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Report to Congressional Committees: 

United States Government Accountability Office: 
GAO: 

January 2010: 

Electronic Health Records: 

DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs 
to Implement Recommended Improvements: 

GAO-10-332: 

GAO Highlights: 

Highlights of GAO-10-332, a report to congressional committees. 

Why GAO Did This Study: 

The National Defense Authorization Act for Fiscal Year 2008 required 
the Department of Defense (DOD) and the Department of Veterans Affairs 
(VA) to accelerate their exchange of health information and to develop 
capabilities that allow for interoperability (generally, the ability 
of systems to exchange data) by September 30, 2009. It also required 
compliance with federal standards and the establishment of a joint 
interagency program office to function as a single point of 
accountability for the effort. 

Further, the act directed GAO to semiannually report on the progress 
made in achieving these requirements. For this fourth report, GAO 
determined the extent to which (1) DOD and VA developed and 
implemented electronic health record systems or capabilities that 
allowed for full interoperability by September 30, 2009, and (2) the 
interagency program office established by the act is functioning as a 
single point of accountability. To do so, GAO analyzed agency 
documentation on project status and conducted interviews with agency 
officials. 

What GAO Found: 

DOD and VA previously established six objectives that they identified 
as necessary for achieving full interoperability; they have now met 
the remaining three interoperability objectives that GAO previously 
reported as being partially achieved—expand questionnaires and self-
assessment tools, expand DOD’s inpatient medical records system, and 
demonstrate initial document scanning. As a result of meeting the six 
objectives, the departments’ officials, including the co-chairs of the 
group responsible for representing the clinician user community, 
believe they have satisfied the September 30, 2009, requirement for 
full interoperability. Nevertheless, DOD and VA are planning 
additional actions to further increase their interoperable 
capabilities and address clinicians’ evolving needs for interoperable 
electronic health records. Specifically, 

* DOD and VA plan to meet additional needs that have emerged with 
respect to social history and physical exam data; 

* DOD plans to further expand the implementation of its inpatient 
medical records system to sites beyond those achieved as of September 
2009; and; 

* DOD and VA plan to test the capability to scan documents, in follow-
up to their demonstration of an initial document scanning capability. 

Additionally, in response to a Presidential announcement, the 
departments are beginning to plan for the development and 
implementation of a virtual lifetime electronic record, which is 
intended to further increase their interoperable capabilities. 

The interagency program office is not yet positioned to function as a 
single point of accountability for the implementation of interoperable 
electronic health record systems or capabilities. The departments have 
made progress in setting up their interagency program office by hiring 
additional staff, including a permanent director. In addition, 
consistent with GAO’s previous recommendations, the office has begun 
to demonstrate responsibilities outlined in its charter in the areas 
of scheduling, planning, and performance measurement. However, the 
office’s effort in these areas does not fully satisfy the 
recommendations and are incomplete. Specifically, the office does not 
yet have a schedule that includes information about tasks, resource 
needs, or relationships between tasks associated with ongoing 
activities to increase interoperability. Also, key IT management 
responsibilities in the areas of planning and performance measurement 
remain incomplete. Among the reasons officials cited for not yet 
completing a schedule, plan, or performance measures were the office’s 
need to focus on verifying achievement of the six interoperability 
objectives and participating in the departments’ efforts to define the 
virtual lifetime electronic record. Nonetheless, if the program office 
does not fulfill key management responsibilities as GAO previously 
recommended, it may not be positioned to function as a single point of 
accountability for the delivery of future interoperable capabilities, 
including the development of the virtual lifetime electronic record. 

What GAO Recommends: 

GAO is not making further recommendations at this time; DOD and VA 
need to implement the recommendations on program planning, scheduling, 
and performance measurement that GAO previously made. Commenting on a 
draft of this report, DOD, VA, and the interagency program office 
concurred with GAO’s findings. 

View [hyperlink, http://www.gao.gov/products/GAO-10-332] or key 
components. For more information, contact Joel Willemssen at (202) 512-
6253 or willemssenj@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Although DOD and VA Have Met Their Six Interoperability Objectives, 
Additional Work Remains to Meet Clinicians' Evolving Needs: 

DOD/VA Interagency Program Office Has Made Progress toward Filling 
Positions, but Has Not Fully Implemented Recommended Management 
Improvements: 

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: Comments from the DOD/VA Interagency Program Office: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Table: 

Table 1: Description of DOD and VA Interoperability Objectives: 

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: 

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: 

VLER: Virtual Lifetime Electronic Record: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

January 28, 2010: 

Congressional Committees: 

The Department of Defense (DOD) and the Department of Veterans Affairs 
(VA) have long-standing efforts to increase sharing of data between 
their health information systems. However, while the departments have 
progressively increased electronic health information sharing, 
questions have been raised about when and to what extent the 
departments intend such sharing capabilities to be fully achieved. To 
expedite the exchange of electronic health information between the two 
departments, the National Defense Authorization Act for Fiscal Year 
2008[Footnote 1] included provisions directing DOD and VA to jointly 
develop and implement, by September 30, 2009, fully interoperable 
[Footnote 2] electronic health record systems or capabilities that are 
compliant with applicable federal interoperability standards. Such 
systems and capabilities are important for making patient information 
more readily available to health care providers in the departments, 
reducing medical errors, and streamlining administrative functions. In 
addition, the act established an interagency program office to be a 
single point of accountability for the departments' efforts. 

