GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

United States General Accounting Office

Washington, DC 20548 

May 14, 2004 

The Honorable Steve Buyer 

Chairman, Subcommittee on Oversight and Investigations 

Committee on Veterans’ Affairs 

House of Representatives 

Subject: Computer-Based Patient Records: Subcommittee Questions Concerning VA 

and DOD Efforts to Achieve a Two-Way Exchange of Health Data

Dear Mr. Chairman: 

This letter responds to your April 7, 2004, request that we provide answers to 

questions relating to our March 17, 2004, testimony.1

 At that hearing, we discussed the 

Department of Veterans Affairs’ (VA) and Department of Defense’s (DOD) progress 

toward defining a detailed strategy and developing the capability for a two-way 

exchange of patient health information. Your questions, along with our responses, 

follow. 

1. How many times has the GAO testified on VA-DOD sharing of medical 

information in the last 10 years? 

In the last 10 years we have testified seven times on matters pertaining to VA’s and 

DOD’s efforts toward achieving the capability to electronically exchange patient 

health information. VA and DOD have been working to achieve this capability since 

1998. Our testimony was delivered between October 2001 and March of this year, and 

is summarized in enclosure I. 

Our statements at these hearings have highlighted significant challenges that VA and 

DOD have faced in pursuing ways to share data in their health information systems 

and create electronic medical records. Although noting the departments’ ultimate 

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

to VA health care facilities, as part of the Federal Health Information Exchange,2

 we 

 

1

U.S. General Accounting Office, 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). 

2

When undertaken in 1998, the initiative to share patient health care information was called the 

Government Computer-Based Patient Record project. The project was renamed the Federal Health 

Information Exchange in 2002. 
Page 2 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

also detailed persistent weaknesses in the departments’ actions toward achieving a 

two-way health data exchange—the focus of the HealthePeople (Federal) initiative. 

For example, our most recent testimony highlighted the limited progress that the 

departments had made toward establishing sound project management and defining a 

specific architecture and technological solution for developing the electronic 

interface that is fundamental to exchanging data between the individual health 

information systems that VA and DOD are developing. 

2. What recommendations have either VA or DOD implemented independently 

or cooperatively? 

VA and DOD have taken action on several recommendations that we have made over 

the past 3 years. These recommendations were aimed at improving the coordination 

and management of the departments’ initial efforts to achieve electronic information 

sharing via the Government Computer-Based Patient Record (GCPR) project, and 

furthering DOD’s development of its new health information system, the Composite 

Health Care System II. Our recommendations, along with the departments’ actions to 

implement them, are summarized in enclosure II. 

In particular, our prior reviews of the project to develop a government computerbased patient record determined that the lack of a lead entity, clear mission, and 

detailed planning to achieve that mission had made it difficult to monitor progress, 

identify project risks, and develop appropriate contingency plans. As a result, in 

reporting on GCPR in April 20013

 and again in June 2002,4 we made several 

recommendations to help strengthen the management and oversight of this project. 

VA and DOD agreed with and took actions that addressed all of these 

recommendations, including designating VA as the lead entity for the initiative, 

reevaluating and revising its original goals and objectives, and assigning a full-time 

project manager and supporting staff to oversee its implementation. 

In addition, in September 2002 we reported on DOD’s acquisition of the Composite 

Health Care System II.5 DOD envisioned achieving a state-of-the-art automated 

medical information system that would lead to improved health-care decisions and 

lower medical and system costs through creating computer-based patient records 

that doctors and other health service providers would be able to access from any 

military treatment facility, irrespective of location. However, our review of the 

initiative noted, among other concerns, DOD’s limited progress during early stages of 

 

3

U.S. General Accounting Office, 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). 

4

U.S. General Accounting Office, Veterans Affairs: Sustained Management Attention Is Key to 

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

 

5

U.S. General Accounting Office, Information Technology: Greater Use of Best Practices Can Reduce 

Risks in Acquiring Defense Health Care System, GAO-02-345 (Washington, D.C.: Sept. 26, 2002). 
Page 3 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

the system’s development that led to a change in its redesign and 

development/deployment schedule. We recommended five actions aimed at 

increasing the project’s likelihood of success, three of which have been implemented. 

DOD is in various stages of implementing the remaining two recommendations. 

3. What is the total dollars spent by DOD and VA on their individual or 

collective efforts on the development of an interoperable medical record? 

