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Report to Congressional Committees: 

United States Government Accountability Office: 
GAO: 

January 2009: 

Electronic Health Records: 

DOD's and VA's Sharing of Information Could Benefit from Improved 
Management: 

GAO-09-268: 

GAO Highlights: 

Highlights of GAO-09-268, a report to congressional committees. 

Why GAO Did This Study: 

Under the National Defense Authorization Act for Fiscal Year 2008, the 
Department of Defense (DOD) and the Department of Veterans Affairs (VA) 
are required to accelerate the exchange of health information between 
the departments and to develop systems or capabilities that allow for 
interoperability (generally, the ability of systems to exchange data) 
and that are compliant with federal standards. The Act also established 
a joint interagency program office to function as a single point of 
accountability for the effort, which is to implement such systems or 
capabilities by September 30, 2009. 

Further, the Act required that GAO semi-annually report on the progress 
made in achieving these goals. For this second report, GAO evaluates 
the departments’ progress and plans toward sharing electronic health 
information that comply with federal standards, and whether the 
interagency program office is positioned to function as a single point 
of accountability. To do so, GAO reviewed its past work, analyzed 
agency documentation, and conducted interviews. 

What GAO Found: 

DOD and VA continue to increase health information sharing through 
ongoing initiatives and related activities. Specifically, the 
departments’ are now exchanging pharmacy and drug allergy data on over 
21,000 shared patients, an increase of about 2,700 patients between 
June and October 2008. Further, they recently expanded the number of 
standards and specifications with which they expect their 
interoperability initiatives will comply. In addition, DOD reported 
that it received certification of its electronic health record system. 
Also, the departments have defined their plans to further increase 
their sharing of electronic health information. In particular, they 
have identified the Joint Executive Council Strategic Plan and the 
DOD/VA Information Interoperability Plan as the key documents defining 
their planned efforts to provide interoperable health records. These 
plans identify various objectives and activities that, according to the 
departments, are aimed at increasing health information sharing and 
achieving full interoperability, as required by the National Defense 
Authorization Act for Fiscal Year 2008. However, neither plan 
identifies results-oriented (i.e., objective, quantifiable, and 
measurable) performance goals and measures that are characteristic of 
effective planning and can be used as a basis to track and assess 
progress toward the delivery of new interoperable capabilities. In the 
absence of results-oriented goals and performance measures, the 
departments are not positioned to adequately assess progress toward 
increasing interoperability. Instead, DOD and VA are limited to 
assessing progress in terms of activities completed and increases in 
data exchanged (e.g., the number of patients for which certain types of 
data are exchanged). 

The departments have continued to take steps to set up the interagency 
program office. For example, they have developed descriptions for key 
positions and agreed with GAO’s July 2008 recommendation that they give 
priority to establishing permanent leadership and hiring staff. Also, 
the departments developed the program office organization structure 
document that depicts the office’s organization and, in January 2009, 
the departments approved a program office charter to describe, among 
other things, the mission and function of the office. Nonetheless, DOD 
and VA have not yet fully executed their plan to set up the program 
office. For example, among other activities, they have not yet filled 
key positions for the Director and Deputy Director, or 22 of 30 other 
positions identified for the office. In the continued absence of a 
fully established program office, the departments will remain 
ineffectively positioned to assure that interoperable electronic health 
records and capabilities are achieved by the required date. 

What GAO Recommends: 

GAO is recommending that the departments develop results-oriented 
performance goals and measures to be used as the basis for reporting 
interoperability progress. Commenting on a draft of this report, DOD 
and VA concurred with GAO’s recommendations. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-268]. For more 
information, contact Valerie Melvin at (202) 512-6304 or 
melvinv@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

DOD and VA Report Continued Progress toward Increased Interoperability; 
however, Plans Lack Results-Oriented Performance Goals and Measures: 

Steps Have Been Taken to Set Up the DOD/VA Interagency Program Office, 
but It Is Not Positioned to Function as a Single Point of 
Accountability: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Comments from the Department of Defense: 

Appendix III: Comments from the Department of Veterans Affairs: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Table: 

Table 1: Status of Selected Key Activities to Establish the DOD/VA 
Interagency Program Office, as of January 2009: 

Figure: 

Figure 1: Levels of Data Interoperability: 

Abbreviations: 

AHLTA: Armed Forces Health Longitudinal Technology Application: 

BHIE: Bidirectional Health Information Exchange: 

CDR: Clinical Data Repository: 

CHCS: Composite Health Care System: 

CHDR: interface between DOD's CDR and VA's HDR: 

CIS: Clinical Information System: 

DOD: Department of Defense: 

FHIE: Federal Health Information Exchange: 

HDR: Health Data Repository: 

HHS: Department of Health and Human Services: 

IT: information technology: 

VA: Department of Veterans Affairs: 

VistA: Veterans Health Information Systems and Technology Architecture: 

[End of section] 

United States Government Accountability Office: Washington, DC 20548: 

January 28, 2009: 

Congressional Committees: 

As you are aware, the Department of Defense (DOD) and the Department of 
Veterans Affairs (VA) have, for over a decade, pursued initiatives to 
share data between their health information systems. The departments' 
efforts have included working toward a long-term vision of a single 
"comprehensive, lifelong medical record"[Footnote 1] that would enable 
each service member to transition seamlessly between the two 
departments, as well as more short-term efforts focused on meeting 
immediate needs to share health information, including responding to 
current military crises. 

However, while important steps have been taken, questions have remained 
concerning when and to what extent the intended electronic sharing 
capabilities of the two departments will be fully achieved, prompting 
continuing calls for progress in the sharing of essential health 
information. Among these, a presidential task force recommended in May 
2003 that DOD and VA develop and deploy bidirectional electronic health 
records by fiscal year 2005. Further, in July 2007, the President's 
Commission on Care for America's Returning Wounded Warriors reported 
that the departments had continued to develop independent, stand-alone 
systems and recommended that DOD and VA move rapidly to make all 
essential health information available to clinicians.[Footnote 2] 

More recently, to expedite the departments' efforts to exchange 
electronic health information, the National Defense Authorization Act 
for Fiscal Year 2008[Footnote 3] included provisions directing DOD and 
VA to jointly develop and implement, by September 30, 2009, fully 
interoperable electronic health record systems or capabilities. The Act 
required that these systems or capabilities be compliant with 
applicable interoperability[Footnote 4] standards of the federal 
government, and it established an interagency program office to be a 
single point of accountability for the departments' efforts. 

