Computer-Based Patient Records: VA and DOD Made Progress, but Much Work Remains to Fully Share Medical Information
Published: 2005-09-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: For the past 7 years, the Departments of Veterans Affairs (VA) and Defense (DOD) have been working to exchange patient health information electronically and ultimately to have interoperable electronic medical records. Sharing medical information helps (1) promote the seamless transition of active duty personnel to veteran status and (2) ensure that active duty military personnel and veterans receive high-quality health care and assistance in adjudicating their disability claims. This is especially critical in the face of current military responses to national and foreign crises. In testimony before the Veterans' Affairs Subcommittee on Oversight and Investigations in March and May 2004, GAO discussed the progress being made by the departments in this endeavor. In June 2004, at the Subcommittee's request, GAO reported on its review of the departments' progress toward the goal of an electronic two-way exchange of patient health records. GAO is providing an update on the departments' efforts, focusing on (1) the status of ongoing, near-term initiatives to exchange data between the agencies' existing systems and (2) progress in achieving the longer term goal of exchanging data between the departments' new systems.
section_title: What GAO Found
paragraphs: In the past year, VA and DOD have begun to implement applications that exchange limited electronic medical information between the departments' existing health information systems. These applications are (1) Bidirectional Health Information Exchange, a project to achieve the two-way exchange of health information on patients who receive care from both VA and DOD, and (2) Laboratory Data Sharing Interface, an application used to electronically transfer laboratory work orders and results between the departments. The Bidirectional Health Information Exchange application has been implemented at five sites, at which it is being used to rapidly exchange information such as pharmacy and allergy data. Also, the Laboratory Data Sharing Interface application has been implemented at six sites, at which it is being used for real-time entry of laboratory orders and retrieval of results. According to the departments, these systems enable lower costs and improved service to patients by saving time and avoiding errors. VA and DOD are continuing with activities to support their longer term goal of sharing health information between their systems, but the goal of two-way electronic exchange of patient records remains far from being realized. Each department is developing its own modern health information system--VA's HealtheVet VistA and DOD's Composite Health Care System II--and they have taken steps to respond to GAO's June 2004 recommendations regarding the program to develop an electronic interface that will enable these systems to share information. That is, they have developed an architecture for the interface, established project accountability, and implemented a joint project management structure. However, they have not yet developed a clearly defined project management plan to guide their efforts, as GAO previously recommended. Further, they have not yet fully populated the repositories that will store the data for their future health systems, and they have experienced delays in their efforts to begin a limited data exchange. Lacking a detailed project management plan increases the risk that the departments will encounter further delays and be unable to deliver the planned capabilities on time and at the cost expected.

section_title: Letter
paragraphs: I am pleased to participate in today’s discussion on the actions  taken by the Departments of Veterans Affairs (VA) and Defense  (DOD) to promote the seamless transition of active duty personnel  to veteran status. Among the two departments’ goals for seamless  transition is to be able to exchange patient health information  electronically and ultimately to have interoperable electronic  medical records. Sharing of medical information is an important tool  to help ensure that active duty military personnel and veterans  receive high-quality health care and assistance in adjudicating their  disability claims—goals that, in the face of current military  responses to national and foreign crises, are more essential than  ever.
For the past 7 years, VA and DOD have been working to achieve  these capabilities, beginning with a joint project in 1998 to develop a  government computer-based patient record. As we have noted in  previous testimony, the departments had achieved a measure of  success in sharing data through the one-way transfer of health  information from DOD to VA health care facilities. However, they  have been severely challenged in their pursuit of the longer term  objective—providing a virtual medical record in which data are  computable. That is, rather than data being provided as text for  viewing only, data would be in a format that the health information  application can act on: for example, providing alerts to clinicians (of  such things as drug allergies) and plotting graphs of changes in vital  signs such as blood pressure. According to the departments, the use  of such computable medical data contributes significantly to the  usefulness of electronic medical records.
As of June 2004, when we last reported on this topic, VA and DOD  were continuing to define the data standards that are essential both  for the exchange of data and for the development of interoperable  electronic medical records. At that time, we identified weaknesses  in the planning and management structure of the departments’  program, and we recommended that the departments take a number  of actions to address these weaknesses.
