Electronic Health Records: DOD's and VA's Sharing of Information Could Benefit from Improved Management
Published: 2009-01-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Under the National Defense Authorization Act for Fiscal Year 2008, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) are required to accelerate the exchange of health information between the departments and to develop systems or capabilities that allow for interoperability (generally, the ability of systems to exchange data) and that are compliant with federal standards. The Act also established a joint interagency program office to function as a single point of accountability for the effort, which is to implement such systems or capabilities by September 30, 2009. Further, the Act required that GAO semi-annually report on the progress made in achieving these goals. For this second report, GAO evaluates the departments' progress and plans toward sharing electronic health information that comply with federal standards, and whether the interagency program office is positioned to function as a single point of accountability. To do so, GAO reviewed its past work, analyzed agency documentation, and conducted interviews.
section_title: What GAO Found
paragraphs: DOD and VA continue to increase health information sharing through ongoing initiatives and related activities. Specifically, the departments' are now exchanging pharmacy and drug allergy data on over 21,000 shared patients, an increase of about 2,700 patients between June and October 2008. Further, they recently expanded the number of standards and specifications with which they expect their interoperability initiatives will comply. In addition, DOD reported that it received certification of its electronic health record system. Also, the departments have defined their plans to further increase their sharing of electronic health information. In particular, they have identified the Joint Executive Council Strategic Plan and the DOD/VA Information Interoperability Plan as the key documents defining their planned efforts to provide interoperable health records. These plans identify various objectives and activities that, according to the departments, are aimed at increasing health information sharing and achieving full interoperability, as required by the National Defense Authorization Act for Fiscal Year 2008. However, neither plan identifies 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. In the absence of results-oriented goals and performance measures, the departments are not positioned to adequately assess progress toward increasing interoperability. Instead, DOD and VA are limited to assessing progress in terms of activities completed and increases in data exchanged (e.g., the number of patients for which certain types of data are exchanged). The departments have continued to take steps to set up the interagency program office. For example, they have developed descriptions for key positions and agreed with GAO's July 2008 recommendation that they give priority to establishing permanent leadership and hiring staff. Also, the departments developed the program office organization structure document that depicts the office's organization and, in January 2009, the departments approved a program office charter to describe, among other things, the mission and function of the office. Nonetheless, DOD and VA have not yet fully executed their plan to set up the program office. For example, among other activities, they have not yet filled key positions for the Director and Deputy Director, or 22 of 30 other positions identified for the office. In the continued absence of a fully established program office, the departments will remain ineffectively positioned to assure that interoperable electronic health records and capabilities are achieved by the required date.

section_title: Letter
paragraphs: As you are aware, the Department of Defense (DOD) and the Department  of Veterans Affairs (VA) have, for over a decade, pursued initiatives to  share data between their health information systems. The departments’  efforts have included working toward a long-term vision of a single  “comprehensive, lifelong medical record” that would enable each service  member to transition seamlessly between the two departments, as well as  more short-term efforts focused on meeting immediate needs to share  health information, including responding to current military crises.
However, while important steps have been taken, questions have remained  concerning when and to what extent the intended electronic sharing  capabilities of the two departments will be fully achieved, prompting  continuing calls for progress in the sharing of essential health information.  Among these, a presidential task force recommended in May 2003 that  DOD and VA develop and deploy bidirectional electronic health records by  fiscal year 2005. Further, in July 2007, the President’s Commission on Care  for America’s Returning Wounded Warriors reported that the departments  had continued to develop independent, stand-alone systems and  recommended that DOD and VA move rapidly to make all essential health  information available to clinicians.
More recently, to expedite the departments’ efforts to exchange electronic  health information, 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. The Act required that these systems or  capabilities be compliant with applicable interoperability standards of the  federal government, and it established an interagency program office to be  a single point of accountability for the departments’ efforts.
