Information Technology: VA and DOD Are Making Progress in Sharing Medical Information, but Are Far from Comprehensive Electronic Medical Records
Published: 2007-05-08T00:00:00

Fast Facts:

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

section_title: Letter
paragraphs: I am pleased to participate in today’s hearing on sharing electronic  medical records between the Department of Defense (DOD) and the  Department of Veterans Affairs (VA). For almost 10 years, the  departments have been engaged in multiple efforts to share  electronic medical information, which is important in helping to  ensure that active-duty military personnel and veterans receive high- quality health care. These include efforts focused on the long-term  vision of a single “comprehensive, lifelong medical record for each  service member” that would allow a seamless transition between  the two departments, as well as more near-term efforts to meet  immediate needs to exchange health information, including  responding to current military crises.
Each department is developing its own modern health information  system to replace its existing (“legacy”) systems, and they are  collaborating on a program to develop an interface to enable these  modernized systems to share data and ultimately to have  interoperable electronic medical records. Unlike the legacy  systems, the modernized systems are to be based on computable  data: that is, the data are to be in a format that a computer  application can act on, for example, to provide alerts to clinicians  (of such things as drug allergies) or to plot graphs of changes in vital  signs such as blood pressure. According to the departments, such  computable data contribute significantly to patient safety and the  usefulness of electronic medical records.
While working on this long-term effort, the two departments have  also been pursuing various near-term initiatives to exchange  electronic medical information in their existing systems. These  include a completed effort to allow the one-way transfer of health  information from DOD to VA when service members leave the  military, ongoing demonstration projects to exchange particular  types of data at selected sites, and efforts to meet the immediate  needs of facilities treating veterans and service members with  multiple injuries.
As you requested, my testimony will summarize the history of the  two departments’ efforts to develop the capability to share health  information, and provide an overview of the current status of the  long- and near-term efforts that the departments are making to share  health information.
The information in my testimony is based largely on our previous  work in this area. To describe the current status of VA and DOD  efforts to exchange patient health information, we reviewed our  previous work, analyzed documents on various health initiatives,  and interviewed VA and DOD officials about current status and  future plans. The costs that have been incurred for the various  projects were provided by cognizant VA and DOD officials. We did  not audit the reported costs and thus cannot attest to their accuracy  or completeness. All work on which this testimony is based was  conducted in accordance with generally accepted government  auditing standards.
subsections: section_title: Background
paragraphs: In their efforts to modernize their health information systems and  share medical information, VA and DOD begin from different  positions. As shown in table 1, VA has one integrated medical  information system, VistA (Veterans Health Information Systems  and Technology Architecture), which uses all electronic records. All  128 VA medical sites thus have access to all VistA information.  (Table 1 also shows, for completeness, VA’s planned modernized  system and its associated data repository.)
In contrast, DOD has multiple medical information systems (see  table 2). DOD’s various systems are not integrated, and its 138 sites  do not necessarily communicate with each other. In addition, not all  of DOD’s medical information is electronic: some records are paper- based.
section_title: VA and DOD Have Been Working to Exchange Health Information Since 1998
paragraphs: For almost a decade, VA and DOD have been pursuing ways to share  data in their health information systems and create comprehensive  electronic records. However, the departments have faced  considerable challenges, leading to repeated changes in the focus of  their initiatives and target dates for accomplishment.
As shown in figure 1, the departments’ efforts have involved a  number of distinct initiatives, both long-term initiatives to develop  future modernized solutions, and short-term initiatives to respond to  more immediate needs to share information in existing systems. As  the figure shows, these initiatives often proceeded in parallel.
The departments’ first initiative, known as the Government  Computer-Based Patient Record (GCPR) project, aimed to develop  an electronic interface that would let physicians and other  authorized users at VA and DOD health facilities access data from  each other’s health information systems. The interface was expected  to compile requested patient information in a virtual record (that is,  electronic as opposed to paper) that could be displayed on a user’s  computer screen.
