United States Government Accountability Office

GAO Testimony

Before the Subcommittee on Oversight 

and Investigations, Committee on 

Veterans’ Affairs, House of 

Representatives

INFORMATION 

TECHNOLOGY 

For Release on Delivery 

Expected at 10:00 a.m. EDT 

Tuesday, May 8, 2007 

VA and DOD Are Making 

Progress in Sharing 

Medical Information, but 

Are Far from 

Comprehensive Electronic 

Medical Records 

 

Statement of Valerie C. Melvin, Director 

Human Capital and Management Information Systems 

Issues 

GAO-07-852T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 8, 2007

INFORMATION TECHNOLOGY 

VA and DOD Are Making Progress in 

Sharing Medical Information, but Are Far 

from Comprehensive Electronic Medical 

Records 

Highlights of GAO-07-852T, a report to 

Subcommittee on Oversight and 

Investigations, Committee on Veterans' 

Affairs, House of Representatives 

The Department of Veterans Affairs 

(VA) and the Department of

Defense (DOD) are engaged in 

ongoing efforts to share medical 

information, which is important in 

helping to ensure high-quality 

health care for active-duty military 

personnel and veterans. These 

efforts include a long-term program 

to develop modernized health 

information systems based on 

computable data: that is, data in a 

format that a computer application 

can act on—for example, to

provide alerts to clinicians of drug

allergies. In addition, the 

departments are engaged in nearterm initiatives involving existing

systems. 

GAO was asked to testify on the

history and current status of these 

long- and near-term efforts to share 

health information. 

To develop this testimony, GAO

reviewed its previous work,

analyzed documents, and 

interviewed VA and DOD officials 

about current status and future

plans. 

What GAO Recommends

GAO has previously made several 

recommendations on these topics, 

including that VA and DOD develop

a detailed project management plan

to guide their efforts to share 

patient health data. The

departments agreed with these 

recommendations. 

For almost a decade, VA and DOD have been pursuing ways to share health 

information and create comprehensive electronic medical records. However, 

they have faced considerable challenges in these efforts, leading to repeated 

changes in the focus of their initiatives and target dates. Currently, the two 

departments are pursuing both long- and short-term initiatives to share 

health information. Under their long-term initiative, the modern health 

information systems being developed by each department are to share 

standardized computable data through an interface between data

repositories associated with each system. The repositories have now been 

developed, and the departments have begun to populate them with limited 

types of health information. In addition, the interface between the 

repositories has been implemented at seven VA and DOD sites, allowing 

computable outpatient pharmacy and drug allergy data to be exchanged.

Implementing this interface is a milestone toward the departments’ longterm goal, but more remains to be done. Besides extending the current 

capability throughout VA and DOD, the departments must still agree to 

standards for the remaining categories of medical information, populate the 

data repositories with this information, complete the development of the two 

modernized health information systems, and transition from their existing 

systems. 

While pursuing their long-term effort to develop modernized systems, the 

two departments have also been working to share information in their 

existing systems. Among various near-term initiatives are a completed effort 

to allow the one-way transfer of health information from DOD to VA when 

service members leave the military, as well as ongoing demonstration 

projects to exchange limited data at selected sites. One of these projects, 

building on the one-way transfer capability, developed an interface between 

certain existing systems that allows a two-way view of current data on 

patients receiving care from both departments. VA and DOD are now 

working to link other systems via this interface and extend its capabilities. 

The departments have also established ad hoc processes to meet the 

immediate need to provide data on severely wounded service members to 

VA’s polytrauma centers, which specialize in treating such patients. These

processes include manual workarounds (such as scanning paper records) 

that are generally feasible only because the number of polytrauma patients is 

small. These multiple initiatives and ad hoc processes highlight the need for 

continued efforts to integrate information systems and automate information 

exchange. In addition, it is not clear how all the initiatives are to be 

incorporated into an overall strategy focused on achieving the departments’ 

goal of comprehensive, seamless exchange of health information. 

www.gao.gov/cgi-bin/getrpt?GAO-07-852T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Valerie Melvin 

at (202) 512-6304 or melvinv@gao.gov. 
Mr. Chairman and Members of the Subcommittee: 

I am pleased to participate in today’s hearing on sharing electronic 

medical records between the Department of Defense (DOD) and the 

Department of Veterans Affairs (VA). For almost 10 years, the 

departments have been engaged in multiple efforts to share 

electronic medical information, which is important in helping to 

ensure that active-duty military personnel and veterans receive highquality health care. These include efforts focused on the long-term 

vision of a single “comprehensive, lifelong medical record for each 

service member” 1 that would allow a seamless transition between 

the two departments, as well as more near-term efforts to meet 

immediate needs to exchange health information, including 

responding to current military crises. 

Each department is developing its own modern health information 

system to replace its existing (“legacy”) systems, and they are 

collaborating on a program to develop an interface to enable these 

modernized systems to share data and ultimately to have 

interoperable2 electronic medical records. Unlike the legacy 

systems, the modernized systems are to be based on computable 

data: that is, the data are to be in a format that a computer 

application can act on, for example, to provide alerts to clinicians 

(of such things as drug allergies) or to plot graphs of changes in vital 

signs such as blood pressure. According to the departments, such 

computable data contribute significantly to patient safety and the 

usefulness of electronic medical records. 

