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United States Government Accountability Office:
GAO:
Testimony:
Before the Subcommittee on Oversight and Investigations, Committee on
Veterans' Affairs, House of Representatives:
For Release on Delivery:
Expected at 10:00 a.m. EDT Tuesday, May 8, 2007:
Information Technology:
VA and DOD Are Making Progress in Sharing Medical Information, but Are
Far from Comprehensive Electronic Medical Records:
Statement of Valerie C. Melvin, Director:
Human Capital and Management Information Systems Issues:
GAO-07-852T:
GAO Highlights:
Highlights of GAO-07-852T, a report to Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, House of
Representatives
Why GAO Did This Study:
The Department of Veterans Affairs (VA) and the Department of Defense
(DOD) are engaged in ongoing efforts to share medical information,
which is important in helping to ensure high-quality health care for
active-duty military personnel and veterans. These efforts include a
long-term program to develop modernized health information systems
based on computable data: that is, data in a format that a computer
application can act on—for example, to provide alerts to clinicians of
drug allergies. In addition, the departments are engaged in near-term
initiatives involving existing systems.
GAO was asked to testify on the history and current status of these
long- and near-term efforts to share health information.
To develop this testimony, GAO reviewed its previous work, analyzed
documents, and interviewed VA and DOD officials about current status
and future plans.
What GAO Found:
For almost a decade, VA and DOD have been pursuing ways to share health
information and create comprehensive electronic medical records.
However, they have faced considerable challenges in these efforts,
leading to repeated changes in the focus of their initiatives and
target dates. Currently, the two departments are pursuing both long-
and short-term initiatives to share health information. Under their
long-term initiative, the modern health information systems being
developed by each department are to share standardized computable data
through an interface between data repositories associated with each
system. The repositories have now been developed, and the departments
have begun to populate them with limited types of health information.
In addition, the interface between the repositories has been
implemented at seven VA and DOD sites, allowing computable outpatient
pharmacy and drug allergy data to be exchanged. Implementing this
interface is a milestone toward the departments’ long-term goal, but
more remains to be done. Besides extending the current capability
throughout VA and DOD, the departments must still agree to standards
for the remaining categories of medical information, populate the data
repositories with this information, complete the development of the two
modernized health information systems, and transition from their
existing systems.
While pursuing their long-term effort to develop modernized systems,
the two departments have also been working to share information in
their existing systems. Among various near-term initiatives are a
completed effort to allow the one-way transfer of health information
from DOD to VA when service members leave the military, as well as
ongoing demonstration projects to exchange limited data at selected
sites. One of these projects, building on the one-way transfer
capability, developed an interface between certain existing systems
that allows a two-way view of current data on patients receiving care
from both departments. VA and DOD are now working to link other systems
via this interface and extend its capabilities. The departments have
also established ad hoc processes to meet the immediate need to provide
data on severely wounded service members to VA’s polytrauma centers,
which specialize in treating such patients. These processes include
manual workarounds (such as scanning paper records) that are generally
feasible only because the number of polytrauma patients is small. These
multiple initiatives and ad hoc processes highlight the need for
continued efforts to integrate information systems and automate
information exchange. In addition, it is not clear how all the
initiatives are to be incorporated into an overall strategy focused on
achieving the departments’ goal of comprehensive, seamless exchange of
health information.
What GAO Recommends:
GAO has previously made several recommendations on these topics,
including that VA and DOD develop a detailed project management plan to
guide their efforts to share patient health data. The departments
agreed with these recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-852T].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Valerie Melvin at (202)
512-6304 or melvinv@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to participate in today's hearing on sharing electronic
medical records between the Department of Defense (DOD) and the
Department of Veterans Affairs (VA). For almost 10 years, the
departments have been engaged in multiple efforts to share electronic
medical information, which is important in helping to ensure that
active-duty military personnel and veterans receive high-quality health
care. These include efforts focused on the long-term vision of a single
"comprehensive, lifelong medical record for each service
member"[Footnote 1] that would allow a seamless transition between the
two departments, as well as more near-term efforts to meet immediate
needs to exchange health information, including responding to current
military crises.
Each department is developing its own modern health information system
to replace its existing ("legacy") systems, and they are collaborating
on a program to develop an interface to enable these modernized systems
to share data and ultimately to have interoperable[Footnote 2]
electronic medical records. Unlike the legacy systems, the modernized
systems are to be based on computable data: that is, the data are to be
in a format that a computer application can act on, for example, to
provide alerts to clinicians (of such things as drug allergies) or to
plot graphs of changes in vital signs such as blood pressure. According
to the departments, such computable data contribute significantly to
patient safety and the usefulness of electronic medical records.
While working on this long-term effort, the two departments have also
been pursuing various near-term initiatives to exchange electronic
medical information in their existing systems. These include a
completed effort to allow the one-way transfer of health information
from DOD to VA when service members leave the military, ongoing
demonstration projects to exchange particular types of data at selected
sites, and efforts to meet the immediate needs of facilities treating
veterans and service members with multiple injuries.