In addition, the Act directed GAO to assess DOD’s and VA’s progress in  implementing the electronic health record systems and to report  semiannually its results to the appropriate congressional committees.  Accordingly, on July 28, 2008, we issued the first of our reports in  response to the Act. Further, we subsequently testified on this report in  September 2008. As agreed with the committees of jurisdiction, our  objectives for this second 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 carry out these objectives, we reviewed our past work in this area;  analyzed current agency documentation (including plans for achieving  interoperability, actions accomplished or planned to establish the  interagency program office, and program documentation for  interoperability standards); and conducted interviews with officials from  DOD, VA, and the Department of Health and Human Services’ Office of the  National Coordinator for Health Information Technology.
We conducted this performance audit from August 2008 through January  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.
Electronic health records are particularly crucial for optimizing the health  care provided to military personnel and veterans. While in military status  and later as veterans, many DOD and VA patients tend to be highly mobile  and may have health records residing at multiple medical facilities within  and outside the United States. Making such records electronic can help  ensure that complete health care information is available for most military  service members and veterans at the time and place of care, no matter  where it originates.
Key to making health care information electronically available is  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, paper records do not provide  decision support capabilities, such as automatic alerts about a particular  patient’s health, or other advantages of automation.)
Interoperability can be achieved at different levels. At the highest level,  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. Figure 1 shows the distinctions between the various levels  of interoperability and examples of the types of data that can be shared at  each level.
According to DOD and VA officials, not all data require the same level of  interoperability. For example, in their initial efforts to implement  computable data, DOD and VA focused on outpatient pharmacy and drug  allergy data because clinicians gave priority to the need for automated  alerts to help medical personnel avoid administering inappropriate drugs  to patients. On the other hand, for such narrative data as clinical notes,  unstructured, viewable data may be sufficient. Achieving even a minimal  level of electronic interoperability is valuable for potentially making all  relevant information available to clinicians.
subsections: section_title: Efforts to Adopt and Implement Federal Interoperability Standards Are Ongoing
paragraphs: Interoperability depends on adherence to common standards to promote  the exchange of health information between participating agencies and  with nonfederal entities in supporting quality and efficient health care. In  the health IT field, standards govern areas ranging from technical issues,  such as file types and interchange systems, to content issues, such as  medical terminology. Developing, coordinating, and agreeing on standards  are only part of the processes involved in achieving interoperability for  electronic health record systems or capabilities. In addition, specifications are needed for implementing the standards, as well as criteria and a  process for verifying compliance with the standards.
In April 2004, the President called for widespread adoption of  interoperable electronic health records by 2014.  Health Information  established the Office of the National Coordinator for Technology within the Department of Health and Human Services (HHS).  This office has been tasked to, among other things, develop, ma direct the implementation of a strategic plan to guide the nationwide  implementation of interoperable health IT in both the public and private  health care sectors. Under the direction of HHS (through the Office of the  National Coordinator), three primary organizations were designated to  play major roles in expanding the implementation of health IT:    The American Health Information Community was created by the  Secretary of HHS as a federal advisory body to make recommendatio on how to accelerate the development and adoption of healt including advancing interoperability, identifying health IT standards,  advancing a nationwide health information exchange, and protecti ng  personal health information. Formed in September 2005, the  community is made up of representatives from both the public and private sectors, including high-level DOD and VA officials. The  community determines specific health care areas of high priority and  develops “use cases” for these areas, which provide the cont ext in  which standards would be applicable. The use cases convey how he care professionals would use such records and what standards w apply.
Executive Order 13335, Incentives for the Use of Health Information Technology and  Establishing the Position of the National Health Information Technology Coordinator  (Washington, D.C.: Apr. 27, 2004).
