Electronic Health Records: DOD and VA Efforts to Achieve Full Interoperability Are Ongoing; Program Office Management Needs Improvement
Published: 2009-07-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The National Defense Authorization Act for Fiscal Year 2008 required the Department of Defense (DOD) and the Department of Veterans Affairs (VA) to accelerate their exchange of health information and to develop systems or capabilities that allow for interoperability (generally, the ability of systems to exchange data) by September 30, 2009. It also required compliance with federal standards and the establishment of a joint interagency program office to function as a single point of accountability for the effort. Further, the act directed GAO to semiannually report on the progress made in achieving these requirements. For this third report, GAO evaluated (1) the departments' progress and plans toward sharing fully interoperable electronic health information that comply with federal standards and (2) whether the interagency program office is positioned to function as a single point of accountability. To do so, GAO analyzed agency documentation on project status and conducted interviews with agency officials.
section_title: What GAO Found
paragraphs: DOD and VA have taken steps to meet six objectives that they identifiedforachieving full interoperability in compliance with applicable standards (see table) by September 30, 2009. Specifically, the departments have achieved planned capabilities for three of the objectives--refine social history data, share physical exam data, and demonstrate initial network gateway operation. For the remaining three objectives, the departments have partially achieved planned capabilities, with additional work needed to fully meet the objectives. Regarding the objective to expand questionnaires and self-assessment tools, this additional work is intended to be completed by the deadline. The departments' officials have stated that they intend to meet the objectives to expand DOD's inpatient medical records system and demonstrate initial document scanning; however, additional work will be required beyond September to perform all the activities necessary to meet clinicians' needs for health information. The DOD/VA Interagency Program Office is not yet effectively positioned to function as a single point of accountability for the implementation of fully interoperable electronic health record systems or capabilities between DOD and VA. While the departments have made progress in setting up the office by hiring additional staff, they continue to fill key leadership positions on an interim basis. Further, while the office has begun to demonstrate responsibilities outlined in its charter, it is not yet fulfilling key information technology management responsibilities in the areas of performance measurement (as GAO previously recommended), project planning, and scheduling, which are essential to establishing the office as a single point of accountability for the departments' interoperability efforts.

section_title: Letter
paragraphs: The Department of Defense (DOD) and the Department of Veterans Affairs  (VA) have been working for over a decade on initiatives to share data  between their health information systems. However, while they have taken  important steps, questions have continued to be raised about when and to  what extent the departments’ intended electronic sharing capabilities will  be fully achieved. In an effort to expedite the exchange of electronic  health information between the two departments, the National Defense  Authorization Act for Fiscal Year 2008 included provisions directing DOD  and VA to jointly develop and implement, by September 30, 2009, fully  interoperable electronic health record systems or capabilities that are  compliant with applicable federal interoperability standards. Such systems  and capabilities are important for making patient information more readily  available to health care providers in both departments, reducing medical  errors, and streamlining administrative functions. In addition, the act  established an interagency program office to be a single point of  accountability for the departments’ efforts.
Further, the act directed us to assess DOD’s and VA’s progress in  implementing the electronic health record systems and to report  semiannually our results to the appropriate congressional committees.  Accordingly, on July 28, 2008, and January 28, 2009, we issued reports in  response to the act. As agreed with the committees of jurisdiction, our  objectives for this third report are to (1) evaluate the departments’  progress and plans toward developing electronic health record systems or  capabilities that allow for full interoperability and comply with applicable  federal interoperability standards and (2) determine whether the  interagency program office established by the National Defense  Authorization Act for Fiscal Year 2008 is positioned to function as a single  point of accountability for developing and implementing electronic health  records.
To accomplish these objectives, we reviewed our past work in this area;  analyzed current agency documentation (including plans outlining  objectives for achieving interoperability, project status information, and  the interagency program office charter); and conducted interviews with  officials from DOD and VA.
We conducted this performance audit from April 2009 through July 2009,  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. For more details on our scope  and methodology, see appendix I.
subsections: section_title: Background
paragraphs: The use of information technology (IT) to electronically collect, store,  retrieve, and transfer clinical, administrative, and financial health  information has great potential to help improve the quality and efficiency  of health care and is important to improving the performance of the U.S.  health care system. Historically, patient health information has been  scattered across paper records kept by many different caregivers in many  different locations, making it difficult for a clinician to access all of a  patient’s health information at the time of care. Lacking access to these  critical data, a clinician may be challenged to make the most informed  decisions on treatment options, potentially putting the patient’s health at  greater risk. The use of electronic health records can help provide this  access and improve clinical decisions.