In 2001 and 2002, we reviewed the GCPR project and noted  disappointing progress, exacerbated in large part by inadequate  accountability and poor planning and oversight, which raised doubts  about the departments’ ability to achieve a virtual medical record.
We determined that the lack of a lead entity, clear mission, and  detailed planning to achieve that mission made it difficult to monitor  progress, identify project risks, and develop appropriate  contingency plans. We made recommendations in both years that  the departments enhance the project’s overall management and  accountability. In particular, we recommended that the departments  designate a lead entity and a clear line of authority for the project;  create comprehensive and coordinated plans that include an agreed- upon mission and clear goals, objectives, and performance  measures; revise the project’s original goals and objectives to align  with the current strategy; commit the executive support necessary  to adequately manage the project; and ensure that it followed sound  project management principles.
In response, the two departments revised their strategy in July 2002,  refocusing the project and dividing it into two initiatives. A short- term initiative (the Federal Health Information Exchange or FHIE)  was to enable DOD, when service members left the military, to  electronically transfer their health information to VA. VA was  designated as the lead entity for implementing FHIE, which was  successfully completed in 2004. A longer term initiative was to  develop a common health information architecture that would allow  the two-way exchange of health information. The common  architecture is to include standardized, computable data,  communications, security, and high-performance health information  systems (these systems, DOD’s CHCS II and VA’s HealtheVet VistA,  were already in development, as shown in the figure). The  departments’ modernized systems are to store information (in  standardized, computable form) in separate data repositories:  DOD’s Clinical Data Repository (CDR) and VA’s Health Data  Repository (HDR). The two repositories are to exchange  information through an interface named CHDR.
In March 2004, the departments began to develop the CHDR  interface, and they planned to begin implementation by October  2005. However, implementation of the first release of the interface  (at one site) occurred in September 2006, almost a year later. In a  review in June 2004, we identified a number of management  weaknesses that could have contributed to this delay and made a  number of recommendations, including creation of a comprehensive  and coordinated project management plan. In response, the  departments agreed to our recommendations and improved the  management of the CHDR program by designating a lead entity with  final decision-making authority and establishing a project  management structure. As we noted in later testimony, however, the  program did not develop a project management plan that would give  a detailed description of the technical and managerial processes  necessary to satisfy project requirements (including a work  breakdown structure and schedule for all development, testing, and  implementation tasks), as we had recommended.
In October 2004, the two departments established two more short- term initiatives in response to a congressional mandate. These  were two demonstration projects: the Laboratory Data Sharing  Interface, aimed at allowing VA and DOD facilities to share  laboratory resources, and the Bidirectional Health Information  Exchange (BHIE), aimed at allowing both departments’ clinicians  access to records on shared patients (that is, those who receive care  from both departments). As demonstration projects, both  initiatives were limited in scope, with the intention of providing  interim solutions to the departments’ need for more immediate  health information sharing. However, because BHIE provided  access to up-to-date information, the departments’ clinicians  expressed strong interest in increasing its use. As a result, the  departments began planning to broaden BHIE’s capabilities and  expand its implementation considerably. Until the departments’  modernized systems are fully developed and implemented,  extending BHIE connectivity could provide each department with  access to most data in the other’s legacy systems. According to a  VA/DOD annual report and program officials, the departments now  consider BHIE an interim step in their overall strategy to create a  two-way exchange of electronic medical records.
Most recently, the departments have announced a further change to  their information-sharing strategy. In January 2007, they announced  their intention to jointly develop a new inpatient medical record  system. According to the departments, adopting this joint solution  will facilitate the seamless transition of active-duty service members  to veteran status, as well as making inpatient healthcare data on  shared patients immediately accessible to both DOD and VA. In  addition, the departments consider that a joint development effort  could allow them to realize significant cost savings. We have not  evaluated the departments’ plans or strategy in this area.