The Healthcare Information Technology Standards Panel, sponsored byerican National Standards Institute and funded by the Office of  the Am the National Coordinator, was established in October 2005 as a public- private partnership to identify competing standards for the use cases  being developed by the American Health Information Community and  to “harmonize” the standards. The panel also develops the  interoperability specifications that are needed for implementing the  standards. Interoperability specifications were developed fo the seven use cases developed by the American Health Information  Community in 2006 and 2007. The community also developed six use cases for 2008. The Healthcare Information Technology Standards  Panel is made up of representatives from both the public and private  sectors, including DOD and VA officials who serve as members and a actively working on several committees and groups within the panel.
section_title: DOD and VA Have Been Pursuing Efforts to Exchange Health Information for Over a Decade
paragraphs: DOD and VA have been working to exchange patient health data  electronically since 1998. As we have previously noted, their effo included both short-term initiatives to share information in existing  (legacy) systems, as well as a long-term initiative to develop moderni zed  health information systems—replacing their legacy systems—that would  be able to share data and, ultimately, use interoperable electronic health  records.
In their short-term initiatives to share information from existing systems,  the departments began from different positions. VA has one integrated  medical information system—the Veterans Health Information Systemsand Technology Architecture (VistA)—which uses all electronic records and was developed in-house by VA clinicians and IT personnel. All VA  medical facilities have access to all VistA information.
In contrast, DOD uses multiple legacy medical information systems, all of  which are commercial software products that are 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 pharmacy, radiology, and laboratory information. In addition, the  Clinical Information System (CIS), a commercial health information  system customized for DOD, is used to support inpatient treatment at  military medical facilities.
The departments’ short-term initiatives to share information in their  existing systems have included the following projects:    The Federal Health Information Exchange (FHIE), completed in 2004,  enables DOD to electronically transfer service members’ electronic  health information to VA when the members leave active duty. he Bidirectional Health Information Exchange (BHIE), also  T established in 2004, was aimed at allowing clinicians at both  departments viewable access to records on shared patients (t those who receive care from both departments—for example, vetera ns  may receive outpatient care from VA clinicians and be hospitalized at a  hat is,  military treatment facility). The interface also allows DOD sites to see  previously inaccessible data at other DOD sites.
As part of the long-term initiative, each of the departments aims to develop  a modernized system in the context of a common health information  architecture that would allow a two-way exchange of health information.  The common architecture is to include standardized, computable data;  communications; security; and high-performance health information  systems: DOD’s Armed Forces Health Longitudinal Technology  Application (AHLTA) and VA’s HealtheVet. The departments’ modernized  systems are to store information (in standardized, computable form) in  separate data repositories: DOD’s Clinical Data Repository (CDR) and VA’s  Health Data Repository (HDR). For the two-way exchange of health  information, in September 2006 the departments implemented an interface  named CHDR, to link the two repositories.
Beyond these initiatives, in January 2007, the departments announced  their intention to jointly determine an approach for inpatient health  records. On July 31, 2007, they awarded a contract for a feasibility study  and exploration of alternatives. In December 2008, the contractor provide the departments with a recommended strategy for jointly developing an  inpatient solution.
section_title: GAO’s Recent Report Highlighted DOD’s and VA’s Efforts to Share Health Information and Identified the Need to Set Up the Program Office and Finalize the Implementation Plan
paragraphs: In reporting on the departments’ progress toward developing fully  interoperable electronic health records in July 2008, we highlighted  several findings:    DOD and VA had established and implemented mechanisms to achieve  sharing of electronic health information at different levels of  interoperability. As of June 2008, pharmacy and drug allergy data on  about 18,300 shared patients were being exchanged at the highest level  of interoperability—that is, in computable form, a standardized format  that a computer application can act on (for example, to provide alerts  to clinicians of drug allergies). Viewable data also were being shared  including, among other types, outpatient pharmacy data, allergy  information, procedures, problem lists, vital signs, microbiology  results, cytology reports, and chemistry and hematology reports.  However, the departments were not sharing all electronic health data,  including for example, immunization records and history, data on  exposure to health hazards, and psychological health treatment and  care records. Finally, although VA’s health information was all  captured electronically, not all health data collected by DOD were  electronic—many DOD medical facilities used paper-based health  records.