As we have previously noted, 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 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  interoperability—that is, the ability to share data among health care  providers. Interoperability enables different information systems or  components to exchange information and to use the information that has  been exchanged. This capability is important because it allows patients’  electronic health information to move with them from provider to  provider, regardless of where the information originated. If electronic  health records conform to interoperability standards, they can be created,  managed, and consulted by authorized clinicians and staff across more  than one health care organization, thus providing patients and their  caregivers the necessary information required for optimal care. 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 depends on the use of agreed-upon standards to ensure  that information can be shared and used. In the health IT field, standards  may govern areas ranging from technical issues, such as file types and  interchange systems, to content issues, such as medical terminology. DOD  and VA have agreed upon numerous common standards that allow them to  share health data. They have also participated in numerous standards- setting organizations tasked to reach consensus on the definition and use  of standards. For example, DOD and VA officials serve as members and  are actively working on several committees and groups within the  Healthcare Information Technology Standards Panel. The panel identifies  and harmonizes competing standards and develops interoperability  specifications that are needed for implementing the standards.
Interoperability can be achieved at different levels. At the highest level,  electronic data are computable (that is, in a format that a computer can  understand and act on to, for example, provide alerts to clinicians on drug  allergies). At a lower level, electronic data are structured and viewable,  but not computable. The value of data at this level is that they are  structured so that data of interest to users are easier to find. At still a  lower level, electronic data are unstructured and viewable, but not  computable. With unstructured electronic data, a user would have to find  needed or relevant information by searching uncategorized data. Beyond  these, paper records also can be considered interoperable (at the lowest  level) because they allow data to be shared, read, and interpreted by  human beings. According to DOD and VA officials, not all data require the  same level of interoperability, nor is interoperability at the highest level  achievable in all cases. For example, unstructured, viewable data may be  sufficient for such narrative information as clinical notes. Figure 1 shows  the distinction between the various levels of interoperability and examples  of the types of data that can be shared at each level.
subsections: section_title: DOD and VA Have Been Working to Exchange Health Information for Over a Decade
paragraphs: DOD and VA have been working to exchange patient health information  electronically since 1998. We have previously noted their efforts on three  key projects:    The Federal Health Information Exchange (FHIE), begun in 2001 and  enhanced through its completion in 2004, enables DOD to electronically  transfer service members’ electronic health information to VA when the  members leave active duty.
The Bidirectional Health Information Exchange (BHIE), established in  2004, was aimed at allowing clinicians at both departments viewable  access to 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.  The interface also allows DOD sites to see previously inaccessible data at  other DOD sites.
The Clinical Data Repository/Health Data Repository (CHDR)  interface,  implemented in September 2006, linked the departments’ separate  repositories of standardized data to enable a two-way exchange of  computable health information. These repositories are a part of the  modernized health information systems that the departments have been  developing—DOD’s AHLTA and VA’s HealtheVet.
In their ongoing initiatives to share information, VA uses its integrated  medical information system—the Veterans Health Information Systems  and Technology Architecture (VistA)—which was developed in-house by  VA clinicians and IT personnel. All VA medical facilities have access to  all VistA information.
DOD currently relies on its AHLTA, which is comprised of multiple legacy  medical information systems that the department developed from  commercial software products that were customized for specific uses. For  example, CHCS, which was formerly DOD’s primary health information  system, is still in use to capture pharmacy, radiology, and laboratory order  management. In addition, the department uses Essentris (also called the  Clinical Information System), a commercial health information system  customized to support inpatient treatment at military medical facilities.  Not all of DOD’s medical facilities yet have this inpatient medical system.
section_title: DOD and VA Have Identified Interoperability Objectives
paragraphs: To facilitate compliance with the act, the Interagency Clinical Informatics  Board, made up of senior clinical leaders from both departments who  represent the user community, began establishing priorities for  interoperable health data between DOD and VA. In this regard, the board  is responsible for determining clinical priorities for electronic data sharing  between the departments, as well as what data should be viewable and  what data should be computable. Based on its work, the board established  six interoperability objectives for meeting the departments’ data sharing  needs. According to the former acting director of the interagency program  office, DOD and VA consider achievement of these six objectives, in  conjunction with capabilities previously achieved (e.g., FHIE, BHIE,  CHDR), to be sufficient to satisfy the requirement for full interoperability  by September 2009. The six objectives are listed in table 1.