As you requested, my testimony will summarize the history of the two
departments' efforts to develop the capability to share health
information, and provide an overview of the current status of the long-
and near-term efforts that the departments are making to share health
information.
The information in my testimony is based largely on our previous work
in this area. To describe the current status of VA and DOD efforts to
exchange patient health information, we reviewed our previous work,
analyzed documents on various health initiatives, and interviewed VA
and DOD officials about current status and future plans. The costs that
have been incurred for the various projects were provided by cognizant
VA and DOD officials. We did not audit the reported costs and thus
cannot attest to their accuracy or completeness. All work on which this
testimony is based was conducted in accordance with generally accepted
government auditing standards.
Results in Brief:
VA and DOD have been pursuing ways to share data in their health
information systems and create comprehensive electronic medical records
since 1998, following the call for the development of a comprehensive
integrated system to allow the two departments to share patient health
information. However, the departments have faced considerable
challenges, leading to repeated changes in the focus of their
initiatives and target dates. In reviewing the departments' initial
project, we noted disappointing progress, exacerbated by inadequate
accountability and poor planning and oversight, which raised doubts
about the departments' ability to achieve a comprehensive electronic
medical record. We made recommendations aimed at enhancing management
and accountability by, among other things, the creation of
comprehensive and coordinated plans that included an agreed-upon
mission and clear goals, objectives, and performance measures. In
response, the departments refocused the project and divided it into
long-and short-term initiatives. The long-term initiative, still
ongoing, is to develop a common health information architecture that
would allow the two-way exchange of health information through the
development of modern health information systems. The short-term
initiative (the Federal Health Information Exchange) was to enable DOD
to electronically transfer to VA health information on service members
when they leave the military; this initiative was completed in 2004.
Other short-term initiatives were subsequently established that were
similarly focused on sharing information in existing systems, an
important requirement until the departments' modern health information
systems are completed. In particular, two demonstration projects were
established in 2004 in response to congressional mandate, one of which
led the two departments to develop an interim strategy to connect
existing systems and allow information sharing among them. Finally, the
two departments announced in January 2007 a further new strategy: their
intention to jointly develop a new inpatient medical record system. The
departments have indicated that by adopting a joint solution, they
could realize significant cost savings and make inpatient health care
data immediately accessible to both departments.
VA and DOD have made progress in both their long-term and short-term
initiatives to share health information, but much work remains to
achieve the goal of a shared electronic medical record and seamless
transition between the two departments. In the long-term project to
develop modernized health information systems, the departments have
begun to implement the first release of the interface between their
modernized data repositories, and computable outpatient pharmacy and
drug allergy data are being exchanged at seven VA and DOD sites.
Although the data being exchanged are limited, implementing this
interface is a milestone toward the long-term goal of modernized
systems with interoperable electronic medical records. In the meantime,
the two departments have also made progress in their short-term
projects to share information in existing systems. Besides completing
the Federal Health Information Exchange, the departments have made
progress on two demonstration projects:
* The Laboratory Data Sharing Interface, which allows DOD and VA
facilities serving the same geographic area to share laboratory
resources, is deployed at 9 localities to communicate orders for lab
test and their results electronically and can be deployed at others if
the need is demonstrated.
* The Bidirectional Health Information Exchange, which allows a real-
time, two-way view of health data from existing systems,[Footnote 3]
provides this capability (for outpatient data) to all VA sites and 25
DOD sites and (for certain inpatient discharge summary data)[Footnote
4] to all VA sites and 5 DOD sites. Expanding this interface is the
foundation of the departments' interim strategy to share information
among their existing systems.
In addition to their technology efforts, the two departments have
undertaken ad hoc activities to accelerate the transmission of health
information on severely wounded patients from DOD to VA's four
polytrauma centers, which care for veterans and service members with
disabling injuries to more than one physical region or organ system.
These ad hoc processes include manual workarounds such as scanning
paper records and individually transmitting radiological images. Such
processes are generally feasible only because the number of polytrauma
patients is small (about 350 in all to date).
Through all these efforts, VA and DOD are achieving exchanges of health
information. However, these exchanges are as yet limited, and it is not
clear how they are to be integrated into an overall strategy toward
achieving the departments' long-term goal of comprehensive, seamless
exchange of health information. To achieve this goal, significant work
remains to be done, including agreeing to standards for the remaining
categories of medical information, populating the data repositories
with all this information, completing the development of their
modernized systems, and transitioning from the legacy systems.
Consequently, it is essential for the departments to develop a
comprehensive project plan to guide this effort to completion, in line
with our earlier recommendations.
Background:
In their efforts to modernize their health information systems and
share medical information, VA and DOD begin from different positions.
