Electronic Health Records: Long History of Management Challenges Raises Concerns about VA's and DOD's New Approach to Sharing Health Information
Published: 2013-02-27T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: VA and DOD operate two of the nation's largest health care systems-- systems that serve populations of veterans and active service members and their dependents. To better serve these populations, VA and DOD have been collaborating for about 15 years on a variety of initiatives to share data among the departments' health information systems. The use of IT to electronically collect, store, retrieve, and transfer such data has the potential to improve the quality and efficiency of health care. Particularly important in this regard is developing electronic health records that can be accessed throughout a patient's military and veteran status. Making such information electronic can ensure greater availability of health care information for service members and veterans at the time and place of care. Although they share many common business needs, both VA and DOD have spent large sums of money to develop and maintain separate electronic health record systems that they use to create and manage patient health information.
GAO was asked to testify on (1) the departments' efforts, and challenges faced, in electronically sharing health information and (2) the recent change in their approach to developing an integrated electronic health record. In preparing this statement, GAO relied primarily on previously published work in this area.
section_title: What GAO Found
paragraphs: The Departments of Veterans Affairs (VA) and Defense (DOD) have undertaken a number of patchwork efforts over the past 15 years to achieve interoperability (i.e., the ability to share data) of records between their information systems; however, these efforts have faced persistent challenges. The departments' early efforts to achieve interoperability included enabling DOD to electronically transfer service members' electronic health information to VA; allowing clinicians at both departments viewable access to records on shared patients; and developing an interface linking the departments' health data repositories. As GAO reported, however, several of these efforts were plagued by project planning and management weaknesses, inadequate accountability, and poor oversight, limiting their ability to realize full interoperability.
To further expedite data sharing, the National Defense Authorization Act of 2008 directed VA and DOD to jointly develop and implement fully interoperable electronic health record capabilities by September 30, 2009. The departments asserted that they met this goal, though they planned additional work to address clinicians' evolving needs. GAO identified weaknesses in the departments' management of these initiatives, such as a lack of defined performance goals and measures that would provide a comprehensive picture for managing progress. In addition, the departments' Interagency Program Office, which was established to be a single point of accountability for electronic health data sharing, had not fulfilled key management responsibilities.
In 2009, the departments began work on the Virtual Lifetime Electronic Record initiative to enable access to all electronic records for service members transitioning from military to veteran status, and throughout their lives. To carry this out, the departments initiated several pilot programs but had not defined a comprehensive plan that defined the full scope of the effort or its projected cost and schedule. Further, in 2010, VA and DOD established a joint medical facility that was, among other things, to have certain information technology (IT) capabilities to facilitate interoperability of the departments' electronic health record systems. Deployment of these capabilities was delayed, however, and some have yet to be implemented.
In 2011, the VA and DOD Secretaries committed to developing a new common integrated electronic health record system, with a goal of implementing it across the departments by 2017. This approach would largely sidestep the challenges in trying to achieve interoperability between separate systems. However, in February 2013, the Secretaries announced that the departments would focus on modernizing their existing systems, rather than developing a single system. They cited cost savings and meeting needs sooner rather than later as reasons for this decision. Given the long history of challenges in achieving interoperability, this reversal of course raises concerns about the departments' ability to successfully collaborate to share electronic health information. Moreover, GAO has identified barriers to the departments jointly addressing their common needs arising from deficiencies in key IT management areas, which could continue to jeopardize their pursuits. GAO is monitoring the departments' progress in overcoming these barriers and has additional ongoing work to evaluate their activities to develop integrated electronic health record capabilities.
section_title: What GAO Recommends
paragraphs: Since 2001, GAO has made numerous recommendations to improve VA's and DOD's management of their efforts to share health information.

section_title: Letter
paragraphs: Thank you for the opportunity to participate in today’s hearing on efforts of  the Department of Veterans Affairs (VA) to share electronic health  records with the Department of Defense (DOD). As you know, VA and  DOD operate two of the nation’s largest health care systems, which, in  fiscal year 2013, are projected to provide coverage to approximately 6.3  million veterans and 9.6 million active duty service members and their  beneficiaries at estimated costs of about $53 billion and $49 billion,  respectively.