section_title: GAO Reports Have Highlighted the Need for DOD and VA to Address Issues in Their Efforts to Share Health Information
paragraphs: Our prior reports on DOD’s and VA’s efforts to develop fully interoperable  electronic health records noted their progress and highlighted issues that  they needed to address to achieve electronic health record  interoperability. Specifically, our July 2008 report noted that the  departments were sharing some, but not all, electronic health information  at different levels of interoperability. At that time the departments’ efforts  to set up the interagency program office were in the early stages.  Leadership positions in the office were not permanently filled, staffing was  not complete, and facilities to house the office had not been designated.  Accordingly, we recommended that the Secretaries of Defense and  Veterans Affairs expedite efforts to put in place permanent leadership,  staff, and facilities for the program office. The departments agreed with  our recommendations and stated that they would take actions to address  them.
Our January 2009 report noted that the departments had defined plans to  further increase their sharing of electronic health information; however,  the plans did not contain results-oriented (i.e., objective, quantifiable, and  measurable) performance goals and measures that could be used as a  basis to track and assess progress. We recommended the departments  develop and document such goals and performance measures for the six  interoperability objectives, to use as the basis for future assessments and  reporting of interoperability progress. DOD and VA agreed with our  recommendation and stated that the departments intended to include  results-oriented goals in their future plans.
section_title: DOD and VA Have Taken Steps to Meet their Objectives, but Activities Are Expected to Remain after the Deadline for Achieving Full Interoperability
paragraphs: DOD and VA continue to take steps toward achieving full interoperability  in compliance with applicable standards by September 30, 2009. In this  regard, the departments have achieved planned capabilities for three of  the interoperability objectives—refine social history data, share physical  exam data, and demonstrate initial network gateway operation. The  following information further explains DOD’s and VA’s activities with  respect to these three objectives.
Refine social history data: The departments established this objective to  enable DOD to share social history data captured in its electronic health  record with VA. These data describe, for example, patients’ involvement in  hazardous activities and tobacco and alcohol use. Our review of DOD and  VA project documentation confirmed that the departments have achieved  sharing of viewable social history data, thus providing VA with additional  clinical information on shared patients that clinicians could not previously  view.
Share physical exam data: The departments established this objective to  implement an initial capability for DOD to share with VA the electronic  health record information that supports the physical exam process when a  service member separates from active military duty. To this end, the  departments achieved the capability for VA to view DOD’s medical exam  data through the BHIE interface, allowing VA to view outpatient treatment  records, pre- and postdeployment health assessments, and  postdeployment health reassessments, which are compiled for the DOD  physical exam.
Demonstrate initial network gateway operation: DOD and VA want to  demonstrate the operation of secure network gateways to support health  information sharing between the departments. These gateways are to  support health record data exchange, thus facilitating future growth in  data sharing. As of early July 2009, the departments reported that five  network gateways were operational and that data migration to two of the  operational gateways had begun. The departments believed these five  gateways satisfy the intent of the objective and will provide sufficient  capacity to support health information sharing between DOD and VA as of  September 2009. The officials stated, however, that they anticipate needing  up to four additional gateways to support future growth in information  sharing between the departments at locations and dates that are to be  determined.
For the remaining three objectives, the departments have partially  achieved planned capabilities, with additional work needed to fully meet  the objectives. Regarding the objective to expand questionnaires and self- assessment tools, this additional work is intended to be completed by  September 2009. With respect to the objectives to expand Essentris and  demonstrate initial document scanning, department officials stated that  they also intend to meet these objectives; however, additional work will be  required beyond September to perform all the activities necessary to meet  clinicians’ needs for health information. The following information further  explains the departments’ activities with respect to these objectives.
Expand questionnaires and self-assessment tools: The departments  intend to provide all periodic health assessment data stored in the DOD  electronic health record to VA in a format that associates questions with  responses. Health assessment data are collected from two sources:  questionnaires administered at military treatment facilities and a DOD  health assessment reporting tool that enables patients to answer questions  about their health upon entry into the military. Questions relate to a wide  range of personal health information, such as dietary habits, physical  exercise, and tobacco and alcohol use. Our review of the departments’  project documentation determined that they have established the  capability for VA to view questions and answers from the questionnaires  collected by DOD at military treatment facilities; however, they have not  yet established the capability for VA to view information from DOD’s  health assessment reporting tool. Department officials stated that they  intend to establish this additional capability by September 2009.
