ELECTRONIC HEALTH 

RECORDS

Long History of 

Management Challenges 

Raises Concerns about VA’s 

and DOD’s New Approach 

to Sharing Health 

Information

Statement of Valerie C. Melvin, Director 

Information Management and Technology Resources 

Issues 

Testimony

Before the Committee on Veterans’ 

Affairs, House of Representatives 

For Release on Delivery 

Expected at 9:15 a.m. EST

Wednesday, February 27, 2013

GAO-13-413T 

United States Government Accountability Office

GAO 
 United States Government Accountability Office 

Highlights of GAO-13-413T, a testimony 

before the Committee on Veterans’ Affairs, 

House of Representatives 

February 27, 2013 

ELECTRONIC HEALTH RECORDS 

Long History of Management Challenges Raises 

Concerns about VA’s and DOD’s New Approach to 

Sharing Health Information 

Why GAO Did This Study 

VA and DOD operate two of the 

nation’s largest health care systems—

systems that serve populations of 

veterans and active service members 

and their dependents. To better serve 

these populations, VA and DOD have 

been collaborating for about 15 years 

on a variety of initiatives to share data 

among the departments’ health 

information systems. The use of IT to 

electronically collect, store, retrieve, 

and transfer such data has the 

potential to improve the quality and 

efficiency of health care. Particularly 

important in this regard is developing 

electronic health records that can be 

accessed throughout a patient’s 

military and veteran status. Making 

such information electronic can ensure 

greater availability of health care 

information for service members and 

veterans at the time and place of care. 

Although they share many common 

business needs, both VA and DOD 

have spent large sums of money to 

develop and maintain separate 

electronic health record systems that 

they use to create and manage patient 

health information. 

GAO was asked to testify on (1) the 

departments’ efforts, and challenges 

faced, in electronically sharing health 

information and (2) the recent change 

in their approach to developing an 

integrated electronic health record. In 

preparing this statement, GAO relied 

primarily on previously published work 

in this area. 

What GAO Recommends 

Since 2001, GAO has made numerous 

recommendations to improve VA’s and 

DOD’s management of their efforts to 

share health information. 

What GAO Found 

The Departments of Veterans Affairs (VA) and Defense (DOD) have undertaken 

a number of patchwork efforts over the past 15 years to achieve interoperability 

(i.e., the ability to share data) of records between their information systems; 

however, these efforts have faced persistent challenges. The departments’ early 

efforts to achieve interoperability included enabling DOD to electronically transfer 

service members’ electronic health information to VA; allowing clinicians at both 

departments viewable access to records on shared patients; and developing an 

interface linking the departments’ health data repositories. As GAO reported, 

however, several of these efforts were plagued by project planning and 

management weaknesses, inadequate accountability, and poor oversight, limiting 

their ability to realize full interoperability. 

To further expedite data sharing, the National Defense Authorization Act of 2008 

directed VA and DOD to jointly develop and implement fully interoperable 

electronic health record capabilities by September 30, 2009. The departments 

asserted that they met this goal, though they planned additional work to address 

clinicians’ evolving needs. GAO identified weaknesses in the departments’ 

management of these initiatives, such as a lack of defined performance goals 

and measures that would provide a comprehensive picture for managing 

progress. In addition, the departments’ Interagency Program Office, which was 

established to be a single point of accountability for electronic health data 

sharing, had not fulfilled key management responsibilities. 

In 2009, the departments began work on the Virtual Lifetime Electronic Record 

initiative to enable access to all electronic records for service members 

transitioning from military to veteran status, and throughout their lives. To carry 

this out, the departments initiated several pilot programs but had not defined a 

comprehensive plan that defined the full scope of the effort or its projected cost 

and schedule. Further, in 2010, VA and DOD established a joint medical facility 

that was, among other things, to have certain information technology (IT) 

capabilities to facilitate interoperability of the departments’ electronic health 

record systems. Deployment of these capabilities was delayed, however, and 

some have yet to be implemented. 

In 2011, the VA and DOD Secretaries committed to developing a new common 

integrated electronic health record system, with a goal of implementing it across 

the departments by 2017. This approach would largely sidestep the challenges in 

trying to achieve interoperability between separate systems. However, in 

February 2013, the Secretaries announced that the departments would focus on 

modernizing their existing systems, rather than developing a single system. They 

cited cost savings and meeting needs sooner rather than later as reasons for this 

decision. Given the long history of challenges in achieving interoperability, this 

reversal of course raises concerns about the departments’ ability to successfully 

collaborate to share electronic health information. Moreover, GAO has identified 

barriers to the departments jointly addressing their common needs arising from 

deficiencies in key IT management areas, which could continue to jeopardize 

their pursuits. GAO is monitoring the departments’ progress in overcoming these 

barriers and has additional ongoing work to evaluate their activities to develop 

integrated electronic health record capabilities. 