In addition, the Act directed GAO to assess DOD's and VA's progress in 
implementing the electronic health record systems and to report 
semiannually its results to the appropriate congressional committees. 
Accordingly, on July 28, 2008, we issued the first of our reports in 
response to the Act.[Footnote 5] Further, we subsequently testified on 
this report in September 2008.[Footnote 6] As agreed with the 
committees of jurisdiction, our objectives for this second report are 
to (1) evaluate the departments' progress and plans toward developing 
electronic health record systems or capabilities that allow for full 
interoperability and comply with applicable federal interoperability 
standards and (2) determine whether the interagency program office 
established by the National Defense Authorization Act for Fiscal Year 
2008 is positioned to function as a single point of accountability for 
developing and implementing electronic health records. 

To carry out these objectives, we reviewed our past work in this area; 
[Footnote 7] analyzed current agency documentation (including plans for 
achieving interoperability, actions accomplished or planned to 
establish the interagency program office, and program documentation for 
interoperability standards); and conducted interviews with officials 
from DOD, VA, and the Department of Health and Human Services' Office 
of the National Coordinator for Health Information Technology. 

We conducted this performance audit from August 2008 through January 
2009, 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. For more 
details on our scope and methodology, see appendix I. 

Results in Brief: 

DOD and VA continue to increase sharing of their electronic health 
information. For example, the departments stated that they are 
exchanging computable pharmacy and drug allergy data on over 21,000 
shared patients, an increase of about 2,700 patients between June and 
October 2008.[Footnote 8] The departments also recently expanded the 
number of standards and specifications with which they expect their 
interoperability initiatives will comply, and DOD reported that it has 
received certification of its electronic health record system. In 
addition, the departments have continued to define their plans to 
further increase their sharing of electronic health information. In 
particular, they have identified the November 2007 Joint Executive 
Council Strategic Plan for Fiscal Years 2008-2010 and the September 
2008 DOD/VA Information Interoperability Plan (Version 1.0) as the key 
documents defining their planned efforts to provide interoperable 
health records. These plans identify various objectives and activities 
that are aimed at increasing health information sharing and achieving 
full interoperability, as required by the Act. For example, the 
Information Interoperability Plan identifies six objectives that are 
intended to be met by September 30, 2009, including an expanded 
capability to increase the sharing of inpatient discharge summaries at 
additional DOD sites. However, while the plans discussed objectives and 
activities to increase information sharing, neither included results- 
oriented goals and performance measures that are characteristic of 
effective planning and can be used as a basis to track and measure 
progress toward the delivery of the interoperable capabilities the 
departments plan to establish by September 30, 2009. In the absence of 
results-oriented goals and performance measures, the departments are 
not positioned to adequately assess progress toward achieving increased 
interoperability and can only report the completion of activities and 
indicate increases in data exchanged. In discussing the absence of 
results-oriented performance goals and measures, DOD and VA officials 
stated that their plans represent their initial efforts to articulate 
interoperability goals. Until the departments establish results- 
oriented goals and performance measures, they will be limited in their 
ability to assess their progress and ensure that they are taking the 
necessary steps to achieve their interoperability goals. 

The Act called for the establishment of an interagency program office 
to be accountable for implementing electronic health record systems or 
capabilities that allow for full interoperability of personal health 
care information between DOD and VA. As we previously reported, 
[Footnote 9] the departments had planned to set up this office by 
December 2008. The departments have continued to take steps to set up 
the office. For example, they have developed descriptions for key 
positions and agreed with our July 2008 recommendation that they give 
priority to establishing permanent leadership and hiring staff. Also, 
the departments developed the program office organization structure 
document that depicts the office's organization and, in January 2009, 
the departments approved a program office charter to describe, among 
other things, the mission and function of the office. However, they 
have not yet fully executed their plan for doing so. For example, among 
other activities, they have not yet filled key positions for the 
Director and Deputy Director, or 22 of 30 other positions identified 
for the office. In the continued absence of a fully established program 
office, the departments will remain ineffectively positioned to ensure 
that interoperable electronic health records and capabilities are 
achieved by the required date. 

To better ensure the successful attainment of interoperable electronic 
health record systems or capabilities, we are recommending that the 
Secretaries of Defense and Veterans Affairs develop and document 
results-oriented goals and performance measures for the departments' 
interoperability plans and that they use such plans as the basis for 
measuring and reporting progress. 

The Assistant Secretary of Defense and the Secretary of Veterans 
Affairs provided written comments on a draft of this report, which are 
reproduced in app. II and app. III, respectively. In the comments, the 
departments concurred with the report's recommendations. DOD and VA 
stated that high priority will be given to the establishment and use of 
results-oriented (i.e., objective, quantifiable, and measurable) goals 
and associated performance measures for the departments' 
interoperability objectives and documentation of these goals in 
interoperability plans. If the recommendations are properly 
implemented, they should better position DOD and VA to effectively 
measure and report progress in achieving interoperability. 

Background: 

The use of information technology (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 important 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 10] 

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 DOD and VA 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. 

Key to making health care information electronically available is 
interoperability--that is, the ability to share data among health care 
providers. 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, paper 
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 11] 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 also can be considered interoperable (at the lowest level) 
because they allow data to be shared, read, and interpreted by human 
beings. Figure 1 shows the distinctions 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] 

This figure is an illustration of levels of data interoperability, 
leading to increasingly sophisticated and standardized data, as 
follows: 

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 based on data from the Center for Information 
Technology Leadership. 

[End of figure] 

According to DOD and VA officials, not all data require the same level 
of interoperability. For example, in their initial efforts to implement 
computable data, DOD and VA 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. On the other hand, for such narrative data as 
clinical notes, unstructured, viewable data may be sufficient. 
Achieving even a minimal level of electronic interoperability is 
valuable for potentially making all relevant information available to 
clinicians. 