DOD and VA were participating in a number of initiatives led by the  Office of the National Coordinator for Health Information Technology  (within HHS), aimed at promoting the adoption of federal standards  and broader use of electronic health records. The involvement of the  departments in these initiatives was an important mechanism for  aligning their electronic health records with emerging standards. The  departments also had jointly published a common (agreed to) set of  interoperability standards called the Target DOD/VA Health Standards  Profile. Updated annually, the profile was used for reviewing joint  DOD/VA initiatives to ensure standards compliance. The departments  anticipate such updates and revisions to the profile as additional  federal standards emerge and are recognized and accepted by HHS. In  addition, according to DOD officials, the department was taking steps  to ensure that its modernized health information system, AHLTA, was  compliant with standards by arranging for certification through the  Certification Commission for Healthcare Information Technology.  Specifically, version 3.3 of AHLTA was conditionally certified in April  2007 against 2006 outpatient electronic health record criteria  established by the commission. DOD officials stated that AHLTA  version 3.3 was installed at three DOD locations.
The departments’ efforts to set up the DOD/VA Interagency Program  Office were still in their early stages. Leadership positions in the office  had not been permanently filled, staffing was not complete, and  facilities to house the office had not been designated. According to the  Acting Director, DOD and VA had begun developing a charter for the  office, but had not yet completed the document. Further, the  implementation plan was in draft, and although it included schedules,  milestones for several activities were not determined (such as  implementing a capability to share immunization records), even though  all capabilities were to be achieved by September 2009. We pointed out  that without a fully established program office and a finalized  implementation plan with set milestones, the departments might be  challenged in meeting the September 2009 date for achieving  interoperable electronic health records and capabilities. As a result, we  recommended that the Secretaries of Defense and Veterans Affairs give  priority to fully establishing the interagency program office and  finalizing the draft implementation plan. Both DOD and VA agreed with  these recommendations.
section_title: DOD and VA Report Continued Progress toward Increased Interoperability; however, Plans Lack Results-Oriented Performance Goals and Measures
paragraphs: Since our July 2008 report and September 2008 testimony, DOD and VA  have continued to make progress toward increased interoperability  through ongoing initiatives and activities documented in their plans  related to increasing information sharing efforts. Also, the departments  recently expanded the number of standards and specifications with which  they expect their interoperability initiatives will comply. However, the  departments’ plans lack results-oriented (i.e., objective, quantifiable, and  measurable) performance goals and measures that are characteristic of  effective planning. As a result, the extent to which the departments’  progress can be assessed and reported in terms of results achieved is  largely limited to reporting on activities completed and increases in  interoperability over time. Consequently, it is unclear what health  information sharing capabilities will be delivered by September 2009.
With regard to their ongoing initiatives, DOD and VA reported increases in  data exchanged between the departments for their long-term initiative  (CHDR) and their short-term initiative (BHIE). For example, between June  and October 2008, the departments increased the number of shared  patients for which computable outpatient pharmacy and drug allergy data  were being exchanged through the CHDR initiative by about 2,700 (from  about 18,300 to over 21,000). For the BHIE initiative, the departments  continued to expand their information exchange by sharing viewable  patient vital signs information in June 2008, and demonstrated the  capability to exchange family history, social history, other history, and  questionnaires data in September 2008.
