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Testimony: 

Before the Subcommittee on Military Construction, Veterans’ Affairs, 
and Related Agencies; House Committee on Appropriations: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery:
Expected at 10:00 a.m. EDT:
Thursday, March 12, 2009: 

Information Technology: 

Challenges Remain for VA’s Sharing of Electronic Health Records with 
DOD: 

Statement of Valerie C. Melvin, Director: 
Information Management and Human Capital Issues: 

GAO-09-427T: 

GAO Highlights: 

Highlights of GAO-09-427T, a testimony before the Subcommittee on 
Military Construction, Veterans' Affairs, and Related Agencies; House 
Committee on Appropriations. 

Why GAO Did This Study: 

For over a decade, the Department of Veterans Affairs (VA) and the 
Department of Defense (DOD) have been engaged in efforts to improve 
their ability to share electronic health information. These efforts are 
vital for making patient information readily available to health care 
providers in both departments, reducing medical errors, and 
streamlining administrative functions. In addition, Congress has 
mandated that VA and DOD jointly develop and implement, by September 
30, 2009, electronic health record systems or capabilities that are 
fully interoperable and compliant with applicable federal 
interoperability standards. (Interoperability is the ability of two or 
more systems or components to exchange information and to use the 
information that has been exchanged.) 

The experience of VA and DOD in this area is also relevant to broader 
efforts to advance the nationwide use of health information technology 
(IT) in both the public and private health care sectors—a goal of both 
current and past administrations. 

In this statement, GAO describes VA’s and DOD’s achievements and 
challenges in developing interoperable electronic health records, 
including brief comments on how these apply to the broader national 
health IT effort. 

What GAO Found: 

Through their long-running electronic health information sharing 
initiatives, VA and DOD have succeeded in increasing their ability to 
share and use health information. In particular, they are sharing 
certain clinical information (pharmacy and drug allergy data) in 
computable form—that is, in a format that a computer can understand and 
act on. This permits health information systems to provide alerts to 
clinicians on drug allergies, an important feature that was given 
priority by the departments’ clinicians. The departments are now 
exchanging this type of data on over 27,000 shared patients—an increase 
of about 9,000 patients between June 2008 and January 2009. Sharing 
computable data is considered the highest level of interoperability, 
but other levels also have value. That is, data that are only viewable 
still provide important information to clinicians, and much of the 
departments’ shared information is of this type. However, the 
departments have more to do: not all electronic health information is 
yet shared, and although VA’s health data are all captured 
electronically, information is still captured on paper at many DOD 
medical facilities. 

To share and use health data has required, among other things, that VA 
and DOD agree on standards. At the same time, they are participating in 
federal standards-related initiatives, which is important both because 
of the experience that the departments bring to the national effort, 
and also because their involvement helps ensure that their adopted 
standards are compliant with federal standards. However, these federal 
standards are still emerging, which could complicate the departments’ 
efforts to maintain compliance. 

Finally, the departments’ efforts face management challenges. 
Specifically, the effectiveness of the departments’ planning for 
meeting the deadline for fully interoperable electronic health records 
is reduced because their plans did not consistently identify results-
oriented performance goals (i.e., goals that are objective, 
quantifiable, and measurable) or measures that would permit progress 
toward the goals to be assessed. Further constraining VA’s and DOD’s 
planning effectiveness is their inability to complete all necessary 
activities to set up the interagency program office, which is intended 
to be accountable for fulfilling the departments’ interoperability 
plans. Defining goals and ensuring that these are met would be an 
important part of the task of the program office. Without a fully 
established office that can manage the effort to meet these goals, the 
departments increase the risk that they will not be able to share 
interoperable electronic health information to the extent and in the 
manner that most effectively serves military service members and 
veterans. Accordingly, GAO has recommended that the departments give 
priority to fully establishing the interagency program office and 
develop results-oriented performance goals and measures to be used as 
the basis for reporting interoperability progress. The departments 
concurred with these recommendations. 