From fiscal year 1998, when VA and DOD began pursuing ways to share data in their 

health information systems and create electronic records for active duty personnel 

and veterans, through fiscal year 2003, the departments reported spending a total of 

about $670 million on their individual and collective efforts. As shown in table 1, this 

amount is attributable to the departments’ joint actions on the Government 

Computer-Based Patient Record (GCPR) project and subsequently the Federal Health 

Information Exchange (FHIE) initiative, which have resulted in the one-way transfer 

of data from DOD’s existing health information system (the Composite Health Care 

System) to a separate database that VA hospitals can access. The amount also 

includes the departments’ reported expenditures for individual health information 

systems—VA’s HealtheVet (VistA) and DOD’s Composite Health Care System II—that 

each is currently developing and anticipates using to support the two-way exchange 

of health data as part of the HealthePeople (Federal) initiative.6

 However, through 

fiscal year 2003, VA and DOD did not report any costs associated with the critical 

tasks of defining and developing the electronic interface that is essential to achieving 

the two-way exchange of patient health information between these systems. 

Table 1: Dollars (in millions) Spent by VA and DOD to Develop Electronic Health Information Systems 

and Sharing Capabilities through Fiscal Year 2003 

 HealthePeople (Federal) 

Agency GCPR FHIE

HealtheVet

 VistAa

Composite Health

Care System II Total

VA $27.8 $20.4 $120.0 0.0 $168.2

DOD 17.7 18.8 0.0 $464.0 500.5

Total $45.5 $39.2 $120.0 $464.0 $668.7

Source: VA and DOD data. 

a Veterans Health Information Systems and Technology Architecture

 

6

DOD began developing CHCS II in 1997 and has completed its associated clinical data repository that 

is key to achieving the electronic interface. DOD expects to complete deployment of all of its major 

system capabilities by September 2008. VA began work on HealtheVet (VistA) and its associated health 

data repository in 2001, and expects to complete the six initiatives that make up this system in 2012. 
Page 4 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

4. GAO testified that there had been very little progress since our last hearing 

in November 2003. How did VA and DOD explain this to you? When 

Congress scheduled its March 17, 2004, hearing, did GAO get the sense that 

this provided an incentive for the two departments to move forward on this 

issue? 

In discussing with VA and DOD their actions since last November toward achieving a 

two-way exchange of patient health information under the HealthePeople (Federal) 

initiative, officials in both departments expressed their belief that progress was being 

made. In response to our finding that the departments had not yet defined an 

architecture to describe in detail how specific technologies will be used to achieve 

the capability to electronically exchange data between their health information 

systems—a significant concern that we also raised in our November testimony—the 

officials stated that they had recently taken an important first step toward 

accomplishing this task. 

In particular, VA and DOD officials referred to a pharmacy prototype project, 

undertaken in response to the Bob Stump National Defense Authorization Act for 

Fiscal Year 2003, to develop a real-time interface, data exchange, and capability to 

check prescription drug data for outpatients by October 1, 2004. According to VA’s 

Deputy Chief Information Officer for Health, the departments hope to determine from 

the prototype, planned for completion by September 2004, whether the interface 

technology developed to meet this mandate can be used to facilitate the exchange of 

data between the health information systems that VA and DOD are currently 

developing. However, as our testimony noted, the departments had not fully defined 

their approach or requirements for developing and demonstrating the capabilities of 

the planned prototype. Further, since VA and DOD have not yet completed their new 

health information systems that are intended to be used under HealthePeople 

(Federal), the demonstration may only test the ability to exchange data in VA’s and 

DOD’s existing health systems—the Veterans Health Information Systems and 

Technology Architecture (VistA) and the Composite Health Care System (CHCS), 

respectively. Consequently, the early stage of the prototype and the uncertainties 

regarding what capabilities it will demonstrate provided little evidence or assurance 

as to how or whether this project would contribute to defining the architecture and 

technological solution for the two-way exchange of patient health information. 

The information collected during our review of the HealthePeople (Federal) initiative 

suggests that the Subcommittee’s scheduled hearing may have provided an incentive 

for VA and DOD to move forward on this issue. In conducting our review from 

December 2003 through March 2004, we observed that the level of activity 

undertaken by the departments to support the initiative increased significantly in the 

month preceding the hearing. For example, the departments’ officials first informed 

us of their intent to rely on the planned pharmacy prototype to determine the 

technology interface for the two-way data exchange capability in early February; a 

contract for development of the prototype was finalized on February 27. Beyond 
Page 5 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

these actions, VA and DOD began steps toward designating a program manager for 

the pharmacy prototype project and establishing an overall project plan in the week 

before the hearing. 

5. GAO stated that success lies with the highest levels of project discipline, 

including a well-defined architecture and an established project 

management structure. At the present time, these criteria are absent. Is that 

correct? Please provide your recommendations on the top five priorities that 

need to be addressed in 2004. 

