United States Government Accountability Office

Washington, DC 20548 

April 30, 2008

The Honorable Daniel K. Akaka 

Chairman 

Committee on Veterans’ Affairs 

United States Senate 

Subject: VA and DOD Health Care: Progress Made on Implementation of 2003 President’s 

Task Force Recommendations on Collaboration and Coordination, but More 

Remains to Be Done 

Dear Mr. Chairman: 

Improving collaboration and health resource sharing between the Department of Veterans 

Affairs (VA) and the Department of Defense (DOD) has been the focus of numerous efforts 

by Congress and the executive branch for more than two decades. In 1982, Congress passed 

the Veterans’ Administration and Department of Defense Health Resources Sharing and 

Emergency Operations Act (Sharing Act), which authorized VA and DOD health care facilities 

to partner and enter into sharing agreements to buy, sell, and barter medical and support 

services.1

 Since then, Congress has passed additional legislation to continue to promote VA 

and DOD health resource sharing.2

 However, in previous work we have pointed out 

continuing barriers to such efforts, including incompatible computer systems that affect the 

exchange of patient health information, inconsistent reimbursement and budgeting policies, 

and burdensome processes for approving agreements between the departments.3

On May 28, 2001, the President established the 15-member President’s Task Force to Improve 

Health Care Delivery for Our Nation’s Veterans. The task force’s mission was to identify ways 

to improve coordination and sharing between VA and DOD in order to improve health care 

for servicemembers and veterans.4

 The task force reviewed barriers and challenges in several 

areas related to coordination, including leadership, transition to veteran status, and 

improving quality of health care. In May 2003, it made recommendations to VA and DOD to 

increase collaboration and coordination between the two departments to improve health care 

 1

Pub. L. No. 97-174, 96 Stat. 70 (1982); Senate Report 97-137. Before the Sharing Act was passed in 

1982, VA and DOD health care facilities—many of which were in close or joint locations—operated

virtually independently of each other. 

2

See the Bob Stump National Defense Authorization Act for Fiscal Year 2003 under which VA and DOD 

were required to develop a joint strategic plan and incorporate the joint goals and strategies into each 

department’s strategic and performance plans. Pub. L. No. 107-314, § 721, 116 Stat. 2458, 2589-2595

(2002) (codified as amended at 38 U.S.C. § 8111). 

3

See Related GAO Products at the end of this report. 

4

Exec. Order No. 13,214, 66 Fed. Reg. 29,447 (May 31, 2001).

 GAO-08-495R VA and DOD Collaboration on Veterans’ Care 
delivery.5

 The task force also recommended that the administration take action through the 

Department of Health and Human Services (HHS) to help improve VA and DOD 

collaboration, and that Congress take additional action to improve such collaboration. Other 

more recent task force and commission reports have voiced similar concerns and identified 

more areas for improvement. These reports include the 2007 Task Force on Returning Global 

War on Terror Heroes report,6

 the 2007 President’s Commission on Care for America’s 

Returning Wounded Warriors “Dole-Shalala report,”7

 and the 2007 Veterans’ Disability 

Benefits Commission report.8

You asked us to examine the status of VA and DOD’s efforts in implementing the 2003 task 

force recommendations. Specifically, this report describes the extent to which VA and DOD 

have implemented the recommendations of the 2003 President’s Task Force to Improve 

Health Care for Our Nation’s Veterans related to collaboration and coordination. 

The scope of this report is the 20 recommendations in the first four chapters of the task 

force’s report, which focus on increased collaboration and coordination.9 To describe the 

extent to which VA and DOD have implemented the task force recommendations, we 

collected information on the departments’ related activities by reviewing documents 

provided by VA and DOD—including the departments’ written responses to our questions, 

annual reports, and other documents; interviewing department officials; reviewing related 

task force and commission reports; and reviewing our prior work on related subjects. We 

examined information provided by VA and DOD officials and compared information provided 

by the departments with relevant findings from our prior reports. Although some of the task 

force recommendations had multiple parts, we considered each recommendation as a whole, 

rather than addressing a recommendation’s parts individually. A few recommendations 

contained deadlines that have lapsed, and we have described the departments’ actions to date 

without consideration of these deadlines. We conducted our work from July 2007 through 

April 2008 in accordance with generally accepted government auditing standards. 

In summary, we found that VA and DOD have made progress in implementing the task force 

recommendations, but more remains to be done to fully implement all task force 

recommendations. Seven of the recommendations have been fully implemented and 11 have 

been partially implemented. We could not determine the status of 1 because of insufficient 

information, and 1 does not require VA or DOD action. 

 5

President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans 

(May 26, 2003). 

6

Task Force on Returning Global War on Terror Heroes (Washington, D.C.: Apr. 19, 2007). 

7

Serve, Support, Simplify: Report of the President’s Commission on Care for America’s Returning 

Wounded Warriors (July 30, 2007). 

8

Honoring the Call to Duty: Veterans’ Disability Benefits in the 21st Century, Veterans’ Disability 

Benefits Commission (Washington, D.C.: Oct. 3, 2007). 

9

The remaining chapter, “Timely Access to Health Services and the Mismatch between Demand and 

Funding,” includes three recommendations that are not included in our scope. The recommendations 

in this chapter focus on congressional appropriations and related actions rather than department

activities. 