Expand Essentris in DOD: By September 30, 2009, DOD intends to  expand Essentris to at least one additional site for each military service  and to increase the percentage of inpatient discharge summaries that it  shares electronically with VA to 63 percent. According to the acting  director of the interagency program office, as of late June 2009, the  departments had expanded the system to two Army sites (but not yet to an  Air Force or Navy site) and were sharing 58 percent of inpatient discharge  summaries. The acting director stated that the departments expect to meet  their goal of sharing 63 percent of inpatient discharge summaries and  expand the system to an Air Force and a Navy site by the September  deadline. Nonetheless, the official stated that to better meet clinicians’  needs, DOD plans to further expand the inpatient medical records system.  In this regard, the department has established a revised goal of making the  inpatient system operational for 92 percent of DOD’s inpatient beds by  September 2010.
Demonstrate initial document scanning: The departments intend to  demonstrate an initial capability to scan service members’ medical  documents into the DOD electronic health record and share the  documents electronically with VA by September 2009. According to the  program office acting director, the departments were in the process of  setting up an interagency test environment to test the initial capability to  query medical documents associated with specific patients as of late June  2009. He stated that the departments expect to begin user testing at up to  nine sites by September 2009. According to this official, these activities are  expected to demonstrate initial document scanning capability. However,  after September, the departments anticipate performing additional work to  expand their initial document scanning capability (e.g., completion of user  testing and deployment of the scanning capability at all DOD sites).
section_title: DOD/VA Interagency Program Office Has Made Progress in Becoming Operational, but Is Not Fully Functioning as a Single Point of Accountability
paragraphs: The DOD/VA Interagency Program Office is not yet effectively positioned  to serve as a single point of accountability for the implementation of fully  interoperable electronic health record systems or capabilities. Since we  last reported in January 2009, the departments have made progress in  setting up the office by hiring additional staff, although they continue to  fill key leadership positions on an interim basis. In addition, the office has  begun to demonstrate responsibilities outlined in its charter, but is not yet  fulfilling key IT management responsibilities in the areas of performance  measurement, scheduling, and project planning.
subsections: section_title: Progress Made in Staffing Interagency Program Office
paragraphs: To address the requirements set forth in the act, the departments  identified in the September 2008 DOD/VA Information Interoperability  Plan a schedule and key activities for setting up the interagency program  office. Since we last reported in January 2009, the departments have  completed all but one of the activities identified in their schedule. For  example, they have completed personnel descriptions for the office’s staff  and have continued efforts to recruit and hire staff for both government  and contractor positions. As of early July 2009, the departments had  selected staff members for 10 of 14 government positions, an increase of 8  staff since our last report. The acting director of the office reported that  recruitment efforts were underway to fill the remaining 4 positions by late  September 2009. Further, all 16 contractor positions had been filled, an  increase of 10 contractor staff since we last reported. Table 2 provides the  status of selected key activities to establish the interagency program  office.
However, while the departments have taken action toward hiring a full- time permanent director and a deputy director to lead the office, these  positions continue to be filled on an interim basis. As of early July, DOD  had selected a candidate for the director position, VA had concurred with  the selection, and the candidate’s application had been sent to the Office  of Personnel Management for approval. In the meantime, the departments  requested and received an extension of the current acting director’s  appointment until September 30, 2009, or until a permanent official is  hired. Further, as of late June 2009, interagency program officials stated  that actions were underway to fill the deputy director position and that VA  was interviewing candidates for this position. According to the acting  director, the departments anticipate making a selection for the deputy  director position by the end of July 2009.
section_title: Interagency Program Office Has Not Fulfilled Key Management Responsibilities Identified in Its Charter
paragraphs: The January 2009 interagency program office charter describes, among  other things, the mission and function of the office associated with  attaining interoperable electronic data. The charter further identifies  responsibilities of the office in carrying out its mission, in areas such as  oversight and management, stakeholder communication, and decision  making.
The office has taken steps toward fulfilling certain responsibilities  described in its charter. For example, the office submitted its first annual  report to Congress that summarized the departments’ efforts toward  achieving full interoperability and the status of key activities completed to  set up the office. Further, the office developed 11 standard operating  procedures in areas such as program management oversight, strategic  communications, and process improvement.
However, the office has yet to carry out other key responsibilities  identified in its charter that are fundamental to effective IT program  management and that would be essential to effectively serving as the  single point of accountability. For example, the office has not yet  established results-oriented (i.e., objective, quantifiable, and measurable)  goals and performance measures for all six interoperability objectives—an  action that we previously recommended that DOD and VA undertake.