Since we last reported, DOD and VA also have made progress toward  adopting additional health data interoperability standards that are newly  recognized and accepted by the Secretary of HHS. The departments have  identified these new standards, which relate to three use cases in the  updated September 2008 Target Standards Profile. Specifically, the profile  now includes Electronic Health Records Laboratory Results Reporting,  Biosurveillance, and Consumer Empowerment use cases. According to  DOD and VA officials, the adoption of recognized standards is a goal of  both departments in order to comply with the provisions set forth in the  National Defense Authorization Act for Fiscal Year 2008. In addition, DOD  has reported progress toward certification of its health IT system in  adhering to applicable standards. Department officials stated that AHLTA  version 3.3 is now fully operational and certified at five DOD locations,  having met certification criteria, including specific functionality,  interoperability, and security requirements. According to DOD officials,  this version of AHLTA is expected to be installed at the remaining  locations by September 30, 2009.
DOD and VA have also reported progress relative to two plans that contain  objectives, initiatives, and activities related to further increasing health  information sharing. Specifically, the departments have identified the  November 2007 VA/DOD Joint Executive Council Strategic Plan for Fiscal  Years 2008-2010 (known as the VA/DOD Joint Strategic Plan) and the  September 2008 DOD/VA Information Interoperability Plan (Version 1.0)  as defining their efforts to provide interoperable health records. The Joint  Strategic Plan identified 39 activities related to information sharing that  the departments planned to complete by September 30, 2008. The  Information Interoperability Plan describes six objectives to be met by  September 30, 2009.
The departments reported that the 39 information sharing activities  identified in the Joint Strategic Plan were completed on or ahead of  schedule. For example, the departments completed a report on the  analysis of alternatives and recommendations for the development of the  joint inpatient electronic health record, and briefed the recommendations  to the Health Executive Council and the Joint Executive Council.  However, only 3 of the 39 activities in the Joint Strategic Plan were  described in results-oriented (i.e., objective, quantifiable, and measurable)  terms that are characteristic of effective planning and can be used as a  basis to track and measure progress toward the delivery of new  interoperable capabilities. For example, among these three, one of the  activities called for the departments to share viewable vital signs data in  real-time and bidirectional for shared patients among all sites by June 30,  2008. In contrast, 36 activities lacked results-oriented performance  measures, limiting the extent to which progress can be reported in terms  of results achieved. For example, one activity calls for the development of  a plan for interagency sharing of essential health images, but does not  provide details on measurable achievement of additional interoperable  capabilities. Another activity calls for the review of national health IT  standards, but does not provide a tangible deliverable to determine  progress in achieving the goal.
According to department officials, DOD and VA have activities underway to  address the six interoperability objectives included in the Information  Interoperability Plan. Among these objectives, one calls for DOD to deploy its  inpatient solution at additional medical sites to expand sharing of inpatient  discharge summaries. Department officials indicated that, as of December  2008, DOD is sharing patient discharge summaries at 50 percent of inpatient  beds compared to their goal of 70 percent by September 30, 2009. However,  this is the only one of six objectives in the Information Interoperability Plan  with an associated results-oriented performance measure. None of the  remaining five objectives are documented in terms that could allow the  departments to measure and report their progress toward delivering new  capabilities. Specifically, the objective for scanning medical documents calls  for providing an initial capability. However, “initial capability” is not defined  in quantifiable terms. As such, this objective cannot be used as a basis to  effectively measure results-oriented performance.
According to DOD and VA officials, their plans are relatively new and  represent their initial efforts to articulate interoperability goals. However,  while the departments’ plans identify interoperable capabilities to be  implemented, the plans do not establish the results-oriented (i.e., objective,  quantifiable, and measurable) goals and associated performance measures  that are a necessary basis for effective management. Without establishing  plans that include results-oriented goals, then reporting progress using  measures relative to the plans, the departments and their stakeholders do not  have the comprehensive information that they need to effectively manage  their progress toward achieving increased interoperability.
section_title: Steps Have Been Taken to Set Up the DOD/VA Interagency Program Office, but It Is Not Positioned to Function as a Single Point of Accountability
paragraphs: The National Defense Authorization Act for Fiscal Year 2008 called for the  establishment of an interagency program office and for the office to be  accountable for implementing electronic health record systems or capabilities  that allow for full interoperability of personal health care information  between DOD and VA. Since we last reported, the departments have  continued taking steps to set up the program office, although they have not  yet fully executed their plan for doing so. As a result, the office is not yet in a  position to be accountable for accelerating the departments’ efforts to  achieve interoperability by the September 30, 2009 deadline.