Both VA and DOD have long recognized the importance of advancing the  use of shared health information systems and capabilities to make patient  information more readily available to their health care providers, reduce  medical errors, and streamline administrative functions. Toward this end,  the two departments have an extensive history of working to achieve  shared health care resources, dating back to the 1980s. Our work has  examined the departments’ efforts over the past 15 years in undertaking a  variety of initiatives to share data between their individual health  information systems and to develop interoperable health record  capabilities. In this regard, reports that we issued between 2001 and 2012  have noted various degrees of progress by the departments; however, we  have also highlighted, and recommended that VA and DOD address,  pervasive and persistent management challenges that have impeded  their ability to achieve fully interoperable electronic health record  capabilities. My testimony today (1) summarizes VA’s and DOD’s efforts,  and challenges faced, in electronically sharing health information and (2)  describes the departments’ recent change in their approach to developing  an integrated electronic health record.
In developing this testimony, we relied on our previous work. We also  obtained and reviewed information on the departments’ actions in  response to our previous recommendations. We conducted our work in  support of this testimony during February 2013. All work on which this  testimony is based was performed 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.
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. Historically, patient health information has been scattered  across paper records kept by many different caregivers in many different  locations, making it difficult for a clinician to access all of a patient’s  health information at the time of care. Lacking access to these critical  data, a clinician may be challenged to make the most informed decisions  on treatment options, potentially putting the patient’s health at greater  risk. The use of electronic health records can help provide this access  and improve clinical decisions.
Electronic health records are particularly crucial for optimizing the health  care provided to military personnel and veterans. While in military status  and later as veterans, many VA and DOD patients tend to be highly  mobile and may have health records residing at multiple medical facilities  within and outside the United States. Making such records electronic can  help ensure that complete health care information is available for most  military service members and veterans at the time and place of care, no  matter where it originates.
Although they have identified many common health care business needs,  both departments have spent large sums of money to develop and  operate separate electronic health record systems that they rely on to  create and manage patient health information. VA uses its integrated  medical information system—the Veterans Health Information Systems  and Technology Architecture (VistA)—which was developed in-house by  VA clinicians and IT personnel. The system consists of 104 separate  computer applications, including 56 health provider applications; 19  management and financial applications; 8 registration, enrollment, and  eligibility applications; 5 health data applications; and 3 information and  education applications. Besides being numerous, these applications have  been customized at all 128 VA sites. According to the department, this  customization increases the cost of maintaining the system, as it requires  that maintenance also be customized.
In 2001, the Veterans Health Administration undertook an initiative to  modernize VistA by standardizing patient data and modernizing the health  information software applications. In doing so, its goal was to move from  the hospital-centric environment that had long characterized the  department’s health care operations to a veteran-centric environment built  on an open, robust systems architecture that would more efficiently  provide both the same functions and benefits of the existing system and  enhanced functions based on computable data. VA planned to take an  incremental approach to the initiative, based on six phases (referred to as  “blocks”) that were to be completed in 2018. Under this strategy, the  department planned to replace the 104 VistA applications that are  currently in use with 67 applications, 3 databases, and 10 common  services. VA reported spending almost $600 million from 2001 to 2007 on  eight projects, including an effort that resulted in a repository containing  selected standardized health data, as part of the effort to modernize  VistA. In April 2008, the department estimated an $11 billion total cost to  complete, by 2018, the modernization that was planned at that time.  However, according to VA officials, the modernization effort was  terminated in August 2010.
For its part, DOD relies on its Armed Forces Health Longitudinal  Technology Application (AHLTA), which comprises multiple legacy  medical information systems that the department developed from  commercial software products that were customized for specific uses. For  example, the Composite Health Care System (CHCS), which was  formerly DOD’s primary health information system, is still in use to  capture information related to pharmacy, radiology, and laboratory order  management. In addition, the department uses Essentris (also called the  Clinical Information System), a commercial health information system  customized to support inpatient treatment at military medical facilities.  DOD obligated approximately $2 billion for AHLTA between 1997 and  2010.
