ELECTRONIC 

HEALTH RECORDS

VA and DOD Need to 

Support Cost and 

Schedule Claims, 

Develop 

Interoperability Plans, 

and Improve 

Collaboration

Report to Congressional Requesters

February 2014

GAO-14-302

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-302, a report to 

congressional requesters 

February 2014 

ELECTRONIC HEALTH RECORDS

VA and DOD Need to Support Cost and Schedule 

Claims, Develop Interoperability Plans, and Improve 

Collaboration

Why GAO Did This Study

VA and DOD operate two of the 

nation’s largest health care systems, 

serving approximately 16 million 

veterans and active duty service 

members, and their beneficiaries, at

total annual costs of over $100 billion. 

The departments have recognized the 

importance of developing capabilities 

for sharing electronic patient health 

information and have worked since 

1998 to develop such capabilities. In 

February 2011, VA and DOD initiated a 

program to develop a single, common 

electronic health record system—

iEHR—to replace their existing health

record systems. This program was to 

be managed by the IPO and 

implemented by 2017. However, the 

departments made significant changes 

to the program in 2013. GAO was 

asked to review the iEHR program. 

This report (1) describes changes to 

the program and evaluates the 

departments’ current plans and (2) 

determines whether the departments 

are effectively collaborating on 

management of the program. GAO 

reviewed relevant program documents 

and interviewed agency officials. 

What GAO Recommends

GAO recommends that VA and DOD 

develop and compare the estimated 

cost and schedule of their current and 

previous approaches to creating an 

interoperable electronic health record 

and, if applicable, provide a rationale 

for pursuing a more costly or timeconsuming approach. GAO also 

recommends that the departments 

develop plans for interoperability and 

ensure the IPO has control over 

needed resources and clearer lines of 

authority. VA and DOD concurred with 

GAO’s recommendations.

What GAO Found

The Departments of Veterans Affairs (VA) and Defense (DOD) abandoned their 

plans to develop an integrated electronic health record (iEHR) system and are 

instead pursuing separate efforts to modernize or replace their existing systems

in an attempt to create an interoperable electronic health record. Specifically, in 

February 2013, the secretaries cited challenges in the cost and schedule for 

developing the single, integrated system and announced that each department 

would focus instead on either building or acquiring similar core sets of electronic 

health record capabilities, then ensuring interoperability between them. However, 

VA and DOD have not substantiated their claims that the current approach will be 

less expensive and more timely than the single-system approach. Major 

investment decisions—including terminating or significantly restructuring an 

ongoing program—should be justified using analyses that compare the costs and 

schedules of alternative proposals. Yet, the departments have not developed 

revised cost and schedule estimates for their new modernization efforts and any 

additional efforts needed to achieve interoperability between the new systems, 

and compared them with the relevant estimates for their former approach. In the 

absence of such a comparison, VA and DOD lack assurance that they are 

pursuing the most cost-effective and timely course of action for delivering the 

fully interoperable electronic health record the departments have long pursued to 

provide the best possible care for service members and veterans. 

The departments have initiated their separate system efforts. VA intends to 

deploy clinical capabilities of its new system at two locations by September 2014, 

and DOD has set a goal of beginning deployment of its new system by the end of 

fiscal year 2016. However, the departments have yet to update their joint 

strategic plan to reflect the new approach or to disclose what the interoperable 

electronic health record will consist of, as well as how, when, and at what cost it 

will be achieved. Without plans that include the scope, lines of responsibility, 

resource requirements, and an estimated schedule for achieving an interoperable 

health record, VA, DOD, and their stakeholders may not have a shared 

understanding of how the departments intend to address their common health 

care business needs. 

VA and DOD have not addressed management barriers to effective collaboration 

on their joint health information technology (IT) efforts. As GAO previously 

reported, the departments faced barriers to effective collaboration in the areas of 

enterprise architecture and IT investment management, among others. However, 

they have yet to address these barriers by, for example, developing a joint health 

care architecture or a joint IT investment management process to guide their 

collaboration. Further, the Interagency Program Office (IPO), established by law 

to act as a single point of accountability for the departments’ development of

interoperable health records, was to better position the departments to 

collaborate; but the departments have not implemented the IPO in a manner 

consistent with effective collaboration. For example, the IPO lacks effective 

control over essential resources such as funding and staffing. In addition, recent 

decisions by the departments have diffused responsibility for achieving integrated 

health records, potentially undermining the IPO’s intended role as the point of 

accountability. Providing the IPO with control over essential resources and 

clearer lines of authority would better position it for effective collaboration. 

View GAO-14-302. For more information, 

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

melvinv@gao.gov. 
Page i GAO-14-302 Electronic Health Records 

Letter 1 

Background 3

VA and DOD Abandoned Plans for a Single System, but Their 

New Approach to Achieving an Interoperable Electronic Health 

Record Is Not Supported by Sufficient Cost and Schedule 

Analysis or a Complete Plan 17

Collaboration between VA and DOD Has Been Hindered by Longstanding Barriers and Ineffective Implementation of the IPO 23

Conclusions 33

Recommendations for Executive Action 34

Agency Comments and Our Evaluation 36

Appendix I Objectives, Scope, and Methodology 37

Appendix II Joint Comments from the Departments of Veterans Affairs and 

Defense 39

Appendix III GAO Contact and Staff Acknowledgments 42

Contents
Page ii GAO-14-302 Electronic Health Records 

Abbreviations

AHLTA Armed Forces Health Longitudinal Technology Application

AT&L Acquisition, Technology, and Logistics

BHIE Bidirectional Health Information Exchange

CHCS Composite Health Care System

CHDR Clinical Data Repository/Health Data Repository initiative

CIO chief information officer

DHMS DOD Healthcare Management Systems

DHMSM DOD Healthcare Management System Modernization

DOD Department of Defense

FHCC Federal Health Care Center

FHIE Federal Health Information Exchange

GCPR Government Computer-Based Patient Record 

iEHR Integrated Electronic Health Record

IPO Interagency Program Office

IT information technology

NDAA National Defense Authorization Act

RFP request for proposals 

VA Department of Veterans Affairs

VistA Veterans Health Information Systems and Technology

 Architecture

VLER Virtual Lifetime Electronic Record 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

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necessary if you wish to reproduce this material separately.
Page 1 GAO-14-302 Electronic Health Records 

441 G St. N.W.

Washington, DC 20548

February 27, 2014

The Honorable Patty Murray

Chairman

Committee on the Budget

United States Senate

The Honorable Bernard Sanders

Chairman 

The Honorable Richard Burr

Ranking Member

Committee on Veterans’ Affairs

United States Senate

The Department of Veterans Affairs (VA) and the Department of Defense 

(DOD) operate two of the nation’s largest health care systems, providing 

health care to approximately 6.3 million veterans and 9.6 million active 

duty service members and their beneficiaries at estimated annual costs of 

about $53 billion and $49 billion, respectively. Electronic health records

are an essential part of delivering quality care to veterans and service 

members—especially the 5 million shared patients—that is, those who 

receive health care and services from both departments.1

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

use of shared health information systems and capabilities to make patient 

information more readily available to their health care providers, reduce 

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

in February 2011, the departments initiated a program to jointly develop a 

single electronic health record system, known as the integrated Electronic 

Health Record (iEHR), which was to replace the two departments’ 

existing electronic health record systems. The DOD/VA Interagency 

Program Office (IPO) was given responsibility for managing the iEHR 

program. More recently, however, the departments have made significant 

changes to the direction of the program.

 

1

An electronic health record is a collection of information about the health of an individual 

or the care provided, such as patient demographics, progress notes, problems, 

medications, vital signs, past medical history, immunizations, laboratory data, and 

radiology reports. 
 

Page 2 GAO-14-302 Electronic Health Records 

At your request, we conducted a review of the iEHR program. 

Specifically, our objectives were to (1) describe the changes VA and DOD 

have made to the iEHR program since its inception and evaluate the 

departments’ current plans for the program and (2) determine whether the 

departments, including the IPO, are effectively collaborating on 

management of the iEHR program.

To accomplish the objectives, we reviewed relevant program 

documentation and interviewed appropriate VA, DOD, and IPO officials. 

Specifically, to describe changes to the iEHR program and evaluate the 

departments’ current plans, we reviewed and compared iEHR program 

planning documentation (e.g., business case, program management plan, 

and integrated program-level requirements document) with program 

status briefings, acquisition decision memoranda, and minutes of 

meetings between the Secretaries of Defense and Veterans Affairs. To 

determine whether the departments are effectively collaborating on 

management of the iEHR program, we evaluated VA’s and DOD’s actions 

in response to recommendations we previously made to address barriers 

the departments face in their efforts to meet electronic health record 

needs. We also compared the departments’ implementation of the IPO 

with effective collaborative practices we have previously identified.2

We conducted this performance audit from September 2012 to February 

2014 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives. A more complete 

discussion of our objectives, scope, and methodology is provided in 

appendix I.

Lastly, we analyzed the governance structure for the program, including 

organizational charts and charters that established the reporting structure 

between the IPO, VA, DOD, and interagency organizations.

 

2

GAO, Results-Oriented Government: Practices That Can Help Enhance and Sustain 

Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: Oct. 21, 2005) 

and Managing for Results: Key Considerations for Implementing Interagency Collaborative 

Mechanisms, GAO-12-1022 (Washington, D.C.: Sept. 27, 2012).
 

Page 3 GAO-14-302 Electronic Health Records 

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

retrieve, and transfer clinical, administrative, and financial health 

information has great potential to help improve the quality and efficiency 

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

across paper records kept by many different caregivers in many different 

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

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

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

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

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

and improve clinical decisions.

Electronic health records are particularly crucial for optimizing the health 

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

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

mobile and may have health records residing at multiple medical facilities 

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

help ensure that complete health care information is available for most 

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

matter where it originates.

