DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers' Transition to VA Services
Published: 2005-05-19T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Since the onset of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), the Department of Defense (DOD) reported that more than 12,000 servicemembers have been injured in combat. While many return to active duty, others with more serious injuries are likely to be discharged from the military. To ensure the continuity of medical care and access to all other Department of Veterans Affairs' (VA) benefits, such as vocational rehabilitation, VA formed its Seamless Transition Task Force. In January 2005, GAO reported that VA had given high priority to OEF/OIF servicemembers, but faced challenges in identifying, locating, and following up with seriously injured servicemembers. GAO recommended that VA and DOD reach an agreement for VA to obtain systematic data from DOD, and the departments concurred. However, DOD raised privacy concerns. GAO was asked to review VA's efforts to expedite vocational rehabilitation services to seriously injured servicemembers and to determine the status of an agreement between DOD and VA to share health data. GAO relied on its prior work; interviewed VA and DOD officials; and reviewed the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA Privacy Rule, which govern the sharing of individually identifiable health data.
section_title: What GAO Found
paragraphs: While VA has taken steps to expedite services to seriously injured servicemembers, VA does not have systematic data from DOD on seriously injured servicemembers who may need VA vocational rehabilitation and other benefits. As a result, VA has had to rely on its regional offices to develop informal data sharing arrangements with local military treatment facility (MTF) staff to identify servicemembers who may need vocational rehabilitation services. However, VA staff have no official data source from DOD from which to confirm the completeness and reliability of the data they obtain. Furthermore, they cannot provide reasonable assurance that some seriously injured servicemembers who may have benefited from vocational rehabilitation services have not been overlooked. Although several VA headquarters officials and regional office staff GAO interviewed said that systematic data from DOD would provide them with a way to reliably identify and follow up with seriously injured servicemembers, DOD and VA have not developed a data sharing agreement. Additionally, VA officials said these data would help VA plan for projected increases in the need for services for newly returning OEF/OIF servicemembers. VA has requested that DOD provide systematic data on seriously injured servicemembers who may need vocational rehabilitation. DOD and VA have been working on a data sharing agreement for over 2 years, but have not reached an agreement. DOD and VA differ in their understanding of HIPAA Privacy Rule provisions that govern the sharing of individually identifiable health data for servicemembers currently receiving treatment at MTFs, and the extent to which the Privacy Rule would permit that exchange. DOD's and VA's inability to resolve these differences has impeded coming to an agreement on exchanging seriously injured servicemembers' individually identifiable health data. Despite being unable to agree on an exchange of individually identifiable health data, DOD and VA are reviewing a draft memorandum of understanding, which the departments believe will move them closer to a data sharing agreement. However, GAO found that the draft memorandum restates many of the legal authorities contained in the Privacy Rule for the use and disclosure of individually identifiable health data. As a result, even if the memorandum of understanding is finalized, DOD and VA will still have to agree on what types of individually identifiable health data can be exchanged and when the data can be shared. DOD and VA generally agreed with GAO's findings.

section_title: Letter
paragraphs: Thank you for inviting me to share our perspectives on seriously injured  servicemembers who could benefit from services offered by the  Department of Veterans Affairs (VA), such as vocational rehabilitation,  disability compensation, and health care, as they transition from  servicemember to veteran status. Since the onset of Operation Enduring  Freedom (OEF) in October 2001 and Operation Iraqi Freedom (OIF) in  March 2003, the Department of Defense (DOD) has reported that more  than 12,000 servicemembers have been injured in combat. While many  return to active duty after they are treated, others who are more seriously  injured are likely to be discharged from their military obligations and  return to civilian life with disabilities. To ensure the continuity of medical  care as a first priority as well as to coordinate efforts to ensure access to  all other VA benefits, such as vocational rehabilitation, VA formed its  Seamless Transition Task Force in August 2003.
In January 2005, we reported that while VA has given high priority to  providing services to OEF/OIF servicemembers, it was challenged in its  efforts to identify, locate, and follow up with seriously injured  servicemembers. One key problem has been the lack of systematic data  from DOD about who is seriously injured, the nature of their injuries, and  where the servicemembers received treatment. As DOD and VA have  worked toward a seamless transition, DOD raised concerns about privacy  issues and the sharing of individually identifiable health data. We  recommended that VA and DOD collaborate to reach an agreement for VA  to have access to DOD data for seriously injured servicemembers that  both departments agree are needed to promote recovery and return to  work and both departments concurred.
You asked us to testify on VA’s and DOD’s efforts to provide a seamless  transition for seriously injured OEF/OIF servicemembers. Specifically, we  (1) reviewed VA’s efforts to expedite vocational rehabilitation services to  seriously injured servicemembers and (2) determined the status of an  agreement between DOD and VA to share health data. My comments today  highlight the findings of our earlier work on VA’s vocational rehabilitation  services for seriously injured servicemembers returning from OEF/OIF  and our ongoing work on DOD’s and VA’s data sharing agreement.