A key goal for sharing health information among providers, such as  between VA’s and DOD’s health care systems, is achieving  interoperability. Interoperability enables different information systems or  components to exchange information and to use the information that has  been exchanged. This capability 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, 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,  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 a still  lower level, electronic data are unstructured and viewable, but not  computable. With unstructured electronic data, a user would have to find  needed or relevant information by searching uncategorized data. Beyond  these, paper records can also be considered interoperable (at the lowest  level) because they allow data to be shared, read, and interpreted by  human beings.
section_title: VA and DOD Have Pursued Various Efforts over Many Years but Have Been Challenged in Achieving Fully Interoperable Electronic Health Records
paragraphs: Since 1998, VA and DOD have relied on a patchwork of initiatives  involving their health information systems to achieve electronic health  record interoperability. These have included efforts to: share viewable  data in existing (legacy) systems; link and share computable data  between the departments’ modernized health data repositories; establish  interoperability objectives to meet specific data-sharing needs; develop a  virtual lifetime electronic health record to track patients through active  service and veteran status; and implement IT capabilities for the first joint  federal health care center. While, collectively, these initiatives have  yielded increased data-sharing in various capacities, a number of them  have nonetheless been plagued by persistent management challenges,  which have created barriers to achieving the fully interoperable electronic  health record capabilities long sought.
subsections: section_title: Early Efforts to Share Information in Legacy Systems Suffered from Project Planning and Management Weaknesses
paragraphs: Among the departments’ earliest efforts to achieve interoperability was  the Government Computer-Based Patient Record (GCPR) initiative,  which was begun in 1998 with the intent of providing an electronic  interface that would allow physicians and other authorized users of VA’s  and DOD’s health facilities to access data from either of the other  agency’s health facilities. The interface was expected to compile  requested patient health information in a temporary, “virtual” record that  could be displayed on a user’s computer screen. However, in reporting on  this initiative in April 2001, we found that accountability for GCPR was  blurred across several management entities and that basic principles of  sound IT project planning, development, and oversight had not been  followed, thus, creating barriers to progress. For example, clear goals  and objectives had not been set; detailed plans for the design,  implementation, and testing of the interface had not been developed; and  critical decisions were not binding on all partners. While both departments  concurred with our recommendations that they, among other things,  create comprehensive and coordinated plans for the effort, progress on  the initiative continued to be disappointing. The department subsequently  revised the strategy for GCPR and, in May 2002, narrowed the scope of  the initiative to focus on enabling DOD to electronically transfer service  members’ electronic health information to VA upon their separation from  active duty. The initiative—renamed the Federal Health Information  Exchange (FHIE)—was completed in 2004.
Building on the architecture and framework of FHIE, VA and DOD also  established the Bidirectional Health Information Exchange (BHIE) in  2004, which was aimed at allowing clinicians at both departments  viewable access to records on shared patients (that is, those who receive  care from both departments, such as veterans who receive outpatient  care from VA clinicians and then are hospitalized at a military treatment  facility). The interface also enabled DOD sites to see previously  inaccessible data at other DOD sites.
Further, in March 2004, the departments began an effort to develop an  interface linking VA’s Health Data Repository and DOD’s Clinical Data  Repository, as part of a long-term initiative to achieve the two-way  exchange of health information between the departments’ modernized  systems—known as CHDR. The departments had planned to be able to  exchange selected health information through CHDR by October 2005.  However, in June 2004, we reported that the efforts of VA and DOD in  this area demonstrated a number of management weaknesses. Among  these were the lack of a well-defined architecture for describing the  interface for a common health information exchange; an established  project management lead entity and structure to guide the investment in  the interface and its implementation; and a project management plan  defining the technical and managerial processes necessary to satisfy  project requirements. Accordingly, we recommended that the  departments address these weaknesses, and they agreed to do so.
In September 2005, we testified that the departments had improved the  management of the CHDR program, but that this program continued to  face significant challenges—in particular, with developing a project  management plan of sufficient specificity to be an effective guide for the  program. In a subsequent testimony, in June 2006, we noted that the  project did not meet a previously established milestone: to be able to  exchange outpatient pharmacy data, laboratory results, allergy  information, and patient demographic information on a limited basis by  October 2005. By September 2006, the departments had taken actions  which ensured that the CHDR interface linked the departments’ separate  repositories of standardized data to enable a two-way exchange of  computable outpatient pharmacy and medication allergy information.  Nonetheless, we noted that the success of CHDR would depend on the  departments instituting a highly disciplined approach to the project’s  management.
