Electronic Health Records: VA's Efforts Raise Concerns about Interoperability Goals and Measures, Duplication with DOD, and Future Plans
Published: 2016-07-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: VA operates one of the nation's largest health care systems, serving millions of veterans each year. For almost two decades, the department has undertaken a patchwork of initiatives with DOD to increase interoperability between their respective electronic health record systems. During much of this time, VA has also been planning to modernize its system. While the department has made progress in these efforts, it has also faced significant information technology challenges that contributed to GAO's designation of VA health care as a high risk area.
This statement summarizes GAO's August 2015 report (GAO-15-530) on VA's efforts to achieve interoperability with DOD's electronic health records system. It also summarizes key content from GAO's reports on duplication, overlap, and fragmentation of federal government programs. Lastly, this statement provides updated information on VA's actions in response to GAO's recommendation calling for an interoperability and electronic health record system plan.
section_title: What GAO Found
paragraphs: Even as the Department of Veterans Affairs (VA) has undertaken numerous initiatives with the Department of Defense (DOD) that were intended to advance the ability of the two departments to share electronic health records, the departments have not identified outcome-oriented goals and metrics to clearly define what they aim to achieve from their interoperability efforts. In an August 2015 report, GAO recommended that the two departments establish a time frame for identifying outcome-oriented metrics, define related goals as a basis for determining the extent to which the departments' systems are achieving interoperability, and update their guidance accordingly. Since that time, VA has established a performance architecture program that has begun to define an approach for identifying outcome-oriented metrics focused on health outcomes in selected clinical areas and has begun to establish baseline measurements. GAO is continuing to monitor VA's and DOD's efforts to define metrics and report on the interoperability results achieved between the departments.
Following an unsuccessful attempt to develop a joint system with DOD, VA switched tactics and moved forward with an effort to modernize its current system separately from DOD's planned acquisition of a commercially available electronic health record system. The department took this course of action even though, in May 2010, it identified 10 areas of health care business needs in common with those of DOD. Further, the results of a 2008 study pointed out that more than 97 percent of inpatient requirements for electronic health record systems are common to both departments. GAO noted that the departments' plans to separately modernize their systems were duplicative and recommended that their decisions should be justified by comparing the costs and schedules of alternate approaches. The departments agreed with GAO's recommendations and stated that their initial comparison indicated that separate systems would be more cost effective. However, the departments have not provided a comparison of the estimated costs of their current and previous approaches. Further, both departments developed schedules that indicated their separate modernization efforts will not be completed until after the 2017 planned completion date for the previous joint system approach.
VA has developed a number of plans to support its development of its electronic health record system, called VistA, including a plan for interoperability and a road map describing functional capabilities to be deployed through fiscal year 2018. According to the road map, the first set of capabilities was delivered by the end of September 2014 and included a foundation for future functionality, such as an enhanced graphical user interface and enterprise messaging infrastructure. However, a recent independent assessment of health information technology (IT) at VA reported that lengthy delays in modernizing VistA had resulted in the system becoming outdated. Further, this study questioned whether the modernization program can overcome a variety of risks and technical issues that have plagued prior VA initiatives of similar size and complexity. Although VA's Under Secretary for Health has asserted that the department will complete the VistA Evolution program in fiscal year 2018, the Chief Information Officer has indicated that the department is reconsidering how best to meet its future electronic health record system needs.
section_title: What GAO Recommends
paragraphs: In prior reports, GAO has made numerous recommendations to VA to improve the modernization of its IT systems. Among other things, GAO has recommended that VA address challenges associated with interoperability, develop goals and metrics to determine the extent to which the modernized systems are achieving interoperability, and address shortcomings with planning. VA generally agreed with GAO's recommendations.

section_title: Letter
paragraphs: Thank you for inviting me to testify at today’s hearing on the Department  of Veterans Affairs’ (VA) electronic health record system—the Veterans  Health Information Systems and Technology Architecture (VistA)—and  the department’s progress toward achieving interoperability with the  Department of Defense (DOD). For almost two decades, VA has been  working with DOD to advance electronic health record interoperability  between their systems, in an attempt to achieve the seamless sharing of  health care data and make patient data more readily available to health  care providers, reduce medical errors, and streamline administrative  functions. Also, for much of this same time period, VA has been planning  and taking steps toward the modernization of its electronic health record  system, with the intent of ensuring that the department can effectively  deliver care for the millions of veterans and others that it serves.