Although they have identified many common health care business needs, 

both departments have spent large sums of money to develop and 

operate separate electronic health record systems that they rely on to 

create and manage patient health information. VA uses its integrated 

medical information system—the Veterans Health Information Systems 

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

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

computer applications, including 56 health provider applications; 19 

management and financial applications; 8 registration, enrollment, and 

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

education applications. Besides being numerous, these applications have 

been customized at all 128 VA sites.3

 

3

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

that store their electronic health data in a single database.

According to the department, this 

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

that maintenance also be customized.

Background
 

Page 4 GAO-14-302 Electronic Health Records 

In 2001, the Veterans Health Administration undertook an initiative to 

modernize VistA by standardizing patient data and modernizing the health 

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

the hospital-centric environment that had long characterized the 

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

on an open, robust systems architecture that would more efficiently 

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

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

incremental approach to the initiative, based on six phases that were to 

be completed in 2018. The department reported spending almost $600 

million from 2001 to 2007 on eight projects, including an effort that 

resulted in a repository containing selected standardized health data, as 

part of the effort to modernize VistA. In April 2008, the department 

estimated an $11 billion total cost to complete, by 2018, the 

modernization that was planned at that time. However, according to VA 

officials, the modernization effort was terminated in August 2010.

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

Technology Application (AHLTA), which comprises multiple legacy 

medical information systems that the department developed from 

commercial software products that were customized for specific uses. For 

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

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

capture information related to pharmacy, radiology, and laboratory order 

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

Clinical Information System), a commercial health information system 

customized to support inpatient treatment at military medical facilities. 

DOD obligated approximately $2 billion for AHLTA between 1997 and 

2010. The department initiated efforts to improve system performance 

and enhance functionality and planned to continue its efforts to stabilize 

the AHLTA system through 2015 as a “bridge” to the new electronic 

health record system it intended to acquire. According to DOD, the 

planned new electronic health record system—known as the EHR Way 

Ahead—was to be the department’s comprehensive, real-time health 

record for service members and their families and beneficiaries. In 

January 2010, the department initiated an analysis of alternatives for 

meeting system capability requirements it had identified.

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

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

interoperability. Interoperability enables different information systems or 

components to exchange information and to use the information that has 

been exchanged. Interoperability can be achieved at different levels. At 
 

Page 5 GAO-14-302 Electronic Health Records 

the highest level, electronic data are computable (that is, in a format that 

a computer can understand and act to, for example, provide alerts to 

clinicians on drug allergies). At a lower level, electronic data are 

structured and viewable, but not computable. The value of data at this 

level is that they are structured so that data of interest to users are easier 

to find. At a still lower level, electronic data are unstructured and 

viewable, but not computable. With unstructured electronic data, a user 

would have to find needed or relevant information by searching 

uncategorized data. Beyond these, paper records can also be considered 

interoperable (at the lowest level) because they allow data to be shared, 

read, and interpreted by human beings. However, they do not provide 

decision support capabilities, such as automatic alerts about a particular 

patient’s health, or other reported advantages of automation. We have 

previously reported that all data may not require the same level of 

interoperability, nor is interoperability at the highest level achievable in all 

cases. For example, unstructured, viewable data may be sufficient for 

such narrative information as clinical notes.4

Interoperability allows patients’ electronic health information to move with 

them from provider to provider, regardless of where the information 

originated. If electronic health records conform to interoperability 

standards, they can be created, managed, and consulted by authorized 

clinicians and staff across more than one health care organization, thus 

providing patients and their caregivers the necessary information required 

for optimal care. Interoperability depends on the use of agreed-upon 

standards to ensure that information can be shared and used. In the 

health IT field, standards may govern areas ranging from technical 

issues, such as file types and interchange systems, to content issues, 

such as medical terminology.5

 

4

GAO, Electronic Health Records: DOD and VA Interoperability Efforts Are Ongoing; 

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

(Washington, D.C.: Jan. 28, 2010).

5

Developing, coordinating, and agreeing on standards are only parts of the processes 

involved in achieving interoperability for electronic health records systems or capabilities. 

In addition, specifications are needed for implementing the standards, as well as criteria 

and a process for verifying compliance with the standards. An interoperability specification 

codifies detailed implementation guidance that includes references to the identified 

standards or parts of standards and explains how they should be applied to specific health 

care topic areas.
 

Page 6 GAO-14-302 Electronic Health Records 

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

involving their health information systems to achieve electronic health 

record interoperability. These have included efforts to share viewable 

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

between the departments’ modernized health data repositories; establish 

and address interoperability objectives to meet specific data-sharing 

needs; develop a virtual lifetime electronic health record to track patients 

through active service and veteran status; and implement IT capabilities 

for the first joint federal health care center. While these initiatives have 

collectively yielded increased data sharing in various capacities, a 

number of them have nonetheless been plagued by persistent 

management challenges, which have created barriers to achieving the 

fully interoperable electronic health record capabilities long sought.

Among the departments’ earliest efforts to achieve interoperability was 

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

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

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

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

facilities.6 The interface was expected to compile requested patient health

information in a temporary, “virtual” record that could be displayed on a 

user’s computer screen. However, in reporting on this initiative in April 

2001, we found that accountability for GCPR was blurred across several 

management entities and that basic principles of sound IT project 

planning, development, and oversight had not been followed, creating 

barriers to progress.7

 

6

Initially, the Indian Health Service was also part of this initiative, having been included 

because of its population-based research expertise and its long-standing relationship with 

VA. However, the Indian Health Service was not included in a later revised strategy for 

electronically sharing patient health information.

For example, clear goals and objectives had not 

been set; detailed plans for the design, implementation, and testing of the 

interface had not been developed; and critical decisions were not binding 

on all partners. While both departments concurred with our 

recommendations that they, among other things, create comprehensive 

and coordinated plans for the effort, progress on the initiative continued to 

be disappointing. The departments subsequently revised the strategy for 

GCPR and, in May 2002, narrowed the scope of the initiative to focus on 

7

GAO, 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).

History of VA and DOD 

Efforts and Challenges to 

Achieve Interoperable 

Electronic Health Records

Sharing Data in Legacy 

Systems
 

Page 7 GAO-14-302 Electronic Health Records 

enabling DOD to electronically transfer service members’ health 

information to VA upon their separation from active duty. The initiative—

renamed the Federal Health Information Exchange (FHIE)—was 

completed in 2004.

Building on FHIE, VA and DOD also established the Bidirectional Health 

Information Exchange (BHIE) in 2004, which was aimed at allowing 

clinicians at both departments viewable access to records on shared 

patients (that is, those who receive care from both departments, such as 

veterans who receive outpatient care from VA clinicians and then are 

hospitalized at a military treatment facility). The interface also enabled 

DOD sites to see previously inaccessible data at other DOD sites.

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

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

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

exchange of health information between the departments’ modernized 

systems—known as the Clinical Data Repository/Health Data Repository 

initiative, or CHDR. The departments had planned to be able to exchange 

selected health information through CHDR by October 2005. However, in 

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

demonstrated a number of management weaknesses.8

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

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

face significant challenges—in particular, with developing a project 

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

Among these 

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

a common health information exchange, an established project 

management lead entity and structure to guide the investment in the 

interface and its implementation, and a project management plan defining 

the technical and managerial processes necessary to satisfy project 

requirements. Accordingly, we recommended that the departments 

address these weaknesses, and they agreed to do so.

 

8

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). 

Linking Modernized Data 

Repositories
 

Page 8 GAO-14-302 Electronic Health Records 

program.9 In a June 2006 testimony we noted that the project did not 

meet a previously established milestone: to be able to exchange 

outpatient pharmacy data, laboratory results, allergy information, and 

patient demographic information on a limited basis by October 2005.10

To accelerate the exchange of electronic health information between the 

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

Fiscal Year 2008 included provisions directing VA and DOD to jointly 

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

electronic health record systems or capabilities.

By 

September 2006, the departments had taken actions which ensured that 

the CHDR interface linked the departments’ separate repositories of 

standardized data to enable a two-way exchange of computable 

outpatient pharmacy and medication allergy information. Nonetheless, we 

noted that the success of CHDR would depend on the departments 

instituting a highly disciplined approach to the project’s management.

11

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

social history data that are captured in the DOD electronic health 

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

hazardous activities and tobacco and alcohol use.

To facilitate compliance 

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

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

began establishing priorities for interoperable health data between VA 

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

priorities for electronic data sharing between the departments, as well as 

what data should be viewable and what data should be computable. 

Based on its work, the board established six interoperability objectives for 

meeting the departments’ data-sharing needs:

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

share with VA its electronic health record information that supports the 

physical exam process when a service member separates from active 

military duty.

 

9

GAO, Computer-Based Patient Records: VA and DOD Made Progress, but Much Work

Remains to Fully Share Medical Information, GAO-05-1051T (Washington, D.C.: Sept. 28,

2005).

10GAO, Information Technology: VA and DOD Face Challenges in Completing Key 

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

11Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-463 (2008).

Establishing and Addressing 

Interoperability Objectives
 

Page 9 GAO-14-302 Electronic Health Records 

• Demonstrate initial network gateway operation: VA and DOD were to 

demonstrate the operation of secure network gateways to support 

joint VA-DOD health information sharing.

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

provide all periodic health assessment data stored in its electronic 

health record to VA such that questionnaire responses would be 

viewable with the questions that elicited them.

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

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

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

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

• Demonstrate initial document scanning: DOD was to demonstrate an 

initial capability for scanning service members’ medical documents 

into its electronic health record and sharing the documents 

electronically with VA.

The departments asserted that they took actions that met the six 

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

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

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

departments planned additional work to further increase their 

interoperable capabilities, stating that these actions reflected the 

departments’ recognition that clinicians’ needs for interoperable electronic 

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

additional efforts to meet clinicians’ evolving needs for interoperable 

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

expanding implementation of Essentris, and additional testing of 

document scanning capabilities.