section_title: Efforts to Comply with 2008 Mandate to Achieve Fully Interoperable Health Records Capabilities Lacked Project Plans and Measures of Effectiveness
paragraphs: To increase the exchange of electronic health information between the  two departments, the National Defense Authorization Act (NDAA) for  Fiscal Year 2008 included provisions directing VA and DOD to jointly  develop and implement, by September 30, 2009, fully interoperable  electronic health record systems or capabilities. To facilitate compliance  with the act, the departments’ Interagency Clinical Informatics Board,  made up of senior clinical leaders who represent the user community,  began establishing priorities for interoperable health data between VA  and DOD. In this regard, the board was responsible for determining  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:    Refine social history data: DOD was to begin sharing with VA the  social history data that are currently captured in the DOD electronic  health record. Such data describe, for example, patients’ involvement  in hazardous activities and tobacco and alcohol use.    Share physical exam data: DOD was to provide an initial capability  to share with VA its electronic health record information that supports  the physical exam process when a service member separates from  active military duty.    Demonstrate initial network gateway operation: VA and DOD were  to demonstrate the operation of secure network gateways to support  joint VA-DOD health information sharing.    Expand questionnaires and self-assessment tools: DOD was to  provide all periodic health assessment data stored in its electronic  health record to VA such that questionnaire responses are viewable  with the questions that elicited them.    Expand Essentris in DOD: DOD was to expand its inpatient medical  records system (CliniComp’s Essentris product suite) to at least one  additional site in each military medical department (one Army, one Air  Force, and one Navy, for a total of three sites).    Demonstrate initial document scanning: DOD was to demonstrate  an initial capability for scanning service members’ medical documents  into its electronic health record and sharing the documents  electronically with VA.
The departments asserted that they took actions that met the six  objectives and, in conjunction with capabilities previously achieved (e.g.,  FHIE, BHIE, and CHDR), had met the September 30, 2009, deadline for  achieving full interoperability as required by the act. Nonetheless, the  departments planned additional work to further increase their  interoperable capabilities, stating that these actions reflected the  departments’ recognition that clinicians’ needs for interoperable electronic  health records are not static. In this regard, the departments focused on  additional efforts to meet clinicians’ evolving needs for interoperable  capabilities in the areas of social history and physical exam data,  expanding implementation of Essentris, and additional testing of  document scanning capabilities.
Even with these actions, however, we identified a number of challenges  the departments faced in managing their efforts in response to the 2008  NDAA. Specifically, we identified challenges with respect to performance  measurement, project scheduling, and planning. For example, in a  January 2009 report, we noted that the departments’ key plans did not  identify results-oriented (i.e., objective, quantifiable, and measurable)  performance goals and measures that are characteristic of effective  planning and can be used as a basis to track and assess progress toward  the delivery of new interoperable capabilities. We pointed out that  without establishing results-oriented goals and reporting progress using  measures relative to the established goals, the departments and their  stakeholders would not have the comprehensive picture that they need to  effectively manage their progress toward achieving increased  interoperability. Accordingly, we recommended that DOD and VA take  action to develop such goals and performance measures to be used as a  basis for providing meaningful information on the status of the  departments’ interoperability initiatives. In response, the departments  stated that such goals and measures would be included in the next  version of the VA/DOD Joint Executive Council Joint Strategic Plan  (known as the joint strategic plan). However, that plan was not approved  until April 2010, 7 months after the departments asserted they had met  the deadline for achieving full interoperability.
In addition to its provisions directing VA and DOD to jointly develop fully  interoperable electronic health records, the 2008 NDAA called for the  departments to set up an Interagency Program Office (IPO) to be  accountable for their efforts to implement these capabilities by the  September deadline. Accordingly, in January 2009, the office completed  its charter, articulating, among other things, its mission and functions with  respect to attaining interoperable electronic health data. The charter  further identified the office’s responsibilities 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.
In July 2009, we reported that the IPO had not fulfilled key management  responsibilities identified in its charter, such as the development of an  integrated master schedule and a project plan for the department’s efforts  to achieve full interoperability. Without these important tools, the office  was limited in its ability to effectively manage and provide meaningful  progress reporting on the delivery of interoperable capabilities. We  recommended that the IPO establish a project plan and a complete and  detailed integrated master schedule. In response to our recommendation,  the office began to develop an integrated master schedule and project  plan that included information about its ongoing interoperability activities.
