United States Government Accountability Office

Washington, DC 20548 

June 30, 2006 

The Honorable Michael Bilirakis 

Chairman 

Subcommittee on Oversight and Investigations 

Committee on Veterans’ Affairs 

House of Representatives 

Subject: VA and DOD Health Care: Efforts to Provide Seamless Transition of 

Care for OEF and OIF Servicemembers and Veterans 

Dear Mr. Chairman: 

As of the end of March 2006, over 1.3 million1

 U.S. military servicemembers had 

served or were serving in Operation Enduring Freedom (OEF) or Operation Iraqi 

Freedom (OIF).2

 These servicemembers, including members of the reserves and 

National Guard, may be eligible to receive health care from the Department of

Veterans Affairs (VA) while serving on active duty or upon separating from active 

duty. Although the Department of Defense (DOD) provides health care services to 

servicemembers under TRICARE,3

 legislation passed by the Congress in May 1982 

authorized VA to provide health care services to servicemembers in time of war or 

national emergency, when DOD may have insufficient resources to care for 

casualties.4

 Through December 16, 2005, DOD had arranged for 193 active duty 

servicemembers with serious injuries—traumatic brain injuries and other complex 

trauma, such as missing limbs—to receive medical and rehabilitative5

 care at VA 

 1

DOD’s Contingency Tracking System Deployment File for Operations Enduring Freedom and Iraqi 

Freedom reported that as of March 31, 2006, the total number of servicemembers ever deployed was

1,312,221.

2 OEF, which began in October 2001, supports combat operations in Afghanistan and other locations,

and OIF, which began in March 2003, supports combat operations in Iraq and other locations.

3

DOD provides health care through TRICARE—a regionally structured program that uses civilian 

contractors to maintain provider networks to complement health care services provided at military

treatment facilities. 

4

The Veterans’ Administration and Department of Defense Health Resources Sharing and Emergency 

Operations Act, Pub. L. No. 97-174, § 4(a), 96 Stat. 70, 74-75. 

5

Most servicemembers receive medical care from DOD providers. However, DOD does not typically 

provide long-term rehabilitative services and looks to VA to be a provider of these services. 

 GAO-06-794R Transition of Care for OEF and OIF Servicemembers 
polytrauma rehabilitation centers (PRC).6

 In addition, about 30 percent (over 144,000) 

of the servicemembers who had separated from active duty following service in OEF 

or OIF have sought VA health care, including over 4,000 who received inpatient care 

at VA medical facilities. 

In September 2005, we testified on VA’s collaboration with DOD to provide seamless 

transition of care for servicemembers between DOD and VA health care systems—

that is, no interruption of care as the person moves from being a DOD patient to 

being a VA patient.7

 We reported that VA has developed policies and procedures that 

direct its medical facilities to provide OEF and OIF servicemembers with timely 

access to care but that the sharing of health information between DOD and VA was 

limited. You asked us to update the information we provided in our testimony by 

reviewing the efforts VA is making to inform servicemembers and veterans about VA 

health care services and to help ensure that there is a seamless transition of care for 

servicemembers from DOD’s to VA’s health care system. We addressed the following 

questions: 

1. What outreach efforts has VA made to inform OEF and OIF servicemembers and 

veterans about the VA health care services that may be available to them? 

2. What actions has VA taken to facilitate the seamless transition of medical and 

rehabilitation care for seriously injured OEF and OIF servicemembers who are 

transferred between DOD medical treatment facilities (MTF) and PRCs? 

3. What special educational activities or clinical tools is VA using to help ensure its 

medical providers are aware of and recognize the needs of eligible OEF and OIF 

servicemembers and veterans? 

To determine outreach efforts VA has made to inform OEF and OIF servicemembers 

and veterans about the VA health care services that may be available to them, we 

interviewed, and collected supporting documentation from, VA officials on their 

efforts and programs that have been established to inform servicemembers and 

veterans about VA health care services. We also observed briefings given by VA 

representatives at two military installations8

 to active duty and reserve 

servicemembers about VA health care services for which they may be eligible. 

 6

The Veterans Health Programs Improvement Act of 2004, Pub. L. No. 108-422, § 302, 118 Stat. 2379, 

2383-86, mandated that VA establish centers for research, education, and clinical activities related to

complex multiple trauma associated with combat injuries. In response to that mandate, VA established

PRCs at four VA medical facilities with expertise in traumatic amputation, spinal cord injury, traumatic

brain injury, and blind rehabilitation. The PRCs address the rehabilitation needs of the combat injured 

in one setting and in a coordinated manner. 

7

GAO, VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth Transition from

DOD Health Care, but Sharing of Health Information Remains Limited, GAO-05-1052T (Washington,

D.C.: Sept. 28, 2005). Also see Related GAO Products at the end of this report. 

8

VA provides briefings at hundreds of MTFs. We attended briefings at two judgmentally selected 

installations—the Naval Station Norfolk, Norfolk, Virginia, and Fort Benning Army Base, Columbus, 

Georgia. 

