COMPUTER-BASED 

PATIENT RECORDS: 

VA and DOD Made 

Progress, but Much Work 

Remains to Fully Share 

Medical Information 

Statement of Linda D. Koontz 

Director, Information Management Issues 

United States Government Accountability Office

GAO Testimony before the Committee on 

Veterans’ Affairs, House of 

Representatives 

For Release on Delivery 

Expected at 10:00 a.m. EDT 

September 28, 2005 

GAO-05-1051T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

www.gao.gov/cgi-bin/getrpt?GAO-05-1051T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Linda D. 

Koontz at (202) 512-6240 or 

koontzl@gao.gov. 

Highlights of GAO-05-1051T, a testimony 

before the Committee on Veterans' Affairs, 

House of Representatives 

September 28, 2005

COMPUTER-BASED PATIENT RECORDS

VA and DOD Have Made Progress, but 

Much Work Remains to Fully Share 

Medical Information 

In the past year, VA and DOD have begun to implement applications that 

exchange limited electronic medical information between the departments’ 

existing health information systems. These applications are (1) Bidirectional 

Health Information Exchange, a project to achieve the two-way exchange of 

health information on patients who receive care from both VA and DOD, and 

(2) Laboratory Data Sharing Interface, an application used to electronically 

transfer laboratory work orders and results between the departments. The 

Bidirectional Health Information Exchange application has been 

implemented at five sites, at which it is being used to rapidly exchange 

information such as pharmacy and allergy data. Also, the Laboratory Data 

Sharing Interface application has been implemented at six sites, at which it 

is being used for real-time entry of laboratory orders and retrieval of results. 

According to the departments, these systems enable lower costs and 

improved service to patients by saving time and avoiding errors. 

VA and DOD are continuing with activities to support their longer term goal 

of sharing health information between their systems (see figure), but the 

goal of two-way electronic exchange of patient records remains far from 

being realized. Each department is developing its own modern health 

information system—VA’s HealtheVet VistA and DOD’s Composite Health 

Care System II—and they have taken steps to respond to GAO’s June 2004 

recommendations regarding the program to develop an electronic interface 

that will enable these systems to share information. That is, they have 

developed an architecture for the interface, established project 

accountability, and implemented a joint project management structure. 

However, they have not yet developed a clearly defined project management 

plan to guide their efforts, as GAO previously recommended. Further, they 

have not yet fully populated the repositories that will store the data for their 

future health systems, and they have experienced delays in their efforts to 

begin a limited data exchange. Lacking a detailed project management plan 

increases the risk that the departments will encounter further delays and be 

unable to deliver the planned capabilities on time and at the cost expected. 

History of Selected VA/DOD Efforts on Electronic Medical Records and Data Sharing 

For the past 7 years, the 

Departments of Veterans Affairs 

(VA) and Defense (DOD) have been 

working to exchange patient health 

information electronically and 

ultimately to have interoperable 

electronic medical records. Sharing 

medical information helps 

(1) promote the seamless transition 

of active duty personnel to veteran 

status and (2) ensure that active 

duty military personnel and 

veterans receive high-quality health 

care and assistance in adjudicating 

their disability claims. This is 

especially critical in the face of 

current military responses to 

national and foreign crises. 

In testimony before the Veterans’ 

Affairs Subcommittee on Oversight 

and Investigations in March and 

May 2004, GAO discussed the 

progress being made by the 

departments in this endeavor. In 

June 2004, at the Subcommittee’s 

request, GAO reported on its 

review of the departments’ 

progress toward the goal of an 

electronic two-way exchange of 

patient health records. 

GAO is providing an update on the 

departments’ efforts, focusing on 

(1) the status of ongoing, near-term 

initiatives to exchange data 

between the agencies’ existing 

systems and (2) progress in 

achieving the longer term goal of 

exchanging data between the 

departments’ new systems. 
Page 1 GAO-05-1051T 

Mr. Chairman and Members of the Committee: 

I am pleased to participate in today’s discussion on the actions 

taken by the Departments of Veterans Affairs (VA) and Defense 

(DOD) to promote the seamless transition of active duty personnel 

to veteran status. Among the two departments’ goals for seamless 

transition is to be able to exchange patient health information 

electronically and ultimately to have interoperable1 electronic 

medical records. Sharing of medical information is an important tool 

to help ensure that active duty military personnel and veterans 

receive high-quality health care and assistance in adjudicating their 

disability claims—goals that, in the face of current military 

responses to national and foreign crises, are more essential than 

ever. 