View [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-427T] or key 
components. 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 be here today to discuss the efforts of the Department 
of Veterans Affairs (VA) to advance the use of health information 
technology to achieve interoperable electronic health records with the 
Department of Defense (DOD). VA has been working with DOD for over a 
decade to pursue initiatives to share data between the two departments' 
health information systems. To expedite the departments' efforts, the 
National Defense Authorization Act for Fiscal Year 2008[Footnote 1] 
included provisions directing VA and DOD to jointly develop and 
implement, by September 30, 2009, fully interoperable electronic health 
record systems or capabilities that are compliant with applicable 
federal interoperability[Footnote 2] standards. Such systems and 
capabilities are important for making patient information more readily 
available to health care providers in both departments, reducing 
medical errors, and streamlining administrative functions. 

The experience of VA and DOD in this area is also relevant to broader 
efforts to advance the nationwide use of health information technology 
(IT) in both the public and private health care sectors --a goal of 
both current and past administrations. As you are aware, a nationwide 
effort is currently under way to promote the use of health IT to help 
improve the efficiency and quality of health care. In April 2004 an 
executive order called for widespread adoption of interoperable 
electronic health records by 2014,[Footnote 3] and it set up the Office 
of the National Coordinator for Health Information Technology within 
the Department of Health and Human Services (HHS) to help guide efforts 
leading to this goal. Most recently, in February, the American Recovery 
and Reinvestment Act of 2009 established the office in law, giving the 
National Coordinator responsibility for coordinating health IT policy 
and standards, among other things.[Footnote 4] 

Since 2001, we have been reviewing aspects of the various federal 
efforts undertaken to implement IT for health care and public health 
solutions. We have reported on VA's and DOD's electronic health 
information sharing initiatives, as well as on HHS's national health IT 
initiatives.[Footnote 5] Overall, our studies have recognized progress 
made by these departments, but we have also pointed out challenges and 
other areas of concern. At your request, in this statement, we will 
describe some of VA's and DOD's achievements and challenges in 
developing interoperable electronic health records, including brief 
comments on how these apply to the broader national health IT effort. 

In developing this testimony, we relied largely on our previous work. 
We conducted our work in support of this testimony during February 2009 
and March 2009, in Washington, D.C. All work on which this testimony is 
based was performed in accordance with generally accepted government 
auditing standards. Those standards require that we plan and perform 
the audit to obtain sufficient, appropriate evidence to provide a 
reasonable basis for our findings and conclusions based on our audit 
objectives. We believe that the evidence obtained provides a reasonable 
basis for our findings and conclusions based on our audit objectives. 

Background: 

The use of IT to electronically collect, store, retrieve, and transfer 
clinical, administrative, and financial health information has great 
potential to help improve the quality and efficiency of health care and 
is critical to improving the performance of the U.S. health care 
system. Historically, patient health information has been scattered 
across paper records kept by many different caregivers in many 
different locations, making it difficult for a clinician to access all 
of a patient's health information at the time of care. Lacking access 
to these critical data, a clinician may be challenged to make the most 
informed decisions on treatment options, potentially putting the 
patient's health at greater risk. The use of electronic health records 
can help provide this access and improve clinical decisions.[Footnote 
6] 

Electronic health records are particularly crucial for optimizing the 
health care provided to military personnel and veterans. While in 
military status and later as veterans, many VA and DOD patients tend to 
be highly mobile and may have health records residing at multiple 
medical facilities within and outside the United States. Making such 
records electronic can help ensure that complete health care 
information is available for most military service members and veterans 
at the time and place of care, no matter where it originates. 

VA Has Been Working with DOD to Exchange Health Information for Over a 
Decade: 

VA and DOD have been working to exchange patient health data 
electronically since 1998. As we have previously noted,[Footnote 7] 
their efforts have included both short-term initiatives to share 
information in existing (legacy) systems, as well as a long-term 
initiative to develop modernized health information systems--replacing 
their legacy systems--that would be able to share data and, ultimately, 
use interoperable electronic health records. 