While working on this long-term effort, the two departments have 

also been pursuing various near-term initiatives to exchange 

electronic medical information in their existing systems. These 

 1

 In 1996, the Presidential Advisory Committee on Gulf War Veterans’ Illnesses reported on

many deficiencies in VA’s and DOD’s data capabilities for handling service members’ health

information. In November 1997, the President called for the two agencies to start 

developing a “comprehensive, lifelong medical record for each service member,” and in 

1998 issued a directive requiring VA and DOD to develop a “computer-based patient record 

system that will accurately and efficiently exchange information.” 

2

 Interoperability is the ability of two or more systems or components to exchange 

information and to use the information that has been exchanged. 

Page 1 GAO-07-852T
include a completed effort to allow the one-way transfer of health 

information from DOD to VA when service members leave the 

military, ongoing demonstration projects to exchange particular 

types of data at selected sites, and efforts to meet the immediate 

needs of facilities treating veterans and service members with 

multiple injuries. 

As you requested, my testimony will summarize the history of the 

two departments’ efforts to develop the capability to share health 

information, and provide an overview of the current status of the 

long- and near-term efforts that the departments are making to share 

health information. 

The information in my testimony is based largely on our previous 

work in this area. To describe the current status of VA and DOD 

efforts to exchange patient health information, we reviewed our 

previous work, analyzed documents on various health initiatives, 

and interviewed VA and DOD officials about current status and 

future plans. The costs that have been incurred for the various 

projects were provided by cognizant VA and DOD officials. We did 

not audit the reported costs and thus cannot attest to their accuracy 

or completeness. All work on which this testimony is based was 

conducted in accordance with generally accepted government 

auditing standards. 

Results in Brief 

VA and DOD have been pursuing ways to share data in their health 

information systems and create comprehensive electronic medical 

records since 1998, following the call for the development of a 

comprehensive integrated system to allow the two departments to 

share patient health information. However, the departments have 

faced considerable challenges, leading to repeated changes in the 

focus of their initiatives and target dates. In reviewing the 

departments’ initial project, we noted disappointing progress, 

exacerbated by inadequate accountability and poor planning and 

oversight, which raised doubts about the departments’ ability to 

achieve a comprehensive electronic medical record. We made 

Page 2 GAO-07-852T
recommendations aimed at enhancing management and 

accountability by, among other things, the creation of 

comprehensive and coordinated plans that included an agreed-upon 

mission and clear goals, objectives, and performance measures. In 

response, the departments refocused the project and divided it into 

long- and short-term initiatives. The long-term initiative, still 

ongoing, is to develop a common health information architecture 

that would allow the two-way exchange of health information 

through the development of modern health information systems. 

The short-term initiative (the Federal Health Information Exchange) 

was to enable DOD to electronically transfer to VA health 

information on service members when they leave the military; this 

initiative was completed in 2004. Other short-term initiatives were 

subsequently established that were similarly focused on sharing 

information in existing systems, an important requirement until the 

departments’ modern health information systems are completed. In

particular, two demonstration projects were established in 2004 in 

response to congressional mandate, one of which led the two 

departments to develop an interim strategy to connect existing 

systems and allow information sharing among them. Finally, the two 

departments announced in January 2007 a further new strategy: 

their intention to jointly develop a new inpatient medical record 

system. The departments have indicated that by adopting a joint 

solution, they could realize significant cost savings and make 

inpatient health care data immediately accessible to both 

departments. 

VA and DOD have made progress in both their long-term and shortterm initiatives to share health information, but much work remains 

to achieve the goal of a shared electronic medical record and 

seamless transition between the two departments. In the long-term 

project to develop modernized health information systems, the 

departments have begun to implement the first release of the 

interface between their modernized data repositories, and 

computable outpatient pharmacy and drug allergy data are being 

exchanged at seven VA and DOD sites. Although the data being 

exchanged are limited, implementing this interface is a milestone 

toward the long-term goal of modernized systems with interoperable 

electronic medical records. In the meantime, the two departments 

have also made progress in their short-term projects to share 

Page 3 GAO-07-852T
information in existing systems. Besides completing the Federal 

Health Information Exchange, the departments have made progress 

on two demonstration projects: 

● The Laboratory Data Sharing Interface, which allows DOD and VA 

facilities serving the same geographic area to share laboratory 

resources, is deployed at 9 localities to communicate orders for lab 

test and their results electronically and can be deployed at others if 

the need is demonstrated. 

● The Bidirectional Health Information Exchange, which allows a realtime, two-way view of health data from existing systems,3

 provides 

this capability (for outpatient data) to all VA sites and 25 DOD sites 

and (for certain inpatient discharge summary data) 4 to all VA sites 

and 5 DOD sites. Expanding this interface is the foundation of the 

departments’ interim strategy to share information among their 

existing systems. 