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

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

NDAA. Specifically, we identified challenges with respect to performance 

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

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

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

performance goals and measures that are characteristic of effective 

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

the delivery of new interoperable capabilities.12

 

12GAO, Electronic Health Records: DOD’s and VA’s Sharing of Information Could Benefit 

from Improved Management,

We pointed out that 

GAO-09-268 (Washington, D.C.: Jan. 28, 2009).
 

Page 10 GAO-14-302 Electronic Health Records 

without establishing results-oriented goals and reporting progress using 

measures relative to the established goals, the departments and their 

stakeholders would not have the comprehensive picture that they needed 

to effectively manage their progress toward achieving increased 

interoperability. Accordingly, we recommended that DOD and VA take 

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

basis for providing meaningful information on the status of the 

departments’ interoperability initiatives. In response, the departments 

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

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

However, that plan was not approved until April 2010—7 months after the 

departments asserted they had met the deadline for achieving full 

interoperability.

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

interoperable electronic health record systems or capabilities, the 2008 

NDAA called for the departments to set up an interagency program office 

(IPO) to be a single point of accountability for their efforts to implement 

these systems or capabilities by the September 30, 2009, deadline. 

Accordingly, in January 2009, the office completed its charter, articulating, 

among other things, its mission and functions with respect to attaining 

interoperable electronic health data. The charter further identified the 

office’s responsibilities for carrying out its mission in areas such as 

oversight and management, stakeholder communication, and decision 

making. Among the specific responsibilities identified in the charter was 

the development of a plan, schedule, and performance measures to guide 

the departments’ electronic health record interoperability efforts.

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

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

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

to achieve full interoperability.13

 

13GAO, Electronic Health Records: DOD and VA Efforts to Achieve Full Interoperability 

Are Ongoing; Program Office Management Needs Improvement,

Without these important tools, the office 

was limited in its ability to effectively manage and meaningfully report 

progress on the delivery of interoperable capabilities. We recommended 

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

integrated master schedule. In response to our recommendation, the 

GAO-09-775 

(Washington, D.C.: July 28, 2009). 
 

Page 11 GAO-14-302 Electronic Health Records 

office began to develop an integrated master schedule and project plan 

that included information about its ongoing interoperability activities.

In another attempt at furthering efforts to increase electronic health record 

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

would work together to define and build the Virtual Lifetime Electronic 

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

and administrative information between the two departments. VLER was 

intended to enable access to electronic records for service members as

they transition from military to veteran status, and throughout their lives. 

Further, the initiative was to expand the departments’ health informationsharing capabilities by enabling access to private-sector health data.

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

working to define and plan for the initiative’s health data-sharing activities, 

which they refer to as VLER Health.14 In June 2009, the departments 

adopted a phased implementation strategy consisting of a series of 6-

month pilot projects to deploy a set of health data exchange capabilities 

between existing electronic health record systems at sites around the 

country. Each pilot project was intended to build upon the technical 

capabilities of its predecessor, resulting in a set of baseline capabilities to 

inform project planning and guide the implementation of VLER 

nationwide. In June 2010, the departments announced their goal to 

deploy VLER Health nationwide by the end of 2012.15

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

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

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

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

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

 

14To date, the departments have only focused on the exchange of health information. 

According to department officials, they intend to pursue initiatives for incorporating 

benefits and administrative data at a later time.

15DOD, Report to the Congressional Defense Committees: Improvements to the 

Governance and Execution of Health Information Management and Information 

Technology Programs (Washington, D.C.: June 21, 2010).

Developing a Virtual Lifetime 

Electronic Record
 

Page 12 GAO-14-302 Electronic Health Records 

the San Diego pilot plus additional laboratory data. Further, during 2011, 

the departments implemented two additional pilots in Washington state.16

In a February 2011 report on the departments’ efforts to address their 

common health IT needs, we noted that VA and DOD had identified a 

high-level approach for implementing VLER and had designated the IPO 

as the single point of accountability for the effort.17

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

resources in 2010 following the National Defense Authorization Act for 

Fiscal Year 2010 and its authorization of a 5-year demonstration project 

to integrate the two departments’ facilities located in the North Chicago, 

Illinois, area into a combined medical facility.

However, the 

departments had not developed a comprehensive plan identifying the 

target set of capabilities that they intended to demonstrate in the pilot 

projects and then implement on a nationwide basis at all domestic VA and 

DOD sites by the end of 2012. Moreover, the departments conducted pilot 

projects without attending to key planning activities that are necessary to 

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

developed an approved integrated master schedule, master program 

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

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

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

joint health IT needs would be uncertain. We recommended that the 

Secretaries of VA and DOD strengthen their efforts to establish VLER by 

developing plans that would include scope definition, cost and schedule 

estimation, and project plan documentation and approval. Officials from 

both departments agreed with the recommendation, and we have 

continued to monitor their actions toward its implementation. 

Nevertheless, the departments were not successful in meeting their 

original goal of implementing VLER nationwide by the end of 2012.

18

 

16According to the departments, DOD spent $38.3 million on the initiative in fiscal year 

2010 and $28.1 million in fiscal year 2011. Similarly, VA spent $19.2 million on the 

initiative in fiscal year 2010 and $26.2 million for fiscal year 2011.

VA and DOD facilities in 

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

17GAO, Electronic Health Records: DOD and VA Should Remove Barriers and Improve 

Efforts to Meet Their Common System Needs, GAO-11-265 (Washington, D.C.: Feb. 2, 

2011).

18Pub. L. No. 111-84, div. A, title XVII, 123 Stat. 2190, 2567-2574 (2009). 

Implementing IT Capabilities 

for a Joint Federal Health Care 

Center
 

Page 13 GAO-14-302 Electronic Health Records 

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

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

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

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

governance.

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

agreement that established the FHCC and, in accordance with the fiscal 

year 2010 NDAA, defined the relationship between the two departments 

for operating the new, integrated facility. Among other things,19

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

access both the VA and DOD electronic health record systems;

the 

executive agreement specified three key IT capabilities that VA and DOD 

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

2010, to facilitate interoperability of their electronic health record systems:

• single patient registration, which would allow staff to register patients 

in both systems simultaneously; and

• orders portability, which would allow VA and DOD clinicians to place, 

manage, and update orders from either department’s electronic health 

records systems for radiology, laboratory, consults (specialty 

referrals), and pharmacy services.

However, in our February 2011 report, we identified improvements the 

departments could make to the FHCC effort, noting that project planning 

for the center’s IT capabilities was incomplete.20

 

19The executive agreement identified 12 areas of integration for the FHCC, 1 of which is 

information technology.

We specifically noted 

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

identified all detailed activities. Consequently, they were not positioned to 

reliably estimate the project cost or establish a baseline schedule that 

could be used to track project performance. Based on these findings, we 

expressed concern that VA and DOD had jeopardized their ability to fully 

and expeditiously provide the FHCC’s needed IT system capabilities. We 

recommended that the Secretaries of VA and DOD strengthen their 

efforts to establish the joint IT system capabilities for the FHCC by 

developing plans that included scope definition, cost and schedule 

estimation, and project plan documentation and approval. Although 

officials from both departments stated agreement with our 

20GAO-11-265. 
 

Page 14 GAO-14-302 Electronic Health Records 

recommendation, the departments’ actions were not sufficient to preclude 

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

subsequently described in July 2011 and June 2012.

Specifically, in a July 2011 report, we noted that none of the three IT 

capabilities had been implemented by the time of the FHCC’s opening in 

October 2010, as required by the executive agreement.21

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

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

portability capability—related to the pharmacy and consults 

components—remained delayed.

However, 

FHCC officials reported that the medical single sign-on and single patient 

registration capabilities had become operational in December 2010.

22

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

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

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

workarounds resulting from delayed IT capabilities.

VA and DOD officials described 

workarounds that the departments had implemented as a result of the 

delays, but could not provide a time line for completion of the pharmacy 

component, and estimated completion of the consults component by 

March 2013.

Even as the departments increased their data-sharing capacities with the 

aforementioned initiatives, they still continued to be faced with 

fragmented patient health information because of the inability to integrate 

their health care records. Thus, resulting from a series of meetings begun 

in February 2011 to discuss, among other things, their approach to 

electronic health records, the Secretaries of Defense and Veterans Affairs 

directed their respective departments to consider three competing 

approaches to meeting their common need for a modernized electronic 

 

21GAO, VA and DOD Health Care: First Federal HealthCare Center Established, but

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

19, 2011).

22GAO, VA/DOD Federal Health Care Center: Costly Information Technology Delays

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

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

June 2011 and for laboratory in March 2012. 

VA and DOD Agreed to 

Jointly Develop a Single 

Integrated Electronic 

Health Record System
 

Page 15 GAO-14-302 Electronic Health Records 

health record: (1) develop a new, joint electronic health record system; (2) 

upgrade either the existing VistA or AHLTA legacy system to meet the 

needs of the other organization; or (3) continue to pursue separate 

systems while coordinating on a common infrastructure with data 

interoperability. In March 2011, the secretaries committed the two 

departments to the first approach—that is, the development of a new 

common integrated electronic health record (iEHR) system. In May 2012, 

they announced their goal of implementing the integrated health record 

across the departments by 2017.

According to the departments, pursuing iEHR was expected to enable VA 

and DOD to align resources and investments with common business 

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

departments’ separate electronic health record systems with a common 

system. In addition, because it would involve both departments using the 

same system, this approach was expected to largely sidestep the 

challenges they had historically encountered in trying to achieve 

interoperability between separate systems. The departments developed 

an iEHR business case in August 2012 to justify this approach, which 

stated that the use of a common integrated system would support 

increased collaboration between both departments and would lead to joint 

investment opportunities. Further, this approach was consistent with a 

previous study conducted by the departments showing that over 97 

percent of inpatient functional requirements were common to both VA and 

DOD.23

Toward this end, initial development plans called for the single, joint iEHR 

system to consist of 54 clinical capabilities that would be delivered in six 

increments between 2014 and 2017, with all existing applications in VistA 

and AHLTA continuing uninterrupted until full delivery of the new 

capabilities. The program had planned to send out requests for proposals 

(RFP) for initial iEHR capabilities in the first quarter of fiscal year 2013.