In their short-term initiatives to share information from existing 
systems, the departments began from different positions. VA has one 
integrated medical information system--the Veterans Health Information 
Systems and Technology Architecture (VistA)--which uses all electronic 
records and was developed in-house by VA clinicians and IT personnel. 
[Footnote 8] All VA medical facilities have access to all VistA 
information. 

In contrast, DOD uses multiple legacy medical information systems, all 
of which are commercial software products that are customized for 
specific uses. For example, the Composite Health Care System (CHCS) 
which was formerly DOD's primary health information system, is still in 
use to capture pharmacy, radiology, and laboratory information. 
[Footnote 9] In addition, the Clinical Information System (CIS), a 
commercial health information system customized for DOD, is used to 
support inpatient treatment at military medical facilities. 

The departments' short-term initiatives to share information in their 
existing systems have included several projects. Most notable are two 
information exchange projects: 

* The Federal Health Information Exchange (FHIE), completed in 2004, 
enables DOD to electronically transfer service members' electronic 
health information to VA when the members leave active duty. 

* The Bidirectional Health Information Exchange (BHIE), also 
established in 2004, was aimed at allowing clinicians at both 
departments viewable access to records on shared patients (that is, 
those who receive care from both departments--veterans may receive 
outpatient care from VA clinicians and be hospitalized at a military 
treatment facility).[Footnote 10] The interface also allows DOD sites 
to see previously inaccessible data at other DOD sites. 

As part of the long-term initiative, each of the departments aims to 
develop a modernized system in the context of a common health 
information architecture that would allow a two-way exchange of health 
information. The common architecture is to include standardized, 
computable data; communications; security; and high-performance health 
information systems: DOD's AHLTA[Footnote 11] and VA's HealtheVet. 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). 
For the two-way exchange of health information, in September 2006 the 
departments implemented an interface named CHDR[Footnote 12], to link 
the two repositories. 

Beyond these initiatives, in January 2007, the departments announced 
their intention to jointly determine an approach for inpatient health 
records. On July 31, 2007, they awarded a contract for a feasibility 
study and exploration of alternatives. In December 2008, the contractor 
provided the departments with a recommended strategy for jointly 
developing an inpatient solution. 

VA and DOD Have Increased Information Sharing, but Continue to Face 
Challenges in Developing and Implementing Interoperable Health Records: 

VA and DOD have increased their ability to share and use health 
information, sharing both computable and viewable data. This 
achievement has required years of effort by the two departments, 
involving, among other things, agreeing on standards and setting 
priorities for the kind of information to be shared and the appropriate 
level of interoperability to work toward. 

Interoperability--the ability to share data among health care 
providers--is key to sharing health care information electronically. 
Interoperability enables different information systems or components to 
exchange information and to use the information that has been 
exchanged. This capability is important because it allows patients' 
electronic health information to move with them from provider to 
provider, regardless of where the information originated. If electronic 
health records conform to interoperability standards, they can be 
created, managed, and consulted by authorized clinicians and staff 
across more than one health care organization, thus providing patients 
and their caregivers the necessary information required for optimal 
care. (Paper-based health records--if available--also provide necessary 
information, but unlike electronic health records, do not provide 
decision support capabilities, such as automatic alerts about a 
particular patient's health, or other advantages of automation.) 

Interoperability can be achieved at different levels.[Footnote 13] At 
the highest level, electronic data are computable (that is, in a format 
that a computer can understand and act on to, for example, provide 
alerts to clinicians on drug allergies). At a lower level, electronic 
data are structured and viewable, but not computable. The value of data 
at this level is that they are structured so that data of interest to 
users are easier to find. At still a lower level, electronic data are 
unstructured and viewable, but not computable. With unstructured 
electronic data, a user would have to find needed or relevant 
information by searching uncategorized data. Beyond these, paper 
records can also be considered interoperable (at the lowest level) 
because they allow data to be shared, read, and interpreted by human 
beings. Figure 1 shows the distinction between the various levels of 
interoperability and examples of the types of data that can be shared 
at each level. 

Figure 1: Levels of Data Interoperability: 

[Refer to PDF for image: illustration] 

Level move toward having increasingly sophisticated and standardized 
data. 

Level 1: Nonelectronic data (i.e., paper forms). 