In addition to their technology efforts, the two departments have 

undertaken ad hoc activities to accelerate the transmission of health 

information on severely wounded patients from DOD to VA’s four 

polytrauma centers, which care for veterans and service members 

with disabling injuries to more than one physical region or organ 

system. These ad hoc processes include manual workarounds such 

as scanning paper records and individually transmitting radiological 

images. Such processes are generally feasible only because the 

number of polytrauma patients is small (about 350 in all to date). 

Through all these efforts, VA and DOD are achieving exchanges of 

health information. However, these exchanges are as yet limited, 

and it is not clear how they are to be integrated into an overall 

strategy toward achieving the departments’ long-term goal of 

comprehensive, seamless exchange of health information. To 

achieve this goal, significant work remains to be done, including 

agreeing to standards for the remaining categories of medical 

 3

 DOD’s Composite Health Care System (CHCS) and VA’s VistA (Veterans Health 

Information Systems and Technology Architecture).

4

 Specifically, inpatient discharge summary data stored in VA’s VistA and DOD’s Clinical 

Information System (CIS), a commercial health information system customized for DOD. 

Page 4 GAO-07-852T
information, populating the data repositories with all this 

information, completing the development of their modernized 

systems, and transitioning from the legacy systems. Consequently, it 

is essential for the departments to develop a comprehensive project 

plan to guide this effort to completion, in line with our earlier 

recommendations. 

Background 

In their efforts to modernize their health information systems and 

share medical information, VA and DOD begin from different 

positions. As shown in table 1, VA has one integrated medical 

information system, VistA (Veterans Health Information Systems 

and Technology Architecture), which uses all electronic records. All 

128 VA medical sites thus have access to all VistA information.5

(Table 1 also shows, for completeness, VA’s planned modernized 

system and its associated data repository.) 

Table 1: VA Medical Information Systems 

System name Description

Legacy systems 

VistA Veterans Health 

Information Systems and 

Technology Architecture 

Existing integrated health information system. 

Modernized system and repository 

HealtheVet VistA Modernized health information system based on 

computable data. 

HDR Health Data Repository Data repository associated with modernized system. 

Source: GAO analysis of VA data. 

In contrast, DOD has multiple medical information systems (see 

table 2). DOD’s various systems are not integrated, and its 138 sites 

do not necessarily communicate with each other. In addition, not all 

of DOD’s medical information is electronic: some records are paperbased. 

 5

 A site represents one or more facilities—medical centers, hospitals, or outpatient 

clinics—that store their electronic health data in a single database. 

Page 5 GAO-07-852T
Table 2: Selected DOD Medical Information Systems 

System name Description

Legacy systems 

CHCS Composite Health Care

System 

Primary existing DOD health information system. 

CIS Clinical Information 

System 

Commercial health information system customized 

for DOD; used by some DOD facilities for inpatients. 

ICDB Integrated Clinical 

Database

Health information system used by many Air Force 

facilities. 

TMDS Theater Medical Data 

Store 

Database to collect electronic medical information in

combat theater for both outpatient care and serious 

injuries. 

JPTA Joint Patient Tracking 

Application 

Web-based application primarily used to track the 

movement of patients as they are transferred from 

location to location, but may include text-based

medical information. 

Modernized system and repository 

AHLTA Armed Forces Health 

Longitudinal Technology 

Application a

Modernized health information system, integrated 

and based on computable data. 

CDR Clinical Data Repository Data repository associated with modernized system. 

Source: GAO analysis of DOD data. 

a Formerly CHCS II. 

VA and DOD Have Been Working to Exchange Health Information 

Since 1998 

For almost a decade, VA and DOD have been pursuing ways to share 

data in their health information systems and create comprehensive 

electronic records.6

 However, the departments have faced 

considerable challenges, leading to repeated changes in the focus of 

their initiatives and target dates for accomplishment. 

As shown in figure 1, the departments’ efforts have involved a 

number of distinct initiatives, both long-term initiatives to develop 

future modernized solutions, and short-term initiatives to respond to 

 6

 Initially, the Indian Health Service (IHS) was also a party to this effort, having been

included because of its population-based research expertise and its long-standing 

relationship with VA. However, IHS was not included in a later revised strategy for 

electronically sharing patient health information. 

Page 6 GAO-07-852T
more immediate needs to share information in existing systems. As 

the figure shows, these initiatives often proceeded in parallel. 

Figure 1: Timeline of Selected VA/DOD Electronic Medical Records and Data Sharing Efforts 

The departments’ first initiative, known as the Government 

Computer-Based Patient Record (GCPR) project, aimed to develop 

an electronic interface that would let physicians and other 

authorized users at VA and DOD health facilities access data from 

each other’s health information systems. The interface was expected 

to compile requested patient information in a virtual record (that is,

electronic as opposed to paper) that could be displayed on a user’s 

computer screen. 

In 2001 and 2002, we reviewed the GCPR project and noted 

disappointing progress, exacerbated in large part by inadequate 

accountability and poor planning and oversight, which raised doubts 

about the departments’ ability to achieve a virtual medical record. 

