Electronic Health Records: DOD and VA Have Increased Their Sharing of Health Information, but More Work Remains
Published: 2008-07-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Under the National Defense Authorization Act for Fiscal Year 2008, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) are required to accelerate the exchange of health information between the departments and to develop systems or capabilities that allow for full interoperability (generally, the ability of systems to use data that are exchanged) and that are compliant with federal standards. The act also established a joint interagency program office to act as a single point of accountability for the effort, whose function is to implement such systems or capabilities by September 30, 2009. Further, the act required that GAO semi-annually report on the progress made in achieving these goals. For this first report, GAO describes the departments' progress to date in sharing electronic health information, developing electronic health records that comply with federal standards, and setting up the joint interagency program office. To do so, GAO reviewed its past work, analyzed agency documentation, and conducted interviews with agency officials.
section_title: What GAO Found
paragraphs: DOD and VA are sharing some, but not all, electronic health information at different levels of interoperability. Specifically, pharmacy and drug allergy data on about 18,300 patients who receive care from both departments are exchanged at the highest level of interoperability--that is, in computable form; at this level, the data are in a standardized format that a computer application can act on (for example, to provide alerts to clinicians of drug allergies). In other cases, data can be viewed only--a lower level of interoperability that still provides clinicians with important information. However, not all electronic health information is yet shared, and information is still captured on paper at many DOD medical facilities. According to the departments, a DOD/VA Information Interoperability Plan (targeted for approval in August 2008) is to address these and other issues and define tasks required to guide the development and implementation of an interoperable electronic health record capability. If properly developed and implemented, the plan could help the departments achieve the goal of seamless sharing of health information. DOD and VA have agreed upon numerous common standards that allow them to share health data, which include standards that are part of current and emerging federal interoperability specifications. This collaboration provided the essential foundation for the departments to begin sharing computable health data. The departments are currently participating in recent initiatives led by the Office of the National Coordinator for Health Information Technology (within the Department of Health and Human Services) that are aimed at promoting the adoption of federal standards and broader use of electronic health records. These initiatives include identifying relevant existing standards, identifying and addressing overlaps and gaps in the standards, and developing interoperability specifications and certification criteria based on these standards. The involvement of the departments in these activities is an important mechanism for aligning their electronic health records with emerging federal standards. In establishing the joint interagency program office, Congress directed the departments to develop an implementation plan for setting up the office and carrying out related activities (such as validating and establishing requirements for interoperable health capabilities). The departments' effort to set up the program office is still in its early stages. Leadership positions in the office are not yet permanently filled, staffing is not complete, and facilities to house the office have not been designated. Further, the implementation plan is currently in draft, and although it includes schedules and milestones, dates for several activities have not yet been determined (such as implementing a capability to share immunization records), even though all capabilities are to be achieved by September 2009. Without a fully established program office and a finalized implementation plan with set milestones, the departments may be challenged in meeting the required date for achieving interoperable electronic health records and capabilities.

section_title: Letter
paragraphs: For the last decade, the Department of Defense (DOD) and the  Department of Veterans Affairs (VA) have been pursuing initiatives to  share data between their health information systems. The departments’  efforts have included working toward a long-term vision of a single  “comprehensive, lifelong medical record” that would allow each service  member to transition seamlessly between the two departments, as well as  more short-term efforts focused on meeting immediate needs to share  health information, including responding to current military crises.
However, the two departments cannot yet share all essential health  information, prompting continuing calls for progress in this area. In May  2003, a presidential task force recommended that DOD and VA develop  and deploy bidirectional electronic health records by fiscal year 2005. In  July 2007, the President’s Commission on Care for America’s Returning  Wounded Warriors reported that the departments had continued to  develop independent, stand-alone systems and recommended that the two  departments move rapidly to make all essential health information  available to clinicians.
To expedite the departments’ efforts to exchange health care information,  Congress included in the National Defense Authorization Act for Fiscal  Year 2008 provisions that DOD and VA jointly develop and implement  electronic health record systems or capabilities and accelerate the  exchange of health care information. The act also required that these  systems or capabilities be compliant with applicable interoperability  standards, implementation specifications, and certification criteria of the  federal government. The act established a joint interagency program office  to act as a single point of accountability for the effort, with the function of  implementing, by September 30, 2009, electronic health record systems or  capabilities that allow for full interoperability of personal health care  information between the departments.
In addition, the act required that GAO semi-annually report on the  progress that DOD and VA have made in achieving the goal of fully  interoperable personal health care information. As agreed with the  committees of jurisdiction, our objectives for this first report are to  describe (1) the departments’ progress to date on developing electronic  health records systems or capabilities that allow for full interoperability of  personal health care information between the departments; (2) steps taken  by the departments to ensure that their health records comply with  applicable interoperability standards, implementation specifications, and  certification criteria of the federal government; and (3) efforts to set up  the joint interagency program office.
To carry out these objectives, we reviewed our past work in this area;  analyzed agency documentation (including schedules and benchmarks for  the establishment of the joint interagency program office, program  documents, and health information standards); and conducted interviews  with officials from DOD, VA, and the Department of Health and Human  Services’ Office of the National Coordinator for Health Information  Technology. We also visited two medical sites (Walter Reed Army Medical  Center and the Washington, D.C., VA Medical Center) to observe the  sharing capabilities of the electronic health information systems that are  currently in place.
