Information Technology: VA and DOD Continue to Expand Sharing of Medical Information, but Still Lack Comprehensive Electronic Medical Records
Published: 2007-10-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA) and the Department of Defense (DOD) are engaged in ongoing efforts to share medical information, which is important in helping to ensure high-quality health care for active-duty military personnel and veterans. These efforts include a long-term program to develop modernized health information systems based on computable data: that is, data in a format that a computer application can act on--for example, to provide alerts to clinicians of drug allergies. In addition, the departments are engaged in short-term initiatives involving existing systems. GAO was asked to testify on the history and current status of the departments' efforts to share health information. To develop this testimony, GAO reviewed its previous work, analyzed documents about current status and future plans and interviewed VA and DOD officials.
section_title: What GAO Found
paragraphs: For almost a decade, VA and DOD have been pursuing ways to share health information and to create comprehensive electronic medical records. However, they have faced considerable challenges in these efforts, leading to repeated changes in the focus of their initiatives and target completion dates. Currently, the two departments are pursuing both long- and short-term initiatives to share health information. Under their long-term initiative, the modern health information systems being developed by each department are to share standardized computable data through an interface between data repositories associated with each system. The repositories have now been developed, and the departments have begun to populate them with limited types of health information. In addition, the interface between the repositories has been implemented at seven VA and DOD sites, allowing computable outpatient pharmacy and drug allergy data to be exchanged. Implementing this interface is a milestone toward the departments' long-term goal, but more remains to be done. Besides extending the current capability throughout VA and DOD, the departments must still agree to standards for the remaining categories of medical information, populate the data repositories with this information, complete the development of the two modernized health information systems, and transition from their existing systems. While pursuing their long-term effort to develop modernized systems, the two departments have also been working to share information in their existing systems. Among various short-term initiatives are a completed effort to allow the one-way transfer of health information from DOD to VA when service members leave the military, as well as ongoing demonstration projects to exchange limited data at selected sites. One of these projects, which builds on the one-way transfer capability, developed an interface between certain existing systems that allows a two-way view of current data on patients receiving care from both departments. VA and DOD are now expanding the sharing of additional medical information by using this interface to link other systems and databases. The departments have also established ad hoc processes to meet the immediate need to provide data on severely wounded service members to VA's polytrauma centers, which specialize in treating such patients. These processes include manual workarounds (such as scanning paper records) that are generally feasible only because the number of polytrauma patients is small. While these multiple initiatives and ad hoc processes have facilitated degrees of data sharing, they nonetheless highlight the need for continued efforts to integrate information systems and automate information exchange. At present, it is not clear how all the initiatives are to be incorporated into an overall strategy focused on achieving the departments' goal of comprehensive, seamless exchange of health information.

section_title: Letter
paragraphs: I am pleased to be a part of today’s continuing dialogue on efforts by the  Department of Veterans Affairs (VA) and the Department of Defense  (DOD) to share electronic medical information. Over most of the past  decade, the departments have been pursuing initiatives to share electronic  medical information to help ensure that active-duty military personnel and  veterans receive high-quality health care. The departments’ efforts have  included working towards a long-term vision of a single “comprehensive,  lifelong medical record” that would allow each service member to  transition seamlessly between the two departments, as well as more short- term efforts focused on meeting immediate needs to exchange health  information, including responding to current military crises.
Since 2001, we have reported or testified numerous times on the various  initiatives undertaken by the departments to develop the capability to  share health information. Our last testimony before this Subcommittee on  May 8, 2007, highlighted key projects that the departments have pursued in  this regard and the progress of their activities. At your request, my  statement today further discusses the history and current status of the  departments’ efforts.