As shown in table 1, VA has one integrated medical information system,
VistA (Veterans Health Information Systems and Technology
Architecture), which uses all electronic records. All 128 VA medical
sites thus have access to all VistA information.[Footnote 5] (Table 1
also shows, for completeness, VA's planned modernized system and its
associated data repository.)
Table 1: VA Medical Information Systems:
Legacy systems.
System name: VistA Veterans Health Information Systems and Technology
Architecture;
Description: Existing integrated health information system.
Modernized system and repository.
System name: HealtheVet VistA;
Description: Modernized health information system based on computable
data.
System name: HDR Health Data Repository;
Description: Data repository associated with modernized system.
Source: GAO analysis of VA data.
[End of table]
In contrast, DOD has multiple medical information systems (see table
2). DOD's various systems are not integrated, and its 138 sites do not
necessarily communicate with each other. In addition, not all of DOD's
medical information is electronic: some records are paper-based.
Table 2: Selected DOD Medical Information Systems:
Legacy systems.
System name: CHCS Composite Health Care System;
Description: Primary existing DOD health information system.
System name: CIS Clinical Information System;
Description: Commercial health information system customized for DOD;
used by some DOD facilities for inpatients.
System name: ICDB Integrated Clinical Database;
Description: Health information system used by many Air Force
facilities.
System name: TMDS Theater Medical Data Store;
Description: Database to collect electronic medical information in
combat theater for both outpatient care and serious injuries.
System name: JPTA Joint Patient Tracking Application;
Description: Web- based application primarily used to track the
movement of patients as they are transferred from location to location,
but may include text- based medical information.
Modernized system and repository.
System name: AHLTA Armed Forces Health Longitudinal Technology
Application [A];
Description: Modernized health information system, integrated and based
on computable data.
System name: CDR Clinical Data Repository;
Description: Data repository associated with modernized system.
Source: GAO analysis of DOD data.
[A] Formerly CHCS II.
[End of table]
VA and DOD Have Been Working to Exchange Health Information Since 1998:
For almost a decade, VA and DOD have been pursuing ways to share data
in their health information systems and create comprehensive electronic
records.[Footnote 6] However, the departments have faced considerable
challenges, leading to repeated changes in the focus of their
initiatives and target dates for accomplishment.
As shown in figure 1, the departments' efforts have involved a number
of distinct initiatives, both long-term initiatives to develop future
modernized solutions, and short-term initiatives to respond to more
immediate needs to share information in existing systems. As the figure
shows, these initiatives often proceeded in parallel.
Figure 1: Timeline of Selected VA/DOD Electronic Medical Records and
Data Sharing Efforts:
[See PDF for image]
Source: GAO analysis of VA and DOD data.
[End of figure]
The departments' first initiative, known as the Government Computer-
Based Patient Record (GCPR) project, aimed to develop an electronic
interface that would let physicians and other authorized users at VA
and DOD health facilities access data from each other's health
information systems. The interface was expected to compile requested
patient information in a virtual record (that is, electronic as opposed
to paper) that could be displayed on a user's computer screen.
In 2001 and 2002, we reviewed the GCPR project and noted disappointing
progress, exacerbated in large part by inadequate accountability and
poor planning and oversight, which raised doubts about the departments'
ability to achieve a virtual medical record. We determined that the
lack of a lead entity, clear mission, and detailed planning to achieve
that mission made it difficult to monitor progress, identify project
risks, and develop appropriate contingency plans.[Footnote 7] We made
recommendations in both years that the departments enhance the
project's overall management and accountability. In particular, we
recommended that the departments designate a lead entity and a clear
line of authority for the project; create comprehensive and coordinated
plans that include an agreed-upon mission and clear goals, objectives,
and performance measures; revise the project's original goals and
objectives to align with the current strategy; commit the executive
support necessary to adequately manage the project; and ensure that it
followed sound project management principles.