Page 7 GAO-07-852T
We determined that the lack of a lead entity, clear mission, and 

detailed planning to achieve that mission made it difficult to monitor 

progress, identify project risks, and develop appropriate 

contingency plans. 7 We made recommendations in both years that 

the departments enhance the project’s overall management and 

accountability. In particular, we recommended that the departments 

designate a lead entity and a clear line of authority for the project; 

create comprehensive and coordinated plans that include an agreedupon mission and clear goals, objectives, and performance 

measures; revise the project’s original goals and objectives to align 

with the current strategy; commit the executive support necessary 

to adequately manage the project; and ensure that it followed sound 

project management principles. 

In response, the two departments revised their strategy in July 2002, 

refocusing the project and dividing it into two initiatives. A shortterm initiative (the Federal Health Information Exchange or FHIE) 

was to enable DOD, when service members left the military, to 

electronically transfer their health information to VA. VA was 

designated as the lead entity for implementing FHIE, which was 

successfully completed in 2004. A longer term initiative was to 

develop a common health information architecture that would allow 

the two-way exchange of health information. The common 

architecture is to include standardized, computable data, 

communications, security, and high-performance health information

systems (these systems, DOD’s CHCS II and VA’s HealtheVet VistA, 

were already in development, as shown in the figure).8

 The 

departments’ modernized systems are to store information (in 

standardized, computable form) in separate data repositories: 

DOD’s Clinical Data Repository (CDR) and VA’s Health Data 

 7

 GAO, Veterans Affairs: Sustained Management Attention Is Key to Achieving 

Information Technology Results, GAO-02-703 (Washington, D.C.: June 12, 2002) and 

Computer-Based Patient Records: Better Planning and Oversight by VA, DOD, and IHS 

Would Enhance Health Data Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001). 

8

 DOD’s existing Composite Health Care System (CHCS) was being modernized as CHCS II, 

now renamed AHLTA (Armed Forces Health Longitudinal Technology Application). VA’s

existing VistA system was being modernized as HealtheVet VistA.

Page 8 GAO-07-852T
Repository (HDR). The two repositories are to exchange

information through an interface named CHDR.9

In March 2004, the departments began to develop the CHDR 

interface, and they planned to begin implementation by October 

2005.10 However, implementation of the first release of the interface 

(at one site) occurred in September 2006, almost a year later. In a 

review in June 2004, we identified a number of management 

weaknesses that could have contributed to this delay11 and made a 

number of recommendations, including creation of a comprehensive 

and coordinated project management plan. In response, the 

departments agreed to our recommendations and improved the 

management of the CHDR program by designating a lead entity with 

final decision-making authority and establishing a project 

management structure. As we noted in later testimony, however, the 

program did not develop a project management plan that would give 

a detailed description of the technical and managerial processes 

necessary to satisfy project requirements (including a work 

breakdown structure and schedule for all development, testing, and

implementation tasks), as we had recommended.12 

In October 2004, the two departments established two more shortterm initiatives in response to a congressional mandate.13 These 

were two demonstration projects: the Laboratory Data Sharing 

Interface, aimed at allowing VA and DOD facilities to share 

 9

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

10 December 2004 VA and DOD Joint Strategic Plan. 

11 GAO, Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data 

Could Benefit from Improved Planning and Project Management, GAO-04-687

(Washington, D.C.: June 7, 2004). 

12 GAO, Computer-Based Patient Records: VA and DOD Made Progress, but Much Work

Remains to Fully Share Medical Information, GAO-05-1051T (Washington, D.C.: Sept. 28,

2005) and Information Technology: VA and DOD Face Challenges in Completing Key

Efforts, GAO-06-905T (Washington, D.C.: June 22, 2006). 

13 The Bob Stump National Defense Authorization Act for Fiscal Year 2003 (Pub. L. 107-314, 

2002) mandated that the departments conduct demonstration projects to test the 

feasibility, advantages, and disadvantages of measures and programs designed to improve

the sharing and coordination of health care and health care resources between the

departments.

Page 9 GAO-07-852T
laboratory resources, and the Bidirectional Health Information 

Exchange (BHIE), aimed at allowing both departments’ clinicians 

access to records on shared patients (that is, those who receive care 

from both departments).14 As demonstration projects, both 

initiatives were limited in scope, with the intention of providing 

interim solutions to the departments’ need for more immediate 

health information sharing. However, because BHIE provided 

access to up-to-date information, the departments’ clinicians 

expressed strong interest in increasing its use. As a result, the 

departments began planning to broaden BHIE’s capabilities and 

expand its implementation considerably. Until the departments’ 

modernized systems are fully developed and implemented, 

extending BHIE connectivity could provide each department with 

access to most data in the other’s legacy systems. According to a 

VA/DOD annual report15 and program officials, the departments now 

consider BHIE an interim step in their overall strategy to create a 

two-way exchange of electronic medical records. 

Most recently, the departments have announced a further change to 

their information-sharing strategy. In January 2007, they announced

their intention to jointly develop a new inpatient medical record 

system. According to the departments, adopting this joint solution 

will facilitate the seamless transition of active-duty service members 

to veteran status, as well as making inpatient healthcare data on 

shared patients immediately accessible to both DOD and VA. In 

addition, the departments consider that a joint development effort 

could allow them to realize significant cost savings. We have not 

evaluated the departments’ plans or strategy in this area.