The information in my testimony is based largely on our previous work in  this area. To describe the history and current status of the departments’  efforts to exchange patient health information, we reviewed our previous  work, analyzed documents on various health initiatives, and interviewed  VA and DOD officials about current status and future plans. We conducted  our work in support of this testimony during October 2007 in the  Washington, D.C., area. Information on costs that have been incurred for  the various projects was provided by responsible officials at each  department. We did not audit the reported costs and thus cannot attest to  their accuracy or completeness. All work on which this testimony is based  was conducted in accordance with generally accepted government  auditing standards.
subsections: section_title: Background
paragraphs: In their efforts to modernize their health information systems and share  medical information, VA and DOD start from different positions. As shown  in table 1, VA has one integrated medical information system—the  Veterans Health Information Systems and Technology Architecture  (VistA)—which uses all electronic records. All 128 VA medical sites thus  have access to all VistA information. (Table 1 also shows, for  completeness, VA’s planned modernized system and its associated data  repository.)
In contrast, DOD has multiple medical information systems (table 2  illustrates certain selected systems). DOD’s various systems are not  integrated, and its 138 sites do not necessarily communicate with each  other. In addition, not all of DOD’s medical information is electronic: some  records are paper-based.
section_title: VA and DOD Have Been Working to Exchange Health Information Since 1998
paragraphs: For nearly a decade, VA and DOD have been undertaking initiatives to  exchange data between their health information systems and create  comprehensive electronic records. However, the departments have faced  considerable challenges in project planning and management, leading to  repeated changes in the focus and target completion dates of the  initiatives.
As shown in figure 1, the departments’ efforts have involved both long- term initiatives to modernize their health information systems and short- term initiatives to respond to more immediate information-sharing needs.
The departments’ first initiative was the Government Computer-Based  Patient Record (GCPR) project, which aimed to develop an electronic  interface that would allow physicians and other authorized users at VA  and DOD health facilities to access data from each other’s health  information systems. The interface was expected to compile requested  patient information in a virtual record (that is, electronic as opposed to  paper) that could be displayed on a user’s computer screen.
We reviewed the GCPR project in 2001 and 2002, noting disappointing  progress exacerbated in large part by inadequate accountability and poor  planning and oversight, which raised questions about the departments’  abilities to achieve a virtual medical record. We determined that the lack  of a lead entity, clear mission, and detailed planning to achieve that  mission made it difficult to monitor progress, identify project risks, and  develop appropriate contingency plans. In both years, we recommended  that the departments enhance the project’s overall management and  accountability. In particular, we recommended that the departments  designate a lead entity and a clear line of authority for the project; create  comprehensive and coordinated plans that include an agreed-upon  mission and clear goals, objectives, and performance measures; revise the  project’s original goals and objectives to align with the current strategy;  commit the executive support necessary to adequately manage the project;  and ensure that it followed sound project management principles.
In response, by July 2002, the two departments had revised their strategy,  refocusing the project and dividing it into two initiatives. A short-term  initiative, the Federal Health Information Exchange (FHIE), was to enable  DOD to electronically transfer service members’ health information to VA  when the members left active duty. VA was designated as the lead entity  for implementing FHIE, which was completed in 2004. A longer-term  initiative was to develop 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 (these  systems, DOD’s Composite Health Care System II and VA’s HealtheVet  VistA, were already in development, as shown in the figure). 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).  The two repositories are to exchange information through an interface  named CHDR.
In March 2004, the departments began to develop the CHDR interface.  They planned to begin implementation by October 2005; however,  implementation of the first release of the interface (at one site) occurred  in September 2006, almost a year beyond the target date. In a report in  June 2004, we identified a number of management weaknesses that could  have contributed to this delay and made a number of recommendations,  including creation of a comprehensive and coordinated project  management plan. The departments agreed with our recommendations  and took steps to improve the management of the CHDR initiative,  designating a lead entity with final decision-making authority and  establishing a project management structure. However, as we noted in  subsequent testimony, the initiative did not have a detailed project  management plan that described the technical and managerial processes  necessary to satisfy project requirements (including a work breakdown  structure and schedule for all development, testing, and implementation  tasks), as we had recommended.