2 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
To identify actions VA has taken to facilitate the seamless transition of care between 

MTFs and PRCs for servicemembers seriously injured in OEF and OIF, we reviewed 

VA directives, policies, and handbooks governing access to VA health care by OEF 

and OIF servicemembers and veterans. We also visited the two MTFs that treat most 

of the seriously injured OEF and OIF servicemembers—Walter Reed Army Medical 

Center and the National Naval Medical Center, both located in the Washington, D.C., 

area—and the four PRCs that treat them. The PRCs are located at VA Medical Centers 

in Palo Alto, California; Tampa, Florida; Minneapolis, Minnesota; and Richmond, 

Virginia. During those visits, we interviewed medical providers and reviewed the VA 

electronic medical records of the 193 seriously injured servicemembers who were 

admitted to the PRCs from January 7, 2002,9

 through December 16, 2005. In addition, 

we attended a discharge planning conference for an OIF servicemember being 

discharged from a PRC to document the information provided to the servicemember 

about his follow-up health care from VA and DOD. We made subsequent visits to the 

Richmond and Tampa PRCs to observe the capability of PRC providers to access 

DOD electronic medical records. 

To identify the special educational activities or clinical tools that VA is using to help 

ensure its medical providers are aware of and recognize the needs of eligible OEF 

and OIF servicemembers and veterans, we interviewed, and collected supporting 

documentation from, VA officials. While we were at the Naval Station Norfolk 

conducting audit work, we also visited the VA Medical Center in Hampton, Virginia, 

to obtain information on the educational activities and clinical tools VA uses when 

treating OEF and OIF servicemembers and veterans. We also obtained this 

information from the four PRCs. Further, we determined the number of VA medical 

providers and other staff who completed online educational courses developed by 

VA. 

Our review was conducted from May 2005 through June 2006 in accordance with 

generally accepted government auditing standards. 

Results in Brief 

VA has made a variety of outreach efforts to provide OEF and OIF servicemembers 

and veterans and their families with information on VA health care services. VA

reported that from October 1, 2000, through May 31, 2006, it provided about 36,000 

briefings to almost 1.4 million active duty, reserve, and National Guard 

servicemembers about VA health care services that may be available to them. In some 

cases, family members also attended these briefings, which were provided at over 

200 sites, including 70 sites outside the United States. VA also maintains a Web site 

containing health information focused on OEF and OIF servicemembers and 

veterans, distributes brochures and pamphlets to provide information about topics of 

interest to OEF and OIF servicemembers and veterans and their families, and sends 

letters and newsletters to veterans about VA health care services and health issues 

specific to veterans. 

 9

Although OEF began in October 2001, the earliest recorded date that a servicemember injured in OEF 

was admitted to a PRC for treatment was January 7, 2002. 

3 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
VA has taken several actions to facilitate the transition of medical and rehabilitative 

care for seriously injured servicemembers who are being transferred from MTFs to 

PRCs. In April 2003, the Secretary of VA authorized VA medical facilities to give 

priority to OEF and OIF servicemembers over veterans, except those with serviceconnected disabilities. In April 2004, VA signed a memorandum of agreement (MOA) 

with DOD that established the referral procedures for transferring injured 

servicemembers from DOD to VA medical facilities. VA and DOD also established 

joint programs to ease the transfer of injured servicemembers to VA medical 

facilities, including a program that assigned VA social workers to selected MTFs to 

coordinate patient transfers to VA medical facilities. Nevertheless, problems remain 

in the process for electronically sharing the medical records VA needs to determine 

whether servicemembers are medically stable enough to participate in vigorous 

rehabilitation activities. According to VA officials, the transfer could be more efficient 

if PRC medical personnel had real-time access to the servicemembers’ complete DOD 

electronic medical records from the referring MTFs. VA and DOD reported that as of 

December 2005 only two of the PRCs had requested and been granted real-time 

access to the electronic medical records maintained at Walter Reed Army Medical 

Center. One of these PRCs had also been granted access to the electronic medical 

records at the National Naval Medical Center. However, problems continue to exist 

with the PRCs’ ability to access DOD electronic medical records. During a visit to the 

two PRCs in April 2006, we found that neither facility could access the DOD 

electronic medical records at Walter Reed Army Medical Center because of technical 

difficulties. Furthermore, while VA’s electronic medical record system captures a 

wide range of patient information, we found that at the time we conducted our audit 

work it did not always contain a complete record of information related to the 

patient’s discharge from the PRC, such as dates and times of follow-up medical 

appointments—information that could be useful for maintaining continuity of care or 

responding to a patient inquiry about future appointments. In response to our 

concerns about this problem, VA has taken corrective action. The department has 

developed a template that identifies the information given to servicemembers at 

discharge from PRCs. The template has been included in VA’s electronic medical 

record for use systemwide. 

VA has developed a number of educational activities and online clinical tools to help 

ensure that VA medical providers and other staff are aware of and recognize the 

health care needs of OEF and OIF servicemembers and veterans. Examples of VA’s 

educational efforts include developing online courses on infectious diseases of 

Southwest Asia; holding conferences on brain injuries; conducting conference calls, 

each of which provided more than 100 VA staff with information on transferring 

servicemembers from DOD to VA health care services; and developing publications 

on the long-term effects of using an antimalarial drug. VA has also provided 

educational activities at two East Coast centers targeting medical professionals (such 

as physicians, nurses, and social workers), including conferences on topics such as 

physical and mental health issues, infectious disease issues, and health care services 

provided by VA. Furthermore, VA has developed clinical tools to help its staff be 

aware of and responsive to the needs of OEF and OIF servicemembers and veterans. 