View GAO-13-413T. For more information, 

contact Valerie C. Melvin at (202) 512-6304 or 

melvinv@gao.gov. 
Page 1 GAO-13-413T 

United States Government Accountability Office

Washington, DC 20548 

Chairman Miller, Ranking Member Michaud, and Members of the 

Committee: 

Thank you for the opportunity to participate in today’s hearing on efforts of 

the Department of Veterans Affairs (VA) to share electronic health 

records with the Department of Defense (DOD). As you know, VA and 

DOD operate two of the nation’s largest health care systems, which, in 

fiscal year 2013, are projected to provide coverage to approximately 6.3 

million veterans and 9.6 million active duty service members and their 

beneficiaries at estimated costs of about $53 billion and $49 billion, 

respectively. 

Both VA and DOD have long recognized the importance of advancing the 

use of shared health information systems and capabilities to make patient 

information more readily available to their health care providers, reduce 

medical errors, and streamline administrative functions. Toward this end, 

the two departments have an extensive history of working to achieve 

shared health care resources, dating back to the 1980s.1

 Our work has 

examined the departments’ efforts over the past 15 years in undertaking a 

variety of initiatives to share data between their individual health 

information systems and to develop interoperable health record 

capabilities. In this regard, reports that we issued between 2001 and 2012 

have noted various degrees of progress by the departments; however, we 

have also highlighted, and recommended that VA and DOD address, 

pervasive and persistent management challenges that have impeded 

their ability to achieve fully interoperable electronic health record 

 

1

Since the 1980s, VA and DOD have entered into many types of collaborations to provide 

health care services—including emergency, specialty, inpatient, and outpatient care—to 

VA and DOD beneficiaries, reimbursing each other for the services provided. These 

collaborations vary in scope, ranging from agreements to jointly provide a single type of 

service to more coordinated “joint ventures,” which encompass multiple health care 

services and facilities and focus on mutual benefit, shared risk, and joint operations in 

specific clinical areas. 

 
 

Page 2 GAO-13-413T 

capabilities.2 My testimony today (1) summarizes VA’s and DOD’s efforts, 

and challenges faced, in electronically sharing health information and (2) 

describes the departments’ recent change in their approach to developing 

an integrated electronic health record. 

In developing this testimony, we relied on our previous work. We also 

obtained and reviewed information on the departments’ actions in 

response to our previous recommendations. We conducted our work in 

support of this testimony during February 2013. All work on which this 

testimony is based was performed in accordance with generally accepted 

government auditing standards. Those standards require that we plan 

and perform the audit to obtain sufficient, appropriate evidence to provide 

a reasonable basis for our findings and conclusions based on our audit 

objectives. We believe that the evidence obtained provides a reasonable 

basis for our findings and conclusions based on our audit objectives. 

The use of information technology (IT) to electronically collect, store, 

retrieve, and transfer clinical, administrative, and financial health 

information has great potential to help improve the quality and efficiency 

of health care. Historically, patient health information has been scattered 

across paper records kept by many different caregivers in many different 

locations, making it difficult for a clinician to access all of a patient’s 

health information at the time of care. Lacking access to these critical 

data, a clinician may be challenged to make the most informed decisions 

on treatment options, potentially putting the patient’s health at greater 

risk. The use of electronic health records can help provide this access 

and improve clinical decisions. 

 

2

See for example, 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); Electronic Health Records: DOD and VA Have Increased Their Sharing of 

Health Information, but More Work Remains, GAO-08-954 (Washington, D.C.: July 28, 

2008); Electronic Health Records: DOD’s and VA’s Sharing of Information Could Benefit 

from Improved Management, GAO-09-268 (Washington, D.C.: Jan. 28, 2009); Electronic 

Health Records: DOD and VA Efforts to Achieve Full Interoperability Are Ongoing; 

Program Office Management Needs Improvement, GAO-09-775 (Washington, D.C.: July 

28, 2009); Electronic Health Records: DOD and VA Interoperability Efforts Are Ongoing; 

Program Office Needs to Implement Recommended Improvements, GAO-10-332 

(Washington, D.C.: Jan. 28, 2010); and Electronic Health Records: DOD and VA Should 

Remove Barriers and Improve Efforts to Meet Their Common System Needs, 

GAO-11-265 (Washington, D.C.: Feb. 2, 2011). 

Background 
 

Page 3 GAO-13-413T 

Electronic health records are particularly crucial for optimizing the health 

care provided to military personnel and veterans. While in military status 

and later as veterans, many VA and DOD patients tend to be highly 

mobile and may have health records residing at multiple medical facilities 

within and outside the United States. Making such records electronic can 

help ensure that complete health care information is available for most 

military service members and veterans at the time and place of care, no 

matter where it originates. 