For the past 7 years, VA and DOD have been working to achieve 

these capabilities, beginning with a joint project in 1998 to develop a 

government computer-based patient record. As we have noted in 

previous testimony,2

 the departments had achieved a measure of 

success in sharing data through the one-way transfer of health 

information from DOD to VA health care facilities. However, they 

have been severely challenged in their pursuit of the longer term 

objective—providing a virtual medical record in which data are 

computable. That is, rather than data being provided as text for 

viewing only, data would be in a format that the health information 

application can act on: for example, providing alerts to clinicians (of 

such things as drug allergies) and plotting graphs of changes in vital 

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

 1

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

information and to use the information that has been exchanged. 

2

 GAO,Computer-Based Patient Records: Improved Planning and Project Management 

Are Critical to Achieving Two-Way VA–DOD Health Data Exchange, GAO-04-811T

(Washington, D.C.: May 19, 2004); 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); and 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). 
Page 2 GAO-05-1051T 

of such computable medical data contributes significantly to the 

usefulness of electronic medical records. 

As of June 2004, when we last reported on this topic,3 VA and DOD 

were continuing to define the data standards that are essential both 

for the exchange of data and for the development of interoperable 

electronic medical records. At that time, we identified weaknesses 

in the planning and management structure of the departments’ 

program, and we recommended that the departments take a number 

of actions to address these weaknesses. 

Also in 2004, in response to a mandate in the Bob Stump National 

Defense Authorization Act for Fiscal Year 2003,4 VA and DOD 

initiated information technology demonstration projects focusing on 

near-term goals: the exchange of electronic medical information 

between the departments’ existing health information systems. 

These projects are to help in the evaluation of the feasibility, 

advantages, and disadvantages of measures to improve sharing and 

coordination of health care and health care resources. The two 

demonstration projects (Bidirectional Health Information Exchange 

and Laboratory Data Sharing Interface) are interim initiatives that 

are separate from the departments’ ongoing long-term efforts in 

sharing data and developing health information systems. 

At your request, my testimony today will discuss the two 

departments’ continued efforts to exchange medical information, 

with a specific focus on (1) the status of ongoing, near-term 

initiatives to exchange data between the agencies’ existing systems 

and (2) progress in achieving the longer term goal of exchanging 

data between the departments’ new systems, still in development, 

which are to be built around electronic patient health records. 

 3

 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). 

4

 Pub. L. No. 107-314, §721 (a)(1), 116 Stat. 2589,2595 (2002). To further encourage on-going 

collaboration, section 721 directed the Secretary of Defense and the Secretary of Veterans 

Affairs to establish a joint program to identify and provide incentives to implement, fund, 

and evaluate creative health care coordination and sharing initiatives between DOD and 

VA. 
Page 3 GAO-05-1051T 

In conducting this work, we reviewed the departments’ 

documentation describing the two demonstration projects, including 

business plans, budget summaries, and project status reports. We 

also reviewed documentation identifying the costs that the 

departments have incurred in developing technology to support the 

sharing of health data, including costs associated with achieving the 

one-way transfer of data from DOD to VA health care facilities, and 

ongoing projects to develop new health information systems. We did 

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

or completeness. We reviewed draft system requirements, design 

specifications, and software descriptions for the electronic interface 

between the departments’ new health systems. We supplemented 

our analyses of the agencies’ documentation with interviews of VA 

and DOD officials responsible for key decisions and actions on the 

health data-sharing initiatives. In addition, to observe the 

Bidirectional Health Information Exchange and Laboratory Data 

Sharing Interface capabilities, we conducted site visits to military 

treatment facilities and VA medical centers in El Paso and San 

Antonio, Texas, and Puget Sound, Washington. We conducted our 

work from June through September 2005, in accordance with 

generally accepted government auditing standards. 

