by the October 1, 2014, deadline established in the National Defense Authorization Act (NDAA) for Fiscal Year 2014 for compliance with national data standards, certify that all health care data in their systems complied with national standards and were computable in real time. Both departments stated that they intend to do so later in calendar year 2015. Further, the departments' system modernization plans identify a number of key activities to be implemented beyond December 31, 2016—the deadline established in the NDAA for the two departments to deploy modernized electronic health record software to support clinicians while ensuring full standards-based interoperability. Specifically, DOD has issued plans and announced the contract award for acquiring a modernized system to include interoperability capabilities across military operations. In addition, VA has issued plans describing an incremental approach to modernizing its existing electronic health records system. These plans—if implemented as currently described—indicate that deployment of the new systems with interoperability capabilities will not be completed across the departments until after 2018.

The IPO has taken steps to develop process metrics intended to monitor progress related to the data standardization and exchange of health information consistent with its responsibilities. For example, it has issued guidance that calls for tracking metrics, such as the percentage of data domains within the departments' current health information systems that are mapped to national standards. However, the office has not yet specified outcome-oriented metrics and established related goals that are important to gauging the impact that interoperability capabilities have on improving health care services for shared patients. IPO officials said this work is ongoing and that a team is working with DOD, VA, and subject matter experts to identify metrics that would provide more meaningful measures of the impact of increased interoperability. However, the IPO has not identified a time frame for when this team will report its results and when the IPO plans to incorporate these metrics and goals into its guidance. Without ensuring that outcome-oriented metrics and related goals are defined and incorporated into the current approach, the departments and the IPO will not be positioned to assess and report on the status of interoperability-related activities and determine areas that need improvement.

Why GAO Did This Study

DOD and VA operate two of the nation's largest health care systems, serving approximately 16 million veterans and active duty service members and their beneficiaries, at a cost of more than $100 billion a year. For almost two decades, the departments have been engaged in various efforts to advance DOD and VA electronic health record interoperability. Among their most recent efforts, the DOD and VA Secretaries have committed the departments to achieving interoperability between their separate electronic health record systems.

The Consolidated Appropriations Act , 2014, and accompanying Joint Explanatory Statement, included a provision for GAO to review the departments' efforts. GAO evaluated the actions taken by DOD, VA, and the IPO to plan for and measure the progress toward achieving interoperability between the departments' electronic health record systems. GAO reviewed relevant program documents and interviewed agency officials.

What GAO Recommends

GAO recommends that DOD and VA, working with the IPO, establish a time frame for identifying outcome-oriented metrics; define related goals to provide a basis for assessing and reporting on the status of interoperability; and update IPO guidance to reflect the metrics and goals identified. DOD and VA 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: Closed - Implemented

    Comments: The Department of Defense (DOD) has established a time frame for identifying outcome-oriented metrics related to the interoperability of health data between DOD and the Department of Veterans Affairs (VA). Specifically, according to the DOD/VA Interagency Program Office (IPO), the office, in conjunction with the departments, developed a Health Outcome-Oriented Metrics Roadmap that describes the process for how DOD and VA intend to identify, define, and measure the impact of interoperability on healthcare outcomes. Further, the IPO completed a proof of concept in October 2016 for measuring and reporting outcome-oriented interoperability metrics and developed a related timeline for implementing the concept in four key four business lines including separating service members/integrated disability evaluation system, patient empowerment, population health, and transitions of care. The implementation projects have staggered start dates, the last of which is planned to begin in November 2017. The projects will run concurrently with completion dates projected between December 2018 and February 2019. By establishing a timeline for identifying outcome-oriented metrics in these key areas, the IPO and the departments have better positioned themselves to report on the progress of interoperability and to ensure accountability for delivering improved outcomes on their healthcare services for service members and veterans.

    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should establish a time frame for identifying outcome-oriented metrics.

