Page 1 GAO-04-292R Defense Health Care 

______________________________________________________________________________________________ 

United States General Accounting Office 

Washington, DC 20548 

November 24, 2003 

The Honorable Christopher H. Smith 

Chairman 

Committee on Veterans’ Affairs 

House of Representatives 

Subject: Veterans Affairs: Posthearing Questions Concerning the Departments of 

Defense and Veterans Affairs Providing Seamless Health Care Coverage to 

Transitioning Veterans 

Dear Mr. Chairman: 

On October 16, 2003, I testified before your Subcommittee at a hearing on Hand-off or 

Fumble: Are DOD and VA Providing Seamless Health Care Coverage to Transitioning 

Veterans?1

 This letter responds to your request that we provide answers to follow-up 

questions from the hearing. Your questions, along with my responses, follow. 

1. “GAO, at the request of this Committee, has examined VA’s Information 

Technology (IT) needs a number of times. Also, GAO has studied DOD’s IT 

infrastructure. VA and DOD have pledged over the years to be working toward 

common solutions to their IT challenges, most particularly in the area of 

computerized patient care records and the portability of these records across the 

several systems involved. Yet, they soldier on separately. What are the basic 

problems in the view of GAO, that prevent or obstruct the accomplishment of this 

goal of a single patient care record that can accompany a military servicemember 

from active duty to veteran status?” 

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

systems and create electronic records since 1998, when the Government Computer-Based 

Patient Record (GCPR) project was initiated. GCPR was envisioned as an electronic 

interface that would allow physicians and other authorized users at VA, DOD, and Indian 

Health Service (IHS) health facilities to access data from any of the other agencies’ health 

facilities.2

 The interface was expected to compile requested patient information in a 

“virtual” record that could be displayed on a user’s computer screen. 

 1

U.S. General Accounting Office, Defense Health Care: DOD Needs to Improve Force Health Protection 

And Surveillance Processes, GAO-04-158T (Washington, D.C.: Oct. 16, 2003). 

2

The Indian Health Service became involved in GCPR because of its expertise in population-based research 

and its longstanding relationship with VA in caring for the American Indian veteran population. 
Page 2 GAO-04-292R Defense Health Care 

Since undertaking this mission, however, VA and DOD have faced considerable 

challenges, leading to repeated changes in the focus of their initiative and the target dates 

for its accomplishment. Our prior reports discussing the initiative3 noted disappointing 

progress, exacerbated in large part by inadequate accountability and poor planning and 

oversight, which raised doubts about the departments’ ability to achieve an electronic 

interface among their health information systems. When we reported on the initiative in 

September 2002,4

 VA and DOD had taken some actions aimed at strengthening their joint 

efforts. For example, they had clarified key roles and responsibilities for the initiative and 

begun executing revised near- and long-term strategies for achieving the electronic 

information exchange capability. 

The near-term initiative—the Federal Health Information Exchange—was completed in 

July 2002 and enabled the one-way transfer of data from DOD’s existing health care 

information system to a separate database that VA hospitals could access. This initiative 

has shown success in allowing clinicians in VA medical centers ready access to 

information—such as laboratory, pharmacy, and radiology records—on almost 2 million 

patients. 

However, the departments’ strategy for an envisioned longer-term, two-way exchange of 

clinical information is farther out on the horizon. This initiative, HealthePeople (Federal), 

is premised upon the departments’ development of a common health information 

infrastructure and architecture comprising standardized data, communications, security, 

and high-performance health information systems. VA and DOD anticipated achieving a 

limited capability for two-way data exchange by the end of 2005. 

Nonetheless, VA and DOD continue to face significant challenges in realizing this longerterm capability. While the departments have developed a high-level strategy for the 

initiative, they face the challenge of clearly articulating a common health information 

infrastructure and architecture to show how they intend to achieve the data exchange 

capability or what exactly they will be able to exchange. Such an architecture is necessary 

for ensuring that the departments have defined a level of detail and specificity needed to 

build the exchange capability, including requirements and design specifications. 

In addition, critical to the two-way exchange will be completing the standardization of the 

clinical data that these departments plan to share. Data standardization is essential to 

allowing the exchange of health information from disparate systems and improving 

decision-making by providing health information when and where it is needed. Currently, 

VA and DOD face an enormous task of standardizing their health data. VA will have to 

migrate over 150 variations of clinical and demographic data to one standard, and DOD 

will have to migrate over 100 variations of clinical data to one standard. VA and DOD 

officials maintain that their departments, along with the Department of Health and Human 

Services, are actively pursuing the development and adoption of data standards. 

Nonetheless, they remain uncertain as to when the necessary standardization will be 

 3

U.S. General Accounting Office, Computer-Based Patient Records: Better Planning and Oversight by VA, 

DOD, and IHS [Indian Health Service] Would Enhance Health Data Sharing, GAO-01-459 (Washington, 

D.C.: Apr. 30, 2001); VA Information Technology: Progress Made, but Continued Management Attention Is 

Key to Achieving Results, GAO-02-369T (Washington, D.C.: Mar. 13, 2002); and VA Information Technology: 

Management Making Important Progress in Addressing Key Challenges GAO-02-1054T (Washington, D.C.: 

Sept. 26, 2002). 

4

GAO-02-1054T.
Page 3 GAO-04-292R Defense Health Care 

accomplished. Without standardization, the task of sharing meaningful data is made more 

complex and may not prove successful. 

2. “Assuming that VA and DOD actually unify their patient care record keeping, 

will this accomplishment solve the “seamless transition” challenge, or will the 

records problem be supplanted by some other new one, such as HIPAA [Health 

Insurance Portability and Accountability Act] or another cause, and what are 

your reasons for this conclusion?” 

Answer: Achieving the technical capability to unify VA’s and DOD’s patient care records 

in and of itself will not ensure the seamless transition of health care data. Other issues that 

the departments need to address include the following: 

• Reaching consensus on and implementing data standards. As we pointed out in our 

previous response, an essential aspect of making the data usable will be establishing 

data standards. Accomplishing this is particularly challenging, as consensus must be 

reached with clinicians and other health care providers to achieve common acceptance 

of the standards. 

• Capturing complete and accurate medical information on service members. The 

departments must establish and closely adhere to a process that will ensure the 

complete and accurate capture of medical information of service members stored in 

their respective databases.5 As noted in our testimony, DOD’s database does not 

currently contain patient health information (such as health assessments and 

immunizations) for all service members. 

• Ensuring privacy and security compliance. The departments will have to ensure that 

the exchange of medical information is compliant with privacy requirements 

established in the HIPAA. In addition, given the sensitivity of patient health 

information, the departments must ensure that adequate security is an integral feature 

of the data exchange capability. 

 -- -- -- -- -- 

We are sending copies of this letter to the Secretary of Veterans Affairs and the Secretary 

of Defense and other interested parties. We will also make copies available to others upon 

request. In addition, this report will be available at no charge on the GAO Web site at 

http://www.gao.gov. Should you or your staff have any questions on matters discussed in 

this letter, please contact me at (757) 552-8100. I can also be reached by e-mail at 

curtinn@gao.gov. 

Sincerely yours, 

Neal P. Curtin 

Director, Operations and Readiness Issues 

(350472) 

 5

VA and DOD plan to implement a capability to share patient health information that will be collected in data 

repositories that each is implementing. 
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