Efforts to Adopt and Implement Federal Interoperability Standards Are 
Ongoing: 

Interoperability depends on adherence to common standards to promote 
the exchange of health information between participating agencies and 
with nonfederal entities in supporting quality and efficient health 
care. In the health IT field, standards govern areas ranging from 
technical issues, such as file types and interchange systems, to 
content issues, such as medical terminology. Developing, coordinating, 
and agreeing on standards are only part of the processes involved in 
achieving interoperability for electronic health record systems or 
capabilities. In addition, specifications are needed for implementing 
the standards, as well as criteria and a process for verifying 
compliance with the standards. 

In April 2004, the President called for widespread adoption of 
interoperable electronic health records by 2014.[Footnote 12] The 
executive order established the Office of the National Coordinator for 
Health Information Technology within the Department of Health and Human 
Services (HHS). This office has been tasked to, among other things, 
develop, maintain, and direct the implementation of a strategic plan to 
guide the nationwide implementation of interoperable health IT in both 
the public and private health care sectors. Under the direction of HHS 
(through the Office of the National Coordinator), three primary 
organizations were designated to play major roles in expanding the 
implementation of health IT: 

* The American Health Information Community was created by the 
Secretary of HHS as a federal advisory body to make recommendations on 
how to accelerate the development and adoption of health IT, including 
advancing interoperability, identifying health IT standards, advancing 
a nationwide health information exchange, and protecting personal 
health information. Formed in September 2005, the community is made up 
of representatives from both the public and private sectors, including 
high-level DOD and VA officials. The community determines specific 
health care areas of high priority and develops "use cases"[Footnote 
13] for these areas, which provide the context in which standards would 
be applicable. The use cases convey how health care professionals would 
use such records and what standards would apply. 

* The Healthcare Information Technology Standards Panel, sponsored by 
the American National Standards Institute[Footnote 14] and funded by 
the Office of the National Coordinator, was established in October 2005 
as a public-private partnership to identify competing standards for the 
use cases being developed by the American Health Information Community 
and to "harmonize"[Footnote 15] the standards. The panel also develops 
the interoperability specifications that are needed for implementing 
the standards. Interoperability specifications were developed for each 
of the seven use cases developed by the American Health Information 
Community in 2006 and 2007.[Footnote 16] The community also developed 
six use cases for 2008.[Footnote 17] The Healthcare Information 
Technology Standards Panel is made up of representatives from both the 
public and private sectors, including DOD and VA officials who serve as 
members and are actively working on several committees and groups 
within the panel. 

* The Certification Commission for Healthcare Information Technology is 
an independent, nonprofit organization that creates certification 
criteria to determine whether health IT systems meet standards accepted 
or recognized by the Secretary of HHS, and then certifies systems that 
meet those criteria. HHS entered into a contract with the commission in 
October 2005 to develop and evaluate the certification criteria and 
inspection process for electronic health records. Certification helps 
assure purchasers and other users of health IT systems that the systems 
will provide needed capabilities (including ensuring security and 
confidentiality) and will work with other systems without 
reprogramming. Certification also encourages adoption of health IT by 
assuring providers that their systems can participate in a nationwide 
health information exchange in the future. 

DOD and VA Have Been Pursuing Efforts to Exchange Health Information 
for Over a Decade: 

DOD and VA have been working to exchange patient health data 
electronically since 1998. As we have previously noted,[Footnote 18] 
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. 
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 19] 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 the following 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--for example, veterans may 
receive outpatient care from VA clinicians and be hospitalized at a 
military treatment facility).[Footnote 20] 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 Armed Forces Health Longitudinal Technology 
Application (AHLTA)[Footnote 21] 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 22], 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. 

GAO's Recent Report Highlighted DOD's and VA's Efforts to Share Health 
Information and Identified the Need to Set Up the Program Office and 
Finalize the Implementation Plan: 

In reporting on the departments' progress toward developing fully 
interoperable electronic health records in July 2008,[Footnote 23] we 
highlighted several findings: 

* DOD and VA had established and implemented mechanisms to achieve 
sharing of electronic health information at different levels of 
interoperability. As of June 2008, pharmacy and drug allergy data on 
about 18,300 shared patients were being exchanged at the highest level 
of interoperability--that is, in computable form, a standardized format 
that a computer application can act on (for example, to provide alerts 
to clinicians of drug allergies). Viewable data also were being shared 
including, among other types, outpatient pharmacy data, allergy 
information, procedures, problem lists, vital signs, microbiology 
results, cytology reports, and chemistry and hematology reports. 
However, the departments were not sharing all electronic health data, 
including for example, immunization records and history, data on 
exposure to health hazards, and psychological health treatment and care 
records. Finally, although VA's health information was all captured 
electronically, not all health data collected by DOD were electronic-- 
many DOD medical facilities used paper-based health records. 

* DOD and VA were participating in a number of initiatives led by the 
Office of the National Coordinator for Health Information Technology 
(within HHS), aimed at promoting the adoption of federal standards and 
broader use of electronic health records. The involvement of the 
departments in these initiatives was an important mechanism for 
aligning their electronic health records with emerging standards. The 
departments also had jointly published a common (agreed to) set of 
interoperability standards called the Target DOD/VA Health Standards 
Profile. Updated annually, the profile was used for reviewing joint 
DOD/VA initiatives to ensure standards compliance. The departments 
anticipate such updates and revisions to the profile as additional 
federal standards emerge and are recognized and accepted by HHS. In 
addition, according to DOD officials, the department was taking steps 
to ensure that its modernized health information system, AHLTA, was 
compliant with standards by arranging for certification through the 
Certification Commission for Healthcare Information Technology. 
Specifically, version 3.3 of AHLTA was conditionally certified in April 
2007 against 2006 outpatient electronic health record criteria 
established by the commission. DOD officials stated that AHLTA version 
3.3 was installed at three DOD locations.[Footnote 24] 

* The departments' efforts to set up the DOD/VA Interagency Program 
Office were still in their early stages. Leadership positions in the 
office had not been permanently filled, staffing was not complete, and 
facilities to house the office had not been designated. According to 
the Acting Director, DOD and VA had begun developing a charter for the 
office, but had not yet completed the document. Further, the 
implementation plan was in draft, and although it included schedules, 
milestones for several activities were not determined (such as 
implementing a capability to share immunization records), even though 
all capabilities were to be achieved by September 2009. We pointed out 
that without a fully established program office and a finalized 
implementation plan with set milestones, the departments might be 
challenged in meeting the September 2009 date for achieving 
interoperable electronic health records and capabilities. As a result, 
we recommended that the Secretaries of Defense and Veterans Affairs 
give priority to fully establishing the interagency program office and 
finalizing the draft implementation plan. Both DOD and VA agreed with 
these recommendations. 

