Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project Management
Published: 2004-06-07T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: A critical element of the Department of Veterans Affairs' (VA) information technology program is its continuing work with the Department of Defense (DOD) to achieve the ability to exchange patient health care information and create electronic medical records for use by veterans, active-duty military personnel, and their health care providers.
section_title: What GAO Found
paragraphs: While VA and DOD continue to move forward in agreeing to and adopting standards for clinical data, they have made little progress since last winter toward defining how they intend to achieve an electronic medical record based on the two-way exchange of patient health data. The departments continue to face significant challenges in achieving this capability. VA and DOD lack an explicit architecture--a blueprint--that provides details on what specific technologies will be used to achieve the electronic medical record by the end of 2005. The departments have not fully implemented a project management structure that establishes lead decision-making authority and ensures the necessary day-to-day guidance of and accountability for their investment in and implementation of this project. They are operating without a project management plan describing the specific responsibilities of each department in developing, testing, and deploying the electronic interface. In seeking to provide a two-way exchange of health information between their separate health information systems, VA and DOD have chosen a complex and challenging approach--one that necessitates the highest levels of project discipline. Yet critical project components are currently lacking. As such, the departments risk investing in a capability that could fall short of what is expected and what is needed. Until a clear approach and sound planning are made integral parts of this initiative, concerns about exactly what capabilities VA and DOD will achieve--and when--will remain.

section_title: Letter
paragraphs: As you know, the Departments of Veterans Affairs (VA) and Defense  (DOD) are currently pursuing the ability to exchange patient health care  data and create an electronic medical record for veterans and active-duty  military personnel. While in military status and later as veterans, many  patients tend to be highly mobile and may have health records residing at  multiple medical facilities within and outside of the United States. Having  readily accessible medical data on these individuals is important to  providing high-quality health care to them and to adjudicating any  disability claims that they may have. This goal of having electronic medical  records that display all available clinical information in each department’s  health information system is a positive and necessary step. However, as  we have previously reported, the lack of progress the departments have  made in accomplishing this two-way exchange of health care data raises  doubts as to when and to what extent a true electronic medical record will  be achieved.
As requested, our objective was to assess VA’s and DOD’s recent progress  toward achieving an electronic two-way exchange of health care data. In  conducting our work, we analyzed key documentation supporting VA’s  and DOD’s strategy for developing and implementing the two-way  electronic exchange of health data. In addition, we reviewed  documentation to identify the costs incurred by VA and DOD in developing  technology to support the sharing of health data, including costs for the  Government Computer-Based Patient Record/Federal Health Information  Exchange (GCPR/FHIE) initiatives, DOD’s Composite Health Care System  II, and VA’s HealtheVet VistA. We did not audit the reported costs, and  thus, cannot attest to their accuracy or completeness. We supplemented  our analyses with interviews of VA and DOD officials responsible for key  decisions and actions on the initiatives. Our work was performed at VA  and DOD offices located in the Washington, D.C., area in accordance with  generally accepted government auditing standards, from December 2003  to May of this year.
subsections: section_title: Background
paragraphs: Since 1998 VA and DOD have been trying to achieve the capability to share  patient health care data electronically. The original effort—the  government computer-based patient record (GCPR) project—included the  Indian Health Service (IHS) and was envisioned as an electronic interface  that would allow physicians and other authorized users at VA, DOD, and  IHS health facilities to access data from any of the other agencies’ health  information systems. The interface was expected to compile requested  patient information in a virtual record that could be displayed on a user’s  computer screen.