Results in Brief 

In the past year, VA and DOD have begun to implement applications 

that exchange limited electronic medical information between the 

departments’ existing health information systems. These 

applications were developed through two information technology 

demonstration projects: (1) Bidirectional Health Information 

Exchange is a project to achieve the two-way exchange of health 

information on shared patients,5 and (2) Laboratory Data Sharing 

Interface is an application used to facilitate the electronic 

transfer/sharing of orders for laboratory work and the results of the 

 5

 Shared patients receive care from both VA and DOD clinicians. For example, veterans 

may receive outpatient care from VA clinicians and be hospitalized at a military treatment 

facility. 
Page 4 GAO-05-1051T 

work. The departments have implemented the Bidirectional Health 

Information Exchange application at five sites, at which it is being 

used for the rapid exchange of specific types of information 

(pharmacy data, drug and food allergy information, patient 

demographics, and laboratory results6

 on shared patients). Also, the 

Laboratory Data Sharing Interface application has been 

implemented at six sites, at which it is being used for real-time entry 

of laboratory orders and retrieval of laboratory results. Although the 

data exchanged by these demonstration projects are in text form 

only (that is, they are not computable), the systems have significant 

benefits, according to the two departments, because they enable 

lower costs and improved service to patients by saving time and 

avoiding errors.

Since our last report on the departments’ efforts to achieve a virtual 

medical record, VA and DOD have taken several actions, but the 

departments continue to be far from achieving the two-way 

electronic data exchange capability originally envisioned. The 

departments have implemented three recommendations that we 

made in June 2004: They have developed an architecture for the 

electronic interface between DOD’s Clinical Data Repository and 

VA’s Health Data Repository; they have established the VA/DOD 

Health Executive Council7

 as the lead entity for the project; and they 

have established a joint project management structure to provide 

day-to-day guidance for this initiative. Additionally, the Health 

Executive Council established working groups to provide 

programmatic oversight and to facilitate interagency collaboration 

on sharing initiatives between DOD and VA. However, VA and DOD 

have not yet developed a clearly defined project management plan 

that gives a detailed description of the technical and managerial 

processes necessary to satisfy project requirements, as we 

previously recommended. Moreover, the departments have 

 6

 These data are text files providing surgical, pathology, cytology, microbiology, chemistry, 

and hematology test results and descriptions of radiology results. 

7

 The VA/DOD Health Executive Council is composed of senior leaders from VA and DOD, 

who work to institutionalize sharing and collaboration of health services and resources. 

The council is cochaired by the VA Undersecretary for Health and DOD Assistant Secretary 

of Defense for Health Affairs, and meets every 2 months. 
Page 5 GAO-05-1051T 

experienced delays in their efforts to begin exchanging computable 

patient health data; they have not yet fully populated the data 

repositories that are to store the medical data for their future health 

systems. As a result, much work remains before the departments 

achieve their ultimate goal—interoperable electronic health records 

and two-way electronic exchange of computable patient health 

information. 

Background 

In 1998, following a presidential call for VA and DOD to start 

developing a “comprehensive, life-long medical record for each 

service member,” the two departments began a joint course of 

action aimed at achieving the capability to share patient health 

information for active duty military personnel and veterans.8 Their 

first initiative, undertaken in that year, was the Government 

Computer-Based Patient Record (GCPR) project, whose goal was an 

electronic interface that would allow physicians and other 

authorized users at VA and DOD health facilities to access data from 

any of the other agency’s health information systems. The interface 

was expected to compile requested patient information in a virtual 

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

In our reviews of the GCPR project, we determined that the lack of a 

lead entity, clear mission, and detailed planning to achieve that 

mission made it difficult to monitor progress, identify project risks, 

and develop appropriate contingency plans. In April 2001 and in 

June 2002,9

 we made recommendations to help strengthen the 

management and oversight of the project. In 2001, we recommended 

 8

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

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

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

electronically sharing patient health information. 

9

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

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

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

Would Enhance Health Data Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001).
Page 6 GAO-05-1051T 

that the participating agencies (1) designate a lead entity with final 

decision-making authority and establish a clear line of authority for 

the GCPR project and (2) create comprehensive and coordinated 

plans that included an agreed-upon mission and clear goals, 

objectives, and performance measures, to ensure that the agencies 

could share comprehensive, meaningful, accurate, and secure 

patient health care data. In 2002, we recommended that the 

participating agencies revise the original goals and objectives of the 

project to align with their current strategy, commit the executive 

support necessary to adequately manage the project, and ensure 

that it followed sound project management principles. 