Although they have identified many common health care business needs, 

both departments have spent large sums of money to develop and 

operate separate electronic health record systems that they rely on to 

create and manage patient health information. VA uses its integrated 

medical information system—the Veterans Health Information Systems 

and Technology Architecture (VistA)—which was developed in-house by 

VA clinicians and IT personnel. The system consists of 104 separate 

computer applications, including 56 health provider applications; 19 

management and financial applications; 8 registration, enrollment, and 

eligibility applications; 5 health data applications; and 3 information and 

education applications. Besides being numerous, these applications have 

been customized at all 128 VA sites.3

 According to the department, this 

customization increases the cost of maintaining the system, as it requires 

that maintenance also be customized. 

In 2001, the Veterans Health Administration undertook an initiative to 

modernize VistA by standardizing patient data and modernizing the health 

information software applications. In doing so, its goal was to move from 

the hospital-centric environment that had long characterized the 

department’s health care operations to a veteran-centric environment built 

on an open, robust systems architecture that would more efficiently 

provide both the same functions and benefits of the existing system and 

enhanced functions based on computable data. VA planned to take an 

incremental approach to the initiative, based on six phases (referred to as 

“blocks”) that were to be completed in 2018. Under this strategy, the 

department planned to replace the 104 VistA applications that are 

currently in use with 67 applications, 3 databases, and 10 common 

services. VA reported spending almost $600 million from 2001 to 2007 on 

 

3

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

that store their electronic health data in a single database. 
 

Page 4 GAO-13-413T 

eight projects, including an effort that resulted in a repository containing 

selected standardized health data, as part of the effort to modernize 

VistA. In April 2008, the department estimated an $11 billion total cost to 

complete, by 2018, the modernization that was planned at that time. 

However, according to VA officials, the modernization effort was 

terminated in August 2010. 

For its part, DOD relies on its Armed Forces Health Longitudinal 

Technology Application (AHLTA), which comprises multiple legacy 

medical information systems that the department developed from 

commercial software products that were customized for specific uses. For 

example, the Composite Health Care System (CHCS), which was 

formerly DOD’s primary health information system, is still in use to 

capture information related to pharmacy, radiology, and laboratory order 

management. In addition, the department uses Essentris (also called the 

Clinical Information System), a commercial health information system 

customized to support inpatient treatment at military medical facilities. 

DOD obligated approximately $2 billion for AHLTA between 1997 and 

2010. 

A key goal for sharing health information among providers, such as 

between VA’s and DOD’s health care systems, is achieving 

interoperability. Interoperability enables different information systems or 

components to exchange information and to use the information that has 

been exchanged. This capability allows patients’ electronic health 

information to move with them from provider to provider, regardless of 

where the information originated. If electronic health records conform to 

interoperability standards, they can be created, managed, and consulted 

by authorized clinicians and staff across more than one health care 

organization, thus providing patients and their caregivers the necessary 

information required for optimal care. (Paper-based health records—if 

available—also provide necessary information, but unlike electronic 

health records, do not provide decision support capabilities, such as 

automatic alerts about a particular patient’s health, or other advantages of 

automation.) 

Interoperability can be achieved at different levels. At the highest level, 

electronic data are computable (that is, in a format that a computer can 

understand and act on to, for example, provide alerts to clinicians on drug 

allergies). At a lower level, electronic data are structured and viewable, 

but not computable. The value of data at this level is that they are 

structured so that data of interest to users are easier to find. At a still 

lower level, electronic data are unstructured and viewable, but not 
 

Page 5 GAO-13-413T 

computable. With unstructured electronic data, a user would have to find 

needed or relevant information by searching uncategorized data. Beyond 

these, paper records can also be considered interoperable (at the lowest 

level) because they allow data to be shared, read, and interpreted by 

human beings. 

Since 1998, VA and DOD have relied on a patchwork of initiatives 

involving their health information systems to achieve electronic health 

record interoperability. These have included efforts to: share viewable 

data in existing (legacy) systems; link and share computable data 

between the departments’ modernized health data repositories; establish 

interoperability objectives to meet specific data-sharing needs; develop a 

virtual lifetime electronic health record to track patients through active 

service and veteran status; and implement IT capabilities for the first joint 

federal health care center. While, collectively, these initiatives have 

yielded increased data-sharing in various capacities, a number of them 

have nonetheless been plagued by persistent management challenges, 

which have created barriers to achieving the fully interoperable electronic 

health record capabilities long sought. 

Among the departments’ earliest efforts to achieve interoperability was 

the Government Computer-Based Patient Record (GCPR) initiative, 

which was begun in 1998 with the intent of providing an electronic 

interface that would allow physicians and other authorized users of VA’s 

and DOD’s health facilities to access data from either of the other 

agency’s health facilities.4

 The interface was expected to compile 

requested patient health information in a temporary, “virtual” record that 

could be displayed on a user’s computer screen. However, in reporting on 

this initiative in April 2001, we found that accountability for GCPR was 

blurred across several management entities and that basic principles of 

sound IT project planning, development, and oversight had not been 

followed, thus, creating barriers to progress.5

 For example, clear goals 

 

4

Initially, the Indian Health Service (IHS) was also part of this initiative, 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. 