We conducted this performance audit from March 2008 through July 2008  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: As we have reported, 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 critical to improving the  performance of the U.S. health care system. Critical health information for  a patient seeking treatment (such as allergies, current treatments or  medications, and prior diagnoses) has, historically, 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  makes it challenging for a clinician to make the most informed decisions  on treatment options, potentially putting the patient’s health at greater  risk. The use of electronic health records can help provide this access and  improve clinical decisions.
Electronic health records are particularly crucial for optimizing the health  care provided to military personnel and veterans. While in military status  and later as veterans, many DOD and VA patients tend to be highly mobile  and may have health records residing at multiple medical facilities within  and outside the United States. Making such records electronic can help  ensure that complete health care information is available for most military  service members and veterans at the time and place of care, no matter  where it originates.
Key to making health care information electronically available is the  ability to share that data among health care providers—that is,  interoperability. Interoperability is the ability for 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.  (Paper-based health records—if available—also provide necessary  information, but unlike electronic health records, paper records do not  provide decision support capabilities, such as automatic alerts about a  particular patient’s health, or other advantages of automation.)
Interoperability can be achieved at different levels. At the highest level,  data are in a format that a computer can understand and operate on,  whereas at the minimum type of interoperability, the data are in a format  that is viewable, so that information is available for a human being to read  and interpret. Figure 1 shows various levels of interoperability and  examples of the types of data that can be shared at each level.
As the figure shows, paper records can be considered interoperable in that  they allow data to be read and interpreted by a human being. In the  remainder of this report, however, we do not discuss interoperability in  this sense; instead, we focus on electronic interoperability, for which the  first level of interoperability is unstructured, viewable electronic data.  With unstructured data, a clinician would have to find needed or relevant  information by scanning uncategorized information. The value of viewable  data is increased if the data are structured so that information is  categorized and easier to find. At the highest level, as shown, the computer  can interpret and act on the data.
Not all data require the same level of interoperability. For example, in  their initial efforts to implement computable data, VA and DOD focused on  outpatient pharmacy and drug allergy data because clinicians gave priority  to the need for automated alerts to help medical personnel avoid  administering inappropriate drugs to patients. On the other hand, for such  narrative data as clinical notes, viewability may be sufficient. Achieving  even a minimal level of interoperability is valuable for potentially making  all relevant information available to clinicians.
subsections: section_title: Efforts to Adopt and Implement Federal Interoperability Standards Are Ongoing
paragraphs: Any type of interoperability depends on the use of agreed-upon standards  to ensure that information can be shared and used. In health IT, standards  govern areas ranging from technical issues, such as file types and  interchange systems, to content issues, such as medical terminology.  Developing, coordinating, and agreeing on standards are only part of the  processes involved in achieving interoperability for electronic health  records systems or capabilities. In addition, specifications are needed for  implementing the standards, as well as criteria and a process for verifying  compliance with the standards.
In December 2001, an effort to establish federal health information  standards was initiated as an Office of Management and Budget (OMB) e- government project to enable federal agencies to build interoperable  health data systems. This project, the Consolidated Health Informatics  initiative, was a collaborative agreement among federal agencies,  including DOD and VA, to adopt a common set of health information  standards for the electronic exchange of clinical health information. Under  the Consolidated Health Informatics initiative, DOD, VA, and other  participating agencies agreed to endorse 20 sets of standards to make it  easier for information to be shared across agencies and to serve as a  model for the private sector. For example, standard medication  terminologies were agreed upon, which DOD and VA then began to adopt  in developing their data repositories.
Recognizing the need for public and private sector collaboration to  achieve a national interoperable health IT infrastructure, the President  issued an executive order in April 2004 that called for widespread  adoption of interoperable electronic health records by 2014. This order  established the Office of the National Coordinator for Health Information  Technology within the Department of Health and Human Services (HHS)  with responsibility, among other things, for developing, maintaining, and  directing the implementation of a strategic plan to guide the nationwide  implementation of interoperable health IT in both the public and private  health care sectors. Among its responsibilities as the chief advisor to the  Secretary of HHS in this area, the Office of the National Coordinator is to  report progress on the implementation of this strategic plan.
Under the direction of HHS (through the Office of the National  Coordinator), three primary organizations were designated to play major  roles in expanding the implementation of health IT:  the American Health Information Community,  the Healthcare Information Technology Standards Panel, and the Certification Commission for Healthcare Information Technology.
All three are involved in various processes related to electronic health  records interoperability standards. The functions of these organizations  are described in the following.
subsections: section_title: American Health Information Community
paragraphs: The community is a federal advisory body created by the Secretary of HHS  to make recommendations on how to accelerate the development and  adoption of health IT, including advancing interoperability, identifying  health IT standards, advancing nationwide health information exchange,  and protecting personal health information. Formed in September 2005,  the community is made up of representatives from both the public and  private sectors.