It is important to note, however, that in testifying before this committee in  July 2011, the office’s former Director stated that the IPO charter  established a modest role for the office, which did not allow the office to  be the single point of accountability for the development and  implementation of interoperable electronic health records. Instead, the  office served the role of coordination and oversight for the departments’  efforts. Additionally, as pointed out by this official, control of the budget,  contracts, and technical development remained with VA and DOD. As a  result, each department had continued to pursue separate strategies and  implementation paths, rather than coming together to build a unified,  interoperable approach.
section_title: Virtual Lifetime Electronic Record Initiative Lacked Comprehensive Planning
paragraphs: In another attempt at furthering efforts to increase electronic health record  interoperability, in April 2009, the President announced that VA and DOD  would work together to define and build the Virtual Lifetime Electronic  Record (VLER) to streamline the transition of electronic medical, benefits,  and administrative information between the two departments. VLER is  intended to enable access to all electronic records for service members  as they transition from military to veteran status, and throughout their  lives. Further, the initiative is to expand the departments’ health  information sharing capabilities by enabling access to private sector  health data.
Shortly after the April 2009 announcement, VA, DOD, and the IPO began  working to define and plan for the initiative. In June 2009, the  departments adopted a phased implementation strategy consisting of a  series of 6-month pilot projects to deploy a set of health data exchange  capabilities between existing electronic health record systems at local  sites around the country. Each VLER pilot project was intended to build  upon the technical capabilities of its predecessor, resulting in a set of  baseline capabilities to inform project planning and guide the  implementation of VLER nationwide.
The first pilot, which started in August 2009, in San Diego, California,  resulted in VA, DOD, and Kaiser Permanente being able to share a  limited set of test patient data. Subsequently, between March 2010 and  January 2011, VA and DOD conducted another pilot in the Tidewater  area of southeastern Virginia, which focused on sharing the same data as  the San Diego pilot plus additional laboratory data. The departments  planned additional pilots, with the goal of deploying VLER nationwide at  or before the end of 2012.
In June 2010, DOD informed us that it planned to spend $33.6 million in  fiscal year 2010, and $61.9 million in fiscal year 2011 on the initiative.  Similarly, VA stated that it planned to spend $23.5 million in fiscal year  2010, and had requested $52 million for fiscal year 2011.
However, in a February 2011 report on the departments’ efforts to  address their common health IT needs, we noted that although VA and  DOD identified a high-level approach for implementing VLER and  designated the IPO as the single point of accountability for the effort, they  had not developed a comprehensive plan identifying the target set of  capabilities that they intended to demonstrate in the pilot projects and  then implement on a nationwide basis at all domestic VA and DOD sites  by the end of 2012. Moreover, the departments conducted VLER pilot  projects without attending to key planning activities that are necessary to  guide the initiative. For example, as of February 2011, the IPO had not  developed an approved integrated master schedule, master program  plan, or performance metrics for the VLER initiative, as outlined in the  office’s charter. We noted that if the departments did not address these  issues, their ability to effectively deliver capabilities to support their joint  health IT needs would be uncertain. We recommended that the  Secretaries of VA and DOD strengthen their ongoing efforts to establish  VLER by developing plans that include scope definition, cost and  schedule estimation, and project plan documentation and approval.  Officials from both departments agreed with the recommendation, and we  are monitoring their actions toward implementing them. Nevertheless, the  departments were not successful in meeting their goal of implementing  VLER nationwide by the end of 2012.
section_title: Poor Project Planning Contributed to Information Technology Delays at the Joint Federal Health Care Center
paragraphs: VA and DOD also continued their efforts to share health information and  resources in 2010 following congressional authorization of a 5-year  demonstration project to more fully integrate the two departments’  facilities that were located in proximity to one another in the North  Chicago, Illinois, area. As authorized by the National Defense  Authorization Act for fiscal year 2010, VA and DOD facilities in and  around North Chicago were integrated into a first-of-its-kind system  known as the Captain James A. Lovell Federal Health Care Center  (FHCC). The FHCC is unique in that it is to be the first fully integrated  federal health care center for use by both VA and DOD beneficiaries, with  an integrated workforce, a joint funding source, and a single line of  governance.