For example, it has added reminder screens to its electronic medical records that pop 

up when staff are accessing patients’ records and prompt them to ask questions about 

4 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
OEF- and OIF-related medical and psychological conditions, such as infectious 

diseases and depression. VA and DOD have also developed guidelines to assist 

clinicians in providing medical care to OEF and OIF veterans. 

We provided a draft of this report to VA and DOD for comment. VA concurred with 

the information presented in our draft report. DOD commented that the report 

portrays the numerous efforts that have been made to improve the efficacy of 

programs designed to ensure a smooth transition and continuity of care as 

servicemembers transition back and forth between DOD and VA health care systems. 

DOD also stated that the report contained several inaccuracies; however, we 

maintain that the information contained in the report accurately presents the results 

of our audit work. 

Background 

DOD has reported that as of June 26, 2006, over 19,000 servicemembers have been 

wounded in action since the onset of OEF and OIF. Some of these servicemembers 

are surviving injuries that would have been fatal in past conflicts. In World War II, 

about 30 percent of American servicemembers wounded in combat died. Because of 

medical advances, this proportion has dropped to 3 percent for OEF and OIF 

servicemembers, but many of them are returning home with severe disabilities, 

including traumatic brain injuries and missing limbs. In 2005, DOD reported that 

about 65 percent of the OEF and OIF servicemembers wounded in action were 

injured by blasts and fragments from improvised explosive devices, land mines, and 

other explosive devices. More recently, DOD estimated in 2006 that the percentage of 

those injured by blasts and fragments who have some degree of trauma to the brain 

ranged from less than 20 percent to 28 percent. These injuries may require 

comprehensive inpatient rehabilitation services to address complex cognitive, 

physical, and mental health impairments.10

 

While servicemembers are on active duty, DOD manages where they receive their 

care—at an MTF, a TRICARE civilian provider, or a VA medical facility.Once 

discharged from the military or demobilized from the reserves or National Guard, 

veterans may be eligible to receive care from VA’s health care system. 

From the OEF and OIF conflict areas, seriously injured servicemembers are usually 

brought to Landstuhl Regional Medical Center in Germany for treatment. From there, 

they are usually transported to MTFs located in the United States, with most of the 

seriously injured admitted to Walter Reed Army Medical Center or the National Naval 

Medical Center. Once seriously injured servicemembers are medically stabilized, 

DOD can elect to send those with traumatic brain injuries and other complex trauma, 

such as missing limbs, to one of the four PRCs for rehabilitative services. 

 10Traumatic brain injuries may cause problems with cognition (concentration, memory, judgment, and 

mood), movement (strength, coordination, and balance), sensation (tactile sensation and vision), and

emotion (instability and impulsivity). 

5 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
The transfer of injured servicemembers from MTFs to VA medical facilities for 

medical care requires the exchange of health information between DOD and VA. In 

August 1998, the President issued a directive requiring VA and DOD to develop a 

computer-based patient record system that would accurately and efficiently exchange 

information between the departments. The directive stated that VA and DOD should 

define, acquire, and implement a fully integrated computer-based patient record 

available across the entire spectrum of health care delivery over the lifetime of the 

patient.11

Since receiving the President’s directive, VA and DOD have been working to 

exchange patient health information electronically and ultimately to have 

interoperable electronic medical records. VA and DOD have begun to implement 

applications that exchange limited electronic medical information between the 

departments’ existing health information systems. One of these applications—the 

Bidirectional Health Information Exchange—is a project to achieve the two-way 

exchange of health information on patients who receive care from both VA and DOD. 

The application has been implemented at all VA sites and at 14 DOD sites to exchange 

information such as pharmacy and allergy data, but as we testified in September 2005, 

the goal of systemwide two-way electronic exchange of patient records remains far 

from being realized.12 As a separate effort, VA and DOD have undertaken an initiative 

to allow the four PRCs to electronically access medical records at Walter Reed Army 

Medical Center and the National Naval Medical Center to obtain information on

seriously injured OEF and OIF servicemembers. The capability for electronic access 

was requested by the Richmond and Tampa PRCs in 2005 and by the Palo Alto and 

Minneapolis PRCs in 2006. This capability will be limited to a small number of 

providers at each of the PRCs. 

Apart from joint efforts to share medical information, VA and DOD separately have 

developed electronic systems for recording and accessing patient health information. 

VA’s electronic medical records are maintained in a system that captures a wide

range of patient information, including doctors’ progress notes, vital signs, laboratory 

results, medications dispensed, drug allergies, radiological images, and clinical 

reminders. VA’s system also allows the patient’s complete medical record to be 

accessed from any VA medical facility. While DOD’s electronic medical record system 

also captures information such as doctors’ progress notes, vital signs, medications 

dispensed, and laboratory results, it does not include radiological images, vision and 

hearing tests, or anesthesia notes. In addition, DOD does not have a systemwide 

approach to electronic medical record management since the information is 

maintained and stored at individual MTFs or, in some locations, in networks that 

service multiple MTFs within a small geographic area. Under DOD’s approach, all 

medical information cannot be electronically accessed by providers throughout 

 11National Science and Technology Council, A National Obligation: Planning for Health 

Preparedness for and Readjustment of the Military, Veterans, and Their Families After Future 

Deployments, Presidential Review Directive 5 (Washington, D.C.: Executive Office of the President,

Office of Science and Technology Policy, August 1998). 