2 GAO-08-495R VA and DOD Collaboration on Veterans’ Care
• Fully implemented. Four out of the seven recommendations we found to be fully 

implemented have been carried out through the Joint Executive Council (JEC), an 

interagency leadership committee of VA and DOD officials.10 The JEC issues annual 

reports on its activities, has developed joint health care outcome metrics, and has 

identified functional areas to reengineer business processes and information technology 

to enhance care, as recommended. It also regularly uses civilian consultants in its 

collaborative efforts, as recommended. In addition, the departments have fully 

implemented three other task force recommendations that address expanding 

collaboration to collect and maintain data on servicemembers’ occupational exposure and 

hazards; sharing routinely information on servicemembers’ assignment history, 

occupational exposures, and injuries; and conducting continuous health surveillance and 

research on the long-term health consequences of military service. 

• Partially implemented. These 11 recommendations address a variety of issues, such as 

developing interoperable electronic medical records, implementing a mandatory single 

physical examination when a servicemember is separating from military service, and 

integrating pharmacy initiatives. The departments have made progress in implementing 

these recommendations, but have more to do to fully implement them. 

• Unable to determine. As of April 2008, VA and DOD had not provided sufficient 

information for us to determine the status of one recommendation. The recommendation 

requires that the departments address staffing shortfalls, develop consistent clinical

scopes of practice for nonphysician providers, and ensure interfacing credentialing 

systems. We were not able to determine the status of this recommendation because VA

and DOD did not provide sufficient information on their efforts to address staffing 

shortfalls and to develop consistent clinical scopes of practice for nonphysician providers. 

• No action required. One recommendation requires that the administration direct HHS to 

declare VA and DOD a single health care system for purposes of facilitating the exchange 

of health information in accordance with the Health Insurance Portability and 

Accountability Act (HIPAA) Privacy Rule.11 According to VA, the departments have 

sufficient authority for data sharing as permitted by HIPAA without becoming one single 

entity.12 In addition, VA and DOD have implemented a data-sharing memorandum of 

understanding (MOU) that outlines agreed-upon authorities for sharing protected health 

information as permitted by HIPAA. 

 10The JEC is co-chaired by the Deputy Secretary of Veterans Affairs and the Under Secretary of 

Defense for Personnel and Readiness, and the membership—which is selected by the co-chairs—

consists of senior executives from both VA and DOD.

11The Privacy Rule applies to covered entities and specifies how individually identifiable health data 

may be used and disclosed by covered entities. See 45 C.F.R. §§ 164.500(a), et seq. (2007). Covered 

entities are defined in the Privacy Rule as health plans, clearinghouses, and certain health care

providers. Both the DOD and VA health care systems are covered entities. See 45 C.F.R. § 160.103 

(2007). All covered entities had to comply with the Privacy Rule by April 14, 2003, with the exception 

of small health plans. 

12The HIPAA Privacy Rule permits the exchange of health care information between VA- and DODcovered entities for a number of purposes, including to provide medical treatment, to make payments 

for health care, and to make VA benefit determinations upon servicemembers’ discharge or separation

from the armed forces. See 45 C.F.R. §§ 164.506, 164.512(k) (2007).

3 GAO-08-495R VA and DOD Collaboration on Veterans’ Care
See table 1 for the implementation status of the task force recommendations. See enclosure I 

for a detailed description of the recommendations, the implementation status, the actions 

taken by VA and DOD, and the actions remaining to fully implement the task force 

recommendations. 

Table 1: Status of 2003 President’s Task Force Recommendations Related to VA and DOD Collaboration

and Coordination 

Recommendation, by type and number Status

Reporting

1.1 Require the interagency leadership committee to annually report to VA and DOD 

Secretaries on task force recommendations and activities 

z

Leadership, collaboration, and oversight

2.1 Broaden the interagency leadership committee charter beyond health care and have the

committee consider using civilian consultants for collaboration 

z

2.2 Use a joint strategic planning and budgeting process 

2.3 Develop joint health care outcome metrics z

Seamless transition to veteran status

3.1 Develop interoperable electronic medical records 

3.2 Require the administration to direct the Department of Health and Human Services (HHS) 

to declare that VA and DOD are a single health care system for Health Insurance 

Portability and Accountability Act (HIPAA) purposes 

;

3.3 Implement a mandatory single physical examination for servicemembers separating from 

military service and electronic transmission of separation information 



3.4 Facilitate a seamless transition to veteran status 

3.5 Collaborate on collecting and maintaining information on servicemember exposure and 

hazards 

z

3.6 Share routinely information on servicemember assignment history, exposure, and injuries z

3.7 Conduct surveillance and research on long-term health consequences of military service z

Removing barriers to collaboration

4.1 Revise health care system organizational structures to improve coordination and enhance

care 



4.2 Enhance local and regional authority, accountability, and incentives for collaborative 

health care efforts 



4.3 Integrate pharmacy initiatives 

4.4 Allow shared patients to obtain prescriptions at both VA and DOD pharmacies 

4.5 Standardize medical supplies and equipment identification for joint acquisition 

4.6 Identify functional areas where the departments have similar requirements for 

reengineering business processes and information technology to enhance care 

z

4.7 Implement facility lifecycle management practices 

4.8 Develop joint policies and lessons learned on joint ventures 

4.9 Address staffing shortfalls, develop consistent clinical scopes of practice for nonphysician

providers, and ensure interfacing credentialing systems 



Source: GAO analysis of VA and DOD information and President’s task force report.