 14 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 system allows clinicians in both departments to view, in real time, 

limited health data (in text form) from the departments’ current health information

systems.

15 December 2004 VA and DOD Joint Strategic Plan. 

Page 10 GAO-07-852T
Others Have Recommended Strengthening the Management and Planning of the 

Departments’ Health Information Initiatives 

Throughout the history of these initiatives, evaluations beyond ours

have also found deficiencies in the departments’ efforts, especially 

with regard to the need for comprehensive planning. For example, 

in fiscal year 2006, the Congress did not provide all the funding 

requested for HealtheVet VistA because it did not consider that the 

funding had been adequately justified. In addition, a recent 

presidential task force identified the need for VA and DOD to 

improve their long-term planning.16 This task force, reporting on 

gaps in services provided to returning veterans, noted problems 

with regard to sharing information on wounded service members, 

including the inability of VA providers to access paper DOD 

inpatient health records. According to the report, although 

significant progress has been made on sharing electronic 

information, more needs to be done. The task force recommended 

that VA and DOD continue to identify long-term initiatives and 

define scope and elements of a joint inpatient electronic health 

record. 

VA and DOD Are Exchanging Limited Medical Information, but 

Much Work Remains to Achieve Seamless Sharing 

VA and DOD have made progress in both their long-term and shortterm initiatives to share health information. In the long-term project 

to develop modernized health information systems, the departments 

have begun to implement the first release of the interface between 

their modernized data repositories, among other things. The two 

departments have also made progress in their short-term projects to 

share information in existing systems, having completed two 

initiatives and making important progress on another. In addition, 

the two departments have undertaken ad hoc activities to accelerate 

the transmission of health information on severely wounded 

 16 Task Force on Returning Global War on Terror Heroes, Report to the President (Apr. 19, 

2007). 

Page 11 GAO-07-852T
patients from DOD to VA’s four polytrauma centers. However, 

despite the progress made and the sharing achieved, the tasks 

remaining to achieve the goal of a shared electronic medical record 

remain substantial. 

VA and DOD Have Begun Deployment of a Modernized Data Interface 

In their long-term effort to share health information, VA and DOD 

have completed the development of their modernized data 

repositories, agreed on standards for various types of data, and 

begun to populate the repositories with these data.17 In addition, 

they have now implemented the first release of the CHDR interface,

which links the two departments’ repositories, at seven sites. The 

first release has enabled the seven sites to share limited medical 

information: specifically, computable outpatient pharmacy and drug 

allergy information for shared patients. 

According to DOD officials, in the third quarter of 2007 the 

department will send out instructions to its remaining sites so that 

they can all begin using CHDR. According to VA officials, the 

interface will be available across the department when necessary 

software updates are released, which is expected this July.18 

Besides being a milestone in the development of the departments’ 

modernized systems, the interface implementation provides benefits 

to the departments’ current systems. Data transmitted by CHDR are 

permanently stored in the modernized data repositories, CDR and 

HDR. Once in the repositories, these computable data can be used 

by DOD and VA at all sites through their existing systems. CHDR 

also provides terminology mediation (translation of one agency’s 

terminology into the other’s). VA and DOD plans call for developing 

the capability to exchange computable laboratory results data 

through CHDR during fiscal year 2008. 

 17 DOD has populated CDR with information for outpatient encounters, drug allergies, and 

order entries and results for outpatient pharmacy/lab orders. VA has populated HDR with 

patient demographics, vital signs records, allergy data, and outpatient pharmacy data; this 

summer, the department plans to include chemistry and hematology laboratory data. 

18 The Remote Data Interoperability software upgrade provides the capability for the

automated checks and alerts allowed by computable data. 

Page 12 GAO-07-852T
Although implementing this interface is an important 

accomplishment, the departments are still a long way from 

completion of the modernized health information systems and 

comprehensive longitudinal health records. While DOD and VA had 

originally projected completion dates for their modernized systems 

of 2011 and 2012, respectively, department officials told us that 

there is currently no scheduled completion date for either system. 

Further, both departments have still to identify the next types of 

data to be stored in the repositories. The two departments will then 

have to populate the repositories with the standardized data, which

involves different tasks for each department. Specifically, although 

VA’s medical records are already electronic, it still has to convert 

these into the interoperable format appropriate for its repository. 

DOD, in addition to converting current records from its multiple 

systems, must also address medical records that are not automated.

As pointed out by a recent Army Inspector General’s report, some 

DOD facilities are having problems with hard-copy records.19 In the 

same report, inaccurate and incomplete health data were identified 

as a problem to be addressed. Before the departments can achieve 

the long-term goal of seamless sharing of medical information, all 

these tasks and challenges will have to be addressed. Consequently, 

it is essential for the departments to develop a comprehensive 

project plan to guide these efforts to completion, as we have 

previously recommended. 

VA and DOD Are Exchanging Limited Health Information through Short-Term Projects 

In addition to the long-term effort described above, the two 

departments have made some progress in meeting immediate needs 

to share information in their respective legacy systems by setting up

short-term projects, as mentioned earlier, which are in various 

stages of completion. In addition, the departments have set up 

special processes to transfer data from DOD facilities to VA’s 

polytrauma centers, which treat traumatic brain injuries and other 

especially severe injuries. 

