Electronic Health Records: DOD and VA Interoperability Efforts Are Ongoing; Program Office Needs to Implement Recommended Improvements
Published: 2010-01-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The National Defense Authorization Act for Fiscal Year 2008 required the Department of Defense (DOD) and the Department of Veterans Affairs (VA) to accelerate their exchange of health information and to develop capabilities that allow for interoperability (generally, the ability of systems to exchange data) by September 30, 2009. It also required compliance with federal standards and the establishment of a joint interagency program office to function as a single point of accountability for the effort. Further, the act directed GAO to semiannually report on the progress made in achieving these requirements. For this fourth report, GAO determined the extent to which (1) DOD and VA developed and implemented electronic health record systems or capabilities that allowed for full interoperability by September 30, 2009, and (2) the interagency program office established by the act is functioning as a single point of accountability. To do so, GAO analyzed agency documentation on project status and conducted interviews with agency officials.
section_title: What GAO Found
paragraphs: DOD and VA previously established six objectives that they identified as necessary for achieving full interoperability; they have now met the remaining three interoperability objectives that GAO previously reported as being partially achieved--expand questionnaires and self-assessment tools, expand DOD's inpatient medical records system, and demonstrate initial document scanning. As a result of meeting the six objectives, the departments' officials, including the co-chairs of the group responsible for representing the clinician user community, believe they have satisfied the September 30, 2009, requirement for full interoperability. Nevertheless, DOD and VA are planning additional actions to further increase their interoperable capabilities and address clinicians' evolving needs for interoperable electronic health records. Specifically, (1) DOD and VA plan to meet additional needs that have emerged with respect to social history and physical exam data; (2) DOD plans to further expand the implementation of its inpatient medical records system to sites beyond those achieved as of September 2009; and (3) DOD and VA plan to test the capability to scan documents, in follow-up to their demonstration of an initial document scanning capability. Additionally, in response to a Presidential announcement, the departments are beginning to plan for the development and implementation of a virtual lifetime electronic record, which is intended to further increase their interoperable capabilities. The interagency program office is not yet positioned to function as a single point of accountability for the implementation of interoperable electronic health record systems or capabilities. The departments have made progress in setting up their interagency program office by hiring additional staff, including a permanent director. In addition, consistent with GAO's previous recommendations, the office has begun to demonstrate responsibilities outlined in its charter in the areas of scheduling, planning, and performance measurement. However, the office's effort in these areas does not fully satisfy the recommendations and are incomplete. Specifically, the office does not yet have a schedule that includes information about tasks, resource needs, or relationships between tasks associated with ongoing activities to increase interoperability. Also, key IT management responsibilities in the areas of planning and performance measurement remain incomplete. Among the reasons officials cited for not yet completing a schedule, plan, or performance measures were the office's need to focus on verifying achievement of the six interoperability objectives and participating in the departments' efforts to define the virtual lifetime electronic record. Nonetheless, if the program office does not fulfill key management responsibilities as GAO previously recommended, it may not be positioned to function as a single point of accountability for the delivery of future interoperable capabilities, including the development of the virtual lifetime electronic record.

section_title: Letter
paragraphs: The Department of Defense (DOD) and the Department of Veterans Affairs  (VA) have long-standing efforts to increase sharing of data between their  health information systems. However, while the departments have  progressively increased electronic health information sharing, questions  have been raised about when and to what extent the departments intend  such sharing capabilities to be fully achieved. To expedite the exchange of  electronic health information between the two departments, the National  Defense Authorization Act for Fiscal Year 2008 included provisions  directing DOD and VA to jointly develop and implement, by September 30,  2009, fully interoperable electronic health record systems or capabilities  that are compliant with applicable federal interoperability standards. Such  systems and capabilities are important for making patient information  more readily available to health care providers in the departments,  reducing medical errors, and streamlining administrative functions. In  addition, the act established an interagency program office to be a single  point of accountability for the departments’ efforts.