5

GAO-01-459. 

VA and DOD Have 

Pursued Various 

Efforts over Many 

Years but Have Been 

Challenged in 

Achieving Fully 

Interoperable 

Electronic Health 

Records 

Early Efforts to Share 

Information in Legacy 

Systems Suffered from 

Project Planning and 

Management Weaknesses 
 

Page 6 GAO-13-413T 

and objectives had not been set; detailed plans for the design, 

implementation, and testing of the interface had not been developed; and 

critical decisions were not binding on all partners. While both departments 

concurred with our recommendations that they, among other things, 

create comprehensive and coordinated plans for the effort, progress on 

the initiative continued to be disappointing. The department subsequently 

revised the strategy for GCPR and, in May 2002, narrowed the scope of 

the initiative to focus on enabling DOD to electronically transfer service 

members’ electronic health information to VA upon their separation from 

active duty. The initiative—renamed the Federal Health Information 

Exchange (FHIE)—was completed in 2004. 

Building on the architecture and framework of FHIE, VA and DOD also 

established the Bidirectional Health Information Exchange (BHIE) in 

2004, which was aimed at allowing clinicians at both departments 

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

care from both departments, such as veterans who receive outpatient 

care from VA clinicians and then are hospitalized at a military treatment 

facility). The interface also enabled DOD sites to see previously 

inaccessible data at other DOD sites. 

Further, in March 2004, the departments began an effort to develop an 

interface linking VA’s Health Data Repository and DOD’s Clinical Data 

Repository, as part of a long-term initiative to achieve the two-way 

exchange of health information between the departments’ modernized 

systems—known as CHDR. The departments had planned to be able to 

exchange selected health information through CHDR by October 2005. 

However, in June 2004, we reported that the efforts of VA and DOD in 

this area demonstrated a number of management weaknesses.6

 Among 

these were the lack of a well-defined architecture for describing the 

interface for a common health information exchange; an established 

project management lead entity and structure to guide the investment in 

the interface and its implementation; and a project management plan 

defining the technical and managerial processes necessary to satisfy 

project requirements. Accordingly, we recommended that the 

departments address these weaknesses, and they agreed to do so. 

 

6

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). 
 

Page 7 GAO-13-413T 

In September 2005, we testified that the departments had improved the 

management of the CHDR program, but that this program continued to 

face significant challenges—in particular, with developing a project 

management plan of sufficient specificity to be an effective guide for the 

program.7

 In a subsequent testimony, in June 2006, we noted that the 

project did not meet a previously established milestone: to be able to 

exchange outpatient pharmacy data, laboratory results, allergy 

information, and patient demographic information on a limited basis by 

October 2005.8

 By September 2006, the departments had taken actions 

which ensured that the CHDR interface linked the departments’ separate 

repositories of standardized data to enable a two-way exchange of 

computable outpatient pharmacy and medication allergy information. 

Nonetheless, we noted that the success of CHDR would depend on the 

departments instituting a highly disciplined approach to the project’s 

management. 

To increase the exchange of electronic health information between the 

two departments, the National Defense Authorization Act (NDAA) for 

Fiscal Year 2008 included provisions directing VA and DOD to jointly 

develop and implement, by September 30, 2009, fully interoperable 

electronic health record systems or capabilities.9

 To facilitate compliance 

with the act, the departments’ Interagency Clinical Informatics Board, 

made up of senior clinical leaders who represent the user community, 

began establishing priorities for interoperable health data between VA 

and DOD. In this regard, the board was responsible for determining 

clinical priorities for electronic data sharing between the departments, as 

well as what data should be viewable and what data should be 

computable. Based on its work, the board established six interoperability 

objectives for meeting the departments’ data-sharing needs: 

 Refine social history data: DOD was to begin sharing with VA the 

social history data that are currently captured in the DOD electronic 

 

7

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). 

8

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

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

9

Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-463 (2008). 

Efforts to Comply with 

2008 Mandate to Achieve 

Fully Interoperable Health 

Records Capabilities 

Lacked Project Plans and 

Measures of Effectiveness 
 

Page 8 GAO-13-413T 

health record. Such data describe, for example, patients’ involvement 

in hazardous activities and tobacco and alcohol use. 

 Share physical exam data: DOD was to provide an initial capability 

to share with VA its electronic health record information that supports 

the physical exam process when a service member separates from 

active military duty. 

 Demonstrate initial network gateway operation: VA and DOD were 

to demonstrate the operation of secure network gateways to support 

joint VA-DOD health information sharing. 