Legend: 

z Fully implemented 

 Partially implemented 

; No action needed 

 Unable to determine 

4 GAO-08-495R VA and DOD Collaboration on Veterans’ Care
We provided draft copies of this report to VA and DOD for review and comment. VA provided 

written comments and technical comments, and agreed with our findings. DOD provided 

written comments and agreed with our findings provided that we incorporate technical 

comments that it provided. We incorporated the agencies’ technical comments as 

appropriate, including comments that changed the implementation status of the task force 

recommendations, updated information, or provided a clearer understanding of the actions 

VA and DOD have taken or actions that remain to be taken. VA and DOD comments are 

reprinted in enclosures II and III, respectively. 

- - - - - 

We are sending copies of this report to the Secretary of Veterans Affairs and the Secretary of 

Defense and appropriate congressional committees. We will also make copies available to 

others upon request. In addition, the report is available at no charge on the GAO Web site at 

http://www.gao.gov. 

If you or your staff have questions about this report, please contact me at (206) 287-4860 or 

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

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

contributions to this report are listed in enclosure IV. 

Sincerely yours, 

Randall B. Williamson 

Director, Health Care 

Enclosures – 4 

5 GAO-08-495R VA and DOD Collaboration on Veterans’ Care
Enclosure I 

6 GAO-08-495R VA and DOD Collaboration on Veterans’ Care 

VA and DOD Actions Taken and Actions Remaining to Fully Implement the 2003 President’s Task 

Force Recommendations Related to Collaboration and Coordination 

Recommendation, by type and number Status Action taken Action remaining 

Reporting 

1.1 The interagency leadership committee 

should, on an annual basis, report to 

the Secretaries on the status of 

implementing its collaboration and 

sharing initiatives and the 

recommendations in this Final Report, 

together with any other matters that 

the committee deems appropriate. 

Within 60 days after receipt, the 

Secretaries shall transmit the report, 

together with any related comments, 

to the President. 

z The VA/DOD Joint Executive Council (JEC), 

first established as the interagency leadership 

committee in 2002,a

 issues an annual report 

describing progress on VA and DOD 

collaborative efforts. According to DOD, the 

JEC annual report is consistent with the 

President’s task force recommendations in that 

it addresses the same key issues. 

None. 

Leadership, collaboration, and oversight 

2.1 Congress should amend the fiscal 

year 2003 National Defense 

Authorization Act to create a broader 

charter beyond health care for the 

interagency leadership committee. 

Additionally, consideration should be 

given to using civilian experts as 

consultants to the committee to bring 

in new perspectives regarding 

collaboration and sharing. 

z Congress expanded the scope of the JEC to 

benefits and services, generally, through the 

National Defense Authorization Act (NDAA) for 

Fiscal Year 2004.b

 VA and DOD have used 

civilian experts as consultants in many areas—

for example, a JEC working group consulted 

with a civilian company on information systems 

and technology. VA and DOD officials also told 

us that they will be using civilian subject matter 

experts to assist each of the JEC working 

groups in developing performance measures 

and targets for the Joint Strategic Plan (JSP). 

None. 

2.2 The departments should consistently 

utilize a joint strategic planning and 

budgeting process for collaboration 

and sharing to institutionalize the 

development of joint objectives, 

strategies, and best practices, along 

with accountability for outcomes. 

 The JEC has developed a new JSP each year 

since 2003. The JSP is reviewed, updated as 

necessary, and included in the annual JEC 

report. According to DOD, the JSP outlines 

actionable objectives, assigns accountability, 

and establishes performance targets. In 

addition, VA told us that the departments 

recently held a joint budget review under the 

auspices of the Senior Oversight Committee 

(SOC) in order to determine budgetary needs 

associated with recommendations and statutory 

requirements related to collaboration activities. 

Further, according to VA, the departments will 

periodically review joint collaboration 

requirements and associated budgets in order 

to ensure recommendations and statutory 

requirements are met. 

VA and DOD are not utilizing a 

joint budgeting process, as 

recommended by the task 

force. According to the 

departments, they do not have 

legal authority to submit joint 

budgets. Instead, VA and DOD 

have begun other efforts to 

align their health care budgets 

that could facilitate fully 

implementing this 

recommendation. 
Enclosure I 

7 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

Recommendation, by type and number Status Action taken Action remaining 

2.3 The departments should jointly 

develop metrics (with indicated 

accountability) that measure health 

care outcomes related to access, 

quality, and cost as well as progress 

toward objectives for collaboration, 

sharing and desired outcomes. In the 

annual report prescribed in 

recommendation 1.1, the interagency 

leadership committee should include 

these results and discuss the coming 

year’s goals. 

z VA and DOD have jointly developed metrics to 

measure health care outcomes related to 

access, quality, and cost, as well as progress 

toward objectives for collaboration, sharing, and 

desired outcomes. Such metrics are included in 

the JSP, which consists of six strategic goals 

accompanied by performance expectations, 

measurements, and timelines.c

 Progress is 

reported in the JEC annual report, and 

according to the departments, also at bimonthly 

Health Executive Council (HEC) and Benefits 

Executive Council meetings and quarterly JEC 

meetings. 

None. 

Seamless transition to veteran status 

3.1 VA and DOD should develop and 

deploy by fiscal year 2005 electronic 

medical records that are interoperable, 

bidirectional, and standards-based. 

 Outpatient pharmacy and drug allergy data, but 

not other health care data, are currently 

electronic, interoperable, bidirectional, and 

standards-based. This computable information 

is exchanged for shared patients at seven sites 

via the interface between the DOD Clinical Data 

Repository and the VA Health Data Repository 

known as CHDR. VA and DOD are also sharing 

health data through other initiatives in which the 

data are not computable. For example, the 

Bidirectional Health Information Exchange 

(BHIE), now operational at all VA and DOD 

sites, does not enable the exchange of data but 

allows clinicians in both departments to view 

selected medical data on screen in real time. 