VA and DOD took specific measures in response to our 

recommendations for enhancing overall management and 

accountability of the project. By July 2002, VA and DOD had revised 

their strategy and had made progress toward being able to 

electronically share patient health data. The two departments had 

refocused the project and named it the Federal Health Information 

Exchange (FHIE) program and, consistent with our prior 

recommendation, had finalized a memorandum of agreement 

designating VA as the lead entity for implementing the program. This 

agreement also established FHIE as a joint activity that would allow 

the exchange of health care information in two phases. 

● The first phase, completed in mid-July 2002, enabled the one-way 

transfer of data from DOD’s existing health information system (the 

Composite Health Care System, CHCS) to a separate database that 

VA clinicians could access. 

● A second phase, finalized in March 2004, completed VA’s and DOD’s 

efforts to add to the base of patient health information available to 

VA clinicians via this one-way sharing capability. 

According to the December 2004 VA/DOD Joint Executive Council10

Annual Report, FHIE was fully operational, and VA providers at all 

 10 The Joint Executive Council is composed of the Deputy Secretary of Veterans Affairs, the 

Undersecretary of Defense for Personnel and Readiness, and the cochairs of joint councils 

on health, benefits, and capital planning. The council meets on a quarterly basis to 

recommend strategic direction of joint coordination and sharing efforts. 
Page 7 GAO-05-1051T 

VA medical centers and clinics nationwide had access to data on 

separated service members. According to the report, the FHIE data 

repository at that time contained historical clinical health data on 

2.3 million unique patients from 1989 on, and the repository made a 

significant contribution to the delivery and continuity of care and 

adjudication of disability claims of separated service members as 

they transitioned to veteran status. The departments reported total 

GCPR/FHIE costs of about $85 million through fiscal year 2003. 

In addition, officials stated that in December 2004, the departments 

began to use the FHIE framework to transfer pre- and 

postdeployment health assessment data from DOD to VA. According 

to these officials, VA has now received about 400,000 of these 

records. 

However, not all DOD medical information is captured in CHCS. For 

example, according to DOD officials, as of September 6, 2005, 1.7 

million patient stay records were stored in the Clinical Information 

System (a commercial product customized for DOD). In addition, 

many Air Force facilities use a system called the Integrated Clinical 

Database for their medical information. 

The revised DOD/VA strategy also envisioned achieving a longer 

term, two-way exchange of health information between DOD and 

VA, which may also address systems outside of CHCS. Known as 

HealthePeople (Federal), this initiative is premised on the 

departments’ development of a common health information 

architecture comprising standardized data, communications, 

security, and high-performance health information systems. The 

joint effort is expected to result in the secured sharing of health data 

between the new systems that each department is currently 

developing and beginning to implement—VA’s HealtheVet VistA and 

DOD’s CHCS II. 

● DOD began developing CHCS II in 1997 and had completed a key 

component for the planned electronic interface—its Clinical Data 

Repository. When we last reported in June 2004, the department 

expected to complete deployment of all of its major system 
Page 8 GAO-05-1051T 

capabilities by September 2008.11 DOD reported expenditures of 

about $600 million for the system through fiscal year 2004.12

● VA began work on HealtheVet VistA and its associated Health Data 

Repository in 2001 and expected to complete all six initiatives 

comprising this system in 2012. VA reported spending about $270 

million on initiatives that comprise HealtheVet VistA through fiscal 

year 2004. 13 

Under the HealthePeople (Federal) initiative, VA and DOD envision 

that, on entering military service, a health record for the service 

member would be created and stored in DOD’s Clinical Data 

Repository. The record would be updated as the service member 

receives medical care. When the individual separated from active 

duty and, if eligible, sought medical care at a VA facility, VA would 

then create a medical record for the individual, which would be 

stored in its Health Data Repository. On viewing the medical record, 

the VA clinician would be alerted and provided with access to the 

individual’s clinical information residing in DOD’s repository. In the 

same manner, when a veteran sought medical care at a military 

treatment facility, the attending DOD clinician would be alerted and 

provided with access to the health information in VA’s repository. 