 Expand questionnaires and self-assessment tools: DOD was to 

provide all periodic health assessment data stored in its electronic 

health record to VA such that questionnaire responses are viewable 

with the questions that elicited them. 

 Expand Essentris in DOD: DOD was to expand its inpatient medical 

records system (CliniComp’s Essentris product suite) to at least one 

additional site in each military medical department (one Army, one Air 

Force, and one Navy, for a total of three sites). 

 Demonstrate initial document scanning: DOD was to demonstrate 

an initial capability for scanning service members’ medical documents 

into its electronic health record and sharing the documents 

electronically with VA. 

The departments asserted that they took actions that met the six 

objectives and, in conjunction with capabilities previously achieved (e.g., 

FHIE, BHIE, and CHDR), had met the September 30, 2009, deadline for 

achieving full interoperability as required by the act. Nonetheless, the 

departments planned additional work to further increase their 

interoperable capabilities, stating that these actions reflected the 

departments’ recognition that clinicians’ needs for interoperable electronic 

health records are not static. In this regard, the departments focused on 

additional efforts to meet clinicians’ evolving needs for interoperable 

capabilities in the areas of social history and physical exam data, 

expanding implementation of Essentris, and additional testing of 

document scanning capabilities. 

Even with these actions, however, we identified a number of challenges 

the departments faced in managing their efforts in response to the 2008 

NDAA. Specifically, we identified challenges with respect to performance 
 

Page 9 GAO-13-413T 

measurement, project scheduling, and planning. For example, in a 

January 2009 report, we noted that the departments’ key plans did not 

identify results-oriented (i.e., objective, quantifiable, and measurable) 

performance goals and measures that are characteristic of effective 

planning and can be used as a basis to track and assess progress toward 

the delivery of new interoperable capabilities.10 We pointed out that 

without establishing results-oriented goals and reporting progress using 

measures relative to the established goals, the departments and their 

stakeholders would not have the comprehensive picture that they need to 

effectively manage their progress toward achieving increased 

interoperability. Accordingly, we recommended that DOD and VA take 

action to develop such goals and performance measures to be used as a 

basis for providing meaningful information on the status of the 

departments’ interoperability initiatives. In response, the departments 

stated that such goals and measures would be included in the next 

version of the VA/DOD Joint Executive Council Joint Strategic Plan 

(known as the joint strategic plan). However, that plan was not approved 

until April 2010, 7 months after the departments asserted they had met 

the deadline for achieving full interoperability. 

In addition to its provisions directing VA and DOD to jointly develop fully 

interoperable electronic health records, the 2008 NDAA called for the 

departments to set up an Interagency Program Office (IPO) to be 

accountable for their efforts to implement these capabilities by the 

September deadline. Accordingly, in January 2009, the office completed 

its charter, articulating, among other things, its mission and functions with 

respect to attaining interoperable electronic health data. The charter 

further identified the office’s responsibilities in carrying out its mission in 

areas such as oversight and management, stakeholder communication, 

and decision making. Among the specific responsibilities identified in the 

charter was the development of a plan, schedule, and performance 

measures to guide the departments’ electronic health record 

interoperability efforts. 

In July 2009, we reported that the IPO had not fulfilled key management 

responsibilities identified in its charter, such as the development of an 

integrated master schedule and a project plan for the department’s efforts 

 

10GAO-09-268. 
 

Page 10 GAO-13-413T 

to achieve full interoperability.11 Without these important tools, the office 

was limited in its ability to effectively manage and provide meaningful 

progress reporting on the delivery of interoperable capabilities. We 

recommended that the IPO establish a project plan and a complete and 

detailed integrated master schedule. In response to our recommendation, 

the office began to develop an integrated master schedule and project 

plan that included information about its ongoing interoperability activities. 

It is important to note, however, that in testifying before this committee in 

July 2011, the office’s former Director stated that the IPO charter 

established a modest role for the office, which did not allow the office to 

be the single point of accountability for the development and 

implementation of interoperable electronic health records.12 Instead, the 

office served the role of coordination and oversight for the departments’ 

efforts. Additionally, as pointed out by this official, control of the budget, 

contracts, and technical development remained with VA and DOD. As a 

result, each department had continued to pursue separate strategies and 

implementation paths, rather than coming together to build a unified, 

interoperable approach. 

In another attempt at furthering efforts to increase electronic health record 

interoperability, in April 2009, the President announced that VA and DOD 

would work together to define and build the Virtual Lifetime Electronic 

Record (VLER) to streamline the transition of electronic medical, benefits, 

and administrative information between the two departments. VLER is 

intended to enable access to all electronic records for service members 

as they transition from military to veteran status, and throughout their 

lives. Further, the initiative is to expand the departments’ health 

information sharing capabilities by enabling access to private sector 

health data. 

 

11GAO-09-775. 