In response, the two departments revised their strategy in July 2002,
refocusing the project and dividing it into two initiatives. A short-
term initiative (the Federal Health Information Exchange or FHIE) was
to enable DOD, when service members left the military, to
electronically transfer their health information to VA. VA was
designated as the lead entity for implementing FHIE, which was
successfully completed in 2004. A longer term initiative was to develop
a common health information architecture that would allow the two-way
exchange of health information. The common architecture is to include
standardized, computable data, communications, security, and high-
performance health information systems (these systems, DOD's CHCS II
and VA's HealtheVet VistA, were already in development, as shown in the
figure).[Footnote 8] The departments' modernized systems are to store
information (in standardized, computable form) in separate data
repositories: DOD's Clinical Data Repository (CDR) and VA's Health Data
Repository (HDR). The two repositories are to exchange information
through an interface named CHDR.[Footnote 9]
In March 2004, the departments began to develop the CHDR interface, and
they planned to begin implementation by October 2005.[Footnote 10]
However, implementation of the first release of the interface (at one
site) occurred in September 2006, almost a year later. In a review in
June 2004, we identified a number of management weaknesses that could
have contributed to this delay[Footnote 11] and made a number of
recommendations, including creation of a comprehensive and coordinated
project management plan. In response, the departments agreed to our
recommendations and improved the management of the CHDR program by
designating a lead entity with final decision-making authority and
establishing a project management structure. As we noted in later
testimony, however, the program did not develop a project management
plan that would give a detailed description of the technical and
managerial processes necessary to satisfy project requirements
(including a work breakdown structure and schedule for all development,
testing, and implementation tasks), as we had recommended.[Footnote 12]
In October 2004, the two departments established two more short-term
initiatives in response to a congressional mandate.[Footnote 13] These
were two demonstration projects: the Laboratory Data Sharing Interface,
aimed at allowing VA and DOD facilities to share laboratory resources,
and the Bidirectional Health Information Exchange (BHIE), aimed at
allowing both departments' clinicians access to records on shared
patients (that is, those who receive care from both
departments).[Footnote 14] As demonstration projects, both initiatives
were limited in scope, with the intention of providing interim
solutions to the departments' need for more immediate health
information sharing. However, because BHIE provided access to up-to-
date information, the departments' clinicians expressed strong interest
in increasing its use. As a result, the departments began planning to
broaden BHIE's capabilities and expand its implementation considerably.
Until the departments' modernized systems are fully developed and
implemented, extending BHIE connectivity could provide each department
with access to most data in the other's legacy systems. According to a
VA/DOD annual report[Footnote 15] and program officials, the
departments now consider BHIE an interim step in their overall strategy
to create a two-way exchange of electronic medical records.
Most recently, the departments have announced a further change to their
information-sharing strategy. In January 2007, they announced their
intention to jointly develop a new inpatient medical record system.
According to the departments, adopting this joint solution will
facilitate the seamless transition of active-duty service members to
veteran status, as well as making inpatient healthcare data on shared
patients immediately accessible to both DOD and VA. In addition, the
departments consider that a joint development effort could allow them
to realize significant cost savings. We have not evaluated the
departments' plans or strategy in this area.
Others Have Recommended Strengthening the Management and Planning of
the Departments' Health Information Initiatives:
Throughout the history of these initiatives, evaluations beyond ours
have also found deficiencies in the departments' efforts, especially
with regard to the need for comprehensive planning. For example, in
fiscal year 2006, the Congress did not provide all the funding
requested for HealtheVet VistA because it did not consider that the
funding had been adequately justified. In addition, a recent
presidential task force identified the need for VA and DOD to improve
their long-term planning.[Footnote 16] This task force, reporting on
gaps in services provided to returning veterans, noted problems with
regard to sharing information on wounded service members, including the
inability of VA providers to access paper DOD inpatient health records.
According to the report, although significant progress has been made on
sharing electronic information, more needs to be done. The task force
recommended that VA and DOD continue to identify long-term initiatives
and define scope and elements of a joint inpatient electronic health
record.
VA and DOD Are Exchanging Limited Medical Information, but Much Work
Remains to Achieve Seamless Sharing:
VA and DOD have made progress in both their long-term and short-term
initiatives to share health information. In the long-term project to
develop modernized health information systems, the departments have
begun to implement the first release of the interface between their
modernized data repositories, among other things. The two departments
have also made progress in their short-term projects to share
information in existing systems, having completed two initiatives and
making important progress on another. In addition, the two departments
have undertaken ad hoc activities to accelerate the transmission of
health information on severely wounded patients from DOD to VA's four
polytrauma centers. However, despite the progress made and the sharing
achieved, the tasks remaining to achieve the goal of a shared
electronic medical record remain substantial.
VA and DOD Have Begun Deployment of a Modernized Data Interface:
In their long-term effort to share health information, VA and DOD have
completed the development of their modernized data repositories, agreed
on standards for various types of data, and begun to populate the
repositories with these data.[Footnote 17] In addition, they have now
implemented the first release of the CHDR interface, which links the
two departments' repositories, at seven sites. The first release has
enabled the seven sites to share limited medical information:
specifically, computable outpatient pharmacy and drug allergy
information for shared patients.
According to DOD officials, in the third quarter of 2007 the department
will send out instructions to its remaining sites so that they can all
begin using CHDR. According to VA officials, the interface will be
available across the department when necessary software updates are
released, which is expected this July.[Footnote 18]
Besides being a milestone in the development of the departments'
modernized systems, the interface implementation provides benefits to
the departments' current systems. Data transmitted by CHDR are
permanently stored in the modernized data repositories, CDR and HDR.
Once in the repositories, these computable data can be used by DOD and
VA at all sites through their existing systems. CHDR also provides
terminology mediation (translation of one agency's terminology into the
other's). VA and DOD plans call for developing the capability to
exchange computable laboratory results data through CHDR during fiscal
year 2008.