According to the departments, this planned approach would make 

virtual medical records displaying all available patient health 

 11 DOD’s CHCS II capabilities are being deployed in five increments. The first provides a 

graphical user interface for clinical outpatient processes, thus providing an electronic 

medical record capability; the second supports general dentistry; the third provides 

pharmacy, laboratory, radiology, and immunizations capabilities; the fourth provides 

inpatient and scheduling capabilities; and the fifth will provide additional capabilities as 

defined. According to DOD, the first increment has been deployed to 64 of the 139 DOD 

health facilities, representing over 6.9 million beneficiaries, or about 75 percent of the total 

9.2 million beneficiaries. 

12 These expenditures represent acquisition costs for software development, test and 

evaluation, hardware acquisition, system implementation, and associated contractor 

personnel costs. They do not include government personnel or operations and maintenance 

costs. 

13 The six initiatives that make up HealtheVet VistA are the Health Data Repository, billing 

replacement, laboratory, pharmacy, imaging, and appointment scheduling replacement. 

This amount includes investments in these six initiatives by VA as reported in their 

submission to the Office of Management and Budget for fiscal year 2004. 
Page 9 GAO-05-1051T 

information from the two repositories accessible to both 

departments’ clinicians. 

To achieve this goal requires the departments to be able to exchange 

computable health information between the data repositories for 

their future health systems: that is, VA’s Health Data Repository (a 

component of HealtheVet VistA) and DOD’s Clinical Data Repository 

(a component of CHCS II). In March 2004, the departments began an 

effort to develop an interface linking these two repositories, known 

as CHDR (a name derived from the abbreviations for DOD’s Clinical 

Data Repository—CDR—and VA’s Health Data Repository—HDR). 

According to the departments,14 they planned to be able to exchange 

selected health information through CHDR by October 2005. 

Developing the two repositories, populating them with data, and 

linking them through the CHDR interface would be important steps 

toward the two departments’ long-term goals as envisioned in 

HealthePeople (Federal). Achieving these goals would then depend 

on completing the development and deployment of the associated 

health information systems—HealtheVet VistA and CHCS II. 

In our most recent review of the CHDR program, issued in June 

2004,15 we reported that the efforts of DOD and VA in this area 

demonstrated a number of management weaknesses. 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. With these critical 

components missing, VA and DOD increased the risk that they 

would not achieve their goals. Accordingly, we recommended that 

the departments 

 14 December 2004 VA and DOD Joint Strategic Plan. 

15 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 10 GAO-05-1051T 

● develop an architecture for the electronic interface between their 

health systems that includes system requirements, design 

specifications, and software descriptions; 

● select a lead entity with final decision-making authority for the 

initiative; 

● establish a project management structure to provide day-to-day 

guidance of and accountability for their investments in and 

implementation of the interface capability; and 

● create and implement a comprehensive and coordinated project 

management plan for the electronic interface that defines the 

technical and managerial processes necessary to satisfy project 

requirements and includes (1) the authority and responsibility of 

each organizational unit; (2) a work breakdown structure for all 

of the tasks to be performed in developing, testing, and 

implementing the software, along with schedules associated with 

the tasks; and (3) a security policy. 

Besides pursuing their long-term goals for future systems through 

the HealthePeople (Federal) strategy, the departments are working 

on two demonstration projects that focus on exchanging 

information between existing systems: (1) Bidirectional Health 

Information Exchange, a project to exchange health information on 

shared patients, and (2) Laboratory Data Sharing Interface, an 

application used to transfer laboratory work orders and results. 

These demonstration projects were planned in response to 

provisions of the Bob Stump National Defense Authorization Act of 

2003, which mandated that VA and DOD conduct demonstration 

projects that included medical information and information 

technology systems to be used as a test for evaluating the feasibility, 

advantages, and disadvantages of measures and programs designed 

to improve the sharing and coordination of health care and health 

care resources between the departments. 

Figure 1 is a time line showing initiation points for the VA and DOD 

efforts discussed here, including strategies, major programs, and the 

recent demonstration projects. 
Page 11 GAO-05-1051T 

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

VA and DOD Are Exchanging Limited Medical Information between 

Existing Health Systems 

VA and DOD have begun to implement applications developed under 

two demonstration projects that focus on the exchange of electronic 

medical information. The first—the Bidirectional Health Information 

Exchange—has been implemented at five VA/DOD locations and the 

second—Laboratory Data Sharing Interface—has been implemented 

at six VA/DOD locations. 