subsections: section_title: Others Have Recommended Strengthening the Management and Planning of the Departments’ Health Information Initiatives
paragraphs: Throughout the history of these initiatives, evaluations beyond ours  have also found deficiencies in the departments’ efforts, especially  with regard to the need for comprehensive planning. For example,  in fiscal year 2006, the Congress did not provide all the funding  requested for HealtheVet VistA because it did not consider that the  funding had been adequately justified. In addition, a recent  presidential task force identified the need for VA and DOD to  improve their long-term planning. This task force, reporting on  gaps in services provided to returning veterans, noted problems  with regard to sharing information on wounded service members,  including the inability of VA providers to access paper DOD  inpatient health records. According to the report, although  significant progress has been made on sharing electronic  information, more needs to be done. The task force recommended  that VA and DOD continue to identify long-term initiatives and  define scope and elements of a joint inpatient electronic health  record.
section_title: VA and DOD Are Exchanging Limited Medical Information, but Much Work Remains to Achieve Seamless Sharing
paragraphs: VA and DOD have made progress in both their long-term and short- term initiatives to share health information. In the long-term project  to develop modernized health information systems, the departments  have begun to implement the first release of the interface between  their modernized data repositories, among other things. The two  departments have also made progress in their short-term projects to  share information in existing systems, having completed two  initiatives and making important progress on another. In addition,  the two departments have undertaken ad hoc activities to accelerate  the transmission of health information on severely wounded  patients from DOD to VA’s four polytrauma centers. However,  despite the progress made and the sharing achieved, the tasks  remaining to achieve the goal of a shared electronic medical record  remain substantial.
subsections: section_title: VA and DOD Have Begun Deployment of a Modernized Data Interface
paragraphs: In their long-term effort to share health information, VA and DOD  have completed the development of their modernized data  repositories, agreed on standards for various types of data, and  begun to populate the repositories with these data. In addition,  they have now implemented the first release of the CHDR interface,  which links the two departments’ repositories, at seven sites. The  first release has enabled the seven sites to share limited medical  information: specifically, computable outpatient pharmacy and drug  allergy information for shared patients.
According to DOD officials, in the third quarter of 2007 the  department will send out instructions to its remaining sites so that  they can all begin using CHDR. According to VA officials, the  interface will be available across the department when necessary  software updates are released, which is expected this July.
Besides being a milestone in the development of the departments’  modernized systems, the interface implementation provides benefits  to the departments’ current systems. Data transmitted by CHDR are  permanently stored in the modernized data repositories, CDR and  HDR. Once in the repositories, these computable data can be used  by DOD and VA at all sites through their existing systems. CHDR  also provides terminology mediation (translation of one agency’s  terminology into the other’s). VA and DOD plans call for developing  the capability to exchange computable laboratory results data  through CHDR during fiscal year 2008.
Although implementing this interface is an important  accomplishment, the departments are still a long way from  completion of the modernized health information systems and  comprehensive longitudinal health records. While DOD and VA had  originally projected completion dates for their modernized systems  of 2011 and 2012, respectively, department officials told us that  there is currently no scheduled completion date for either system.  Further, both departments have still to identify the next types of  data to be stored in the repositories. The two departments will then  have to populate the repositories with the standardized data, which  involves different tasks for each department. Specifically, although  VA’s medical records are already electronic, it still has to convert  these into the interoperable format appropriate for its repository.  DOD, in addition to converting current records from its multiple  systems, must also address medical records that are not automated.  As pointed out by a recent Army Inspector General’s report, some  DOD facilities are having problems with hard-copy records. In the  same report, inaccurate and incomplete health data were identified  as a problem to be addressed. Before the departments can achieve  the long-term goal of seamless sharing of medical information, all  these tasks and challenges will have to be addressed. Consequently,  it is essential for the departments to develop a comprehensive  project plan to guide these efforts to completion, as we have  previously recommended.
section_title: VA and DOD Are Exchanging Limited Health Information through Short-Term Projects
paragraphs: In addition to the long-term effort described above, the two  departments have made some progress in meeting immediate needs  to share information in their respective legacy systems by setting up  short-term projects, as mentioned earlier, which are in various  stages of completion. In addition, the departments have set up  special processes to transfer data from DOD facilities to VA’s  polytrauma centers, which treat traumatic brain injuries and other  especially severe injuries.