Also in 2004, in response to a mandate in the Bob Stump National  Defense Authorization Act for Fiscal Year 2003, VA and DOD  initiated information technology demonstration projects focusing on  near-term goals: the exchange of electronic medical information  between the departments’ existing health information systems.  These projects are to help in the evaluation of the feasibility,  advantages, and disadvantages of measures to improve sharing and  coordination of health care and health care resources. The two  demonstration projects (Bidirectional Health Information Exchange  and Laboratory Data Sharing Interface) are interim initiatives that  are separate from the departments’ ongoing long-term efforts in  sharing data and developing health information systems.
At your request, my testimony today will discuss the two  departments’ continued efforts to exchange medical information,  with a specific focus on (1) the status of ongoing, near-term  initiatives to exchange data between the agencies’ existing systems  and (2) progress in achieving the longer term goal of exchanging  data between the departments’ new systems, still in development,  which are to be built around electronic patient health records.
In conducting this work, we reviewed the departments’  documentation describing the two demonstration projects, including  business plans, budget summaries, and project status reports. We  also reviewed documentation identifying the costs that the  departments have incurred in developing technology to support the  sharing of health data, including costs associated with achieving the  one-way transfer of data from DOD to VA health care facilities, and  ongoing projects to develop new health information systems. We did  not audit the reported costs and thus cannot attest to their accuracy  or completeness. We reviewed draft system requirements, design  specifications, and software descriptions for the electronic interface  between the departments’ new health systems. We supplemented  our analyses of the agencies’ documentation with interviews of VA  and DOD officials responsible for key decisions and actions on the  health data-sharing initiatives. In addition, to observe the  Bidirectional Health Information Exchange and Laboratory Data  Sharing Interface capabilities, we conducted site visits to military  treatment facilities and VA medical centers in El Paso and San  Antonio, Texas, and Puget Sound, Washington. We conducted our  work from June through September 2005, in accordance with  generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: In 1998, following a presidential call for VA and DOD to start  developing a “comprehensive, life-long medical record for each  service member,” the two departments began a joint course of  action aimed at achieving the capability to share patient health  information for active duty military personnel and veterans. Their  first initiative, undertaken in that year, was the Government  Computer-Based Patient Record (GCPR) project, whose goal was an  electronic interface that would allow physicians and other  authorized users at VA and DOD health facilities to access data from  any of the other agency’s health information systems. The interface  was expected to compile requested patient information in a virtual  record that could be displayed on a user’s computer screen.
In our reviews of the GCPR project, we determined that the lack of a  lead entity, clear mission, and detailed planning to achieve that  mission made it difficult to monitor progress, identify project risks,  and develop appropriate contingency plans. In April 2001 and in  June 2002, we made recommendations to help strengthen the  management and oversight of the project. In 2001, we recommended  that the participating agencies (1) designate a lead entity with final  decision-making authority and establish a clear line of authority for  the GCPR project and (2) create comprehensive and coordinated  plans that included an agreed-upon mission and clear goals,  objectives, and performance measures, to ensure that the agencies  could share comprehensive, meaningful, accurate, and secure  patient health care data. In 2002, we recommended that the  participating agencies revise the original goals and objectives of the  project to align with their current strategy, commit the executive  support necessary to adequately manage the project, and ensure  that it followed sound project management principles.
VA and DOD took specific measures in response to our  recommendations for enhancing overall management and  accountability of the project. By July 2002, VA and DOD had revised  their strategy and had made progress toward being able to  electronically share patient health data. The two departments had  refocused the project and named it the Federal Health Information  Exchange (FHIE) program and, consistent with our prior  recommendation, had finalized a memorandum of agreement  designating VA as the lead entity for implementing the program. This  agreement also established FHIE as a joint activity that would allow  the exchange of health care information in two phases.  ●  The first phase, completed in mid-July 2002, enabled the one-way  transfer of data from DOD’s existing health information system (the  Composite Health Care System, CHCS) to a separate database that  VA clinicians could access.   ●  A second phase, finalized in March 2004, completed VA’s and DOD’s  efforts to add to the base of patient health information available to  VA clinicians via this one-way sharing capability.