According to the iEHR business case, the use of a common 

integrated system would address their similar health information system 

needs.

 

23As we reported in GAO-11-265, in 2007 the Joint Executive Council commissioned a 

two-phase study on the feasibility of implementing a joint VA/DOD inpatient electronic 

health record system, and potential alternatives for doing so. The study team reported in 

January 2008 that a joint inpatient electronic health record was feasible based on finding 

that over 97 percent of inpatient functional requirements were common to both VA and 

DOD. The study made a series of recommendations to the departments, and the 

departments accepted these recommendations in October 2008.
 

Page 16 GAO-14-302 Electronic Health Records 

Among the agreed-upon capabilities to be delivered were those 

supporting laboratory, anatomic pathology, pharmacy, and 

immunizations. In addition, the initiative was to deliver several common 

infrastructure components—an enterprise architecture,

24

According to the departments’ plans, initial operating capability, which 

was to be achieved in 2014, was intended to establish the architecture 

and include deployment of new immunization and laboratory capabilities 

to VA and DOD facilities in San Antonio, Texas, and Hampton Roads, 

Virginia. Full operating capability, planned for 2017, was intended to 

deploy all iEHR capabilities to all VA and DOD medical facilities.

presentation 

layer or graphical user interface, data centers, and interface and 

exchange standards. The system was to be primarily built by purchasing 

commercially available solutions for joint use, with noncommercial 

solutions developed or adopted only when a commercial alternative was 

unavailable.

In October 2011, VA and DOD re-chartered the IPO with increased 

authority and expanded responsibilities for leading the integrated system 

effort. The charter gave the IPO responsibility for program planning and 

budgeting, acquisition and development, and implementation of clinical 

capabilities. In particular, the IPO Director was given authority to acquire, 

develop, and implement IT systems for iEHR, as well as to develop 

interagency budget and acquisition strategies that would meet VA’s and 

DOD’s respective requirements in these areas. Further, as program 

executive for iEHR, the director of this office was given the authority to 

use DOD and VA staff to support the program.

An estimate developed by the IPO in August 2012 put the cost of the 

integrated system at $29 billion (adjusted for inflation) from fiscal year 

2013 through fiscal year 2029. According to the office’s director, this 

estimate included $9 billion for the acquisition of the system and $20 

billion to sustain its operations. The office reported actually spending 

about $564 million on iEHR between October 2011 and June 2013. 

According to the June 2013 IPO expenditure plan, these expenditures 

included deployment of a new graphical user interface for viewing patient 

 

24The iEHR architecture was defined as a modular, open, and service-oriented approach 

for sharing business capabilities across the DOD and VA enterprises by designing 

functions and applications as discrete, reusable, and business-oriented services intended 

to reduce redundancy and increase integration. 
 

Page 17 GAO-14-302 Electronic Health Records 

data to selected locations; creation of a development and test 

center/environment for iEHR; planning efforts required for acquisition of 

the initial capabilities—laboratory, immunization, and pharmacy with 

orders services; and acquisition of program management, systems 

integration, and engineering and testing services required to ensure 

completion of required planning activities.

About 2 years after taking actions toward the development of iEHR, VA 

and DOD announced changes to their plan—essentially abandoning their 

effort to develop a single, integrated electronic health record system for 

both departments. In place of this initiative, the departments stated that 

VA would modernize its existing VistA health information system, DOD 

would buy a commercially available system to replace its existing AHLTA 

system, and the departments would ensure interoperability between the 

two new systems. However, the decision to change the iEHR program 

strategy was not justified on the basis of analyses that considered the 

estimated cost and schedule for the new approach of using separate 

systems. In addition, while the departments have begun planning for their 

separate modernization efforts, they have not completed plans describing 

how and in what time frame they intend to achieve an interoperable 

electronic health record.

In February 2013, the Secretaries of Defense and Veterans Affairs 

announced that they would not continue with their joint development of a 

single electronic health record system that was intended to result in an 

integrated electronic health record. This decision resulted from an 

assessment of the iEHR program that the secretaries requested in 

December 2012 because of their concerns about the program facing 

challenges in meeting deadlines, costing too much, and taking too long to 

deliver capabilities. Based on this assessment, the departments 

announced that they would rely on separate systems to achieve an 

interoperable electronic health record, departing from their originally 

planned solution of using a single system to meet their similar health 

information system needs. Specifically, this new approach would involve 

each department either developing or acquiring a new core set of 

electronic health record capabilities (e.g., workflow and order 

VA and DOD 

Abandoned Plans for 

a Single System, but 

Their New Approach 

to Achieving an 

Interoperable 

Electronic Health 

Record Is Not 

Supported by 

Sufficient Cost and 

Schedule Analysis or 

a Complete Plan

The Departments 

Abandoned Plans for a 

Single System in Favor of 

Separate Modernization 

Efforts
 

Page 18 GAO-14-302 Electronic Health Records 

management)25

According to senior VA and DOD officials, the development or acquisition 

of similar core sets of electronic health record capabilities would be 

achieved by VA modernizing its existing VistA health information system 

and DOD buying a commercially available system to replace its existing 

AHLTA health information system. In this regard, VA has stated that it 

intends to enhance and modernize its existing VistA system under a new 

program, called VistA Evolution. For its part, in May 2013, DOD 

announced that it would competitively award a contract to acquire a 

limited set of core capabilities that might include VistA-based commercial 

solutions. However, DOD then determined that, because of the need to 

integrate future capabilities, it would cost more to acquire and add to a 

limited core set of capabilities than to acquire a full suite of capabilities. 

Thus, the department subsequently expanded its effort and has stated 

that it is now pursuing the acquisition of a replacement system for its 

multiple legacy electronic health record systems under a new program—

the DOD Healthcare Management System Modernization (DHMSM) 

program—that is being managed by DOD’s Under Secretary of Defense 

for Acquisition, Technology, and Logistics.

with additional applications or capabilities to be added as 

needed.

In addition, the departments have said they intend to focus on existing 

projects aimed at increasing the interoperability of health data between 

their legacy systems. These included expanding the use of a graphical 

user interface for viewing patient information; agreeing upon an approach 

for jointly identifying patients; developing a secure network infrastructure 

for VA and DOD clinicians to access patient information; and correlating, 

or mapping, department data to seven clinical domains26

 

25A DOD-VA work group agreed to eight core requirements for iEHR. They are system 

management, interoperability, data model, clinical workflow, clinical display, clinical 

documentation and data capture, clinical decision support, and order management.

and organizing 

them in a standardized patient record. According to the IPO’s December 

18, 2013, report to Congress, the departments completed the initial 

activities for these projects in December 2013 and outlined further actions 

the departments plan to take on these efforts.

26Seven clinical domains (Laboratory, Pharmacy, Problem List, Allergies, Immunizations, 

Vitals, and Note Titles) will be correlated to relevant national standards.
 

Page 19 GAO-14-302 Electronic Health Records 

Although VA and DOD based their decision to no longer pursue a single 

system on the assertion that their new approach to pursue separate 

systems would be less expensive and faster, the departments have not 

demonstrated the credibility of this assertion. Best practices have 

identified the development and use of cost and schedule estimates as 

essential elements for informed decision making when selecting potential 

IT investments.27

However, VA and DOD have proceeded with their current plan without 

developing cost and schedule analyses to support the assertion that the 

current plan to pursue separate modernized systems while enabling 

interoperability between them would be less expensive and could be 

achieved faster than developing a single system. Consistent with best 

practices, such analyses would require, for example, development and 

documentation of revised cost and schedule estimates that include DOD’s 

commercial acquisition, VA’s modernization of VistA, and the joint 

interoperability effort, as well as a comparison of these with the estimates 

for the original single-system approach. Instead of developing such a joint 

analysis to consider their common health care business needs, however, 

each department made its own individual determination on what the best 

course of action would be. These determinations reflect VA’s and DOD’s 

divergent philosophies for pursuing IT systems development: VA strongly 

supports in-house development and modernization of its homegrown 

system, and DOD supports acquiring commercial solutions. Specifically, 

according to the VA Under Secretary for Health, pursuing a modernization 

of VistA instead of another solution was an obvious choice for VA 

because the department already owns the system and has in-house 

technical expertise to modernize and maintain it. Similarly, DOD 

considered alternatives to replace its legacy electronic health record 

In particular, major investment decisions (which can 

include, for example, terminating or significantly restructuring an ongoing 

program) should be justified using analyses that compare relative costs 

and schedules for proposed investments. When effectively implemented, 

these practices help ensure that agencies have a sound rationale for their 

investment decisions.

 

27GAO, Information Technology Investment Management: A Framework for Assessing 

and Improving Process Maturity, GAO-04-394G (Washington, D.C.: March 2004); GAO 

Cost Estimating and Assessment Guide: Best Practices for Developing and Managing 

Capital Program Costs, GAO-09-3SP (Washington, D.C.: March 2009); and GAO 

Schedule Assessment Guide: Best Practices for Project Schedules, GAO-12-120G 

(Washington, D.C.: May 2012).

VA and DOD Did Not 

Justify Their Change of 

Approach with 

Comparisons of Costs and 

Schedules
 

Page 20 GAO-14-302 Electronic Health Records 

system and concluded that pursuing a competitively based commercial 

system would be best for the department. The Under Secretary of 

Defense for Acquisition, Technology, and Logistics (AT&L) stated that 

acquiring a commercial system was the right business decision for DOD 

because the department is not in the business of developing IT systems, 

particularly when more advanced electronic health record solutions are 

available commercially. He added that VA’s reasons for modernizing 

VistA were logical for that department but did not apply to DOD. However, 

neither of the determinations made by VA and DOD considered cost and 

schedule estimates for modernizing or acquiring the departments’ new 

systems and achieving interoperability between them. Further, VA and 

DOD lack a process for identifying joint IT investments, which could be a 

means of reconciling the departments’ divergent approaches, and is one 

of the barriers to jointly addressing their health care system needs that we 

identified in February 2011 and recommended they address.28

Because their new approach is based on the courses of action that VA 

and DOD have independently determined to be best for them, and 

because they lack cost and schedule analyses to guide their decision 

making, the departments have not demonstrated that their new approach 

will provide service members, veterans, and their health care providers 

with an interoperable electronic health record at lower cost and in less 

time than the original plan.