12Legislative Hearing on H.R. 2383, H.R. 2243, H.R. 2388 and H.R. 2470, Before the 

Subcommittee on Oversight and Investigations of the Committee on Veterans’ Affairs, 

U.S. House of Representatives, 112th Cong., First Session (July 20, 2011) (statement of 

Debra M. Filippi, Former Director, U.S. Department of Defense/U.S. Department of 

Veterans Affairs Interagency Program Office), February 25, 2012, 

http://veterans.house.gov/prepared-statement/prepared-statement-debra-m-filippi-formerdirector-us-department-defenseus. 

Virtual Lifetime Electronic 

Record Initiative Lacked 

Comprehensive Planning 
 

Page 11 GAO-13-413T 

Shortly after the April 2009 announcement, VA, DOD, and the IPO began 

working to define and plan for the initiative. In June 2009, the 

departments adopted a phased implementation strategy consisting of a 

series of 6-month pilot projects to deploy a set of health data exchange 

capabilities between existing electronic health record systems at local 

sites around the country. Each VLER pilot project was intended to build 

upon the technical capabilities of its predecessor, resulting in a set of 

baseline capabilities to inform project planning and guide the 

implementation of VLER nationwide. 

The first pilot, which started in August 2009, in San Diego, California, 

resulted in VA, DOD, and Kaiser Permanente being able to share a 

limited set of test patient data. Subsequently, between March 2010 and 

January 2011, VA and DOD conducted another pilot in the Tidewater 

area of southeastern Virginia, which focused on sharing the same data as 

the San Diego pilot plus additional laboratory data. The departments 

planned additional pilots, with the goal of deploying VLER nationwide at 

or before the end of 2012. 

In June 2010, DOD informed us that it planned to spend $33.6 million in 

fiscal year 2010, and $61.9 million in fiscal year 2011 on the initiative. 

Similarly, VA stated that it planned to spend $23.5 million in fiscal year 

2010, and had requested $52 million for fiscal year 2011. 

However, in a February 2011 report on the departments’ efforts to 

address their common health IT needs, we noted that although VA and 

DOD identified a high-level approach for implementing VLER and 

designated the IPO as the single point of accountability for the effort, they 

had not developed a comprehensive plan identifying the target set of 

capabilities that they intended to demonstrate in the pilot projects and 

then implement on a nationwide basis at all domestic VA and DOD sites 

by the end of 2012.13 Moreover, the departments conducted VLER pilot 

projects without attending to key planning activities that are necessary to 

guide the initiative. For example, as of February 2011, the IPO had not 

developed an approved integrated master schedule, master program 

plan, or performance metrics for the VLER initiative, as outlined in the 

office’s charter. We noted that if the departments did not address these 

issues, their ability to effectively deliver capabilities to support their joint 

 

13GAO-11-265. 
 

Page 12 GAO-13-413T 

health IT needs would be uncertain. We recommended that the 

Secretaries of VA and DOD strengthen their ongoing efforts to establish 

VLER by developing plans that include scope definition, cost and 

schedule estimation, and project plan documentation and approval. 

Officials from both departments agreed with the recommendation, and we 

are monitoring their actions toward implementing them. Nevertheless, the 

departments were not successful in meeting their goal of implementing 

VLER nationwide by the end of 2012. 

VA and DOD also continued their efforts to share health information and 

resources in 2010 following congressional authorization of a 5-year 

demonstration project to more fully integrate the two departments’ 

facilities that were located in proximity to one another in the North 

Chicago, Illinois, area. As authorized by the National Defense 

Authorization Act for fiscal year 2010,14 VA and DOD facilities in and 

around North Chicago were integrated into a first-of-its-kind system 

known as the Captain James A. Lovell Federal Health Care Center 

(FHCC). The FHCC is unique in that it is to be the first fully integrated 

federal health care center for use by both VA and DOD beneficiaries, with 

an integrated workforce, a joint funding source, and a single line of 

governance. 

In April 2010, the Secretaries of VA and DOD signed an Executive 

Agreement that established the FHCC and defined the relationship 

between the two departments for operating the new, integrated facility, in 

accordance with the 2010 NDAA. Among other things,15 the Executive 

Agreement specified three key IT capabilities that VA and DOD were 

required to have in place by the FHCC’s opening day, in October 2010, to 

facilitate interoperability of their electronic health record systems: 

 medical single sign-on, which would allow staff to use one screen to 

access both the VA and DOD electronic health record systems; 

 single patient registration, which would allow staff to register 

patients in both systems simultaneously; and 

 

14Pub. L. No. 111-84, div. A, title XVII, 123 Stat. 2190, 2567-2574 (2009). 

15The Executive Agreement identified 12 areas of integration for the FHCC, one of which 

is information technology. 