Level 2: Unstructured, viewable electronic data (i.e., scans of paper 
forms). 

Level 3: Structured, viewable electronic data (i.e., electronically 
entered data that cannot be computed by other systems). 

Level 4: Computable electronic data (i.e., electronically entered data 
that can be computed by other systems. 

Source: GAO analysis of data from the Center for Information TEchnology 
Leadership. 

[End of figure] 

VA and DOD have adopted a classification framework like the one in the 
figure to define what level of interoperability they are aiming to 
achieve in various information areas. For example, in their initial 
efforts to implement computable data, VA and DOD focused on outpatient 
pharmacy and drug allergy data because clinicians gave priority to the 
need for automated alerts to help medical personnel avoid administering 
inappropriate drugs to patients. As of January 31, 2009, the 
departments were exchanging computable outpatient pharmacy and drug 
allergy data through the CHDR interface on over 27,000 shared patients-
-an increase of about 9,000 patients since June 2008. 

However, according to VA and DOD officials, not all data require the 
same level of interoperability, nor is interoperability at the highest 
level achievable in all cases. For example, unstructured, viewable data 
may be sufficient for such narrative information as clinical notes. 
According to the departments, much of the information being shared 
today is currently at the structured, viewable level. For example, 
through BHIE, the departments exchange surgical pathology reports, 
microbiology results, cytology reports, chemistry and hematology 
reports, laboratory orders, vital signs, and other data in structured, 
viewable form. Some of this information is from scanned documents that 
are viewable but unstructured. With this format, a clinician would have 
to find needed or relevant information by scanning uncategorized 
information. The value of viewable data is increased if the data are 
structured so that information is categorized and easier to find. 
Nonetheless, achieving even a minimal level of electronic 
interoperability is valuable for potentially making all relevant 
information available to clinicians. 

However, the departments have more to do: not all electronic health 
information is yet shared. In addition, although VA's health data are 
all captured electronically, information is still captured on paper at 
many DOD medical facilities. 

VA and DOD Have Adopted Standards to Allow Sharing and Are Taking Steps 
to Follow Evolving Federal Standards: 

Any level of interoperability depends on the use of agreed-upon 
standards to ensure that information can be shared and used. In the 
health IT field, standards may govern areas ranging from technical 
issues, such as file types and interchange systems, to content issues, 
such as medical terminology. 

* For example, vocabulary standards provide common definitions and 
codes for medical terms and determine how information will be 
documented for diagnoses and procedures. These standards are intended 
to lead to consistent descriptions of a patient's medical condition by 
all practitioners. Without such standards, the terms used to describe 
the same diagnoses and procedures may vary (the condition known as 
hepatitis, for example, may be described as a liver inflammation). The 
use of different terms to indicate the same condition or treatment 
complicates retrieval and reduces the reliability and consistency of 
data. 

* Another example is messaging standards, which establish the order and 
sequence of data during transmission and provide for the uniform and 
predictable electronic exchange of data. For example, they might 
require the first segment to include the patient's name, hospital 
number, and birth date. A series of subsequent segments might transmit 
the results of a complete blood count, dictating one result (e.g., iron 
content) per segment. Messaging standards can be adopted to enable 
intelligible communication between organizations via the Internet or 
some other communications pathway. Without them, the interoperability 
of health IT systems may be limited, reducing the data that can be 
shared. 

VA and DOD have agreed upon numerous common standards that allow them 
to share health data. These are listed in a jointly published common 
set of interoperability standards called the Target DOD/VA Health 
Standards Profile, updated annually. The profile includes federal 
standards (such as data standards established by the Food and Drug 
Administration and security standards established by the National 
Institute of Standards and Technology); industry standards (such as 
wireless communications standards established by the Institute of 
Electrical and Electronics Engineers and Web file sharing standards 
established by the American National Standards Institute); and 
international standards (such as the Systematized Nomenclature of 
Medicine Clinical Terms, or SNOMED CT, and security standards 
established by the International Organization for Standardization). 