The American Health Information Community determines specific health  care areas of high priority and develops “use cases” for these areas,  which provide the context in which standards would be applicable. For  example, the community has developed a use case regarding the creation  of standardized, secure records of past and current laboratory test results  for access by health professionals. The use case conveys how health care  professionals would use such records and what standards would apply.
section_title: Healthcare Information Technology Standards Panel (HITSP)
paragraphs: Developed in October 2005, the Healthcare Information Technology  Standards Panel (HITSP) is a public-private partnership, sponsored by the  American National Standards Institute and funded by the Office of the  National Coordinator. (HITSP is the successor to the Consolidated Health  Informatics initiative, which was dissolved and absorbed into the panel on  September 30, 2006.) The panel was established to identify competing  standards for the use cases developed by the American Health Information  Community and “harmonize” the standards. (Harmonization is the process  of identifying overlaps and gaps in relevant standards and developing  recommendations to address these overlaps and gaps.)
For example, for the three initial use cases developed by the American  Health Information Community, HITSP identified competing standards by  converting the use cases into detailed requirements documents; it then  examined and assessed more than 700 existing standards that would meet  those requirements. From those 700 standards, the panel identified 30  named standards and produced detailed implementation guidance  describing the specific transactions and use of these named standards.  This guidance is codified in an interoperability specification for each use  case that integrates the standards.
Each of the interoperability specifications developed by HITSP includes  references to the identified standards or parts of standards and explains  how they should be applied to specific topics. For example, among the  standards referred to in one interoperability specification is the  Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT).  This standard is to be used in the “Lab Result Terminology Component” of  the specification.
Once developed, the specifications are presented to the American Health  Information Community, which assesses them for recommendation to the  Secretary of HHS. The Secretary publicly “accepts” recommended  specifications for a 1-year period of implementation testing, after which  the Secretary can formally “recognize” the specifications and associated  guidance as interoperability standards. This two-step process is intended  to ensure that software developers have adequate time to implement  recognized standards in their software. The year between acceptance and  recognition allows the panel to refine its implementation guidance based  on feedback from actual software implementation.
Table 1 shows the current status of the interoperability specifications  developed by HITSP.
Each of the interoperability specifications in the table is associated with  one of the seven use cases developed by the American Health Information  Community in 2006 and 2007. The community is also developing six use  cases for 2008, for which interoperability specifications have not yet been  released:    Consultation and Transfers of Care,    Public Health Case Reporting, and  Immunizations & Response Management.
section_title: Certification Commission for Healthcare Information Technology
paragraphs: The commission is an independent, nonprofit organization that certifies  health IT products. HHS entered into a contract with the commission in  October 2005 to develop and evaluate the certification criteria and  inspection process for electronic health records. According to HHS,  certification is to be the process by which the IT systems of federal health  contractors are established to meet federal interoperability standards.  Certification helps assure purchasers and other users of health IT systems  that the systems will provide needed capabilities (including ensuring  security and confidentiality) and will work with other systems without  reprogramming. Certification also encourages adoption of health IT by  assuring providers that their systems can participate in nationwide health  information exchange in the future. In 2006, the commission certified the  first 37 ambulatory—or clinician office-based—electronic health record  products as meeting baseline criteria for functionality, security, and  interoperability. In 2007, the commission expanded certification to  inpatient—or hospital—electronic health record products, which could  significantly increase patients’ and providers’ access to the health  information generated during a hospitalization. To date, the commission  has certified over 100 electronic health record products.
section_title: Our Previous Work Has Emphasized the Importance of a National Strategy
paragraphs: Since 2005, we have reported and testified on the various actions that HHS  and the Office of the National Coordinator have taken to advance  nationwide implementation of health IT, which include the establishment  of the American Health Information Community and related activities,  selection of initial standards to address specific health areas, and the  release in July 2004 of a framework for strategic action. We pointed out in  2005 that this framework did not constitute a comprehensive national  strategy with detailed plans, milestones, and performance measures  needed to ensure that the outcomes of the department’s various initiatives  are integrated and its goals are met. As a result, we recommend that HHS  establish detailed plans and milestones for each phase of the framework  for strategic action and take steps to ensure that those plans are followed  and milestones met.
In this regard, in June 2008, the Office of the National Coordinator  released a four-year strategic plan. Although we have not yet fully assessed  this plan, if its milestones and measures for achieving an interoperable  national infrastructure for health IT are appropriate, the plan could  provide a useful roadmap to support the goal of widespread adoption of  interoperable electronic health records.
section_title: DOD and VA Have Been Pursuing Efforts to Exchange Health Information for a Decade
paragraphs: DOD and VA have been working to exchange patient health data  electronically since 1998. However, the departments have faced  considerable challenges in project planning and management, leading to  repeated changes in the focus of their initiatives and target completion  dates. In reviews in 2001 and 2002, we noted management weaknesses,  such as inadequate accountability and poor planning and oversight, and  recommended that the departments apply principles of sound project  management. In response, by July 2002, DOD and VA had revised their  strategy to pursue two initiatives: (1) sharing information in existing  systems and (2) developing modernized health information systems— replacing their existing (legacy) systems—that would be able to share data  and, ultimately, use interoperable electronic health records.