Further, the act directed us to assess DOD’s and VA’s progress in  implementing the electronic health record systems and to semiannually  report our results to the appropriate congressional committees.  Accordingly, we issued reports in July 2008, January 2009, and   July 2009 in response to the act. As agreed with the committees of  jurisdiction, our objectives for this fourth report are to determine the  extent to which (1) DOD and VA developed and implemented electronic  health record systems or capabilities that allowed for full interoperability  by the September 30, 2009, deadline and (2) the interagency program  office established by the National Defense Authorization Act for Fiscal  Year 2008 is functioning as a single point of accountability for developing  and implementing electronic health records.
To accomplish these objectives, we reviewed our past work in this area;  analyzed current agency documentation (including the departments’  objectives for achieving interoperability, project status information, and  the interagency program office charter); and conducted interviews with  officials from DOD and VA.
We conducted this performance audit from September 2009 through  January 2010, 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. For more details on our  scope and methodology, see appendix I.
subsections: section_title: Background
paragraphs: 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 and is important to improving the performance of the U.S.  health care system. 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.
Interoperability—the ability to share data among health care providers—is  key to making health care information electronically available.  Interoperability enables different information systems or components to  exchange information and to use the information that has been exchanged.  This capability is important because it 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. Unlike paper-based health records,  electronic health records can provide decision support capabilities, such  as automatic alerts about a particular patient’s health, or other advantages  of automation.
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. DOD  and VA have agreed upon numerous common standards that allow them to  share health data. They have also participated in numerous standards- setting organizations tasked to reach consensus on the definition and use  of standards. For example, DOD and VA officials serve as members and  are actively working on several committees and groups within the  Healthcare Information Technology Standards Panel. The panel identifies  and harmonizes competing standards and develops interoperability  specifications that are needed for implementing the standards.
Interoperability can be achieved at different levels. At the highest level,  electronic data are computable (that is, in a format that a computer can  understand and act on to, for example, provide alerts to clinicians on drug  allergies). At a lower level, electronic data are structured and viewable,  but not computable. The value of data at this level is that they are  structured so that data of interest to users are easier to find. At still a  lower level, electronic data are unstructured and viewable, but not  computable. With unstructured electronic data, a user would have to  search through uncategorized data to find needed or relevant information.  Beyond these, paper records also can be considered interoperable (at the  lowest level) because they allow data to be shared, read, and interpreted  by human beings. According to DOD and VA officials, not all data 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. Figure 1  shows the distinction between the various levels of interoperability and  examples of the types of data that can be shared at each level.
subsections: section_title: DOD and VA Efforts to Exchange Health Information Are Long- standing
paragraphs: DOD and VA have been working to exchange patient health information  electronically since 1998. We have previously described their efforts on  three key projects:    The Federal Health Information Exchange (FHIE), begun in 2001 and  enhanced through its completion in 2004, enables DOD to electronically  transfer service members’ electronic health information to VA when the  members leave active duty.
The Bidirectional Health Information Exchange (BHIE), established in  2004, was aimed at allowing clinicians at both departments viewable  access to health information on shared patients—that is, those who  receive care from both departments. For example, veterans may receive  outpatient care from VA clinicians and be hospitalized at a military  treatment facility. The interface also allows DOD sites to see previously  inaccessible data at other DOD sites.
The Clinical Data Repository/Health Data Repository (CHDR)  interface,  implemented in September 2006, linked the department’s separate  repositories of standardized data to enable a two-way exchange of  computable outpatient pharmacy and medication allergy information.  These repositories are a part of the modernized health information  systems that the departments have been developing—DOD’s AHLTA and  VA’s HealtheVet.
In its ongoing initiatives to share 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. All VA medical facilities have access to  all VistA information.