With BHIE, the clinicians can view outpatient 

pharmacy data, allergy information, radiology 

reports, surgical pathology reports, microbiology 

results, cytology reports, laboratory orders, 

chemistry and hematology reports, and at some 

sites, inpatient discharge summaries and/or 

emergency room notes. The departments have 

teamed to develop the Joint DOD/VA 

Information Interoperability Plan, targeted for 

approval in August 2008, to guide the 

development and implementation of an 

interoperable, bidirectional, and standards 

based electronic health record capability for 

military and veteran beneficiaries. 

The departments are not able 

to exchange all health care 

data as computable medical 

records that are interoperable, 

bidirectional, and standardsbased, as recommended by 

the task force. Further, they 

have not developed a 

comprehensive project plan 

with a completion date, which 

would guide their efforts until 

the goal of the comprehensive, 

seamless exchange of 

electronic medical records is 

achieved.d,e

3.2 The administration should direct HHS 

[the Department of Health and Human 

Services] to declare the two 

departments to be a single health care 

system for purposes of implementing 

HIPAA [the Health Insurance 

Portability and Accountability Act] 

regulations. 

; According to VA, the departments have 

sufficient authority for data sharing as permitted 

by HIPAA without becoming a single entity.f In 

addition, VA and DOD have implemented a 

data-sharing memorandum of understanding 

(MOU) that outlines agreed-upon authorities for 

sharing protected health information as 

permitted by HIPAA. VA and DOD officials also 

told us that the departments are sharing data at 

an unprecedented level and are continuing to 

expand shared access to data. 

None. 
Enclosure I 

8 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

Recommendation, by type and number Status Action taken Action remaining 

3.3 The departments should implement by 

fiscal year 2005 a mandatory single 

separation physical as a prerequisite 

of promptly completing the military 

separation process. Upon separation, 

DOD should transmit an electronic 

DD214 [military discharge document] 

to VA. 

 VA and DOD have established procedures 

for single separation physical examinations 

and methods to monitor their conduct. 

However, as we noted in a November 2004 

report, the agencies face challenges in 

expanding use of single separation physicals, 

such as lack of requirements for separation 

physical examinations in all services and lack 

of resources.g

 In comments on our November 

2004 report, DOD identified problems with 

DOD-VA electronic data interchange as a 

barrier to better monitoring of single 

separation physicals. Recently enacted 

legislation mandates joint DOD-VA processes, 

procedures, and standards for transition of 

recovering servicemembers from DOD to VA, 

including a process for single separation 

physical examinations.h

DOD and VA are piloting a joint disability 

evaluation process, including a single 

physical examination. For pilot participants, 

this examination is also intended to serve as 

the single separation examination. 

According to DOD officials, the Defense 

Integrated Military Human Resources 

System (DIMHRS) is being developed to 

provide the electronic, computable 

interface between VA and DOD systems 

 for transmittal and use of an electronic DD214. 

As of February 2008, DIMHRS has not been 

deployed. Plans are for the Army to start using 

DIMHRS in late 2008. The Air Force is planning 

to begin using DIMHRS in early 2009. The Navy 

and Marine Corps will start using DIMHRS at a 

date to be determined. 

VA and DOD have not fully 

implemented a mandatory 

single separation physical 

examination for all 

servicemembers completing 

their military service, which 

would be facilitated by 

developing the mandated 

transition process. 

The departments have also not 

fully implemented a process for 

transmitting computable 

electronic DD214s from DOD 

to VA, as DOD has not 

completed the development of 

DIMHRS to transmit the 

information electronically. 
Enclosure I 

9 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

Recommendation, by type and number Status Action taken Action remaining 

3.4 VA and DOD should expand the onestop shopping process to facilitate a 

more effective seamless transition to 

veteran status. This process should 

provide, at a minimum: (1) a standard 

discharge examination suitable to 

document conditions that might 

indicate a compensable condition; 

(2) full outreach; (3) claimant 

counseling; (4) when appropriate, 

referral for a compensation and 

pension examination and follow-up 

claims adjudication and rating. 

 For a discussion of the single separation 

physical examination issue, see 

recommendation 3.3. 

Under the Transition Assistance Program and 

Disabled Transition Assistance Program, VA 

provides job-search, employment, education, 

and VA benefits information. In fiscal year 2007, 

VA conducted over 8,000 briefings to almost 

300,000 servicemembers. 

According to VA, the department has stationed 

personnel at major military treatment facilities 

(MTF) to help wounded servicemembers as 

they transition from military to civilian life. These 

include personnel to help servicemembers 

apply for VA disability benefits. Under the 

DOD-VA disability evaluation pilot, DOD 

Physical Evaluation Board Liaison Officers and 

VA Military Service Coordinators are tasked to 

assist servicemembers during the disability 

evaluation process. In addition, VA has hired 

and trained eight Federal Recovery 

Coordinators, as recommended by the 

Dole-Shalala Commission, to help assist 

wounded, ill, and injured servicemembers at 

three DOD medical facilities. 

Under its Benefits Delivery at Discharge (BDD) 

program, VA takes disability claims from 

servicemembers prior to discharge and begins 

to process them. VA and DOD have 

agreements to take such claims at about 140 

sites. According to VA, of all original disability 

compensation claims filed within 1 year of 

discharge, 53 percent were filed prior to 

discharge at BDD sites. Under the DOD-VA 

disability evaluation pilot, VA is taking claims 

from servicemembers early in the DOD 

evaluation process. 