In October 2004, responding to a congressional mandate, the departments  established two more short-term initiatives: the Laboratory Data Sharing  Interface, aimed at allowing VA and DOD facilities to share laboratory  resources, and the Bidirectional Health Information Exchange (BHIE),  aimed at giving both departments’ clinicians access to records on shared  patients (that is, those who receive care from both departments). As  demonstration projects, these initiatives were limited in scope, with the  intention of providing interim solutions to the departments’ needs for  more immediate health information sharing. However, because BHIE  provided access to up-to-date information, the departments’ clinicians  expressed strong interest in expanding its use. As a result, the  departments began planning to broaden this capability and expand its  implementation considerably. Extending BHIE connectivity could provide  each department with access to most data in the other’s legacy systems,  until such time as the departments’ modernized systems are fully  developed and implemented. According to a VA/DOD annual report and  program officials, the departments now consider BHIE an interim step in  their overall strategy to create a two-way exchange of electronic medical  records.
The departments’ reported costs for the various sharing initiatives and the  modernization of their health information systems through fiscal year 2007  are shown in table 3.
Beyond these initiatives, in January 2007, the departments announced a  further change to their information-sharing strategy: their intention to  jointly develop a new inpatient medical record system. On July 31, 2007,  they awarded a contract for a feasibility study. According to the  departments, adopting this joint solution is expected to facilitate the  seamless transition of active-duty service members to veteran status, and  make inpatient health care data on shared patients immediately accessible  to both DOD and VA. In addition, the departments believe that a joint  development effort could enable them to realize significant cost savings.  We have not evaluated the departments’ plans or strategy for this new  system.
subsections: section_title: Other Evaluations Have Recommended Strengthening the Management and Planning of the Departments’ Health Information Initiatives
paragraphs: Throughout the history of these initiatives, evaluations besides our own  have found deficiencies in the departments’ efforts, especially with regard  to the lack of comprehensive planning. For example, a recent presidential  task force identified the need for VA and DOD to improve their long-term  planning. This task force, reporting on gaps in services provided to  returning veterans, noted problems in sharing information on wounded  service members, including the inability of VA providers to access paper  DOD inpatient health records. The task force stated that although  significant progress has been made towards sharing electronic  information, more needs to be done, and recommended that VA and DOD  continue to identify long-term initiatives and define the scope and  elements of a joint inpatient electronic health record. In addition, in fiscal  year 2006, Congress did not provide all the funding requested for  HealtheVet VistA because it did not consider that the funding had been  adequately justified.
section_title: VA and DOD Are Exchanging Limited Medical Information, but a Seamlessly Shared Medical Record Will Require Much More Work
paragraphs: VA and DOD have made progress in both their long-term and short-term  initiatives to share health information. In the long-term project to  modernize their health information systems, the departments have begun,  among other things, to implement the first release of the interface between  their modernized data repositories. The departments have also made  progress in their short-term projects to share information in existing  systems, having completed two initiatives, and are making important  progress on another. In addition, the departments have undertaken ad hoc  activities to accelerate the transmission of health information on severely  wounded patients from DOD to VA’s four polytrauma centers. However,  despite the progress made and the sharing achieved, the tasks remaining  to reach the goal of a shared electronic medical record are substantial.
subsections: section_title: VA and DOD Have Begun Deployment of a Modernized Data Interface
paragraphs: In their long-term effort to share health information, VA and DOD have  completed the development of their modernized data repositories, agreed  on standards for various types of data, and begun to populate the  repositories with these data. In addition, they have now implemented the  first release of the CHDR interface. According to the departments’  officials, all DOD sites can now access the interface, and it is expected to  be available across VA when necessary software updates are released.  (Currently 103 of 128 VA sites have received these updates.) At 7 sites, VA  and DOD are now exchanging limited medical information for shared  patients: specifically, computable outpatient pharmacy and drug allergy  information.
CHDR is the conduit for exchanging computable medical information  between the departments. Data transmitted via the interface are  permanently stored in each department’s new data repository, CDR, and  HDR. Once in the repositories, these computable data can be used by DOD  and VA at all sites through their existing systems. CHDR also provides  terminology mediation (translation of one agency’s terminology into the  other’s). The departments’ plans call for further developing the capability  to exchange computable laboratory results data through the interface  during fiscal year 2008.