Further, the act directed us to assess DOD's and VA's progress in 
implementing the electronic health record systems and to semiannually 
report our results to the appropriate congressional committees. 
Accordingly, we issued reports in July 2008,[Footnote 3] January 2009, 
[Footnote 4] and July 2009[Footnote 5] in response to the act. As 
agreed with the committees of jurisdiction, our objectives for this 
fourth report are to determine the extent to which (1) DOD and VA 
developed and implemented electronic health record systems or 
capabilities that allowed for full interoperability by the September 
30, 2009, deadline and (2) the interagency program office established 
by the National Defense Authorization Act for Fiscal Year 2008 is 
functioning as a single point of accountability for developing and 
implementing electronic health records. 

To accomplish these objectives, we reviewed our past work in this 
area; analyzed current agency documentation (including the 
departments' objectives for achieving interoperability, project status 
information, and the interagency program office charter); and 
conducted interviews with officials from DOD and VA. 

We conducted this performance audit from September 2009 through 
January 2010, 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. 

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 6] 

Interoperability--the ability to share data among health care 
providers--is key to making health care information electronically 
available. 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. Unlike paper-based health records, 
electronic health records can provide decision support capabilities, 
such as automatic alerts about a particular patient's health, or other 
advantages of automation. 

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. DOD and VA have agreed upon numerous common standards 
that allow them to share health data. They have also participated in 
numerous standards-setting organizations tasked to reach consensus on 
the definition and use of standards. For example, DOD and VA officials 
serve as members and are actively working on several committees and 
groups within the Healthcare Information Technology Standards 
Panel.[Footnote 7] The panel identifies and harmonizes[Footnote 8] 
competing standards and develops interoperability specifications that 
are needed for implementing the standards.[Footnote 9] 

Interoperability can be achieved at different levels.[Footnote 10] 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 search through 
uncategorized data to find needed or relevant information. 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. According to DOD and VA 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. 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] 

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] 

DOD and VA Efforts to Exchange Health Information Are Long-standing: 

DOD and VA have been working to exchange patient health information 
electronically since 1998. We have previously described their efforts 
on three key projects:[Footnote 11] 

* The Federal Health Information Exchange (FHIE), begun in 2001 and 
enhanced through its completion 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), established in 
2004, was aimed at allowing clinicians at both departments viewable 
access to health information 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 12] The interface also allows DOD sites 
to see previously inaccessible data at other DOD sites. 

* The Clinical Data Repository/Health Data Repository (CHDR) [Footnote 
13] interface, implemented in September 2006, linked the department's 
separate repositories of standardized data to enable a two-way 
exchange of computable outpatient pharmacy and medication allergy 
information. These repositories are a part of the modernized health 
information systems that the departments have been developing--DOD's 
AHLTA[Footnote 14] and VA's HealtheVet. 

In its ongoing initiatives to share information, VA uses its 
integrated medical information system--the Veterans Health Information 
Systems and Technology Architecture (VistA)--which was developed in-
house by VA clinicians and IT personnel.[Footnote 15] All VA medical 
facilities have access to all VistA information. 

DOD currently relies on its AHLTA, which comprises multiple legacy 
medical information systems that the department developed from 
commercial software products that were 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 order management.[Footnote 
16] In addition, the department uses Essentris (also called the 
Clinical Information System), a commercial health information system 
customized to support inpatient treatment at military medical 
facilities. Not all of DOD's medical facilities yet have this 
inpatient medical system. 

DOD and VA Identified Interoperability Objectives and Formed an 
Interagency Program Office: 

As previously noted, the National Defense Authorization Act for Fiscal 
Year 2008 called for DOD and VA to jointly develop and implement, by 
September 30, 2009, electronic health record systems or capabilities 
that allow for full interoperability of personal health care 
information that are compliant with applicable federal 
interoperability standards. To facilitate compliance with the act, the 
departments' Interagency Clinical Informatics Board,[Footnote 17] made 
up of senior clinical leaders who represent the user community, began 
establishing priorities for interoperable health data between DOD and 
VA. In this regard, the board is responsible for determining clinical 
priorities for electronic data sharing between the departments, as 
well as what data should be viewable and what data should be 
computable. Based on its work, the board established six 
interoperability objectives for meeting the departments' data sharing 
needs. According to the former acting director of the interagency 
program office, DOD and VA considered achievement of these six 
objectives, in conjunction with capabilities previously achieved 
(e.g., FHIE, BHIE, and CHDR), to be sufficient to satisfy the 
requirement for full interoperability by September 2009. The six 
objectives are listed in table 1. 