At the time of our testimony, these critical project components were absent from 

VA’s and DOD’s initiative to develop a two-way exchange of patient health 

information. Specifically, VA and DOD lacked a clearly defined architecture to 

describe how they planned to develop the electronic interface needed to exchange 

data between their health information systems. In addition, the departments had not 

fully established a project management structure to ensure the necessary day-to-day 

guidance of and accountability for their investments in and implementation of this 

capability. 

Given the implications that an electronic interface can have for improving the quality 

of health care and disability claims processing for military members and veterans, the 

top five priorities that VA and DOD need to address in 2004 to increase the likelihood 

of a successful outcome are 

• development of an architecture for the electronic interface that articulates system 

requirements, design specifications, and software descriptions; 

• selection of a lead entity with final decision-making authority for the initiative; 

• establishment of a project management structure (i.e., project manager and 

supporting staff) to provide day-to-day guidance of and accountability for the 

investments in and implementation of the electronic interface capability; 

• development and implementation of a comprehensive and coordinated project 

plan that defines the technical and managerial processes necessary to satisfy 

project requirements and that includes the authority and responsibility of each 

organizational unit; a work breakdown structure and schedule for all of the tasks 

to be performed in developing, testing, and deploying the electronic interface; and 

a security plan; and 

• implementation of project review milestones and measures to provide the basis 

for comprehensive management, progressive decision making, and authorization 

of funding for each step in the development process. 

VA and DOD officials stated at the conclusion of our review that they had begun 

discussions to establish an overall project plan and finalize roles and responsibilities 

for managing the joint initiative to develop an electronic interface. 
Page 6 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

6. To your knowledge, has any major VA or DOD IT project ever been initiated 

with such criteria firmly established from the beginning? 

To date, we have evaluated only a small portion of VA’s and DOD’s respective 

portfolios of information technology investments. Based on our work, we cannot 

point to any instances in which either department has initiated a major information 

technology project with a clearly defined architecture and sound project management 

having been established. At the same time, we are generally aware that DOD has held 

out certain projects undertaken by its component organizations as examples in which 

well-defined architectures and sound project management existed. However, we did 

not participate in, and therefore cannot comment on, the validity of those 

representations. 

During our reviews of the Government Computer-Based Patient Record project, we 

did see evidence that implementing critical project management processes after a 

project has been undertaken can positively affect its outcome. As our testimony 

noted,7

 VA’s and DOD’s designation of clear lines of authority and a manager to 

provide day-to-day oversight helped strengthen overall project management and 

accountability and contributed to successfully achieving the transfer of patient health 

information from DOD to VA’s medical facilities. 

Agency Comments and Our Evaluation 

We received comments orally and via e-mail on a draft of this correspondence from 

VA’s Assistant Secretary for Information and Technology and DOD’s Interagency 

Program Integration and External Liaison for Health Affairs. In commenting on our 

responses, these officials offered additional perspectives and suggested clarifications, 

which have been incorporated where appropriate. Both departments’ officials 

disagreed with the way in which our response to question 4 characterized their 

progress toward developing a two-way electronic data exchange capability. 

Regarding our response to question 1, VA and DOD officials commented that they 

have now designated a single manager for the electronic interface initiative. They 

have not yet, however, provided for our analysis any documentation on the project 

management structure and the manager’s and supporting staff’s roles and 

responsibilities for overseeing and ensuring accountability for this initiative. 

Regarding our response to question 2, VA and DOD officials stated that both 

departments have cooperatively implemented our recommendations. Our response 

has been clarified to reflect that VA and DOD took actions that addressed all of our 

recommendations for improving management of the Government Computer-Based 

Patient Record project, and to reflect that DOD has implemented three of five 

recommendations that we made to improve its CHCS II project. 

 

 

7

GAO-04-402T.
Page 7 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

In commenting on our response to question 3, which addressed the total dollars spent 

by VA and DOD on developing an electronic medical record through fiscal year 2003 

(the latest time frame for which we had complete information reported by the 

departments), both VA and DOD referred to initiatives other than GCPR, FHIE, and 

their individual health information systems, which they believed reflected work on 

developing the electronic data exchange capability. For example, both departments 

identified the pharmacy prototype as a critical effort toward developing an electronic 

interface for which resources were being expended. Our testimony, as well as this 

correspondence, acknowledges that the departments had taken action related to the 

pharmacy prototype. However, this initiative was not undertaken until late February 

of this year, which was outside of the time frame of the reported costs reflected in 

our response to the question. We have revised our response to more clearly reflect 

our use of cost information reported through fiscal year 2003. 