Using results-oriented metrics to measure progress is an important IT  program management activity because they can serve as a basis to provide  meaningful information on the status of a program. As noted earlier, DOD  and VA agreed with our recommendation calling for the establishment of  results-oriented performance goals and measures. Further, the program  office charter identifies the development of metrics to monitor the  departments’ performance against interoperability goals as a responsibility  of the office. Nonetheless, the office has only developed such a goal for  one interoperability objective—expand Essentris in DOD. It has not  developed results-oriented goals and measures for the other five  objectives, instead stating that such goals and measures will be included in  the next version of the DOD/VA Joint Executive Council Joint Strategic  Plan (known as the joint strategic plan), which the office expects to  complete by December 2009. If the departments complete the  development of results-oriented performance goals and measures for their  interoperability objectives, they will be better positioned to gauge their  progress toward achieving fully interoperable capabilities and improving  veterans’ health care.
Development of an integrated master schedule is also a key IT program  management activity, especially given the complexity of the departments’  efforts to achieve full interoperability. According to DOD guidance, an  integrated master schedule should identify detailed project tasks and the  associated start, completion, and interim milestone dates; resource needs;  and relationships (e.g., sequence and dependencies) between tasks.
While the program office has begun to develop an integrated master  schedule as required by its charter, the current version does not include  the attributes of an effective schedule. For example, the schedule included  limited information for three of the six interoperability objectives (i.e.,  refine social history data, share physical exam data, and expand  questionnaires and self-assessment tools). Specifically, the schedule  included the name of each objective and a completion date of September  30, 2009. However, the schedule contained no information on tasks to be  performed to meet the objectives. Further, the schedule did not reflect  start dates, resource needs, or relationships between tasks for any of the  six interoperability objectives. Without a complete and detailed integrated  master schedule, the departments are missing another key activity that  could be useful in determining their progress towards achieving full  interoperability.
Similarly, development of a project plan is an important activity for IT  program management. Industry best practices and IT project management  principles stress the importance of sound planning for any project.  Inherent in such planning is the development and use of a project  management plan that describes, among other factors, the project’s scope,  resources, and key milestones. The interagency program office charter  identifies the need to develop a project plan, but, as of late June 2009, the  office had not yet done so. Without a project plan, the departments lack a  key tool that could be used to guide their efforts in achieving full  interoperability.
In discussing these activities, the program office’s acting director and  former acting director cited three reasons for why performance  measurement, scheduling, and project planning responsibilities had not  been accomplished. First, they stated that because it has taken longer than  anticipated to hire staff, the office has not been able to perform all of its  responsibilities. Second, the office’s interim leadership and staff have  focused their efforts on providing to interested parties (e.g., federal  agencies and military organizations) briefings, presentations, and status  information on activities the office is undertaking to achieve  interoperability, in addition to participating in efforts to develop a strategy  for implementation of the Virtual Lifetime Electronic Record, which the  President announced in April 2009. Finally, according to the officials, the  office waited until June 2009 to begin the process of developing metrics so  that they could do so in conjunction with the departments’ annual update  to the joint strategic plan that is scheduled for completion in late 2009.  However, without metrics to monitor progress, a complete integrated  master schedule, and a project plan, the interagency program office’s  ability to effectively provide oversight and management, including  meaningful progress reporting on the delivery of interoperable  capabilities, is jeopardized. Moreover, in the absence of these critical  activities, the office is not effectively positioned to function as the single  point of accountability for achieving full interoperability.
section_title: Conclusions
paragraphs: DOD and VA have continued to increase electronic health information  interoperability. In particular, the departments have taken steps to meet  their six interoperability objectives by September 30, 2009. However, for  two of the six interoperability objectives, the departments subsequently  plan to perform significant additional activities that are necessary to meet  clinicians’ needs. Further, the departments’ lack of progress in establishing  fundamental IT management capabilities that are specific responsibilities  of the interagency program office contributes to uncertainty about the  extent to which the departments will progress toward achievement of full  interoperability by the deadline. While the departments have generally  made progress toward making the program office operational, the office  has not yet completed a project plan or a detailed integrated master  schedule. Without these important tools, the office is limited in its ability  to effectively manage and provide meaningful progress reporting on the  delivery of interoperable capabilities that are intended to improve the  quality of health care provided to our nation’s veterans.