In their shorter-term initiatives to share information from existing systems,  the departments began from different positions. VA has one integrated  medical information system—the Veterans Health Information Systems  and Technology Architecture (VistA)—which uses all electronic records  and was developed in-house by VA clinicians and IT personnel. All VA  medical facilities have access to all VistA information.
In contrast, DOD uses multiple legacy medical information systems (table  1 illustrates selected systems), all of which are commercial software  products that are customized for specific uses. Until recently, these  systems could not share information. In addition, not all of DOD’s medical  information is electronic: certain records are paper-based.
As we have reported, the departments’ efforts to share information in  their existing systems eventually included several sharing initiatives and  exchange projects:    The Federal Health Information Exchange (FHIE), completed in 2004,  enabled DOD to electronically transfer service members’ electronic health  information to VA when the members left active duty.
The Laboratory Data Sharing Interface (LDSI), a project established in  2004, allows DOD and VA facilities to share laboratory resources. This  interface, now deployed at nine locations, allows the departments to  communicate orders for lab tests and their results electronically.
The Bidirectional Health Information Exchange (BHIE), also established  in 2004, was aimed at allowing clinicians at both departments viewable  access to records 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).
Another benefit of the interface is that it allows DOD sites to see  previously inaccessible data at other DOD sites.
In the long term, each of the departments aims to develop a modernized  system in the context of a common health information architecture that  would allow a two-way exchange of health information. The common  architecture is to include standardized, computable data; communications;  security; and high-performance health information systems: DOD’s Armed  Forces Health Longitudinal Technology Application (AHLTA) and VA’s  HealtheVet. The departments’ modernized systems are to store  information (in standardized, computable form) in separate data  repositories: DOD’s Clinical Data Repository (CDR) and VA’s Health Data  Repository (HDR). For the two-way exchange of health information, the  two repositories are to be linked through an interface named CHDR,  which the departments began to develop in March 2004; implementation of  the first release of the interface (at one site) occurred in September 2006.
Beyond these initiatives, in January 2007, the departments announced a  further change to their information-sharing strategy: their intention to  jointly determine an approach for inpatient health records. On July 31,  2007, they awarded a contract for a feasibility study and exploration of  alternatives. According to the departments, one of the options would be  adopting a joint solution, which would be expected to facilitate the  seamless transition of active-duty service members to veteran status, and  make inpatient health care data on shared patients more readily accessible  to both DOD and VA. In addition, the departments believe that a joint  development effort could enable them to realize cost savings; however, no  decision on a joint system has yet been made. According to the  departments, they expect to receive recommendations on possible  approaches at the end of July 2008.
In our previous work (see Related GAO Products), we pointed out that in  view of the many tasks and challenges associated with the departments’  long-term goal of seamless sharing of health information, it was essential  that the departments develop a comprehensive project plan to guide these  efforts to completion. Accordingly, in 2004, we recommended that the  departments develop such a plan for the CHDR interface and that it  include a work breakdown structure and schedule for all development,  testing, and implementation tasks. Subsequently, the departments began  work on the short-term initiatives described, and we raised concerns  regarding how all these initiatives were to be incorporated into an overall  strategy toward achieving the departments’ goal of a comprehensive,  seamless exchange of health information.
In response to our concerns, the departments began to develop such a  comprehensive plan, which they called the DOD/VA Information  Interoperability Plan. To provide input to the plan and determine  priorities, in December 2007, the departments established the Joint  Clinical Information Board, made up of senior clinical leaders from both  departments. The board is responsible for establishing clinical priorities  for electronic data sharing between the departments, determining  essential health information to be shared, and further identifying and  prioritizing data that should be viewable and data that should be  computable.
The departments produced a draft DOD/VA Information Interoperability  Plan in March 2008. According to DOD and VA officials, the draft defines  the technical and managerial processes necessary to satisfy the  departments’ requirements and guide their activities to completion.  According to these officials, review of this draft by senior DOD and VA  officials is currently ongoing and is scheduled to be completed by August  2008.
section_title: DOD and VA Are Currently Sharing Health Information at Different Levels of Interoperability, but More Work Remains to Share All Health Information
paragraphs: DOD and VA have established and implemented mechanisms for  electronic sharing of health information, some of which is exchanged in  computable form, while other information is viewable only. However, not  all electronic health information is yet shared (for example, immunization  records and history, data on exposure to health hazards, and psychological  health treatment and care records). Further, although VA’s health  information is all captured electronically, not all health data collected by  DOD are electronic—many DOD medical facilities use paper-based health  records.
Computable data. Data in computable form are exchanged through the  CHDR interface, which links the modernized health data repositories for  the new systems that each department is developing. Implementing the  interface required the departments to agree on standards for various types  of data, put the data into the agreed standard formats, and populate the  repositories with the standardized data. Currently, the types of  computable health data being exchanged are limited to outpatient  pharmacy and drug allergy data. The next type of data to be standardized,  included in the repositories, and exchanged is laboratory data.