Although implementing this interface is an important accomplishment, the  departments are still a long way from completing the modernized health  information systems and comprehensive longitudinal health records.  While DOD and VA had originally projected completion dates of 2011 and  2012, respectively, for their modernized systems, the departments’ officials  told us that there is currently no scheduled completion date for either  system. VA is evaluating a proposal that would result in completion of its  system in 2015; DOD is evaluating the impact of the new study on a joint  inpatient medical record and has not indicated a new completion date.
Further, both departments have still to identify the next types of data to be  stored in the repositories. The departments will then have to populate the  repositories with the standardized data. This involves different tasks for  each department. Specifically, while VA’s medical records are already  electronic, it must still convert them into the interoperable format  appropriate for its repository. DOD, in addition to converting current  records from its multiple systems, must also address medical records that  are not automated. As pointed out by a recent Army Inspector General’s  report, some DOD facilities are having problems with hard copy records.  The report also identified inaccurate and incomplete health data as a  problem to be addressed. Before the departments can achieve the long- term goal of seamless sharing of medical information, all of these tasks  and challenges will have to be addressed. Accordingly, it is essential that  the departments develop a comprehensive project plan to guide these  efforts to completion, as we have previously recommended.
section_title: Short-Term Projects Are Allowing VA and DOD to Exchange Limited Health Information
paragraphs: In addition to the long-term effort previously described, the two  departments have made some progress in meeting immediate needs to  share information in their respective legacy systems through short-term  projects which, as mentioned earlier, are in various stages of completion.  They have also set up special processes to transfer data from DOD  facilities to VA’s polytrauma centers in a further effort to more effectively  treat traumatic brain injuries and other especially severe injuries.
subsections: section_title: One-Way Transfer Capability Is Operational
paragraphs: DOD has been using FHIE to transfer information to VA since 2002.  According to DOD officials, 194 million clinical messages on more than 4  million veterans had been transferred to the FHIE data repository as of  September 2007, including laboratory results, radiology results, outpatient  pharmacy data, allergy information, consultation reports, elements of the  standard ambulatory data record, and demographic data. Further, since  July 2005, FHIE has been used to transfer pre- and post-deployment health  assessment and reassessment data; as of September 2007, VA had access  to data for more than 793,000 separated service members and demobilized  Reserve and National Guard members who had been deployed. Transfers  are done in batches once a month, or weekly for veterans who have been  referred to VA treatment facilities. According to a joint VA/DOD report,  FHIE has made a significant contribution to the delivery and continuity of  care of separated service members as they transition to veteran status, as  well as to the adjudication of disability claims.
section_title: Laboratory Interface Initiative Allows VA and DOD to Share Lab Resources
paragraphs: One of the departments’ demonstration projects—the Laboratory Data  Sharing Interface (LDSI)—is now fully operational and is deployed when  local agencies have a business case for its use and sign an agreement. It  requires customization for each locality and is currently deployed at nine  locations. LDSI currently supports a variety of chemistry and hematology  tests, and, at one of the nine locations, anatomic pathology and  microbiology tests.
Once LDSI is implemented at a facility, the only nonautomated action  needed for a laboratory test is transporting the specimens. If a test is not  performed at a VA or DOD doctor’s home facility, the doctor can order the  test, the order is transmitted electronically to the appropriate lab (the  other department’s facility or in some cases a local commercial lab), and  the results are returned electronically.
Among the benefits of the LDSI interface, according to VA and DOD, are  increased speed in receiving laboratory results and decreased errors from  manual entry of orders. The LDSI project manager in San Antonio stated  that another benefit of the project is the time saved by eliminating the  need to rekey orders at processing labs to input the information into the  laboratories’ systems. Additionally, the San Antonio VA facility no longer  has to contract out some of its laboratory work to private companies, but  instead uses the DOD laboratory.
section_title: Two-Way Interface Allows Real-Time Viewing of Text Information
paragraphs: Developed under a second demonstration project, the BHIE interface  permits a medical care provider to query selected health information on  patients from all VA and DOD sites and to view that data onscreen almost  immediately. It not only allows the two departments to view each other’s  information, but it also allows DOD sites to see previously inaccessible  data at other DOD sites.
