Electronic Health Records: VA and DOD Need to Support Cost and Schedule Claims, Develop Interoperability Plans, and Improve Collaboration
Published: 2014-02-27T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: VA and DOD operate two of the nation's largest health care systems, serving approximately 16 million veterans and active duty service members, and their beneficiaries, at total annual costs of over $100 billion. The departments have recognized the importance of developing capabilities for sharing electronic patient health information and have worked since 1998 to develop such capabilities. In February 2011, VA and DOD initiated a program to develop a single, common electronic health record system—iEHR—to replace their existing health record systems. This program was to be managed by the IPO and implemented by 2017. However, the departments made significant changes to the program in 2013. GAO was asked to review the iEHR program. This report (1) describes changes to the program and evaluates the departments' current plans and (2) determines whether the departments are effectively collaborating on management of the program. GAO reviewed relevant program documents and interviewed agency officials.
section_title: What GAO Found
paragraphs: The Departments of Veterans Affairs (VA) and Defense (DOD) abandoned their plans to develop an integrated electronic health record (iEHR) system and are instead pursuing separate efforts to modernize or replace their existing systems in an attempt to create an interoperable electronic health record. Specifically, in February 2013, the secretaries cited challenges in the cost and schedule for developing the single, integrated system and announced that each department would focus instead on either building or acquiring similar core sets of electronic health record capabilities, then ensuring interoperability between them. However, VA and DOD have not substantiated their claims that the current approach will be less expensive and more timely than the single-system approach. Major investment decisions—including terminating or significantly restructuring an ongoing program—should be justified using analyses that compare the costs and schedules of alternative proposals. Yet, the departments have not developed revised cost and schedule estimates for their new modernization efforts and any additional efforts needed to achieve interoperability between the new systems, and compared them with the relevant estimates for their former approach. In the absence of such a comparison, VA and DOD lack assurance that they are pursuing the most cost-effective and timely course of action for delivering the fully interoperable electronic health record the departments have long pursued to provide the best possible care for service members and veterans.
The departments have initiated their separate system efforts. VA intends to deploy clinical capabilities of its new system at two locations by September 2014, and DOD has set a goal of beginning deployment of its new system by the end of fiscal year 2016. However, the departments have yet to update their joint strategic plan to reflect the new approach or to disclose what the interoperable electronic health record will consist of, as well as how, when, and at what cost it will be achieved. Without plans that include the scope, lines of responsibility, resource requirements, and an estimated schedule for achieving an interoperable health record, VA, DOD, and their stakeholders may not have a shared understanding of how the departments intend to address their common health care business needs.
VA and DOD have not addressed management barriers to effective collaboration on their joint health information technology (IT) efforts. As GAO previously reported, the departments faced barriers to effective collaboration in the areas of enterprise architecture and IT investment management, among others. However, they have yet to address these barriers by, for example, developing a joint health care architecture or a joint IT investment management process to guide their collaboration. Further, the Interagency Program Office (IPO), established by law to act as a single point of accountability for the departments' development of interoperable health records, was to better position the departments to collaborate; but the departments have not implemented the IPO in a manner consistent with effective collaboration. For example, the IPO lacks effective control over essential resources such as funding and staffing. In addition, recent decisions by the departments have diffused responsibility for achieving integrated health records, potentially undermining the IPO's intended role as the point of accountability. Providing the IPO with control over essential resources and clearer lines of authority would better position it for effective collaboration.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA and DOD develop and compare the estimated cost and schedule of their current and previous approaches to creating an interoperable electronic health record and, if applicable, provide a rationale for pursuing a more costly or time-consuming approach. GAO also recommends that the departments develop plans for interoperability and ensure the IPO has control over needed resources and clearer lines of authority. VA and DOD concurred with GAO's recommendations.

section_title: Letter
paragraphs: The Department of Veterans Affairs (VA) and the Department of Defense  (DOD) operate two of the nation’s largest health care systems, providing  health care to approximately 6.3 million veterans and 9.6 million active  duty service members and their beneficiaries at estimated annual costs of  about $53 billion and $49 billion, respectively. Electronic health records  are an essential part of delivering quality care to veterans and service  members—especially the 5 million shared patients—that is, those who  receive health care and services from both departments.
Both VA and DOD have long recognized the importance of advancing the  use of shared health information systems and capabilities to make patient  information more readily available to their health care providers, reduce  medical errors, and streamline administrative functions. Toward this end,  in February 2011, the departments initiated a program to jointly develop a  single electronic health record system, known as the integrated Electronic  Health Record (iEHR), which was to replace the two departments’  existing electronic health record systems. The DOD/VA Interagency  Program Office (IPO) was given responsibility for managing the iEHR  program. More recently, however, the departments have made significant  changes to the direction of the program.
At your request, we conducted a review of the iEHR program.  Specifically, our objectives were to (1) describe the changes VA and DOD  have made to the iEHR program since its inception and evaluate the  departments’ current plans for the program and (2) determine whether the  departments, including the IPO, are effectively collaborating on  management of the iEHR program.
To accomplish the objectives, we reviewed relevant program  documentation and interviewed appropriate VA, DOD, and IPO officials.  Specifically, to describe changes to the iEHR program and evaluate the  departments’ current plans, we reviewed and compared iEHR program  planning documentation (e.g., business case, program management plan,  and integrated program-level requirements document) with program  status briefings, acquisition decision memoranda, and minutes of  meetings between the Secretaries of Defense and Veterans Affairs. To  determine whether the departments are effectively collaborating on  management of the iEHR program, we evaluated VA’s and DOD’s actions  in response to recommendations we previously made to address barriers  the departments face in their efforts to meet electronic health record  needs. We also compared the departments’ implementation of the IPO  with effective collaborative practices we have previously identified.  Lastly, we analyzed the governance structure for the program, including  organizational charts and charters that established the reporting structure  between the IPO, VA, DOD, and interagency organizations.
We conducted this performance audit from September 2012 to February  2014 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. A more complete  discussion of our objectives, scope, and methodology is provided in  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. 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 VA and DOD 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.
Although they have identified many common health care business needs,  both departments have spent large sums of money to develop and  operate separate electronic health record systems that they rely on to  create and manage patient health information. VA uses its integrated  medical information system—the Veterans Health Information Systems  and Technology Architecture (VistA)—which was developed in-house by  VA clinicians and IT personnel. 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. Besides being numerous, these applications have  been customized at all 128 VA sites. According to the department, this  customization increases the cost of maintaining the system, as it requires  that maintenance also be customized.
In 2001, the Veterans Health Administration undertook an initiative to  modernize VistA by standardizing patient data and modernizing the health  information software applications. In doing so, its goal was to move from  the hospital-centric environment that had long characterized the  department’s health care operations to a veteran-centric environment built  on an open, robust systems architecture that would more efficiently  provide both the same functions and benefits of the existing system and  enhanced functions based on computable data. VA planned to take an  incremental approach to the initiative, based on six phases that were to  be completed in 2018. The department reported spending almost $600  million from 2001 to 2007 on eight projects, including an effort that  resulted in a repository containing selected standardized health data, as  part of the effort to modernize VistA. In April 2008, the department  estimated an $11 billion total cost to complete, by 2018, the  modernization that was planned at that time. However, according to VA  officials, the modernization effort was terminated in August 2010.
For its part, DOD relies on its Armed Forces Health Longitudinal  Technology Application (AHLTA), which comprises multiple legacy  medical information systems that the department developed from  commercial software products that were 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 information related to pharmacy, radiology, and laboratory order  management. In addition, the department uses Essentris (also called the  Clinical Information System), a commercial health information system  customized to support inpatient treatment at military medical facilities.  DOD obligated approximately $2 billion for AHLTA between 1997 and  2010. The department initiated efforts to improve system performance  and enhance functionality and planned to continue its efforts to stabilize  the AHLTA system through 2015 as a “bridge” to the new electronic  health record system it intended to acquire. According to DOD, the  planned new electronic health record system—known as the EHR Way  Ahead—was to be the department’s comprehensive, real-time health  record for service members and their families and beneficiaries. In  January 2010, the department initiated an analysis of alternatives for  meeting system capability requirements it had identified.