These data are not shared for all patients—only those who are seen at  both DOD and VA medical facilities, identified as shared patients, and then  “activated.” Once a patient is activated, all DOD and VA sites can access  information on that patient and receive alerts on allergies and drug  interactions for that patient. According to DOD and VA officials, outpatient  pharmacy and drug allergy data were being exchanged on more than  18,300 shared patients as of June 2008; however, officials stated that they  are unable to track the number of shared patients currently receiving care  from both departments, so the number of patients for whom data could  potentially be shared is unknown.
Viewable data. Data in viewable form are shared through the BHIE  interface. Through BHIE, clinicians can query selected health information  on patients from all VA and DOD sites and view current data onscreen  almost immediately. Because the BHIE interface provides access to up-to- date information, the departments’ clinicians expressed strong interest in  expanding its use. As a result, the departments decided to broaden the  capability and expand its implementation. For example, the departments  completed a BHIE interface with DOD’s Clinical Data Repository in July  2007, and they began sharing viewable patient vital signs information  through BHIE in June 2008. Extending BHIE connectivity could provide  both departments with the ability to view additional data in DOD’s legacy  systems, until such time as the departments’ modernized systems are fully  developed and implemented. According to a DOD/VA annual report and  program officials, the departments now consider BHIE an interim step in  their overall strategy to create a two-way exchange of electronic health  records.
Table 1 summarizes the types of health data currently shared via the  departments’ various initiatives (including FHIE and LDSI), as well as  additional types of data that are currently planned for sharing.
As depicted in table 3, DOD and VA are sharing or plan to share a wide  range of health information; however, other health information that the  departments currently capture has not yet been addressed (for example,  immunization records and history and data on exposure to health  hazards). Further, although VA’s health information is all captured  electronically, many DOD medical facilities continue to rely on paper  records. Also, clinical encounters for those enrolled in the military’s  TRICARE health care program are not captured in DOD’s electronic  health system unless care is received at a military treatment facility.
According to the departments’ officials, the DOD/VA Information  Interoperability Plan (targeted for approval in August 2008) is to address  these and other issues and define tasks required to guide the development  and implementation of interoperable, bidirectional, and standards-based  electronic health records and capabilities for military and veteran  beneficiaries. DOD and VA are in the process of finalizing the plan, and we  have not yet performed an assessment. However, if it includes the  essential elements needed to guide the departments in achieving their  long-term goal of seamless sharing of health information, it could improve  the prospects for the successful achievement of this goal.
section_title: DOD and VA Have Adopted Standards to Allow Sharing and Are Taking Steps to Follow Federal Standards, Which Continue to Evolve
paragraphs: DOD and VA have agreed upon numerous common standards that allow  them to share health data, which include standards that are part of current  and emerging federal interoperability specifications. The foundation built  by this collaborative process has allowed DOD and VA to begin sharing  computable health data (the highest level of interoperability). Continuing  their historical involvement in efforts to agree upon standards for the  electronic exchange of clinical health information, the departments are  also participating in recent ongoing standards-related initiatives led by the  Office of the National Coordinator for Health Information Technology  (within the Department of Health and Human Services). In addition, DOD  is taking steps to arrange for certification of its modernized health  information system (a customized commercial system) against current  standards.
The standards agreed to by the two departments are listed in a jointly  published common set of interoperability standards called the Target  DOD/VA Health Standards Profile. This profile resulted from an effort that  took place beginning in 2001, in which the two departments compared  their individual standards profiles for compatibility and began converging  them. First developed in 2004, the Target Standards Profile is updated  annually and is used for reviewing joint DOD/VA initiatives to ensure  standards compliance. According to the departments, they anticipate  continued updates and revisions to the Target Standards Profile as  additional federal standards emerge and are in varying stages of  recognition and acceptance by HHS (as previously presented in table 1).
The current version of the profile, dated September 2007, includes federal  standards (such as data standards established by the Food and Drug  Administration and security standards established by the National Institute  of Standards and Technology); industry standards (such as wireless  communications standards established by the Institute of Electrical and  Electronics Engineers and Web file sharing standards established by the  American National Standards Institute); and international standards (such  as SNOMED CT, which was mentioned earlier, and security standards  established by the International Organization for Standardization). The  profile also indicates which of these standards support the HHS- recognized use cases and HITSP interoperability specifications. For  example, for clinical data on allergy reactions, the departments agreed to  use SNOMED CT codes (mentioned previously), which are included as  part of HITSP interoperability specifications.
In particular, for the two kinds of data now being exchanged in  computable form through CHDR (pharmacy and allergy data), DOD and  VA adopted National Library of Medicine data standards for medications  and drug allergies, as well as SNOMED CT codes for allergy reactions.  According to officials, the departments rely on published versions of the  library standards, and they can also submit new terms to the National  Library of Medicine for inclusion in the standards. Also, the departments  can exchange a standardized allergy reaction as long as it is mapped to a  SNOMED CT code in each department’s allergy reaction file. If a coded  term is not available in the files, clinicians can exchange descriptions of  allergy reactions in free text. This standardization was a prerequisite for  exchanging computable medical information—an accomplishment that,  according to the National Coordinator for Health IT, has not yet been  achieved in any other sector.