DOD and VA Report Continued Progress toward Increased Interoperability; 
however, Plans Lack Results-Oriented Performance Goals and Measures: 

Since our July 2008 report and September 2008 testimony, DOD and VA 
have continued to make progress toward increased interoperability 
through ongoing initiatives and activities documented in their plans 
related to increasing information sharing efforts. Also, the 
departments recently expanded the number of standards and 
specifications with which they expect their interoperability 
initiatives will comply. However, the departments' plans lack results- 
oriented (i.e., objective, quantifiable, and measurable) performance 
goals and measures that are characteristic of effective planning. As a 
result, the extent to which the departments' progress can be assessed 
and reported in terms of results achieved is largely limited to 
reporting on activities completed and increases in interoperability 
over time. Consequently, it is unclear what health information sharing 
capabilities will be delivered by September 2009. 

With regard to their ongoing initiatives, DOD and VA reported increases 
in data exchanged between the departments for their long-term 
initiative (CHDR) and their short-term initiative (BHIE). For example, 
between June and October 2008, the departments increased the number of 
shared patients for which computable outpatient pharmacy and drug 
allergy data were being exchanged through the CHDR initiative by about 
2,700 (from about 18,300 to over 21,000). For the BHIE initiative, the 
departments continued to expand their information exchange by sharing 
viewable patient vital signs information in June 2008, and demonstrated 
the capability to exchange family history, social history, other 
history, and questionnaires data in September 2008. 

Since we last reported,[Footnote 25] DOD and VA also have made progress 
toward adopting additional 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 
use cases in the updated September 2008 Target Standards Profile. 
Specifically, the profile now includes Electronic Health Records 
Laboratory Results Reporting, Biosurveillance, and Consumer Empowerment 
use cases. According to DOD and VA officials, the adoption of 
recognized standards is a goal of both departments in order to comply 
with the provisions set forth in the National Defense Authorization Act 
for Fiscal Year 2008. In addition, DOD has reported progress toward 
certification of its health IT system in adhering to applicable 
standards. Department officials stated that AHLTA version 3.3 is now 
fully operational and certified at five DOD locations,[Footnote 26] 
having met certification criteria, including specific functionality, 
interoperability, and security requirements. According to DOD 
officials, this version of AHLTA is expected to be installed at the 
remaining locations by September 30, 2009. 

DOD and VA have also reported progress relative to two plans that 
contain objectives, initiatives, and activities related to further 
increasing health information sharing. Specifically, the departments 
have identified 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) as defining their efforts to 
provide interoperable health records. The Joint Strategic Plan 
identified 39 activities related to information sharing that the 
departments planned to complete by September 30, 2008. The Information 
Interoperability Plan describes six objectives to be met by September 
30, 2009. 

The departments reported that the 39 information sharing activities 
identified in the Joint Strategic Plan were completed on or ahead of 
schedule. For example, the departments completed a report on the 
analysis of alternatives and recommendations for the development of the 
joint inpatient electronic health record,[Footnote 27] and briefed the 
recommendations to the Health Executive Council and the Joint Executive 
Council.[Footnote 28] However, only 3 of the 39 activities in the Joint 
Strategic Plan were described in results-oriented (i.e., objective, 
quantifiable, and measurable) terms that are characteristic of 
effective planning and can be used as a basis to track and measure 
progress toward the delivery of new interoperable capabilities. For 
example, among these three, one of the activities called for the 
departments to share viewable vital signs data in real-time and 
bidirectional for shared patients among all sites by June 30, 2008. In 
contrast, 36 activities lacked results-oriented performance measures, 
limiting the extent to which progress can be reported in terms of 
results achieved. For example, one activity calls for the development 
of a plan for interagency sharing of essential health images, but does 
not provide details on measurable achievement of additional 
interoperable capabilities. Another activity calls for the review of 
national health IT standards, but does not provide a tangible 
deliverable to determine progress in achieving the goal. 

According to department officials, DOD and VA have activities underway 
to address the six interoperability objectives included in the 
Information Interoperability Plan. Among these objectives, one calls 
for DOD to deploy its inpatient solution at additional medical sites to 
expand sharing of inpatient discharge summaries. Department officials 
indicated that, as of December 2008, DOD is sharing patient discharge 
summaries at 50 percent of inpatient beds compared to their goal of 70 
percent by September 30, 2009. However, this is the only one of six 
objectives in the Information Interoperability Plan with an associated 
results-oriented performance measure. None of the remaining five 
objectives are documented in terms that could allow the departments to 
measure and report their progress toward delivering new capabilities. 
Specifically, the objective for scanning medical documents calls for 
providing an initial capability. However, "initial capability" is not 
defined in quantifiable terms. As such, this objective cannot be used 
as a basis to effectively measure results-oriented performance. 

According to DOD and VA officials, their plans are relatively new and 
represent their initial efforts to articulate interoperability goals. 
However, while the departments' plans identify interoperable 
capabilities to be implemented, the plans do not establish the results- 
oriented (i.e., objective, quantifiable, and measurable) goals and 
associated performance measures that are a necessary basis for 
effective management. Without establishing plans that include results- 
oriented goals, then reporting progress using measures relative to the 
plans, the departments and their stakeholders do not have the 
comprehensive information that they need to effectively manage their 
progress toward achieving increased interoperability. 