Table 1: Description of DOD and VA Interoperability Objectives: 

Objective: Refine social history data; 
Description: DOD will begin sharing with VA the social history data 
that are currently captured in the DOD electronic health record. Such 
data describe, for example, patients' involvement in hazardous 
activities and tobacco and alcohol use; 
Associated interoperability level: Level 3: Structured, viewable 
electronic data. 

Objective: Share physical exam data; 
Description: DOD will provide an initial capability to share with VA 
its electronic health record information that supports the physical 
exam process when a service member separates from active military duty; 
Associated interoperability level: Level 3: Structured, viewable 
electronic data. 

Objective: Demonstrate initial network gateway operation; 
Description: DOD and VA will demonstrate the operation of the secure 
network gateways[A] to support joint DOD-VA health information sharing; 
Associated interoperability level: There is no interoperability level 
associated with this objective. 

Objective: Expand questionnaires and self-assessment tools; 
Description: DOD will provide all periodic health assessment data 
stored in its electronic health record to VA such that questionnaire 
responses are viewable with the questions that elicited them; 
Associated interoperability level: Level 3: Structured, viewable 
electronic data. 

Objective: Expand Essentris in DOD; 
Description: DOD will expand its inpatient medical records system 
(CliniComp's Essentris product suite) to at least one additional site 
in each military medical department (one Army, one Air Force, and one 
Navy for a total of three sites); 
Associated interoperability level: Level 2: Unstructured, viewable 
electronic data. 

Objective: Demonstrate initial document scanning; 
Description: DOD will demonstrate an initial capability for scanning 
service members' medical documents into its electronic health record 
and sharing the documents electronically with VA; 
Associated interoperability level: Level 2: Unstructured, viewable 
electronic data. 

Source: GAO based on DOD and VA data. 

[A] Secure network gateways provide expanded bandwidth to support 
information sharing and ensure secure and reliable data communications 
between DOD and VA health care facilities. 

[End of table] 

Also since April 2008, the departments have been working to set up an 
interagency program office to be accountable for their efforts to 
implement fully interoperable electronic health record systems or 
capabilities by the September deadline. In January 2009, the office 
completed its charter, articulating, among other things, its mission 
and functions with respect to attaining interoperable electronic 
health data. The charter further identified the office's 
responsibilities in carrying out its mission, in areas such as 
oversight and management, stakeholder communication, and decision 
making. Among the specific responsibilities identified in the charter 
was the development of a plan, schedule, and performance measures to 
guide the departments' electronic health record interoperability 
efforts. 

Subsequent to an April 2009 Presidential announcement, the departments 
approved a new version of the interagency program office's charter in 
September to expand the office's responsibilities to include 
coordination and oversight of the development of a Virtual Lifetime 
Electronic Record (VLER).[Footnote 18] Still in the planning stages, 
VLER is intended to enable access to all electronic records for 
service members as they transition from military to veteran status, 
and throughout their lives. According to the Director of the DOD/VA 
Interagency Program Office, VLER is to expand the departments' 
existing electronic health record capabilities by enabling access to 
private sector health data as well. The revised charter describes that 
the office is responsible for developing and maintaining a master 
plan, integrated master schedule, and performance metrics for the VLER 
initiative. 

GAO Reports Have Identified the Need for DOD and VA to Improve Their 
Efforts to Share Health Information: 

Our prior reports on DOD's and VA's efforts to develop fully 
interoperable electronic health record systems or capabilities noted 
their progress and highlighted issues that the departments needed to 
address to achieve electronic health record interoperability. 
Specifically, our July 2008 report[Footnote 19] noted that the 
departments were sharing some, but not all, electronic health 
information at different levels of interoperability. At that time the 
departments' efforts to set up the interagency program office were in 
the early stages. Leadership positions in the office were not 
permanently filled, staffing was not complete, and facilities to house 
the office had not been designated. Accordingly, we recommended that 
the Secretaries of Defense and Veterans Affairs expedite efforts to 
put in place permanent leadership, staff, and facilities for the 
program office. The departments agreed with this recommendation and 
have taken actions to address it. 