According to the December 2004 VA/DOD Joint Executive Council  Annual Report, FHIE was fully operational, and VA providers at all  VA medical centers and clinics nationwide had access to data on  separated service members. According to the report, the FHIE data  repository at that time contained historical clinical health data on  2.3 million unique patients from 1989 on, and the repository made a  significant contribution to the delivery and continuity of care and  adjudication of disability claims of separated service members as  they transitioned to veteran status. The departments reported total  GCPR/FHIE costs of about $85 million through fiscal year 2003.
In addition, officials stated that in December 2004, the departments  began to use the FHIE framework to transfer pre- and  postdeployment health assessment data from DOD to VA. According  to these officials, VA has now received about 400,000 of these  records.
However, not all DOD medical information is captured in CHCS. For  example, according to DOD officials, as of September 6, 2005, 1.7  million patient stay records were stored in the Clinical Information  System (a commercial product customized for DOD). In addition,  many Air Force facilities use a system called the Integrated Clinical  Database for their medical information.
The revised DOD/VA strategy also envisioned achieving a longer  term, two-way exchange of health information between DOD and  VA, which may also address systems outside of CHCS. Known as  HealthePeople (Federal), this initiative is premised on the  departments’ development of a common health information  architecture comprising standardized data, communications,  security, and high-performance health information systems. The  joint effort is expected to result in the secured sharing of health data  between the new systems that each department is currently  developing and beginning to implement—VA’s HealtheVet VistA and  DOD’s CHCS II.  ●  DOD began developing CHCS II in 1997 and had completed a key  component for the planned electronic interface—its Clinical Data  Repository. When we last reported in June 2004, the department  expected to complete deployment of all of its major system  capabilities by September 2008. DOD reported expenditures of  about $600 million for the system through fiscal year 2004.   ●  VA began work on HealtheVet VistA and its associated Health Data  Repository in 2001 and expected to complete all six initiatives  comprising this system in 2012. VA reported spending about $270  million on initiatives that comprise HealtheVet VistA through fiscal  year 2004.
Under the HealthePeople (Federal) initiative, VA and DOD envision  that, on entering military service, a health record for the service  member would be created and stored in DOD’s Clinical Data  Repository. The record would be updated as the service member  receives medical care. When the individual separated from active  duty and, if eligible, sought medical care at a VA facility, VA would  then create a medical record for the individual, which would be  stored in its Health Data Repository. On viewing the medical record,  the VA clinician would be alerted and provided with access to the  individual’s clinical information residing in DOD’s repository. In the  same manner, when a veteran sought medical care at a military  treatment facility, the attending DOD clinician would be alerted and  provided with access to the health information in VA’s repository.  According to the departments, this planned approach would make  virtual medical records displaying all available patient health  information from the two repositories accessible to both  departments’ clinicians.
To achieve this goal requires the departments to be able to exchange  computable health information between the data repositories for  their future health systems: that is, VA’s Health Data Repository (a  component of HealtheVet VistA) and DOD’s Clinical Data Repository  (a component of CHCS II). In March 2004, the departments began an  effort to develop an interface linking these two repositories, known  as CHDR (a name derived from the abbreviations for DOD’s Clinical  Data Repository—CDR—and VA’s Health Data Repository—HDR).  According to the departments, they planned to be able to exchange  selected health information through CHDR by October 2005.  Developing the two repositories, populating them with data, and  linking them through the CHDR interface would be important steps  toward the two departments’ long-term goals as envisioned in  HealthePeople (Federal). Achieving these goals would then depend  on completing the development and deployment of the associated  health information systems—HealtheVet VistA and CHCS II.