To address the requirements set forth in the Act, the departments  identified in the September 2008 DOD/VA Information Interoperability  Plan a schedule for standing up the interagency program office. Consistent  with the plan, the departments have taken steps, such as developing  descriptions for key positions, including those of the Director and Deputy  Director. Further, the departments have begun to hire personnel for  program staff positions. Specifically, out of 30 total program office  positions, they have hired staff for 2 of 14 government positions, 6 of 16  contractor positions, and have actions underway to fill the remaining 22  positions. Also, since we reported in July 2008, the departments developed  the program office organization structure document that depicts the  program office’s organization. Further, in December 2008, DOD issued a  Delegation of Authority Memorandum, signed by the Deputy Secretary of  Defense that formally recognizes the program office. In January 2009, the  departments approved a program office charter to describe, among other  things, the mission and function of the office.
Nonetheless, even with the actions taken, four of eight selected key activities  that the departments identified in their plan to set up the program office  remain incomplete, including filling the remaining 22 positions, in addition to  those of the Director and Deputy Director (as shown in table 1).
DOD and VA officials stated that the reason the departments have not  completed the execution of their plan to fully set up an interagency  program office is the longer than anticipated time needed to obtain  approval from multiple DOD and VA offices for key program office  documentation (for example, the delegation of authority memorandum  and charter). They stated that this was because the departments’  leadership broadened the program office’s scope to include the sharing of  personnel and benefits data in addition to health information.
Our July 2008 report recommended that the departments give priority to  establishing the program office by establishing permanent leadership and  hiring staff. Without completion of these and other key activities to set up  the program office, the office is not yet positioned to be fully functional, or  accountable, for fulfilling the departments’ interoperability plans. Coupled  with the lack of results-oriented plans that establish program commitments in  measurable terms, the absence of a fully operational interagency program  office leaves DOD and VA without a clearly established approach for ensuring  that their actions will achieve the desired purpose of the Act.
section_title: Conclusions
paragraphs: In the more than 10 years since DOD and VA began collaborating to  electronically share health information, the two departments have increased  interoperability. Nevertheless, while the departments continue to make  progress, the manner in which they report progress—by reporting increases  in interoperability over time—has limitations. These limitations are rooted in  the departments’ plans, which identify interoperable capabilities to be  implemented, but lack the results-oriented (i.e., objective, quantifiable, and  measurable) goals and associated performance measures that are a necessary  basis for effective management. Without establishing results-oriented goals,  then reporting progress using measures relative to the established goals, the  departments and their stakeholders do not have the comprehensive picture  that they need to effectively manage their progress toward achieving  increased interoperability. Further constraining the departments’  management effectiveness is their slow pace in addressing our July 2008  recommendation related to setting up the interagency program office that  Congress called for to function as a single point of accountability in the  development and implementation of electronic health record capabilities.
section_title: Recommendations for Executive Action
paragraphs: To better ensure that DOD and VA achieve interoperable electronic health  record systems or capabilities, we recommend that the Secretaries of  Defense and Veterans Affairs take the following two actions:  Develop results-oriented (i.e., objective, quantifiable, and measurable)  goals and associated performance measures for the departments’  interoperability objectives and document these goals and measures in  their interoperability plans.