In April 2010, the Secretaries of VA and DOD signed an Executive  Agreement that established the FHCC and defined the relationship  between the two departments for operating the new, integrated facility, in  accordance with the 2010 NDAA. Among other things, the Executive  Agreement specified three key IT capabilities that VA and DOD were  required to have in place by the FHCC’s opening day, in October 2010, to  facilitate interoperability of their electronic health record systems:    medical single sign-on, which would allow staff to use one screen to  access both the VA and DOD electronic health record systems;    single patient registration, which would allow staff to register  patients in both systems simultaneously; and    orders portability, which would allow VA and DOD clinicians to  place, manage, and update clinical orders from either department’s  electronic health records systems for radiology, laboratory, consults  (specialty referrals), and pharmacy services.
However, in a February 2011 report that identified improvements the  departments could make to the FHCC effort, we noted that project  planning for the center’s IT capabilities was incomplete. We specifically  noted that the departments had not defined the project scope in a manner  that identified all detailed activities. Consequently, they were not  positioned to reliably estimate the project cost or establish a baseline  schedule that could be used to track project performance. Based on these  findings, we expressed concern that VA and DOD had jeopardized their  ability to fully and expeditiously provide the FHCC’s needed IT system  capabilities. We recommended that the Secretaries of VA and DOD  strengthen their efforts to establish the joint IT system capabilities for the  FHCC by developing plans that included scope definition, cost and  schedule estimation, and project plan documentation and approval.  Although officials from both departments stated agreement with our  recommendation, the departments’ actions were not sufficient to preclude  delays in delivering the FHCC’s IT system capabilities, as we  subsequently described in July 2011 and June 2012.
Specifically, our 2011 report noted that none of the three IT capabilities  had been implemented by the time of the FHCC’s opening, as required by  the Executive Agreement; however, FHCC officials reported that the  medical single sign-on and single patient registration capabilities  subsequently became operational in December 2010.
In June 2012, we again reported on the departments’ efforts to implement  the FHCC’s required IT capabilities, and found that portions of the orders  portability capability—related to the pharmacy and consults  components—remained delayed. VA and DOD officials described  workarounds that the departments had implemented as a result of the  delays, but did not have a timeline for completion of the pharmacy  component, and estimated completion of the consults component by  March 2013.
The officials reported that as of March 2012, the departments had spent  about $122 million on developing and implementing IT capabilities at the  FHCC. However, they were unable to quantify the total cost for all the  workarounds resulting from delayed IT capabilities.
section_title: VA and DOD Recently Changed Their Approach to Developing an Integrated Electronic Health Record
paragraphs: Beyond the aforementioned initiatives, in March 2011 the Secretaries of  VA and DOD committed the two departments to developing a new  common integrated electronic health record (iEHR), and in May 2012  announced their goal of implementing it across the departments by 2017.  According to the departments, the decision to pursue iEHR would enable  VA and DOD to align resources and investments with common business  needs and programs, resulting in a platform that would replace the two  departments’ electronic health record systems with a common system. In  addition, because it would involve both departments using the same  system, this approach would largely sidestep the challenges they have  encountered in trying to achieve interoperability between separate  systems.
To oversee this new effort, in October 2011, the IPO was re-chartered  and given authority to expand its staffing level and provided with new  authorities under the charter, including control over the budget. According  to IPO officials, the office was expected to have a staff of 236  personnel—more than 7 times the number of staff originally allotted to the  office by VA and DOD—when hiring under the charter was completed.  However, IPO officials told us that, as of January 2013, the office was  staffed at approximately 62 percent and that hiring additional staff  remained one of its biggest challenges.
Earlier this month, the Secretaries of VA and DOD announced that  instead of developing a new common integrated electronic health record  system, the departments would now focus on integrating health records  from separate VA and DOD systems, while working to modernize their  existing electronic health record systems. VA has stated that it will  continue to modernize VistA while pursuing the integration of health data,  while DOD has stated that it plans to evaluate whether it will adopt VistA  or purchase a commercial off-the-shelf product. The Secretaries offered  several reasons for this new direction, including cutting costs, simplifying  the problem of integrating VA and DOD health data, and meeting the  needs of veterans and service members sooner rather than later.
