Recommendation: The Commissioner of CBP should develop and implement additional guidance for ensuring funds appropriated for specific purposes are obligated consistent with the purpose of the funds. (Recommendation 1)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. In July 2020, CBP's Office of Finance issued new guidance on how to execute the remaining funds CBP received in the 2019 Emergency Supplemental. In September 2020, the CBP Budget Directorate's Program Analysis Division also updated its standard operating procedures to describe how it will review samples of purchase requests for supplemental funds. To fully implement our recommendation, CBP should develop and implement guidance for ensuring all funds appropriated for specific purposes, including future appropriations CBP may receive, are obligated consistent with the purpose of the funds.

Recommendation: The Commissioner of CBP should establish and document oversight roles and responsibilities to ensure funds appropriated for specific purposes are obligated consistent with the purpose of the funds. (Recommendation 2)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. In September 2020, the CBP Budget Directorate's Program Analysis Division updated its standard operating procedures to describe how it will review samples of purchase requests for supplemental funds. To fully implement our recommendation, CBP should establish and document oversight roles and responsibilities to ensure all funds appropriated for specific purposes, including regular appropriations, are obligated consistent with the purpose of the funds.

Recommendation: The Commissioner of CBP should develop and implement oversight mechanisms for CBP's implementation of policies and procedures relating to medical care for individuals in its custody to include documentation of expected practices, metrics and corresponding performance targets, and roles and responsibilities for taking corrective action. (Recommendation 3)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should document what information it is using to assess whether to offer the influenza vaccine to individuals in custody, including how it weighs costs and benefits. (Recommendation 4)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should develop and implement training on recognizing medical distress in children for all CBP officers and Border Patrol agents who may come into contact with children in custody. (Recommendation 5)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should provide additional guidance to field personnel to ensure they classify significant incident reports on deaths, serious injuries, and suicide attempts, in accordance with CBP policy. (Recommendation 7)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should update the Significant Incident Reporting System to include categories that align with CBP's directive on the reporting of significant incidents. (Recommendation 8)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should provide additional guidance to components on the procedures for reporting deaths in custody to OPR and other entities within CBP. (Recommendation 9)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should ensure that timely, reliable information on deaths in custody is reported to Congress, as directed, and maintain documentation on those reports. (Recommendation 10)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: For implementation of the EHR system at future VA medical facilities, we recommend that the Secretary of VA direct the EHRM Executive Director to clarify terminology and include adequate detail in descriptions of local workshop sessions to facilitate the participation of all relevant stakeholders including medical facility clinicians and staff. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of VA should direct the Under Secretary for Health and the Assistant Secretary for Information and Technology/Chief Information Officer to develop and implement a methodology for reliably identifying and reporting the total costs of VistA. The methodology should include steps to identify the definition of VistA and what is to be included in its sustainment activities, as well as ensure that comprehensive costs are corroborated by reliable data. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs (VA) generally agreed with our conclusions and concurred with our recommendation. In a January 2020 update, the department described steps it planned to take to address the recommendation including establishing a team of experts to formulate a comprehensive taxonomy for VistA and all of its components, identifying authoritative and reliable data sources to assign costs to those components, and developing a methodology for ongoing cost tracking and reporting. The department expects these steps to be implemented by September 30, 2020. We will continue to monitor the department's progress to address this recommendation.

Recommendation: The Secretary of Veterans Affairs should ensure that the role and responsibilities of the Interagency Program Office are clearly defined within the governance plans for acquisition of the department's new electronic health record system. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation to ensure that the role and responsibilities of the Interagency Program Office (IPO) were clearly defined within the governance plans for acquisition of the department's new electronic health record system. As of December 2019, VA and the Department of Defense (DOD) have replaced the IPO with a new joint governance body. Specifically, the Federal Electronic Health Record Modernization (FEHRM) program office has been established to serve as the single point of accountability in the delivery of a common health record between the departments and the advancement of interoperability with the private sector. In its charter, the FEHRM was described as a single decision-making authority to manage issues in support of the departments' integrated electronic health record objectives and its leadership is responsible for, among other things, working to formulate, oversee, de-conflict, and ensure adherence to electronic health record-related VA and DOD policies. However, the corresponding Implementation Plan that is intended to document how the FEHRM executes its full responsibilities has yet to be issued. To fully implement this recommendation, VA needs to document the role and responsibilities of the FEHRM with respect to VA's acquisition of its new electronic health record system, explaining the role, if any, the FEHRM will have in the governance process. We will continue to monitor the departments' incorporation of the FEHRM into the plans for the ongoing acquisition.