12GAO, 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).

6 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
DOD’s health care system. For example, providers at Walter Reed Army Medical 

Center and the National Naval Medical Center can access each other’s electronic 

medical records but cannot access medical records from Landstuhl Regional Medical 

Center in Germany. 

VA’s Outreach Includes Briefings, Web Sites, and Newsletters 

VA has taken a number of actions to provide OEF and OIF servicemembers and their 

families with information about VA health care services, such as the cost of the 

services, how to register for VA health care, and where to obtain VA health care. VA 

reported that from October 1, 2000, through May 31, 2006, it held about 36,000 

briefings for almost 1.4 million active duty, reserve, and National Guard 

servicemembers. These briefings were held at over 200 sites, including 70 sites 

located outside the United States. VA reported that over 8,000 family members 

attended some of these briefings from October 1, 2005, through May 31, 2006. In 

addition, under a May 2005 MOA between VA and the National Guard, VA has trained 

staff hired by the National Guard to provide VA health and benefit information to 

National Guard units in each state.

For both servicemembers and veterans, VA has also created a Web site13 that provides 

information for those who served in OEF and OIF, such as information on VA health 

and medical services, dependents’ benefits and services, and transition assistance 

from military to civilian life. The Web site contains information about VA benefits 

available to active duty military personnel, including a page that briefly describes 

these benefits. VA has also developed a variety of informational materials, including a 

wallet-sized card with relevant toll-free telephone numbers and Web site addresses, 

fact sheets and pamphlets summarizing VA benefits, and a monthly video magazine 

called The American Veteran. VA reported that almost 1.4 million of the wallet-sized 

cards have been distributed during briefings. Fact sheets and pamphlets are sent to 

VA medical facilities for distribution to veterans and are also available on VA’s Web 

site. The video magazine reports information about VA services on a VA Web site14

and on the Pentagon Channel, which is available online15 and on cable television. 

VA also has outreach efforts designed specifically for active duty, reserve, and 

National Guard OEF and OIF veterans. The Secretary of VA sends new veterans a 

letter thanking them for their service to the country and informing them about VA 

health care services and assistance in their transition to civilian life. As of May 15, 

2006, the Secretary had sent letters to over 530,000 OEF and OIF servicemembers 

who had left active duty. These letters include information about the VA health care 

services available to veterans and a toll-free number for obtaining additional health 

care information. In addition, from December 2003 through March 2006 VA sent four 

newsletters to OEF and OIF veterans with information on health issues of interest to 

these veterans. 

 13See http://www.seamlesstransition.va.gov. 

14See http://www1.va.gov/opa/feature/amervet/index.htm. 

15See http://www.pentagonchannel.mil. 

7 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
VA Activities Facilitate the Transition of Care for Seriously Injured OEF and 

OIF Servicemembers Transferred to PRCs

VA has taken a number of actions to facilitate the transition of medical and 

rehabilitation care for servicemembers who have been seriously injured in OEF and 

OIF and are being transferred between DOD and VA medical facilities. These actions 

focus on establishing and expanding internal initiatives for providing care to this 

population as well as VA’s efforts to electronically share medical records with DOD. 

In April 2003, when the President declared a national emergency with respect to the 

Iraq conflict, the Secretary of VA issued a memorandum authorizing VA medical 

facilities to give priority to servicemembers who sustained injuries in OEF and OIF 

over veterans and others eligible for VA health care, except those with serviceconnected disabilities. In October 2003, VA issued a directive requiring its medical 

facilities to designate a point of contact to receive and expedite transfers of 

servicemembers from DOD to VA medical facilities. In April 2004, VA signed an MOA 

with DOD to provide health care and rehabilitation services to servicemembers who 

sustain spinal cord injury, traumatic brain injury, or visual impairment. The MOA 

established the referral procedures for transferring active duty inpatient 

servicemembers from DOD to VA medical facilities.16 In June 2005, VA issued a 

directive expanding the scope of care it would provide to include psychological 

treatment for family members and intensive clinical and social work case 

management services17 at its four regional traumatic brain injury rehabilitation 

centers and renamed these facilities PRCs. 

VA has also established joint programs with DOD to ease the transfer of injured 

servicemembers to VA medical facilities. In August 2003, VA and DOD established a 

program that assigned VA social workers to selected MTFs18 to coordinate patient 

transfers between DOD and VA medical facilities. The social workers make 

appointments for care, ensure continuity of therapy and medications, and follow up 

with patients after discharge. By late February 2006, VA reported that the social 

workers had received requests for transfer of care for over 6,000 patients, and over 

three-fourths of them had been transferred to VA facilities; the rest of the requests 

 16In addition to outlining DOD’s and VA’s responsibilities in the transfer process, the MOA also 

established the reimbursement rate between the two departments for inpatient care that VA would

provide. 

17Case management includes assessment of the individual’s health care needs, care planning and 

implementation, referral coordination, monitoring, and periodic reassessment of the individual’s health

care needs. 