Since 2001, we have issued a number of reports that addressed VA’s  progress, in conjunction with DOD, toward achieving interoperable  electronic health records between their separate systems, as well as its  project with DOD to jointly develop a shared electronic health record  system. In addition, we have reported on actions that VA has taken with  regard to modernizing its electronic health record system. While the  department has made progress in these efforts, it has also faced  significant information technology challenges that contributed to our  designation of VA health care as a high risk area.
At your invitation, my testimony today summarizes our key findings and  concerns from this overall body of work. Specifically, in developing this  testimony, we relied on our previous reports, as well as information that  we obtained and reviewed on VA’s actions in response to our previous  recommendations. The reports cited throughout this statement include  detailed information on the scope and methodology for our reviews.
The work upon which this statement is based was conducted in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: VA operates one of the largest health care systems in America, providing  care to millions of veterans and their families each year. The  department’s health information system—VistA—serves an essential role  in helping the department to fulfill its health care delivery mission.  Specifically, VistA is an integrated medical information system that was  developed in-house by the department’s clinicians and information  technology (IT) personnel, and has been in operation since the early  1980s. The system consists of 104 separate computer applications,  including 56 health provider applications; 19 management and financial  applications; 8 registration, enrollment, and eligibility applications; 5  health data applications; and 3 information and education applications.  Within VistA, an application called the Computerized Patient Record  System enables the department to create and manage an individual  electronic health record for each VA patient.
Electronic health records are particularly crucial for optimizing the health  care provided to veterans, many of whom may have health records  residing at multiple medical facilities within and outside the United States.  Taking these steps toward interoperability—that is, collecting, storing,  retrieving, and transferring veterans’ health records electronically—is  significant to improving the quality and efficiency of care. One of the goals  of interoperability is to ensure that patients’ electronic health information  is available from provider to provider, regardless of where it originated or  resides.
Since 1998, VA has undertaken a patchwork of initiatives with DOD to  allow the departments’ health information systems to exchange  information and increase interoperability. Among others, these have  included initiatives to share viewable data in the two departments’ existing  (legacy) systems, link and share computable data between the  departments’ updated heath data repositories, and jointly develop a single  integrated system that would be used by both departments. Table 1  summarizes a number of these key initiatives.
In addition to the initiatives mentioned in table 1, VA has worked in  conjunction with DOD to respond to provisions in the National Defense  Authorization Act for Fiscal Year 2008, which required the departments  to jointly develop and implement fully interoperable electronic health  record systems or capabilities in 2009. Yet, even as the departments  undertook numerous interoperability and modernization initiatives, they  faced significant challenges and slow progress. For example, VA’s and  DOD’s success in identifying and implementing joint IT solutions has  been hindered by an inability to articulate explicit plans, goals, and time  frames for meeting their common health IT needs.
In March 2011, the secretaries of VA and DOD announced that they  would develop a new, joint integrated electronic health record system  (referred to as iEHR). This was intended to replace the departments’  separate systems with a single common system, thus sidestepping many  of the challenges they had previously encountered in trying to achieve  interoperability. However, in February 2013, about 2 years after initiating  iEHR, the secretaries announced that the departments were abandoning  plans to develop a joint system, due to concerns about the program’s  cost, schedule, and ability to meet deadlines. The Interagency Program  Office (IPO), put in place to be accountable for VA’s and DOD’s efforts to  achieve interoperability, reported spending about $564 million on iEHR  between October 2011 and June 2013.
In light of VA and DOD not implementing a solution that allowed for the  seamless electronic sharing of health care data, the National Defense  Authorization Act for Fiscal Year 2014 included requirements pertaining  to the implementation, design, and planning for interoperability between  the departments’ electronic health record systems. Among other actions,  provisions in the act directed each department to (1) ensure that all health  care data contained in their systems (VA’s VistA and DOD’s Armed  Forces Health Longitudinal Technology Application, referred to as  AHLTA) complied with national standards and were computable in real  time by October 1, 2014; and (2) deploy modernized electronic health  record software to support clinicians while ensuring full standards-based  interoperability by December 31, 2016.
In August 2015, we reported that VA, in conjunction with DOD, had  engaged in several near-term efforts focused on expanding  interoperability between their existing electronic health record systems.  For example, the departments had analyzed data related to 25 “domains”  identified by the Interagency Clinical Informatics Board and mapped  health data in their existing systems to standards identified by the IPO.  The departments also had expanded the functionality of their Joint  Legacy Viewer—a tool that allows clinicians to view certain health care  data from both departments in a single interface.