section_title: Recommendation for Executive Action
paragraphs: To better improve management of DOD’s and VA’s efforts to achieve fully  interoperable electronic health record systems, including satisfaction of  the departments’ interoperability objectives, we recommend that the  Secretaries of Defense and Veterans Affairs direct the Director of the  DOD/VA Interagency Program Office to establish a project plan and a  complete and detailed integrated master schedule.
section_title: Agency Comments and Our Evaluation
paragraphs: In written comments on a draft of this report, the DOD official who is  performing the duties of the Assistant Secretary of Defense (Health  Affairs) and the Acting Director of the DOD/VA Interagency Program  Office concurred with our findings and recommendation. The VA Chief of  Staff also provided written comments, in which the department concurred  with our recommendation. In this regard, DOD and VA stated that they will  provide the necessary information for the DOD/VA Interagency Program  Office to establish a project plan and to complete a detailed integrated  master schedule. If the recommendation is properly implemented, it  should better position DOD and VA to effectively measure and report  progress in achieving full interoperability.
Beyond its concurrence with the recommendation, the VA Chief of Staff  stated that the department disagreed with the report’s characterization of  the six interoperability objectives and expressed concern about the report  projecting that the objective to demonstrate initial document scanning  would not be completed by the September 30, 2009 deadline. Specifically,  VA stated that our report portrayed the six interoperability objectives as  the necessary steps to achieving full interoperability, even though the  departments consider the objectives to be just one component of  achieving full interoperability, along with existing data exchange  capabilities. However, in discussing the objectives, we stated that  according to the former acting director of the interagency program office,  the departments consider achievement of the six objectives, in  conjunction with capabilities previously achieved (e.g., FHIE, BHIE,  CHDR), to be sufficient to satisfy the requirement for full interoperability  by September 2009.
With respect to the objective to demonstrate initial document scanning,  the Chief of Staff stated that our report projects that the objective will not  be met by the September deadline. However, while our report states that  according to the acting program office director, additional work will be  required beyond September to perform all the activities necessary to meet  clinicians’ needs related to document scanning, we did not report that the  departments would not meet this objective by the September deadline. In  fact, our report noted that according to this official the departments  expect to begin user testing at up to nine sites by September 2009, and that  these activities are expected to demonstrate initial document scanning  capability. Nonetheless, we revised our report as appropriate, in an  attempt to more clearly reflect the departments’ intent with regard to this  objective.
DOD, VA, and the interagency program office also provided technical  comments on the draft report, which we incorporated as appropriate. The  departments and the DOD/VA Interagency Program Office comments are  reproduced in app. II, app. III, and app. IV, respectively.
We are sending copies of this report to the Secretaries of Defense and  Veterans Affairs, appropriate congressional committees, and other  interested parties. In addition, the report is available at no charge on the  GAO Web site at http://www.gao.gov.
If you or your staffs have questions about this report, please contact me at  (202) 512-6304 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 V.
section_title: Appendix I: Scope and Methodology
paragraphs: To evaluate the Department of Defense’s (DOD) and Veterans Affairs’ (VA)  progress toward developing electronic health record systems or  capabilities that allow for full interoperability of personal health care  information, we reviewed our previous work on DOD and VA efforts to  develop health information systems, interoperable health records, and  interoperability standards to be implemented in federal health care  programs. We obtained and analyzed agency documentation and  interviewed program officials to determine DOD’s and VA’s progress  towards achieving full interoperability by September 30, 2009, as required  by the National Defense Authorization Act for Fiscal Year 2008. We also  analyzed information gathered from agency documentation to identify  interoperability objectives, milestones, and target dates for ongoing and  planned interoperability initiatives whose target dates extend beyond  September 30, 2009. In addition, through interviews with cognizant DOD  and VA officials, we obtained and assessed information regarding the  departments’ plans for achieving full interoperability of electronic health  information.
To determine whether the interagency program office is positioned to  serve as a single point of accountability for developing and implementing  electronic health records, we obtained and reviewed program office  documentation, including its charter and standard operating procedures.  We compared the responsibilities identified in the charter with actions  taken by the office to exercise the responsibilities. Additionally, we  interviewed interagency program office officials to determine the status of  filling leadership and staffing positions within the office.
We conducted this performance audit at DOD and VA locations in the  greater Washington, D.C., metropolitan area from April through July 2009,  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: Comments from the DOD/VA Interagency Program Office
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributions to this report  were made by Mark Bird, Assistant Director; Rebecca Eyler; Lee  McCracken; Michael Redfern; J. Michael Resser; Kelly Shaw; Eric Trout;  and Merry Woo.