Poor Project Planning 

Contributed to Information 

Technology Delays at the 

Joint Federal Health Care 

Center 
 

Page 13 GAO-13-413T 

 orders portability, which would allow VA and DOD clinicians to 

place, manage, and update clinical orders from either department’s 

electronic health records systems for radiology, laboratory, consults 

(specialty referrals), and pharmacy services. 

However, in a February 2011 report that identified improvements the 

departments could make to the FHCC effort, we noted that project 

planning for the center’s IT capabilities was incomplete.16 We specifically 

noted that the departments had not defined the project scope in a manner 

that identified all detailed activities. Consequently, they were not 

positioned to reliably estimate the project cost or establish a baseline 

schedule that could be used to track project performance. Based on these 

findings, we expressed concern that VA and DOD had jeopardized their 

ability to fully and expeditiously provide the FHCC’s needed IT system 

capabilities. We recommended that the Secretaries of VA and DOD 

strengthen their efforts to establish the joint IT system capabilities for the 

FHCC by developing plans that included scope definition, cost and 

schedule estimation, and project plan documentation and approval. 

Although officials from both departments stated agreement with our 

recommendation, the departments’ actions were not sufficient to preclude 

delays in delivering the FHCC’s IT system capabilities, as we 

subsequently described in July 2011 and June 2012. 

Specifically, our 2011 report noted that none of the three IT capabilities 

had been implemented by the time of the FHCC’s opening, as required by 

the Executive Agreement;17 however, FHCC officials reported that the 

medical single sign-on and single patient registration capabilities 

subsequently became operational in December 2010. 

In June 2012, we again reported on the departments’ efforts to implement 

the FHCC’s required IT capabilities, and found that portions of the orders 

portability capability—related to the pharmacy and consults 

 

16GAO-11-265. 

17GAO, VA and DOD Health Care: First Federal HealthCare Center Established, but 

Implementation Concerns Need to Be Addressed, GAO-11-570 (Washington, D.C.: 

July 19, 2011).
 

Page 14 GAO-13-413T 

components—remained delayed.18 VA and DOD officials described 

workarounds that the departments had implemented as a result of the 

delays, but did not have a timeline for completion of the pharmacy 

component, and estimated completion of the consults component by 

March 2013. 

The officials reported that as of March 2012, the departments had spent 

about $122 million on developing and implementing IT capabilities at the 

FHCC. However, they were unable to quantify the total cost for all the 

workarounds resulting from delayed IT capabilities. 

Beyond the aforementioned initiatives, in March 2011 the Secretaries of 

VA and DOD committed the two departments to developing a new 

common integrated electronic health record (iEHR), and in May 2012 

announced their goal of implementing it across the departments by 2017. 

According to the departments, the decision to pursue iEHR would enable 

VA and DOD to align resources and investments with common business 

needs and programs, resulting in a platform that would replace the two 

departments’ electronic health record systems with a common system. In 

addition, because it would involve both departments using the same 

system, this approach would largely sidestep the challenges they have 

encountered in trying to achieve interoperability between separate 

systems. 

To oversee this new effort, in October 2011, the IPO was re-chartered 

and given authority to expand its staffing level and provided with new 

authorities under the charter, including control over the budget. According 

to IPO officials, the office was expected to have a staff of 236 

personnel—more than 7 times the number of staff originally allotted to the 

office by VA and DOD—when hiring under the charter was completed. 

However, IPO officials told us that, as of January 2013, the office was 

staffed at approximately 62 percent and that hiring additional staff 

remained one of its biggest challenges. 

 

18GAO, VA/DOD Federal Health Care Center: Costly Information Technology Delays 

Continue and Evaluation Plan Lacking, GAO-12-669 (Washington, D.C.: June 26, 2012). 

In this report, we noted that orders portability for radiology had become operational in 

June 2011 and for laboratory in March 2012. 

VA and DOD Recently 

Changed Their 

Approach to 

Developing an 

Integrated Electronic 

Health Record 
 

Page 15 GAO-13-413T 

Earlier this month, the Secretaries of VA and DOD announced that 

instead of developing a new common integrated electronic health record 

system, the departments would now focus on integrating health records 

from separate VA and DOD systems, while working to modernize their 

existing electronic health record systems. VA has stated that it will 

continue to modernize VistA while pursuing the integration of health data, 

while DOD has stated that it plans to evaluate whether it will adopt VistA 

or purchase a commercial off-the-shelf product. The Secretaries offered 

several reasons for this new direction, including cutting costs, simplifying 

the problem of integrating VA and DOD health data, and meeting the 

needs of veterans and service members sooner rather than later. 

The numerous challenges that the departments have faced in past efforts 

to achieve full interoperability between their existing health information 

systems heighten longstanding concerns about whether this latest 

initiative will be successful. We have ongoing work—undertaken at the 

request of the Chairman and Ranking Member of the Senate Committee 

on Veterans Affairs—to examine VA’s and DOD’s decisions and activities 

related to this endeavor. 