 19 Inspector General, Army, Army Physical Disability Evaluation System Inspection

(March 2007). 

Page 13 GAO-07-852T
One-Way Transfer Capability Is Operational 

DOD has been using FHIE to transfer information to VA since 2002. 

According to department officials, over 184 million clinical 

messages on more than 3.8 million veterans have been transferred to 

the FHIE data repository as of March 2007. Data elements 

transferred are laboratory results, radiology results, outpatient 

pharmacy data, allergy information, consultation reports, elements 

of the standard ambulatory data record, and demographic data. 

Further, since July 2005, FHIE has been used to transfer pre- and 

post-deployment health assessment and reassessment data; as of 

March 2007, VA has access to data for more than 681,000 separated 

service members and demobilized Reserve and National Guard 

members who had been deployed. Transfers are done in batches 

once a month, or weekly for veterans who have been referred to VA 

treatment facilities. 

According to a joint DOD/VA report,20 FHIE has made a significant 

contribution to the delivery and continuity of care of separated 

service members as they transition to veteran status, as well as to 

the adjudication of disability claims. 

Laboratory Interface Initiative Allows VA and DOD to Share Lab Resources 

One of the departments’ demonstration projects, the Laboratory 

Data Sharing Interface (LDSI), is now fully operational and is 

deployed when local agencies have a business case for its use and 

sign an agreement. It requires customization for each locality and is 

currently deployed at nine locations. LDSI currently supports a 

variety of chemistry and hematology tests, and work is under way to 

include microbiology and anatomic pathology. 

Once LDSI is implemented at a facility, the only nonautomated 

action needed for a laboratory test is transporting the specimens. If 

a test is not performed at a VA or DOD doctor’s home facility, the 

doctor can order the test, the order is transmitted electronically to 

 20 December 2004 VA and DOD Joint Strategic Plan. 

Page 14 GAO-07-852T
the appropriate lab (the other department’s facility or in some cases 

a local commercial lab), and the results are returned electronically. 

Among the benefits of LDSI, according to VA and DOD, are 

increased speed in receiving laboratory results and decreased errors 

from manual entry of orders. The LDSI project manager in San 

Antonio stated that another benefit of the project is the time saved 

by eliminating the need to rekey orders at processing labs to input 

the information into the laboratories’ systems. Additionally, the San 

Antonio VA facility no longer has to contract out some of its 

laboratory work to private companies, but instead uses the DOD 

laboratory.

Two-Way Interface Allows Real-Time Viewing of Text Information 

Developed under a second demonstration project, the BHIE 

interface is now available throughout VA and partially deployed at 

DOD. It is currently deployed at 25 DOD sites, providing access to 

15 medical centers, 18 hospitals, and over 190 outpatient clinics 

associated with these sites. DOD plans to make current BHIE 

capabilities available departmentwide by June 2007. 

The interface permits a medical care provider to query patient data 

from all VA sites and any DOD site where it is installed and to view 

that data onscreen almost immediately. It not only allows DOD and 

VA to view each other’s information, it also allows DOD sites to see 

previously inaccessible data at other DOD sites. 

As initially developed, the BHIE interface provides access to 

information in VA’s VistA and DOD’s CHCS, but it is currently being 

expanded to query data in other DOD databases (in addition to 

CHCS). In particular, DOD has developed an interface to the Clinical 

Information System (CIS), an inpatient system used by many DOD 

facilities, which will provide bidirectional views of discharge 

summaries. The BHIE-CIS interface is currently deployed at five 

DOD sites and planned for eight others. Further, interfaces to two

additional systems are planned for June and July 2007: An interface 

to DOD’s modernized data repository, CDR, will give access to 

outpatient data from combat theaters. An interface to another DOD 

Page 15 GAO-07-852T
database, the Theater Medical Data Store, will give access to 

inpatient information from combat theaters. 

The departments also plan to make more data elements available. 

Currently, BHIE enables text-only viewing of patient identification, 

outpatient pharmacy, microbiology, cytology, radiology, laboratory 

orders, and allergy data from its interface with DOD’s CHCS. Where 

it interfaces with CIS, it also allows viewing of discharge summaries 

from VA and the five DOD sites. DOD staff told us that in early fiscal 

year 2008, they plan to add provider notes, procedures, and problem 

lists. Later in fiscal year 2008, they plan to add vital signs, scanned 

images and documents, family history, social history, and other 

history questionnaires. In addition, at the VA/DOD site in El Paso, a 

trial is under way of a process for exchanging radiological images 

using the BHIE/FHIE infrastructure.21 Some images have 

successfully been exchanged. 

Through their efforts on these long- and near-term initiatives, VA 

and DOD are achieving exchanges of various types of health 

information (see attachment 1 for a summary of all the types of data 

currently being shared and those planned for the future, as well as 

cost data on the initiatives). However, these exchanges are as yet 

limited, and significant work remains to be done to expand the data 

shared and integrate the various initiatives. 