DOD currently relies on its 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  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. Not all of DOD’s medical facilities  yet have this inpatient medical system.
section_title: DOD and VA Identified Interoperability Objectives and Formed an Interagency Program Office
paragraphs: As previously noted, the National Defense Authorization Act for Fiscal  Year 2008 called for DOD and VA to jointly develop and implement, by  September 30, 2009, electronic health record systems or capabilities that  allow for full interoperability of personal health care information that are  compliant with applicable federal interoperability standards. 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 DOD and VA. In this regard, the board is responsible for  determining clinical priorities for electronic data sharing between the  departments, as well as what data should be viewable and what data  should be computable. Based on its work, the board established six  interoperability objectives for meeting the departments’ data sharing  needs. According to the former acting director of the interagency program  office, DOD and VA considered achievement of these six objectives, in  conjunction with capabilities previously achieved (e.g., FHIE, BHIE, and  CHDR), to be sufficient to satisfy the requirement for full interoperability  by September 2009. The six objectives are listed in table 1.
Also since April 2008, the departments have been working to set up an  interagency program office to be accountable for their efforts to  implement fully interoperable electronic health record systems or  capabilities by the September deadline. In January 2009, the office  completed its charter, articulating, among other things, its mission and  functions with respect to attaining interoperable electronic health data.  The charter further identified the office’s responsibilities in carrying out its  mission, in areas such as oversight and management, stakeholder  communication, and decision making. Among the specific responsibilities  identified in the charter was the development of a plan, schedule, and  performance measures to guide the departments’ electronic health record  interoperability efforts.
Subsequent to an April 2009 Presidential announcement, the departments  approved a new version of the interagency program office’s charter in  September to expand the office’s responsibilities to include coordination  and oversight of the development of a Virtual Lifetime Electronic Record  (VLER). Still in the planning stages, VLER is intended to enable access to  all electronic records for service members as they transition from military  to veteran status, and throughout their lives. According to the Director of  the DOD/VA Interagency Program Office, VLER is to expand the  departments’ existing electronic health record capabilities by enabling  access to private sector health data as well. The revised charter describes  that the office is responsible for developing and maintaining a master plan,  integrated master schedule, and performance metrics for the VLER  initiative.
section_title: GAO Reports Have Identified the Need for DOD and VA to Improve Their Efforts to Share Health Information
paragraphs: Our prior reports on DOD’s and VA’s efforts to develop fully interoperable  electronic health record systems or capabilities noted their progress and  highlighted issues that the departments needed to address to achieve  electronic health record interoperability. Specifically, our July 2008  report noted that the departments were sharing some, but not all,  electronic health information at different levels of interoperability. At that  time the departments’ efforts to set up the interagency program office  were in the early stages. Leadership positions in the office were not  permanently filled, staffing was not complete, and facilities to house the  office had not been designated. Accordingly, we recommended that the  Secretaries of Defense and Veterans Affairs expedite efforts to put in place  permanent leadership, staff, and facilities for the program office. The  departments agreed with this recommendation and have taken actions to  address it.
Our January 2009 report noted that the departments had defined plans to  further increase their sharing of electronic health information; however,  the plans did not contain results-oriented (i.e., objective, quantifiable, and  measurable) performance goals and measures that could be used as a  basis to track and assess progress. We recommended the departments  develop and document such goals and performance measures for the six  interoperability objectives, to use as the basis for future assessments and  reporting of interoperability progress. DOD and VA agreed with our  recommendation and stated that the departments intended to include  results-oriented goals in their future plans.
We also reported and testified in July 2009 that the departments were  continuing to take steps toward achieving full interoperability by the  September 2009 deadline. Specifically, we noted that they had identified  six interoperability objectives and had fulfilled three of the six. For the  remaining three objectives, DOD and VA had partially achieved planned  capabilities but additional work was needed to meet the objectives.  Moreover, our report and testimony also noted that the departments’  interagency program office was not effectively positioned to function as a  single point of accountability for achievement of full interoperability  because it did not yet have fundamental IT management capabilities and  was not fulfilling key responsibilities, including establishment of  performance measures, a project plan, or a detailed schedule. As a result,  we recommended that the departments improve management of their  interoperability efforts by establishing a project plan and a complete and  detailed integrated master schedule.
section_title: Although DOD and VA Have Met Their Six Interoperability Objectives, Additional Work Remains to Meet Clinicians’ Evolving Needs
paragraphs: DOD and VA have achieved planned capabilities for the three remaining  objectives (expand questionnaires and self-assessment tools, expand  Essentris in DOD, and demonstrate initial document scanning). Having  now met all six of their interoperability objectives, the departments’  officials, including the co-chairs of the group responsible for representing  the clinician user community, believe they have satisfied the September  30, 2009, requirement for developing and implementing systems or  capabilities that allow for full interoperability. Nevertheless, the  departments are planning additional actions to further increase their  interoperable capabilities, recognizing that clinicians’ needs for  interoperable electronic health records are evolving.