Continuing the departments’ historical involvement in efforts to agree  upon standards for the electronic exchange of clinical health information,  health officials from both DOD and VA participate as members of the  American Health Information Community and HITSP. For example, the 18- member community includes high-level representatives from both DOD  (the Assistant Secretary of Defense for Health Affairs) and VA (the  Director, Health Data and Informatics, Veterans Health Administration).  DOD and VA are members of the HITSP Board and are actively working on  several committees and groups (Provider Perspective Technical  Committee; Population Perspective Technical Committee; Security,  Privacy and Infrastructure Domain Technical Committee; Care  Management and Health Records Domain Technical Committee;  Administrative and Financial Domain Technical Committee;  Harmonization Committee; and Foundation Committee). The National  Coordinator indicated that such participation is important and stated that  it would not be advisable for DOD and VA to move significantly ahead of  the national standards initiative; if they did, the departments might have to  change the way their systems share information by adjusting them to the  national standards later, as the standards continue to evolve.
In addition, according to DOD officials, the department is taking steps to  ensure that the electronic health records produced by its modernized  health information system, AHLTA, which is a customized commercial  software application, are compliant with standards by arranging for  certification through the Certification Commission for Healthcare  Information Technology. Specifically, version 3.3 of AHLTA, which is still  undergoing beta testing, was conditionally certified in April 2007 against  2006 outpatient electronic health record criteria established by the  commission. DOD officials stated that AHLTA version 3.3 has been  installed at three DOD locations for beta testing and has met specific  functionality, interoperability, and security requirements. The commission  cannot fully certify this version of AHLTA until it has verified that the  system has been in operational use at a medical site.
The departments’ efforts to share data and to be involved in  standardization activities are important mechanisms for ensuring that their  electronic health records are both interoperable and aligned with  emerging standards and specifications.
section_title: DOD and VA Have Taken Steps to Establish the Joint Interagency Program Office, but the Office Does Not Yet Have Permanent Leadership, Staff, or Facilities
paragraphs: To accelerate the departments’ ongoing interoperability efforts, Congress  included provisions establishing a joint interagency program office in the  National Defense Authorization Act for Fiscal Year 2008. Under the act,  the Secretary of Defense and the Secretary of Veterans Affairs were  required to jointly develop schedules and benchmarks for setting up the  DOD/VA Interagency Program Office, as well as for other activities for  achieving interoperable health information (that is, establishing system  requirements, acquisition and testing, and implementation of interoperable  electronic health records or capabilities). The schedules and benchmarks  were due 30 days after passage of the act (February 28, 2008).
The departments developed a draft implementation plan defining fiscal  years 2008 and 2009 schedules and milestones; the date of the draft was  April 25—almost 2 months after the due date. In the effort to set up the  program office, the departments appointed an Acting Director from DOD  and an Acting Deputy Director from VA on April 17, 2008. According to  the Acting Director, they have also detailed staff and provided temporary  space and equipment to a transition team.
According to this official, through the efforts of the transition team, the  departments are currently developing a charter for the office, defining and  approving an organizational structure, and preparing to begin recruiting  permanent staff for the office, who are expected to number about 30.  According to the implementation plan, the departments expect to appoint  a permanent Director and Deputy and begin recruiting staff by October  2008. According to the Acting Director, program staff are expected to be in  place, and the office is expected to be fully operational by December 2008.  According to the departments, $4.94 million was requested to fund the  office for fiscal year 2008, which is expected to be received this July.  Funding requirements of $6.94 million for fiscal year 2009 were submitted  in June.
The draft implementation plan includes schedules and milestones for  achieving interoperable health information in two stages. The first stage— Interoperability I, to be completed by September 2008—is to address those  health data most commonly required by health care providers, as validated  by the Joint Clinical Information Board. The first milestone for  Interoperability I, sharing vital signs information, has been achieved. The  remaining milestones (sharing questionnaires and forms, family history,  social history, and other history) are all due September 2008.
The second stage—Interoperability II, to be completed by September  2009—is to address additional health information enhancements.  However, the information to be covered by these enhancements has not  yet been fully defined, and milestone dates are not fully established:    According to the plan, the requirements for the Interoperability II  enhancements are to be validated by the Joint Clinical Information Board,  which sets the clinical priorities for what electronic health information  should be shared next. This validation, followed by approval by senior  department leadership, was to be complete by June 2008. However,  according to department officials, the completion date is now expected to  be the end of July 2008.
Of 52 milestone dates for Interoperability II, 19 are yet to be determined.
For example, milestone dates have not been identified regarding  capabilities to share data on exposures to health hazards, immunization  records and history, family history, and psychological health treatment  and care records.
Officials stated that decisions on these milestone dates will depend on  clinical priorities, technical considerations, and policy decisions. For  example, the exchange of psychological health treatment and care records  requires policy decisions regarding appropriate access. Further, according  to the implementation plan draft, the plan is intended to serve as a “living  document” that will be updated and refined as more detailed information  becomes known on planned fiscal year 2008 and fiscal year 2009  initiatives, and as health care information needs change.