Although implementing this interface is an important accomplishment,
the departments are still a long way from completion of the modernized
health information systems and comprehensive longitudinal health
records. While DOD and VA had originally projected completion dates for
their modernized systems of 2011 and 2012, respectively, department
officials told us that there is currently no scheduled completion date
for either system. Further, both departments have still to identify the
next types of data to be stored in the repositories. The two
departments will then have to populate the repositories with the
standardized data, which involves different tasks for each department.
Specifically, although VA's medical records are already electronic, it
still has to convert these into the interoperable format appropriate
for its repository. DOD, in addition to converting current records from
its multiple systems, must also address medical records that are not
automated. As pointed out by a recent Army Inspector General's report,
some DOD facilities are having problems with hard-copy
records.[Footnote 19] In the same report, inaccurate and incomplete
health data were identified as a problem to be addressed. Before the
departments can achieve the long-term goal of seamless sharing of
medical information, all these tasks and challenges will have to be
addressed. Consequently, it is essential for the departments to develop
a comprehensive project plan to guide these efforts to completion, as
we have previously recommended.
VA and DOD Are Exchanging Limited Health Information through Short-Term
Projects:
In addition to the long-term effort described above, the two
departments have made some progress in meeting immediate needs to share
information in their respective legacy systems by setting up short-term
projects, as mentioned earlier, which are in various stages of
completion. In addition, the departments have set up special processes
to transfer data from DOD facilities to VA's polytrauma centers, which
treat traumatic brain injuries and other especially severe injuries.
One-Way Transfer Capability Is Operational:
DOD has been using FHIE to transfer information to VA since 2002.
According to department officials, over 184 million clinical messages
on more than 3.8 million veterans have been transferred to the FHIE
data repository as of March 2007. Data elements transferred are
laboratory results, radiology results, outpatient pharmacy data,
allergy information, consultation reports, elements of the standard
ambulatory data record, and demographic data. Further, since July 2005,
FHIE has been used to transfer pre-and post-deployment health
assessment and reassessment data; as of March 2007, VA has access to
data for more than 681,000 separated service members and demobilized
Reserve and National Guard members who had been deployed. Transfers are
done in batches once a month, or weekly for veterans who have been
referred to VA treatment facilities.
According to a joint DOD/VA report,[Footnote 20] FHIE has made a
significant contribution to the delivery and continuity of care of
separated service members as they transition to veteran status, as well
as to the adjudication of disability claims.
Laboratory Interface Initiative Allows VA and DOD to Share Lab
Resources:
One of the departments' demonstration projects, the Laboratory Data
Sharing Interface (LDSI), is now fully operational and is deployed when
local agencies have a business case for its use and sign an agreement.
It requires customization for each locality and is currently deployed
at nine locations. LDSI currently supports a variety of chemistry and
hematology tests, and work is under way to include microbiology and
anatomic pathology.
Once LDSI is implemented at a facility, the only nonautomated action
needed for a laboratory test is transporting the specimens. If a test
is not performed at a VA or DOD doctor's home facility, the doctor can
order the test, the order is transmitted electronically to the
appropriate lab (the other department's facility or in some cases a
local commercial lab), and the results are returned electronically.
Among the benefits of LDSI, according to VA and DOD, are increased
speed in receiving laboratory results and decreased errors from manual
entry of orders. The LDSI project manager in San Antonio stated that
another benefit of the project is the time saved by eliminating the
need to rekey orders at processing labs to input the information into
the laboratories' systems. Additionally, the San Antonio VA facility no
longer has to contract out some of its laboratory work to private
companies, but instead uses the DOD laboratory.
Two-Way Interface Allows Real-Time Viewing of Text Information:
Developed under a second demonstration project, the BHIE interface is
now available throughout VA and partially deployed at DOD. It is
currently deployed at 25 DOD sites, providing access to 15 medical
centers, 18 hospitals, and over 190 outpatient clinics associated with
these sites. DOD plans to make current BHIE capabilities available
departmentwide by June 2007.
The interface permits a medical care provider to query patient data
from all VA sites and any DOD site where it is installed and to view
that data onscreen almost immediately. It not only allows DOD and VA to
view each other's information, it also allows DOD sites to see
previously inaccessible data at other DOD sites.
As initially developed, the BHIE interface provides access to
information in VA's VistA and DOD's CHCS, but it is currently being
expanded to query data in other DOD databases (in addition to CHCS). In
particular, DOD has developed an interface to the Clinical Information
System (CIS), an inpatient system used by many DOD facilities, which
will provide bidirectional views of discharge summaries. The BHIE-CIS
interface is currently deployed at five DOD sites and planned for eight
others. Further, interfaces to two additional systems are planned for
June and July 2007: An interface to DOD's modernized data repository,
CDR, will give access to outpatient data from combat theaters. An
interface to another DOD database, the Theater Medical Data Store, will
give access to inpatient information from combat theaters.