VA and DOD have not 

expanded the one-stop 

shopping process to create a 

seamless transition to veteran 

status for all veterans, as 

recommended by the task 

force. 

The streamlined process 

currently being piloted has the 

potential to expedite VA claims 

processing, with VA taking 

claims and making disability 

rating decisions for some 

servicemembers prior to 

discharge.i

 While DOD and VA 

plan to expand the pilot 

beyond its current sites, they 

have not developed expansion 

criteria. Also, their evaluation 

plans do not have some key 

elements, including an 

approach for measuring pilot 

performance against the 

current process. 

3.5 VA and DOD should expand their 

collaboration in order to identify, 

collect, and maintain the specific data 

needed by both departments to 

recognize, treat, and prevent illness 

and injury resulting from occupational 

exposures and hazards experienced 

while serving in the Armed Forces; 

and to conduct epidemiological studies 

to understand the consequences of 

such events. 

z DOD collects pre- and post-deployment health 

assessments from each servicemember on 

overall physical and mental health, injuries, and 

possible environmental or occupational 

exposures. DOD routinely shares this 

information with VA for the diagnosis and care 

of Operation Enduring Freedom (OEF) and 

Operation Iraqi Freedom (OIF) 

servicemembers. DOD also collects and 

monitors air, soil, and water samples where 

troops are deployed. These and other shared 

information are used for cooperative medical 

care and research efforts. DOD has made 

progress in improving collection and reporting of 

health information as part of its health quality 

assurance program, including standardizing, 

documenting, and auditing its efforts. 

(See action taken on recommendation 3.7 for 

information on epidemiological studies.) 

None. 
Enclosure I 

10 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

Recommendation, by type and number Status Action taken Action remaining 

3.6 By fiscal year 2004, VA and DOD 

should initiate a process for routine 

sharing of each servicemember’s 

assignment history, location, 

occupational exposure, and injuries 

information. 

z Since 2005, DOD has sent VA monthly 

electronic health assessment and assignment 

information on deactivated or separated 

servicemembers. The assessment data include 

assignment history, location, occupational 

exposure, and injuries. In addition, DOD 

routinely sends VA data on servicemembers 

deployed to OEF/OIF and on those who have 

entered DOD’s physical evaluation process, 

which is used to determine disability status. The 

Information Management/Information 

Technology Working Group of the HEC 

continues efforts to improve medical data 

sharing. 

None. 

3.7 The department should: (1) add an ex 

officio member from VA to the Armed 

Forces Epidemiological Board and to 

the DOD Safety and Occupational 

Health Committee; (2) implement 

continuous health surveillance and 

research programs to identify the longterm health consequences of military 

service in high-risk occupations, 

settings, or events; and (3) jointly 

issue an annual report on force health 

protection, and make it available to the 

public. 

z An ex officio member from VA was added to the 

Defense Health Board (formerly the Armed 

Forces Epidemiological Board) and the DOD 

Safety and Occupational Health Committee. 

VA and DOD conduct health surveillance and 

research using data collected on high-risk 

occupations, settings, and events through preand post-deployment health assessments. Data 

collected by DOD are also used to monitor air, 

soil, and water samples from each deployment 

location for health surveillance and research. 

VA and DOD, along with HHS, funded medical 

surveillance initiatives and long-term research 

projects related to OIF/OEF deployment and 

illnesses in veterans of the 1991 Gulf War. For 

example, VA and DOD collaborated on 

epidemiological projects related to exposure to 

depleted uranium and chemical warfare agents. 

VA and DOD also developed an inventory of 

432 medical research projects on the health of 

deployed servicemembers and veterans that is 

updated annually. 

VA and DOD officials told us that the 

Deployment Health section of the JEC annual 

report, available online, serves as the force 

health protection report. 

None. 

Removing barriers to collaboration 

4.1 The Secretaries of Veterans Affairs 

and Defense should revise their health 

care organizational structures in order 

to provide more effective and 

coordinated management of their 

individual health care systems, 

enhance overall health care outcomes, 

and improve the structural congruence 

between the two departments. 

 VA and DOD officials told us that the JEC and 

the SOC provide more effective and 

coordinated management of the departments’ 

individual health care systems and that they do 

not believe revising health care organizational 

structures would necessarily improve 

coordination. The SOC was established in 2007 

to bring high-level attention to addressing 

problems with the care and services for 

servicemembers returning from OEF/OIF.j

According to VA and DOD officials, the SOC is 

expected to disband by the end of 2008 or early 

2009, and responsibilities for VA and DOD 

collaboration will shift to the JEC. 

VA and DOD have not revised 

their health care organizational 

structures to improve structural 

congruence between the two 

departments. The departments 

are relying on the JEC and the 

SOC to coordinate efforts 

between their individual health 

care systems. 
Enclosure I 

11 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

Recommendation, by type and number Status Action taken Action remaining 

4.2 The Secretaries of Veterans Affairs 

and Defense, based on the 

recommendations of the interagency 

leadership committee, should provide 

significantly enhanced authority, 

accountability, and incentives to health 

care managers at the local and 

regional levels in order to enhance 

standardized and collaborative 

activities that improve health care 

delivery and control costs. 

 The departments provided leadership and 

authority for local and regional health care 

managers to enhance collaboration, improve 

health care delivery, and control costs. VA 

states that it has provided accountability and 

incentives for local and regional managers 

through performance plans and appraisals 

and scoring factors for shared capital 

investment projects. DOD states that it has 

also eliminated some financial disincentives 

for collaboration for local MTF managers. In 

addition, the departments had 504 direct 

sharing agreements covering 2,090 unique 

services in fiscal year 2006. 