A key goal for sharing health information among providers, such as  between VA’s and DOD’s health care systems, is achieving  interoperability. Interoperability enables different information systems or  components to exchange information and to use the information that has  been exchanged. 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 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 a still 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 can also be considered  interoperable (at the lowest level) because they allow data to be shared,  read, and interpreted by human beings. However, they do not provide  decision support capabilities, such as automatic alerts about a particular  patient’s health, or other reported advantages of automation. We have  previously reported that all data may not require the same level of  interoperability, nor is interoperability at the highest level achievable in all  cases. For example, unstructured, viewable data may be sufficient for  such narrative information as clinical notes.
Interoperability 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. Interoperability depends on the use of agreed-upon  standards to ensure that information can be shared and used. In the  health IT field, standards may govern areas ranging from technical  issues, such as file types and interchange systems, to content issues,  such as medical terminology.
subsections: section_title: History of VA and DOD Efforts and Challenges to Achieve Interoperable Electronic Health Records
paragraphs: Since 1998, VA and DOD have relied on a patchwork of initiatives  involving their health information systems to achieve electronic health  record interoperability. These have included efforts to share viewable  data in existing (legacy) systems; link and share computable data  between the departments’ modernized health data repositories; establish  and address interoperability objectives to meet specific data-sharing  needs; develop a virtual lifetime electronic health record to track patients  through active service and veteran status; and implement IT capabilities  for the first joint federal health care center. While these initiatives have  collectively yielded increased data sharing in various capacities, a  number of them have nonetheless been plagued by persistent  management challenges, which have created barriers to achieving the  fully interoperable electronic health record capabilities long sought.
subsections: section_title: Sharing Data in Legacy Systems
paragraphs: Among the departments’ earliest efforts to achieve interoperability was  the Government Computer-Based Patient Record (GCPR) initiative,  which was begun in 1998 with the intent of providing an electronic  interface that would allow physicians and other authorized users of VA’s  and DOD’s health facilities to access data from the other agency’s health  facilities. The interface was expected to compile requested patient health  information in a temporary, “virtual” record that could be displayed on a  user’s computer screen. However, in reporting on this initiative in April  2001, we found that accountability for GCPR was blurred across several  management entities and that basic principles of sound IT project  planning, development, and oversight had not been followed, creating  barriers to progress. For example, clear goals and objectives had not  been set; detailed plans for the design, implementation, and testing of the  interface had not been developed; and critical decisions were not binding  on all partners. While both departments concurred with our  recommendations that they, among other things, create comprehensive  and coordinated plans for the effort, progress on the initiative continued to  be disappointing. The departments subsequently revised the strategy for  GCPR and, in May 2002, narrowed the scope of the initiative to focus on  enabling DOD to electronically transfer service members’ health  information to VA upon their separation from active duty. The initiative— renamed the Federal Health Information Exchange (FHIE)—was  completed in 2004.
Building on FHIE, VA and DOD also established the Bidirectional Health  Information Exchange (BHIE) in 2004, which was aimed at allowing  clinicians at both departments viewable access to records on shared  patients (that is, those who receive care from both departments, such as  veterans who receive outpatient care from VA clinicians and then are  hospitalized at a military treatment facility). The interface also enabled  DOD sites to see previously inaccessible data at other DOD sites.
section_title: Linking Modernized Data Repositories
paragraphs: Further, in March 2004, the departments began an effort to develop an  interface linking VA’s Health Data Repository and DOD’s Clinical Data  Repository, as part of a long-term initiative to achieve the two-way  exchange of health information between the departments’ modernized  systems—known as the Clinical Data Repository/Health Data Repository  initiative, or CHDR. The departments had planned to be able to exchange  selected health information through CHDR by October 2005. However, in  June 2004, we reported that the efforts of VA and DOD in this area  demonstrated a number of management weaknesses. Among these  were the lack of a well-defined architecture for describing the interface for  a common health information exchange, an established project  management lead entity and structure to guide the investment in the  interface and its implementation, and a project management plan defining  the technical and managerial processes necessary to satisfy project  requirements. Accordingly, we recommended that the departments  address these weaknesses, and they agreed to do so.
In September 2005, we testified that the departments had improved the  management of the CHDR program, but that this program continued to  face significant challenges—in particular, with developing a project  management plan of sufficient specificity to be an effective guide for the  program. In a June 2006 testimony we noted that the project did not  meet a previously established milestone: to be able to exchange  outpatient pharmacy data, laboratory results, allergy information, and  patient demographic information on a limited basis by October 2005. By  September 2006, the departments had taken actions which ensured that  the CHDR interface linked the departments’ separate repositories of  standardized data to enable a two-way exchange of computable  outpatient pharmacy and medication allergy information. Nonetheless, we  noted that the success of CHDR would depend on the departments  instituting a highly disciplined approach to the project’s management.
section_title: Establishing and Addressing Interoperability Objectives
paragraphs: To accelerate the exchange of electronic health information between the  two departments, the National Defense Authorization Act (NDAA) for  Fiscal Year 2008 included provisions directing VA and DOD to jointly  develop and implement, by September 30, 2009, fully interoperable  electronic health record systems or capabilities. To facilitate compliance with the act, the departments’ Interagency Clinical Informatics Board,  made up of senior clinical leaders who represent the user community,  began establishing priorities for interoperable health data between VA  and DOD. In this regard, the board was responsible for determining  priorities for electronic data sharing between the departments, as well as  what data should be viewable and what data should be computable.  Based on its work, the board established six interoperability objectives for  meeting the departments’ data-sharing needs:
Refine social history data: DOD was to begin sharing with VA the  social history data that are captured in the DOD electronic health  record. Such data describe, for example, patients’ involvement in  hazardous activities and tobacco and alcohol use.
Share physical exam data: DOD was to provide an initial capability to  share with VA its electronic health record information that supports the  physical exam process when a service member separates from active  military duty.
Demonstrate initial network gateway operation: VA and DOD were to  demonstrate the operation of secure network gateways to support  joint VA-DOD health information sharing.
Expand questionnaires and self-assessment tools: DOD was to  provide all periodic health assessment data stored in its electronic  health record to VA such that questionnaire responses would be  viewable with the questions that elicited them.
Expand Essentris in DOD: DOD was to expand its inpatient medical  records system (CliniComp’s Essentris product suite) to at least one  additional site in each military medical department (one Army, one Air  Force, and one Navy, for a total of three sites).
Demonstrate initial document scanning: DOD was to demonstrate an  initial capability for scanning service members’ medical documents  into its electronic health record and sharing the documents  electronically with VA.
The departments asserted that they took actions that met the six  objectives and, in conjunction with capabilities previously achieved (e.g.,  FHIE, BHIE, and CHDR), had met the September 30, 2009, deadline for  achieving full interoperability as required by the act. Nonetheless, the  departments planned additional work to further increase their  interoperable capabilities, stating that these actions reflected the  departments’ recognition that clinicians’ needs for interoperable electronic  health records are not static. In this regard, the departments focused on  additional efforts to meet clinicians’ evolving needs for interoperable  capabilities in the areas of social history and physical exam data,  expanding implementation of Essentris, and additional testing of  document scanning capabilities.
Even with these actions, however, we identified a number of challenges  the departments faced in managing their efforts in response to the 2008  NDAA. Specifically, we identified challenges with respect to performance  measurement, project scheduling, and planning. For example, in a  January 2009 report, we noted that the departments’ key plans did not  identify 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. We pointed out that  without establishing results-oriented goals and reporting progress using  measures relative to the established goals, the departments and their  stakeholders would not have the comprehensive picture that they needed  to effectively manage their progress toward achieving increased  interoperability. Accordingly, we recommended that DOD and VA take  action to develop such goals and performance measures to be used as a  basis for providing meaningful information on the status of the  departments’ interoperability initiatives. In response, the departments  stated that such goals and measures would be included in the next  version of the VA/DOD Joint Executive Council Joint Strategic Plan.  However, that plan was not approved until April 2010—7 months after the  departments asserted they had met the deadline for achieving full  interoperability.