Beyond the pharmacy prototype, VA stated that a number of other initiatives had also 

demonstrated progress toward achieving an electronic interface. It stated, for 

example, that the departments had contributed “in-kind” resources to efforts 

supporting the Consolidated Health Informatics initiative and internal standards 

boards within each department. However, VA did not provide any specific cost 

information for these actions. 

Finally, in commenting on the reported costs, DOD suggested that we clarify the title 

of our table identifying the departments’ expenditures, to better reflect that not all 

costs reported through fiscal year 2003 were directly attributable to achieving the 

two-way electronic health data exchange. We have revised the table to more clearly 

reflect the reported expenditures for GCPR, FHIE, and the departments’ individual 

health information system initiatives. 

Regarding our response to question 4, VA and DOD stated that they did not agree 

with our assessment that the departments’ progress since November 2003 had been 

limited, or that most progress had been apparent just before the March hearing. Both 

departments cited their work related to the pharmacy prototype project as evidence 

of their progress toward developing the electronic interface. For example, DOD 

stated that although the departments may not have informed us, before last February, 

of their intent to rely on the pharmacy prototype to determine the technology for the 

electronic interface, a memorandum discussing the pharmacy data exchange strategy 

had been signed in October 2003. However, we were not provided with copies of any 

such documentation, and without information on such an activity, we cannot offer an 

assessment of any actions taken by VA and DOD on the pharmacy prototype earlier 

than February 2004—the point at which we were made aware that this prototype 

would be used to help define the electronic interface. Further, in its comments, VA 

said it continued to anticipate that the prototype would assist in determining an 

appropriate architecture for the electronic interface. Given the stage of the pharmacy 

project and the supporting documentation available to us when our review ended, our 

analysis determined that the departments lacked evidence as to how or whether the 
Page 8 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

project would contribute to defining the architecture and technological solution for a 

two-way exchange of patient health information. 

Beyond the pharmacy prototype, VA cited numerous other initiatives involving the 

departments’ existing health information systems (VistA and CHCS) and 

infrastructure that it considered to be evidence of progress. These included a project 

aimed at automatically sending to VA relevant electronic health information for 

patients sent to DOD for VA-paid care as veterans; and a data-sharing interface 

project, involving the use of VA’s and DOD’s existing health information systems to 

produce real-time, bidirectional exchange of clinically relevant data, including 

outpatient pharmacy, allergy, and patient demographic information at VA and DOD 

locations with medical sharing agreements. During our review, VA and DOD did not 

offer information on these initiatives or identify them as being part of the 

HealthePeople (Federal) strategy for an electronic two-way data exchange capability. 

Therefore, we are unable to make an assessment of these initiatives or how they 

relate to VA’s and DOD’s progress toward achieving the intended capability to 

electronically exchange patient data between the new health information systems—

HealtheVet (VistA) and CHCS II—that the departments are developing. 

In commenting on the response to question 5, the departments identified various 

actions that, in their views, addressed our identified priorities for disciplined project 

management. Regarding the development of an architecture to define the electronic 

interface, the departments anticipated that the pharmacy prototype would assist 

them in determining the appropriate architecture and emphasized their continued 

work on developing standards that will affect the interface requirements. Our 

testimony acknowledged the departments’ actions on developing data standards, and 

also noted their plans for using the pharmacy prototype to determine the architecture 

for the electronic interface. As we pointed out, however, the early stage of the 

prototype and the uncertainties regarding what capabilities it would demonstrate 

provided little evidence or assurance as to how or whether the project would 

contribute to defining the architecture and technological solution for a two-way 

exchange of patient health information. 

Regarding the selection of a lead entity with final decision-making authority for the 

electronic interface initiative, the departments stated that the VA/DOD Health 

Executive Council was serving in this capacity. VA added that this council provides a 

fully integrated body in which decisions are made and accountability for progress is 

provided for both departments. We agree that the Health Executive Council plays an 

important role in helping to ensure full accountability for the HealthePeople (Federal) 

initiative. Nonetheless, as established, this council meets on a bimonthly basis and is 

composed of senior VA and DOD leaders who work from a high-level, 

departmentwide perspective, to institutionalize all of VA’s and DOD’s sharing and 

collaboration on health services and resources. As our testimony noted, there is no 

one entity dedicated to making binding decisions for the HealthePeople (Federal) 

project. Our prior work on GCPR noted the importance of a lead entity to exercise 

final authority over the project, and VA and DOD demonstrated improvements in 
Page 9 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

managing GCPR as a result of implementing our recommendation that it establish 

such an entity. 