Bidirectional Health Information Exchange 

According to a VA/DOD annual report and program officials, 

Bidirectional Health Information Exchange (BHIE) is an interim 

step in the departments’ overall strategy to create a two-way 

exchange of electronic medical records. BHIE builds on the 

architecture and framework of FHIE, the current application used to 

transfer health data on separated service members from DOD to VA. 

As discussed earlier, FHIE provides an interface between VA’s and 

DOD’s current health information systems that allows one-way 

transfers only, which do not occur in real time: VA clinicians do not 
Page 12 GAO-05-1051T 

have access to transferred information until about 6 weeks after 

separation. In contrast, BHIE focuses on the two-way, near-real-time 

exchange of information (text only) on shared patients (such as 

those at sites jointly occupied by VA and DOD facilities). This 

application exchanges data between VA’s VistA system and DOD’s 

CHCS system (and CHCS II where implemented). To date, the 

departments reported having spent $2.6 million on BHIE. 

The primary benefit of BHIE is the near-real-time access to patient 

medical information for both VA and DOD, which is not available 

through FHIE. During a site visit to a VA and DOD location in Puget 

Sound, we viewed a demonstration of this capability and were told 

by a VA clinician that the near-real-time access to medical 

information has been very beneficial in treating shared patients. 

As of August 2005, BHIE was tested and deployed at VA and DOD 

facilities in Puget Sound, Washington, and El Paso, Texas, where the 

exchange of demographic, outpatient pharmacy, radiology, 

laboratory, and allergy data (text only) has been achieved. The 

application has also been deployed to three other locations this 

month (see table 1). According to the program manager, a plan to 

export BHIE to additional locations has been approved. The 

additional locations were selected based on a number of factors, 

including the number and types of VA and DOD medical facilities in 

the area, FHIE usage, and retiree population at the locations. The 

program manager stated that implementation of BHIE requires 

training of staff from both departments. In addition, implementation 

at DOD facilities requires installation of a server; implementation at 

VA facilities requires installation of a software patch (downloaded 

from a VA computer center), but no additional equipment. As shown 

in table 1, five additional implementations are scheduled for the first 

quarter of fiscal year 2006. 
Page 13 GAO-05-1051T 

Table 1: Scheduled Rollout of BHIE at Selected DOD Facilities 

Facility Implementation date 

Madigan Army Medical Center, Washington October 2004 

William Beaumont Army Medical Center, Texas October 2004 

Eisenhower Army Medical Center, Georgia September 2005 

Naval Hospital Great Lakes, Illinois September 2005 

Naval Medical Center, California September 2005 

Brooke Army Medical Center, Texas First quarter, fiscal year 2006 

Landstuhl Regional Medical Center, Germany First quarter, fiscal year 2006 

Bassett Army Community Hospital, Alaska First quarter, fiscal year 2006 

Walter Reed Army Medical Center, Maryland First quarter, fiscal year 2006 

Bethesda Naval Medical Center, Maryland First quarter, fiscal year 2006 

Sources: VA and DOD. 

Note: VA facilities are sited near all the DOD facilities shown. 

Additionally, because DOD stores electronic medical information in 

systems other than CHCS (such as the Clinical Information System 

and the Integrated Clinical Database), work is currently under way 

to allow BHIE to have the ability to exchange information with 

those systems. The Puget Sound Demonstration site is also working 

on sharing consultation reports stored in the VA and DOD systems. 

Laboratory Data Sharing Interface 

The Laboratory Data Sharing Interface (LDSI) initiative enables the 

two departments to share laboratory resources. Through LDSI, a VA 

provider can use VA’s health information system to write an order 

for laboratory tests, and that order is electronically transferred to 

DOD, which performs the test. The results of the laboratory tests are 

electronically transferred back to VA and included in the patient’s 

medical record. Similarly, a DOD provider can choose to use a VA 

lab for testing and receive the results electronically. Once LDSI is 

fully implemented at a facility, the only nonautomated action in 

performing laboratory tests is the transport of the specimens. 