In addition to its provisions directing VA and DOD to jointly develop fully  interoperable electronic health record systems or capabilities, the 2008  NDAA called for the departments to set up an interagency program office  (IPO) to be a single point of accountability for their efforts to implement  these systems or capabilities by the September 30, 2009, deadline.  Accordingly, in January 2009, the office completed its charter, articulating,  among other things, its mission and functions with respect to attaining  interoperable electronic health data. The charter further identified the  office’s responsibilities for carrying out its mission in areas such as  oversight and management, stakeholder communication, and decision  making. Among the specific responsibilities identified in the charter was  the development of a plan, schedule, and performance measures to guide  the departments’ electronic health record interoperability efforts.
In July 2009, we reported that the IPO had not fulfilled key management  responsibilities identified in its charter, such as the development of an  integrated master schedule and a project plan for the department’s efforts  to achieve full interoperability. Without these important tools, the office  was limited in its ability to effectively manage and meaningfully report  progress on the delivery of interoperable capabilities. We recommended  that the IPO establish a project plan and a complete and detailed  integrated master schedule. In response to our recommendation, the  office began to develop an integrated master schedule and project plan  that included information about its ongoing interoperability activities.
section_title: Developing a Virtual Lifetime Electronic Record
paragraphs: In another attempt at furthering efforts to increase electronic health record  interoperability, in April 2009, the President announced that VA and DOD  would work together to define and build the Virtual Lifetime Electronic  Record (VLER) to streamline the transition of electronic medical, benefits,  and administrative information between the two departments. VLER was  intended to enable access to electronic records for service members as  they transition from military to veteran status, and throughout their lives.  Further, the initiative was to expand the departments’ health information- sharing capabilities by enabling access to private-sector health data.
Shortly after the April 2009 announcement, VA, DOD, and the IPO began  working to define and plan for the initiative’s health data-sharing activities,  which they refer to as VLER Health. In June 2009, the departments  adopted a phased implementation strategy consisting of a series of 6- month pilot projects to deploy a set of health data exchange capabilities  between existing electronic health record systems at sites around the  country. Each pilot project was intended to build upon the technical  capabilities of its predecessor, resulting in a set of baseline capabilities to  inform project planning and guide the implementation of VLER  nationwide. In June 2010, the departments announced their goal to  deploy VLER Health nationwide by the end of 2012.
The first pilot, which started in August 2009, in San Diego, California,  resulted in VA, DOD, and Kaiser Permanente being able to share a  limited set of test patient data. Subsequently, between March 2010 and  January 2011, VA and DOD conducted another pilot in the Tidewater  area of southeastern Virginia, which focused on sharing the same data as  the San Diego pilot plus additional laboratory data. Further, during 2011,  the departments implemented two additional pilots in Washington state.
In a February 2011 report on the departments’ efforts to address their  common health IT needs, we noted that VA and DOD had identified a  high-level approach for implementing VLER and had designated the IPO  as the single point of accountability for the effort. departments had not developed a comprehensive plan identifying the  target set of capabilities that they intended to demonstrate in the pilot  projects and then implement on a nationwide basis at all domestic VA and  DOD sites by the end of 2012. Moreover, the departments conducted pilot  projects without attending to key planning activities that are necessary to  guide the initiative. For example, as of February 2011, the IPO had not  developed an approved integrated master schedule, master program  plan, or performance metrics for the VLER Health initiative, as outlined in  the office’s charter. We noted that if the departments did not address  these issues, their ability to effectively deliver capabilities to support their  joint health IT needs would be uncertain. We recommended that the  Secretaries of VA and DOD strengthen their efforts to establish VLER by  developing plans that would include scope definition, cost and schedule  estimation, and project plan documentation and approval. Officials from  both departments agreed with the recommendation, and we have  continued to monitor their actions toward its implementation.  Nevertheless, the departments were not successful in meeting their  original goal of implementing VLER nationwide by the end of 2012.
section_title: Implementing IT Capabilities for a Joint Federal Health Care Center
paragraphs: GAO, Electronic Health Records: DOD and VA Should Remove Barriers and Improve  Efforts to Meet Their Common System Needs, GAO-11-265 (Washington, D.C.: Feb. 2,  2011). known as the Captain James A. Lovell Federal Health Care Center  (FHCC). The FHCC is unique in that it is to be the first fully integrated  federal health care center for use by both VA and DOD beneficiaries, with  an integrated workforce, a joint funding source, and a single line of  governance.
In April 2010, the Secretaries of VA and DOD signed an executive  agreement that established the FHCC and, in accordance with the fiscal  year 2010 NDAA, defined the relationship between the two departments  for operating the new, integrated facility. Among other things, the  executive agreement specified three key IT capabilities that VA and DOD  were required to have in place by the FHCC’s opening day, in October  2010, to facilitate interoperability of their electronic health record systems: medical single sign-on, which would allow staff to use one screen to  access both the VA and DOD electronic health record systems;  single patient registration, which would allow staff to register patients  in both systems simultaneously; and orders portability, which would allow VA and DOD clinicians to place,  manage, and update orders from either department’s electronic health  records systems for radiology, laboratory, consults (specialty  referrals), and pharmacy services.
However, in our February 2011 report, we identified improvements the  departments could make to the FHCC effort, noting that project planning  for the center’s IT capabilities was incomplete. We specifically noted  that the departments had not defined the project scope in a manner that  identified all detailed activities. Consequently, they were not positioned to  reliably estimate the project cost or establish a baseline schedule that  could be used to track project performance. Based on these findings, we  expressed concern that VA and DOD had jeopardized their ability to fully  and expeditiously provide the FHCC’s needed IT system capabilities. We  recommended that the Secretaries of VA and DOD strengthen their  efforts to establish the joint IT system capabilities for the FHCC by  developing plans that included scope definition, cost and schedule  estimation, and project plan documentation and approval. Although  officials from both departments stated agreement with our  recommendation, the departments’ actions were not sufficient to preclude  delays in delivering the FHCC’s IT system capabilities, as we  subsequently described in July 2011 and June 2012.
Specifically, in a July 2011 report, we noted that none of the three IT  capabilities had been implemented by the time of the FHCC’s opening in  October 2010, as required by the executive agreement. However,  FHCC officials reported that the medical single sign-on and single patient  registration capabilities had become operational in December 2010.
In June 2012, we again reported on the departments’ efforts to implement  the FHCC’s required IT capabilities and found that portions of the orders  portability capability—related to the pharmacy and consults  components—remained delayed. workarounds that the departments had implemented as a result of the  delays, but could not provide a time line for completion of the pharmacy  component, and estimated completion of the consults component by  March 2013.
VA and DOD officials described  The officials reported that, as of March 2012, the departments had spent  about $122 million on developing and implementing IT capabilities at the  FHCC. However, they were unable to quantify the total cost for all of the  workarounds resulting from delayed IT capabilities.
section_title: VA and DOD Agreed to Jointly Develop a Single Integrated Electronic Health Record System
paragraphs: GAO, VA/DOD Federal Health Care Center: Costly Information Technology Delays  Continue and Evaluation Plan Lacking, GAO-12-669 (Washington, D.C.: June 26, 2012).  In this report, we noted that orders portability for radiology had become operational in  June 2011 and for laboratory in March 2012. health record: (1) develop a new, joint electronic health record system; (2)  upgrade either the existing VistA or AHLTA legacy system to meet the  needs of the other organization; or (3) continue to pursue separate  systems while coordinating on a common infrastructure with data  interoperability. In March 2011, the secretaries committed the two  departments to the first approach—that is, the development of a new  common integrated electronic health record (iEHR) system. In May 2012,  they announced their goal of implementing the integrated health record  across the departments by 2017.