Special Procedures Provide Information to VA Polytrauma Centers 

In addition to the information technology initiatives described, DOD 

and VA have set up special activities to transfer medical information 

to VA’s four polytrauma centers, which are treating active-duty 

service members severely wounded in combat.22 Polytrauma centers 

care for veterans and returning service members with injuries to 

more than one physical region or organ system, one of which may 

be life threatening, and which results in physical, cognitive, 

 21 To create BHIE, the departments drew on the architecture and framework of the 

information transfer system established by the FHIE project.

22 In particular, clinicians required access to discharge notices, which describe the 

treatment given at previous medical facilities and the status of patients when they left 

those facilities.

Page 16 GAO-07-852T
psychological, or psychosocial impairments and functional 

disability. Some examples of polytrauma include traumatic brain 

injury (TBI), amputations, and loss of hearing or vision. 

When service members are seriously injured in a combat theater 

overseas, they are first treated locally. They are then generally 

evacuated to Landstuhl Medical Center in Germany, after which 

they are transferred to a military treatment facility in the United 

States, usually Walter Reed Army Medical Center in Washington, 

D.C.; the National Naval Medical Center in Bethesda, Maryland; or 

Brooke Army Medical Center, at Fort Sam Houston, Texas. From 

these facilities, service members suffering from polytrauma may be 

transferred to one of VA’s four polytrauma centers for treatment.23

At each of these locations, the injured service members will 

accumulate medical records, in addition to medical records already 

in existence before they were injured. However, the DOD medical 

information is currently collected in many different systems and is 

not easily accessible to VA polytrauma centers. Specifically: 

1. In the combat theater, electronic medical information may be 

collected for a variety of reasons, including routine outpatient 

care, as well as serious injuries. These data are stored in the 

Theater Medical Data Store, which can be accessed by unit 

commanders and others. (As mentioned earlier, the departments 

have plans to develop a BHIE interface to this system by July 

2007. Until then, VA cannot access these data.) In addition, both 

inpatient and outpatient medical data for patients who are 

evacuated are entered into the Joint Patient Tracking 

Application. (A few VA polytrauma center staff have been given 

access to this application.) 

2. At Landstuhl, inpatient medical records are paper-based (except 

for discharge summaries). The paper records are sent with a 

patient as the individual is transferred for treatment in the 

United States. 

 23 The four Polytrauma Rehabilitation Centers are in Richmond, Tampa, Minneapolis, and 

Palo Alto. 

Page 17 GAO-07-852T
3. At the DOD treatment facility (Walter Reed, Bethesda, or 

Brooke), additional information will be recorded in CIS and 

CHCS/CDR.24 

When service members are transferred to a VA polytrauma center, 

VA and DOD have several ad hoc processes in place to electronically 

transfer the patients’ medical information: 

● DOD has set up secure links to enable a limited number of clinicians 

at the polytrauma centers to log directly into CIS at Walter Reed and 

Bethesda Naval Hospital to access patient data. 

● Staff at Walter Reed collect paper records, print records from CIS, 

scan all these, and transmit the scanned data to three of the four 

polytrauma centers. DOD staff said that they are working on 

establishing this capability at the Brooke and Bethesda medical 

centers, as well as the fourth VA polytrauma center. According to 

VA staff, although the initiative began several months ago, it has 

only recently begun running smoothly as the contractor became 

more skilled at assembling the records. DOD staff also pointed out 

that this laborious process is feasible only because the number of 

polytrauma patients is small (about 350 in all to date); it would not 

be practical on a large scale. 

● Staff at Walter Reed and Bethesda are transmitting radiology images 

electronically to three polytrauma centers. (A fourth has this 

capability, but at this time no radiology images have been 

transferred there.) Access to radiology images is a high priority for 

polytrauma center doctors, but like scanning paper records, 

transmitting these images requires manual intervention: when each 

image is received at VA, it must be individually uploaded to VistA’s 

imagery viewing capability. This process would not be practical for 

large volumes of images. 

● VA has access to outpatient data (via BHIE) from 25 DOD sites, 

including Landstuhl. 

Although these various efforts to transfer medical information on 

seriously wounded patients are working, and the departments are to 

be commended on their efforts, the multiple processes and 

 24 Pharmacy and drug information would be stored in CDR; other health information 

continues to be stored in local CHCS databases. 

Page 18 GAO-07-852T
laborious manual tasks illustrate the effects of the lack of in

health information systems and the difficulties of exchanging 

information in their absence. 

tegrated 

In conclusion, through the long- and short-term initiatives described, 

se

aining

as well as efforts such as those at the polytrauma centers, VA and 

DOD are achieving exchanges of health information. However, the

exchanges are as yet limited, and significant work remains to be 

done to fully achieve the goal of exchanging interoperable, 

computable data, including agreeing to standards for the rem

categories of medical information, populating the data repositories 

with all this information, completing the development of HealtheVet

VistA and AHLTA, and transitioning from the legacy systems. To 

complete these tasks, a detailed project management plan continu

to be of vital importance to the ultimate success of the effort to 

develop a lifelong virtual medical record. We have previously 

recommended that the departments develop a clearly defined 

project management plan that describes the technical and 

managerial processes necessary to satisfy project requirem

including a work breakdown structure and schedule for all 

development, testing, and implementation tasks. Without a p

sufficient detail, VA and DOD increase the risk that the long-time 

project will not deliver the planned capabilities in the time and at 

the cost expected. Further, it is not clear how all the initiatives we

have described today are to be incorporated into an overall strategy

toward achieving the departments’ goal of comprehensive, seamless 

exchange of health information. 

e

ents,

lan of

Mr. Chairman, this concludes my statement. I would be happy to 

Contacts and Acknowledgments 

respond to any questions that you or other members of the 

subcommittee may have. 