Among the benefits of LDSI is increased speed in receiving 

laboratory results and decreased errors from multiple entry of 

orders. However, according to the LDSI project manager in San 

Antonio, a primary benefit of the project will be the time saved by 

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

information into the laboratories’ systems. Additionally, the San 
Page 14 GAO-05-1051T 

Antonio VA facility will no longer have to contract out some of its 

laboratory work to private companies, but instead use the DOD 

laboratory. To date, the departments reported having spent about 

$3.3 million on LDSI. 

An early version of what is now LDSI was originally tested and 

implemented at a joint VA and DOD medical facility in Hawaii in 

May 2003. The demonstration project built on this application and 

enhanced it; the resulting application was tested in San Antonio and 

El Paso. It has now been deployed to six sites in all. According to 

the departments, a plan to export LDSI to additional locations has 

been approved. Table 2 shows the locations at which it has been or 

is to be implemented. 

Table 2: VA/DOD Facilities with LDSI Implementations 

Facility Implementation Date 

Tripler Army Medical Center and 

VA Spark M. Matsunaga Medical Center, Hawaii 

May 2003 

Kirtland Air Force Base and 

Albuquerque VA Medical Center, New Mexico 

May 2003 

Naval Medical Center and 

San Diego VA Health Care System, California 

July 2004 

Great Lakes Naval Hospital and 

VA Medical Center, Illinois 

October 2004 

William Beaumont Army Medical Center, El Paso, Texas October 2004 

Brooke Army Medical Center, San Antonio, Texas August 2005 

Bassett Army Community Hospital, Alaska Pre-implementation 

Nellis Air Force Base, Nevada Pre-implementation 

Sources: VA and DOD. 

VA and DOD Are Taking Actions to Achieve a Virtual Medical 

Record, but Much Work Remains 

Besides the near-term initiatives just discussed, VA and DOD 

continue their efforts on the longer term goal: to achieve a virtual 

medical record based on the two-way exchange of computable data 

between the health information systems that each is currently 

developing. The cornerstone for this exchange is CHDR, the planned 

electronic interface between the data repositories for the new 

systems. 
Page 15 GAO-05-1051T 

The departments have taken important actions on the CHDR 

initiative. In September 2004 they successfully completed Phase I of 

CHDR by demonstrating the two-way exchange of pharmacy 

information with a prototype in a controlled laboratory 

environment.16 According to department officials, the pharmacy 

prototype provided invaluable insight into each other’s data 

repository systems, architecture, and the work that is necessary to 

support the exchange of computable information. These officials 

stated that lessons learned from the development of the prototype 

were documented and are being applied to Phase II of CHDR, the 

production phase, which is to implement the two-way exchange of 

patient health records between the departments’ data repositories. 

Further, the same DOD and VA teams that developed the prototype 

are now developing the production version. 

In addition, the departments developed an architecture for the 

CHDR electronic interface, as we recommended in June 2004. The 

architecture for CHDR includes major elements required in a 

complete architecture. For example, it defines system requirements 

and allows these to be traced to the functional requirements, it 

includes the design and control specifications for the interface 

design, and it includes design descriptions for the software. 

Also in response to our recommendations, the departments have 

established project accountability and implemented a joint project 

management structure. Specifically, the Health Executive Council 

has been established as the lead entity for the project. The joint 

project management structure consists of a Program Manager from 

VA and a Deputy Program Manager from DOD to provide day-to-day 

guidance for this initiative. Additionally, the Health Executive 

Council established the DOD/VA Information 

Management/Information Technology Working Group and the 

DOD/VA Health Architecture Interagency Group, to provide 

programmatic oversight and to facilitate interagency collaboration 

on sharing initiatives between DOD and VA. 