DOD has been using FHIE to transfer information to VA since 2002.  According to department officials, over 184 million clinical  messages on more than 3.8 million veterans have been transferred to  the FHIE data repository as of March 2007. Data elements  transferred are laboratory results, radiology results, outpatient  pharmacy data, allergy information, consultation reports, elements  of the standard ambulatory data record, and demographic data.  Further, since July 2005, FHIE has been used to transfer pre- and  post-deployment health assessment and reassessment data; as of  March 2007, VA has access to data for more than 681,000 separated  service members and demobilized Reserve and National Guard  members who had been deployed. Transfers are done in batches  once a month, or weekly for veterans who have been referred to VA  treatment facilities.
According to a joint DOD/VA report, FHIE has made a significant  contribution to the delivery and continuity of care of separated  service members as they transition to veteran status, as well as to  the adjudication of disability claims.
One of the departments’ demonstration projects, the Laboratory  Data Sharing Interface (LDSI), is now fully operational and is  deployed when local agencies have a business case for its use and  sign an agreement. It requires customization for each locality and is  currently deployed at nine locations. LDSI currently supports a  variety of chemistry and hematology tests, and work is under way to  include microbiology and anatomic pathology.
Once LDSI is implemented at a facility, the only nonautomated  action needed for a laboratory test is transporting the specimens. If  a test is not performed at a VA or DOD doctor’s home facility, the  doctor can order the test, the order is transmitted electronically to  the appropriate lab (the other department’s facility or in some cases  a local commercial lab), and the results are returned electronically.
Among the benefits of LDSI, according to VA and DOD, are  increased speed in receiving laboratory results and decreased errors  from manual entry of orders. The LDSI project manager in San  Antonio stated that another benefit of the project is the time saved  by eliminating the need to rekey orders at processing labs to input  the information into the laboratories’ systems. Additionally, the San  Antonio VA facility no longer has to contract out some of its  laboratory work to private companies, but instead uses the DOD  laboratory.
Developed under a second demonstration project, the BHIE  interface is now available throughout VA and partially deployed at  DOD. It is currently deployed at 25 DOD sites, providing access to  15 medical centers, 18 hospitals, and over 190 outpatient clinics  associated with these sites. DOD plans to make current BHIE  capabilities available departmentwide by June 2007.
The interface permits a medical care provider to query patient data  from all VA sites and any DOD site where it is installed and to view  that data onscreen almost immediately. It not only allows DOD and  VA to view each other’s information, it also allows DOD sites to see  previously inaccessible data at other DOD sites.
As initially developed, the BHIE interface provides access to  information in VA’s VistA and DOD’s CHCS, but it is currently being  expanded to query data in other DOD databases (in addition to  CHCS). In particular, DOD has developed an interface to the Clinical  Information System (CIS), an inpatient system used by many DOD  facilities, which will provide bidirectional views of discharge  summaries. The BHIE-CIS interface is currently deployed at five  DOD sites and planned for eight others. Further, interfaces to two  additional systems are planned for June and July 2007: An interface  to DOD’s modernized data repository, CDR, will give access to  outpatient data from combat theaters. An interface to another DOD  database, the Theater Medical Data Store, will give access to  inpatient information from combat theaters.
The departments also plan to make more data elements available.  Currently, BHIE enables text-only viewing of patient identification,  outpatient pharmacy, microbiology, cytology, radiology, laboratory  orders, and allergy data from its interface with DOD’s CHCS. Where  it interfaces with CIS, it also allows viewing of discharge summaries  from VA and the five DOD sites. DOD staff told us that in early fiscal  year 2008, they plan to add provider notes, procedures, and problem  lists. Later in fiscal year 2008, they plan to add vital signs, scanned  images and documents, family history, social history, and other  history questionnaires. In addition, at the VA/DOD site in El Paso, a  trial is under way of a process for exchanging radiological images  using the BHIE/FHIE infrastructure. Some images have  successfully been exchanged.