If you have any questions concerning this testimony, please contact

.gov. 

Valerie C. Melvin, Director, Human Capital and Management 

Information Systems Issues, at (202) 512-6304 or melvinv@gao

Page 19 GAO-07-852T
Other individuals who made key contributions to this testimony 

include Barbara Oliver, Assistant Director; Barbara Collier; and 

Glenn Spiegel. 

Page 20 GAO-07-852T
Attachment 1: Supplementary Tables 

Types of Data Shared by DOD and VA Are Growing but Remain Limited 

Table 3 summarizes the types of health data currently shared 

through the long- and near-term initiatives we have described, as 

well as types of data that are currently planned for addition. While 

this gives some indication of the scale of the tasks involved in 

sharing medical information, it does not depict the full extent of 

information that is currently being captured in health information 

systems and that remains to be addressed. 

Table 3: Data Elements Made Available and Planned by DOD-VA Initiatives 

Data elements

Initiative Available Planned Comments

CHDR Outpatient pharmacy

Drug allergy 

Laboratory data Computable data are exchanged 

between one department’s data 

repository and the other’s. 

FHIE Patient demographics

Laboratory results 

Radiology reports 

Outpatient pharmacy information 

Admission discharge transfer data 

Discharge summaries 

Consult reports

Allergies 

Data from the DoD Standard Ambulatory Data Record 

Pre- and post-deployment assessments 

None One-way batch transfer of text data 

from DOD to VA occurs weekly if 

discharged patient has been 

referred to VA for treatment; 

otherwise monthly. 

LDSI Laboratory orders

Laboratory results (chemistry and hematology only) 

Microbiology 

Anatomic pathology 

Noncomputable text data are 

transferred. 

BHIE Outpatient pharmacy data 

Drug & food allergy information

Surgical pathology reports 

Microbiology results 

Cytology reports

Chemistry & hematology reports 

Laboratory orders 

Radiology text reports 

Inpatient discharge summaries and/or emergency 

room notes from CIS at five DOD and all VA sites 

Provider notes 

Procedures 

Problem lists 

Vital signs 

Scanned images and 

documents 

Family history 

Social history 

Other history questionnaires 

Radiology images 

Data are not transferred but can be 

viewed. 

Source: GAO analysis of VA and DOD data.

Page 21 GAO-07-852T
Reported Costs 

Table 4 shows costs expended on these information sharing 

initiatives since their inception. 

Table 4: Costs of DOD and VA Initiatives Since Inception

Project VA expenditure DOD expenditure 

HealtheVet VistA $514 million through FY 2005 — 

AHLTA — $755 million through FY 2006 

(estimated) 

Joint initiatives:

CHDR 5.3 million

FHIE 62.4 million

LDSI 1.5 million

BHIE 7.0 million

through about 

April 2007 

DOD does not account for these 

projects separately. 

Total $76.2 million $72.6 million though FY 2006

Source: GAO analysis of DOD and VA data. 

Page 22 GAO-07-852T
Related GAO Products 

Computer-Based Patient Records: Better Planning and Oversight 

by VA, DOD, and IHS Would Enhance Health Data Sharing. GAO01-459. Washington, D.C.: April 30, 2001. 

Veterans Affairs: Sustained Management Attention Is Key to 

Achieving Information Technology Results. GAO-02-703. 

Washington, D.C.: June 12, 2002. 

Computer-Based Patient Records: Short-Term Progress Made, but 

Much Work Remains to Achieve a Two-Way Data Exchange 

Between VA and DOD Health Systems. GAO-04-271T. Washington, 

D.C.: November 19, 2003. 

Computer-Based Patient Records: Sound Planning and Project 

Management Are Needed to Achieve a Two-Way Exchange of VA 

and DOD Health Data. GAO-04-402T. Washington, D.C.: March 17, 

2004. 

Computer-Based Patient Records: VA and DOD Efforts to 

Exchange Health Data Could Benefit from Improved Planning and 

Project Management. GAO-04-687. Washington, D.C.: June 7, 2004. 

Computer-Based Patient Records: VA and DOD Made Progress, but 

Much Work Remains to Fully Share Medical Information. GAO-05-

1051T. Washington, D.C.: September 28, 2005. 

Information Technology: VA and DOD Face Challenges in 

Completing Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 

2006. 

DOD and VA Exchange of Computable Pharmacy Data. GAO-07-

554R. Washington, D.C.: April 30, 2007. 

Page 23 GAO-07-852T

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