Recommendation: To help ensure that its efforts to increase patients' electronic access to health information are successful, the Secretary of HHS should direct ONC to use the information these performance measures provide to make program adjustments, as appropriate. Such actions may include, for example, assessing the status of program operations or identifying areas that need improvement in order to help achieve program goals related to increasing patients' ability to access their health information electronically.

Agency: Department of Health and Human Services
Status: Open

Comments: As of May 2019, ONC is collecting and evaluating information from national surveys, program data, and third-party data sources. As ONC works to implement its evaluations, it should identify how evidence collected from national surveys, program data and third-party data sources has been used to assess the outcomes of key efforts and adjust programs accordingly.

Recommendation: To improve efforts to promote EHR use and electronic exchange of health information in post-acute care settings, the Secretary of Health and Human Services should direct CMS and ONC to comprehensively plan for how to achieve the department's goal related to the use of EHRs and electronic information exchange in post-acute care settings. This planning may include, for example, identifying specific actions related to post-acute care settings and identifying and considering external factors.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with this recommendation. As of February 2020, HHS provided information describing actions it has taken to help increase the use of EHRs and electronic information exchange in post-acute care settings. These actions are important, but do not address the comprehensive planning that GAO recommended. To fully implement this recommendation, HHS should provide information to show comprehensive planning for how HHS's specific actions are expected to lead to achieving the goal of increasing the use of EHRs and electronic information exchange in post-acute settings.

Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should establish performance measures for the Office of Civil Rights (OCR) audit program.

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services (HHS) concurred with the recommendation but has not yet provided sufficient evidence that it had implemented the recommendation. In particular, as of August 2020, the HHS Office for Civil Rights (OCR) has not yet reviewed the feasibility of performance measures as part of its audit program, and plans to do so only after implementing a future redesign of its audit program. We will continue to monitor HHS actions in response to this recommendation.

Recommendation: To ensure that CMS and ONC can effectively monitor the effect of the EHR programs and progress made toward goals, the Secretary of Health and Human Services should direct the agencies to develop performance measures to assess outcomes of the EHR programs--including any effects on health care quality, efficiency, and patient safety and other health care reform efforts that are intended to work toward similar outcomes.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS neither agreed nor disagreed with our recommendation. In July 2015, CMS noted that the agency is working to align the programs to better enable monitoring using outcome-oriented performance measures and noted that the agency is collecting data that will help them to develop such measures. CMS did not indicate when HHS plans to develop such measures as GAO recommended. In June 2016, CMS also noted that it analyzed the results of the EHR programs as of October 2015, but did not indicate that it used performance measures that assess outcomes. In September 2017, HHS officials provided us a variety of publically available reports, which they indicated show how program participants are progressing in the EHR programs and the related impacts. In 2018, CMS changed the name of these programs to the Promoting Interoperability programs to focus on improving interoperability and patients' access to health information, and officials noted that the agency is working to develop related outcome-based measures. To fully implement this recommendation, CMS needs to develop performance measures that enable the agency to assess whether the Promoting Interoperability programs are improving outcomes, such as health care quality, efficiency, and patient safety, as we recommended.

Recommendation: To ensure that CMS and ONC can effectively monitor the effect of the EHR programs and progress made toward goals, the Secretary of Health and Human Services should direct the agencies to use the information these performance measures provide to make program adjustments, as appropriate, to better achieve program goals.

Agency: Department of Health and Human Services
Status: Open

Comments: In written responses provided by HHS in February 2014, on a draft of the report, the agency indicated that it agrees that outcome-oriented performance measures will be useful to evaluating the extent that the EHR programs--enacted through legislation--achieve the expected results. However, HHS did not identify any specific actions that it might undertake to address our recommendation. In July 2015, CMS indicated that the agency is still working to develop additional performance measures, which is a necessary first step towards implementing our recommendation to HHS that CMS and ONC use the outcome-oriented performance measures to make program adjustments, as appropriate. In September 2017 and March 2018, HHS officials provided us documents, which they indicated show how information gathered through monitoring activities was used to inform the EHR programs. In November 2018, HHS officials noted that CMS is actively working to use data submitted for the Promoting Interoperability Programs to improve upon the outcomes of patients, and also indicated (as noted above) that CMS is collaborating with stakeholders to develop outcome-based measures for the Promoting Interoperability Programs. To fully implement this recommendation, CMS needs to develop outcome-oriented performance measures and then demonstrate it is using them to make appropriate program adjustments. We will update the status of this recommendation when we receive additional information.