The departments also plan to make more data elements available.
Currently, BHIE enables text-only viewing of patient identification,
outpatient pharmacy, microbiology, cytology, radiology, laboratory
orders, and allergy data from its interface with DOD's CHCS. Where it
interfaces with CIS, it also allows viewing of discharge summaries from
VA and the five DOD sites. DOD staff told us that in early fiscal year
2008, they plan to add provider notes, procedures, and problem lists.
Later in fiscal year 2008, they plan to add vital signs, scanned images
and documents, family history, social history, and other history
questionnaires. In addition, at the VA/DOD site in El Paso, a trial is
under way of a process for exchanging radiological images using the
BHIE/FHIE infrastructure.[Footnote 21] Some images have successfully
been exchanged.
Through their efforts on these long-and near-term initiatives, VA and
DOD are achieving exchanges of various types of health information (see
attachment 1 for a summary of all the types of data currently being
shared and those planned for the future, as well as cost data on the
initiatives). However, these exchanges are as yet limited, and
significant work remains to be done to expand the data shared and
integrate the various initiatives.
Special Procedures Provide Information to VA Polytrauma Centers:
In addition to the information technology initiatives described, DOD
and VA have set up special activities to transfer medical information
to VA's four polytrauma centers, which are treating active-duty service
members severely wounded in combat.[Footnote 22] Polytrauma centers
care for veterans and returning service members with injuries to more
than one physical region or organ system, one of which may be life
threatening, and which results in physical, cognitive, psychological,
or psychosocial impairments and functional disability. Some examples of
polytrauma include traumatic brain injury (TBI), amputations, and loss
of hearing or vision.
When service members are seriously injured in a combat theater
overseas, they are first treated locally. They are then generally
evacuated to Landstuhl Medical Center in Germany, after which they are
transferred to a military treatment facility in the United States,
usually Walter Reed Army Medical Center in Washington, D.C; the
National Naval Medical Center in Bethesda, Maryland; or Brooke Army
Medical Center, at Fort Sam Houston, Texas. From these facilities,
service members suffering from polytrauma may be transferred to one of
VA's four polytrauma centers for treatment.[Footnote 23]
At each of these locations, the injured service members will accumulate
medical records, in addition to medical records already in existence
before they were injured. However, the DOD medical information is
currently collected in many different systems and is not easily
accessible to VA polytrauma centers. Specifically:
1. In the combat theater, electronic medical information may be
collected for a variety of reasons, including routine outpatient care,
as well as serious injuries. These data are stored in the Theater
Medical Data Store, which can be accessed by unit commanders and
others. (As mentioned earlier, the departments have plans to develop a
BHIE interface to this system by July 2007. Until then, VA cannot
access these data.) In addition, both inpatient and outpatient medical
data for patients who are evacuated are entered into the Joint Patient
Tracking Application. (A few VA polytrauma center staff have been given
access to this application.)
2. At Landstuhl, inpatient medical records are paper-based (except for
discharge summaries). The paper records are sent with a patient as the
individual is transferred for treatment in the United States.
3. At the DOD treatment facility (Walter Reed, Bethesda, or Brooke),
additional information will be recorded in CIS and CHCS/CDR.[Footnote
24]
When service members are transferred to a VA polytrauma center, VA and
DOD have several ad hoc processes in place to electronically transfer
the patients' medical information:
* DOD has set up secure links to enable a limited number of clinicians
at the polytrauma centers to log directly into CIS at Walter Reed and
Bethesda Naval Hospital to access patient data.
* Staff at Walter Reed collect paper records, print records from CIS,
scan all these, and transmit the scanned data to three of the four
polytrauma centers. DOD staff said that they are working on
establishing this capability at the Brooke and Bethesda medical
centers, as well as the fourth VA polytrauma center. According to VA
staff, although the initiative began several months ago, it has only
recently begun running smoothly as the contractor became more skilled
at assembling the records. DOD staff also pointed out that this
laborious process is feasible only because the number of polytrauma
patients is small (about 350 in all to date); it would not be practical
on a large scale.
* Staff at Walter Reed and Bethesda are transmitting radiology images
electronically to three polytrauma centers. (A fourth has this
capability, but at this time no radiology images have been transferred
there.) Access to radiology images is a high priority for polytrauma
center doctors, but like scanning paper records, transmitting these
images requires manual intervention: when each image is received at VA,
it must be individually uploaded to VistA's imagery viewing capability.
This process would not be practical for large volumes of images.
* VA has access to outpatient data (via BHIE) from 25 DOD sites,
including Landstuhl.
Although these various efforts to transfer medical information on
seriously wounded patients are working, and the departments are to be
commended on their efforts, the multiple processes and laborious manual
tasks illustrate the effects of the lack of integrated health
information systems and the difficulties of exchanging information in
their absence.