According to the Acting Director, the draft implementation plan has not  been finalized because of remaining uncertainties regarding such issues as  space and staffing needs. For example, although the scope of the office’s  responsibility is to be for electronic health records and capabilities, the  departments’ leadership may broaden its scope to include sharing of  personnel and benefits data, which would affect the number of staff  required. However, although the implementation plan (as a planning tool)  is appropriately a living document, it is nonetheless important to complete  the planning and make the decisions needed to finalize the initial plan,  particularly in view of the fast approaching September 2009 deadline.
Further, according to department officials, the joint interagency program  office will play a crucial role in coordinating the departments’ efforts to  accelerate their interoperability efforts. An important aspect of this  coordination will be managing the further development and  implementation of the DOD/VA Information Interoperability Plan,  currently under review by senior management. According to these  officials, having a centralized office to take on this role will be a primary  benefit. However, the effort to set up the program office is still in its early  stages. The positions of Director and Deputy Director are not yet  permanently filled, permanent staff have not yet been hired, and facilities  have not yet been designated for housing the office. Until the program  office is fully established, it will not be able to play this crucial role  effectively.
section_title: Conclusions
paragraphs: DOD and VA are currently sharing more health information than ever  before, including exchanging some at the highest level of interoperability,  that is, in computable form. The departments also have efforts under way  to share additional information. Additional issues remaining to be  addressed include electronic sharing of the information in paper-based  health records and the completion of their long-range plans to develop  fully interoperable health information systems. According to the  departments, the DOD/VA Information Interoperability Plan is to address  these and other issues. Once the plan is finalized and approved by DOD  and VA officials, we intend to perform an assessment of the plan.  However, if the plan includes the essential elements needed to guide the  departments in achieving their long-term goal of seamless sharing of  health information, it could improve the prospects for the successful  achievement of this goal.
Further enhancing interoperability depends on adherence to common  standards. The two departments have agreed on standards and are  working with each other and federal groups to help ensure that their  systems are both interoperable and compliant with current and emerging  federal standards.
The joint interagency program office is to play a crucial role in  accelerating the departments’ efforts to achieve electronic health records  and capabilities that allow for full interoperability. However, it is not  expected to be fully set up until the end of the year, after which only 9  months will remain to meet the goal of full interoperability between the  departments by September 2009. The implementation plan, which was  almost 2 months late, remains in draft, with many milestone dates yet to  be determined. In view of the short timeframes, without a fully established  program office and a finalized implementation plan with set milestones,  the departments may be challenged in meeting the required date for  achieving interoperable electronic health records and capabilities.
section_title: Recommendations for Executive Action
paragraphs: To better ensure that the effort by DOD and VA to achieve fully  interoperable electronic health record systems or capabilities is  accelerated, we recommend that the Secretaries of Defense and Veterans  Affairs give priority to fully establishing the Joint Interagency Program  Office by expediting efforts to    put in place permanent leadership, staff, and facilities and    make the necessary decisions to finalize the draft implementation plan.
section_title: Agency Comments and Our Evaluation
paragraphs: In providing written comments on a draft of this report, the Assistant  Secretary of Defense for Health Affairs and the Secretary of Veterans  Affairs agreed with our recommendations. (The departments’ comments  are reproduced in app.II and app. III, respectively.) DOD stated that high  priority will be given to fully establishing the Joint Interagency Program  Office, with specific focus on expanding efforts related to permanent  leadership, staff, and facilities. DOD also provided technical comments on  the draft report, which we incorporated as appropriate.
VA’s comments described actions planned or being taken that respond to  our recommendations. For example, according to VA, the Deputy Director  of the Interagency Program Office is expected to be appointed by October  2008. In addition, VA stated that the departments collaboratively  determined the number and type of staff required for the new office and  expect to hire permanent staff by December 2008. In this regard, DOD has  taken the lead on securing permanent facilities for the program office and  is currently working with the General Services Administration to find  suitable space. In addition, VA stated the departments are in the process of  finalizing the implementation plan and that by October 31, 2008, they  expect to identify the milestones and timelines for defining requirements  to support interoperable health records. The department noted that the  Joint Clinical Information Board is expected to identify, by July 31, 2008,  the specific data types and format for sharing that must be achieved by  September 2009. If the actions planned or currently under way are  properly implemented, they should help ensure that DOD and VA will be  successful in meeting their goals for sharing interoperable health  information.
We are sending copies of this report to the Secretaries of Veterans Affairs  and Defense, appropriate congressional committees, and other interested  parties. 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 staffs have questions about this report, please contact me at  (202) 512-6304 or melvinv@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. Key contributors to this report are listed in appendix IV.
section_title: Appendix I: Scope and Methodology
paragraphs: To describe the progress of the Department of Defense (DOD) and  Department of Veterans Affairs (VA) to date on developing electronic  health records systems or capabilities that allow for full interoperability of  personal health care information between the departments, 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. Additionally, we reviewed  information gathered from agency documentation and interviews with  cognizant DOD and VA officials relating to the departments’ efforts to  share electronic health information. Further, we visited a DOD military  treatment facility and a VA medical center (Walter Reed Army Medical  Center and the Washington, D.C., VA Medical Center), chosen because  they were accessible and allowed us to observe the sharing capabilities  and functionality of the two departments’ electronic health information  systems.