Through their efforts on these long- and near-term initiatives, VA  and DOD are achieving exchanges of various types of health  information (see attachment 1 for a summary of all the types of data  currently being shared and those planned for the future, as well as  cost data on the initiatives). However, these exchanges are as yet  limited, and significant work remains to be done to expand the data  shared and integrate the various initiatives.
section_title: Special Procedures Provide Information to VA Polytrauma Centers
paragraphs: In addition to the information technology initiatives described, DOD  and VA have set up special activities to transfer medical information  to VA’s four polytrauma centers, which are treating active-duty  service members severely wounded in combat. Polytrauma centers  care for veterans and returning service members with injuries to  more than one physical region or organ system, one of which may  be life threatening, and which results in physical, cognitive,  psychological, or psychosocial impairments and functional  disability. Some examples of polytrauma include traumatic brain  injury (TBI), amputations, and loss of hearing or vision.
When service members are seriously injured in a combat theater  overseas, they are first treated locally. They are then generally  evacuated to Landstuhl Medical Center in Germany, after which  they are transferred to a military treatment facility in the United  States, usually Walter Reed Army Medical Center in Washington,  D.C.; the National Naval Medical Center in Bethesda, Maryland; or  Brooke Army Medical Center, at Fort Sam Houston, Texas. From  these facilities, service members suffering from polytrauma may be  transferred to one of VA’s four polytrauma centers for treatment.
At each of these locations, the injured service members will  accumulate medical records, in addition to medical records already  in existence before they were injured. However, the DOD medical  information is currently collected in many different systems and is  not easily accessible to VA polytrauma centers. Specifically:   1.  In the combat theater, electronic medical information may be  collected for a variety of reasons, including routine outpatient  care, as well as serious injuries. These data are stored in the  Theater Medical Data Store, which can be accessed by unit  commanders and others. (As mentioned earlier, the departments  have plans to develop a BHIE interface to this system by July  2007. Until then, VA cannot access these data.) In addition, both  inpatient and outpatient medical data for patients who are  evacuated are entered into the Joint Patient Tracking  Application. (A few VA polytrauma center staff have been given  access to this application.)  2.  At Landstuhl, inpatient medical records are paper-based (except  for discharge summaries). The paper records are sent with a  patient as the individual is transferred for treatment in the  United States.   3.  At the DOD treatment facility (Walter Reed, Bethesda, or  Brooke), additional information will be recorded in CIS and  CHCS/CDR.
When service members are transferred to a VA polytrauma center,  VA and DOD have several ad hoc processes in place to electronically  transfer the patients’ medical information:  ●  DOD has set up secure links to enable a limited number of clinicians  at the polytrauma centers to log directly into CIS at Walter Reed and  Bethesda Naval Hospital to access patient data.  ●  Staff at Walter Reed collect paper records, print records from CIS,  scan all these, and transmit the scanned data to three of the four  polytrauma centers. DOD staff said that they are working on  establishing this capability at the Brooke and Bethesda medical  centers, as well as the fourth VA polytrauma center. According to  VA staff, although the initiative began several months ago, it has  only recently begun running smoothly as the contractor became  more skilled at assembling the records. DOD staff also pointed out  that this laborious process is feasible only because the number of  polytrauma patients is small (about 350 in all to date); it would not  be practical on a large scale.  ●  Staff at Walter Reed and Bethesda are transmitting radiology images  electronically to three polytrauma centers. (A fourth has this  capability, but at this time no radiology images have been  transferred there.) Access to radiology images is a high priority for  polytrauma center doctors, but like scanning paper records,  transmitting these images requires manual intervention: when each  image is received at VA, it must be individually uploaded to VistA’s  imagery viewing capability. This process would not be practical for  large volumes of images.   ●  VA has access to outpatient data (via BHIE) from 25 DOD sites,  including Landstuhl.