The departments have also implemented the 

ongoing DOD-VA Health Care Sharing Joint 

Incentive Fund (JIF), to identify, provide 

incentives to, implement, fund, and evaluate 

creative coordination and sharing initiatives at 

the facility, regional, and national levels.k

Federal law requires that VA and DOD each 

contribute a minimum of $15 million 

($30 million total) into this fund annually. With 

these funds, VA and DOD had approved and 

funded 47 projects as of February 2007. In 

addition, 7 demonstration projects were 

implemented to evaluate the success of joint 

projects and share lessons learned with other 

sites. 

VA and DOD have not 

demonstrated how they have 

provided either accountability 

or system-wide incentives for 

local and regional health care 

managers in support of 

collaboration, as 

recommended by the task 

force. 

4.3 VA and DOD should integrate clinical 

pharmacy initiatives through the 

coordinated development of: (1) a 

national joint core formulary; and (2) a 

single, common clinical data screening 

tool by fiscal year 2005 that ensures 

reliable, electronic access to complete 

pharmaceutical profiles for VA/DOD 

dual users across both systems. 

 VA and DOD do not accept that a national joint 

core formulary is needed. As an alternative, 

they had awarded 77 joint national contracts for 

medications as of the first three quarters of 

fiscal year 2007 and continue to evaluate 24 

additional drugs for joint contracts. 

VA and DOD’s CHDR allows real-time 

bidirectional exchange of electronic pharmacy 

and drug allergy data for shared patients at 

seven sites. This enables them to share a 

common pharmaceutical clinical data screening 

tool, including computable data that allow both 

departments’ systems to screen for potential 

drug interactions and allergies. VA and DOD 

officials plan to have CHDR available at all sites 

by summer 2008. 

The Pharmacy Re-engineering Project is under 

development and a joint team is working to 

improve the percentage of pharmacy data that 

can be exchanged for shared patients. Both 

departments have adopted a standard for 

exchanging medication-allergy data. 

The DOD Uniform Formulary, 

created under regulations 

issued pursuant to the DOD 

pharmacy statute,l

 prevents 

DOD from participating in a 

joint formulary with VA, as 

recommended by the task 

force. As an alternative, the 

departments will continue to 

collaborate on formulary 

decisions and expand joint 

pharmaceutical purchases. 

The departments have not yet 

fully implemented a clinical 

data screening tool and 

electronic pharmaceutical 

profiles for all shared patients, 

as recommended by the task 

force. To do so, VA and DOD 

are continuing their efforts to 

expand CHDR to all sites.m

 
Enclosure I 

12 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

Recommendation, by type and number Status Action taken Action remaining 

4.4 VA and DOD should collaborate on 

policy and program changes, through 

local sharing arrangements, which 

would permit prescriptions written by 

either VA or MTF providers to be filled 

for dual users by the other 

department’s pharmacies. 

 According to the departments, DOD is able to fill 

prescriptions from any physician, including VA 

providers, for all shared patients at MTFs, retail 

network pharmacies, or TRICARE mail-order 

pharmacy programs. VA will fill prescriptions for 

shared patients who are using VA providers, 

and may fill prescriptions written by non-VA 

providers in rare circumstances. In some 

locations, VA and DOD have local sharing 

agreements allowing prescriptions for shared 

patients to be filled at VA pharmacies. 

VA does not always fill 

prescriptions for shared 

patients, as recommended by 

the task force, because its 

regulations do not permit VA to 

do so.n

4.5 VA and DOD should work with 

industry to establish a uniform 

methodology for medical supplies and 

equipment identification and 

standardization and to facilitate 

additional joint contracting initiatives. 

VA and DOD should identify 

opportunities for joint acquisitions in all 

areas of products and services. 

 VA and DOD have worked with industry to 

standardize identification data for medical 

supplies and equipment through the HEC, and 

according to DOD, the departments will 

continue to work with industry and follow 

industry recommendations. For example, initial 

results released in September 2007 for a health 

care industry pilot demonstrated that the Global 

Data Synchronization Network (GDSN) has the 

potential to work for the health care industry, 

and industry leaders have recommended the 

GDSN as an industry-wide information sharing 

solution. In addition, according to VA, the 

departments have developed their own joint 

Medical/Surgical Product Data Bank as part of 

their JIF-funded joint data synchronization 

project. Also through the HEC, VA and DOD 

have rechartered the Acquisition and Medical 

Material Working Group to identify more ways to 

collaboratively acquire health care commodities 

and services. 

VA and DOD have not fully 

established a uniform 

methodology for medical 

supplies and equipment 

identification and 

standardization, as 

recommended by the task 

force. Their continued work 

with industry could facilitate 

their efforts on this 

recommendation. 

In addition, VA and DOD have 

not demonstrated that they 

have identified opportunities 

for joint acquisitions in all 

areas of products and 

services, as recommended by 

the task force, though the 

rechartered working group may 

have the potential to do so. 

4.6 The interagency leadership committee 

should identify those functional areas 

where the departments have similar 

information requirements so that they 

can work together to reengineer 

business processes and information 

technology in order to enhance 

interoperability and efficiency. 

z VA and DOD have identified functional areas 

and included them in the JSP. For example, the 

fiscal year 2004 JSP states as part of Goal 2 

that VA and DOD will collaborate on internal 

and external reporting systems for patient 

safety. Goals 3, 4, and 5 of the fiscal year 2004 

JSP present information about goals directed to 

the seamless coordination of benefits, 

integrated information sharing, and efficiency of 

operations, respectively. Functions identified 

within these goals include health information 

technology; health clinical data sharing, such as 

in-patient assessments; imaging; laboratory 

data sharing; and delivery of benefits. 