On establishing a project manager and supporting staff to provide day-to-day 

guidance for the electronic interface initiative, VA and DOD cited their designation of 

a single manager with accountability and day-to-day responsibility for project 

implementation. However, as discussed, the departments have not yet provided 

documentation of the management structure that they have implemented, including 

information on the roles and responsibilities that the manager and supporting staff 

will have for the joint electronic interface initiative. 

Regarding the development and implementation of a comprehensive and coordinated 

project plan for the electronic interface initiative, the departments stated that a 

project management plan had been developed for the pharmacy prototype. We agree 

that such a plan is necessary for the pharmacy prototype. However, it is also essential 

that the departments have a project management plan for the electronic interface 

initiative to define the technical and managerial processes needed to satisfy project 

requirements, and assign responsibilities, tasks, and schedules associated with 

developing, testing, and deploying the electronic interface between the new health 

information systems that VA and DOD are developing. 

Further, regarding the implementation of project review milestones and measures for 

the electronic interface initiative, VA and DOD stated that the departments provide 

updates to the Health Executive Council and the Joint Executive Council. VA added 

that performance measures for interoperability are built into the joint strategic plan 

managed by the Joint Executive Council. As our March testimony noted, the Health 

Executive Council meets bimonthly to institutionalize sharing and collaboration of 

health services and resources, and the Joint Executive Council meets quarterly to 

recommend strategic direction of joint coordination and sharing efforts. VA and DOD 

did not provide any evidence to explain the levels of update being provided to these 

councils or how the councils’ reviews address critical milestones and measures of the 

initiative’s progress. In addition, our review of the joint strategic plan found that this 

high-level strategy established broad time frames and a general approach for 

achieving a health data exchange between VA and DOD, but did not articulate 

specific details regarding the incremental design and development of the electronic 

interface capability. For example, the strategy lacked specific milestones or measures 

that would enable the departments to track the status of their actions toward 

developing the interface at critical intervals in the project’s life cycle. 

Finally, in commenting on our response to question 6, VA officials stated that the 

department has implemented all of its major health information initiatives under the 

Veterans Health Information Systems and Technology Architecture. For its part, DOD 

stated that it is guided by a rigorous project management system, and cited our 

September 2002 report8

 in which we stated that the CHCS II initiative was generally 

 

8

GAO-02-345. 
Page 10 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

aligned with the Military Health System’s (MHS) enterprise architecture. As noted, 

our evaluations have not identified any major initiatives that VA and DOD have begun 

with both a clearly defined architecture and sound project management already 

established. While our report on DOD’s CHCS II noted that this system and the MHS 

architecture were generally aligned, it also highlighted deficiencies in the project’s 

management during its early years. For example, performance-based contracting 

methods were not used to ensure contractor accountability. 

-- -- -- -- -- 

In responding to these questions, we relied on past work related to our review of VA’s 

and DOD’s actions since last November toward defining a detailed strategy and 

developing the capability for a two-way exchange of patient health information. We 

reviewed our prior analyses of key documentation supporting the departments’ 

strategy, including deployment and conversion plans, project schedules, and status 

reports for their individual health information systems. In addition, we reviewed 

documentation identifying the costs incurred by VA and DOD in developing 

technology to support the sharing of health data, including costs for the Government 

Computer-Based Patient Record and Federal Health Information Exchange 

initiatives, and with their 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 conducted our work in accordance with generally accepted 

government auditing standards, during April 2004. 

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

Defense, and to other interested parties. Copies will also be available at no charge at 

our Web site at www.gao.gov. 

Should you or your office have any questions on matters discussed in this letter, 

please contact me at (202) 512-6240 or Valerie Melvin, Assistant Director, at (202) 

512-6304. We can also be reached by e-mail at koontzl@gao.gov and 

melvinv@gao.gov, respectively. Key contributors to this correspondence include 

Barbara S. Oliver, J. Michael Resser, and Eric Trout. 

Sincerely yours, 

Linda D. Koontz 

Director, Information Management Issues 
Page 11 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

Enclosure I: GAO Testimony on VA-DOD Sharing of Patient Health Information 

Testimony 

date/number Summary of results 

March 17, 2004 

GAO-04-402T 

VA and DOD had made little progress since November 2003 toward defining how 

they intended to achieve the two-way exchange of patient health information 

under the HealthePeople (Federal) initiative. While VA officials recognized the 

importance of an architecture to describe in detail how the departments would 

electronically interface their health systems, they continued to rely on a lessspecific, high-level strategy—in place since September 2002—to guide the 

development and implementation of this capability. The departments intended to 

rely on a pharmacy prototype project undertaken in March 2004 to better define 

the electronic interface needed to exchange patient health data, but had not fully 

determined the approach or requirements for this undertaking. Thus, there was 

little evidence of how this project would contribute to defining a specific 

architecture and technological solution for achieving a two-way exchange of 

patient health information. These uncertainties were further complicated by the 

absence of sound project management to guide the departments’ actions on the 

HealthePeople (Federal) initiative. Although progress toward defining data 

standards continued, delays had occurred in VA’s and DOD’s development and 

deployment of their individual health information systems, critical for achieving the 

electronic interface. 