Our January 2009 report[Footnote 20] noted that the departments had 
defined plans to further increase their sharing of electronic health 
information; however, the plans did not contain results-oriented 
(i.e., objective, quantifiable, and measurable) performance goals and 
measures that could be used as a basis to track and assess progress. 
We recommended the departments develop and document such goals and 
performance measures for the six interoperability objectives, to use 
as the basis for future assessments and reporting of interoperability 
progress. DOD and VA agreed with our recommendation and stated that 
the departments intended to include results-oriented goals in their 
future plans. 

We also reported and testified in July 2009[Footnote 21] that the 
departments were continuing to take steps toward achieving full 
interoperability by the September 2009 deadline. Specifically, we 
noted that they had identified six interoperability objectives and had 
fulfilled three of the six. For the remaining three objectives, DOD 
and VA had partially achieved planned capabilities but additional work 
was needed to meet the objectives. Moreover, our report and testimony 
also noted that the departments' interagency program office was not 
effectively positioned to function as a single point of accountability 
for achievement of full interoperability because it did not yet have 
fundamental IT management capabilities and was not fulfilling key 
responsibilities, including establishment of performance measures, a 
project plan, or a detailed schedule. As a result, we recommended that 
the departments improve management of their interoperability efforts 
by establishing a project plan and a complete and detailed integrated 
master schedule. 

Although DOD and VA Have Met Their Six Interoperability Objectives, 
Additional Work Remains to Meet Clinicians' Evolving Needs: 

DOD and VA have achieved planned capabilities for the three remaining 
objectives (expand questionnaires and self-assessment tools, expand 
Essentris in DOD, and demonstrate initial document scanning). Having 
now met all six of their interoperability objectives, the departments' 
officials, including the co-chairs of the group responsible for 
representing the clinician user community, believe they have satisfied 
the September 30, 2009, requirement for developing and implementing 
systems or capabilities that allow for full interoperability. 
Nevertheless, the departments are planning additional actions to 
further increase their interoperable capabilities, recognizing that 
clinicians' needs for interoperable electronic health records are 
evolving. 

The following describes the departments' activities with respect to 
the three remaining objectives. 

Expand questionnaires and self-assessment tools: The departments 
intended to provide all periodic health assessment data stored in the 
DOD electronic health record to VA in a format that associates 
questions with responses. Health assessment data are collected from 
two sources: questionnaires administered at military treatment 
facilities and a DOD health assessment reporting tool that enables 
patients to answer questions about their health. Questions relate to a 
wide range of personal health information, such as dietary habits, 
physical exercise, and tobacco and alcohol use. While the departments 
had established the capability for VA to view questions and answers 
from the questionnaires collected by DOD at military treatment 
facilities, they had not yet achieved the capability for VA to view 
information from the second source--DOD's health assessment reporting 
tool. Since our last review, the departments have established this 
capability and have therefore met their objective. 

Expand Essentris in DOD: DOD intended to expand Essentris to at least 
one additional site for each military service and to increase the 
percentage of inpatient discharge summaries that it shares 
electronically with VA. While the departments had previously expanded 
the system to two Army sites, they had not yet expanded to the 
remaining two military departments (Air Force and Navy). Since we last 
reported, the departments have met this objective by successfully 
deploying Essentris to an additional Air Force and Navy site. In 
addition, the departments expanded the system to two more Army sites 
and are sharing inpatient discharge summaries from 59 percent of DOD 
inpatient beds.[Footnote 22] 

Demonstrate initial document scanning: The departments intended to 
demonstrate an initial capability to scan service members' medical 
documents into the DOD electronic health record and share the 
documents electronically with VA. Since our last review, the 
departments have met this objective by successfully demonstrating the 
capability in a joint test environment. Specifically, DOD has 
demonstrated the capability to scan a medical document, associate the 
document with a test patient, and save the document into the patient's 
electronic health record; and VA demonstrated the capability to search 
and retrieve the scanned document associated with that patient. 

While the departments have met the remaining three objectives and 
believe they have met the September 30, 2009, deadline for achieving 
full interoperability as required by the act, they are planning 
additional work to further increase their interoperable capabilities. 
These actions reflect the departments' recognition that clinicians' 
needs for interoperable electronic health records are not static. 
Currently, the departments are focusing their efforts to meet 
clinicians' evolving needs for interoperable capabilities in the 
following areas. 

Clinicians have identified additional needs with respect to social 
history and physical exam data that have emerged since existing 
capabilities were made available in those areas. To meet these needs, 
the departments are planning additional efforts to provide, for 
example, the capabilities to search, sort, and filter patient social 
history and physical exam data based on criteria such as date, 
location of care, and type of document. 

DOD plans to further expand the implementation of Essentris to sites 
beyond those achieved as of September 2009. In this regard, the 
department has established a goal of making the inpatient system 
operational for 90 percent of its inpatient beds by January 31, 2011. 