None. 
Enclosure I 

13 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

Recommendation, by type and number Status Action taken Action remaining 

4.7 VA and DOD should implement facility 

lifecycle management practices on an 

enterprise-wide basis. This should be 

accomplished by aligning business 

rules, eliminating statutory barriers, 

and adopting best practices. 

 In 2003, the JEC established the VA-DOD 

Construction Planning Committee (CPC) 

that provides a formalized structure to 

facilitate collaboration and coordination in 

achieving an integrated approach to capital 

coordination that considers both short-term 

and long-term strategic capital issues. The 

CPC was charged with providing oversight to 

ensure that collaborative opportunities for joint 

capital asset planning are maximized, and 

provides the final review and approval of all 

joint capital asset initiatives recommended by 

any element of the JEC structure. Under the 

CPC framework, collaborative efforts have 

been initiated for aligning business rules, 

eliminating statutory barriers, and identifying 

best practices for VA and DOD. 

For example, according to VA and DOD, 

the two departments have begun to share 

planning documents for major construction 

projects to determine those with collaborative 

potential and explore methods to ensure high 

potential projects are fully considered and 

included in both departments’ capital 

investment processes. In addition, DOD 

adopted VA’s capital investment methodology 

and adapted its analytical process for 

evaluating, prioritizing, and ranking major 

construction projects. VA, in turn, adopted 

DOD’s facilities sustainment model to 

standardize the process for estimating 

funding levels for sustaining its capital 

assets portfolio. VA and DOD now use the 

same planning platform to develop projects, 

thus making future collaborative opportunities 

easier to define requirements. 

VA and DOD have not 

demonstrated that they have 

implemented facility lifecycle 

management practices on an 

enterprise-wide basis, as 

recommended by the task 

force. 
Enclosure I 

14 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

Recommendation, by type and number Status Action taken Action remaining 

4.8 VA and DOD should declare that joint 

ventures are integral to the standard 

operations of both departments. 

Through the interagency leadership 

committee, the departments should 

articulate policy requiring that: (1) all 

major initiatives of each department be 

designed and tested for effectiveness 

and suitability in joint venture sites; 

(2) lessons learned from successful 

joint ventures be shared with other 

joint venture sites and also throughout 

the health care delivery systems of the 

two departments; and (3) all proposed 

VA and DOD facility construction 

within a geographic area be evaluated 

as a potential joint venture. 

 In 2005, DOD issued a policy directive that 

assigned responsibilities and prescribed 

procedures for the development and operation 

of DOD-VA health care resource sharing 

agreements. The directive also defined joint 

ventures and discussed departmental policy on 

joint ventures, among other things. 

In 2005, 2006, and 2007, VA and DOD 

sponsored annual conferences to bring together 

leadership from all joint venture sites to share 

lessons learned. 

In 2006, VA established a Joint Venture 

Proposals Working Group to develop criteria for 

evaluating joint venture proposals at the 

department level and a communications 

strategy for use during joint venture 

negotiations. VA issued the criteria and 

communications strategy in a handbook in 

November 2007. The handbook details 

departmental policy on joint ventures, defines 

joint ventures, and identifies the process for 

reviewing and approving joint venture 

proposals, among other things. 

VA and DOD have also established a Joint 

Market Opportunities Work Group to examine 

the existing VA-DOD joint ventures and the 

potential for additional joint ventures. In the first 

phase of its review, the working group studied 

all eight existing VA-DOD joint venture sites to 

identify best practices, lessons learned, and 

challenges. The working group reported the 

findings from the first phase of its review to the 

JEC in January 2008. In the second phase of its 

review, the working group plans to assess 

potential opportunities for colocation and 

comanagement of VA-DOD facilities. The 

working group has identified some locations to 

study and expects to report its findings from the 

second phase to the JEC in July 2008. 

VA and DOD have not fully 

developed and implemented 

joint policies that state that 

joint ventures are integral to 

the standard operations of both 

departments or ensure that all 

major initiatives of each 

department are designed and 

tested for the effectiveness 

and suitability in joint venture 

sites, as recommended by the 

task force. 

4.9 VA and DOD should work together to 

identify and address staffing shortfalls, 

develop consistent clinical scopes of 

practice for nonphysician providers, 

and ensure that their provider 

credentialing systems interface with 

each other. 

 VA and DOD piloted a credentialing interface 

that was shown to be technically feasible, but 

both departments told us that the time and 

money required to support and maintain a 

mutual electronic credentialing system was not 

warranted as the number of credentialed 

providers working in both VA and DOD facilities 

is too small to justify the expenditure. The 

interface is no longer in use, but according to 

VA, it may be reestablished if it is needed in the 

future. 

We are unable to determine 

what remains to be done to 

fully implement this 

recommendation, because VA 

and DOD have not provided 

sufficient information to 

determine the status of their 

progress on addressing 

staffing shortfalls or on 

developing consistent clinical 

scopes of practice for 

nonphysician providers. 

Source: GAO analysis of VA and DOD information and President’s task force report. 