November 19, 2003 

GAO-04-271T 

The one-way transfer of health information resulting from VA’s and DOD’s nearterm solution—the Federal Health Information Exchange (FHIE)—represented a 

positive undertaking and had enabled electronic health data from separated 

(retired or discharged) service members contained in DOD’s Military Health 

System Composite Health Care System to be transmitted monthly to a VA FHIE 

repository, giving VA clinicians more ready access to DOD health data, such as 

laboratory, pharmacy, and radiology records, on almost 2 million patients. The 

departments’ longer term strategy to enable electronic, two-way information 

sharing—HealthePeople (Federal)—was farther out on the horizon, and VA and 

DOD faced significant challenges in implementing a full data exchange capability. 

Although a high-level strategy existed, the departments had not clearly articulated 

a common health information infrastructure and architecture to show how they 

intended to achieve the data exchange capability or what they would be able to 

exchange by the end of 2005. Critical to achieving the two-way exchange was 

completing the standardization of the clinical data that the departments planned to 

share. 

September 26, 2002 

GAO-02-1054T 

VA and DOD reported some progress in achieving the capability to share patient 

health care data under the Government Computer-Based Patient Record (GCPR) 

initiative. The agencies had, since March 2002, formally renamed the initiative the 

Federal Health Information Exchange and begun implementing a more narrowly 

defined strategy involving the one-way transfer of patient health data from DOD to 

VA; a two-way exchange was planned by 2005. 

March 13, 2002 

GAO-02-369T 

VA had achieved limited progress in its joint efforts with DOD and the Indian 

Health Service to create an interface for sharing data in their health information 

systems, as part of GCPR. Strategies for implementing the project continued to be 

revised, its scope had been substantially narrowed from its original objectives, 

and it continued to operate without clear lines of authority or comprehensive, 

coordinated plans. Consequently, the future success of this project remained 

uncertain, raising questions as to whether it would ever fully achieve its original 

objective of allowing health care professionals to share clinical information via a 

comprehensive, lifelong medical record. 
Page 12 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

Testimony 

date/number Summary of results 

February 27, 2002 

GAO-02-478T 

DOD’s and VA’s numerous databases and electronic systems for capturing 

mission-critical data, including health information, were not linked, and information 

could not be readily shared. DOD had several initiatives under way to link many of 

its information systems—some with VA. For example, to create a comprehensive, 

lifelong medical record for service members and veterans and to allow health care 

professionals to share clinical information, the departments, along with the Indian 

Health Service, initiated the Government Computer-Based Patient Record 

(GCPR) project in 1998. However, several factors, including planning 

weaknesses, competing priorities, and inadequate accountability, made it unlikely 

that they would achieve a GCPR or realize its benefits in the near future. To 

strengthen management and oversight of the project, we recommended 

designating a lead entity with clear lines of authority for the project and the 

creation of comprehensive and coordinated plans for sharing meaningful, 

accurate, and secure patient health data. For the near term, DOD and VA had 

decided to reconsider their approach to GCPR and focus on allowing VA to 

access selected service members’ health data captured by DOD, such as 

laboratory and radiology results, outpatient pharmacy data, and patient 

demographic information. However, GCPR would not provide VA with access to 

information on the health status of personnel when they entered military service; 

on medical care provided to Reservists while not on active duty; or on the care 

military personnel received from providers outside DOD, including those from 

TRICARE.a

 

January 24, 2002 

GAO-02-377T 

DOD improved its medical surveillance system under Operation Joint Endeavor. 

However, system problems included lack of a single, comprehensive electronic 

system to document and access medical surveillance data. Some DOD initiatives 

to improve information technology capability were several years away from full 

implementation. The ability of VA to fulfill its role in serving veterans and providing 

backup to DOD in times of war was to be enhanced as DOD increased its medical 

surveillance capability. GCPR was a joint DOD/VA initiative in conjunction with the 

Indian Health Service to link information systems. However, because of planning 

weaknesses, competing priorities, and inadequate accountability, it was unlikely 

that the departments would accomplish GCPR or realize its benefits in the near 

future. To strengthen management and oversight of the initiative, we again 

recommended designating a lead entity with clear lines of authority for the project 

and the creation of comprehensive and coordinated plans for sharing meaningful, 

accurate, and secure patient health data. 