The following describes the departments’ activities with respect to the  three remaining objectives.
Expand questionnaires and self-assessment tools: The departments  intended to provide all periodic health assessment data stored in the DOD  electronic health record to VA in a format that associates questions with  responses. Health assessment data are collected from two sources:  questionnaires administered at military treatment facilities and a DOD  health assessment reporting tool that enables patients to answer questions  about their health. Questions relate to a wide range of personal health  information, such as dietary habits, physical exercise, and tobacco and  alcohol use. While the departments had established the capability for VA  to view questions and answers from the questionnaires collected by DOD  at military treatment facilities, they had not yet achieved the capability for  VA to view information from the second source—DOD’s health  assessment reporting tool. Since our last review, the departments have  established this capability and have therefore met their objective.
Expand Essentris in DOD: DOD intended to expand Essentris to at least  one additional site for each military service and to increase the percentage  of inpatient discharge summaries that it shares electronically with VA.  While the departments had previously expanded the system to two Army  sites, they had not yet expanded to the remaining two military  departments (Air Force and Navy). Since we last reported, the  departments have met this objective by successfully deploying Essentris to  an additional Air Force and Navy site. In addition, the departments  expanded the system to two more Army sites and are sharing inpatient  discharge summaries from 59 percent of DOD inpatient beds.
Demonstrate initial document scanning: The departments intended to  demonstrate an initial capability to scan service members’ medical  documents into the DOD electronic health record and share the  documents electronically with VA. Since our last review, the departments  have met this objective by successfully demonstrating the capability in a  joint test environment. Specifically, DOD has demonstrated the capability  to scan a medical document, associate the document with a test patient,  and save the document into the patient’s electronic health record; and VA  demonstrated the capability to search and retrieve the scanned document  associated with that patient.
While the departments have met the remaining three objectives and  believe they have met the September 30, 2009, deadline for achieving full  interoperability as required by the act, they are planning additional work  to further increase their interoperable capabilities. These actions reflect  the departments’ recognition that clinicians’ needs for interoperable  electronic health records are not static. Currently, the departments are  focusing their efforts to meet clinicians’ evolving needs for interoperable  capabilities in the following areas.
Clinicians have identified additional needs with respect to social history  and physical exam data that have emerged since existing capabilities were  made available in those areas. To meet these needs, the departments are  planning additional efforts to provide, for example, the capabilities to  search, sort, and filter patient social history and physical exam data based  on criteria such as date, location of care, and type of document.
DOD plans to further expand the implementation of Essentris to sites  beyond those achieved as of September 2009. In this regard, the  department has established a goal of making the inpatient system  operational for 90 percent of its inpatient beds by January 31, 2011.
In December 2009, DOD began limited user testing of the document  scanning capability that was demonstrated in September 2009. According  to department officials, this testing entails use of test data by a limited  number of users at nine sites and is expected to be completed in March  2010. After that, further testing of the document scanning capability using  actual data is expected at sites and dates that are to be determined.
Beyond these ongoing efforts to meet their clinicians’ evolving  interoperability needs, the departments have begun planning their efforts  to define and build VLER. For example, in mid-December 2009, VA and a  private health care provider in San Diego, California, began a pilot project  to demonstrate that clinical information such as patient demographic,  allergy, and active medication information can be securely sent and  received. DOD plans to be added to this pilot on January 31, 2010. Further,  the departments are working in cooperation with the interagency program  office and the Interagency Clinical Informatics Board to define additional  clinical information to be exchanged, additional functionality, and  additional geographic areas of interest for future VLER deployment.