In December 2009, DOD began limited user testing of the document 
scanning capability that was demonstrated in September 2009. According 
to department officials, this testing entails use of test data by a 
limited number of users at nine sites and is expected to be completed 
in March 2010. After that, further testing of the document scanning 
capability using actual data is expected at sites and dates that are 
to be determined. 

Beyond these ongoing efforts to meet their clinicians' evolving 
interoperability needs, the departments have begun planning their 
efforts to define and build VLER. For example, in mid-December 2009, 
VA and a private health care provider in San Diego, California, began 
a pilot project to demonstrate that clinical information such as 
patient demographic, allergy, and active medication information can be 
securely sent and received. DOD plans to be added to this pilot on 
January 31, 2010. Further, the departments are working in cooperation 
with the interagency program office and the Interagency Clinical 
Informatics Board to define additional clinical information to be 
exchanged, additional functionality, and additional geographic areas 
of interest for future VLER deployment. 

DOD/VA Interagency Program Office Has Made Progress toward Filling 
Positions, but Has Not Fully Implemented Recommended Management 
Improvements: 

The interagency program office is not yet positioned to function as a 
single point of accountability for the implementation of interoperable 
electronic health record systems or capabilities. Since we last 
reported, the departments have made progress in setting up the office 
by hiring additional staff, including a permanent director. In 
addition, consistent with our prior recommendations, the office has 
begun to demonstrate responsibilities outlined in its charter in the 
areas of scheduling, planning, and performance measurement. However, 
the office's efforts to develop its capabilities in these areas are 
incomplete. 

Staffing of the Interagency Program Office Is Nearly Completed: 

Among the activities the departments identified in the September 2008 
DOD/VA Information Interoperability Plan as necessary for setting up 
the interagency program office were appointing a permanent director 
and deputy director, as well as recruiting and hiring staff. Since we 
last reported in July 2009,[Footnote 23] DOD appointed a permanent 
director to lead the office, effective October 27, 2009. Also, VA 
filled the permanent deputy director position, effective January 17, 
2010.[Footnote 24] 

According to the former acting deputy director, the departments have 
also filled 13 of 14 government staff positions, an increase of 3 
staff since our last report.[Footnote 25] Additionally, this official 
stated the departments have taken steps to fill the remaining senior 
health program analyst position. He reported that a selection had been 
made to fill this remaining position, but a date for when this 
position would be filled remained to be determined. 

Interagency Program Office Has Not Fully Established a Schedule, Plan, 
or Performance Measures: 

As previously noted, DOD, VA, and the interagency program office 
developed a new version of the office's charter in September 2009. 
Consistent with the office's original charter, the new version 
describes the office's responsibilities in carrying out its mission 
and function associated with attaining interoperable electronic data. 
For example, it identifies the office's responsibilities to develop an 
integrated master schedule, plan, and performance metrics to monitor 
the departments' performance against interoperability goals. Since we 
last reported, the office has taken steps toward developing, but has 
not yet fully established, these management tools. 

We previously recommended in July 2009 that the program office 
establish a complete and detailed master schedule to improve its 
management of the departments' efforts to achieve fully interoperable 
electronic health record systems.[Footnote 26] In response to our 
recommendation, the office has begun to develop an integrated master 
schedule that includes information about its ongoing interoperability 
activities, including VLER. For example, the schedule identifies the 
limited user testing of the document scanning capability that DOD 
plans between December 2009 and March 2010. However, the schedule does 
not include information about the tasks, resource needs, or 
relationships between tasks for the testing activity. The office's 
acting deputy director stated that the program office is currently 
working to improve the schedule by including task dependencies to help 
in identifying the critical path for the office's interoperability 
activities.[Footnote 27] 

Similarly, we recommended that the program office establish a project 
plan, which is an important tool for effective IT program management. 
The program office has concurred with the recommendation and has 
reported that it is developing a master program plan.[Footnote 28] In 
January 2010, department officials stated that this plan is undergoing 
review by the departments and is expected to be approved in February 
2010. 

In January 2009 we recommended that DOD and VA take action to complete 
results-oriented (i.e., objective, quantifiable, and measurable) goals 
and performance measures to be used as a basis for the office to 
provide meaningful information on the status of the departments' 
interoperability initiatives. In November 2009, program office 
officials stated that such goals and measures would be included in the 
next version of the VA/DOD Joint Executive Council Joint Strategic 
Plan (known as the joint strategic plan), which the office expects to 
be approved in February 2010.[Footnote 29] 

While the departments have agreed with our past recommendations and 
have indicated that they are working toward addressing them, officials 
stated that other priorities have prevented full implementation of our 
recommendations. Specifically, the office has been focused on 
verifying achievement of the six interoperability objectives. 
Moreover, according to the former interim director, the office was 
focused on providing briefings and status information on activities 
the office has undertaken to achieve interoperability, in addition to 
participating in the departments' efforts to define VLER. In addition, 
the office director told us that it has taken the departments longer 
than anticipated to provide the detailed information that is needed by 
the office to prepare a schedule for joint interagency data sharing 
goals. 