October 16, 2001 

GAO-02-173T 

DOD and VA were establishing a medical surveillance system for the health care 

needs of military personnel and veterans. The system was to collect and analyze 

uniform information on deployments, environmental health threats, disease 

monitoring, medical assessments, and medical encounters. We identified 

weaknesses in DOD’s medical surveillance capability and performance in the Gulf 

War and Operation Joint Endeavor, and uncovered deficiencies in its ability to 

collect, maintain, and transfer accurate data. The department had several 

initiatives under way to improve the reliability of deployment information and to 

enhance its information technology capabilities, although some initiatives were 

several years away from full implementation. VA’s ability to serve veterans and 

provide backup to DOD in times of war was to be enhanced as DOD increased its 

medical surveillance capability. GCPR was one initiative to link the departments’ 

information systems. However, because of planning weaknesses, competing 

priorities, and inadequate accountability, it was unlikely that they would 

accomplish GCPR or realize its benefits in the near future. To strengthen 

management and oversight of the initiative, we recommended designating a lead 

entity with clear lines of authority for the project and the creation of 

comprehensive and coordinated plans for sharing meaningful, accurate, and 

secure patient health data. 

Source: GAO. 

a

TRICARE is the Department of Defense’s worldwide health care program for active duty and retired uniformed services 

members and their families. 
Page 13 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

Enclosure II: Actions Taken by VA and DOD on GAO Recommendations 

Report date/number Recommendations Actions taken by VA and/or DOD 

June 12, 2002 

GAO-02-703 

The Secretary of Veterans Affairs, to make 

significant progress beyond the current 

strategy for the government computer-based 

patient record, should instruct the Veterans 

Health Administration (VHA) undersecretary 

and VHA chief information officer, in 

cooperation with DOD and the Indian Health 

Service (IHS), to revisit the original goals and 

objectives of the Government ComputerBased Patient Record (GCPR) initiative to 

determine if they remain valid, and where 

necessary, revise the goals and objectives to 

be aligned with the current strategy and 

direction of the project. 

The Department of Veterans Affairs (VA), in 

conjunction with DOD, implemented this 

recommendation. The departments reevaluated 

and revised the original goals and objectives of 

the GCPR initiative. A May 3, 2002, 

memorandum of agreement between VA and 

DOD established the Federal Health Information 

Exchange (FHIE), which replaced the GCPR 

initiative. As of mid-July 2002, all VA medical 

centers had access to FHIE data on over 1 

million service personnel who separated 

between 1987 and 2001. 

June 12, 2002 

GAO-02-703 

The Secretary of Veterans Affairs, to make 

significant progress beyond the current 

strategy for GCPR, should instruct the VHA 

undersecretary and VHA chief information 

officer, in cooperation with DOD and IHS, to 

commit the executive support necessary for 

adequately managing the project, and ensure 

that sound project management principles are 

followed in carrying out the initiative. 

VA, in conjunction with DOD, implemented this 

recommendation. The departments committed 

the executive support necessary for adequately 

managing the GCPR project. They also ensured 

that project management principles were 

followed in carrying out the initiative. 

Specifically, in May 2002 VA and DOD signed a 

memorandum of agreement that designated VA 

as the lead entity in implementing the project 

(formally renamed FHIE). VA committed 

executive support for the project by way of 

monthly updates, given by the FHIE program 

manager, to the VA chief information officer, as 

well as quarterly updates to the joint VA/DOD 

Executive Council. In addition, VA procured and 

implemented project management software to 

better track the assignment and status of project 

tasks and initiatives. 

September 26, 2002 

GAO-02-345 

The Secretary of Defense, through the 

Assistant Secretary of Health Affairs, should 

direct the Military Health System (MHS) chief 

information officer to give expanded use of 

best practices in managing CHCS II the 

attention and priority it deserves. At a 

minimum, the Assistant Secretary should 

direct the MHS chief information officer to, as 

part of the CHCS II deployment decisions, 

consider the aggregate impact on defense 

health affairs mission performance caused by 

the workarounds needed to compensate for 

all unresolved defects affecting the system's 

operational efficiency. 