Steps Have Been Taken to Set Up the DOD/VA Interagency Program Office, 
but It Is Not Positioned to Function as a Single Point of 
Accountability: 

The National Defense Authorization Act for Fiscal Year 2008 called for 
the establishment of an interagency program office and for the office 
to be accountable for implementing electronic health record systems or 
capabilities that allow for full interoperability of personal health 
care information between DOD and VA. Since we last reported, the 
departments have continued taking steps to set up the program office, 
although they have not yet fully executed their plan for doing so. As a 
result, the office is not yet in a position to be accountable for 
accelerating the departments' efforts to achieve interoperability by 
the September 30, 2009 deadline. 

To address the requirements set forth in the Act, the departments 
identified in the September 2008 DOD/VA Information Interoperability 
Plan a schedule for standing up the interagency program office. 
Consistent with the plan, the departments have taken steps, such as 
developing descriptions for key positions, including those of the 
Director and Deputy Director. Further, the departments have begun to 
hire personnel for program staff positions. Specifically, out of 30 
total program office positions, they have hired staff for 2 of 14 
government positions, 6 of 16 contractor positions, and have actions 
underway to fill the remaining 22 positions. Also, since we reported in 
July 2008, the departments developed the program office organization 
structure document that depicts the program office's organization. 
Further, in December 2008, DOD issued a Delegation of Authority 
Memorandum, signed by the Deputy Secretary of Defense that formally 
recognizes the program office. In January 2009, the departments 
approved a program office charter to describe, among other things, the 
mission and function of the office. 

Nonetheless, even with the actions taken, four of eight selected key 
activities that the departments identified in their plan to set up the 
program office remain incomplete, including filling the remaining 22 
positions, in addition to those of the Director and Deputy Director (as 
shown in table 1). 

Table 1: Status of Selected Key Activities to Establish the DOD/VA 
Interagency Program Office, as of January 2009: 

Interagency program office activities: Appoint interim Acting Director 
and Acting Deputy Director; 
Due date: April 2008; 
Status: Complete. 

Interagency program office activities: Provide interim detailed staff, 
temporary space, and equipment; 
Due date: May 2008; 
Status: Complete. 

Interagency program office activities: Develop and approve the program 
office organization structure document to include mission, function, 
manpower, internal governance, accountability, and authority; 
Due date: June 2008; 
Status: Complete. 

Interagency program office activities: Develop and approve program 
office charter or interagency agreement; 
Due date: July 2008; 
Status: Complete. 

Interagency program office activities: Complete resource management 
plan to include budget, space, equipment, and human resources; 
Due date: July 2008; 
Status: Not yet complete. 

Interagency program office activities: Complete personnel position 
descriptions and rating schemes; 
Due date: August 2008; 
Status: Not yet complete. 

Interagency program office activities: Appoint permanent Director and 
Deputy Director; 
Due date: October 2008; 
Status: Not yet complete. 

Interagency program office activities: Advertise and recruit program 
staff; 
Due date: October 2008; 
Status: Not yet complete. 

Source: GAO analysis of DOD and VA data. 

[End of table] 

DOD and VA officials stated that the reason the departments have not 
completed the execution of their plan to fully set up an interagency 
program office is the longer than anticipated time needed to obtain 
approval from multiple DOD and VA offices for key program office 
documentation (for example, the delegation of authority memorandum and 
charter). They stated that this was because the departments' leadership 
broadened the program office's scope to include the sharing of 
personnel and benefits data in addition to health information. 

Our July 2008 report recommended that the departments give priority to 
establishing the program office by establishing permanent leadership 
and hiring staff.[Footnote 29] Without completion of these and other 
key activities to set up the program office, the office is not yet 
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 
DOD and VA without a clearly established approach for ensuring that 
their actions will achieve the desired purpose of the Act. 

Conclusions: 

In the more than 10 years since DOD and VA began collaborating to 
electronically share health information, the two departments have 
increased interoperability. Nevertheless, while the departments 
continue to make progress, the manner in which they report progress--by 
reporting increases in interoperability over time--has limitations. 
These limitations are rooted in the departments' plans, which identify 
interoperable capabilities to be implemented, but lack the results- 
oriented (i.e., objective, quantifiable, and measurable) goals and 
associated performance measures that are a necessary basis for 
effective management. Without establishing results-oriented goals, then 
reporting progress using measures relative to the established goals, 
the departments and their stakeholders do not have the comprehensive 
picture that they need to effectively manage their progress toward 
achieving increased interoperability. Further constraining the 
departments' management effectiveness is their slow pace in addressing 
our July 2008 recommendation related to setting up the interagency 
program office that Congress called for to function as a single point 
of accountability in the development and implementation of electronic 
health record capabilities. 

Recommendations for Executive Action: 

To better ensure that DOD and VA achieve interoperable electronic 
health record systems or capabilities, we recommend that the 
Secretaries of Defense and Veterans Affairs take the following two 
actions: 

* Develop results-oriented (i.e., objective, quantifiable, and 
measurable) goals and associated performance measures for the 
departments' interoperability objectives and document these goals and 
measures in their interoperability plans. 

* Use results-oriented performance goals and measures as the basis for 
future assessments and reporting of interoperability progress. 

Agency Comments and Our Evaluation: 

In providing written comments on a draft of this report in a January 
22, 2009 letter, the Assistant Secretary of Defense for Health Affairs 
concurred with our recommendations. In a January 17, 2009 letter, the 
Secretary of Veterans Affairs also concurred with our recommendations. 
(The departments' comments are reproduced in app. II and app. III, 
respectively.) DOD and VA stated that high priority will be given to 
the establishment and use of results-oriented (i.e., objective, 
quantifiable, and measurable) goals and associated performance measures 
for the departments' interoperability objectives. If the 
recommendations are properly implemented, they should better position 
DOD and VA to effectively measure and report progress in achieving full 
interoperability. The departments also provided technical comments on 
the draft report, which we incorporated as appropriate. 

We are sending copies of this report to the Secretaries of Defense and 
Veterans Affairs, appropriate congressional committees, and other 
interested parties. In addition, the report is available at no charge 
on the GAO Web site at [hyperlink, http://www.gao.gov]. 

If you or your staffs have questions about this report, please contact 
me at (202) 512-6304 or melvinv@gao.gov. Contact points for our Offices 
of Congressional Relations and Public Affairs may be found on the last 
page of this report. Key contributors to this report are listed in 
appendix II. 