While VA and DOD have begun to pursue separate systems, they have 

not developed plans at either a strategic or program level that describe 

how they intend to achieve an interoperable electronic health record. 

Industry best practices and IT project management principles stress the 

importance of sound planning for any project.29

 

28

Inherent in such planning 

is the development and use of a project management plan that includes 

the project’s scope, lines of responsibility for all stakeholders, resource 

requirements, an estimated schedule for development and 

implementation, and performance measures. Additionally, plans should 

identify and prioritize program risks so that potential problems can be 

avoided before they become actual cost, schedule, and performance 

GAO-11-265. 

29Institute of Electrical and Electronics Engineers, IEEE/EIA Guide for Information 

Technology, IEEE/EIA 12207.1-1997 (April 1998).

The Departments Have 

Begun Separate 

Modernization Efforts, but 

Plans for Delivering an 

Interoperable Electronic 

Health Record Remain 

Undeveloped
 

Page 21 GAO-14-302 Electronic Health Records 

shortfalls. In addition, the National Defense Authorization Act (NDAA) for 

Fiscal Year 2014 required the departments to provide a detailed 

programs plan for the oversight and execution of an interoperable 

electronic health record between the departments no later than January 

31, 2014.30

Since VA and DOD announced their new approach in February 2013, the 

departments have been focused on planning for their separate 

modernization efforts:

• In December 2013, VA developed a VistA Evolution program plan for 

initial operating capability that is focused on system enhancements for 

VistA intended to provide at least two enhanced clinical capabilities to 

be deployed at two VA sites by the end of fiscal year 2014. The 

department is in the process of developing a separate program plan 

for VistA Evolution that is intended to provide an overview of VA’s 

efforts to achieve full operating capability by September 30, 2017. 

• DOD released an initial draft RFP to industry on January 29, 2014, 

with a goal to release the final RFP for the system’s acquisition in July 

2014. According to the DOD Healthcare Management Systems 

(DHMS) Program Executive Officer, following the release of the RFP, 

the department plans to award a contract for the replacement system 

in the third quarter of fiscal year 2015, with a goal of achieving initial 

operating capability for the program in the fourth quarter of fiscal year 

2016. According to a DOD Acquisition Decision Memorandum in 

January 2014, the DHMS Program Executive Officer is to develop a 

health data-sharing and interoperability road map that is to address 

interoperability with VA, private health care providers, and patients. 

The road map is to be provided to DOD management by March 2014 

for review. 

Additionally, in response to the fiscal year 2014 NDAA, VA and DOD 

briefed congressional staff in late January 2014 on their plans for VistA 

Evolution, plans for the DHMSM program, and their intention to achieve 

an interoperable electronic health record. Despite this briefing and initial 

steps toward their separate modernization efforts, the departments have 

not developed a plan that describes how they intend to achieve an 

interoperable electronic health record under their new approach of 

pursuing separate system modernizations. Specifically, the departments 

 

30Pub. L. No. 113-66, § 713, 127 Stat. 672, 794-799 (2013).
 

Page 22 GAO-14-302 Electronic Health Records 

have not identified which clinical domains of health data will comprise the 

interoperable electronic health record, the estimated cost and schedule 

for the effort, or the lines of responsibility for all stakeholders involved. In 

addition, risks have not been identified and prioritized in order to help 

avoid potential problems before they become actual cost, schedule, and 

performance problems. Without having plans in place to provide key 

information on their effort to create an interoperable electronic health 

record, the departments are increasing the risk that the new approach will 

not be more cost efficient and timely than if they had continued with the 

single-system approach.

Moreover, in 2011, we reported that VA’s and DOD’s joint strategic plan 

did not discuss how or when they proposed to identify and develop joint 

solutions to address their common health IT needs.31

 

31

Accordingly, we 

recommended that they revise the joint strategic plan to include 

information discussing their electronic health record system 

modernization efforts and how those efforts will address the departments’ 

common health care business needs. However, the departments’ most 

recent joint strategic plan, which was released in March 2013 and covers 

fiscal years 2013 through 2015, does not reflect their current approach. In 

July 2013, the VA/DOD Joint Executive Council tasked the IPO with 

preparing an addendum to the joint strategic plan that would reflect the 

departments’ revised joint activities, milestones, metrics, and time lines 

for creating an interoperable health record. However, while the 

departments have begun planning to separately modernize their 

electronic health record systems and have identified the need to make 

these systems interoperable, they have not revised their plan for doing 

so. According to VA and DOD officials, as of January 2014, a draft 

addendum to the joint strategic plan was being reviewed by the 

departments’ senior leaders, but the officials could not say when the 

addendum is to be finalized. Until VA and DOD provide a plan that 

reflects their current approach, the departments and their stakeholders 

may not have a shared understanding of how they intend to address their 

common health care business needs, including an interoperable 

electronic health record, going forward.

GAO-11-265. 
 

Page 23 GAO-14-302 Electronic Health Records 

We have previously reported on IT management barriers that prevented 

the departments from effectively collaborating to address their common 

health care system needs in the areas of enterprise architecture and IT 

investment management. We have followed the departments’ efforts to 

address these barriers and have found that important work still remains.32

In addition, the Interagency Program Office, established by the fiscal year 

2008 NDAA to act as a single point of accountability for the departments’ 

development and implementation of interoperable health records, was to 

better position the departments to collaborate. Our work on interagency 

collaboration has shown that successful collaboration depends on a 

number of factors, including identifying resources, establishing compatible 

policies and procedures, and agreeing on clear lines of responsibility and 

accountability.33 We have also identified a variety of mechanisms that 

federal agencies use to implement interagency collaborative efforts, 

including interagency offices, to carry out joint activities on behalf of the 

participating departments.34

 

32GAO, Government Operations: Opportunities to Reduce Potential Duplication in 

Government Programs, Save Tax Dollars, and Enhance Revenue,

However, despite the direction given in the 

fiscal year 2008 NDAA, and the departments’ repeated efforts to recharter the office, VA and DOD did not implement the IPO as an effective 

mechanism for interagency collaboration. Specifically, the departments 

did not provide the IPO with authority over essential resources or with the 

autonomy to establish key interagency processes for managing joint 

activities. Additionally, VA and DOD established a complex governance 

structure for the office, which weakened its ability to serve as the single 

point of accountability for the departments’ development and 

implementation of fully interoperable electronic health record systems or 

capabilities. Moreover, the departments’ December 2013 re-chartering of 

the IPO significantly reduces the office’s role, responsibilities, and 

authority over VA and DOD’s joint health IT efforts, and raises concerns 

about the office’s ability to serve as an effective mechanism for 

interagency collaboration and the single point of accountability for the 

departments’ joint health IT efforts.

GAO-11-318SP 

(Washington, D.C.: March 2011); Follow-up on 2011 Report: Status of Actions Taken to 

Reduce Duplication, Overlap, and Fragmentation, Save Tax Dollars, and Enhance 

Revenue, GAO-12-453SP (Washington, D.C.: February 2012); GAO-13-413T; and 

http://www.gao.gov/duplication/action_tracker/DOD_and_VA_Electronic_Health_Records_

Systems/action1.

33GAO-06-15. 

34GAO-12-1022. 

Collaboration 

between VA and DOD 

Has Been Hindered 

by Long-standing 

Barriers and 

Ineffective 

Implementation of the 

IPO
 

Page 24 GAO-14-302 Electronic Health Records 

In February 2011, we highlighted barriers that VA and DOD faced in 

addressing their common health IT needs.35

• Further develop the departments’ joint health architecture to include 

the planned future state and plan for transitioning from their current 

state to the next generation of electronic health record capabilities.

For example, although VA 

and DOD had taken steps toward developing and maintaining artifacts 

related to a joint health architecture (i.e., a description of business 

processes and supporting technologies), the architecture was not 

sufficiently mature to guide the departments’ joint health IT modernization 

efforts. Further, the departments had not established a joint process for 

selecting IT investments based on criteria that consider cost, benefit, 

schedule, and risk elements, limiting their ability to pursue joint health IT 

solutions that both meet their needs and provide better value and benefits 

to the government as a whole. We noted that without having these key IT 

management capabilities in place, the departments would continue to 

face barriers to identifying and implementing IT solutions that addressed 

their common needs. Accordingly, we identified several actions that the 

Secretaries of Defense and Veterans Affairs could take to overcome 

these barriers, including the following:

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

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

investments to meet the departments’ common health care business 

needs.

Officials from both VA and DOD agreed with these recommendations, 

and we have continued to monitor their actions toward implementing 

them.36

For example, VA and DOD have not further developed a joint health 

architecture that could guide their efforts to address their common health 

care business needs, as we recommended. The departments had 

undertaken certain actions, but these have been overtaken by events or 

are tangential to developing the architecture. For example, in January 

Nonetheless, the actions taken by VA and DOD have not been 

sufficient to overcome the departments’ long-standing barriers to 

collaborating on their joint health IT efforts, and important work remains.

 

35GAO-11-265. 

36GAO-11-318SP; GAO-12-453SP; GAO-13-413T; and 

http://www.gao.gov/duplication/action_tracker/DOD_and_VA_Electronic_Health_Records_

Systems/action1.