For the two kinds of data now being exchanged in computable form 
through CHDR (pharmacy and drug allergy data), VA and DOD adopted the 
National Library of Medicine data standards for medications and drug 
allergies, as well as the SNOMED CT codes for allergy reactions. This 
standardization was a prerequisite for exchanging computable medical 
information--an accomplishment that, according to the Department of 
Health and Human Services' National Coordinator for Health IT, has not 
been widely achieved. 

Further, VA and DOD are continuing their historical involvement in 
efforts to agree upon standards for the electronic exchange of clinical 
health information by participating in ongoing initiatives led by the 
Office of the National Coordinator under the direction of HHS. These 
initiatives have included the designation of standards-setting 
organizations tasked to reach consensus on the definition and use of 
standards. For example, these organizations have been responsible for, 
among other things, 

* developing use cases,[Footnote 14] which provide the context in which 
standards would be applicable; 

* identifying competing standards for the use cases and harmonizing the 
standards; 

* developing interoperability specifications that are needed for 
implementing the standards;[Footnote 15] and: 

* creating certification criteria to determine whether health IT 
systems meet standards accepted or recognized by the Secretary of HHS, 
and then certifying systems that meet those criteria. 

The involvement of the two departments in these initiatives is 
important both because of the experience that the departments can offer 
the national effort, and also because their involvement helps ensure 
that the standards they adopt are consistent with the emerging federal 
standards. DOD and VA have made progress toward adopting health data 
interoperability standards that are newly recognized and accepted by 
the Secretary of HHS. The departments have identified these new 
standards, which relate to three HHS-recognized use cases,[Footnote 16] 
in their most recent Target Standards Profile. 

Nonetheless, the need to be consistent with the emerging federal 
standards adds complexity to the task faced by the two departments of 
extending their standards efforts to additional types of health 
information. The National Coordinator recognized the importance of 
their participation and stated it would not be advisable for VA and DOD 
to move significantly ahead of the national standards initiative; if 
they did, the departments might have to change the way their systems 
share information by adjusting them to the national standards later, as 
the standards continue to evolve. 

VA and DOD Plans Lack Results-Oriented Performance Goals and Measures, 
and Interagency Program Office Is Not Fully Set Up: 

Using interoperable health IT to help improve the efficiency and 
quality of health care is a complex goal that requires the involvement 
of multiple stakeholders in both departments, as well as numerous 
activities taking place over an expanse of time. In view of this 
complexity, it is important to develop comprehensive plans that cover 
the full scope of the activities needed to reach the goal of 
interoperable health capabilities or systems. To be effective, these 
plans should be grounded in results-oriented goals and performance 
measures that allow the results of the activities to be monitored and 
assessed, so that the departments can take corrective action if needed. 

In the course of their health IT efforts, VA and DOD have faced 
considerable challenges in project planning and management. As far back 
as 2001 and 2002, we reported management weaknesses, such as inadequate 
accountability and poor planning and oversight, and recommended that 
the departments apply principles of sound project management.[Footnote 
17] The departments' efforts to meet the recent requirements of the 
National Defense Authorization Act for Fiscal Year 2008 provide 
additional examples of such challenges, raising concerns regarding 
their ability to most effectively meet the September 2009 deadline for 
developing and implementing interoperable electronic health record 
systems or capabilities. 

The departments have identified key documents as defining their planned 
efforts to meet this deadline: the November 2007 VA/DOD Joint Executive 
Council Strategic Plan for Fiscal Years 2008-2010 (known as the VA/DOD 
Joint Strategic Plan) and the September 2008 DOD/VA Information 
Interoperability Plan (Version 1.0). These plans identify various 
objectives and activities that, according to the departments, are aimed 
at increasing health information sharing and achieving full 
interoperability. However, of the 45 objectives and activities 
identified in their plans, we previously reported that only 4 were 
documented with results-oriented (i.e., objective, quantifiable, and 
measurable) performance goals and measures that are characteristic of 
effective planning.[Footnote 18] 

* An example of an objective, quantifiable, and measurable performance 
goal is DOD's objective of increasing the percentage for inpatient 
discharge summaries that it shares with VA from 51 percent as of March 
2009, to 70 percent by September 30, 2009. 