Signed by: 

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

List of Congressional Committees: 

The Honorable Carl Levin: 
Chairman: 
The Honorable John McCain: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Daniel K. Akaka: 
Chairman: 
The Honorable Richard M. Burr: 
Ranking Member: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Daniel K. Inouye: 
Chairman: 
The Honorable Thad Cochran: 
Ranking Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
United States Senate: 

The Honorable Tim Johnson: 
Chairman: 
The Honorable Kay Bailey Hutchison: 
Ranking Member: 
Subcommittee on Military Construction, Veterans' Affairs, and Related 
Agencies: 
Committee on Appropriations: 
United States Senate: 

The Honorable Ike Skelton: 
Chairman: 
The Honorable John M. McHugh: 
Ranking Member: 
Committee on Armed Services: 
United States House of Representatives: 

The Honorable Bob Filner: 
Chairman: 
The Honorable Steve Buyer: 
Ranking Member: 
Committee on Veterans' Affairs: 
United States House of Representatives: 

The Honorable John P. Murtha: 
Chairman: 
The Honorable C.W. Bill Young: 
Ranking Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
United States House of Representatives: 

The Honorable Chet Edwards: 
Chairman: 
The Honorable Zach Wamp: 
Ranking Member: 
Subcommittee on Military Construction, Veterans' Affairs, and Related 
Agencies: 
Committee on Appropriations: 
United States House of Representatives: 

[End of section] 

Appendix I: Scope and Methodology: 

To evaluate the Department of Defense's (DOD) and the Department of 
Veterans Affairs' (VA) progress toward developing electronic health 
record systems or capabilities that allow for full interoperability of 
personal health care information, we reviewed our previous work on DOD 
and VA efforts to develop health information systems, interoperable 
health records, and interoperability standards to be implemented in 
federal health care programs. To describe the departments' efforts to 
ensure that their health records comply with applicable 
interoperability standards, we analyzed information gathered from DOD 
and VA documentation and interviews pertaining to the interoperability 
standards that the two departments have agreed to for exchanging health 
information via their health care information systems. We reviewed 
documentation and interviewed agency officials from the Department of 
Health and Human Services' Office of the National Coordinator for 
Health Information Technology to obtain information regarding the 
defined federal interoperability standards, implementation 
specifications, and certification criteria. Further, we interviewed 
responsible officials to obtain information regarding the steps taken 
by the departments to certify their electronic health record products. 

To evaluate DOD and VA plans toward developing electronic health record 
systems or capabilities, we obtained information from agency 
documentation and interviews with cognizant DOD and VA officials 
pertaining to the November 2007 VA/DOD Joint Executive Council 
Strategic Plan for Fiscal Years 2008-2010, and the September 2008 DOD/ 
VA Information Interoperability Plan (Version 1.0) which together 
constitute the departments' overall plans for achieving full 
interoperability of electronic health information. Additionally, we 
reviewed information gathered from agency documentation to identify 
interoperability objectives, milestones, and target dates. Further, we 
analyzed objectives and activities from their plans to determine if DOD 
and VA had established results-oriented performance measures that 
enable the departments to assess progress toward achieving increased 
sharing capabilities and functionality of their electronic health 
information systems. 

To determine whether the interagency program office is fully 
operational and positioned to function as a single point of 
accountability for developing and implementing electronic health 
records, we analyzed DOD and VA documentation, including the schedule 
for setting up the office identified in the DOD/VA Information 
Interoperability Plan. Additionally, we interviewed responsible 
officials to determine the departments' progress to date in setting up 
the interagency program office. Further, we reviewed documentation and 
interviewed DOD and VA officials to determine the extent to which the 
departments have positioned the office to function as a single point of 
accountability for developing electronic health records. 

We conducted this performance audit at DOD sites and also the 
Department of Heath and Human Services' Office of the National 
Coordinator for Health Information Technology in the greater 
Washington, D.C., metropolitan area from August 2008 through January 
2009 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. 

[End of section] 

Appendix II: Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 
Health Affairs: 
1200 Defense Pentagon: 
Washington, DC 20301-1200: 

The Honorable Valerie C. Melvin: 
Director, Human Capital and Management Information Systems Issues: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

January 22, 2009: 

Dear Ms. Melvin: 

The enclosed Department of Defense (DoD) response addresses 
recommendations from the Government Accountability Office (GAO) Draft 
Report, GAO-09-268, "Electronic Health Records: DoD's and VA's Sharing 
of Information Could Benefit from Improved Management," dated January 
8, 2009 (GAO Code 310928). 

The Department acknowledges receipt of the draft audit report and 
concurs with the overall findings and recommendations. We have provided 
several suggested technical corrections in the enclosed document. ' 

Thank you for the opportunity to review and comment on the draft 
report. My points of contact for additional information are Ms. Lois 
Kellett, Lois.Kellett@tma.osd.mil or (703) 681-9530, and Mr. Gunther 
Zimmerman, Gunther.Zimmmerman@tma.osd.mil or (703) 681-4360. 

Sincerely, 

Signed by: 

S. Ward Casscells, MD: 

Enclosures: As stated: 

Government Accountability Office (GAO) Draft Report-Dated January 8, 
2009: 
GAO 09-268 (GAO Code 310928): 

"Electronic Health Records: DOD'S And VA'S Sharing Of Information Could 
Benefit From Improved Management" 

Department Of Defense Comments To GAO Recommendations: 

Recommendation 1: GAO recommended that the Secretary of Defense and 
Veterans Affairs develop results-oriented (i.e., objective, 
quantifiable, and measurable) goals and associated performance measures 
for the departments' interoperability objectives and document these 
goals and measures in their interoperability plans. 

DoD Response: Concur. Department of Defense (DoD) will give high 
priority to the establishment of results-oriented (i.e., objective, 
quantifiable, and measurable) goals and associated performance measures 
for the departments' interoperability objectives and document these 
goals and measures in interoperability plans. 

Recommendation 2: The GAO recommended that the Secretary of Defense and 
Veteran Affairs use results-oriented performance goals and measures as 
the basis for future assessments and reporting of interoperability 
progress. 

