GAO 

United States Government Accountability Office

Report to Congressional Committees

ELECTRONIC 

HEALTH RECORDS 

DOD and VA 

Interoperability 

Efforts Are Ongoing; 

Program Office Needs 

to Implement 

Recommended 

Improvements 

January 2010 

GAO-10-332 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

January 2010

ELECTRONIC HEALTH RECORDS 

DOD and VA Interoperability Efforts Are Ongoing; 

Program Office Needs to Implement Recommended 

Highlights of GAO-10-332, a report to Improvements

congressional committees 

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 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. 

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. View GAO-10-332 or key components.

For more information, contact Joel 

Willemssen at (202) 512-6253 or 

willemssenj@gao.gov. 
Page i GAO-10-332 

Contents 

Letter 1

Background 2 

Although DOD and VA Have Met Their Six Interoperability 

Objectives, Additional Work Remains to Meet Clinicians’ 

Evolving Needs 10 

DOD/VA Interagency Program Office Has Made Progress toward 

Filling Positions, but Has Not Fully Implemented Recommended 

Management Improvements 13 

Agency Comments and Our Evaluation 16 

Appendix I Scope and Methodology 20 

Appendix II Comments from the Department of Defense 21 

Appendix III Comments from the Department of Veterans Affairs 22 

Appendix IV Comments from the DOD/VA Interagency 

Program Office 25 

Appendix V GAO Contact and Staff Acknowledgments 26 

Table 

Table 1: Description of DOD and VA Interoperability Objectives 8 

Figure 

Figure 1: Levels of Data Interoperability 5 

 Electronic Health Records 
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 

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Page ii GAO-10-332 Electronic Health Records
Page 1 GAO-10-332 

 

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 20081 included provisions 

directing DOD and VA to jointly develop and implement, by September 30, 

2009, fully interoperable2

 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 2008,3

 January 2009,4 and 

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, 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, 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. 

 Electronic Health Records 
 

July 20095 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. 

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 

Background 

 

5

See GAO, Electronic Health Records: DOD and VA Efforts to Achieve Full 

Interoperability Are Ongoing; Program Office Management Needs Improvement, 

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. 

Page 2 GAO-10-332 Electronic Health Records
 

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.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 standardssetting 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.7

 The panel identifies 

 

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. 

Page 3 GAO-10-332 Electronic Health Records
 

and harmonizes8 competing standards and develops interoperability 

specifications that are needed for implementing the standards.9

Interoperability can be achieved at different levels.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. 

 

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. 

10These 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. 

Page 4 GAO-10-332 Electronic Health Records
 

Figure 1: Levels of Data Interoperability 

Increasingly sophisticated 

and standardized data

Source: GAO analysis based on data from the Center for Information Technology Leadership. 

Level 4: Computable electronic data

(i.e., electronically entered data that can be 

computed by other systems)

Level 3: Structured, viewable electronic data

(i.e., electronically entered data that cannot

be computed by other systems)

Level 2: Unstructured, viewable electronic data

(i.e., scans of paper forms)

Level 1: Nonelectronic data

(i.e., paper forms)

00111101011011010101011010101010101010101010010111010100010101011111101010

1010010110101101001101010100110110101010101010110101010101111011010111010

DOD and VA Efforts to 

Exchange Health 

Information Are Longstanding 

DOD and VA have been working to exchange patient health information 

electronically since 1998. We have previously described their efforts on 

three key projects: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. 

 

11GAO-09-775. 

Page 5 GAO-10-332 Electronic Health Records
 

• 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.12 The interface also allows DOD sites to see previously 

inaccessible data at other DOD sites. 

• The Clinical Data Repository/Health Data Repository (CHDR) 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 AHLTA14 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.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 

12To 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. 

13The name CHDR, pronounced “cheddar,” combines the names of these two repositories. 

14The 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. 

15VistA 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. 

Page 6 GAO-10-332 Electronic Health Records
 

pharmacy, radiology, and laboratory order management.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,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. 

 

16According to DOD, CHCS applications are now accessed through its modernized health 

information system, AHLTA. 