DOD implemented this recommendation. In late 

2002, the program office produced a 

maintenance release for CHCS II that corrected 

many of the remaining bugs that required 

workarounds, and the limited deployment sites 

have that version. In addition, MHS has put a 

standard operating procedure in place to 

evaluate the effect of all workarounds required 

for new systems/versions before 

implementation. The standard operating 

procedure is part of the configuration control 

board procedures and the service components 

have agreed to these procedures. Finally, a test 

and evaluation master plan that addresses the 

aggregate impact of workarounds has been 

completed for the CHCS II release of 

functionality supporting general dentistry, and 

will be used as a template for future plans. 
Page 14 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

Report date/number Recommendations Actions taken by VA and/or DOD 

September 26, 2002 

GAO-02-345 

The Assistant Secretary of Health Affairs 

should direct the MHS chief information 

officer to verify that the CHCS II inventory of 

risks is complete and correct, and report this 

to the Assistant Secretary for Health Affairs 

every 6 months, along with a report on the 

status of all top priority risks, including each 

risk's probability of occurrence and impact on 

mission. 

DOD implemented this recommendation. The 

program office updated the risk management 

plan to require continuous risk management 

database updates and monthly risk reports. An 

initial 6-month report was provided to the 

Assistant Secretary in April 2003 that included 

the status of all program risks, with details on 

priority 1 risks, including probability of 

occurrence and impact on mission. 

September 26, 2002 

GAO-02-345 

The Secretary of Defense should direct the 

Assistant Secretary of Defense for Command, 

Control, Communications, and Intelligence, 

who is the designated approval authority for 

CHCS II, to monitor the project's use of best 

practices, including implementation of each of 

the above recommendations, and use this 

information to oversee the project's 

movement through its acquisition cycle. To 

this end, the Assistant Secretary, or other 

designated CHCS II approval authority, 

should not grant any request for deployment 

approval of any CHCS II release that is not 

justified by reliable analysis of the release's 

costs, benefits, and risks. 

DOD implemented this recommendation. The 

program office updated its cost-benefit analysis 

in September 2002, and the Naval Center for 

Cost Analysis validated the cost estimate. This 

was used to approve the limited deployment of 

a graphical user interface for clinical outpatient 

processes in January 2003, and is available for 

use by the milestone decision authority for the 

full deployment decision. 

September 26, 2002 

GAO-02-345 

The Secretary of Defense, through the 

Assistant Secretary of Health Affairs, should 

direct the MHS CIO to give expanded use of 

best practices in managing CHCS II the 

attention and priority they deserve. At a 

minimum, the Assistant Secretary should 

direct the MHS CIO to define and implement 

incremental investment management 

processes to include (1) modifying the CHCS 

II investment strategy to define how this 

approach will be implemented; (2) justifying 

investment in each system release before 

beginning detailed design and development of 

the release; (3) requiring that such justification 

be based on reliable estimates of costs, 

benefits, and risks; (4) measuring whether 

actual return-on-investment for each deployed 

release is in line with justification forecasts; 

and (5) using actual return-on investment 

results in deciding whether to begin detailed 

design and development of the next system 

release. 

Actions to implement this recommendation are 

ongoing. MHS has contracted with the Army 

Test and Evaluation Command and a private 

contractor to assess limited deployment sites 

and obtain data on initial benefits to support 

return-on-investment analyses. Deployments of 

the initial version of the system were delayed 

until fiscal year 2004; it is therefore unlikely that 

this recommendation will be fully addressed 

before the end of the fiscal year. 
Page 15 GAO-04-691R Post-Hearing Questions on VA/DOD Health Data Exchange 

Report date/number Recommendations Actions taken by VA and/or DOD 

September 26, 2002 

GAO-02-345 

The Secretary of Defense, through the 

Assistant Secretary of Health Affairs, should 

direct the MHS CIO to give expanded use of 

best practices in managing CHCS II the 

attention and priority they deserve. At a 

minimum, the Assistant Secretary should 

direct the MHS CIO to employ performancebased contracting practices on all future 

CHCS II delivery orders to the maximum 

extent possible, including (1) defining 

performance standards against which 

deliverables can be judged, (2) developing 

and using quality assurance plans that 

describe how contractor performance against 

the standards will be measured, and (3) 

defining and using contractor incentives and 

penalties tied to the quality plan. 

Actions to implement this recommendation are 

ongoing. The program office received approval 

to begin acquiring commercial off-the-shelf 

software packages to develop prototype 

pharmacy/laboratory/radiology capabilities, and 

plans to conduct full and open competition 

contracts for these packages. A performancebased, firm fixed-price integration contract, with 

incentives, is being prepared and is expected to 

be awarded in the 3rd quarter of fiscal year 2004. 

As the program office re-negotiates the 

contracts for a graphical user interface for 

clinical outpatient processes and general 

dentistry, they will also be moved to this 

performance-based type of contract. 

 Source: GAO. 

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