18Five MTFs were originally selected because they received most of the OEF and OIF casualties. These 

facilities were Walter Reed Army Medical Center (Washington, D.C.), Brooke Army Medical Center

(San Antonio, Texas), Dwight David Eisenhower Army Medical Center (Augusta, Georgia), Madigan 

Army Medical Center (Tacoma, Washington), and the National Naval Medical Center (Bethesda, 

Maryland). In 2004 and 2005, three additional MTFs—Darnall Army Community Hospital (Fort Hood,

Texas), Evans Army Community Hospital (Fort Carson, Colorado), and the Naval Hospital Camp 

Pendleton (Camp Pendleton, California)—were added to care for returning OEF and OIF 

servicemembers. 

8 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
were pending.19 Under another program, a uniformed servicemember was stationed at 

each PRC beginning in March 2005 to assist servicemembers being admitted to the 

PRC. The uniformed servicemembers serve as liaisons among injured 

servicemembers and their families, the MTFs, the PRCs, and the servicemembers’ 

units. For example, they assist with reimbursement for travel and lodging costs for 

immediate family members. 

In January 2005, VA established the Seamless Transition Office to enhance 

servicemembers’ transition back to civilian life by improving coordination within the 

Veterans Benefits Administration and the Veterans Health Administration,20 as well as 

between DOD and VA. The goals of the Seamless Transition Office related to health 

care include improving communication, coordination, and collaboration within VA 

and with DOD concerning health care, educating VA staff about OEF and OIF 

veterans’ health care, and other needs. The office has been active in areas such as 

coordinating efforts of the VA social workers assigned to MTFs to help 

servicemembers transfer their health care from MTFs to VA health care facilities and 

issuing a handbook on the policy and procedures for PRCs, including recommended 

staffing levels for the different types of medical providers caring for patients. 

There are also a number of routinely scheduled teleconferences and 

videoconferences within VA and between VA and the military medical facilities to 

coordinate medical care for injured servicemembers and to discuss and resolve 

medical issues. Topics include issues that are general in nature and would apply to a 

number of servicemembers or that are specific to individual servicemembers. For 

example, monthly, and as needed, VA’s Seamless Transition Office and PRC staff hold 

teleconferences to discuss such issues as obtaining DOD medical records and how to 

provide follow-up medical care once the servicemember is discharged from the PRC. 

Further, on a bimonthly basis, PRCs hold teleconferences or videoconferences with 

Walter Reed Army Medical Center and the National Naval Medical Center to discuss 

issues arising during the transfer of injured servicemembers from their facilities to 

the PRCs, such as obtaining military medical records. Servicemembers and their 

families sometimes participate in the videoconference to meet PRC staff prior to 

transfer. Also on a monthly basis, VA and DOD hold videoconferences to discuss 

medical and logistical issues that arise with injured servicemembers. These 

videoconferences include DOD medical providers from Landstuhl Regional Medical 

Center in Germany and combat medical units located in Iraq. For example, during 

one videoconference, VA and DOD staff discussed the blood filters21 that were being 

 19According to VA, patients remain in pending status until DOD determines that the patient is ready for 

transfer to a VA facility and VA determines the patient’s medical condition is stable. 

20The Veterans Benefits Administration provides benefits and services, such as disability

compensation, to veterans. The Veterans Health Administration’s primary responsibility is the delivery

of health care to veterans. 

21Blood filters are filters that screen blood to remove clots that could result in death. 

9 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
surgically implanted in injured servicemembers in Iraq.22 Medical providers in 

Baghdad asked if there was a different type of blood filter that they could use that 

would make removal easier at the stateside MTF or PRC. 

Despite coordination, we found that the departments are having problems 

exchanging health care information electronically between the four PRCs and the two 

MTFs—Walter Reed Army Medical Center and the National Naval Medical Center. 

While our current review focused on the electronic transfer of information among 

these six facilities, over 5 years ago we recommended that VA and DOD create 

comprehensive and coordinated plans to ensure that the departments can share 

comprehensive, meaningful, accurate, and secure patient health data.23 Both VA and 

DOD concurred with this recommendation and are in the process of implementing it. 

From a systemwide perspective, we testified over 2 years ago and again last 

September on the need for VA and DOD to intensify their efforts to implement the 

capability to share health care information electronically. In those testimonies, we 

recognized the actions VA and DOD had taken to electronically exchange health 

information but also acknowledged that much work remains to attain this goal.24

 

During our visits to the PRCs from October through December 2005, we observed 

that none of the PRCs had real-time access to the injured servicemembers’ DOD 

electronic medical records from the transferring MTFs. Instead, the MTF faxed 

copies of some of the medical information, such as the servicemember’s medical 

history and physical and doctor’s progress notes from these records, to the PRC. 

Because this information did not always provide enough data for the PRC provider to 

determine if the servicemember was medically stable enough to be admitted to the 

PRC and to engage in vigorous rehabilitation activities and because the PRC did not 

have access to the complete medical records (paper or electronic), VA developed a 

standardized list of the minimum types of health care information needed about each 

servicemember transferring from an MTF. However, after they reviewed this basic 

medical information PRC providers stated that they frequently needed additional 

information and had to ask the PRC social worker to obtain it from the VA social 

worker at the MTF. For example, if the PRC provider noticed that the servicemember 

was on a particular antibiotic therapy, the provider might request the results of the 

most recent blood and urine cultures to determine if the servicemember was 

medically stable enough to participate in strenuous rehabilitation activities. 