    Agency Affected: Department of Defense

  2. Status: Closed - Implemented

    Comments: The Department of Veterans Affairs (VA) has established a time frame for identifying outcome-oriented metrics related to the interoperability of health data between VA and the Department of Defense (DOD). Specifically, according to the DOD/VA Interagency Program Office (IPO), the office, in conjunction with the departments, developed a Health Outcome-Oriented Metrics Roadmap that describes the process for how VA and DOD intend to identify, define, and measure the impact of interoperability on healthcare outcomes. Further, the IPO completed a proof of concept in October 2016 for measuring and reporting outcome-oriented interoperability metrics and developed a related timeline for implementing the concept in four key four business lines including separating service members/integrated disability evaluation system, patient empowerment, population health, and transitions of care. The implementation projects have staggered start dates, the last of which is planned to begin in November 2017. The projects will run concurrently with completion dates projected between December 2018 and February 2019. By establishing this timeline for identifying outcome-oriented metrics in these key areas, the IPO and the departments have better positioned themselves to report on the progress of interoperability and to ensure accountability for delivering improved outcomes on their healthcare services for service members and veterans.

    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should establish a time frame for identifying outcome-oriented metrics.

    Agency Affected: Department of Veterans Affairs

  3. Status: Open

    Comments: The Department of Defense (DOD) and the Department of Veterans Affairs (VA) are working to define goals to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems. Specifically, according to the DOD/VA Interagency Program Office (IPO), the office, in conjunction with the departments, has employed use cases in the Joint Interoperability Plan to define the interoperability-related goal areas, which are to be used as the basis for the development of outcome-oriented metrics, assessments, and reporting. The departments, the IPO, and workgroups within the Health Executive Committee's data sharing areas have focused on the feasibility and development of metrics aligned to six use cases as they relate to electronic health record interoperability between DOD and VA and outcomes to service members, veterans, and healthcare providers. The IPO reports that the work to establish these goals will be completed by December 2017. GAO will continue to review the results of these efforts.

    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should ensure related goals are defined to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems.

    Agency Affected: Department of Defense

  4. Status: Open

    Comments: The Department of Veterans Affairs (VA) and the Department of Defense (DOD) are working to define goals to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems. Specifically, according to the DOD/VA Interagency Program Office (IPO), the office, in conjunction with the departments, has employed use cases in the Joint Interoperability Plan to define the interoperability-related goal areas, which are to be used as the basis for the development of outcome-oriented metrics, assessments, and reporting. The departments, the IPO, and workgroups within the Health Executive Committee's data sharing areas have focused on the feasibility and development of metrics aligned to six use cases as they relate to electronic health record interoperability between VA and DOD and outcomes to service members, veterans, and healthcare providers. The IPO reports that the work to establish these goals will be completed by December 2017. GAO will continue to review the results of these efforts.

    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should ensure related goals are defined to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems.

    Agency Affected: Department of Veterans Affairs

  5. Status: Open

    Comments: According to the Department of Defense (DOD)/Department of Veterans Affairs (VA) Interagency Program Office (IPO), the office has issued an update to the Health Data Interoperability Management Plan that documents the IPO's role and outlines governance for supporting interoperability between the departments. The IPO is also in the process of updating additional guidance to describe the benefits of interoperability and reflect associated outcome-oriented metrics and goals. Specifically, IPO officials reported that the IPO's Joint Interoperability Plan is transitioning to the Joint Interoperability Strategic Plan and is expected to be finalized in November 2017. GAO will review this guidance once it is approved by DOD and VA.

    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should update IPO guidance to reflect the metrics and goals identified.

    Agency Affected: Department of Defense

  6. Status: Open

    Comments: According to the Department of Defense (DOD)/Department of Veterans Affairs (VA) Interagency Program Office (IPO), the office has issued an update to the Health Data Interoperability Management Plan that documents the IPO's role and outlines governance for supporting interoperability between the departments. The IPO is also in the process of updating additional guidance to describe the benefits of interoperability and reflect associated outcome-oriented metrics and goals. Specifically, IPO officials reported that the IPO's Joint Interoperability Plan is transitioning to the Joint Interoperability Strategic Plan and is expected to be finalized in November 2017. GAO will review this guidance once it is approved by VA and DOD.

    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should update IPO guidance to reflect the metrics and goals identified.

    Agency Affected: Department of Veterans Affairs

 

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