Although these various efforts to transfer medical information on  seriously wounded patients are working, and the departments are to  be commended on their efforts, the multiple processes and  laborious manual tasks illustrate the effects of the lack of in health information systems and the difficulties of exchanging  information in their absence.
In conclusion, through the long- and short-term initiatives described,  as well as efforts such as those at the polytrauma centers, VA and  DOD are achieving exchanges of health information. However, the exchanges are as yet limited, and significant work remains to be  done to fully achieve the goal of exchanging interoperable,  computable data, including agreeing to standards for the rem aining  categories of medical information, populating the data repositories  with all this information, completing the development of HealtheVet VistA and AHLTA, and transitioning from the legacy systems. To  complete these tasks, a detailed project management plan continu to be of vital importance to the ultimate success of the effort to  develop a lifelong virtual medical record. We have previously  recommended that the departments develop a clearly defined  project management plan that describes the technical and  managerial processes necessary to satisfy project requirem including a work breakdown structure and schedule for all  development, testing, and implementation tasks. Without a p sufficient detail, VA and DOD increase the risk that the long-time  project will not deliver the planned capabilities in the time and at  the cost expected. Further, it is not clear how all the initiatives we have described today are to be incorporated into an overall strategytoward achieving the departments’ goal of comprehensive, seamless  exchange of health information.
Mr. Chairman, this concludes my statement. I would be happy to  respond to any questions that you or other members of the  subcommittee may have.
section_title: Contacts and Acknowledgments
paragraphs: If you have any questions concerning this testimony, please contact  Valerie C. Melvin, Director, Human Capital and Management  Information Systems Issues, at (202) 512-6304 or melvinv@gao.gov.
Other individuals who made key contributions to this testimony  include Barbara Oliver, Assistant Director; Barbara Collier; and  Glenn Spiegel.
section_title: Attachment 1: Supplementary Tables
subsections: section_title: Types of Data Shared by DOD and VA Are Growing but Remain Limited
paragraphs: Table 3 summarizes the types of health data currently shared  through the long- and near-term initiatives we have described, as  well as types of data that are currently planned for addition. While  this gives some indication of the scale of the tasks involved in  sharing medical information, it does not depict the full extent of  information that is currently being captured in health information  systems and that remains to be addressed.
section_title: Reported Costs
paragraphs: Table 4 shows costs expended on these information sharing  initiatives since their inception.
section_title: Related GAO Products
paragraphs: Computer-Based Patient Records: Better Planning and Oversight  by VA, DOD, and IHS Would Enhance Health Data Sharing. GAO- 01-459. Washington, D.C.: April 30, 2001.
Veterans Affairs: Sustained Management Attention Is Key to  Achieving Information Technology Results. GAO-02-703.  Washington, D.C.: June 12, 2002.
Computer-Based Patient Records: Short-Term Progress Made, but  Much Work Remains to Achieve a Two-Way Data Exchange  Between VA and DOD Health Systems. GAO-04-271T. Washington,  D.C.: November 19, 2003.
Computer-Based Patient Records: Sound Planning and Project  Management Are Needed to Achieve a Two-Way Exchange of VA  and DOD Health Data. GAO-04-402T. Washington, D.C.: March 17,  2004.
Computer-Based Patient Records: VA and DOD Efforts to  Exchange Health Data Could Benefit from Improved Planning and  Project Management. GAO-04-687. Washington, D.C.: June 7, 2004.
Computer-Based Patient Records: VA and DOD Made Progress, but  Much Work Remains to Fully Share Medical Information. GAO-05- 1051T. Washington, D.C.: September 28, 2005.
Information Technology: VA and DOD Face Challenges in  Completing Key Efforts. GAO-06-905T. Washington, D.C.: June 22,  2006.
DOD and VA Exchange of Computable Pharmacy Data. GAO-07- 554R. Washington, D.C.: April 30, 2007.
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