More recently, in April 2016, VA and DOD certified that all health care  data in their systems complied with national standards and were  computable in real time. However, VA acknowledged that it did not expect  to complete a number of key activities related to its electronic health  record system until sometime after the December 31, 2016, statutory  deadline for deploying modernized electronic health record software with  interoperability. Specifically, the department stated that deployment of a  modernized VistA system at all locations and for all users is not planned  until 2018.
section_title: Together with DOD and the Interagency Program Office, VA Needs to Develop Goals and Metrics for Assessing Interoperability
paragraphs: Even as VA has undertaken numerous initiatives with DOD that were  intended to advance electronic health record interoperability, a significant  concern is that these departments have not identified outcome-oriented  goals and metrics to clearly define what they aim to achieve from their  interoperability efforts, and the value and benefits these efforts are  expected to yield. As we have stressed in our prior work and guidance,  assessing the performance of a program should include measuring its  outcomes in terms of the results of products or services. In this case,  such outcomes could include improvements in the quality of health care  or clinician satisfaction. Establishing outcome-oriented goals and metrics  is essential to determining whether a program is delivering value.
The IPO is responsible for monitoring and reporting on VA’s and DOD’s  progress in achieving interoperability and coordinating with the  departments to ensure that these efforts enhance health care services.  Toward this end, the office issued guidance that identified a variety of  process-oriented metrics to be tracked, such as the percentage of health  data domains that have been mapped to national standards. The  guidance also identified metrics to be reported that relate to tracking the  amounts of certain types of data being exchanged between the  departments, using existing capabilities. This would include, for example,  laboratory reports transferred from DOD to VA via the Federal Health  Information Exchange and patient queries submitted by providers through  the Bidirectional Health Information Exchange.
Nevertheless, in our August 2015 report, we noted that the IPO had not  specified outcome-oriented metrics and goals that could be used to  gauge the impact of the interoperable health record capabilities on the  departments’ health care services. At that time, the acting director of the  IPO stated that the office was working to identify metrics that would be  more meaningful, such as metrics on the quality of a user’s experience or  on improvements in health outcomes. However, the office had not  established a time frame for completing the outcome-oriented metrics and  incorporating them into the office’s guidance.
In the report, we stressed that using an effective outcome-based  approach could provide the two departments with a more accurate picture  of their progress toward achieving interoperability, and the value and  benefits generated. Accordingly, we recommended that the departments,  working with the IPO, establish a time frame for identifying outcome- oriented metrics; define related goals as a basis for determining the  extent to which the departments’ modernized electronic health record  systems are achieving interoperability; and update IPO guidance  accordingly.
Both departments concurred with our recommendations. Further, since  that time, VA has established a performance architecture program that  has begun to define an approach for identifying outcome-oriented metrics  focused on health outcomes in selected clinical areas, and it also has  begun to establish baseline measurements. We intend to continue  monitoring the department’s efforts to determine how these metrics define  and report on the results achieved by interoperability between the  departments.
section_title: VA’s Plan to Modernize VistA Raises Concern about Duplication with DOD’s Electronic Health Record System Acquisition
paragraphs: Following the termination of the iEHR initiative, VA moved forward with an  effort to modernize VistA separately from DOD’s planned acquisition of a  commercially available electronic health record system. The department  took this course of action even though it has many health care business  needs in common with those of DOD. For example, in May 2010, VA (and  DOD) issued a report on medical IT to Congressional committees that  identified 10 areas—inpatient documentation, outpatient documentation,  pharmacy, laboratory, order entry and management, scheduling, imaging  and radiology, third-party billing, registration, and data sharing—in which  the departments have common business needs. Further, the results of a  2008 study pointed out that over 97 percent of inpatient requirements for  electronic health record systems are common to both departments.
We also issued several prior reports regarding the plans for separate  systems, in which we noted that the departments did not substantiate  their claims that VA’s VistA modernization, together with DOD’s  acquisition of a new system, would be achieved faster and at less cost  than developing a single, joint system. Moreover, we noted that the  departments’ plans to modernize their two separate systems were  duplicative and stressed that their decisions should be justified by  comparing the costs and schedules of alternate approaches.
We recommended that VA and DOD develop cost and schedule  estimates that would include all elements of their approach (i.e.,  modernizing both departments’ health information systems and  establishing interoperability between them) and compare them with  estimates of the cost and schedule for developing a single, integrated  system. If the planned approach for separate systems was projected to  cost more or take longer, we recommended that the departments provide  a rationale for pursuing such an approach.