The numerous challenges that the departments have faced in past efforts  to achieve full interoperability between their existing health information  systems heighten longstanding concerns about whether this latest  initiative will be successful. We have ongoing work—undertaken at the  request of the Chairman and Ranking Member of the Senate Committee  on Veterans Affairs—to examine VA’s and DOD’s decisions and activities  related to this endeavor.
subsections: section_title: Barriers Exist to Jointly Addressing VA’s and DOD’s Health Care System Needs
paragraphs: VA’s and DOD’s revised approach to developing iEHR highlights the need  for the departments to address barriers they have faced in key IT  management areas. Specifically, in a February 2011 report, we  highlighted barriers that the departments faced to jointly addressing their  common health care system needs in the areas of strategic planning,  enterprise architecture, and investment management. In particular, the  departments had not articulated explicit plans, goals, and time frames for  jointly addressing the health IT requirements common to both  departments’ electronic health record systems, and their joint strategic  plan did not discuss how or when they propose to identify and develop  joint solutions to address their common health IT needs. In addition,  although DOD and VA had taken steps toward developing and  maintaining artifacts related to a joint health architecture (i.e., a  description of business processes and supporting technologies), the  architecture was not sufficiently mature to guide the departments’ joint  health IT modernization efforts. Further, the departments had not  established a joint process for selecting IT investments based on criteria  that consider cost, benefit, schedule, and risk elements, limiting their  ability to pursue joint health IT solutions that both meet their needs and  provide better value and benefits to the government as a whole. We  noted that without having these key IT management capabilities in place,  the departments would continue to face barriers to identifying and  implementing IT solutions that addressed their common needs.
In our report, we identified several actions that the Secretaries of Defense  and Veterans Affairs could take to overcome these barriers, including the  following:    Revise the departments’ joint strategic plan to include information  discussing their electronic health record system modernization efforts  and how those efforts will address the departments’ common health  care business needs.    Further develop the departments’ joint health architecture to include  their planned future state and transition plan from their current state to  the next generation of electronic health record capabilities.    Define and implement a process, including criteria that consider costs,  benefits, schedule, and risks, for identifying and selecting joint IT  investments to meet the departments’ common health care business  needs.
Officials from both VA and DOD agreed with these recommendations,  and we have been monitoring their actions toward implementing them.  Nonetheless, important work remains, and it takes on increased urgency  in light of the departments’ revised approach to developing the iEHR. For  example, with respect to planning, the departments’ joint strategic plan  does not describe the new approach to how the departments will address  their common health care business needs. Regarding architecture, in  February 2012, the departments established the Health Architecture  Review Board to provide architecture oversight, approval, and decision  support for joint VA and DOD health information technology programs.  While the board has generally met monthly since May 2012 and has been  working to establish mechanisms for overseeing architecture activities,  the extent to which the departments’ revised approach to iEHR is guided  by a joint health architecture remains to be seen. With regard to defining  a process for identifying and selecting joint investments, the departments  have established such a governance structure, but the effectiveness of  this structure has not yet been demonstrated. In particular, the  departments have not yet demonstrated the extent to which criteria that  consider costs, benefits, schedule, and risks have been or will be used to  identify and select planned investments.
In summary, while VA and DOD have made progress in increasing  interoperability between their health information systems over the past 15  years, these efforts have faced longstanding challenges. In large part,  these have been the result of inadequate program management and  accountability. In particular, there has been a persistent absence of  clearly defined, measurable goals and metrics, together with associated  plans and time frames, that would enable the departments to report  progress in achieving full interoperability. Moreover, the Integrated  Program Office has not functioned as it was intended—as a single point  of accountability for efforts to implement fully interoperable electronic  health record systems or capabilities. The 2011 decision to develop a  single, integrated electronic health record system to be used across both  departments could have avoided or mitigated some of these challenges.  However, the more recent decision to reverse course and continue to  operate separate systems and develop additional interoperable  capabilities raises concern in light of historical challenges. Further,  although the departments have asserted that their now planned approach  will deliver capabilities sooner and at lower cost, deficiencies in key IT  management areas of strategic planning, enterprise architecture, and  investment management could continue to stand in the way of VA’s and  DOD’s attempts to jointly address their common health care system  needs in the most efficient and effective manner.
Chairman Miller, Ranking Member Michaud, and Members of the  Committee, this concludes my statement. I would be pleased to respond  to any questions that you may have.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: If you have any questions concerning this statement, please contact  Valerie C. Melvin, Director, Information Management and Technology  Resources Issues, at (202) 512-6304 or melvinv@gao.gov. Other  individuals who made key contributions include Mark T. Bird, Assistant  Director; Heather A. Collins; Kelly R. Dodson; Lee A. McCracken;   Umesh Thakkar; and Eric L. Trout.
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