While the interagency program office is nearly fully staffed and has 
begun to establish important management tools, it has not yet 
completed an integrated schedule, project plan, and results-oriented 
goals and measures. As a result, the interagency program office's 
ability to effectively provide oversight and management, including 
meaningful progress reporting on the delivery of interoperable 
capabilities, is jeopardized. If the departments fully implement our 
recommendations, they will have the comprehensive picture that they 
need for effectively defining and managing progress toward meeting 
their interoperability objectives and goals, including VLER. 
Furthermore, implementation of our recommendations will also better 
position the office to function as a single point of accountability 
for the delivery of interoperable electronic health records, which are 
intended to improve service members' and veterans' health care. 

Agency Comments and Our Evaluation: 

In written comments on a draft of this report, the DOD official who is 
performing the duties of the Assistant Secretary of Defense (Health 
Affairs), the VA Chief of Staff, and the Director of the DOD/VA 
Interagency Program Office concurred with our findings. Beyond its 
concurrence with our findings, the VA Chief of Staff provided 
information regarding the department's efforts to address 
recommendations from our prior reports.[Footnote 30] For example, in 
response to our previous recommendation that the departments use 
results-oriented performance goals and measures as the basis for 
future assessments and reporting of interoperability progress, the 
Chief of Staff stated that the departments have prepared draft goals 
and measures for their joint strategic plan, which is to be finalized 
in February 2010. Additionally, in response to our prior 
recommendation that the departments establish a project plan and a 
compete and detailed integrated master schedule to improve management 
of their interoperability efforts, the Chief of Staff asserted that 
the interagency program office expects to have a draft project plan by 
the end of January 2010 and that VA meets monthly with DOD and the 
program office to coordinate input into an integrated master schedule. 
If the departments continue to implement our recommendations, they 
should be better positioned to effectively manage their ongoing 
efforts to increase their interoperable electronic health record 
capabilities. DOD and the interagency program office also provided 
technical comments on the draft report, which we incorporated as 
appropriate. Comments from the Departments of Defense and Veterans 
Affairs, and the DOD/VA Interagency Program Office are reproduced in 
appendixes II, III, and IV, respectively. 

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) 512-6253 or willemssenj@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 V. 

Signed by: 

Joel C. Willemssen: 
Managing Director, Information Technology: 

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 Howard P. "Buck" McKeon: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

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

[End of section] 

Appendix I: Scope and Methodology: 

To determine the extent to which the Department of Defense (DOD) and 
the Department of Veterans Affairs (VA) developed and implemented 
electronic health record systems or capabilities that allowed for full 
interoperability by the September 30, 2009, deadline, 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. We obtained and 
analyzed agency documentation and interviewed program officials to 
determine the departments' progress toward achieving full 
interoperability by September 30, 2009, as required by the National 
Defense Authorization Act for Fiscal Year 2008. Specifically, we 
compared the departments' interoperability plans, objectives, and 
requirements with the reported status of efforts to achieve full 
interoperability, corroborating officials' statements about progress 
through analyses of available documentation including test results and 
status reports. In addition, we analyzed agency plans and interviewed 
cognizant DOD and VA officials to determine the work required to meet 
additional clinician requirements and increase interoperability of 
electronic health information beyond September 30, 2009. 

To determine whether the interagency program office was functioning as 
a single point of accountability for developing and implementing 
electronic health records, we obtained and reviewed program office 
documentation, including its new charter and its integrated master 
schedule. We compared the responsibilities identified in the charter 
with actions taken by the office to exercise the responsibilities. 
Additionally, we interviewed interagency program office officials to 
determine the status of filling leadership and staffing positions 
within the office and to examine the level to which the departments 
have addressed our prior recommendations to develop needed management 
tools including results-oriented (i.e., objective, quantifiable, and 
measurable) goals and performance measures, a complete and detailed 
master schedule, and a project plan. 

We conducted this performance audit at DOD offices and the DOD/VA 
Interagency Program Office in the greater Washington, D.C., 
metropolitan area from September 2009 through January 2010, 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: 

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

January 22, 2010: 

Mr. Joel C. Willemssen: 
Managing Director, Information Technology: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Mr. Willemssen: 

This is the Department of Defense's (DoD) response to the Government 
Accountability Office (GAO) Draft Report, GAO-10-332, "Electronic 
Health Records: DoD and VA Interoperability Efforts Are Ongoing; 
Program Office Needs to Implement Recommended Improvement," January 
12, 2010, (Engagement Code 310945). 

