Computer-Based Patient Records: Improved Planning and Project Management Are Critical to Achieving Two-Way VA-DOD Health Data Exchange
Published: 2004-05-19T00:00:00

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Highlights:
section_title: Why GAO Did This Study
paragraphs: Providing readily accessible health information on veterans and active duty military personnel is highly essential to ensuring that these individuals are given quality health care and assistance in adjudicating disability claims. Moreover, ready access to health information is consistent with the President's recently announced intention to provide electronic health records for most Americans within 10 years. In an attempt to improve the sharing of health information, the Departments of Veterans Affairs (VA) and Defense (DOD) have been working, since 1998, toward the ability to exchange electronic health records for use by veterans, military personnel, and their health care providers. In testimony before Congress last November and again this past March, GAO discussed the progress being made by the departments in this endeavor. While a measure of success has been achieved--the one-way transfer of health data from DOD to VA health care facilities--identifying the technical solution for a two-way exchange, as part of a longer term HealthePeople (Federal) initiative, has proven elusive. At Congress's request, GAO reported on its continuing review of the departments' progress toward this goal of an electronic two-way exchange of patient health records.
section_title: What GAO Found
paragraphs: VA and DOD are continuing with activities to support the sharing of health data; nonetheless, achieving the two-way electronic exchange of patient health information, as envisioned in the HealthePeople (Federal) strategy, remains far from being realized. Each department is proceeding with the development of its own health information system--VA's HealtheVet VistA and DOD's Composite Health Care System (CHCS) II; these are critical components for the eventual electronic data exchange capability. The departments are also proceeding with the essential task of defining data and message standards that are important for exchanging health information between their disparate systems. In addition, a pharmacy data prototype initiative begun this past March, which the departments stated is an initial step to defining the technology for the two-way data exchange, is ongoing. However, VA and DOD have not yet defined an architecture to guide the development of the electronic data exchange capability, and lack a strategy to explain how the pharmacy prototype will contribute toward determining the technical solution for achieving HealthePeople (Federal). As such, there continues to be no clear vision of how this capability will be achieved, and in what time period. Compounding the challenge faced by the departments is that they continue to lack a fully established project management structure for the HealthePeople (Federal) initiative. As a result, the relationships between the departments' managers is not clearly defined, a lead entity with final decision-making authority has not been designated, and a coordinated, comprehensive project plan that articulates the joint initiative's resource requirements, time frames, and respective roles and responsibilities of each department has not yet been established. In discussing the need for these components, VA and DOD program officials stated this week that the departments had begun actions to develop a project plan and define the management structure for HealthePeople (Federal). In the absence of such components, the progress that VA and DOD have achieved is at risk of compromise, as is assurance that the ultimate goal of a common, exchangeable two-way health record will be reached. Given the importance of readily accessible health data for improving the quality of health care and disability claims processing for military members and veterans, we currently have a draft report at the departments for comment, in which we are making recommendations to the Secretaries of Veterans Affairs and Defense for addressing the challenges to, and improving the likelihood of successfully achieving the electronic two-way exchange of patient health information.

section_title: Letter
paragraphs: I am pleased to participate in today’s continuing discussion of  electronic health records and the Department of Veterans Affairs’  (VA) and Department of Defense’s (DOD) actions toward  developing the capability to electronically exchange patient health  information. In the face of terrorism, related military responses, and  a general call for improved health care delivery, providing readily  accessible medical data on active duty military personnel and  veterans is more essential than ever to ensuring that these  individuals receive high-quality health care and assistance in  adjudicating any disability claims that they may have. The  President’s recently announced proclamation to provide electronic  health records for most Americans within the next 10 years further  highlights the significance and potential contributions of the  departments’ actions in pointing the way toward the delivery of  more effective health care services.
For the past 6 years, VA and DOD have been working to achieve an  electronic medical record and patient health information-sharing  capability, beginning with a joint project in 1998 to develop a  government computer-based patient record. As we noted in previous   testimony, the departments have achieved a measure of success in  sharing data through the one-way transfer of health information  from DOD to VA health care facilities. However, they have been  severely challenged in their pursuit of a longer term objective— providing a virtual medical record based on the two-way exchange  of patient health care information, as part of their HealthePeople  (Federal) initiative. This past March, we reported that VA and DOD  had made little progress in identifying a technological solution for  achieving a two-way exchange of patient health data and lacked  discipline in their approach to managing this initiative.