According to the departments, pursuing iEHR was expected to enable VA  and DOD to align resources and investments with common business  needs and programs, resulting in a platform that would replace the two  departments’ separate electronic health record systems with a common  system. In addition, because it would involve both departments using the  same system, this approach was expected to largely sidestep the  challenges they had historically encountered in trying to achieve  interoperability between separate systems. The departments developed  an iEHR business case in August 2012 to justify this approach, which  stated that the use of a common integrated system would support  increased collaboration between both departments and would lead to joint  investment opportunities. Further, this approach was consistent with a  previous study conducted by the departments showing that over 97  percent of inpatient functional requirements were common to both VA and  DOD. According to the iEHR business case, the use of a common  integrated system would address their similar health information system  needs.
Toward this end, initial development plans called for the single, joint iEHR  system to consist of 54 clinical capabilities that would be delivered in six  increments between 2014 and 2017, with all existing applications in VistA  and AHLTA continuing uninterrupted until full delivery of the new  capabilities. The program had planned to send out requests for proposals  (RFP) for initial iEHR capabilities in the first quarter of fiscal year 2013.
Among the agreed-upon capabilities to be delivered were those  supporting laboratory, anatomic pathology, pharmacy, and  immunizations. In addition, the initiative was to deliver several common  infrastructure components—an enterprise architecture, presentation  layer or graphical user interface, data centers, and interface and  exchange standards. The system was to be primarily built by purchasing  commercially available solutions for joint use, with noncommercial  solutions developed or adopted only when a commercial alternative was  unavailable.
According to the departments’ plans, initial operating capability, which  was to be achieved in 2014, was intended to establish the architecture  and include deployment of new immunization and laboratory capabilities  to VA and DOD facilities in San Antonio, Texas, and Hampton Roads,  Virginia. Full operating capability, planned for 2017, was intended to  deploy all iEHR capabilities to all VA and DOD medical facilities.
In October 2011, VA and DOD re-chartered the IPO with increased  authority and expanded responsibilities for leading the integrated system  effort. The charter gave the IPO responsibility for program planning and  budgeting, acquisition and development, and implementation of clinical  capabilities. In particular, the IPO Director was given authority to acquire,  develop, and implement IT systems for iEHR, as well as to develop  interagency budget and acquisition strategies that would meet VA’s and  DOD’s respective requirements in these areas. Further, as program  executive for iEHR, the director of this office was given the authority to  use DOD and VA staff to support the program.
An estimate developed by the IPO in August 2012 put the cost of the  integrated system at $29 billion (adjusted for inflation) from fiscal year  2013 through fiscal year 2029. According to the office’s director, this  estimate included $9 billion for the acquisition of the system and $20  billion to sustain its operations. The office reported actually spending  about $564 million on iEHR between October 2011 and June 2013.  According to the June 2013 IPO expenditure plan, these expenditures  included deployment of a new graphical user interface for viewing patient  data to selected locations; creation of a development and test  center/environment for iEHR; planning efforts required for acquisition of  the initial capabilities—laboratory, immunization, and pharmacy with  orders services; and acquisition of program management, systems  integration, and engineering and testing services required to ensure  completion of required planning activities.
section_title: VA and DOD Abandoned Plans for a Single System, but Their New Approach to Achieving an Interoperable Electronic Health Record Is Not Supported by Sufficient Cost and Schedule Analysis or a Complete Plan
paragraphs: About 2 years after taking actions toward the development of iEHR, VA  and DOD announced changes to their plan—essentially abandoning their  effort to develop a single, integrated electronic health record system for  both departments. In place of this initiative, the departments stated that  VA would modernize its existing VistA health information system, DOD  would buy a commercially available system to replace its existing AHLTA  system, and the departments would ensure interoperability between the  two new systems. However, the decision to change the iEHR program  strategy was not justified on the basis of analyses that considered the  estimated cost and schedule for the new approach of using separate  systems. In addition, while the departments have begun planning for their  separate modernization efforts, they have not completed plans describing  how and in what time frame they intend to achieve an interoperable  electronic health record.
subsections: section_title: The Departments Abandoned Plans for a Single System in Favor of Separate Modernization Efforts
paragraphs: In February 2013, the Secretaries of Defense and Veterans Affairs  announced that they would not continue with their joint development of a  single electronic health record system that was intended to result in an  integrated electronic health record. This decision resulted from an  assessment of the iEHR program that the secretaries requested in  December 2012 because of their concerns about the program facing  challenges in meeting deadlines, costing too much, and taking too long to  deliver capabilities. Based on this assessment, the departments  announced that they would rely on separate systems to achieve an  interoperable electronic health record, departing from their originally  planned solution of using a single system to meet their similar health  information system needs. Specifically, this new approach would involve  each department either developing or acquiring a new core set of  electronic health record capabilities (e.g., workflow and order  management)needed. with additional applications or capabilities to be added as  According to senior VA and DOD officials, the development or acquisition  of similar core sets of electronic health record capabilities would be  achieved by VA modernizing its existing VistA health information system  and DOD buying a commercially available system to replace its existing  AHLTA health information system. In this regard, VA has stated that it  intends to enhance and modernize its existing VistA system under a new  program, called VistA Evolution. For its part, in May 2013, DOD  announced that it would competitively award a contract to acquire a  limited set of core capabilities that might include VistA-based commercial  solutions. However, DOD then determined that, because of the need to  integrate future capabilities, it would cost more to acquire and add to a  limited core set of capabilities than to acquire a full suite of capabilities.  Thus, the department subsequently expanded its effort and has stated  that it is now pursuing the acquisition of a replacement system for its  multiple legacy electronic health record systems under a new program— the DOD Healthcare Management System Modernization (DHMSM)  program—that is being managed by DOD’s Under Secretary of Defense  for Acquisition, Technology, and Logistics.
In addition, the departments have said they intend to focus on existing  projects aimed at increasing the interoperability of health data between  their legacy systems. These included expanding the use of a graphical  user interface for viewing patient information; agreeing upon an approach  for jointly identifying patients; developing a secure network infrastructure  for VA and DOD clinicians to access patient information; and correlating,  or mapping, department data to seven clinical domains and organizing  them in a standardized patient record. According to the IPO’s December  18, 2013, report to Congress, the departments completed the initial  activities for these projects in December 2013 and outlined further actions  the departments plan to take on these efforts.
section_title: VA and DOD Did Not Justify Their Change of Approach with Comparisons of Costs and Schedules
paragraphs: Although VA and DOD based their decision to no longer pursue a single  system on the assertion that their new approach to pursue separate  systems would be less expensive and faster, the departments have not  demonstrated the credibility of this assertion. Best practices have  identified the development and use of cost and schedule estimates as  essential elements for informed decision making when selecting potential  IT investments. In particular, major investment decisions (which can  include, for example, terminating or significantly restructuring an ongoing  program) should be justified using analyses that compare relative costs  and schedules for proposed investments. When effectively implemented,  these practices help ensure that agencies have a sound rationale for their  investment decisions.
However, VA and DOD have proceeded with their current plan without  developing cost and schedule analyses to support the assertion that the  current plan to pursue separate modernized systems while enabling  interoperability between them would be less expensive and could be  achieved faster than developing a single system. Consistent with best  practices, such analyses would require, for example, development and  documentation of revised cost and schedule estimates that include DOD’s  commercial acquisition, VA’s modernization of VistA, and the joint  interoperability effort, as well as a comparison of these with the estimates  for the original single-system approach. Instead of developing such a joint  analysis to consider their common health care business needs, however,  each department made its own individual determination on what the best  course of action would be. These determinations reflect VA’s and DOD’s  divergent philosophies for pursuing IT systems development: VA strongly  supports in-house development and modernization of its homegrown  system, and DOD supports acquiring commercial solutions. Specifically,  according to the VA Under Secretary for Health, pursuing a modernization  of VistA instead of another solution was an obvious choice for VA  because the department already owns the system and has in-house  technical expertise to modernize and maintain it. Similarly, DOD  considered alternatives to replace its legacy electronic health record  system and concluded that pursuing a competitively based commercial  system would be best for the department. The Under Secretary of  Defense for Acquisition, Technology, and Logistics (AT&L) stated that  acquiring a commercial system was the right business decision for DOD  because the department is not in the business of developing IT systems,  particularly when more advanced electronic health record solutions are  available commercially. He added that VA’s reasons for modernizing  VistA were logical for that department but did not apply to DOD. However,  neither of the determinations made by VA and DOD considered cost and  schedule estimates for modernizing or acquiring the departments’ new  systems and achieving interoperability between them. Further, VA and  DOD lack a process for identifying joint IT investments, which could be a  means of reconciling the departments’ divergent approaches, and is one  of the barriers to jointly addressing their health care system needs that we  identified in February 2011 and recommended they address.