 22VA officials in attendance included staff from the PRCs and the Seamless Transition Office. DOD

officials in attendance included staff from Walter Reed Army Medical Center; the National Naval

Medical Center; Brooke Army Medical Center; Wilford Hall Medical Center; Army Institute for Surgical

Research; Landstuhl Regional Medical Center in Germany; and combat medical units located in Balad 

and Baghdad, Iraq. 

23GAO, 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). 

24GAO, 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.: 

Mar. 17, 2004); 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.: Nov. 19, 2003); and GAO-05-1051T. 

10 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
According to PRC officials, obtaining additional medical information in this way 

rather than electronically was very time consuming and often required multiple 

phone calls and faxes between the facilities. 

According to VA officials, the main barrier to PRC medical providers’ getting realtime access to medical records was DOD’s interpretation of the Health Insurance 

Portability and Accountability Act of 1996 (HIPAA)25 and the HIPAA Privacy Rule.26

The HIPAA Privacy Rule permits VA and DOD to share servicemembers’ health 

information under certain circumstances, such as for purposes of treatment or if the 

individual signs a proper authorization. However, DOD officials told us they initially 

were reluctant to provide this access to VA because they were concerned that VA 

would have access to health information of all servicemembers, not only the 

information of those being transferred to the PRC for treatment. 

Since we initiated our review, the four PRCs and Walter Reed Army Medical Center 

and the National Naval Medical Center have reached separate agreements on the 

records VA would be able to access and have begun to take action to share medical 

records.27 During our initial visits, two PRCs—Richmond and Tampa—were in the 

process of separately negotiating with Walter Reed Army Medical Center to obtain 

real-time access to injured servicemembers’ electronic medical records. VA reported 

that as of December 27, 2005, PRC providers in Richmond and Tampa have real-time 

access to these records. The Tampa PRC also gained access to the National Naval 

Medical Center’s electronic medical records on February 21, 2006. VA and DOD 

officials have not established a date when all PRCs would have real-time access to 

electronic records at Walter Reed Army Medical Center and the National Naval 

Medical Center. 

In April 2006, we revisited the Tampa and Richmond PRCs and found that problems 

continued with access to DOD electronic medical records. Providers at both PRCs 

that had been granted electronic access by DOD to obtain medical information stated 

that they could not always access the DOD electronic records. For example, during 

our visits neither facility could access the DOD electronic medical records at Walter 

Reed Army Medical Center because of a technical problem. Furthermore, while a 

nurse practitioner at the Tampa PRC was able to access the electronic medical 

records at the National Naval Medical Center, the admitting PRC provider for 

rehabilitative services could not. 

 25Pub. L. No. 104-191, 110 Stat. 1936 (1996). 

26The Privacy Rule, which became effective on April 14, 2001, specifies how individually identifiable

health information may be used and disclosed by covered entities, which include health plans, health

care clearinghouses, and certain health care providers. See 45 C.F.R. §§ 164.500(a), 164.502 (2005). 

Both TRICARE and the VA health care system are health plans. See 45 C.F.R. § 160.103 (2005). 

27This initiative is a unique undertaking by the four PRCs, Walter Reed Army Medical Center, and the

National Naval Medical Center. It is distinct from VA’s and DOD’s Bidirectional Health Information 

Exchange. 

11 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
While VA’s electronic medical records offer ready access to VA medical information 

for its medical providers, we found that during our site visits some information

related to servicemembers’ and veterans’ discharge from PRCs was not always 

entered into the records. When servicemembers and veterans are discharged from 

PRCs, many still require follow-up medical care at VA, DOD, or private-sector 

facilities. The social worker at the PRC is responsible for arranging follow-up 

appointments prior to the patient’s discharge from the PRC. Information on follow-up 

appointments and points of contact is provided to the servicemember or veteran 

during the discharge planning conference, along with a large amount of other medical 

information and discharge instructions. Our review of 193 servicemembers’ VA 

electronic medical records showed that 126 patients required follow-up medical 

appointments after discharge from the PRC.28 An examination of the 126 records 

indicated that appointments were made for 122 of the patients, with the remaining 

4 patients instructed to call their local VA medical centers for appointments. 

However, while the date and time for the appointment was in the electronic medical 

record, it was not clearly summarized in 96 of 122 of these records, nor was there 

evidence that it was given to the patient. In addition, 75 of the 122 records did not 

clearly indicate the points of contact, nor was there evidence that this information 

was given to the patient. If this information were clearly documented in patients’ 

electronic medical records, it would be available to VA providers who may need it to 

manage future care. 

In February 2006, in response to questions we raised during our review, VA developed 

a template for PRC social workers to complete when a patient is discharged. The 

social worker includes on the template information on follow-up medical 

appointments, contact names and telephone numbers for the medical facilities where 

the servicemember is going to obtain follow-up medical care, military contacts, and 

PRC contacts. This template is entered into the electronic medical record. During our 

visit to the Tampa and Richmond PRCs in April 2006, we found that the social 

workers had been using the templates for patients discharged since mid-March 2006. 