At your request, my testimony today will discuss our continuing  assessment of VA’s and DOD’s progress in realizing the  HealthePeople (Federal) goal of an electronic patient health record  and two-way data exchange capability. In conducting this work, we  reviewed the departments’ documentation describing VA’s and  DOD’s actions to develop new health information systems and  determine a strategy for developing a secure, electronic two-way  data exchange capability, including project schedules, project status  reports, and conversion and deployment plans. We also reviewed  documentation identifying the costs that the departments have  incurred in developing technology to support the sharing of health  data, including costs associated with achieving the one-way transfer  of data from DOD to VA health care facilities, and ongoing projects  to develop new health information systems. We did not audit the  reported costs, and thus cannot attest to their accuracy or  completeness. We supplemented our analyses of the agencies’  documentation with interviews of VA and DOD officials responsible  for key decisions and actions on the health data-sharing initiatives.  We conducted our work in accordance with generally accepted  government auditing standards, during May of this year.
subsections: section_title: Background
paragraphs: In 1998, following a Presidential call for VA and DOD to start  developing a “comprehensive, life-long medical record for each  service member,” the two departments began a joint course of  action toward achieving the capability to share patient health  information for active duty military personnel and veterans. As their  first initiative, undertaken in that year, the Government Computer- Based Patient Record (GCPR) project was envisioned as an  electronic interface that would allow physicians and other  authorized users at VA and DOD 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  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 activity 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 (the Composite  Health Care 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.  According to program officials, FHIE is now fully operational and is  showing positive results by providing a wide range of health care  information to enable clinicians to make more informed decisions  regarding the care of veterans and to facilitate processing disability  claims. The officials stated that the departments have now begun  leveraging the FHIE infrastructure to achieve interim exchanges of  health information on a limited basis, using existing health systems  at joint VA/DOD facilities. The departments reported total  GCPR/FHIE costs of about $85 million through fiscal year 2003.
The revised strategy also envisioned achieving 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 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 with 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 anticipated 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 2005.
section_title: Progress Toward Achieving HealthePeople (Federal) Faces Continued Challenges and Risks
paragraphs: As we have noted, achieving the longer term capability to exchange  health data in a secure, two-way electronic format between new  health information systems that VA and DOD are developing is a  challenging and complex undertaking, in which success depends on  having a clearly articulated architecture, or blueprint, defining how  specific technologies will be used to deliver the capability.  Developing, maintaining, and using an architecture is a best practice  in engineering information systems and other technological  solutions, articulating, for example, the systems and interface  requirements, design specifications, and database descriptions for  the manner in which the departments will electronically store,  update, and transmit their data.
Successfully carrying out the initiative also depends on the  departments’ instituting a highly disciplined approach to the  project’s management. 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 this one. Such  planning involves developing and using a project management plan  that describes, among other factors, the project’s scope,  implementation strategy, lines of responsibility, resources, and  estimated schedules for development and implementation.
Currently, VA and DOD are proceeding with the development of  their new health information systems and with the identification of  standards that are essential to sharing common health data. DOD is  deploying its first release of CHCS II functionality (a capability for  integrating DOD clinical outpatient processes into a single patient  record), with scheduled completion in June 2006. For its part, VA  continues to work toward completing a prototype for the  department’s health data repository, scheduled for completion at the  end of next month. In addition, as we reported in March, the  departments have continued essential steps toward standardizing  clinical data, having adopted data and message standards that are  important for exchanging health information between disparate  systems. Department officials also stated that they were proceeding  with a pharmacy data prototype initiative, begun in March to satisfy  a mandate of the Bob Stump National Defense Authorization Act for  Fiscal Year 2003, as an initial step toward achieving HealthePeople  (Federal). The officials maintain that they expect to be positioned to  begin exchanging patient health information between their new  systems on a limited basis in the fall of 2005, identifying four  categories of data that they expect to be able to exchange:  outpatient pharmacy data, laboratory results, allergies, and patient  demographics.
However, VA’s and DOD’s approach to meeting this HealthePeople  (Federal) goal is fraught with uncertainty and lacks a solid  foundation for ensuring that this mission can be successfully  accomplished. As we reported in March, the departments continue  to lack an architecture detailing how they intend to use technology  to achieve the two-way electronic data exchange capability. In  discussing their intentions for developing such an architecture, VA’s  Deputy Chief Information Officer for Health stated last week that  the departments do not expect to have an established architecture  until a future unspecified date. He added that VA and DOD planned  to take an incremental approach to determining the architecture and  technological solution for the data exchange capability. He  explained, for example, that they hope to gain from the pharmacy  data prototype project an understanding of what technology is  necessary and how it should be deployed to enable the two-way  exchange of patient health records between their data repositories.  VA and DOD reported approval of the contractor’s technical  requirements for the prototype last month and have a draft  architecture for the prototype. They expect to complete the  prototype in mid-September of this year.