VA and DOD Have Not 

Addressed Barriers to 

Jointly Addressing Their 

Common Health Care 

System Needs
 

Page 25 GAO-14-302 Electronic Health Records 

2013 the IPO developed an Enterprise Architecture Management Plan to 

provide guidance for developing joint architecture products, identify 

architecture governance bodies and stakeholder responsibilities, and 

propose high-level time lines for architecture-related activities. However, 

according to VA and DOD officials, this plan is no longer operative 

because it does not reflect the departments’ decision to pursue separate 

electronic health record system modernization efforts. In addition, in 

December 2013 the departments revised the charter for the IPO, which 

describes the importance of identifying and adopting health IT standards 

to seamlessly integrate VA and DOD health care record data. The charter 

also specifies that the IPO is responsible for working with the 

departments’ Health Architecture Review Board to ensure that both 

departments are appropriately synchronized and coordinated. While 

these recent activities are peripherally related to development of the joint 

health architecture, VA and DOD have not yet developed architecture 

artifacts that describe their planned future state and how they intend to 

transition to that future state. Until the departments have an 

understanding of the common business processes and technologies that 

a joint health architecture can provide, they will continue to lack an 

essential tool for jointly addressing their common health IT needs.

Further, VA and DOD initiated, but did not sustain, two courses of action 

that were potentially responsive to our recommendation to establish a 

joint IT investment management process. First, the departments 

established the IPO Advisory Board in October 2011 to monitor the iEHR 

program’s progress toward meeting cost, schedule, and performance 

milestones. However, the advisory board did not meet after June 2013 

and was disbanded as a result of the departments’ decision to pursue 

separate modernizations of their electronic health record systems. 

Second, in August 2012 the departments established a working group 

under the Interagency Clinical Informatics Board to identify potential 

health IT investments for the departments to consider for joint adoption. 

However, the group has not met since June 2013 and, according to VA 

and DOD officials, its activities have been suspended while the 

departments continue to define their separate modernization efforts and 

their electronic health data interoperability needs. Moreover, the group 

was not involved in helping the departments identify and select the 

separate electronic health record investments VA and DOD now plan to 

undertake to meet their common health care business needs. Because 

VA and DOD have not implemented a process for identifying and 

selecting joint IT investments, the departments have not demonstrated 

that their approach to meeting their common health care business needs 
 

Page 26 GAO-14-302 Electronic Health Records 

has considered the costs, benefits, schedule, and risks of planned 

investments.

Best practices recognize that an office such as the IPO has the potential 

to serve as a mechanism for interagency collaboration, provided that the 

collaborating departments adopt a number of practices to sustain it. 

These include identifying resources, establishing compatible policies and 

procedures, and agreeing on clear lines of responsibility and 

accountability, including how the collaborative effort will be led. Best 

practices have also found that without this, the collaborating departments 

may not be willing to fully commit to the joint effort, and may also be 

unable to overcome other barriers, such as concerns about protecting 

jurisdiction over missions and control over resources.37

Despite VA and DOD’s pledge to work together to address their common 

health IT needs, the departments did not implement the IPO consistent 

with best practices for interagency collaboration and, in some cases, with 

the office’s charter.38

Budgetary control: Historically, the IPO has been challenged by a lack 

of control over the funding designated for the departments’ joint health IT 

Specifically, the departments did not follow through 

with commitments made in the IPO’s 2011 charter related to its authority 

over the iEHR program’s budget, staffing, and interagency processes. In 

addition, the departments implemented the office with multiple layers of 

governance and oversight, which has resulted in unclear lines of authority 

and accountability for the departments’ collaborative health IT efforts.

 

37GAO-06-15. 

38The departments have issued four charters since the IPO was established in law in 

2008. The IPO’s first charter was signed by the Under Secretary of Defense for Personnel 

and Readiness and Deputy Secretary of VA in January 2009. Both the second and third 

charters were signed by the Deputy Secretary of Defense and Deputy Secretary of VA in 

September 2009 and October 2011, respectively. Finally, the IPO’s fourth charter was 

signed in December 2013 by the Under Secretary of Defense for Acquisition, Technology, 

and Logistics and the VA Executive in Charge, Office of Information and Technology and 

Chief Information Officer.

VA and DOD Did Not 

Implement the IPO 

Consistent with Effective 

Collaboration Practices
 

Page 27 GAO-14-302 Electronic Health Records 

efforts. For example, in July 2011 a former director of the office testified39

that the IPO’s 2009 charter had established a modest role for the office, 

and thus, the office did not have control over the budget for those 

initiatives for which it was responsible; rather, this control remained with 

VA and DOD.40

Staffing: When VA and DOD designated the IPO to lead the iEHR 

program in 2011, they recognized that the office would need to be 

When the departments re-chartered the IPO in 2011, they 

included language related to the office having budgetary control over the 

iEHR program. For example, this charter gave the IPO Director the 

authority to manage budgeting and finances related to the planning and 

acquisition of the iEHR capabilities. In addition, the charter provided the 

director with the authority to develop and propose interagency budget 

submissions for iEHR to the departments. Nevertheless, even with these 

revisions to its charter, the IPO was not fully empowered to execute funds 

related to iEHR because the departments have different processes for 

budgeting IT programs and, in VA’s case, for releasing funds for IT 

development. According to the Deputy Chief Management Officer, DOD 

had a dedicated fund for the iEHR program, which the IPO Director had 

authority to execute. However, VA funded the iEHR program through 

several funds, including IT appropriations that VA officials asserted could 

only be executed by the Chief Information Officer (CIO). As a result, the 

IPO Director was required to request funding for iEHR-related activities 

from VA on a project-by-project basis. According to one of the iEHR 

program managers, although this process did not necessarily cause 

delays to iEHR projects, it was a source of continuous frustration for the 

IPO Director because it did not provide the expected level of control over 

the program’s budget, as described in the office’s charter.

 

39This testimony was in reference to legislation that called for VA and DOD to address 

some of the IPO’s organizational limitations, including the office’s lack of a separate, 

dedicated budget line item in the departments’ respective annual budget submissions, and 

the office’s governance structure. See Ensuring Servicemembers’ Electronic Records’ 

Viability Act (H.R. 2470), introduced on July 8, 2011; referred to the House Subcommittee 

on Military Personnel on August 15, 2011.

40Legislative Hearing on H.R. 2383, H.R. 2243, H.R. 2388, and H.R. 2470, Before the 

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

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

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

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

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

Page 28 GAO-14-302 Electronic Health Records 

expanded to accommodate its new responsibilities. To this end, the 

departments and the IPO determined that the office would require a 

significant increase in personnel—more than 7 times the number of staff 

originally allotted to the office by VA and DOD—to complete hiring under 

the office’s 2011 charter. However, while each of the departments 

provided personnel to the IPO through reassignments and short-term 

details of personnel, the departments did not fully staff the office as 

planned.41

Interagency processes: As the departments began establishing the 

infrastructure to support the iEHR program in mid-2011, they recognized 

that their disparate processes related to, for example, acquisitions and 

contracting would need to be aligned in order for the IPO to effectively 

fulfill its responsibilities.

For example, a staffing report from early November 2012 

showed that, at that time, the IPO was staffed at about 60 percent. 

Specifically, while the office consisted of 101 reassigned VA and DOD 

staff and 43 detailed staff, 95 positions remained vacant. Further, in 

January 2013, the IPO Director stated that the office was staffed at 

approximately 62 percent and that hiring additional staff remained one of 

its biggest challenges, partly due to a hiring freeze within the TRICARE 

Management Activity. In addition, VA’s iEHR program manager noted that 

recruiting staff for the IPO was a persistent challenge because the 

departments required health IT professionals with specialized technical 

expertise. Further, the official noted that VA faced a disadvantage in

hiring qualified candidates because it had to compete with private-sector 

companies and also had decided to generally limit the hiring pool to 

candidates in the Washington, D.C., area.

42

 

41In order to help meet the IPO’s hiring needs, the departments agreed that staff could be 

detailed to the IPO for a period of 120 days. The departments used this process to fill 

several key leadership positions, including the IPO Deputy Director. 

To accomplish this, the departments provided 

the IPO Director with the authority to develop interagency processes in 

the office’s 2011 charter. However, instead of agreeing to use one 

process or developing a truly integrated approach to joint acquisitions, the 

office opted to follow both VA’s and DOD’s processes—an inherently 

42Within their respective departments, VA and DOD have established their own processes 

for managing acquisitions and contracting. Although the IPO had a contracting officer on 

staff at the time of our review, all of the contracts for work conducted for the iEHR program 

had been issued and managed through existing VA and DOD contracting offices, including 

VA’s Technology Acquisition Center, the Space and Naval Warfare Systems Command, 

and the United States Army Medical Research Acquisition Activity.
 

Page 29 GAO-14-302 Electronic Health Records 

inefficient approach.43

Governance and oversight: As the departments proceeded to 

implement the IPO and move forward with the iEHR program, they 

established a complex governance structure to oversee the office’s 

activities. However, this contributed to conflict over who was ultimately 

responsible for making program decisions and has resulted in unclear 

lines of authority and accountability for the departments’ collaborative 

health IT efforts. Specifically, while the IPO’s 2011 charter provided broad 

decision-making authority to the IPO Director related to acquiring, 

developing, and implementing all common VA/DOD health IT systems, 

capabilities, and initiatives, it also provided numerous officials with 

operational oversight over the office;

According to a senior official within VA’s Office of 

Information and Technology, this decision created an undue burden on 

the iEHR program office because it had to meet the requirements of two 

different contracting and acquisition processes. For example, according to 

iEHR program documentation, the office would have had to develop over 

1,300 documents for one of the planned iEHR increments composed of 

14 projects in order to comply with both departments’ acquisition 

requirements. Although the iEHR program was redirected before the IPO 

made significant progress toward acquiring joint EHR capabilities, this 

provides an example of one area where the departments were unable to 

compromise on their own processes in order to further their common 

health IT goals.