VA Is Using Courses, Conferences, and Online Clinical Tools to Help Ensure 

Medical Providers Are Aware of and Recognize Needs of Eligible OEF and 

OIF Servicemembers and Veterans 

VA has developed activities to educate its medical providers and other staff on the 

health care needs of those who are or have been deployed in OEF and OIF. As part of 

its Veterans Health Initiatives, VA produced 14 educational courses that address OEFand OIF-related topics, such as traumatic brain injuries and infectious diseases of 

Southwest Asia. These courses are available on VA’s intranet, over the Internet, and 

on compact discs. As of December 31, 2005, VA reported that nearly 2,000 courses 

had been completed by VA staff, including nearly 1,200 courses that were completed 

by physicians. Also over 12,000 courses were completed by non-VA staff, such as 

veterans, family members, and staff from veterans service organizations.

 28The remaining 67 patients did not need follow-up outpatient appointments because they were still 

patients in the PRC; had been transferred to another inpatient facility, such as an MTF or VA long-term 

care facility; or did not need follow-up medical care. 

12 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
VA medical centers have also used conferences and in-house presentations to train 

staff on the needs of OEF and OIF servicemembers and veterans. For example, the 

Tampa PRC sponsored blast injury conferences in 2004 and 2005 that were attended 

by physicians, nurses, psychologists, and social workers. In addition, from April 2005 

through April 2006, VA held five 11⁄2-hour conference calls for VA social workers that 

focused on the transfer of care for servicemembers from DOD to VA medical 

facilities, including information such as ways to be proactive in working with military 

families as they transition from active duty to veteran status and recognizing the signs 

and symptoms of stress and post-traumatic stress disorder in returning OEF and OIF 

veterans. VA reported that attendance for the conference calls ranged from 105 to 

360 social workers. 

VA’s educational efforts have also included publications. VA’s Under Secretary for 

Health has issued five informational letters to VA’s medical providers offering 

guidance on OEF- and OIF-related topics. The topics of these letters include the longterm effects of heat-related illnesses and the long-term effects of using an 

antimalarial drug. In addition, VA’s War-Related Illness and Injury Study Centers have 

produced publications providing information for combat veterans and providers on 

topics such as management of chronic pain and the effects of exposure to depleted 

uranium.29

VA’s War-Related Illness and Injury Study Centers have also provided educational 

activities and clinical tools to help medical professionals treat OEF and OIF 

servicemembers and veterans. In 2004 and 2005 the centers reported that they held 

three conferences, with a total attendance of more that 450 health care providers, 

including physicians, nurses, and social workers, that addressed such topics as 

physical and mental health issues, infectious disease issues, and health care services 

provided by VA. They also held six workshops from 2003 through 2005 on topics such 

as patient-provider communication and the recognition and treatment of undiagnosed 

illnesses, and established Web sites that provide links to their publications and to 

other sources of education for medical providers. 

VA has also developed various clinical tools to enhance the ability of its providers 

and other staff to be aware of and responsive to the needs of OEF and OIF 

servicemembers and veterans. For example, VA has added reminder screens to its 

electronic medical records that pop up when a patient’s record is opened if the 

veteran served in the military after September 11, 2001. These screens prompt 

providers to ask questions about medical and psychological issues related to OEF 

and OIF veterans, such as infectious diseases and depression. The screens continue 

to pop up each time the patient’s medical record is opened until the information 

requested is entered into that record. The pop-up reminder screens were the subject 

of one of the informational letters issued to VA staff. Further, VA and DOD developed 

 29In May 2001, VA established the two War-Related Illness and Injury Study Centers, one in Washington,

D.C., and one in East Orange, New Jersey. The mission of these centers includes providing healthrelated educational services to veterans and health care professionals.

13 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
25 guidelines for clinical practice,30 which can be viewed on a VA Web site.31 VA 

officials stated that any of the guidelines may be used for OEF and OIF 

servicemembers and veterans depending on their needs. Finally, VA’s National Center 

for Post-Traumatic Stress Disorder and DOD developed the Iraq War Clinician

Guide. It addresses the needs of veterans of the Iraq war and is available on a VA 

Web site.32

Agency Comments and Our Evaluation 

VA and DOD reviewed a draft of this report and provided written comments, which 

appear in enclosures I and II respectively. VA concurred with the information

presented in our draft report. It also stated that PRCs’ access to DOD’s electronic 

medical records has been a significant challenge for VA in accomplishing its mission. 

VA further commented that it is justifiably proud of the accomplishments of its 

dedicated staff in successfully responding to the often overwhelming transitional 

needs of these young servicemembers and their families. DOD commented that the 

report portrays the numerous efforts that have been made to improve the efficacy of 

programs designed to ensure a smooth transition and continuity of care as 

servicemembers transition back and forth between DOD and VA health care systems. 

DOD commented that the statements in the draft report concerning its lack of a 

systemwide approach to electronic medical record management and the inability of 

providers throughout DOD’s health care system to access medical records is 

completely inaccurate. Our statements are not inaccurate. While our draft report 

recognizes DOD’s long-standing ongoing efforts to achieve the capability to 

electronically share the complete medical record, we did not find that this capability 

exists yet at DOD. For example, in March 2006 the Chief Information Officer at the 

National Naval Medical Center explained to us that MTFs did not have access to 

electronic medical records at other MTFs across the United States. He told us that 

while information could be shared among providers linked by a local area network, 

those providers could not electronically access medical records from other local area 

networks. Specifically, he noted that providers at Walter Reed Army Medical Center 

and the National Naval Medical Center can access each other’s medical records 

electronically, but they cannot access medical records from Landstuhl Regional 

Medical Center in Germany or from MTFs in San Antonio, Texas. He acknowledged 

that DOD’s Armed Forces Health Longitudinal Technology Application (AHLTA)—a 

comprehensive electronic health record—will allow providers to access medical 

information. In its comments, DOD also cited the access that AHLTA will provide. 