Our January 2005 report on VA’s efforts to expedite vocational  rehabilitation services to OEF/OIF servicemembers was based on  interviews with officials at VA headquarters and at 12 of VA’s 57 regional  offices. Five of the 12 regional offices are located near the five major Army  military treatment facilities (MTF) treating the majority of seriously  injured OEF/OIF servicemembers during our review. We visited Walter  Reed Army Medical Center where most seriously injured Army  servicemembers are initially treated. To do our work on the status of  DOD’s and VA’s data sharing agreement, we reviewed a draft  memorandum of understanding for the sharing of data between DOD and  VA, pertinent provisions of the Health Insurance Portability and  Accountability Act of 1996 (HIPAA) and the HIPAA Privacy Rule, which  govern the sharing of individually identifiable health data. We also spoke  with officials responsible for the implementation of the Privacy Rule at  DOD and VA. We discussed the information contained in this statement  with DOD and VA officials who agreed with our findings. We did our work  from March through May 2005 in accordance with generally accepted  government auditing standards.
In summary, while VA has taken steps to expedite services to seriously  injured OEF/OIF servicemembers, VA does not have systematic data from  DOD on those servicemembers who may need vocational rehabilitation  and other benefits from VA. As a result, VA has had to rely on its regional  offices to develop informal data sharing arrangements with local MTF staff  to identify servicemembers who may need vocational rehabilitation  services. However, VA staff have no official data source from DOD from  which to confirm the completeness and reliability of the data obtained  through these informal, local arrangements. Furthermore, VA staff cannot  provide reasonable assurance that some seriously injured servicemembers  who may have benefited from early intervention by a vocational  rehabilitation counselor have not been overlooked. Unresolved issues  between DOD and VA continue to delay the systematic sharing of data. To  obtain systematic data from DOD on seriously injured OEF/OIF  servicemembers who may need VA services, DOD and VA have been  working on an agreement to exchange servicemembers’ health data for  over 2 years. DOD and VA differ in their understanding of HIPAA Privacy  Rule provisions that govern the sharing of individually identifiable health  data for seriously injured servicemembers receiving treatment in MTFs,  and the extent to which the Privacy Rule would permit that exchange.  DOD’s and VA’s inability to resolve these differences has impeded coming  to an agreement on exchanging seriously injured servicemembers’  individually identifiable health data. We continue to believe that an  agreement between DOD and VA to share health data would expedite the  delivery of VA services to OEF/OIF servicemembers, as well as help  ensure a seamless transition.
subsections: section_title: Background
paragraphs: Servicemembers deployed to Afghanistan and Iraq are surviving injuries  that would have been fatal in past conflicts due, in part, to advances in  battlefield medicine and protective equipment. However, the severity of  their injuries can result in a lengthy transition from injured servicemember  to veteran. Initially, most seriously injured servicemembers are brought to  Landstuhl Regional Medical Center in Germany for treatment. From there,  they are usually transported to major MTFs in the United States.  According to DOD officials, once stabilized and discharged from MTFs,  servicemembers usually relocate closer to their homes or military bases  and are treated as outpatients. At this point, the military generally begins  to assess whether the servicemember will be able to remain in the military,  a process that could take months to complete.
Faced with the need to provide benefits and services to a new generation  of veterans with disabilities, VA formed an internal task force—the  Seamless Transition Task Force—in August 2003 to develop and  implement policies to improve the transition of injured servicemembers  back to civilian life. Although the task force’s initial priority was to ensure  the continuity of medical care for injured servicemembers as they  transitioned from military to VA health care, it also coordinated efforts to  ensure access to all other VA benefits, including vocational rehabilitation.
DOD has also supported transition assistance in various ways. For  example, the VA/DOD Joint Executive Committee was established in  February 2002 to promote collaboration between the two departments,  including resolving obstacles to information sharing. The committee is  chaired by the Deputy Secretary of Veterans Affairs and the Under  Secretary of Defense for Personnel and Readiness. In addition, the Army— in cooperation with VA—established the Disabled Soldier Support System  in April 2004 as an advocacy group and information clearinghouse to  clarify the services available to disabled soldiers as they transition to  civilian life. In addition, DOD participated at times on VA’s Seamless  Transition Task Force.