VA, as well as DOD, agreed with our recommendations and stated that  an initial comparison had indicated that the approach involving separate  systems would be more cost effective. However, as of June 2016, the  departments had not provided us with a comparison of the estimated  costs of their current and previous approaches. Further, with respect to  their assertions that separate systems could be achieved faster, both  departments had developed schedules which indicated that their separate  modernization efforts are not expected to be completed until after the  2017 planned completion date for the previous single-system approach.
section_title: VA Has Begun to Implement VistA Modernization Plans amid Uncertainty about Its Approach; the Department Is Currently Reconsidering How to Proceed
paragraphs: As VA has proceeded with its program to modernize VistA (known as  VistA Evolution), the department has developed a number of plans to  support its efforts. These include an interoperability plan and a road map  describing functional capabilities to be deployed through fiscal year 2018.  Specifically, these documents describe the department’s approach for  modernizing its existing electronic health record system through the VistA  Evolution program, while helping to facilitate interoperability with DOD’s  system and the private sector. For example, the VA Interoperability Plan,  issued in June 2014, describes activities intended to improve VistA’s  technical interoperability, such as standardizing the VistA software  across the department to simplify sharing data.
In addition, the VistA 4 Roadmap, last revised in February 2015,  describes four sets of functional capabilities that are expected to be  incrementally deployed during fiscal years 2014 through 2018 to  modernize the VistA system and enhance interoperability. According to  the road map, the first set of capabilities was delivered by the end of  September 2014 and included access to the Joint Legacy Viewer and a  foundation for future functionality, such as an enhanced graphical user  interface and enterprise messaging infrastructure.
Another interoperable capability that is expected to be incrementally  delivered over the course of the VistA modernization program is the  enterprise health management platform. The department has stated that  this platform is expected to provide clinicians with a customizable view of  a health record that can integrate data from VA, DOD, and third-party  providers. Also, when fully deployed, VA expects the enterprise health  management platform to replace the Joint Legacy Viewer.
However, a recent independent assessment of health IT at VA reported  that lengthy delays in modernizing VistA had resulted in the system  becoming outdated. Further, this study questioned whether the VistA  Evolution program to modernize the electronic health record system can  overcome a variety of risks and technical issues that have plagued prior  VA initiatives of similar size and complexity. For example, the study  raised questions regarding the lack of any clear advances made during  the past decade and the increasing amount of time needed for VA to  release new health IT capabilities. Given the concerns identified, the  study recommended that VA assess the cost versus benefits of various  alternatives for delivering the modernized capabilities, such as  commercially available off-the-shelf electronic health record systems,  open source systems, and the continued development of VistA.
In speaking about this matter, VA’s Under Secretary for Health has  asserted that the department will follow through on its plans to complete  the VistA Evolution program in fiscal year 2018. However, the Chief  Information Officer has also indicated that the department is taking a step  back in reconsidering how best to meet its electronic health record  system needs beyond fiscal year 2018. As such, VA’s approach to  addressing its electronic health record system needs remains uncertain.
In summary, VA’s approach to pursuing electronic health record  interoperability with DOD has resulted in an increasing amount of  standardized health data and has made an integrated view of that data  available to department clinicians. Nevertheless, a modernized VA  electronic health record system that is fully interoperable with DOD’s  system is still years away. Thus, important questions remain about when  VA intends to define the extent of interoperability it needs to provide the  highest possible quality of care to its patients, as well as how and when  the department intends to achieve this extent of interoperability with DOD.  In addition, VA’s unsuccessful efforts over many years to modernize its  VistA system raise concern about how the department can continue to  justify the development and operation of an electronic health record  system that is separate from DOD’s system, even though the  departments have common system needs. Finally, VA’s recent  reconsideration of its approach to modernizing VistA raises uncertainty  about how it intends to accomplish this important endeavor.
Chairman Kirk, Ranking Member Tester, and Members of the  Subcommittee, this concludes my prepared statement. I would be  pleased to respond to any questions that you may have.
section_title: Contact and Acknowledgments
paragraphs: If you or your staff have any questions about this testimony, please  contact Valerie C. Melvin 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 testimony statement. GAO staff who  made key contributions to this statement are Mark T. Bird (Assistant  Director), Jennifer Stavros-Turner (Analyst in Charge), Rebecca Eyler,  Nancy Glover, Jacqueline Mai, and Scott Pettis.
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