In our most recent review of the CHDR program, issued in June  2004, we reported that the efforts of DOD and VA in this area  demonstrated a number of management weaknesses. Among these  were the lack of a well-defined architecture for describing the  interface for a common health information exchange; an established  project management lead entity and structure to guide the  investment in the interface and its implementation; and a project  management plan defining the technical and managerial processes  necessary to satisfy project requirements. With these critical  components missing, VA and DOD increased the risk that they  would not achieve their goals. Accordingly, we recommended that  the departments  ●  develop an architecture for the electronic interface between their  health systems that includes system requirements, design  specifications, and software descriptions;  ●  select a lead entity with final decision-making authority for the  ●  establish a project management structure to provide day-to-day  guidance of and accountability for their investments in and  implementation of the interface capability; and  ●  create and implement a comprehensive and coordinated project  management plan for the electronic interface that defines the  technical and managerial processes necessary to satisfy project  requirements and includes (1) the authority and responsibility of  each organizational unit; (2) a work breakdown structure for all  of the tasks to be performed in developing, testing, and  implementing the software, along with schedules associated with  the tasks; and (3) a security policy.
Besides pursuing their long-term goals for future systems through  the HealthePeople (Federal) strategy, the departments are working  on two demonstration projects that focus on exchanging  information between existing systems: (1) Bidirectional Health  Information Exchange, a project to exchange health information on  shared patients, and (2) Laboratory Data Sharing Interface, an  application used to transfer laboratory work orders and results.  These demonstration projects were planned in response to  provisions of the Bob Stump National Defense Authorization Act of  2003, which mandated that VA and DOD conduct demonstration  projects that included medical information and information  technology systems to be used as a test for evaluating the feasibility,  advantages, and disadvantages of measures and programs designed  to improve the sharing and coordination of health care and health  care resources between the departments.
Figure 1 is a time line showing initiation points for the VA and DOD  efforts discussed here, including strategies, major programs, and the  recent demonstration projects.
section_title: VA and DOD Are Exchanging Limited Medical Information between Existing Health Systems
paragraphs: VA and DOD have begun to implement applications developed under  two demonstration projects that focus on the exchange of electronic  medical information. The first—the Bidirectional Health Information  Exchange—has been implemented at five VA/DOD locations and the  second—Laboratory Data Sharing Interface—has been implemented  at six VA/DOD locations.
subsections: section_title: Bidirectional Health Information Exchange
paragraphs: According to a VA/DOD annual report and program officials,  Bidirectional Health Information Exchange (BHIE) is an interim  step in the departments’ overall strategy to create a two-way  exchange of electronic medical records. BHIE builds on the  architecture and framework of FHIE, the current application used to  transfer health data on separated service members from DOD to VA.  As discussed earlier, FHIE provides an interface between VA’s and  DOD’s current health information systems that allows one-way  transfers only, which do not occur in real time: VA clinicians do not  have access to transferred information until about 6 weeks after  separation. In contrast, BHIE focuses on the two-way, near-real-time  exchange of information (text only) on shared patients (such as  those at sites jointly occupied by VA and DOD facilities). This  application exchanges data between VA’s VistA system and DOD’s  CHCS system (and CHCS II where implemented). To date, the  departments reported having spent $2.6 million on BHIE.
The primary benefit of BHIE is the near-real-time access to patient  medical information for both VA and DOD, which is not available  through FHIE. During a site visit to a VA and DOD location in Puget  Sound, we viewed a demonstration of this capability and were told  by a VA clinician that the near-real-time access to medical  information has been very beneficial in treating shared patients.
As of August 2005, BHIE was tested and deployed at VA and DOD  facilities in Puget Sound, Washington, and El Paso, Texas, where the  exchange of demographic, outpatient pharmacy, radiology,  laboratory, and allergy data (text only) has been achieved. The  application has also been deployed to three other locations this  month (see table 1). According to the program manager, a plan to  export BHIE to additional locations has been approved. The  additional locations were selected based on a number of factors,  including the number and types of VA and DOD medical facilities in  the area, FHIE usage, and retiree population at the locations. The  program manager stated that implementation of BHIE requires  training of staff from both departments. In addition, implementation  at DOD facilities requires installation of a server; implementation at  VA facilities requires installation of a software patch (downloaded  from a VA computer center), but no additional equipment. As shown  in table 1, five additional implementations are scheduled for the first  quarter of fiscal year 2006.