In conclusion, through the long-and short-term initiatives described,
as well as efforts such as those at the polytrauma centers, VA and DOD
are achieving exchanges of health information. However, these exchanges
are as yet limited, and significant work remains to be done to fully
achieve the goal of exchanging interoperable, computable data,
including agreeing to standards for the remaining categories of medical
information, populating the data repositories with all this
information, completing the development of HealtheVet VistA and AHLTA,
and transitioning from the legacy systems. To complete these tasks, a
detailed project management plan continue to be of vital importance to
the ultimate success of the effort to develop a lifelong virtual
medical record. We have previously recommended that the departments
develop a clearly defined project management plan that describes the
technical and managerial processes necessary to satisfy project
requirements, including a work breakdown structure and schedule for all
development, testing, and implementation tasks. Without a plan of
sufficient detail, VA and DOD increase the risk that the long-time
project will not deliver the planned capabilities in the time and at
the cost expected. Further, it is not clear how all the initiatives we
have described today are to be incorporated into an overall strategy
toward achieving the departments' goal of comprehensive, seamless
exchange of health information.
Mr. Chairman, this concludes my statement. I would be happy to respond
to any questions that you or other members of the subcommittee may
have.
Contacts and Acknowledgments:
If you have any questions concerning this testimony, please contact
Valerie C. Melvin, Director, Human Capital and Management Information
Systems Issues, at (202) 512-6304 or melvinv@gao.gov. Other individuals
who made key contributions to this testimony include Barbara Oliver,
Assistant Director; Barbara Collier; and Glenn Spiegel.
Attachment 1: Supplementary Tables:
Types of Data Shared by DOD and VA Are Growing but Remain Limited:
Table 3 summarizes the types of health data currently shared through
the long-and near-term initiatives we have described, as well as types
of data that are currently planned for addition. While this gives some
indication of the scale of the tasks involved in sharing medical
information, it does not depict the full extent of information that is
currently being captured in health information systems and that remains
to be addressed.
Table 3: Data Elements Made Available and Planned by DOD-VA
Initiatives:
Initiative: CHDR;
Data elements: Available: Outpatient pharmacy; Drug allergy;
Data elements: Planned: Laboratory data;
Comments: Computable data are exchanged between one department's data
repository and the other's.
Initiative: FHIE;
Data elements: Available: Patient demographics; Laboratory results;
Radiology reports; Outpatient pharmacy information; Admission discharge
transfer data; Discharge summaries; Consult reports; Allergies;
Data from the DoD Standard Ambulatory Data Record; Pre-and post-
deployment assessments; Data elements: Planned: None;
Comments: One-way batch transfer of text data from DOD to VA occurs
weekly if discharged patient has been referred to VA for treatment;
otherwise monthly.
Initiative: LDSI;
Data elements: Available: Laboratory orders; Laboratory results
(chemistry and hematology only);
Data elements: Planned: Microbiology; Anatomic pathology;
Comments: Noncomputable text data are transferred.
Initiative: BHIE;
Data elements: Available: Outpatient pharmacy data; Drug & food allergy
information; Surgical pathology reports; Microbiology results; Cytology
reports; Chemistry & hematology reports; Laboratory orders; Radiology
text reports; Inpatient discharge summaries and/or emergency room notes
from CIS at five DOD and all VA sites;
Data elements: Planned: Provider notes; Procedures; Problem lists;
Vital signs; Scanned images and documents; Family history; Social
history; Other history questionnaires; Radiology images;
Comments: Data are not transferred but can be viewed.
Source: GAO analysis of VA and DOD data.
[End of table]
Reported Costs:
Table 4 shows costs expended on these information sharing initiatives
since their inception.
Table 4: Costs of DOD and VA Initiatives Since Inception:
Project: HealtheVet VistA;
VA expenditure: $514 million through FY 2005;
DOD expenditure: --.
Project: AHLTA;
VA expenditure: --;
DOD expenditure: $755 million through FY 2006 (estimated).
Joint initiatives.
Project: CHDR;
VA expenditure: 5.3 million through about April 2007;
DOD expenditure: DOD does not account for these projects separately.
Project: FHIE;
VA expenditure: 62.4 million.
Project: LDSI;
VA expenditure: 1.5 million.
Project: BHIE;
VA expenditure: 7.0 million.
Project: Total;
VA expenditure: $76.2 million;
DOD expenditure: $72.6 million though FY 2006.
Source: GAO analysis of DOD and VA data.
[End of table]
Related GAO Products:
Computer-Based Patient Records: Better Planning and Oversight by VA,
DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459. Washington,
D.C.: April 30, 2001.
Veterans Affairs: Sustained Management Attention Is Key to Achieving
Information Technology Results. GAO-02-703. Washington, D.C.: June 12,
2002.