Our prior reviews of the GCPR project determined that the lack of a lead  entity, clear mission, and detailed planning to achieve that mission made it  difficult to monitor progress, identify project risks, and develop  appropriate contingency plans. Accordingly, reporting on this project in  April 2001 and again in June 2002, we made several recommendations to  help strengthen the management and oversight of GCPR. Specifically, in  2001 we recommended that the participating agencies (1) designate a lead  entity with final decision-making authority and establish a clear line of  authority for the GCPR project, and (2) create comprehensive and  coordinated plans that included an agreed-upon mission and clear goals,  objectives, and performance measures, to ensure that the agencies could  share comprehensive, meaningful, accurate, and secure patient health care  data. In 2002, we recommended that the participating agencies revise the  original goals and objectives of the project to align with their current  strategy, commit the executive support necessary to adequately manage  the project, and ensure that it followed sound project management  principles. VA and DOD took specific measures in response to our  recommendations for enhancing overall management and accountability  of the project.
By July 2002, VA and DOD had revised their strategy and had made some  progress toward electronically sharing patient health data. The two  departments had renamed the project the Federal Health Information  Exchange (FHIE) program and, consistent with our prior  recommendation, had finalized a memorandum of agreement designating  VA as the lead entity for implementing the program. This agreement also  established FHIE as a joint effort that would allow the exchange of health  care information in two phases. The first phase, completed in mid-July  2002, enabled the one-way transfer of data from DOD’s existing health  information system to a separate database that VA clinicians could access.  A second phase, finalized this past March, completed VA’s and DOD’s  efforts to add to the base of patient health information available to VA  clinicians via this one-way sharing capability. The departments reported  total GCPR/FHIE costs of about $85 million through fiscal year 2003.
The revised strategy also envisioned the pursuit of a longer term, two-way  exchange of health information between DOD and VA. Known as  HealthePeople (Federal), this initiative is premised upon the departments’  development of a common health information architecture comprising  standardized data, communications, security, and high-performance health  information systems. The joint effort is expected to result in the secured  sharing of health data required by VA’s and DOD’s health care providers  between systems that each department is currently developing—DOD’s  Composite Health Care System (CHCS) II and VA’s HealtheVet VistA.
DOD began developing CHCS II in 1997 and has completed the  development of its associated clinical data repository—a key component  for the planned electronic interface. The department expects to complete  deployment of all of its major system capabilities by September 2008. It  reported expenditures of about $464 million for the system through fiscal  year 2003. VA began work on HealtheVet VistA and its associated health  data repository in 2001, and expects to complete all six initiatives  comprising this system in 2012. VA reported spending about $120 million  on HealtheVet VistA through fiscal year 2003.
Under the HealthePeople (Federal) initiative, VA and DOD envision that,  upon entering military service, a health record for the service member will  be created and stored in DOD’s CHCS II clinical data repository. The  record will be updated as the service member receives medical care. When  the individual separates from active duty and, if eligible, seeks medical  care at a VA facility, VA will then create a medical record for the  individual, which will be stored in its health data repository. Upon viewing  the medical record, the VA clinician would be alerted and provided access  to the individual’s clinical information residing in DOD’s repository. In the  same manner, when a veteran seeks medical care at a military treatment  facility, the attending DOD clinician would be alerted and provided with  access to the health information in VA’s repository. According to the  departments, this planned approach would make virtual medical records  displaying all available patient health information from the two  repositories accessible to both departments’ clinicians. VA officials have  stated that they anticipate being able to exchange some degree of health  information through an interface of their health data repository with  DOD’s clinical data repository by the end of calendar year 2005.
section_title: The Two-Way Exchange Could Benefit from Improved Planning and Project Management
paragraphs: While VA and DOD are making progress in agreeing to and adopting  standards for clinical data, they continue to face significant challenges in  providing a virtual medical record based on the two-way exchange of data  as part of their HealthePeople (Federal) initiative. Specifically, VA and  DOD do not have    an explicit architecture that provides details on what specific technologies  they will use to achieve the exchange capability;   a fully established project management structure that will ensure the  necessary day-to-day guidance of and accountability for the departments’  investment in and implementation of the exchange; and   a project management plan describing the specific responsibilities of each  department in developing, testing, and deploying the interface and  addressing security requirements.
subsections: section_title: System Architecture Not Developed
paragraphs: VA’s and DOD’s ability to exchange data between their separate health  information systems is crucial to achieving the goals of HealthePeople  (Federal). Yet, successfully sharing health data between the departments  via a secure electronic interface between each of their data repositories  can be complex and challenging, and depends significantly on the  departments’ having a clearly articulated architecture, or blueprint,  defining how specific technologies will be used to achieve the interface.  Developing, maintaining, and using an architecture is a best practice in  engineering information systems and other technological solutions. An  architecture would articulate, for example, the system requirements and  design specifications, database descriptions, and software descriptions  that define the manner in which the departments will electronically store,  update, and transmit their data.