Additionally, because DOD stores electronic medical information in  systems other than CHCS (such as the Clinical Information System  and the Integrated Clinical Database), work is currently under way  to allow BHIE to have the ability to exchange information with  those systems. The Puget Sound Demonstration site is also working  on sharing consultation reports stored in the VA and DOD systems.
section_title: Laboratory Data Sharing Interface
paragraphs: The Laboratory Data Sharing Interface (LDSI) initiative enables the  two departments to share laboratory resources. Through LDSI, a VA  provider can use VA’s health information system to write an order  for laboratory tests, and that order is electronically transferred to  DOD, which performs the test. The results of the laboratory tests are  electronically transferred back to VA and included in the patient’s  medical record. Similarly, a DOD provider can choose to use a VA  lab for testing and receive the results electronically. Once LDSI is  fully implemented at a facility, the only nonautomated action in  performing laboratory tests is the transport of the specimens.
Among the benefits of LDSI is increased speed in receiving  laboratory results and decreased errors from multiple entry of  orders. However, according to the LDSI project manager in San  Antonio, a primary benefit of the project will be the time saved by  eliminating the need to rekey orders at processing labs to input the  information into the laboratories’ systems. Additionally, the San  Antonio VA facility will no longer have to contract out some of its  laboratory work to private companies, but instead use the DOD  laboratory. To date, the departments reported having spent about  $3.3 million on LDSI.
An early version of what is now LDSI was originally tested and  implemented at a joint VA and DOD medical facility in Hawaii in  May 2003. The demonstration project built on this application and  enhanced it; the resulting application was tested in San Antonio and  El Paso. It has now been deployed to six sites in all. According to  the departments, a plan to export LDSI to additional locations has  been approved. Table 2 shows the locations at which it has been or  is to be implemented.
section_title: VA and DOD Are Taking Actions to Achieve a Virtual Medical Record, but Much Work Remains
paragraphs: Besides the near-term initiatives just discussed, VA and DOD  continue their efforts on the longer term goal: to achieve a virtual  medical record based on the two-way exchange of computable data  between the health information systems that each is currently  developing. The cornerstone for this exchange is CHDR, the planned  electronic interface between the data repositories for the new  systems.
The departments have taken important actions on the CHDR  initiative. In September 2004 they successfully completed Phase I of  CHDR by demonstrating the two-way exchange of pharmacy  information with a prototype in a controlled laboratory  environment. According to department officials, the pharmacy  prototype provided invaluable insight into each other’s data  repository systems, architecture, and the work that is necessary to  support the exchange of computable information. These officials  stated that lessons learned from the development of the prototype  were documented and are being applied to Phase II of CHDR, the  production phase, which is to implement the two-way exchange of  patient health records between the departments’ data repositories.  Further, the same DOD and VA teams that developed the prototype  are now developing the production version.
In addition, the departments developed an architecture for the  CHDR electronic interface, as we recommended in June 2004. The  architecture for CHDR includes major elements required in a  complete architecture. For example, it defines system requirements  and allows these to be traced to the functional requirements, it  includes the design and control specifications for the interface  design, and it includes design descriptions for the software.
Also in response to our recommendations, the departments have  established project accountability and implemented a joint project  management structure. Specifically, the Health Executive Council  has been established as the lead entity for the project. The joint  project management structure consists of a Program Manager from  VA and a Deputy Program Manager from DOD to provide day-to-day  guidance for this initiative. Additionally, the Health Executive  Council established the DOD/VA Information  Management/Information Technology Working Group and the  DOD/VA Health Architecture Interagency Group, to provide  programmatic oversight and to facilitate interagency collaboration  on sharing initiatives between DOD and VA.