Although department officials consider the pharmacy data prototype  to be an initial step toward achieving HealthePeople (Federal), how  and to what extent the prototype will contribute to defining the  electronic interface for a two-way data exchange between VA’s and  DOD’s new health information systems are unclear. Such  prototypes, if accomplished successfully, can offer valuable  contributions to the process of determining the technological  solution for larger, more encompassing initiatives. However,  ensuring the effective application of lessons learned from the  prototype requires that VA and DOD have a well-defined strategy to  show how this project will be integrated with the HealthePeople  (Federal) initiative. Yet VA and DOD have not developed a strategy  to articulate the integration approach, time frames, and resource  requirements associated with implementing the prototype results to  define the technological features of the two-way data exchange  capability under HealthePeople (Federal). Until VA and DOD are  able to determine the architecture and technological solution for  achieving a secure electronic systems interface, they will lack  assurance that the capability to begin electronically exchanging  patient health information between their new systems in 2005 can  be successfully accomplished.
In addition to lacking an explicit architecture and technological  solution to guide the development of the electronic data exchange  capability, VA and DOD continue to be challenged in ensuring that  this undertaking will be managed in a sound, disciplined manner. As  was the situation in March, VA and DOD continue to lack a fully  established project management structure for the HealthePeople  (Federal) initiative. The relationships among the management  entities involved with the initiative have not been clearly  established, and no one entity has authority to make final project  decisions binding on the other. As we noted during the March  hearing, the departments’ implementation of our recommendation  that it establish a lead entity for the Government Computer-Based  Patient Record project helped strengthen the overall accountability  and management of that project and contributed to its successful  accomplishment.
Further, although the departments have designated a project  manager and established a project plan defining the work tasks and  management structure for the pharmacy prototype, they continue to  lack a comprehensive and coordinated project plan for  HealthePeople (Federal), to explain the technical and managerial  processes that have been instituted to satisfy project requirements  for this broader initiative. Such a plan would include, among other  information, details on the authority and responsibility of each  organizational unit; the work breakdown structure and schedule for  all of the tasks to be performed in developing, testing, and deploying  the electronic interface; as well as a security plan. The departments  also have not instituted necessary project review milestones and  measures to provide a basis for comprehensive management of the  project at critical intervals, progressive decision making, or  authorization of funding for each step in the development process.  As a result, current plans for the development of the electronic data  exchange capability between VA’s and DOD’s new health  information systems do not offer a clear vision for the project or  demonstrate sufficient attention to the effective day-to-day guidance  of and accountability for the investments in and implementation of  this capability. In discussing their management of HealthePeople  (Federal), VA and DOD program officials stated this week that the  departments had begun actions to develop a project plan and define  the management structure for this initiative.
Given the significance of readily accessible health data for  improving the quality of health care and disability claims processing  for military members and veterans, we currently have a draft report  at the departments for comment, in which we are recommending to  the Secretaries of Veterans Affairs and Defense, a number of actions  for addressing the challenges to, and improving the likelihood of,  successfully achieving the electronic two-way exchange of patient  health information.
In summary, VA’s and DOD’s pursuit of various initiatives to achieve  the electronic sharing of patient health data represents an important  step toward providing more high-quality health care for active duty  military personnel and veterans. Moreover, in undertaking  HealthePeople (Federal), the departments have an opportunity to  help lead the nation to a new frontier of health care delivery.  However, the continued absence of an architecture and defined  technological solution for an electronic interface for their new  health information systems, coupled with the need for more  comprehensive and coordinated management of the projects  supporting the development of this capability, elevates the  uncertainty about how VA and DOD intend to achieve this capability  and in what time frame. Until these critical components have been  put into place, the departments will continue to lack a convincing  position regarding their approach to and progress toward achieving  the HealthePeople (Federal) goals and, ultimately, risk jeopardizing  the initiative’s overall success.
Mr. Chairman, this concludes my statement. I would be pleased to  respond to any questions that you or other members of the  Subcommittee may have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For information about this testimony, please contact Linda D.  Koontz, Director, Information Management Issues, at (202) 512-6240  or at koontzl@gao.gov, or Valerie C. Melvin, Assistant Director, at  (202) 512-6304 or at melvinv@gao.gov. Other individuals making key  contributions to this testimony include Barbara S. Oliver, J. Michael  Resser, and Eric L. Trout.
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