Coast Guard Health Records:

Timely Acquisition of New System Is Critical to Overcoming Challenges with Paper Process

GAO-18-59: Published: Jan 24, 2018. Publicly Released: Jan 30, 2018.

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What GAO Found

Financial, technical, schedule, and personnel risks led to the United States Coast Guard's (Coast Guard) decision to terminate the Integrated Health Information System (IHiS) project in 2015. According to the Coast Guard (a military service within the Department of Homeland Security), as of August 2017, $59.9 million was spent on the project over nearly 7 years and no equipment or software could be reused for future efforts. In addition, the Coast Guard could not fully demonstrate the project management actions taken for IHiS, lacked governance mechanisms, and did not document lessons learned for the failed project.

As a result of the cancelation of the IHiS project and the decommissioning of the two legacy electronic health record (EHR) systems IHiS was to replace, the Coast Guard directed its clinics to revert to maintaining health records using a predominantly paper process. Coast Guard Regional Managers and clinic and sick bay administrators informed GAO of the many challenges encountered in returning to a paper process. These challenges include the inability for some clinics to adequately track vital information such as the medications members are taking—potentially causing harm to them.

Top Four Challenges Reported by Clinic and Sick Bay Administrators in Managing Paper Heath Records

Top Four Challenges Reported by Clinic and Sick Bay Administrators in Managing Paper Heath Records

To help alleviate several of these challenges, the Coast Guard has developed alternative work-around processes. However, these alternative processes may not provide sustained solutions to overcoming these challenges.

In February 2016, the Coast Guard initiated the process for acquiring a new EHR system. As of November 2017, agency officials had conducted research and recommended a solution based on performance, risk, cost, and schedule advantages. However, 2 years after canceling IHiS and moving toward a predominately manual process, the agency has not yet made a final determination on this. Successfully and quickly implementing an EHR system is vital to overcoming the challenges Coast Guard currently faces in managing paper health records. The expeditious implementation of such a system can significantly improve the quality and efficiency of care to the thousands of Coast Guard active duty and reserve members that receive health care.

Why GAO Did This Study

In 2010, the Coast Guard initiated an effort—known as IHiS—to replace its aging EHR system with a suite of modernized systems that was to automate various health care services for its nearly 50,000 military members. However, in October 2015, the Coast Guard announced that the modernization project would be canceled.

GAO was asked to review the Coast Guard's efforts to develop a modernized EHR system. GAO's objectives were to (1) describe what led the Coast Guard to terminate further IHiS development, and how much was spent on the project; (2) evaluate the Coast Guard's management and oversight for the discontinued project and what, if any, lessons learned were identified; (3) describe the Coast Guard's current process for managing health records and the challenges, if any, it is encountering; and (4) determine the Coast Guard's plans for effectively implementing a new EHR system and the current status of its efforts. To do so, GAO reviewed project expenditures, analyzed key project management documentation, surveyed Regional Managers and clinical staff, and interviewed knowledgeable staff.

What GAO Recommends

GAO is recommending the Coast Guard (1) expeditiously and judiciously pursue the acquisition of a new EHR system, and in doing so (2) ensure key processes are implemented, (3) establish project governance boards, and (4) document lessons learned. The Department of Homeland Security concurred with GAO's recommendations.

For more information, contact David A. Powner at (202) 512-9286 or pownerd@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Priority recommendation

    Comments: In April 2018, the Coast Guard stated that they continue to follow the Non-Major Acquisition Process (NMAP) and have designated the Electronic Health Records Acquisition (eHRa) as a non-major acquisition, governed by the Executive Oversight Council (EOC) on February 13, 2016. On February 6, 2018, the Coast Guard EOC approved eHRa to enter the Obtain phase. According to Coast Guard, the progress of its electronic health records program has been accelerated due to the increased involvement of, and support from Coast Guard, DHS, and Department of Defense senior leadership, and officials estimated that the new EHR system would be fully operational by the first quarter of fiscal year 2024. The agency reported in November 2018 that the acquisition remained in the Obtain phase. While increased involvement of senior leadership is a positive first step, until Coast Guard can demonstrate that they have more fully implemented the eHRa acquisition, this recommendation will remain open.

    Recommendation: The Commandant should direct the Chief Information Officer and the Chief Acquisition Officer to expeditiously and judiciously pursue the acquisition of a new EHR system. (Recommendation 1)

    Agency Affected: Department of Homeland Security: United States Coast Guard

  2. Status: Open

    Comments: On February 6, 2018, the Coast Guard Executive Oversight Council approved eHRa to enter the Obtain phase. The agency is providing periodic updates on the progress they are making to implement and document the requirements for the eHRa acquisition process. This recommendation will remain open until we can confirm that the required processes for the Obtain phase, as well as subsequent acquisition process phases, are fully implemented and documented.

    Recommendation: The Commandant should direct the Chief Information Officer and the Chief Acquisition Officer to ensure established processes required for the future acquisition or development of an EHR are effectively implemented and adequately documented. (Recommendation 2)

    Agency Affected: Department of Homeland Security: United States Coast Guard

  3. Status: Open

    Comments: In December 2017, the Coast Guard stated that the NMAP manual established governance boards for eHRA that include both the Chief Acquisition Officer and the Chief Information Officer (CIO) as members or representatives. The Coast Guard is in the process of providing additional documentation on the CIO's involvement in these governance boards. We will update the recommendation when our review of the additional documentation is complete.

    Recommendation: The Commandant should direct the Chief Information Officer and the Chief Acquisition Officer to establish and fully implement project governance boards for the future EHR effort that include the Chief Information Officer. (Recommendation 3)

    Agency Affected: Department of Homeland Security: United States Coast Guard

  4. Status: Closed - Implemented

    Comments: In April and October 2018, Coast Guard provided three lessons learned from the IHiS project, including that IT investments at Coast Guard need adequate program/project management and governance oversight. Officials shared these lessons learned with the new project management team and have taken steps to ensure they are utilized for the eHRa effort. For example, to help ensure that the eHRa project receives adequate management and governance oversight, Coast Guard has taken steps to provide the eHRa project manager with the appropriate project management certifications, and has established a data sharing agreement with the Department of Defense, among other things.

    Recommendation: The Commandant should direct the Chief Information Officer and the Chief Acquisition Officer to document any lessons learned from the discontinued IHiS project, share them with the new project management team, and ensure lessons learned are utilized for the future EHR effort. (Recommendation 4)

    Agency Affected: Department of Homeland Security: United States Coast Guard

 

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