However, DOD documentation that describes the system states that it is for 

outpatient care—only one part of the complete medical record. VA providers treating 

OEF and OIF servicemembers are in need of information concerning the inpatient 

care—not just the outpatient care—that servicemembers received at DOD. 

Furthermore, AHLTA cannot be accessed by all of DOD’s providers. In its comments 

 30Clinical practice guidelines are recommendations for treating specific diseases or conditions. 

31See http://www.oqp.med.va.gov/cpg/cpg.htm. 

32See http://www.ncptsd.va.gov/war/guide/index.html. 

14 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
on our draft report DOD stated that AHLTA is not operational at 19 percent of DOD’s 

MTFs and that full deployment is not expected until December 2006. In comparison, 

VA’s system allows the patient’s complete medical record to be accessed from any VA 

medical facility. 

In its comments, DOD also mentioned that a section of our draft report that described 

the actions VA has taken to facilitate the transition of care from DOD to VA is 

misleading. However, the section is an accurate presentation of VA initiatives as 

presented to us by VA and as observed during our audit work. Furthermore, DOD 

stated that it transmits certain medical information to VA on a monthly basis, 

although VA providers told us they need ready electronic access to current medical 

record information for the seriously injured OEF and OIF servicemembers. We 

believe that in order to plan and begin appropriate treatment immediately upon a 

servicemember’s arrival at a PRC, medical record information is best provided 

through direct electronic access, not through monthly transmissions. Our draft report 

recognized the technical advances that VA has made in that it has the capability to 

electronically share the complete medical record of each of its beneficiaries among 

all its providers at all its medical facilities. This means that all medical services 

provided by VA to its beneficiaries—including information such as outpatient or 

inpatient procedures, pharmacy, or radiology notes—are included in VA’s electronic 

record. 

VA and DOD provided technical comments that we incorporated where appropriate. 

- - - - - 

As agreed with your office, unless you publicly announced its contents earlier, we 

plan no further distribution of this report until 30 days after its report date. We will 

then send copies of this report to the Secretaries of Veterans Affairs and Defense and 

appropriate congressional committees. We will also make copies available to others 

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

http://www.gao.gov. 

If you or your staff have any questions, please contact me at (202) 512-7101 or 

bascettac@gao.gov. Contact points for our Offices of Congressional Relations and 

Public Affairs may be found on the last page of this report. GAO staff who made

major contributions to this report are Michael T. Blair, Jr., Assistant Director; Cynthia 

Forbes; Roseanne Price; Shannon Slawter; and Cherie’ Starck. 

Sincerely yours, 

Cynthia A. Bascetta 

Director, Health Care 

Enclosures - 2 

15 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
Enclosure I Enclosure I

Comments from the Department of Veterans Affairs 

16 GAO-06-794R Transition of Care for OEF and OIF Servicemembers 
Enclosure I Enclosure I

17 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
Enclosure II Enclosure II

Comments from the Department of Defense 

18 GAO-06-794R Transition of Care for OEF and OIF Servicemembers 
Enclosure II Enclosure II

19 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
Enclosure II Enclosure II

20 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
Enclosure II Enclosure II

21 GAO-06-794R Transition of Care for OEF and OIF Servicemembers
Related GAO Products 

Information Technology: VA and DOD Face Challenges in Completing Key Efforts. 

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

VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth 

Transition from DOD Health Care, but Sharing of Health Information Remains 

Limited. GAO-05-1052T. Washington, D.C.: September 28, 2005. 

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. 

Military and Veterans’ Benefits: Improvements Needed in Transition Assistance 

Services for Reserves and National Guard. GAO-05-844T. Washington, D.C.: June 29, 

2005. 

Military and Veterans’ Benefits: Enhanced Services Could Improve Transition

Assistance for Reserves and National Guard. GAO-05-544. Washington, D.C.: May 20, 

2005. 

DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers’ 

Transition to VA Services. GAO-05-722T. Washington, D.C.: May 19, 2005. 

Vocational Rehabilitation: VA Has Opportunities to Improve Services, but Faces 

Significant Challenges. GAO-05-572T. Washington, D.C.: April 20, 2005. 

VA Disability Benefits and Health Care: Providing Certain Services to the 

Seriously Injured Poses Challenges. GAO-05-444T. Washington, D.C.: March 17, 2005. 

Vocational Rehabilitation: More VA and DOD Collaboration Needed to Expedite 

Services for Seriously Injured Servicemembers. GAO-05-167. Washington, D.C.: 

January 14, 2005. 

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: 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: Better Planning and Oversight by VA, DOD, and 

IHS Would Enhance Health Data Sharing. GAO-01-459. Washington, D.C.: 

April 30, 2001. 

(290463) 

22 GAO-06-794R Transition of Care for OEF and OIF Servicemembers 
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