VA and DOD have been making progress on expanding the BHIE interface.  As initially developed, the interface provided access to information in VA’s  VistA and DOD’s Composite Health Care System, but it is currently being  expanded to query data in other DOD systems and databases. In particular,  the interface has been expanded to DOD’s:    Modernized data repository, CDR, which has enabled department-wide  access to outpatient data for pharmacy and inpatient and outpatient  allergy, radiology, chemistry, and hematology data since July 2007, and to  microbiology data since September 2007.
Clinical Information System (CIS), an inpatient system used by some DOD  facilities; the interface enables bidirectional views of discharge summaries  and is currently deployed at 13 large DOD sites.
Theater Medical Data Store, which became operational in October 2007,  enabling access to inpatient and outpatient clinical information from  combat theaters.
The departments are also taking steps to make more data elements  available through BHIE. VA and DOD staff told us that by the end of the  first quarter of fiscal year 2008, they plan to add provider notes,  procedures, and problem lists. Later in fiscal year 2008, they plan to add  vital signs, scanned images and documents, family history, social history,  and other history questionnaires. In addition, a VA/DOD demonstration  site in El Paso began sharing radiological images between the VA and DOD  facilities in September 2007 using the BHIE/FHIE infrastructure.
section_title: Types of Data Shared by DOD and VA Are Growing but Remain Limited
paragraphs: Although VA and DOD are sharing various types of health data, the type of  data being shared has been limited and significant work remains to expand  the data shared and integrate the various initiatives. Table 4 summarizes  the types of health data currently shared via the long- and short-term  initiatives we have described, as well as additional types of data that are  currently planned for sharing. While this gives some indication of the scale  of the tasks involved in sharing medical information, it does not depict the  full extent of information that is currently being captured in the health  information systems at VA and DOD.
section_title: Special Procedures Provide Information to VA Polytrauma Centers
paragraphs: In addition to the information technology initiatives described, DOD and  VA have set up special procedures to transfer medical information to VA’s  four polytrauma centers, which treat active duty service members and  veterans severely wounded in combat. Some examples of polytrauma  include traumatic brain injury, amputations, and loss of hearing or vision.
When service members are seriously injured in a combat theater overseas,  they are first treated locally. They are then generally evacuated to  Landstuhl Medical Center in Germany, after which they are transferred to  a military treatment facility in the United States, usually Walter Reed Army  Medical Center in Washington, D.C.; the National Naval Medical Center in  Bethesda, Maryland; or Brooke Army Medical Center, at Fort Sam  Houston, Texas. From these facilities, service members suffering from  polytrauma may be transferred to one of VA’s four polytrauma centers for  treatment.
At each of these locations, the injured service members will accumulate  medical records, in addition to medical records already in existence before  they were injured. According to DOD officials, when patients are referred  to VA for care, DOD sends copies of medical records documenting  treatment provided by the referring DOD facility along with them. The  DOD medical information is currently collected in several different  systems:  1.  In the combat theater, electronic medical information may be collected  for a variety of reasons, including routine outpatient care, as well as  serious injuries. These data are stored in the Theater Medical Data  Store. As mentioned earlier, the BHIE interface to this database  became operational in October.  2.  At Landstuhl, inpatient medical records are paper-based (except for  discharge summaries). The paper records are sent with a patient as the  individual is transferred for treatment in the United States. DOD  officials told us that the paper record is the official DOD medical  record, although AHLTA is used extensively to provide outpatient  encounter information for medical records purposes.  3.  At the DOD treatment facility (Walter Reed, Bethesda, or Brooke),  additional inpatient information is recorded in CIS and outpatient  pharmacy and drug information are stored in CDR; other health  information continues to be stored in local CHCS databases.