Separation from the military and return to civilian life often entail the  exchange of individually identifiable health data between DOD and VA.  The exchange of these data must comply with the HIPAA Privacy Rule,  which became effective April 14, 2001. The Privacy Rule permits VA and  DOD to share servicemembers’ health data under certain circumstances.
section_title: VA Has Taken Steps to Expedite Vocational Rehabilitation Services, but Lack of Systematic Data from DOD Poses a Challenge
paragraphs: VA has given priority consideration and assistance to seriously injured  servicemembers returning from Afghanistan and Iraq. In a September 2003  letter, VA asked its regional offices to coordinate with staff at MTFs in  their areas to ascertain the identities, medical conditions, and military  status of the seriously injured OEF/OIF servicemembers. VA specifically  instructed regional offices to focus on servicemembers whose disabilities  were definitely or likely to result in military separation. Minimally, this  included servicemembers with injuries that had been classified as “very  serious,” “serious,” or in a “special category.” In this letter, VA instructed  its regional offices to assign a case manager to each seriously injured  servicemember who applied for disability compensation. In addition, VA  noted the particular importance of early intervention for those who were  seriously injured and emphasized that seriously injured servicemembers  applying for vocational rehabilitation should receive the fastest possible  service. Moreover, VA reminded vocational rehabilitation staff that they  can initiate evaluation and counseling and, in some cases, authorize  training before a servicemember was discharged.
Since most seriously injured servicemembers are initially treated at major  MTFs, VA has detailed staff to these facilities to identify and educate these  servicemembers about VA services. These staff include VA social workers  and disability compensation benefits counselors. At Walter Reed Army  Medical Center, where the largest number of seriously injured  servicemembers has been treated, VA’s Washington, D.C. regional office  has since 2001 also provided a vocational rehabilitation counselor to work  with hospitalized patients, specifically to offer and provide vocational  counseling and evaluation. The counselor reported attempting to contact  all patients within 48 hours of their arrival and visited them routinely  thereafter to establish rapport. Her primary mission is to work with  servicemembers who will need to prepare for civilian employment,  although she told us that her early intervention efforts could also help  servicemembers who are able to remain in the military.
Staff at another regional office noted that they also advocate early  intervention. These staff said that they try to contact servicemembers as  soon as possible to establish rapport and provide vocational rehabilitation  program information even before the servicemembers are physically ready  to begin vocational rehabilitation. We previously reported on the  importance of early intervention to maximize the work potential of  individuals with disabilities. We reported, for example, that rehabilitation  offered as close as possible to the onset of disabling impairments has the  greatest likelihood of success.
Despite efforts by VA’s regional offices to identify and obtain medical  information on seriously injured OEF/OIF servicemembers, lack of  systematic data from DOD poses a challenge. Although VA requested in  the spring of 2004 that DOD provide on a systematic basis personal  identifying data, medical data, and DOD’s injury classification for seriously  injured servicemembers, DOD and VA have not developed a data sharing  agreement. In the absence of a data sharing agreement with DOD, VA  cannot reliably identify all seriously injured servicemembers or know with  certainty when they are medically stabilized, when they may be  undergoing evaluation for a medical discharge, or when they are  discharged from the military. As a result, VA cannot provide reasonable  assurance that some seriously injured servicemembers who may benefit  from vocational rehabilitation services have not been overlooked.
In our review of 12 VA regional offices, we found that the nature of the  local relationship between VA staff and MTF staff was a key factor in the  completeness and reliability of the information that the MTF provided on  seriously injured servicemembers. For example, at one location, the MTF  staff provided VA regional office staff with the names of new patients but  no indication of the severity of their conditions or the combat theater from  which they were returning. Another regional office reported receiving lists  of servicemembers for whom the Army had initiated a medical separation  in addition to lists of patients with information on the severity of their  injuries. Some regional offices were able to capitalize on long-standing  informal relationships. For example, the VA coordinator responsible for  identifying and monitoring the seriously injured servicemembers at one  regional office had served as an Army nurse at the local MTF and was  provided all pertinent information.
VA staff at the 12 regional offices generally expressed confidence that the  data sources they developed enabled them to identify most seriously  injured servicemembers. However, we noted that informal data sharing  relationships could break down with changes in personnel at either the  MTF or the VA regional office. Several VA headquarters’ officials and  regional office staff we interviewed said that systematic data from DOD  would provide them with a way to reliably identify and follow up with  seriously injured servicemembers. Additionally, VA officials said these  data would help them plan for projected increases in services for newly  returning OEF/OIF servicemembers.
section_title: Unresolved Issues Continue to Delay a Data Sharing Agreement
paragraphs: After more than 2 years of discussion, DOD and VA have not developed a  data sharing agreement. Although DOD and VA officials agree that the  HIPAA Privacy Rule permits the exchange of individually identifiable  health data if the individual signs a proper authorization, the departments  have not pursued this as an alternative to a data sharing agreement. DOD  and VA officials said the departments want to pursue options under other  provisions of the Privacy Rule that may permit them to exchange data  without individual authorizations. However, DOD and VA differ in their  understanding of HIPAA Privacy Rule provisions that govern the sharing  of individually identifiable health data for servicemembers currently  receiving treatment in MTFs without an authorization, and the extent to  which the Privacy Rule would permit that exchange. DOD’s and VA’s  inability to resolve these differences has impeded coming to an agreement  on exchanging servicemembers’ individually identifiable health data.