DoD Response: Concur. DoD will give high priority to the use of results-
oriented performance goals and measures as the basis for future 
assessments and reporting of interoperability progress. 

[End of section] 

Appendix III: Comments from the Department of Veterans Affairs: 

The Secretary Of Veterans Affairs: 
Washington: 

January 17, 2009: 
Ms. Valerie C. Melvin: 
Director: 
Human Capital and Management Information Systems Issues: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Melvin: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, Electronic Health Records: 
DOD's and VA's Sharing of Information Could Benefit from Improved 
Management (GAO-09-268). We agree with your findings and concur with 
your recommendations. 

GAO's observations have been very beneficial to us and will form the 
basis of discussion and action. The enclosure provides our response to 
your recommendations and technical comments suggested to provide 
clarification for the overall report's accuracy. 

Sincerely yours, 

Signed by: 
James B. Peake, M.D. 

Enclosure: 

Department of Veterans Affairs: 
Comments to Government Accountability Office (GAO) Draft Report: 
Electronic Health Records: DOD's and VA's Sharing of Information Could 
Benefit from Improved Management (GAO-09-268): 

GAO Recommendations: 

To better ensure that DOD and VA achieve interoperable electronic 
health record systems or capabilities, GAO recommends that the 
Secretaries of Defense and Veterans Affairs take the following actions: 

Recommendation 1: Develop results-oriented (i.e., objective, 
quantifiable, and measurable) goals and associated performance measures 
for the Departments' interoperability objectives and document these 
goals and measures in their interoperability plans. 

Response: Concur. VA and DoD will give high priority to the 
establishment of results-oriented (i.e., objective, quantifiable, and 
measurable) goals and associated performance measures for the 
Departments' interoperability objectives and document these goals and 
measures in interoperability plans. 

Recommendation 2: Use results-oriented performance goals and measures 
as the basis for future assessments and reporting of interoperability 
progress. 

Response: Concur. VA and DoD will give high priority to the use of 
results-oriented performance goals and measures as the basis for future 
assessments and reporting of interoperability progress. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

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

Staff Acknowledgments: 

In addition to the contact named above, key contributions to this 
report were made by Mark Bird, Assistant Director; Neil Doherty; 
Rebecca LaPaze; J. Michael Resser; Kelly Shaw; and Eric Trout. 

[End of section] 

Related GAO Products: 

Information Technology: DOD and VA Have Increased Their Sharing of 
Health Information, but Further Actions Are Needed. [hyperlink, 
http://www.gao.gov/products/GAO-08-1158T]. Washington, D.C.: September 
24, 2008. 

Electronic Health Records: 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. 

VA and DOD Health Care: Progress Made on Implementation of 2003 
President's Task Force Recommendations on Collaboration and 
Coordination, but More Remains to Be Done. [hyperlink, 
http://www.gao.gov/products/GAO-08-495R]. Washington, D.C.: April 30, 
2008. 

Health Information Technology: HHS Is Pursuing Efforts to Advance 
Nationwide Implementation, but Has Not Yet Completed a National 
Strategy. [hyperlink, http://www.gao.gov/products/GAO-08-499T]. 
Washington, D.C.: February 14, 2008. 

Information Technology: VA and DOD Continue to Expand Sharing of 
Medical Information, but Still Lack Comprehensive Electronic Medical 
Records. [hyperlink, http://www.gao.gov/products/GAO-08-207T]. 
Washington, D.C.: October 24, 2007. 

Veterans Affairs: Progress Made in Centralizing Information Technology 
Management, but Challenges Persist. [hyperlink, 
http://www.gao.gov/products/GAO-07-1246T]. Washington, D.C.: September 
19, 2007. 

Information Technology: VA and DOD Are Making Progress in Sharing 
Medical Information, but Remain Far from Having Comprehensive 
Electronic Medical Records. [hyperlink, 
http://www.gao.gov/products/GAO-07-1108T]. Washington, D.C.: July 18, 
2007. 

Health Information Technology: Efforts Continue but Comprehensive 
Privacy Approach Needed for National Strategy. [hyperlink, 
http://www.gao.gov/products/GAO-07-988T]. Washington, D.C.: June 19, 
2007. 

Information Technology: VA and DOD Are Making Progress in Sharing 
Medical Information, but Are Far from Comprehensive Electronic Medical 
Records. [hyperlink, http://www.gao.gov/products/GAO-07-852T]. 
Washington, D.C.: May 8, 2007. 

DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for 
Some Shared Patients, but Additional Steps Could Facilitate Exchanging 
These Data for All Shared Patients. [hyperlink, 
http://www.gao.gov/products/GAO-07-554R]. Washington, D.C.: April 30, 
2007. 

Health Information Technology: Early Efforts Initiated but 
Comprehensive Privacy Approach Needed for National Strategy. 
[hyperlink, http://www.gao.gov/products/GAO-07-400T]. Washington, D.C.: 
February 1, 2007. 

Health Information Technology: Early Efforts Initiated, but 
Comprehensive Privacy Approach Needed for National Strategy. 
[hyperlink, http://www.gao.gov/products/GAO-07-238]. Washington, D.C.: 
January 10, 2007. 

Health Information Technology: HHS is Continuing Efforts to Define Its 
National Strategy. [hyperlink, 
http://www.gao.gov/products/GAO-06-1071T]. Washington, D.C.: September 
1, 2006. 

Information Technology: VA and DOD Face Challenges in Completing Key 
Efforts. [hyperlink, http://www.gao.gov/products/GAO-06-905T]. 
Washington, D.C.: June 22, 2006. 

Health Information Technology: HHS Is Continuing Efforts to Define a 
National Strategy. [hyperlink, 
http://www.gao.gov/products/GAO-06-346T]. Washington, D.C.: March 15, 
2006. 

Computer-Based Patient Records: VA and DOD Made Progress, but Much Work 
Remains to Fully Share Medical Information. [hyperlink, 
http://www.gao.gov/products/GAO-05-1051T]. Washington, D.C.: September 
28, 2005. 

Health Information Technology: HHS Is Taking Steps to Develop a 
National Strategy. [hyperlink, http://www.gao.gov/products/GAO-05-628]. 
Washington, D.C.: May 27, 2005. 