44

 

43Specifically, the IPO’s “integrated acquisition framework” consisted of using DOD’s 

Business Capability Lifecycle process to manage the iEHR program’s multiple increments 

concurrently with VA’s Project Management Accountability System to oversee and monitor 

multiple iEHR projects within each increment. 

identified several interagency 

organizations to provide oversight to the IPO related to, for example, 

requirements development and enterprise architecture; and established 

an advisory board to provide counsel and recommendations on the iEHR 

program to VA and DOD leadership. As a result, the IPO Director did not 

always have full authority over program decisions as described in the 

44The IPO’s 2011 charter provided DOD’s Deputy Chief Management Officer and VA’s 

Assistant Secretary for Information and Technology with operational oversight of the IPO. 

In addition the charter cited the Assistant Secretary of Defense for Health Affairs and the 

Under Secretary of Defense for Personnel and Readiness as having authority, direction, 

and control over the IPO, due to the office’s organizational placement within DOD for the 

purposes of administrative management and supervision. Note that on October 1, 2013, 

DOD established the Defense Health Agency to manage the activities of the Military 

Health System (including TRICARE Management Activity).
 

Page 30 GAO-14-302 Electronic Health Records 

office’s charter, and was expected to seek consensus from VA and DOD 

supervising officials or the IPO’s governance organizations before 

proceeding. Conversely, one of the IPO’s governing bodies raised 

concerns about the office’s willingness to appropriately involve them in 

the iEHR program. Specifically, the co-chairs of the Health Architecture 

Review Board raised concerns to the Health Executive Committee that 

the IPO had not been receptive to involving the board throughout the 

design and acquisition process for the iEHR program. According to these 

officials, the board’s inability to participate throughout the process 

resulted in unnecessary delays to the IT acquisition process. In a 

December 2012 assessment prepared to help define the iEHR program’s 

new direction, VA and DOD officials cited governance and oversight as 

challenges to the program, including group decision making. In an effort 

to mitigate this problem, the departments chose to shift decision-making 

authority away from the IPO Director and in January 2013 established an 

executive committee of two VA and two DOD executive officials to 

oversee the IPO and make decisions for the iEHR program.

Given the changes that VA and DOD have made to their approach for 

developing an interoperable electronic health record, it remains to be 

seen how the departments will proceed with implementing the IPO and to 

what extent the office will be leveraged as a mechanism for effective 

interagency collaboration. Nevertheless, until VA and DOD address these 

long-standing issues, their ability to effectively collaborate through the 

IPO on their joint health IT efforts will be limited.

As stated earlier, the fiscal year 2008 NDAA established the IPO under 

the direction, supervision, and control of both the Secretaries of VA and 

Defense to serve as the single point of accountability for the departments’ 

development and implementation of interoperable electronic health 

records. The IPO was to better position the departments to collaborate on 

joint health IT initiatives. However, the departments recently made 

decisions that reduced the IPO’s role, responsibilities, and authority over 

the departments’ joint health IT efforts, jeopardizing its ability to serve as 

the single point of accountability for the development and implementation 

of interoperable electronic health records.

In December 2013, VA and DOD revised the IPO’s charter, thus reducing 

the office’s responsibilities from leading and managing all aspects of the 

iEHR program to overseeing the departments’ adoption of health data 

standards for ensuring integration of health data between their 

modernized health IT systems. For example, the IPO’s 2011 charter 

VA and DOD Have 

Reduced the IPO’s Role 

and Responsibilities
 

Page 31 GAO-14-302 Electronic Health Records 

authorized the office to lead and manage all interagency planning, 

programming and budgeting, contracting, acquisition, data strategy and 

management (including identifying standards for interoperability), testing, 

and implementation for the iEHR program. In contrast, under the revised 

charter, the IPO is to engage with national and international health 

standards-setting organizations to ensure their resulting standards meet 

the needs of VA and DOD; identify data and messaging standards for VA 

and DOD health IT solutions; and monitor and report on the departments’ 

use of and compliance with the adopted standards. Moreover, the revised 

charter does not acknowledge or address the office’s long-standing 

weaknesses related to budgetary control, staffing, developing interagency 

processes, and governance. Specifically:

• Although the 2013 charter describes how the departments generally 

intend to share the costs of their planned interoperability work, VA and 

DOD have not explicitly addressed whether or not the IPO Director

has budgetary control over the office’s initiatives. As written, the 

charter suggests that this authority will remain with the departments.

• Similar to the 2011 charter, the 2013 charter states that the 

departments will rely on a combination of reassigned VA and DOD 

personnel and detailees to fill the IPO’s positions. As of early January 

2014, VA and DOD officials stated that they were in the process of 

transitioning IPO personnel back to their respective departments, and 

were identifying individuals to serve as leads within each department 

for their joint interoperability projects. However, although these 

officials stated that they anticipate the office will require significantly 

fewer personnel than expected under the iEHR program, staffing for 

the IPO remains uncertain. Moreover, the departments have not yet 

addressed how to competitively recruit and retain personnel with the 

required technical expertise to develop and implement an 

interoperable electronic health record.

• The 2013 charter does not explicitly address the extent to which the 

IPO has the authority to develop interagency processes to fulfill its 

mission, although it is implied in the office’s responsibilities. For 

example, the charter states that the IPO will work with the Health 

Architecture Review Board “to ensure that both departments are 

appropriately synchronized and coordinated”; yet, according to the cochairs of this board, the details of this process have not been 

discussed or defined.
 

Page 32 GAO-14-302 Electronic Health Records 

• In addition, despite the IPO’s reduced role and responsibilities, the 

2013 charter maintains a complex governance structure. For example, 

the charter states that the IPO Director45 reports through the DHMS 

Program Executive Officer to the Under Secretary of Defense (AT&L), 

while the IPO Deputy Director reports through the IPO Director to the 

VA Assistant Secretary for Information and Technology and CIO. 

However, the charter does not describe whether or how the IPO 

Director reports to VA leadership. Further, the charter identifies 

numerous executive-level individuals and organizations to provide 

direction, oversight, and guidance to the IPO, including the Joint 

Executive Committee, the Under Secretary of Defense (AT&L), the VA 

CIO, and a DOD/VA Senior Stakeholder Group that will include 

functional, technical, acquisition, and resource leadership from both 

departments.46

Further, the IPO’s 2013 charter maintains that the office will remain the 

single point of accountability for the development and implementation of 

interoperable electronic health records between VA and DOD. However, 

in addition to reducing the IPO’s role, responsibilities, and authority over 

these efforts in its 2013 charter, the departments have identified other 

offices to execute health data interoperability initiatives formerly managed 

by the IPO. For example, in January 2014, the Under Secretary of 

Defense (AT&L) decided to consolidate the execution of all DOD IT health 

data-sharing projects formerly managed by the IPO and the Defense 

Health Agency within a new program office under the DHMS Program 

Executive Officer. These projects include VLER Health, ongoing data 

federation efforts, and longtime data-sharing initiatives with VA, including 

the Federal Health Information Exchange, the Bidirectional Health 

Information Exchange, and the Clinical Data Repository/Health Data 

Repository. According to the decision memo, resources associated with 

these health data interoperability efforts will be reassigned from the IPO 

and the Defense Health Agency to the DHMSM program. Similarly, in 

Given this extensive level of management and 

oversight, it is unclear to what extent the IPO leadership will have 

decision-making authority over the office’s interoperability efforts.

 

45Currently, the DHMS Program Executive Officer serves as both the acting IPO Director

and the head of DOD’s EHR modernization effort. 

46According to the IPO’s 2013 charter, the DOD/VA Senior Stakeholder Group will be cochaired by the Under Secretary of Defense (AT&L) and VA CIO and will be responsible for 

directing and overseeing the IPO’s execution of its responsibilities; the group will also 

consult and provide recommendations to department officials regarding the IPO’s budget 

and staffing plans.
 

Page 33 GAO-14-302 Electronic Health Records 

January 2014 the Veterans Health Administration’s Chief Medical 

Informatics Officer stated that interoperability programs are in the process 

of being consolidated under their Office of Health Informatics and 

Analytics and will be managed along with VA’s Office of Information and 

Technology.

Overall, a disconnect exists between the IPO’s responsibility to serve as 

VA and DOD’s single point of accountability for their health data 

interoperability efforts and the role described in the office’s December 

2013 charter. When asked how the IPO will be able to serve as the single 

point of accountability for the departments’ joint health IT efforts given 

these changes, the DHMS Program Executive Officer stated that he did 

not think that the changes impact the IPO’s role at all because the office 

is responsible for ensuring that the departments adopt a sound technical 

approach for interoperability. Nevertheless, VA’s and DOD’s decisions to 

diminish the IPO’s role and move responsibilities for interoperability 

elsewhere within their respective departments jeopardize the office’s 

ability to serve as the departments’ single point of accountability for the 

development and implementation of interoperable electronic health 

records. Moreover, the departments’ recent actions raise concerns about 

their intention to use the IPO as a mechanism for collaboration going 

forward.

VA and DOD lost valuable time toward providing service members, 

veterans, and their health care providers with a long-awaited 

interoperable electronic health record by agreeing to initiate joint 

development of a single system in March 2011, and then deciding in 

February 2013 that the endeavor was too expensive and that the planned 

system would take too long to develop. The departments are now in the 

process of planning to use separate systems—VA intends to modernize 

its existing VistA system and DOD plans to acquire a commercially 

available system—while they are also to jointly develop capabilities to 

provide interoperability between the systems. In abandoning the singlesystem approach, the departments asserted that their new, multiplesystem approach will be less expensive and faster. However, the 

departments’ assertion is questionable because they have not developed 

cost and schedule estimates to substantiate their claim or justify their 

decision. In the absence of credible analyses to guide decisions about 

how to cost-effectively and expeditiously develop the interoperable 

electronic health record needed to provide service members and veterans 

with the best possible care, VA and DOD have fallen back on the 

divergent approaches that each department has determined to be best for 

Conclusions
 

Page 34 GAO-14-302 Electronic Health Records 

it—VA intends to modernize VistA, and DOD expects to acquire a new 

commercially available system. While the departments have begun 

planning for these separate systems, they have yet to develop plans 

describing what a future interoperable health record will consist of or how, 

when, and at what cost it will be achieved.