* However, other goals in the plans are not measurable: For example, 
one objective is the development of a plan for interagency sharing of 
essential health images. Another objective is to review national health 
IT standards. In neither case are tangible deliverables described that 
would permit the departments to determine progress in achieving these 
goals. 

In view of the complexity and scale of the tasks required for the two 
departments to develop interoperable electronic health records, the 
lack of documented results-oriented performance goals and measures 
hinder their ability to measure and report their progress toward 
delivering new capabilities. Both departments agreed with our January 
2009 recommendation that they develop results-oriented goals and 
associated performance measures to help them manage this effort. 
[Footnote 19] Until they develop these goals and measures, the 
departments will be challenged to effectively assess their progress. 

In addition, we previously reported that the departments had not fully 
set up the interagency program office that was established in the 
National Defense Authorization Act for Fiscal Year 2008. According to 
department officials, this office will play a crucial role in 
coordinating the departments' efforts to accelerate their 
interoperability efforts. These officials stated that having a 
centralized office to take on this role will be a primary benefit. 
Further, defining results-oriented performance goals and ensuring that 
these are met would be an important part of the task of the program 
office. However, the effort to set up the program office was still in 
its early stages. The departments had taken steps to set up the program 
office, such as developing descriptions for key positions and beginning 
to hire personnel, but they had not completed all necessary activities 
to meet their December 2008 deadline for the office to be fully 
operational. Both departments agreed with our July 2008 recommendation 
that the departments give priority to fully establishing the 
interagency program office.[Footnote 20] Since we last reported, the 
departments have continued their efforts to hire staff for the office 
with 18 of 30 positions filled as of March 5, 2009, but the positions 
of Director and Deputy Director are not yet filled with permanent 
hires. 

Until the departments complete key activities to set up the program 
office, it will not be positioned to be fully functional, or 
accountable for fulfilling the departments' interoperability plans. 
Coupled with the lack of results-oriented plans that establish program 
commitments in measurable terms, the absence of a fully operational 
interagency program office leaves VA and DOD without a clearly 
established approach for ensuring that their actions will achieve the 
desired purpose of the act. 

In closing, Mr. Chairman, VA and DOD have made important progress in 
achieving electronic health records that are interoperable, but the 
departments continue to face challenges in managing the activities 
required to achieve this inherently complex goal. These include the 
need to continue to agree on standards for their own systems while 
ensuring that they maintain compliance with federal standards, which 
are still emerging as part of the effort to promote the nationwide 
adoption of health IT. In addition, the departments' efforts face 
managerial challenges in defining goals and measures and setting up the 
interagency program office. Until these challenges are addressed, the 
risk is increased that the departments will not achieve the ability to 
share interoperable electronic health information to the extent and in 
the manner that most effectively serves military service members and 
veterans. 

This concludes my statement. I would be pleased to respond to any 
questions that you or other members of the subcommittee may have. 

Contacts and Acknowledgements: 

If you have any questions on matters discussed in this testimony, 
please contact Valerie C. Melvin, Director, Information Management and 
Human Capital Issues, at (202) 512-6304 or melvinv@gao.gov. Other 
individuals who made key contributions to this testimony are Mark Bird, 
Assistant Director; Barbara Collier; Neil Doherty; Rebecca LaPaze; J. 
Michael Resser; Kelly Shaw; and Eric Trout. 

[End of section] 

Footnotes: 

[1] The National Defense Authorization Act for Fiscal Year 2008, Pub. 
L. No. 110-181, Section 1635 (Jan. 28, 2008). 

[2] Interoperability is the ability of two or more systems or 
components to exchange information and to use the information that has 
been exchanged. Further discussion of levels of interoperability is 
provided later in this testimony. 

[3] Executive Order 13335, Incentives for the Use of Health Information 
Technology and Establishing the Position of the National Health 
Information Technology Coordinator (Washington, D.C.: Apr. 27, 2004). 