section_title: DOD/VA Interagency Program Office Has Made Progress toward Filling Positions, but Has Not Fully Implemented Recommended Management Improvements
paragraphs: The interagency program office is not yet positioned to function as a single  point of accountability for the implementation of interoperable electronic  health record systems or capabilities. Since we last reported, the  departments have made progress in setting up the office by hiring  additional staff, including a permanent director. In addition, consistent  with our prior recommendations, the office has begun to demonstrate  responsibilities outlined in its charter in the areas of scheduling, planning,  and performance measurement. However, the office’s efforts to develop its  capabilities in these areas are incomplete.
subsections: section_title: Staffing of the Interagency Program Office Is Nearly Completed
paragraphs: Among the activities the departments identified in the September 2008  DOD/VA Information Interoperability Plan as necessary for setting up the  interagency program office were appointing a permanent director and  deputy director, as well as recruiting and hiring staff. Since we last  reported in July 2009, DOD appointed a permanent director to lead the  office, effective October 27, 2009. Also, VA filled the permanent deputy  director position, effective January 17, 2010.
According to the former acting deputy director, the departments have also  filled 13 of 14 government staff positions, an increase of 3 staff since our  last report. Additionally, this official stated the departments have taken  steps to fill the remaining senior health program analyst position. He  reported that a selection had been made to fill this remaining position, but  a date for when this position would be filled remained to be determined.
section_title: Interagency Program Office Has Not Fully Established a Schedule, Plan, or Performance Measures
paragraphs: As previously noted, DOD, VA, and the interagency program office  developed a new version of the office’s charter in September 2009.  Consistent with the office’s original charter, the new version describes the  office’s responsibilities in carrying out its mission and function associated  with attaining interoperable electronic data. For example, it identifies the  office’s responsibilities to develop an integrated master schedule, plan,  and performance metrics to monitor the departments’ performance against  interoperability goals. Since we last reported, the office has taken steps  toward developing, but has not yet fully established, these management  tools.
We previously recommended in July 2009 that the program office establish  a complete and detailed master schedule to improve its management of  the departments’ efforts to achieve fully interoperable electronic health  record systems. In response to our recommendation, the office has begun  to develop an integrated master schedule that includes information about  its ongoing interoperability activities, including VLER. For example, the  schedule identifies the limited user testing of the document scanning  capability that DOD plans between December 2009 and March 2010.  However, the schedule does not include information about the tasks,  resource needs, or relationships between tasks for the testing activity. The  office’s acting deputy director stated that the program office is currently  working to improve the schedule by including task dependencies to help in  identifying the critical path for the office’s interoperability activities.
Similarly, we recommended that the program office establish a project  plan, which is an important tool for effective IT program management. The  program office has concurred with the recommendation and has reported  that it is developing a master program plan. In January 2010, department  officials stated that this plan is undergoing review by the departments and  is expected to be approved in February 2010.
In January 2009 we recommended that DOD and VA take action to  complete results-oriented (i.e., objective, quantifiable, and measurable)  goals and performance measures to be used as a basis for the office to  provide meaningful information on the status of the departments’  interoperability initiatives. In November 2009, program office officials  stated that such goals and measures would be included in the next version  of the VA/DOD Joint Executive Council Joint Strategic Plan (known as the  joint strategic plan), which the office expects to be approved in February  2010.
While the departments have agreed with our past recommendations and  have indicated that they are working toward addressing them, officials  stated that other priorities have prevented full implementation of our  recommendations. Specifically, the office has been focused on verifying  achievement of the six interoperability objectives. Moreover, according to  the former interim director, the office was focused on providing briefings  and status information on activities the office has undertaken to achieve  interoperability, in addition to participating in the departments’ efforts to  define VLER. In addition, the office director told us that it has taken the  departments longer than anticipated to provide the detailed information  that is needed by the office to prepare a schedule for joint interagency  data sharing goals.