To build on these actions and successfully carry out the CHDR  initiative, however, the departments still have a number of  challenges to overcome. The success of CHDR will depend on the  departments’ instituting a highly disciplined approach to the  project’s management. Industry best practices and information  technology project management principles stress the importance of  accountability and sound planning for any project, particularly an  interagency effort of the magnitude and complexity of this one. We  recommended in 2004 that the departments develop a clearly  defined project management plan that describes the technical and  managerial processes necessary to satisfy project requirements and  includes (1) the authority and responsibility of each organizational  unit; (2) a work breakdown structure for all of the tasks to be  performed in developing, testing, and implementing the software,  along with schedules associated with the tasks; and (3) a security  policy. Currently, the departments have an interagency project  management plan that provides the program management principles  and procedures to be followed by the project. However, the plan  does not specify the authority and responsibility of organizational  units for particular tasks; the work breakdown structure is at a high  level and lacks detail on specific tasks and time frames; and security  policy is still being drafted. Without a plan of sufficient detail, VA  and DOD increase the risk that the CHDR project will not deliver the  planned capabilities in the time and at the cost expected.
In addition, officials now acknowledge that they will not meet a  previously established milestone: by October 2005, the departments  had planned to be able to exchange outpatient pharmacy data,  laboratory results, allergy information, and patient demographic  information on a limited basis. However, according to officials, the  work required to implement standards for pharmacy and medication  allergy data was more complex than originally anticipated and led to  the delay. They stated that the schedule for CHDR is presently being  revised. Development and data quality testing must be completed  and the results reviewed. The new target date for medication  allergy, outpatient pharmacy, and patient demographic data  exchange is now February 2006.
Finally, the health information currently in the data repositories has  various limitations.   ●  Although DOD’s Clinical Data Repository includes data in the  categories that were to be exchanged at the missed milestone  described above: outpatient pharmacy data, laboratory results,  allergy information, and patient demographic information, these  data are not yet complete. First, the information in the Clinical Data  Repository is limited to those locations that have implemented the  first increment of CHCS II, DOD’s new health information system.  As of September 9, 2005, according to DOD officials, 64 of 139  medical treatment facilities worldwide have implemented this  increment. Second, at present, health information in systems other  than CHCS (such as the Clinical Information System and the  Integrated Clinical Database) is not yet being captured in the  Clinical Data Repository. For example, according to DOD officials,  as of September 9, 2005, the Clinical Information System contained  1.7 million patient stay records.   ●  The information in VA’s Health Data Repository is also limited:  although all VA medical records are currently electronic, VA has to  convert these into the interoperable format appropriate for the  Health Data Repository. So far, the data in the Health Data  Repository consist of patient demographics and vital signs records  for the 6 million veterans who have electronic medical records in  VA’s current system, VistA (this system contains all the department’s  medical records in electronic form). VA officials told us that they  plan next to sequentially convert allergy information, outpatient  pharmacy data, and lab results for the limited exchange that is now  planned for February 2006.
In summary, developing an electronic interface that will enable VA  and DOD to exchange computable patient medical records is a  highly complex undertaking that could lead to substantial benefits— improving the quality of health care and disability claims processing  for the nation’s military members and veterans. VA and DOD have  made progress in the electronic sharing of patient health data in  their limited, near-term demonstration projects, and have taken an  important step toward their long-term goals by improving the  management of the CHDR program. However, the departments face  considerable work and significant challenges before they can  achieve these long-term goals. While the departments have made  progress in developing a project management plan defining the  technical and managerial processes necessary to satisfy project  requirements, this plan does not specify the authority and  responsibility of organizational units for particular tasks, the work  breakdown structure lacks detail on specific tasks and time frames,  and security policy has not yet been finalized. Without a project  management plan of sufficient specificity, the departments risk  further delays in their schedule and continuing to invest in a  capability that could fall short of expectations.
Mr. Chairman, this concludes my statement. I would be pleased to  respond to any questions that you or other members of the  Committee may have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For information about this testimony, please contact Linda D.  Koontz, Director, Information Management Issues, at (202) 512-6240  or at koontzl@gao.gov. Other individuals making key contributions  to this testimony include Nabajyoti Barkakati, Barbara S. Collier,  Nancy E. Glover, James T. MacAulay, Barbara S. Oliver, J. Michael  Resser, and Eric L. Trout.
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