VA’s and DOD’s revised approach to developing iEHR highlights the need 

for the departments to address barriers they have faced in key IT 

management areas. Specifically, in a February 2011 report, we 

highlighted barriers that the departments faced to jointly addressing their 

common health care system needs in the areas of strategic planning, 

enterprise architecture, and investment management.19 In particular, the 

departments had not articulated explicit plans, goals, and time frames for 

jointly addressing the health IT requirements common to both 

departments’ electronic health record systems, and their joint strategic 

plan did not discuss how or when they propose to identify and develop 

joint solutions to address their common health IT needs. In addition, 

although DOD and VA had taken steps toward developing and 

maintaining artifacts related to a joint health architecture (i.e., a 

description of business processes and supporting technologies), the 

architecture was not sufficiently mature to guide the departments’ joint 

health IT modernization efforts. Further, the departments had not 

established a joint process for selecting IT investments based on criteria 

 

19GAO-11-265. 

Barriers Exist to Jointly 

Addressing VA’s and DOD’s 

Health Care System Needs 
 

Page 16 GAO-13-413T 

that consider cost, benefit, schedule, and risk elements, limiting their 

ability to pursue joint health IT solutions that both meet their needs and 

provide better value and benefits to the government as a whole. We 

noted that without having these key IT management capabilities in place, 

the departments would continue to face barriers to identifying and 

implementing IT solutions that addressed their common needs. 

In our report, we identified several actions that the Secretaries of Defense 

and Veterans Affairs could take to overcome these barriers, including the 

following: 

 Revise the departments’ joint strategic plan to include information 

discussing their electronic health record system modernization efforts 

and how those efforts will address the departments’ common health 

care business needs. 

 Further develop the departments’ joint health architecture to include 

their planned future state and transition plan from their current state to 

the next generation of electronic health record capabilities. 

 Define and implement a process, including criteria that consider costs, 

benefits, schedule, and risks, for identifying and selecting joint IT 

investments to meet the departments’ common health care business 

needs. 

Officials from both VA and DOD agreed with these recommendations, 

and we have been monitoring their actions toward implementing them. 

Nonetheless, important work remains, and it takes on increased urgency 

in light of the departments’ revised approach to developing the iEHR. For 

example, with respect to planning, the departments’ joint strategic plan 

does not describe the new approach to how the departments will address 

their common health care business needs. Regarding architecture, in 

February 2012, the departments established the Health Architecture 

Review Board to provide architecture oversight, approval, and decision 

support for joint VA and DOD health information technology programs. 

While the board has generally met monthly since May 2012 and has been 

working to establish mechanisms for overseeing architecture activities, 

the extent to which the departments’ revised approach to iEHR is guided 

by a joint health architecture remains to be seen. With regard to defining 

a process for identifying and selecting joint investments, the departments 

have established such a governance structure, but the effectiveness of 

this structure has not yet been demonstrated. In particular, the 

departments have not yet demonstrated the extent to which criteria that 
 

Page 17 GAO-13-413T 

consider costs, benefits, schedule, and risks have been or will be used to 

identify and select planned investments. 

In summary, while VA and DOD have made progress in increasing 

interoperability between their health information systems over the past 15 

years, these efforts have faced longstanding challenges. In large part, 

these have been the result of inadequate program management and 

accountability. In particular, there has been a persistent absence of 

clearly defined, measurable goals and metrics, together with associated 

plans and time frames, that would enable the departments to report 

progress in achieving full interoperability. Moreover, the Integrated 

Program Office has not functioned as it was intended—as a single point 

of accountability for efforts to implement fully interoperable electronic 

health record systems or capabilities. The 2011 decision to develop a 

single, integrated electronic health record system to be used across both 

departments could have avoided or mitigated some of these challenges. 

However, the more recent decision to reverse course and continue to 

operate separate systems and develop additional interoperable 

capabilities raises concern in light of historical challenges. Further, 

although the departments have asserted that their now planned approach 

will deliver capabilities sooner and at lower cost, deficiencies in key IT 

management areas of strategic planning, enterprise architecture, and 

investment management could continue to stand in the way of VA’s and 

DOD’s attempts to jointly address their common health care system 

needs in the most efficient and effective manner. 

Chairman Miller, Ranking Member Michaud, and Members of the 

Committee, this concludes my statement. I would be pleased to respond 

to any questions that you may have. 

If you have any questions concerning this statement, please contact 

Valerie C. Melvin, Director, Information Management and Technology 

Resources Issues, at (202) 512-6304 or melvinv@gao.gov. Other 

individuals who made key contributions include Mark T. Bird, Assistant 

Director; Heather A. Collins; Kelly R. Dodson; Lee A. McCracken; 

Umesh Thakkar; and Eric L. Trout. 

GAO Contact and 

Staff 

Acknowledgments 

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