Computer-Based Patient Records: Short-Term Progress Made, but Much Work
Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health
Systems. GAO-04-271T. Washington, D.C.: November 19, 2003.
Computer-Based Patient Records: Sound Planning and Project Management
Are Needed to Achieve a Two-Way Exchange of VA and DOD Health Data. GAO-
04-402T. Washington, D.C.: March 17, 2004.
Computer-Based Patient Records: VA and DOD Efforts to Exchange Health
Data Could Benefit from Improved Planning and Project Management. GAO-
04-687. Washington, D.C.: June 7, 2004.
Computer-Based Patient Records: VA and DOD Made Progress, but Much Work
Remains to Fully Share Medical Information. GAO-05-1051T. Washington,
D.C.: September 28, 2005.
Information Technology: VA and DOD Face Challenges in Completing Key
Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
DOD and VA Exchange of Computable Pharmacy Data. GAO-07-554R.
Washington, D.C.: April 30, 2007.
FOOTNOTES
[1] In 1996, the Presidential Advisory Committee on Gulf War Veterans'
Illnesses reported on many deficiencies in VA's and DOD's data
capabilities for handling service members' health information. In
November 1997, the President called for the two agencies to start
developing a "comprehensive, lifelong medical record for each service
member," and in 1998 issued a directive requiring VA and DOD to develop
a "computer-based patient record system that will accurately and
efficiently exchange information."
[2] Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
[3] DOD's Composite Health Care System (CHCS) and VA's VistA (Veterans
Health Information Systems and Technology Architecture).
[4] Specifically, inpatient discharge summary data stored in VA's VistA
and DOD's Clinical Information System (CIS), a commercial health
information system customized for DOD.
[5] A site represents one or more facilities--medical centers,
hospitals, or outpatient clinics--that store their electronic health
data in a single database.
[6] Initially, the Indian Health Service (IHS) was also a party to this
effort, having been included because of its population-based research
expertise and its long-standing relationship with VA. However, IHS was
not included in a later revised strategy for electronically sharing
patient health information.
[7] GAO, Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results, GAO-02-703 (Washington, D.C.:
June 12, 2002) and Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-01-
459 (Washington, D.C.: Apr. 30, 2001).
[8] DOD's existing Composite Health Care System (CHCS) was being
modernized as CHCS II, now renamed AHLTA (Armed Forces Health
Longitudinal Technology Application). VA's existing VistA system was
being modernized as HealtheVet VistA.
[9] The name CHDR, pronounced "cheddar," combines the names of the two
repositories.
[10] December 2004 VA and DOD Joint Strategic Plan.
[11] GAO, Computer-Based Patient Records: VA and DOD Efforts to
Exchange Health Data Could Benefit from Improved Planning and Project
Management, GAO-04-687 (Washington, D.C.: June 7, 2004).
[12] GAO, Computer-Based Patient Records: VA and DOD Made Progress, but
Much Work Remains to Fully Share Medical Information, GAO-05-1051T
(Washington, D.C.: Sept. 28, 2005) and Information Technology: VA and
DOD Face Challenges in Completing Key Efforts, GAO-06-905T (Washington,
D.C.: June 22, 2006).
[13] The Bob Stump National Defense Authorization Act for Fiscal Year
2003 (Pub. L. 107-314, 2002) mandated that the departments conduct
demonstration projects to test the feasibility, advantages, and
disadvantages of measures and programs designed to improve the sharing
and coordination of health care and health care resources between the
departments.
[14] To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project. Unlike FHIE, which provides a one-way transfer of information
to VA when a service member separates from the military, the two-way
system allows clinicians in both departments to view, in real time,
limited health data (in text form) from the departments' current health
information systems.
[15] December 2004 VA and DOD Joint Strategic Plan.
[16] Task Force on Returning Global War on Terror Heroes, Report to the
President (Apr. 19, 2007).
[17] DOD has populated CDR with information for outpatient encounters,
drug allergies, and order entries and results for outpatient pharmacy/
lab orders. VA has populated HDR with patient demographics, vital signs
records, allergy data, and outpatient pharmacy data; this summer, the
department plans to include chemistry and hematology laboratory data.
[18] The Remote Data Interoperability software upgrade provides the
capability for the automated checks and alerts allowed by computable
data.
[19] Inspector General, Army, Army Physical Disability Evaluation
System Inspection (March 2007).
[20] December 2004 VA and DOD Joint Strategic Plan.
[21] To create BHIE, the departments drew on the architecture and
framework of the information transfer system established by the FHIE
project.
[22] In particular, clinicians required access to discharge notices,
which describe the treatment given at previous medical facilities and
the status of patients when they left those facilities.
[23] The four Polytrauma Rehabilitation Centers are in Richmond, Tampa,
Minneapolis, and Palo Alto.
[24] Pharmacy and drug information would be stored in CDR; other health
information continues to be stored in local CHCS databases.
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