When service members are transferred to a VA polytrauma center, VA  and DOD have several ad hoc processes in place to electronically  transfer the patients’ medical information:    DOD has set up secure links to enable a limited number of clinicians at the  polytrauma centers to log directly into CIS at Walter Reed and Bethesda  Naval Hospital to access patient data.
Staff at Walter Reed, Brooke, and Bethesda medical centers collect paper  records, print records from CIS, scan all these, and transmit the scanned  data to the four polytrauma centers. DOD staff pointed out that this  laborious process is feasible only because the number of polytrauma  patients is small. According to VA officials, 460 severe traumatic brain  injury patients had been treated at the polytrauma centers through fiscal  year 2007. According to DOD officials, the medical records for 81 patients  planned for transfer or already at a VA polytrauma center were scanned  and provided to VA between April 1 and October 11 of this year. Digital  radiology images were also provided for 48 patients.
Staff at Walter Reed and Bethesda are transmitting radiology images  electronically to the four polytrauma centers. Access to radiology images  is a high priority for polytrauma center doctors, but like scanning paper  records, transmitting these images requires manual intervention: when  each image is received at VA, it must be individually uploaded to VistA’s  imagery viewing capability. This process would not be practical for large  volumes of images.
VA has access to outpatient data (via BHIE) from all DOD sites, including  Landstuhl.
These special efforts to transfer medical information on seriously  wounded patients represent important additional steps to facilitate the  sharing of information that is vital to providing polytrauma patients with  quality health care.
In summary, VA and DOD are exchanging health information via their  long- and short-term initiatives and continue to expand sharing of medical  information via BHIE. However, these exchanges have been limited, and  significant work remains to fully achieve the goal of exchanging  interoperable, computable data. Work still to be done includes agreeing to  standards for the remaining categories of medical information; populating  the data repositories with all this information; completing the  development of HealtheVet VistA, and AHLTA; and transitioning from the  legacy systems. To complete this work and achieve the departments’  ultimate goal of a maintaining a lifelong electronic medical record that will  follow service members as they transition from active to veteran status, a  comprehensive and coordinated project management plan that defines the  technical and managerial processes necessary to satisfy project  requirements and to guide their activities continues to be of vital  importance. We have previously recommended that the departments  develop such a plan and that it include a work breakdown structure and  schedule for all development, testing, and implementation tasks. Without  such a detailed plan, VA and DOD increase the risk that the long-term  project will not deliver the planned capabilities in the time and at the cost  expected. Further, it is not clear how all the initiatives we have described  today are to be incorporated into an overall strategy toward achieving the  departments’ goal of a comprehensive, seamless exchange of health  information.
This concludes my statement. I would be pleased to respond to any  questions that you may have.
section_title: Contacts and Acknowledgments
paragraphs: If you have any questions concerning this testimony, please contact  Valerie C. Melvin, Director, Human Capital and Management Information  Systems Issues, at (202) 512-6304 or melvinv@gao.gov. Other individuals  who made key contributions to this testimony are Barbara Oliver  (Assistant Director), Nancy Glover, Glenn Spiegel, and Amos Tevelow.
section_title: Related GAO Products
paragraphs: 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.
Veterans Affairs: Sustained Management Attention Is Key to Achieving  Information Technology Results. GAO-02-703. Washington, D.C.: June 12,  2002.
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.
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: 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: VA and DOD Made Progress, but Much  Work Remains to Fully Share Medical Information. GAO-05-1051T.  Washington, D.C.: September 28, 2005.
Information Technology: VA and DOD Face Challenges in Completing  Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
DOD and VA Exchange of Computable Pharmacy Data. GAO-07-554R.  Washington, D.C.: April 30, 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.
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.
This is a work of the U.S. government and is not subject to copyright protection in the  United States. It may be reproduced and distributed in its entirety without further  permission from GAO. However, because this work may contain copyrighted images or  other material, permission from the copyright holder may be necessary if you wish to  reproduce this material separately.