 16 The completion of the pharmacy prototype project satisfied a mandate of the 2003 Bob 

Stump National Defense Authorization Act, Pub. L. 107-314, sec. 724 (2002). 
Page 16 GAO-05-1051T 

To build on these actions and successfully carry out the CHDR 

initiative, however, the departments still have a number of 

challenges to overcome. The success of CHDR will depend on the 

departments’ instituting a highly disciplined approach to the 

project’s management. Industry best practices and information 

technology project management principles stress the importance of 

accountability and sound planning for any project, particularly an 

interagency effort of the magnitude and complexity of this one. We 

recommended in 2004 that the departments develop a clearly 

defined project management plan that describes the technical and 

managerial processes necessary to satisfy project requirements and 

includes (1) the authority and responsibility of each organizational 

unit; (2) a work breakdown structure for all of the tasks to be 

performed in developing, testing, and implementing the software, 

along with schedules associated with the tasks; and (3) a security 

policy. Currently, the departments have an interagency project 

management plan that provides the program management principles 

and procedures to be followed by the project. However, the plan 

does not specify the authority and responsibility of organizational 

units for particular tasks; the work breakdown structure is at a high 

level and lacks detail on specific tasks and time frames; and security 

policy is still being drafted. Without a plan of sufficient detail, VA 

and DOD increase the risk that the CHDR project will not deliver the 

planned capabilities in the time and at the cost expected. 

In addition, officials now acknowledge that they will not meet a 

previously established milestone: by October 2005, the departments 

had planned to be able to exchange outpatient pharmacy data, 

laboratory results, allergy information, and patient demographic 

information on a limited basis. However, according to officials, the 

work required to implement standards for pharmacy and medication 

allergy data was more complex than originally anticipated and led to 

the delay. They stated that the schedule for CHDR is presently being 

revised. Development and data quality testing must be completed 

and the results reviewed. The new target date for medication 

allergy, outpatient pharmacy, and patient demographic data 

exchange is now February 2006. 

Finally, the health information currently in the data repositories has 

various limitations. 
Page 17 GAO-05-1051T 

● Although DOD’s Clinical Data Repository includes data in the 

categories that were to be exchanged at the missed milestone 

described above: outpatient pharmacy data, laboratory results, 

allergy information, and patient demographic information, these 

data are not yet complete. First, the information in the Clinical Data 

Repository is limited to those locations that have implemented the 

first increment of CHCS II, DOD’s new health information system. 

As of September 9, 2005, according to DOD officials, 64 of 139 

medical treatment facilities worldwide have implemented this 

increment. Second, at present, health information in systems other 

than CHCS (such as the Clinical Information System and the 

Integrated Clinical Database) is not yet being captured in the 

Clinical Data Repository. For example, according to DOD officials, 

as of September 9, 2005, the Clinical Information System contained 

1.7 million patient stay records. 

● The information in VA’s Health Data Repository is also limited: 

although all VA medical records are currently electronic, VA has to 

convert these into the interoperable format appropriate for the 

Health Data Repository. So far, the data in the Health Data 

Repository consist of patient demographics and vital signs records 

for the 6 million veterans who have electronic medical records in 

VA’s current system, VistA (this system contains all the department’s 

medical records in electronic form). VA officials told us that they 

plan next to sequentially convert allergy information, outpatient 

pharmacy data, and lab results for the limited exchange that is now 

planned for February 2006. 

In summary, developing an electronic interface that will enable VA 

and DOD to exchange computable patient medical records is a 

highly complex undertaking that could lead to substantial benefits—

improving the quality of health care and disability claims processing 

for the nation’s military members and veterans. VA and DOD have 

made progress in the electronic sharing of patient health data in 

their limited, near-term demonstration projects, and have taken an 

important step toward their long-term goals by improving the 

management of the CHDR program. However, the departments face 

considerable work and significant challenges before they can 

achieve these long-term goals. While the departments have made 
Page 18 GAO-05-1051T 

progress in developing a project management plan defining the 

technical and managerial processes necessary to satisfy project 

requirements, this plan does not specify the authority and 

responsibility of organizational units for particular tasks, the work 

breakdown structure lacks detail on specific tasks and time frames, 

and security policy has not yet been finalized. Without a project 

management plan of sufficient specificity, the departments risk 

further delays in their schedule and continuing to invest in a 

capability that could fall short of expectations. 

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

respond to any questions that you or other members of the 

Committee may have at this time. 

Contacts and Acknowledgments 

For information about this testimony, please contact Linda D. 

Koontz, Director, Information Management Issues, at (202) 512-6240 

or at koontzl@gao.gov. Other individuals making key contributions 

to this testimony include Nabajyoti Barkakati, Barbara S. Collier, 

Nancy E. Glover, James T. MacAulay, Barbara S. Oliver, J. Michael 

Resser, and Eric L. Trout. 

(310744) 
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