[4] Health Information Technology for Economic and Clinical Health 
(HITECH) Act, sec. 13101, Title XIII of the American Recovery and 
Reinvestment Act of 2009, Pub. L. No. 111-5, Feb. 17, 2009, adding sec. 
3001 to the Public Health Service Act, 42 U.S.C. sec. 300jj-11. 

[5] GAO, Computer-Based Patient Records: Better Planning and Oversight 
by VA, DOD, and IHS Would Enhance Health Data Sharing, [hyperlink, 
http://www.gao.gov/products/GAO-01-459] (Washington, D.C.: Apr. 30, 
2001); Computer-Based Patient Records: VA and DOD Efforts to Exchange 
Health Data Could Benefit from Improved Planning and Project 
Management, [hyperlink, http://www.gao.gov/products/GAO-04-687] 
(Washington, D.C.: June 7, 2004); Health Information Technology: HHS Is 
Continuing Efforts to Define its National Strategy, [hyperlink, 
http://www.gao.gov/products/GAO-06-1071T] (Washington, D.C.: Sept. 1, 
2006); Information Technology: DOD and VA Have Increased Their Sharing 
of Health Information, but More Work Remains, [hyperlink, 
http://www.gao.gov/products/GAO-08-954] (Washington, D.C.: July 28, 
2008); and Electronic Health Records: DOD's and VA's Sharing of 
Information Could Benefit from Improved Management, [hyperlink, 
http://www.gao.gov/products/GAO-09-268] (Washington, D.C.: Jan. 28, 
2009). 

[6] An electronic health record is a collection of information about 
the health of an individual or the care provided, such as patient 
demographics, progress notes, problems, medications, vital signs, past 
medical history, immunizations, laboratory data, and radiology reports. 

[7] [hyperlink, http://www.gao.gov/products/GAO-08-954]. 

[8] VistA began operation in 1983 as the Decentralized Hospital 
Computer Program. In 1996, the name of the system was changed to the 
Veterans Health Information Systems and Technology Architecture. 

[9] According to DOD, CHCS applications are now accessed through its 
modernized health information system, AHLTA. 

[10] 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 
interface allows clinicians in both departments to view, in real time, 
limited health data (in text form) from the departments' existing 
health information systems. 

[11] The department considers AHLTA the official name of the system. 
(It was formerly an abbreviation for Armed Forces Health Longitudinal 
Technology Application). Previously, AHLTA was known as CHCS II. 

[12] The name CHDR, pronounced "cheddar," combines the names of the two 
repositories. 

[13] These levels were identified by the Center for Information 
Technology Leadership, which was chartered in 2002 as a research 
organization established to help guide the health care community in 
making more informed strategic IT investment decisions. According to VA 
and DOD, the different levels of interoperability have been accepted 
for use by the Office of the National Coordinator for Health 
Information Technology. 

[14] Use cases are descriptions of events that detail what a system (or 
systems) needs to do to achieve a specific mission or goal; they convey 
how individuals and organizations (actors) interact with the systems. 
For health IT, use cases strive to provide enough detail and context 
for follow-up activities to occur related to specific health care areas 
of high priority, such as standards harmonization, architecture 
specification, certification consideration, and detailed policy 
discussions to advance the national health IT agenda. 

[15] An interoperability specification codifies detailed implementation 
guidance that includes references to the identified standards or parts 
of standards and explains how they should be applied to specific health 
care topic areas. 

[16] Specifically, the profile now includes the use cases for 
Electronic Health Records Laboratory Results Reporting, 
Biosurveillance, and Consumer Empowerment. 

[17] GAO, Veterans Affairs: Sustained Management Attention Is Key to 
Achieving Information Technology Results, [hyperlink, 
http://www.gao.gov/products/GAO-02-703] (Washington, D.C.: June 12, 
2002) and [hyperlink, http://www.gao.gov/products/GAO-01-459]. 

[18] [hyperlink, http://www.gao.gov/products/GAO-09-268]. 

[19] [hyperlink, http://www.gao.gov/products/GAO-09-268]. 

[20] [hyperlink, http://www.gao.gov/products/GAO-08-954]. 

[End of section] 

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