DoD acknowledges receipt of the draft audit report and concurs with 
the overall findings. We have provided suggested technical corrections 
in the enclosed formal response. 

Thank you for the opportunity to review and comment on the draft 
report. The points of contact for additional information are Ms. Lois 
Kellett, Lois.Kellett@tma.osd.mil, or (703) 681-8836, and Mr Gunther 
Zimmerman, Gunther.Zimmerman@tma.osd.mil, or (703) 681-4360. 

Sincerely, 

Signed by: [Illegible], for: 
	
Ellen P. Embrey: 
Deputy Assistant Secretary of Defense (Force Health Protection and 
Readiness): 
Performing the Duties of the Assistant Secretary of Defense (Health 
Affairs): 

Attachments: As stated: 

[End of section] 

Appendix III: Comments from the Department of Veterans Affairs: 

The Secretary Of Veterans Affairs: 
Washington: 

January 22, 2010: 

Mr. Joel C. Willemssen: 
Managing Director, Information Technology: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Willemssen: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, Electronic Health Records: 
DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs 
to Implement Recommended Improvements (GAO-10-332), and concurs with 
GAO's findings. 

Enhancing health information sharing between VA and the Department of 
Defense (DoD) is a key step towards achieving seamless health care for 
our Nation's Veterans. The report accurately states that, even though 
VA and DoD have now met the six objectives necessary for achieving 
full interoperability, the Departments are planning further actions to 
increase interoperable capability. 

The enclosure provides a status update on recommendations from 
previous related reports: (1) Electronic Health Records: DoD and VA 
Sharing of Information Could Benefit from Improved Management (GA0-09-
268); and (2) Electronic Health Records: DoD and VA Efforts to Achieve 
Full Interoperability Are Ongoing; Program Office Management Needs 
Improvement (GAO-09-775). 

VA appreciates the opportunity to comment on your draft report. 

Sincerely, 

Signed by: 

John R. Gingrich: 
Chief of Staff: 

Enclosure: 

[End of letter] 

Enclosure: 

The Department of Veterans Affairs (VA) Comments to Government 
Accountability Office (GAO) Draft Report: 

Electronic Health Records: DOD and VA Interoperability Efforts Are
Ongoing; Program Office Needs to Implement Recommended Improvements
(GA0-10-332): 

Outstanding Recommendations from GAO Report, Electronic Health 
Records: DOD's and VA's Sharing of Information Could Benefit from 
Improved Management (GAO-09-268). 

GAO Recommendation: To better ensure that DOD and VA achieve 
interoperable electronic health record systems or capabilities, GAO 
recommends that the Secretaries of Defense and VA 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. 

VA Status Update January 2010: By agreement of VA and DOD, and as 
verified by the DoD and VA Interagency Program Office, the Departments 
successfully achieved the interoperability objectives contained in the 
fiscal year 2008 National Defense Authorization Act (NDAA). The NDAA 
required the Departments to implement systems allowing for full 
interoperability by September 2009. 

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

VA Status Update January 2010: VA and DoD have prepared draft results-
oriented goals and performance measures related to future 
interoperability objectives for the DoD and VA Joint Strategic Plan 
(JSP) for 2010-2012. The Departments anticipate that the JSP will be 
finalized and signed by departmental leadership in February 2010. 

Outstanding Recommendation from GAO Report, Electronic Health Records: 
DOD's and VA's Efforts to Achieve Full Interoperability Are Ongoing; 
Program Office Management Needs Improvement (GAO-09-775). 

Recommendation 1: To better improve management of VA's and DOD's 
efforts to achieve fully interoperable electronic health records 
systems, including satisfaction of the departments' interoperability 
objectives, GAO recommends that the Secretaries of Defense and VA 
direct the Director of the Interagency Program Office to establish a 
project plan and a complete and detailed integrated master schedule. 

VA Status Update January 2010: The Interagency Program Office (IPO) 
has developed an integrated master schedule and the Veterans Health 
Administration's Office of Health Information continues to work 
closely with VA's Office of Information Technology, the lead office, 
to continue to enhance the schedule. VA, DoD, and the !PO now meet at 
least once a month to coordinate interagency input. The IPO reports 
that it is on target to provide a draft project plan by the end of 
January 2010. 