Because their new approach is based on the courses of action that VA  and DOD have independently determined to be best for them, and  because they lack cost and schedule analyses to guide their decision  making, the departments have not demonstrated that their new approach  will provide service members, veterans, and their health care providers  with an interoperable electronic health record at lower cost and in less  time than the original plan.
section_title: The Departments Have Begun Separate Modernization Efforts, but Plans for Delivering an Interoperable Electronic Health Record Remain Undeveloped
paragraphs: While VA and DOD have begun to pursue separate systems, they have  not developed plans at either a strategic or program level that describe  how they intend to achieve an interoperable electronic health record.  Industry best practices and IT project management principles stress the  importance of sound planning for any project.is the development and use of a project management plan that includes  the project’s scope, lines of responsibility for all stakeholders, resource  requirements, an estimated schedule for development and  implementation, and performance measures. Additionally, plans should  identify and prioritize program risks so that potential problems can be  avoided before they become actual cost, schedule, and performance   Inherent in such planning  shortfalls. In addition, the National Defense Authorization Act (NDAA) for  Fiscal Year 2014 required the departments to provide a detailed  programs plan for the oversight and execution of an interoperable  electronic health record between the departments no later than January  31, 2014.
Since VA and DOD announced their new approach in February 2013, the  departments have been focused on planning for their separate  modernization efforts:  In December 2013, VA developed a VistA Evolution program plan for  initial operating capability that is focused on system enhancements for  VistA intended to provide at least two enhanced clinical capabilities to  be deployed at two VA sites by the end of fiscal year 2014. The  department is in the process of developing a separate program plan  for VistA Evolution that is intended to provide an overview of VA’s  efforts to achieve full operating capability by September 30, 2017.
DOD released an initial draft RFP to industry on January 29, 2014,  with a goal to release the final RFP for the system’s acquisition in July  2014. According to the DOD Healthcare Management Systems  (DHMS) Program Executive Officer, following the release of the RFP,  the department plans to award a contract for the replacement system  in the third quarter of fiscal year 2015, with a goal of achieving initial  operating capability for the program in the fourth quarter of fiscal year  2016. According to a DOD Acquisition Decision Memorandum in  January 2014, the DHMS Program Executive Officer is to develop a  health data-sharing and interoperability road map that is to address  interoperability with VA, private health care providers, and patients.  The road map is to be provided to DOD management by March 2014  for review.
Additionally, in response to the fiscal year 2014 NDAA, VA and DOD  briefed congressional staff in late January 2014 on their plans for VistA  Evolution, plans for the DHMSM program, and their intention to achieve  an interoperable electronic health record. Despite this briefing and initial  steps toward their separate modernization efforts, the departments have  not developed a plan that describes how they intend to achieve an  interoperable electronic health record under their new approach of  pursuing separate system modernizations. Specifically, the departments  have not identified which clinical domains of health data will comprise the  interoperable electronic health record, the estimated cost and schedule  for the effort, or the lines of responsibility for all stakeholders involved. In  addition, risks have not been identified and prioritized in order to help  avoid potential problems before they become actual cost, schedule, and  performance problems. Without having plans in place to provide key  information on their effort to create an interoperable electronic health  record, the departments are increasing the risk that the new approach will  not be more cost efficient and timely than if they had continued with the  single-system approach.
Moreover, in 2011, we reported that VA’s and DOD’s joint strategic plan  did not discuss how or when they proposed to identify and develop joint  solutions to address their common health IT needs. Accordingly, we  recommended that they revise the joint strategic plan to include  information discussing their electronic health record system  modernization efforts and how those efforts will address the departments’  common health care business needs. However, the departments’ most  recent joint strategic plan, which was released in March 2013 and covers  fiscal years 2013 through 2015, does not reflect their current approach. In  July 2013, the VA/DOD Joint Executive Council tasked the IPO with  preparing an addendum to the joint strategic plan that would reflect the  departments’ revised joint activities, milestones, metrics, and time lines  for creating an interoperable health record. However, while the  departments have begun planning to separately modernize their  electronic health record systems and have identified the need to make  these systems interoperable, they have not revised their plan for doing  so. According to VA and DOD officials, as of January 2014, a draft  addendum to the joint strategic plan was being reviewed by the  departments’ senior leaders, but the officials could not say when the  addendum is to be finalized. Until VA and DOD provide a plan that  reflects their current approach, the departments and their stakeholders  may not have a shared understanding of how they intend to address their  common health care business needs, including an interoperable  electronic health record, going forward.
section_title: Collaboration between VA and DOD Has Been Hindered by Long-standing Barriers and Ineffective Implementation of the IPO
paragraphs: We have previously reported on IT management barriers that prevented  the departments from effectively collaborating to address their common  health care system needs in the areas of enterprise architecture and IT  investment management. We have followed the departments’ efforts to  address these barriers and have found that important work still remains.  In addition, the Interagency Program Office, established by the fiscal year  2008 NDAA to act as a single point of accountability for the departments’  development and implementation of interoperable health records, was to  better position the departments to collaborate. Our work on interagency  collaboration has shown that successful collaboration depends on a  number of factors, including identifying resources, establishing compatible  policies and procedures, and agreeing on clear lines of responsibility and  accountability. We have also identified a variety of mechanisms that  federal agencies use to implement interagency collaborative efforts,  including interagency offices, to carry out joint activities on behalf of the  participating departments. However, despite the direction given in the  fiscal year 2008 NDAA, and the departments’ repeated efforts to re- charter the office, VA and DOD did not implement the IPO as an effective  mechanism for interagency collaboration. Specifically, the departments  did not provide the IPO with authority over essential resources or with the  autonomy to establish key interagency processes for managing joint  activities. Additionally, VA and DOD established a complex governance  structure for the office, which weakened its ability to serve as the single  point of accountability for the departments’ development and  implementation of fully interoperable electronic health record systems or  capabilities. Moreover, the departments’ December 2013 re-chartering of  the IPO significantly reduces the office’s role, responsibilities, and  authority over VA and DOD’s joint health IT efforts, and raises concerns  about the office’s ability to serve as an effective mechanism for  interagency collaboration and the single point of accountability for the  departments’ joint health IT efforts.
subsections: section_title: VA and DOD Have Not Addressed Barriers to Jointly Addressing Their Common Health Care System Needs
paragraphs: In February 2011, we highlighted barriers that VA and DOD faced in  addressing their common health IT needs. For example, although VA  and DOD had taken steps toward developing and maintaining artifacts  related to a joint health architecture (i.e., a description of business  processes and supporting technologies), the architecture was not  sufficiently mature to guide the departments’ joint health IT modernization  efforts. Further, the departments had not established a joint process for  selecting IT investments based on criteria that consider cost, benefit,  schedule, and risk elements, limiting their ability to pursue joint health IT  solutions that both meet their needs and provide better value and benefits  to the government as a whole. We noted that without having these key IT  management capabilities in place, the departments would continue to  face barriers to identifying and implementing IT solutions that addressed  their common needs. Accordingly, we identified several actions that the  Secretaries of Defense and Veterans Affairs could take to overcome  these barriers, including the following:
Further develop the departments’ joint health architecture to include  the planned future state and plan for transitioning from their current  state to the next generation of electronic health record capabilities.