VA and DOD lack an explicit architecture that provides details on what  specific technologies they will use to achieve the exchange capability, or  just what they will be able to exchange by the end of 2005—their projected  date for having this capability operational. While VA officials stated that  they recognize the importance of a clearly defined architecture, they  acknowledged that the departments’ actions were continuing to be driven  by the less specific, high-level strategy that has been in place since  September 2002.
Officials in both departments stated that a planned pharmacy prototype  initiative, begun this past March in response to requirements of the  National Defense Authorization Act of 2003, would assist them in defining  the electronic interface technology needed to exchange patient health  information. The act mandated that VA and DOD develop a real-time  interface, data exchange, and capability to check prescription drug data  for outpatients by October 1, 2004. In late February, VA hired a contractor  to develop the planned prototype but the departments had not yet fully  determined the approach or requirements for it. DOD officials stated that  the contractor was expected to more fully define the technical  requirements for the prototype. In late April, the departments reported  approval of the contractor’s requirements and technical design for the  prototype.
While the pharmacy prototype may help define a technical solution for the  two-way exchange of health information between the two departments’  existing systems, there is no assurance that this same solution can be used  to interface the new systems under development. Because the  departments’ new health information systems—major components of  HealthePeople (Federal)—are scheduled for completion over the next 4 to  9 years, the prototype may only test the ability to exchange data in VA’s  and DOD’s existing health systems. Thus, given the uncertainties regarding  what capabilities the pharmacy prototype will demonstrate, it is difficult to  predict how or whether the prototype initiative will contribute to defining  the architecture and technological solution for the two-way exchange of  patient health information for the HealthePeople (Federal) initiative.
section_title: Fully Established Project Management Structure Not in Place
paragraphs: Industry best practices and information technology project management  principles stress the importance of accountability and sound planning for  any project, particularly an interagency effort of the magnitude and  complexity of HealthePeople (Federal). Based on our past work, we have  found that a project management structure should establish relationships  between managing entities with each entity’s roles and responsibilities  clearly articulated. Further, it is important to establish final decision- making authority with one entity.
However, VA and DOD have not fully established a project management  structure that will ensure the necessary day-to-day guidance of and  accountability for the departments’ investment in and implementation of  the two-way capability. According to officials in both departments a joint  working group and oversight by the Joint Executive Council and VA/DOD  Health Executive Council has provided the collaboration necessary for  HealthePeople (Federal). However, this oversight by the executive  councils is at a very high level, occurs either bimonthly or quarterly, and  encompasses all of the joint coordination and sharing efforts for health  services and resources. Since a lead entity has not been designated,  neither department has had the authority to make final project decisions  binding on the other. Further, the roles and responsibilities for each  department have not been clearly articulated. Without a clearly defined  project management structure, accountability and a means to monitor  progress are difficult to establish.
In early March, VA officials stated that the departments had designated a  program manager for the planned pharmacy prototype and were  establishing roles and responsibilities for managing the joint initiative to  develop an electronic interface. Just this month, officials from both  departments told us that this individual would be the program manager for  the electronic interface. However, they had not yet designated a lead entity  or provided documentation for the project management structure or their  roles and responsibilities for the HealthePeople (Federal) initiative.
section_title: Project Management Plan Lacking
paragraphs: An equally important component necessary for guiding the development of  the electronic interface is a project management plan. Information  technology project management principles and industry best practices  emphasize that a project management plan is needed to define the  technical and managerial processes necessary to satisfy project  requirements. Specifically, the plan should include, among other things,  the authority and responsibility of each organizational unit; a work  breakdown structure for all of the tasks to be performed in developing,  testing, and deploying the software, along with schedules associated with  the tasks; and a security policy.