[End of section] 

Appendix IV: Comments from the DOD/VA Interagency Program Office: 

Department of Defense: 
Department of Veterans Affairs: 

Mr. Joel C. Willemssen: 
Managing Director, Information Technology: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Willemssen: 

This is the DOD/VA Interagency Program Office's (IPO) response to the 
Government Accountability Office (GAO) Draft Report GAO-10-332, 
"Electronic Health Records: DOD and VA Interoperability Efforts Are 
Ongoing; Program Office Needs to Implement Recommended Improvements," 
January 12, 2010, (Engagement Code 310945). 

IPO acknowledges receipt of the draft audit report and concurs with 
the overall findings. We have provided suggested technical corrections 
in the enclosed formal response. 

Thanks you for the opportunity to review and comment on the draft 
report. The points of contact for additional information are Mr. Ryan 
Cool, Ryan.Cool@osd.mil or (703)696-3636, and Mr. Kevin Tewes, 
Kevin.Tewes@osd.mil or (703)696-2856. 

Sincerely, 

Signed by: 

Debra M. Filippi: 
Director: 
DID/VA Interagency Program Office: 

Attachments: As stated: 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Joel C. Willemssen, (202) 512-6253 or willemssenj@gao.gov: 

Staff Acknowledgments: 

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

[End of section] 

Footnotes: 

[1] Pub. L. No. 110-181, § 1635 (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. 

[3] 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. 

[4] See GAO, 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). In this report, we noted that DOD and VA have increased their 
sharing of health information, and defined plans to further increase 
their sharing of electronic health information. However, the plans did 
not identify results-oriented (i.e., objective, quantifiable, and 
measurable) performance goals and measures that are characteristic of 
effective planning. 

[5] See GAO, Electronic Health Records: DOD and VA Efforts to Achieve 
Full Interoperability Are Ongoing; Program Office Management Needs 
Improvement, [hyperlink, http://www.gao.gov/products/GAO-09-775] 
(Washington, D.C.: July 28, 2009). In this report, we found that DOD 
and VA had taken steps to meet six objectives that they identified for 
achieving full interoperability by September 30, 2009, but had 
additional work planned to fully meet the objectives. In addition, we 
noted that the DOD/VA Interagency Program Office was not effectively 
positioned to function as the single point of accountability for the 
implementation of fully interoperable electronic health records. 

[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] The panel was established in October 2005 as a public-private 
partnership funded by the Office of the National Coordinator. This 
panel is sponsored by the American National Standards Institute, which 
is a private, nonprofit organization whose mission is to promote and 
facilitate voluntary consensus standards and ensure their integrity. 

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

[9] Developing, coordinating, and agreeing on standards are only part 
of the processes involved in achieving interoperability for electronic 
health records 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. 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. 

[10] 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. 

[11] [hyperlink, http://www.gao.gov/products/GAO-09-775]. 

[12] 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. 

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

[14] 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. 

[15] 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. 

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

[17] This board was originally named the Joint Clinical Information 
Board. 

[18] On April 9, 2009, the President announced that DOD and VA will 
work together to define and build a Virtual Lifetime Electronic Record 
capability to streamline the transition of electronic records between 
the two departments. 

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

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

[21] GAO, Electronic Health Records: Program Office Improvements 
Needed to Strengthen Management of VA and DOD Efforts to Achieve Full 
Interoperability, GAO-09-895T (Washington, D.C.: July 14, 2009) and 
[hyperlink, http://www.gao.gov/products/GAO-09-775]. 

[22] The Army sites are Reynolds Army Community Hospital at Fort Sill, 
Okla.; Moncrief Army Community Hospital at Fort Jackson, S.C.; the 
United States Army Hospital in Seoul, Korea; and Fort Leonard Wood 
Army Community Hospital at Fort Leonard Wood, Mo. The Navy site is the 
Naval Hospital Bremerton in Bremerton, Wash. The Air Force site is the 
David Grant United States Air Force Medical Center at Travis Air Force 
Base, Calif. 

[23] [hyperlink, http://www.gao.gov/products/GAO-09-775]. 

[24] The director is a DOD employee and the deputy director is a VA 
employee. 

[25] The office staff include both government and contractor personnel. 

[26] [hyperlink, http://www.gao.gov/products/GAO-09-775]. 

[27] The critical path is the single longest path of activities 
through a project's schedule. Each day of delay in the critical path 
could delay the completion of the entire project. 

[28] The plan was originally considered a project plan in the previous 
charter, but the name was changed to a program plan, which according 
to the former interim director of the program office, represents a 
higher level of oversight that is required of the interagency program 
office. 

[29] In July, we reported that the office had expected to complete the 
joint strategic plan by December 2009, but in interviews with program 
office officials, we were told that the plan would not be released 
until February 2010 as part of the presidential budget submission. 

[30] [hyperlink, http://www.gao.gov/products/GAO-09-268] and 
[hyperlink, http://www.gao.gov/products/GAO-09-775]. 

[End of section] 

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