Define and implement a process, including criteria that consider costs,  benefits, schedule, and risks, for identifying and selecting joint IT  investments to meet the departments’ common health care business  needs.
Officials from both VA and DOD agreed with these recommendations,  and we have continued to monitor their actions toward implementing  them. Nonetheless, the actions taken by VA and DOD have not been  sufficient to overcome the departments’ long-standing barriers to  collaborating on their joint health IT efforts, and important work remains.
For example, VA and DOD have not further developed a joint health  architecture that could guide their efforts to address their common health  care business needs, as we recommended. The departments had  undertaken certain actions, but these have been overtaken by events or  are tangential to developing the architecture. For example, in January  2013 the IPO developed an Enterprise Architecture Management Plan to  provide guidance for developing joint architecture products, identify  architecture governance bodies and stakeholder responsibilities, and  propose high-level time lines for architecture-related activities. However,  according to VA and DOD officials, this plan is no longer operative  because it does not reflect the departments’ decision to pursue separate  electronic health record system modernization efforts. In addition, in  December 2013 the departments revised the charter for the IPO, which  describes the importance of identifying and adopting health IT standards  to seamlessly integrate VA and DOD health care record data. The charter  also specifies that the IPO is responsible for working with the  departments’ Health Architecture Review Board to ensure that both  departments are appropriately synchronized and coordinated. While  these recent activities are peripherally related to development of the joint  health architecture, VA and DOD have not yet developed architecture  artifacts that describe their planned future state and how they intend to  transition to that future state. Until the departments have an  understanding of the common business processes and technologies that  a joint health architecture can provide, they will continue to lack an  essential tool for jointly addressing their common health IT needs.
Further, VA and DOD initiated, but did not sustain, two courses of action  that were potentially responsive to our recommendation to establish a  joint IT investment management process. First, the departments  established the IPO Advisory Board in October 2011 to monitor the iEHR  program’s progress toward meeting cost, schedule, and performance  milestones. However, the advisory board did not meet after June 2013  and was disbanded as a result of the departments’ decision to pursue  separate modernizations of their electronic health record systems.  Second, in August 2012 the departments established a working group  under the Interagency Clinical Informatics Board to identify potential  health IT investments for the departments to consider for joint adoption.  However, the group has not met since June 2013 and, according to VA  and DOD officials, its activities have been suspended while the  departments continue to define their separate modernization efforts and  their electronic health data interoperability needs. Moreover, the group  was not involved in helping the departments identify and select the  separate electronic health record investments VA and DOD now plan to  undertake to meet their common health care business needs. Because  VA and DOD have not implemented a process for identifying and  selecting joint IT investments, the departments have not demonstrated  that their approach to meeting their common health care business needs  has considered the costs, benefits, schedule, and risks of planned  investments.
section_title: VA and DOD Did Not Implement the IPO Consistent with Effective Collaboration Practices
paragraphs: Best practices recognize that an office such as the IPO has the potential  to serve as a mechanism for interagency collaboration, provided that the  collaborating departments adopt a number of practices to sustain it.  These include identifying resources, establishing compatible policies and  procedures, and agreeing on clear lines of responsibility and  accountability, including how the collaborative effort will be led. Best  practices have also found that without this, the collaborating departments  may not be willing to fully commit to the joint effort, and may also be  unable to overcome other barriers, such as concerns about protecting  jurisdiction over missions and control over resources.
Despite VA and DOD’s pledge to work together to address their common  health IT needs, the departments did not implement the IPO consistent  with best practices for interagency collaboration and, in some cases, with   Specifically, the departments did not follow through  the office’s charter. with commitments made in the IPO’s 2011 charter related to its authority  over the iEHR program’s budget, staffing, and interagency processes. In  addition, the departments implemented the office with multiple layers of  governance and oversight, which has resulted in unclear lines of authority  and accountability for the departments’ collaborative health IT efforts.
The departments have issued four charters since the IPO was established in law in  2008. The IPO’s first charter was signed by the Under Secretary of Defense for Personnel  and Readiness and Deputy Secretary of VA in January 2009. Both the second and third  charters were signed by the Deputy Secretary of Defense and Deputy Secretary of VA in  September 2009 and October 2011, respectively. Finally, the IPO’s fourth charter was  signed in December 2013 by the Under Secretary of Defense for Acquisition, Technology,  and Logistics and the VA Executive in Charge, Office of Information and Technology and  Chief Information Officer. efforts. For example, in July 2011 a former director of the office testified  that the IPO’s 2009 charter had established a modest role for the office,  and thus, the office did not have control over the budget for those  initiatives for which it was responsible; rather, this control remained with  VA and DOD. When the departments re-chartered the IPO in 2011, they  included language related to the office having budgetary control over the  iEHR program. For example, this charter gave the IPO Director the  authority to manage budgeting and finances related to the planning and  acquisition of the iEHR capabilities. In addition, the charter provided the  director with the authority to develop and propose interagency budget  submissions for iEHR to the departments. Nevertheless, even with these  revisions to its charter, the IPO was not fully empowered to execute funds  related to iEHR because the departments have different processes for  budgeting IT programs and, in VA’s case, for releasing funds for IT  development. According to the Deputy Chief Management Officer, DOD  had a dedicated fund for the iEHR program, which the IPO Director had  authority to execute. However, VA funded the iEHR program through  several funds, including IT appropriations that VA officials asserted could  only be executed by the Chief Information Officer (CIO). As a result, the  IPO Director was required to request funding for iEHR-related activities  from VA on a project-by-project basis. According to one of the iEHR  program managers, although this process did not necessarily cause  delays to iEHR projects, it was a source of continuous frustration for the  IPO Director because it did not provide the expected level of control over  the program’s budget, as described in the office’s charter.
Staffing: When VA and DOD designated the IPO to lead the iEHR  program in 2011, they recognized that the office would need to be  expanded to accommodate its new responsibilities. To this end, the  departments and the IPO determined that the office would require a  significant increase in personnel—more than 7 times the number of staff  originally allotted to the office by VA and DOD—to complete hiring under  the office’s 2011 charter. However, while each of the departments  provided personnel to the IPO through reassignments and short-term  details of personnel, the departments did not fully staff the office as  planned. For example, a staffing report from early November 2012  showed that, at that time, the IPO was staffed at about 60 percent.  Specifically, while the office consisted of 101 reassigned VA and DOD  staff and 43 detailed staff, 95 positions remained vacant. Further, in  January 2013, the IPO Director stated that the office was staffed at  approximately 62 percent and that hiring additional staff remained one of  its biggest challenges, partly due to a hiring freeze within the TRICARE  Management Activity. In addition, VA’s iEHR program manager noted that  recruiting staff for the IPO was a persistent challenge because the  departments required health IT professionals with specialized technical  expertise. Further, the official noted that VA faced a disadvantage in  hiring qualified candidates because it had to compete with private-sector  companies and also had decided to generally limit the hiring pool to  candidates in the Washington, D.C., area.
Within their respective departments, VA and DOD have established their own processes  for managing acquisitions and contracting. Although the IPO had a contracting officer on  staff at the time of our review, all of the contracts for work conducted for the iEHR program  had been issued and managed through existing VA and DOD contracting offices, including  VA’s Technology Acquisition Center, the Space and Naval Warfare Systems Command,  and the United States Army Medical Research Acquisition Activity. inefficient approach.Information and Technology, this decision created an undue burden on  the iEHR program office because it had to meet the requirements of two  different contracting and acquisition processes. For example, according to  iEHR program documentation, the office would have had to develop over  1,300 documents for one of the planned iEHR increments composed of  14 projects in order to comply with both departments’ acquisition  requirements. Although the iEHR program was redirected before the IPO  made significant progress toward acquiring joint EHR capabilities, this  provides an example of one area where the departments were unable to  compromise on their own processes in order to further their common  health IT goals.