Legend: 

z Fully implemented 

 Partially implemented 

; No action needed 

 Unable to determine 
Enclosure I 

15 GAO-08-495R VA and DOD Collaboration on Veterans’ Care

a

In accordance with the Bob Stump National Defense Authorization Act for Fiscal Year 2003, Pub. L. No. 107-314, § 712(a), 116 Stat. 2590. The JEC 

was originally called the DOD-VA Health Executive Committee. 

b

Pub. L. No. 108-136, § 583, 117 Stat. 1392, 1490 (2003) (codified as amended at 38 U.S.C. § 320). 

c

The six strategic goals in the JSP are related to leadership, commitment, and accountability; high-quality health care; seamless coordination of benefits; 

integrated information sharing; efficiency of operations; and joint medical contingency/readiness capabilities. 

d

See GAO, Information Technology: VA and DOD Are Making Progress in Sharing Medical Information, but Are Far from Comprehensive Electronic 

Medical Records, GAO-07-852T (Washington, D.C.: May 8, 2007). 

e

See GAO, Information Technology: VA and DOD Continue to Expand Sharing of Medical Information, but Still Lack Comprehensive Electronic Medical 

Records, GAO-08-207T (Washington, D.C.: Oct. 24, 2007). 

f

The HIPAA Privacy Rule permits the exchange of health care information between VA- and DOD-covered entities for a number of purposes, including to 

provide medical treatment, to make payments for health care, and to make VA benefit determinations upon servicemembers’ discharge or separation 

from the armed forces. See 45 C.F.R. §§ 164.506, 164.512(k) (2007). 

g

See GAO, VA and DOD Health Care: Efforts to Coordinate a Single Physical Exam Process for Servicemembers Leaving the Military, 

GAO-05-64 (Washington, D.C.: Nov. 12, 2004). 

h

NDAA for Fiscal Year 2008, Pub. L. No. 110-181, § 1614, 122 Stat. 3, 443-46. 

i

See GAO, DOD and VA: Preliminary Observations on Efforts to Improve Care Management and Disability Evaluations for Servicemembers, 

GAO-08-514T (Washington, D.C.: Feb. 27, 2008). 

j

To conduct its work, the SOC established work groups that focused on specific areas, including case management; disability evaluation systems; 

traumatic brain injury; psychological health, including post-traumatic stress disorder; and data sharing between VA and DOD. 

k

In accordance with the Bob Stump National Defense Authorization Act for Fiscal Year 2003, Pub. L. No. 107-314, § 721, 116 Stat. 2458, 2589-2595 

(2002) (codified as amended at 38 U.S.C. § 8111). 

l

10 U.S.C. § 1074g. 

m

See GAO, DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for Some Shared Patients, but Additional Steps Could Facilitate 

Exchanging These Data for All Shared Patients, GAO-07-554R (Washington, D.C.: Apr. 30, 2007). 

n

38 C.F.R. § 17.96. 
Enclosure II 

Comments from the Department of Veterans Affairs 

16 GAO-08-495R VA and DOD Collaboration on Veterans’ Care 
Enclosure III 

Comments from the Department of Defense 

17 GAO-08-495R VA and DOD Collaboration on Veterans’ Care 
Enclosure IV 

GAO Contact and Staff Acknowledgments 

GAO Contact 

Randall Williamson, (206) 287-4860 or williamsonr@gao.gov 

Acknowledgments 

In addition to the contact named above, James C. Musselwhite, Jr., Assistant Director; 

Kye Briesath; Vashun Cole; Julie L. Thomas; Timothy Walker; Greg Whitney; and 

Robert L. Williams, Jr. made major contributions to this report. 

18 GAO-08-495R VA and DOD Collaboration on Veterans’ Care 
Related GAO Products

VA Health Care: Additional Efforts to Better Assess Joint Ventures Needed. GAO-08-399. 

Washington, D.C.: March 28, 2008. 

DOD and VA: Preliminary Observations on Efforts to Improve Care Management and 

Disability Evaluations for Servicemembers. GAO-08-514T. Washington, D.C.: 

February 27, 2008. 

Information Technology: VA and DOD Continue to Expand Sharing of Medical 

Information, but Still Lack Comprehensive Electronic Medical Records. GAO-08-207T. 

Washington, D.C.: October 24, 2007. 

DOD and VA: Preliminary Observations on Efforts to Improve Health Care and Disability 

Evaluations for Returning Servicemembers. GAO-07-1256T. Washington, D.C.: 

September 26, 2007. 

GAO Findings and Recommendations Regarding DOD and VA Disability Systems. 

GAO-07-906R. Washington, D.C.: May 25, 2007. 

Information Technology: VA and DOD Are Making Progress in Sharing Medical 

Information, but Are Far from Comprehensive Electronic Medical Records. GAO-07-852T. 

Washington, D.C.: May 8, 2007. 

DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for Some 

Shared Patients, but Additional Steps Could Facilitate Exchanging These Data for All 

Shared Patients. GAO-07-554R. Washington, D.C.: April 30, 2007. 

VA and DOD Health Care: Opportunities to Maximize Resource Sharing Remain. 

GAO-06-315. Washington, D.C.: March 20, 2006. 

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

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

Defense Health Care: Improvements Needed in Occupational and Environmental Health 

Surveillance during Deployments to Address Immediate and Long-term Health Issues. 

GAO-05-632. Washington, D.C.: July 14, 2005. 

VA and DOD Health Care: Efforts to Coordinate a Single Physical Exam Process for 

Servicemembers Leaving the Military. GAO-05-64. Washington, D.C.: November 12, 2004. 

Department of Veterans Affairs: Federal Gulf War Illnesses Research Strategy Needs 

Reassessment. GAO-04-767. Washington, D.C.: June 1, 2004.

(290646) 

19 GAO-08-495R VA and DOD Collaboration on Veterans’ Care 
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