While the interagency program office is nearly fully staffed and has begun  to establish important management tools, it has not yet completed an  integrated schedule, project plan, and results-oriented goals and measures.  As a result, the interagency program office’s ability to effectively provide  oversight and management, including meaningful progress reporting on  the delivery of interoperable capabilities, is jeopardized. If the  departments fully implement our recommendations, they will have the  comprehensive picture that they need for effectively defining and  managing progress toward meeting their interoperability objectives and  goals, including VLER. Furthermore, implementation of our  recommendations will also better position the office to function as a single  point of accountability for the delivery of interoperable electronic health  records, which are intended to improve service members’ and veterans’  health care.
section_title: Agency Comments and Our Evaluation
paragraphs: In written comments on a draft of this report, the DOD official who is  performing the duties of the Assistant Secretary of Defense (Health  Affairs), the VA Chief of Staff, and the Director of the DOD/VA Interagency  Program Office concurred with our findings. Beyond its concurrence with  our findings, the VA Chief of Staff provided information regarding the  department’s efforts to address recommendations from our prior reports.  For example, in response to our previous recommendation that the  departments use results-oriented performance goals and measures as the  basis for future assessments and reporting of interoperability progress, the  Chief of Staff stated that the departments have prepared draft goals and  measures for their joint strategic plan, which is to be finalized in February  2010. Additionally, in response to our prior recommendation that the  departments establish a project plan and a compete and detailed  integrated master schedule to improve management of their  interoperability efforts, the Chief of Staff asserted that the interagency  program office expects to have a draft project plan by the end of January  2010 and that VA meets monthly with DOD and the program office to  coordinate input into an integrated master schedule. If the departments  continue to implement our recommendations, they should be better  positioned to effectively manage their ongoing efforts to increase their  interoperable electronic health record capabilities. DOD and the  interagency program office also provided technical comments on the draft  report, which we incorporated as appropriate. Comments from the  Departments of Defense and Veterans Affairs, and the DOD/VA  Interagency Program Office are reproduced in appendixes II, III, and IV,  respectively.
We are sending copies of this report to the Secretaries of Defense and  Veterans Affairs, appropriate congressional committees, and other  interested parties. In addition, the report is available at no charge on the  GAO Web site at http://www.gao.gov.
If you or your staffs have questions about this report, please contact me at  (202) 512-6253 or willemssenj@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 V.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine the extent to which the Department of Defense (DOD) and  the Department of Veterans Affairs (VA) developed and implemented  electronic health record systems or capabilities that allowed for full  interoperability by the September 30, 2009, deadline, we reviewed our  previous work on DOD and VA efforts to develop health information  systems, interoperable health records, and interoperability standards to be  implemented in federal health care programs. We obtained and analyzed  agency documentation and interviewed program officials to determine the  departments’ progress toward achieving full interoperability by September  30, 2009, as required by the National Defense Authorization Act for Fiscal  Year 2008. Specifically, we compared the departments’ interoperability  plans, objectives, and requirements with the reported status of efforts to  achieve full interoperability, corroborating officials’ statements about  progress through analyses of available documentation including test  results and status reports. In addition, we analyzed agency plans and  interviewed cognizant DOD and VA officials to determine the work  required to meet additional clinician requirements and increase  interoperability of electronic health information beyond September 30,  2009.
To determine whether the interagency program office was functioning as a  single point of accountability for developing and implementing electronic  health records, we obtained and reviewed program office documentation,  including its new charter and its integrated master schedule. We compared  the responsibilities identified in the charter with actions taken by the  office to exercise the responsibilities. Additionally, we interviewed  interagency program office officials to determine the status of filling  leadership and staffing positions within the office and to examine the level  to which the departments have addressed our prior recommendations to  develop needed management tools including results-oriented (i.e.,  objective, quantifiable, and measurable) goals and performance measures,  a complete and detailed master schedule, and a project plan.
We conducted this performance audit at DOD offices and the DOD/VA  Interagency Program Office in the greater Washington, D.C., metropolitan  area from September 2009 through January 2010, 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.
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: Comments from the DOD/VA Interagency Program Office
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributions to this report  were made by Mark Bird, Assistant Director; Rebecca Eyler; J. Michael  Resser; and Kelly Shaw.