Further, even though VA and DOD have determined that their electronic 

health record system needs overlap, the departments have neither 

removed long-standing barriers to working together to address their 

common needs nor positioned the Interagency Program Office for 

effective collaboration going forward. Their slow pace in addressing 

recommendations we made to address these barriers has hindered their 

efforts to identify and implement IT solutions that meet their common 

needs. Further, the departments’ failure to implement the IPO consistent 

with effective collaboration practices may hamper its efforts to serve as a 

focal point for future collaboration. Moreover, the departments’ recent 

decisions to move certain interoperability responsibilities to other offices 

within VA and DOD may further undermine the IPO’s effectiveness. 

Because the IPO is expected to play a key role—establishing 

interoperability between VA’s modernized VistA and DOD’s to-beacquired system—it is important that the departments take steps to better 

implement the office as an effective mechanism for collaboration and the 

single point of accountability for their joint health IT efforts.

To bring transparency and credibility to the Secretaries of Veterans 

Affairs and Defense’s assertion that VA and DOD’s current approach to 

achieving an interoperable electronic health record will cost less and take 

less time than the previous single-system approach, we recommend that 

the secretaries

• develop a cost and schedule estimate for their current approach, from 

the perspective of both departments, that includes the estimated cost 

and schedule of VA’s VistA Evolution program, DOD’s DHMSM 

program, and the departments’ joint efforts to achieve interoperability 

between the two systems; then,

• compare the cost and schedule estimates of the departments’ current 

and previous (i.e., single-system) approaches. 

If the results of the comparison indicate that the departments’ current 

approach is estimated to cost more and/or take longer than the singlesystem approach,

Recommendations for 

Executive Action
 

Page 35 GAO-14-302 Electronic Health Records 

• provide a rationale for pursuing the current approach despite its 

higher cost and/or longer schedule and

• report the cost and schedule estimates of the current and previous 

approaches, results of the comparison of the estimates, and reasons 

(if applicable) for pursuing a more costly or time-consuming approach 

to VA’s and DOD’s congressional authorizing and appropriations 

committees.

To better position VA and DOD to achieve an interoperable electronic 

health record, we recommend that the Secretaries of Veterans Affairs and 

Defense develop a plan that, at a minimum, describes

• the clinical domains that the interoperable electronic health record will 

address;

• a schedule for implementing the interoperable record at each VA and 

DOD location;

• the estimated cost of each major component (i.e., VistA Evolution, 

DHMSM, etc.) and the total cost of the departments’ interoperability 

efforts;

• the organizations within VA and DOD that are involved in acquiring, 

developing, and implementing the record, as well as the roles and 

responsibilities of these organizations;

• major risks to the departments’ interoperability efforts and mitigation 

plans for those risks; and

• the departments’ approach to defining, measuring, tracking, and 

reporting progress toward achieving expected performance (i.e., 

benefits and results) of the interoperable record.

To better position the Interagency Program Office for effective 

collaboration between VA and DOD and to efficiently and effectively fulfill 

the office’s stated purpose of functioning as the single point of 

accountability for achieving interoperability between the departments’ 

electronic health record systems, we recommend that the Secretaries of 

Veterans Affairs and Defense ensure that the IPO has authority

• over dedicated resources (e.g., budget and staff),

• to develop interagency processes, and

• to make decisions over the departments’ interoperability efforts.
 

Page 36 GAO-14-302 Electronic Health Records 

We received written comments on a draft of this report (reprinted in 

appendix II), signed by the VA Chief of Staff and the Acting Under 

Secretary of Defense for Personnel and Readiness. In their comments, 

the departments concurred with our recommendations and noted actions 

that were being taken. In particular, with regard to our recommendation 

that VA and DOD develop cost and schedule estimates for their current 

approach to creating an interoperable electronic health record, and then 

compare them with the estimated cost and schedule for the iEHR 

approach, both departments said they have these actions under way and 

that initial comparisons have indicated that their current approach will be 

more cost effective. Further, with regard to our recommendation calling 

for a detailed interoperability plan, the departments stated that they are 

developing such a plan. Lastly, with respect to our recommendation to

strengthen the IPO for effective collaboration, the departments stated that 

the IPO will remain the single point of accountability for achieving 

interoperability between VA’s and DOD’s electronic health record 

systems. If the departments fully implement our recommendations, they 

should be better positioned to economically and efficiently achieve the 

interoperable electronic health record they have long pursued. VA and 

DOD also provided technical comments on the draft report, which we 

incorporated as appropriate.

We are sending copies of this report to appropriate congressional 

committees, the Secretary of Veterans Affairs, the Secretary of Defense, 

and other interested parties. In addition, the report is available at no 

charge on the GAO website at http://www.gao.gov. 

If you or your staff have questions about this report, please contact me at 

(202) 512-6304 or melvinv@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. Key contributors to this report are listed in appendix III.

Sincerely yours,

Valerie C. Melvin 

Director, Information Management 

and Technology Resources Issues

Agency Comments 

and Our Evaluation
Appendix I: Objectives, Scope, and 

Methodology

Page 37 GAO-14-302 Electronic Health Records 

The objectives of this study were to (1) describe changes the Department 

of Defense (DOD) and Department of Veterans Affairs (VA) have made to 

the Integrated Electronic Health Record (iEHR) program since its 

inception, and evaluate the departments’ current plans for the program 

and (2) determine whether the departments, including the DOD/VA 

Interagency Program Office (IPO), are effectively collaborating on 

management of the iEHR program. 

To describe the changes to the iEHR program since its inception, we 

obtained and reviewed minutes and briefing slides from meetings held 

between the VA and DOD Secretaries between February 2011 and 

February 2013. In addition, we obtained and reviewed DOD acquisition 

decision memorandums issued between 2011 and 2013 and minutes and 

briefing slides from meetings for the IPO Advisory Board between April 

2012 and April 2013. We also reviewed iEHR program documentation, 

including the business case, program management plan, integrated 

program-level requirements document, the June 2013 iEHR expenditure 

plan, and program management review briefings.

To evaluate the current plans for the program, we reviewed 

documentation and plans supporting efforts to complete four iEHR nearterm projects, including iEHR project briefing slides and iEHR program 

management review briefings. We obtained information on the 

departments’ new health modernization efforts, VA’s VistA Evolution 

program and DOD’s Healthcare Management System Modernization

program, through interviews with relevant officials. We also attended 

three iEHR and health information exchange summits in Washington, 

D.C., and Alexandria, Virginia. In addition, we compared statements 

made and documentation the departments provided to support the shift in 

the program strategy for iEHR against effective management practices.1

To determine the effectiveness of collaboration by VA, DOD, and the IPO, 

we identified and analyzed the departments’ actions in response to 

recommendations we previously made to address barriers VA and DOD 

 

1

GAO, Information Technology Investment Management: A Framework for Assessing and 

Improving Process Maturity, GAO-04-394G (Washington, D.C.: March 2004); GAO Cost 

Estimating and Assessment Guide: Best Practices for Developing and Managing Capital 

Program Costs, GAO-09-3SP (Washington, D.C.: March 2009); GAO Schedule 

Assessment Guide: Best Practices for project schedules, GAO-12-120G (Washington, 

D.C.: May 2012).

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 38 GAO-14-302 Electronic Health Records 

faced in addressing their common health IT needs.2

We supplemented our analyses with interviews of VA, DOD, and IPO 

officials with knowledge of the iEHR Program, including VA’s Under 

Secretary for Health, VA’s Assistant Secretary for Information and 

Technology and Chief Information Officer, DOD’s Assistant Secretary of 

Defense for Health Affairs, DOD’s Deputy Chief Management Officer, and 

the IPO Director.

Additionally, we 

analyzed the 2011 and 2013 IPO charters and compared them to the 

requirements that were established for the IPO in the National Defense 

Authorization Act for 2008. We focused our analysis in the areas of 

funding, staffing, and interagency processes and compared written and 

verbal information on the departments’ implementation of the IPO against 

best practices for facilitating interagency collaboration. We also analyzed 

the governance structure for the IPO and the iEHR program, including 

organizational charts and charters that established the reporting structure 

between the IPO, VA and DOD, and several interagency organizations 

designated to provide oversight to the iEHR program. To better 

understand the decision making for the program, we analyzed briefing 

slides and minutes from the secretaries’ quarterly meetings, and the IPO 

Advisory Board’s bi-weekly meetings, as well as iEHR-related decision 

memorandums issued by the departments.

We conducted this performance audit from September 2012 to February 

2014 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

 

2

GAO, Electronic Health Records: DOD and VA Should Remove Barriers and Improve 

Efforts to Meet Their Common System Needs, GAO-11-265 (Washington, D.C.: Feb. 2, 

2011).
Appendix II: Joint Comments from the 

Departments of Veterans Affairs and Defense 

Page 39 GAO-14-302 Electronic Health Records 

Appendix II: Joint Comments from the 

Departments of Veterans Affairs and 

Defense
Appendix II: Joint Comments from the 

Departments of Veterans Affairs and Defense 

Page 40 GAO-14-302 Electronic Health Records 
Appendix II: Joint Comments from the 

Departments of Veterans Affairs and Defense 

Page 41 GAO-14-302 Electronic Health Records 
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 42 GAO-14-302 Electronic Health Records 

Valerie C. Melvin, (202) 512-6304 or melvinv@gao.gov

In addition to the contact named above, Mark T. Bird (Assistant Director), 

Heather A. Collins, Kelly R. Dodson, Lee McCracken, Brandon S. Pettis, 

Umesh Thakkar, and Eric Trout made key contributions to this report.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(310992)
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