Two examples help illustrate the different views of DOD and VA regarding  the HIPAA Privacy Rule. First, the Privacy Rule permits covered entities  that are also government agencies providing public benefits to disclose  individually identifiable health data to each other when the programs  serve the same or similar populations, and the disclosure is necessary to  coordinate the covered functions of such programs or to improve  administration and management related to the covered functions of the  programs. VA officials have said they believe that this provision allows  DOD to share servicemembers’ health data with VA because the  departments serve the same or similar populations—active duty  servicemembers who transition to veteran status. VA officials also said  they believe that DOD and VA provide public benefits. In contrast, a DOD  official who is responsible for implementation of the Privacy Rule does not  agree that DOD and VA serve the same or similar populations or that DOD  provides public benefits. This official said he believes that serving the  same or similar populations means that servicemembers have a dual  eligibility for both DOD and VA services. Although the official said that  while some former servicemembers are dually eligible for DOD and VA  services, not all qualify for both services simultaneously. This official also  said that the services that DOD provides are not public benefits because  they are unlike the examples of public benefits programs provided in the  preamble to the Privacy Rule. The Privacy Rule does not define public  benefits.
In the second example, the Privacy Rule explicitly permits the disclosure  of individually identifiable health data by DOD to VA upon the separation  or discharge of a servicemember in order to determine eligibility for VA  benefits. DOD views “upon the separation or discharge” as referring to  the separation process that varies by servicemember, but which begins  with the decision by DOD that the servicemember will separate. According  to VA officials, the HIPAA Privacy Rule would allow DOD to share data  sooner than the decision by DOD that the servicemember will separate.  However, DOD is reluctant to provide individually identifiable health data  to VA until DOD is certain that a servicemember will separate from the  military. DOD is concerned that VA’s outreach to servicemembers who are  still on active duty could work at cross-purposes to the military’s retention  goals. According to DOD officials, it would be premature for VA to begin  working with servicemembers who may eventually return to active duty.  VA contends that DOD could define the specific point of separation or  discharge earlier in the process. In commenting on our January 2005  report, VA said that a memorandum of understanding was then being  negotiated that would allow VA to obtain from DOD the servicemember’s  medical information prior to discharge from military service. VA added  that its Office of General Counsel was confident that there are exceptions  in the Privacy Rule that would permit military service medical information  to be disclosed for VA benefits purposes and that it had pressed the case  with DOD’s General Counsel. As of May 17, 2005, the memorandum of  understanding between DOD and VA has not been finalized.
Despite being unable to agree on an exchange of individually identifiable  health data, DOD and VA are currently reviewing a draft memorandum of  understanding. DOD and VA officials told us they believe that the  memorandum of understanding will move the two departments closer to a  data sharing agreement. However, we found that the draft memorandum of  understanding restates many of the legal authorities contained in the  Privacy Rule for the use and disclosure of individually identifiable health  data. For example, the draft memorandum of understanding does not  specify that individually identifiable health data of OEF/OIF  servicemembers shall be disclosed and restates that data will be shared  upon separation or discharge without further defining the specific point  during the separation or discharge process when data can be shared. As a  result, even if the memorandum of understanding is finalized, DOD and VA  will still not have a data sharing agreement that specifies what types of  individually identifiable health data can be exchanged and when the data  can be shared.
Mr. Chairman, this completes my prepared remarks. I will be pleased to  answer any questions you or other Members of the Subcommittee may  have at this time.
section_title: Contact and Acknowledgments
paragraphs: For further information, please contact Cynthia A. Bascetta at (202) 512- 7101. Also contributing to this statement were Mary Ann Curran, Marcia  Mann, Kevin Milne, and Janet Overton.
section_title: Related GAO Products
paragraphs: Vocational Rehabilitation: VA Has Opportunities to Improve Services,  but Faces Significant Challenges. GAO-05-572T. Washington, D.C.:   April 20, 2005.
VA Disability Benefits and Health Care: Providing Certain Services to  the Seriously Injured Poses Challenges. GAO-05-444T. Washington, D.C.:  March 17, 2005.
Vocational Rehabilitation: More VA and DOD Collaboration Needed to  Expedite Services for Seriously Injured Servicemembers. GAO-05-167.  Washington, D.C.: January 14, 2005.
Health Information: First-Year Experiences under the Federal Privacy  Rule. GAO-04-965. Washington, D.C.: September 3, 2004.
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