To describe steps taken by the departments to ensure that their health  records comply with applicable interoperability standards, implementation  specifications, and certification criteria of the federal government, we  analyzed information gathered from DOD and VA documentation and  interviews pertaining to the interoperability standards and implementation  specifications that the two departments have agreed to for exchanging  health information via their health care information systems. We reviewed  documentation and interviewed agency officials from the Department of  Health and Human Services’ Office of the National Coordinator for Health  Information technology to obtain information regarding the defined  federal interoperability standards, implementation specifications, and  certification criteria. We also reviewed documentation and interviewed  DOD and VA officials from the Joint Clinical Information Board to  determine the extent to which the departments have adopted federal  interoperability standards, implementation specifications, and certification  criteria.
To describe efforts to set up the joint interagency program office, we  analyzed documentation regarding the establishment of the office and  interviewed responsible officials.
We conducted this performance audit at VA and DOD sites in the greater  Washington, D.C., metropolitan area from March 2008 through July 2008 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: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributions were made to  this report by Barbara S. Oliver (Assistant Director), Barbara Collier, Kelly  Shaw, and Robert Williams, Jr.
section_title: Related GAO Products
paragraphs: 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. GAO-08-495R. Washington,  D.C.: April 30, 2008.
Health Information Technology: HHS Is Pursuing Efforts to Advance  Nationwide Implementation, but Has Not Yet Completed a National  Strategy. GAO-08-499T. Washington, D.C.: February 14, 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.
Veterans Affairs: Progress Made in Centralizing Information  Technology Management, but Challenges Persist. GAO-07-1246T.  Washington, D.C.: September 19, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing  Medical Information, but Remain Far from Having Comprehensive  Electronic Medical Records. GAO-07-1108T. Washington, D.C.: July 18,  2007.
Health Information Technology: Efforts Continue but Comprehensive  Privacy Approach Needed for National Strategy. GAO-07-988T.  Washington, D.C.: June 19, 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.
Health Information Technology: Early Efforts Initiated but  Comprehensive Privacy Approach Needed for National Strategy. GAO-07- 400T. Washington, D.C.: February 1, 2007.
Health Information Technology: Early Efforts Initiated, but  Comprehensive Privacy Approach Needed for National Strategy. GAO-07- 238. Washington, D.C.: January 10, 2007.
Health Information Technology: HHS is Continuing Efforts to Define Its  National Strategy. GAO-06-1071T. Washington, D.C.: September 1, 2006.
Information Technology: VA and DOD Face Challenges in Completing  Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
Health Information Technology: HHS Is Continuing Efforts to Define a  National Strategy. GAO-06-346T. Washington, D.C.: March 15, 2006.
Computer-Based Patient Records: VA and DOD Made Progress, but Much  Work Remains to Fully Share Medical Information. GAO-05-1051T.  Washington, D.C.: September 28, 2005.
Health Information Technology: HHS Is Taking Steps to Develop a  National Strategy. GAO-05-628. Washington, D.C.: May 27, 2005.
Computer-Based Patient Records: VA and DOD Efforts to Exchange  Health Data Could Benefit from Improved Planning and Project  Management. GAO-04-687. Washington, D.C.: June 7, 2004.
Computer-Based Patient Records: Improved Planning and Project  Management Are Critical to Achieving Two-Way VA-DOD Health Data  Exchange. GAO-04-811T. Washington, D.C.: May 19, 2004.
Computer-Based Patient Records: Sound Planning and Project  Management Are Needed to Achieve a Two-Way Exchange of VA and  DOD Health Data. GAO-04-402T. Washington, D.C.: March 17, 2004.
Computer-Based Patient Records: Short-Term Progress Made, but Much  Work Remains to Achieve a Two-Way Data Exchange Between VA and  DOD Health Systems. GAO-04-271T. Washington, D.C.: November 19,  2003.
VA Information Technology: Management Making Important Progress in  Addressing Key Challenges. GAO-02-1054T. Washington, D.C.: September  26, 2002.
Veterans Affairs: Sustained Management Attention Is Key to Achieving  Information Technology Results. GAO-02-703. Washington, D.C.: June 12,  2002.
VA Information Technology: Progress Made, but Continued Management  Attention Is Key to Achieving Results. GAO-02-369T. Washington, D.C.:  March 13, 2002.
VA and Defense Health Care: Military Medical Surveillance Policies in  Place, but Implementation Challenges Remain. GAO-02-478T.  Washington, D.C.: February 27, 2002.
VA and Defense Health Care: Progress Made, but DOD Continues to Face  Military Medical Surveillance System Challenges. GAO-02-377T.  Washington, D.C.: January 24, 2002.
VA and Defense Health Care: Progress and Challenges DOD Faces in  Executing a Military Medical Surveillance System. GAO-02-173T.  Washington, D.C.: October 16, 2001.
Computer-Based Patient Records: Better Planning and Oversight by VA,  DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459.  Washington, D.C.: April 30, 2001.