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. 

Computer-Based Patient Records: Improved Planning and Project 
Management Are Critical to Achieving Two-Way VA-DOD Health Data 
Exchange. [hyperlink, http://www.gao.gov/products/GAO-04-811T]. 
Washington, D.C.: May 19, 2004. 

Computer-Based Patient Records: Sound Planning and Project Management 
Are Needed to Achieve a Two-Way Exchange of VA and DOD Health Data. 
[hyperlink, http://www.gao.gov/products/GAO-04-402T]. Washington, D.C.: 
March 17, 2004. 

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. [hyperlink, http://www.gao.gov/products/GAO-04-271T]. 
Washington, D.C.: November 19, 2003. 

VA Information Technology: Management Making Important Progress in 
Addressing Key Challenges. [hyperlink, 
http://www.gao.gov/products/GAO-02-1054T]. Washington, D.C.: September 
26, 2002. 

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. 

VA Information Technology: Progress Made, but Continued Management 
Attention Is Key to Achieving Results. [hyperlink, 
http://www.gao.gov/products/GAO-02-369T]. Washington, D.C.: March 13, 
2002. 

VA and Defense Health Care: Military Medical Surveillance Policies in 
Place, but Implementation Challenges Remain. [hyperlink, 
http://www.gao.gov/products/GAO-02-478T]. Washington, D.C.: February 
27, 2002. 

VA and Defense Health Care: Progress Made, but DOD Continues to Face 
Military Medical Surveillance System Challenges. [hyperlink, 
http://www.gao.gov/products/GAO-02-377T]. Washington, D.C.: January 24, 
2002. 

VA and Defense Health Care: Progress and Challenges DOD Faces in 
Executing a Military Medical Surveillance System. [hyperlink, 
http://www.gao.gov/products/GAO-02-173T]. Washington, D.C.: October 16, 
2001. 

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.: April 30, 
2001. 

[End of section] 

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 August 1998 issued a directive requiring VA and DOD to 
develop a "computer-based patient record system that will accurately 
and efficiently exchange information." 

[2] The commission recommended that DOD and VA work toward a "fully 
interoperable information system that will meet the long-term 
administrative and clinical needs of all military personnel over time." 

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

[4] 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 report. 

[5] See GAO, Electronic Health Records: 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). In this report, we highlighted the departments' progress in 
sharing electronic health information, developing electronic records 
that comply with national standards, and setting up the interagency 
program office. 

[6] See GAO, Information Technology: DOD and VA Have Increased Their 
Sharing of Health Information, but Further Actions Are Needed, 
[hyperlink, http://www.gao.gov/products/GAO-08-1158T] (Washington, 
D.C.: Sept. 24, 2008). In this testimony, we noted that DOD and VA have 
increased their sharing of health information, but still face 
significant work to plan and implement new capabilities that could 
further increase electronic health information sharing between the 
departments and to determine the desired level of data 
interoperability. 

[7] See Related GAO Products at the end of this report for previous GAO 
reports and testimonies on DOD/VA health information sharing and 
national health information technology issues. 

[8] In our July 2008 report, we noted that the departments were 
exchanging pharmacy and drug allergy data on more than 18,300 shared 
patients as of June 2008. 

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

[10] 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. 

[11] 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 
DOD and VA, the different levels of interoperability have been accepted 
for use by the Office of the National Coordinator for Health 
Information Technology. 

[12] 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). 

[13] 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, such as standards harmonization, 
architecture specification, certification consideration, and detailed 
policy discussions to advance the national health IT agenda. 

[14] The American National Standards Institute is a private, nonprofit 
organization whose mission is to promote and facilitate voluntary 
consensus standards and ensure their integrity. 

[15] Harmonization is the process of identifying overlaps and gaps in 
relevant standards and developing recommendations to address these 
overlaps and gaps. 

[16] The seven use cases are Emergency Responder; Consumer Empowerment; 
Medication Management; Quality; Registration and Medication History; 
Laboratory Results Reporting; and Visit, Utilization, and Lab Result 
Data. 

[17] The six use cases are Remote Monitoring, Patient-Provider Secure 
Messaging, Personalized Healthcare, Consultation and Transfers of Care, 
Public Health Case Reporting, and Immunizations and Response 
Management. 

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

[19] According to DOD, CHCS applications are now accessed through its 
modernized health information system, Armed Forces Health Longitudinal 
Technology Application (AHLTA). The department no longer considers 
AHLTA as an acronym but as the official name of the system. 

[20] 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. 

[21] AHLTA was formerly known as CHCS II. 

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

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

[24] These sites are the Naval Medical Center in Portsmouth, Va.; 
Eisenhower Army Medical Center in Fort Gordon, Ga.; and Goodfellow Air 
Force Base in San Angelo, Tex. 

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

[26] These locations are the Naval Medical Center in Portsmouth, Va.; 
Goodfellow Air Force Base in San Angelo, Tex; U.S. Naval Hospital, 
Naples, Italy; Wright Patterson Air Force Base in Dayton, Ohio; and 
U.S. Army Installation Management Command at Fort Huachuca, Ariz. 

[27] A contractor, tasked to study the issue, recommended that the 
departments should invest in a common services strategy for jointly 
developing an inpatient solution. Common services are administrative 
computer services, such as messaging and security, on which application 
software can call as needed. Such services are used in service-oriented 
architectures, in which application software locates, selects, and uses 
separately provided software services that it needs to perform its 
intended function. 

[28] The Joint Executive Council is comprised of the Deputy Secretary 
of Veterans Affairs; the Under Secretary of Defense for Personnel and 
Readiness; and the cochairs of joint councils on health, benefits, and 
capital planning. The council meets on a quarterly basis to recommend 
strategic direction of joint coordination and sharing efforts. The VA/ 
DOD Health Executive Council is comprised of senior leaders from VA and 
DOD, who work to institutionalize sharing and collaboration of health 
services and resources. The council is cochaired by the VA Under 
Secretary for Health and DOD Assistant Secretary of Defense for Health 
Affairs, and meets on a bimonthly basis. 

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

[End of section] 

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