The IPO’s 2011 charter provided DOD’s Deputy Chief Management Officer and VA’s  Assistant Secretary for Information and Technology with operational oversight of the IPO.  In addition the charter cited the Assistant Secretary of Defense for Health Affairs and the  Under Secretary of Defense for Personnel and Readiness as having authority, direction,  and control over the IPO, due to the office’s organizational placement within DOD for the  purposes of administrative management and supervision. Note that on October 1, 2013,  DOD established the Defense Health Agency to manage the activities of the Military  Health System (including TRICARE Management Activity). office’s charter, and was expected to seek consensus from VA and DOD  supervising officials or the IPO’s governance organizations before  proceeding. Conversely, one of the IPO’s governing bodies raised  concerns about the office’s willingness to appropriately involve them in  the iEHR program. Specifically, the co-chairs of the Health Architecture  Review Board raised concerns to the Health Executive Committee that  the IPO had not been receptive to involving the board throughout the  design and acquisition process for the iEHR program. According to these  officials, the board’s inability to participate throughout the process  resulted in unnecessary delays to the IT acquisition process. In a  December 2012 assessment prepared to help define the iEHR program’s  new direction, VA and DOD officials cited governance and oversight as  challenges to the program, including group decision making. In an effort  to mitigate this problem, the departments chose to shift decision-making  authority away from the IPO Director and in January 2013 established an  executive committee of two VA and two DOD executive officials to  oversee the IPO and make decisions for the iEHR program.
Given the changes that VA and DOD have made to their approach for  developing an interoperable electronic health record, it remains to be  seen how the departments will proceed with implementing the IPO and to  what extent the office will be leveraged as a mechanism for effective  interagency collaboration. Nevertheless, until VA and DOD address these  long-standing issues, their ability to effectively collaborate through the  IPO on their joint health IT efforts will be limited.
section_title: VA and DOD Have Reduced the IPO’s Role and Responsibilities
paragraphs: As stated earlier, the fiscal year 2008 NDAA established the IPO under  the direction, supervision, and control of both the Secretaries of VA and  Defense to serve as the single point of accountability for the departments’  development and implementation of interoperable electronic health  records. The IPO was to better position the departments to collaborate on  joint health IT initiatives. However, the departments recently made  decisions that reduced the IPO’s role, responsibilities, and authority over  the departments’ joint health IT efforts, jeopardizing its ability to serve as  the single point of accountability for the development and implementation  of interoperable electronic health records.
In December 2013, VA and DOD revised the IPO’s charter, thus reducing  the office’s responsibilities from leading and managing all aspects of the  iEHR program to overseeing the departments’ adoption of health data  standards for ensuring integration of health data between their  modernized health IT systems. For example, the IPO’s 2011 charter  authorized the office to lead and manage all interagency planning,  programming and budgeting, contracting, acquisition, data strategy and  management (including identifying standards for interoperability), testing,  and implementation for the iEHR program. In contrast, under the revised  charter, the IPO is to engage with national and international health  standards-setting organizations to ensure their resulting standards meet  the needs of VA and DOD; identify data and messaging standards for VA  and DOD health IT solutions; and monitor and report on the departments’  use of and compliance with the adopted standards. Moreover, the revised  charter does not acknowledge or address the office’s long-standing  weaknesses related to budgetary control, staffing, developing interagency  processes, and governance. Specifically:
Although the 2013 charter describes how the departments generally  intend to share the costs of their planned interoperability work, VA and  DOD have not explicitly addressed whether or not the IPO Director  has budgetary control over the office’s initiatives. As written, the  charter suggests that this authority will remain with the departments.
Similar to the 2011 charter, the 2013 charter states that the  departments will rely on a combination of reassigned VA and DOD  personnel and detailees to fill the IPO’s positions. As of early January  2014, VA and DOD officials stated that they were in the process of  transitioning IPO personnel back to their respective departments, and  were identifying individuals to serve as leads within each department  for their joint interoperability projects. However, although these  officials stated that they anticipate the office will require significantly  fewer personnel than expected under the iEHR program, staffing for  the IPO remains uncertain. Moreover, the departments have not yet  addressed how to competitively recruit and retain personnel with the  required technical expertise to develop and implement an  interoperable electronic health record.
The 2013 charter does not explicitly address the extent to which the  IPO has the authority to develop interagency processes to fulfill its  mission, although it is implied in the office’s responsibilities. For  example, the charter states that the IPO will work with the Health  Architecture Review Board “to ensure that both departments are  appropriately synchronized and coordinated”; yet, according to the co- chairs of this board, the details of this process have not been  discussed or defined.
In addition, despite the IPO’s reduced role and responsibilities, the  2013 charter maintains a complex governance structure. For example,  the charter states that the IPO Director reports through the DHMS  Program Executive Officer to the Under Secretary of Defense (AT&L),  while the IPO Deputy Director reports through the IPO Director to the  VA Assistant Secretary for Information and Technology and CIO.  However, the charter does not describe whether or how the IPO  Director reports to VA leadership. Further, the charter identifies  numerous executive-level individuals and organizations to provide  direction, oversight, and guidance to the IPO, including the Joint  Executive Committee, the Under Secretary of Defense (AT&L), the VA  CIO, and a DOD/VA Senior Stakeholder Group that will include  functional, technical, acquisition, and resource leadership from both  departments.oversight, it is unclear to what extent the IPO leadership will have  decision-making authority over the office’s interoperability efforts.
Given this extensive level of management and  Further, the IPO’s 2013 charter maintains that the office will remain the  single point of accountability for the development and implementation of  interoperable electronic health records between VA and DOD. However,  in addition to reducing the IPO’s role, responsibilities, and authority over  these efforts in its 2013 charter, the departments have identified other  offices to execute health data interoperability initiatives formerly managed  by the IPO. For example, in January 2014, the Under Secretary of  Defense (AT&L) decided to consolidate the execution of all DOD IT health  data-sharing projects formerly managed by the IPO and the Defense  Health Agency within a new program office under the DHMS Program  Executive Officer. These projects include VLER Health, ongoing data  federation efforts, and longtime data-sharing initiatives with VA, including  the Federal Health Information Exchange, the Bidirectional Health  Information Exchange, and the Clinical Data Repository/Health Data  Repository. According to the decision memo, resources associated with  these health data interoperability efforts will be reassigned from the IPO  and the Defense Health Agency to the DHMSM program. Similarly, in  January 2014 the Veterans Health Administration’s Chief Medical  Informatics Officer stated that interoperability programs are in the process  of being consolidated under their Office of Health Informatics and  Analytics and will be managed along with VA’s Office of Information and  Technology.
Overall, a disconnect exists between the IPO’s responsibility to serve as  VA and DOD’s single point of accountability for their health data  interoperability efforts and the role described in the office’s December  2013 charter. When asked how the IPO will be able to serve as the single  point of accountability for the departments’ joint health IT efforts given  these changes, the DHMS Program Executive Officer stated that he did  not think that the changes impact the IPO’s role at all because the office  is responsible for ensuring that the departments adopt a sound technical  approach for interoperability. Nevertheless, VA’s and DOD’s decisions to  diminish the IPO’s role and move responsibilities for interoperability  elsewhere within their respective departments jeopardize the office’s  ability to serve as the departments’ single point of accountability for the  development and implementation of interoperable electronic health  records. Moreover, the departments’ recent actions raise concerns about  their intention to use the IPO as a mechanism for collaboration going  forward.
section_title: Conclusions
paragraphs: VA and DOD lost valuable time toward providing service members,  veterans, and their health care providers with a long-awaited  interoperable electronic health record by agreeing to initiate joint  development of a single system in March 2011, and then deciding in  February 2013 that the endeavor was too expensive and that the planned  system would take too long to develop. The departments are now in the  process of planning to use separate systems—VA intends to modernize  its existing VistA system and DOD plans to acquire a commercially  available system—while they are also to jointly develop capabilities to  provide interoperability between the systems. In abandoning the single- system approach, the departments asserted that their new, multiple- system approach will be less expensive and faster. However, the  departments’ assertion is questionable because they have not developed  cost and schedule estimates to substantiate their claim or justify their  decision. In the absence of credible analyses to guide decisions about  how to cost-effectively and expeditiously develop the interoperable  electronic health record needed to provide service members and veterans  with the best possible care, VA and DOD have fallen back on the  divergent approaches that each department has determined to be best for  it—VA intends to modernize VistA, and DOD expects to acquire a new  commercially available system. While the departments have begun  planning for these separate systems, they have yet to develop plans  describing what a future interoperable health record will consist of or how,  when, and at what cost it will be achieved.