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

Page 7 GAO-10-332 Electronic Health Records
 

Table 1: Description of DOD and VA Interoperability Objectives 

Objective Description Associated interoperability level 

Refine social history data 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. 

Level 3: Structured, viewable electronic data 

Share physical exam 

data 

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. 

Level 3: Structured, viewable electronic data 

Demonstrate initial 

network gateway 

operation 

DOD and VA will demonstrate the operation of the 

secure network gatewaysa

 to support joint DOD-VA 

health information sharing. 

There is no interoperability level associated 

with this objective. 

Expand questionnaires 

and self-assessment 

tools 

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. 

Level 3: Structured, viewable electronic data 

Expand Essentris in 

DOD 

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). 

Level 2: Unstructured, viewable electronic data 

Demonstrate initial 

document scanning 

DOD will demonstrate an initial capability for scanning 

service members’ medical documents into its electronic 

health record and sharing the documents electronically 

with VA. 

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. 

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. 

Page 8 GAO-10-332 Electronic Health Records
 

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).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 

report19 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 report20 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 

 

18On 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. 

19GAO-08-954. 

20GAO-09-268. 

Page 9 GAO-10-332 Electronic Health Records
 

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 200921 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. 

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. 

Although DOD and VA 

Have Met Their Six 

Interoperability 

Objectives, Additional 

Work Remains to 

Meet Clinicians’ 

Evolving Needs 

 

21GAO, 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 GAO-09-775. 

Page 10 GAO-10-332 Electronic Health Records
 

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.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, 

 

22The 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. 

Page 11 GAO-10-332 Electronic Health Records
 

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. 

Page 12 GAO-10-332 Electronic Health Records
 

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. 

DOD/VA Interagency 

Program Office Has 

Made Progress 

toward Filling 

Positions, but Has Not 

Fully Implemented 

Recommended 

Management 

Improvements 

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 2009,23 DOD appointed a permanent director to lead the 

office, effective October 27, 2009. Also, VA filled the permanent deputy 

director position, effective January 17, 2010.24

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.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. 

 

23GAO-09-775. 

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

25The office staff include both government and contractor personnel. 

Page 13 GAO-10-332 Electronic Health Records
 

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. 

Interagency Program 

Office Has Not Fully 

Established a Schedule, 

Plan, or Performance 

Measures 

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.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.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.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. 

 

26GAO-09-775. 

27The 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. 

28The 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. 

Page 14 GAO-10-332 Electronic Health Records
 

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 

2010.29

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. 

 

29In 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. 

Page 15 GAO-10-332 Electronic Health Records
 

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.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. 

Agency Comments 

and Our Evaluation 

 

30GAO-09-268 and GAO-09-775. 

Page 16 GAO-10-332 Electronic Health Records
 

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 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 

Joel C. Willemssen 

of this report. Key contributors to this report are listed in appendix V. 

Managing Director, Information Technology 

Page 17 GAO-10-332 Electronic Health Records
 

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 

Page 18 GAO-10-332 Electronic Health Records
 

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 

Page 19 GAO-10-332 Electronic Health Records
Appendix I: Scope and Methodology 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. 

Page 20 GAO-10-332 Electronic Health Records 
Appendix II: Comments from the Department Appendix II: Comments from the Department of Defense 

of Defense 

Page 21 GAO-10-332 Electronic Health Records
Appendix III: Comments from the Department Appendix III: Comments from the of Veterans Affairs 

Department of Veterans Affairs 

Page 22 GAO-10-332 Electronic Health Records
Appendix III: Comments from the Department 

of Veterans Affairs 

Page 23 GAO-10-332 Electronic Health Records
Appendix III: Comments from the Department 

of Veterans Affairs 

Page 24 GAO-10-332 Electronic Health Records
Appendix IV: Comments from the DOD/VA Appendix IV: Comments from the DOD/VA Interagency Program Office 

Interagency Program Office 

Page 25 GAO-10-332 Electronic Health Records 
Appendix V: GAO Contact and Staff Appendix V: GAO Contact and Staff Acknowledgments 

Acknowledgments 

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

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. 

Page 26 GAO-10-332 Electronic Health Records

GAO Contact 

Staff 

Acknowledgments 

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