Use results-oriented performance goals and measures as the basis for  future assessments and reporting of interoperability progress.
section_title: Agency Comments and Our Evaluation
paragraphs: In providing written comments on a draft of this report in a January 22, 2009  letter, the Assistant Secretary of Defense for Health Affairs concurred with  our recommendations. In a January 17, 2009 letter, the Secretary of Veterans  Affairs also concurred with our recommendations. (The departments’  comments are reproduced in app. II and app. III, respectively.) DOD and VA  stated that high priority will be given to the establishment and use of results- oriented (i.e., objective, quantifiable, and measurable) goals and associated  performance measures for the departments’ interoperability objectives. If the  recommendations are properly implemented, they should better position  DOD and VA to effectively measure and report progress in achieving full  interoperability. The departments also provided technical comments on the  draft report, which we incorporated as appropriate.
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 II.
section_title: Appendix I: Scope and Methodology
paragraphs: To evaluate the Department of Defense’s (DOD) and the Department of  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. To describe the departments’ efforts to ensure that  their health records comply with applicable interoperability standards, we  analyzed information gathered from DOD and VA documentation and  interviews pertaining to the interoperability standards that the two  departments have agreed to for exchanging health information via their  health care information systems. We reviewed documentation and  interviewed agency officials from the Department of Health and Human  Services’ Office of the National Coordinator for Health Information  Technology to obtain information regarding the defined federal  interoperability standards, implementation specifications, and certification  criteria. Further, we interviewed responsible officials to obtain  information regarding the steps taken by the departments to certify their  electronic health record products.
To evaluate DOD and VA plans toward developing electronic health record  systems or capabilities, we obtained information from agency  documentation and interviews with cognizant DOD and VA officials  pertaining to the November 2007 VA/DOD Joint Executive Council  Strategic Plan for Fiscal Years 2008-2010, and the September 2008 DOD/VA  Information Interoperability Plan (Version 1.0) which together constitute  the departments’ overall plans for achieving full interoperability of  electronic health information. Additionally, we reviewed information  gathered from agency documentation to identify interoperability  objectives, milestones, and target dates. Further, we analyzed objectives  and activities from their plans to determine if DOD and VA had established  results-oriented performance measures that enable the departments to  assess progress toward achieving increased sharing capabilities and  functionality of their electronic health information systems.
To determine whether the interagency program office is fully operational  and positioned to function as a single point of accountability for  developing and implementing electronic health records, we analyzed DOD  and VA documentation, including the schedule for setting up the office  identified in the DOD/VA Information Interoperability Plan. Additionally,  we interviewed responsible officials to determine the departments’  progress to date in setting up the interagency program office. Further, we  reviewed documentation and interviewed DOD and VA officials to  determine the extent to which the departments have positioned the office  to function as a single point of accountability for developing electronic  health records.
We conducted this performance audit at DOD sites and also the  Department of Heath and Human Services’ Office of the National  Coordinator for Health Information Technology in the greater Washington,  D.C., metropolitan area from August 2008 through January 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: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributions to this report  were made by Mark Bird, Assistant Director; Neil Doherty; Rebecca  LaPaze; J. Michael Resser; Kelly Shaw; and Eric Trout.
section_title: Related GAO Products
paragraphs: Information Technology: DOD and VA Have Increased Their Sharing of  Health Information, but Further Actions Are Needed. GAO-08-1158T.  Washington, D.C.: September 24, 2008.
Electronic Health Records: DOD and VA Have Increased Their Sharing of  Health Information, but More Work Remains. GAO-08-954. Washington,  D.C.: July 28, 2008.
VA and DOD Health Care: Progress Made on Implementation of 2003  President’s Task Force Recommendations on Collaboration and  Coordination, but More Remains to Be Done. GAO-08-495R. Washington,  D.C.: April 30, 2008.
Health Information Technology: HHS Is Pursuing Efforts to Advance  Nationwide Implementation, but Has Not Yet Completed a National  Strategy. GAO-08-499T. Washington, D.C.: February 14, 2008.
Information Technology: VA and DOD Continue to Expand Sharing of  Medical Information, but Still Lack Comprehensive Electronic Medical  Records. GAO-08-207T. Washington, D.C.: October 24, 2007.