Further, even though VA and DOD have determined that their electronic  health record system needs overlap, the departments have neither  removed long-standing barriers to working together to address their  common needs nor positioned the Interagency Program Office for  effective collaboration going forward. Their slow pace in addressing  recommendations we made to address these barriers has hindered their  efforts to identify and implement IT solutions that meet their common  needs. Further, the departments’ failure to implement the IPO consistent  with effective collaboration practices may hamper its efforts to serve as a  focal point for future collaboration. Moreover, the departments’ recent  decisions to move certain interoperability responsibilities to other offices  within VA and DOD may further undermine the IPO’s effectiveness.  Because the IPO is expected to play a key role—establishing  interoperability between VA’s modernized VistA and DOD’s to-be- acquired system—it is important that the departments take steps to better  implement the office as an effective mechanism for collaboration and the  single point of accountability for their joint health IT efforts.
section_title: Recommendations for Executive Action
paragraphs: To bring transparency and credibility to the Secretaries of Veterans  Affairs and Defense’s assertion that VA and DOD’s current approach to  achieving an interoperable electronic health record will cost less and take  less time than the previous single-system approach, we recommend that  the secretaries develop a cost and schedule estimate for their current approach, from  the perspective of both departments, that includes the estimated cost  and schedule of VA’s VistA Evolution program, DOD’s DHMSM  program, and the departments’ joint efforts to achieve interoperability  between the two systems; then,  compare the cost and schedule estimates of the departments’ current  and previous (i.e., single-system) approaches.
If the results of the comparison indicate that the departments’ current  approach is estimated to cost more and/or take longer than the single- system approach, provide a rationale for pursuing the current approach despite its  higher cost and/or longer schedule and  report the cost and schedule estimates of the current and previous  approaches, results of the comparison of the estimates, and reasons  (if applicable) for pursuing a more costly or time-consuming approach  to VA’s and DOD’s congressional authorizing and appropriations  committees.
To better position VA and DOD to achieve an interoperable electronic  health record, we recommend that the Secretaries of Veterans Affairs and  Defense develop a plan that, at a minimum, describes  the clinical domains that the interoperable electronic health record will  address; a schedule for implementing the interoperable record at each VA and  DOD location;  the estimated cost of each major component (i.e., VistA Evolution,  DHMSM, etc.) and the total cost of the departments’ interoperability  efforts;  the organizations within VA and DOD that are involved in acquiring,  developing, and implementing the record, as well as the roles and  responsibilities of these organizations; major risks to the departments’ interoperability efforts and mitigation  plans for those risks; and  the departments’ approach to defining, measuring, tracking, and  reporting progress toward achieving expected performance (i.e.,  benefits and results) of the interoperable record.
To better position the Interagency Program Office for effective  collaboration between VA and DOD and to efficiently and effectively fulfill  the office’s stated purpose of functioning as the single point of  accountability for achieving interoperability between the departments’  electronic health record systems, we recommend that the Secretaries of  Veterans Affairs and Defense ensure that the IPO has authority over dedicated resources (e.g., budget and staff), to develop interagency processes, and  to make decisions over the departments’ interoperability efforts.
section_title: Agency Comments and Our Evaluation
paragraphs: We received written comments on a draft of this report (reprinted in  appendix II), signed by the VA Chief of Staff and the Acting Under  Secretary of Defense for Personnel and Readiness. In their comments,  the departments concurred with our recommendations and noted actions  that were being taken. In particular, with regard to our recommendation  that VA and DOD develop cost and schedule estimates for their current  approach to creating an interoperable electronic health record, and then  compare them with the estimated cost and schedule for the iEHR  approach, both departments said they have these actions under way and  that initial comparisons have indicated that their current approach will be  more cost effective. Further, with regard to our recommendation calling  for a detailed interoperability plan, the departments stated that they are  developing such a plan. Lastly, with respect to our recommendation to  strengthen the IPO for effective collaboration, the departments stated that  the IPO will remain the single point of accountability for achieving  interoperability between VA’s and DOD’s electronic health record  systems. If the departments fully implement our recommendations, they  should be better positioned to economically and efficiently achieve the  interoperable electronic health record they have long pursued. VA and  DOD also provided technical comments on the draft report, which we  incorporated as appropriate.
We are sending copies of this report to appropriate congressional  committees, the Secretary of Veterans Affairs, the Secretary of Defense,  and other interested parties. In addition, the report is available at no  charge on the GAO website at http://www.gao.gov.
If you or your staff 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 III.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of this study were to (1) describe changes the Department  of Defense (DOD) and Department of Veterans Affairs (VA) have made to  the Integrated Electronic Health Record (iEHR) program since its  inception, and evaluate the departments’ current plans for the program  and (2) determine whether the departments, including the DOD/VA  Interagency Program Office (IPO), are effectively collaborating on  management of the iEHR program.
To describe the changes to the iEHR program since its inception, we  obtained and reviewed minutes and briefing slides from meetings held  between the VA and DOD Secretaries between February 2011 and  February 2013. In addition, we obtained and reviewed DOD acquisition  decision memorandums issued between 2011 and 2013 and minutes and  briefing slides from meetings for the IPO Advisory Board between April  2012 and April 2013. We also reviewed iEHR program documentation,  including the business case, program management plan, integrated  program-level requirements document, the June 2013 iEHR expenditure  plan, and program management review briefings.
To evaluate the current plans for the program, we reviewed  documentation and plans supporting efforts to complete four iEHR near- term projects, including iEHR project briefing slides and iEHR program  management review briefings. We obtained information on the  departments’ new health modernization efforts, VA’s VistA Evolution  program and DOD’s Healthcare Management System Modernization  program, through interviews with relevant officials. We also attended  three iEHR and health information exchange summits in Washington,  D.C., and Alexandria, Virginia. In addition, we compared statements  made and documentation the departments provided to support the shift in  the program strategy for iEHR against effective management practices.
To determine the effectiveness of collaboration by VA, DOD, and the IPO,  we identified and analyzed the departments’ actions in response to  recommendations we previously made to address barriers VA and DOD  faced in addressing their common health IT needs.analyzed the 2011 and 2013 IPO charters and compared them to the  requirements that were established for the IPO in the National Defense  Authorization Act for 2008. We focused our analysis in the areas of  funding, staffing, and interagency processes and compared written and  verbal information on the departments’ implementation of the IPO against  best practices for facilitating interagency collaboration. We also analyzed  the governance structure for the IPO and the iEHR program, including  organizational charts and charters that established the reporting structure  between the IPO, VA and DOD, and several interagency organizations  designated to provide oversight to the iEHR program. To better  understand the decision making for the program, we analyzed briefing  slides and minutes from the secretaries’ quarterly meetings, and the IPO  Advisory Board’s bi-weekly meetings, as well as iEHR-related decision  memorandums issued by the departments.
We supplemented our analyses with interviews of VA, DOD, and IPO  officials with knowledge of the iEHR Program, including VA’s Under  Secretary for Health, VA’s Assistant Secretary for Information and  Technology and Chief Information Officer, DOD’s Assistant Secretary of  Defense for Health Affairs, DOD’s Deputy Chief Management Officer, and  the IPO Director.
We conducted this performance audit from September 2012 to February  2014 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: Joint Comments from the Departments of Veterans Affairs and Defense
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Mark T. Bird (Assistant Director),  Heather A. Collins, Kelly R. Dodson, Lee McCracken, Brandon S. Pettis,  Umesh Thakkar, and Eric Trout made key contributions to this report.