However, the departments are currently operating without a project  management plan for HealthePeople (Federal) that describes the specific  responsibilities of each department in developing, testing, and deploying  the interface and addressing security requirements. This month, officials  from both departments stated that a pharmacy prototype project  management plan that includes a work breakdown structure and schedule  was developed in mid-March. They further stated that a work group that  reports to the integrated project team has been given responsibility for the  development of security and information assurance provisions. While  these actions should prove useful in guiding the development of the  prototype, they do not address the larger issue of how the departments  will develop and implement an interface to exchange health care  information between their systems by 2005.
Without a project management plan, VA and DOD lack assurance that they  can successfully develop and implement an electronic interface and the  associated capability for exchanging health information within the time  frames that they have established. VA and DOD officials stated that they  have begun discussions to establish an overall project plan.
section_title: Conclusions
paragraphs: Achieving an electronic interface that will enable VA and DOD to  exchange patient medical records is an important goal, with substantial  implications for improving the quality of health care and disability claims  processing for the nation’s military members and veterans. In seeking a  virtual medical record based on the two-way exchange of data between  their separate health information systems, VA and DOD have chosen a  complex and challenging approach that necessitates the highest levels of  project discipline, including a well-defined architecture for describing the  interface for a common health information exchange; an established  project management structure to guide the investment in and  implementation of this electronic capability; and a project management  plan that defines the technical and managerial processes necessary to  satisfy project requirements. These critical components are currently  lacking; thus, the departments risk investing in a capability that could fall  short of expectations. The continued absence of these components  elevates concerns about exactly what capabilities VA and DOD will  achieve—and when.
section_title: Recommendations for Executive Action
paragraphs: To encourage significant progress on achieving the two-way exchange of  health information, we recommend that the Secretaries of Veterans Affairs  and Defense instruct the Acting Chief Information Officer for Health and  the Chief Information Officer for the Military Health System, respectively,  to    develop an architecture for the electronic interface between their health  systems that includes system requirements, design specifications, and  software descriptions;   select a lead entity with final decision-making authority for the initiative;    establish a project management structure to provide day-to-day guidance  of and accountability for their investments in and implementation of the  interface capability; and   create and implement a comprehensive and coordinated project  management plan for the electronic interface that defines the technical  and managerial processes necessary to satisfy project requirements and  includes (1) the authority and responsibility of each organizational unit;  (2) a work breakdown structure for all of the tasks to be performed in  developing, testing, and implementing the software, along with schedules  associated with the tasks; and (3) a security policy.
section_title: Agency Comments
paragraphs: The Secretary of Veterans Affairs provided written comments on a draft of  this report and we received comments via e-mail from DOD’s Interagency  Program Integration and External Liaison for Health Affairs; both  concurred with the recommendations. Each department’s comments are  reprinted in their entirety as appendixes I and II, respectively. In their  comments, the officials also provided information on actions taken or  underway that, in their view, address our recommendations.
We are sending copies of this report to the Secretaries of Veterans Affairs  and Defense and to the Director, Office of Management and Budget.  Copies will also be available at no charge on GAO’s Web site at  www.gao.gov.
Should you have any question on matters contained in this report, please  contact me at (202) 512-6240, or Barbara Oliver, Assistant Director, at  (202) 512-9396. We can also be reached by e-mail at koontzl@gao.gov and  oliverb@gao.gov, respectively. Other key contributors to this report were  Michael P. Fruitman, Valerie C. Melvin, J. Michael Resser, and Eric L.  Trout.
section_title: Appendix I: Comments from the Secretary of Veterans Affairs
section_title: Appendix II: Comments from the Director, Interagency Program Integration & External Liaison for Health Affairs