Veterans Affairs: Progress Made in Centralizing Information  Technology Management, but Challenges Persist. GAO-07-1246T.  Washington, D.C.: September 19, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing  Medical Information, but Remain Far from Having Comprehensive  Electronic Medical Records. GAO-07-1108T. Washington, D.C.:   July 18, 2007.
Health Information Technology: Efforts Continue but Comprehensive  Privacy Approach Needed for National Strategy. GAO-07-988T.  Washington, D.C.: June 19, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing  Medical Information, but Are Far from Comprehensive Electronic  Medical Records. GAO-07-852T. Washington, D.C.: May 8, 2007.
DOD and VA Outpatient Pharmacy Data: Computable Data Are  Exchanged for Some Shared Patients, but Additional Steps Could  Facilitate Exchanging These Data for All Shared Patients. GAO-07-554R.  Washington, D.C.: April 30, 2007.
Health Information Technology: Early Efforts Initiated but  Comprehensive Privacy Approach Needed for National Strategy.  GAO-07-400T. Washington, D.C.: February 1, 2007.
Health Information Technology: Early Efforts Initiated, but  Comprehensive Privacy Approach Needed for National Strategy.   GAO-07-238. Washington, D.C.: January 10, 2007.
Health Information Technology: HHS is Continuing Efforts to Define Its  National Strategy. GAO-06-1071T. Washington, D.C.: September 1, 2006.
Information Technology: VA and DOD Face Challenges in Completing  Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
Health Information Technology: HHS Is Continuing Efforts to Define a  National Strategy. GAO-06-346T. Washington, D.C.: March 15, 2006.
Computer-Based Patient Records: VA and DOD Made Progress, but Much  Work Remains to Fully Share Medical Information. GAO-05-1051T.  Washington, D.C.: September 28, 2005.
Health Information Technology: HHS Is Taking Steps to Develop a  National Strategy. GAO-05-628. Washington, D.C.: May 27, 2005.
Computer-Based Patient Records: VA and DOD Efforts to Exchange  Health Data Could Benefit from Improved Planning and Project  Management. GAO-04-687. Washington, D.C.: June 7, 2004.
Computer-Based Patient Records: Improved Planning and Project  Management Are Critical to Achieving Two-Way VA-DOD Health Data  Exchange. GAO-04-811T. Washington, D.C.: May 19, 2004.
Computer-Based Patient Records: Sound Planning and Project  Management Are Needed to Achieve a Two-Way Exchange of VA and  DOD Health Data. GAO-04-402T. Washington, D.C.: March 17, 2004.
Computer-Based Patient Records: Short-Term Progress Made, but Much  Work Remains to Achieve a Two-Way Data Exchange Between VA and  DOD Health Systems. GAO-04-271T. Washington, D.C.:   November 19, 2003.
VA Information Technology: Management Making Important Progress in  Addressing Key Challenges. GAO-02-1054T. Washington, D.C.: September  26, 2002.
Veterans Affairs: Sustained Management Attention Is Key to Achieving  Information Technology Results. GAO-02-703. Washington, D.C.:   June 12, 2002.
VA Information Technology: Progress Made, but Continued Management  Attention Is Key to Achieving Results. GAO-02-369T. Washington, D.C.:  March 13, 2002.
VA and Defense Health Care: Military Medical Surveillance Policies in  Place, but Implementation Challenges Remain. GAO-02-478T.  Washington, D.C.: February 27, 2002.
VA and Defense Health Care: Progress Made, but DOD Continues to Face  Military Medical Surveillance System Challenges. GAO-02-377T.  Washington, D.C.: January 24, 2002.
VA and Defense Health Care: Progress and Challenges DOD Faces in  Executing a Military Medical Surveillance System. GAO-02-173T.  Washington, D.C.: October 16, 2001.
Computer-Based Patient Records: Better Planning and Oversight by VA,  DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459.  Washington, D.C.: April 30, 2001.