Veterans Affairs: Health Information System Modernization Far from Complete; Improved Project Planning and Oversight Needed
Published: 2008-06-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA), through its Veterans Health Administration (VHA), provides health care for more than 5 million veterans each year. In 2001, VHA began an initiative, HealtheVet, to modernize its current medical information system. GAO's objectives were to determine the status of the modernization, VA's overall plan for completing it, and how VA is providing oversight to ensure the success of the initiative. To conduct this review, GAO analyzed project documentation and interviewed officials responsible for the development and implementation of the new system.
section_title: What GAO Found
paragraphs: As of June 2008, the HealtheVet initiative has these eight major software development projects under way. One project is to further develop the Health Data Repository, a database of standardized health data. This database, which is currently operational, is not yet complete; additional types of health data remain to be standardized and added to the repository. Four application projects are currently in development. One application project is in the planning stage. Two projects are being pursued to enhance current systems, prepare them for transition to HealtheVet, and develop new applications. From 2001 through fiscal year 2007, VA reported spending almost $600 million for these eight projects. The time frame for completing the projects and the HealtheVet system as a whole was 2012, but the projected completion date has now been delayed until 2018. The department has a high-level strategy for HealtheVet, in which the remainder of the initiative is to be completed incrementally in phases (referred to as "blocks"), but it does not have a comprehensive project management plan to guide the remaining work. This work is considerable: the department plans to replace the 104 applications in its current medical information system with 67 modernized applications (of which 5 are currently in development, as described), 3 databases, and 10 common services (general software functions, such as messaging and security, on which application software can call as needed). In view of this scope, the importance is increased of developing a comprehensive project management plan that includes, among other things, an integrated schedule that considers all dependencies and defines subtasks to ensure that deadlines are realistic. Another important component of such planning is determining the resources necessary to accomplish tasks throughout the life cycle of the initiative. In April 2008, VA provided an $11 billion cost estimate for completion of HealtheVet; however, it has not yet independently validated this estimate. Having a validated cost estimate is essential to improve the accuracy of cost, schedule, and performance management. Without an integrated plan that includes independently validated cost estimates, VA increases the risk that HealtheVet could incur cost increases and continued schedule slippages and not achieve its intended outcomes. Various levels and types of oversight are currently being provided for the HealtheVet initiative by business owners, developers, and departmental information technology governance boards. However, the business owners have not yet implemented a complete governance structure, several key leadership positions within the developers' organization are either vacant or filled with acting personnel, and the governance boards have not yet scheduled critical reviews of HealtheVet projects. Until all elements of governance and oversight are in place, the risk to the success of the HealtheVet initiative is increased.

section_title: Letter
paragraphs: The Department of Veterans Affairs (VA) operates the largest health care  delivery system in America, providing health care to more than 5 million  patients in more than 1,000 facilities. The department’s health information  system—the Veterans Health Information Systems and Technology  Architecture (VistA)—is an essential part of health care delivery, helping  to ensure the quality of health care received by the nation’s veterans and  their dependents. The use of VistA, which includes electronic health  records, has been widely credited with improving health care among VA  patients.
However, VistA currently consists of numerous applications, some of  which have been in operation for more than 20 years and, according to VA,  have become increasingly difficult and costly to maintain. Further, these  applications contain data that are not standardized across VA’s medical  facilities. Standardization is a prerequisite for data to be computable—that  is, acted on by computer applications. Such data can provide important  improvements to health care decision making—for example, allowing  applications to provide alerts to clinicians (for drug allergies) or plot  graphs of changes in vital signs such as blood pressure.
Accordingly, in 2001, the Veterans Health Administration (VHA) began an  initiative to modernize VistA—the HealtheVet initiative. With HealtheVet,  VA plans to standardize patient data and modernize health information  software applications. In doing so, its goal is to move from the hospital- centric environment that has long characterized the department’s health  care operations to a veteran-centric environment built on an open, robust  systems architecture that will more efficiently provide both the same  functions and benefits of the existing system and enhanced functions  based on computable data. The development and implementation of  HealtheVet is also key to achieving electronic medical records that are  interoperable between VA and the Department of Defense (DOD).
Until the new system is fully implemented, the department continues to  depend on the VistA system, which it intends to maintain concurrently—a  complex task that requires VA to develop interfaces between HealtheVet  and existing VistA software applications to ensure seamless delivery of  care to veterans. According to the department, HealtheVet—the largest  investment in the department’s information technology portfolio—is  scheduled to be fully implemented by 2018 at a total estimated cost of  about $11 billion.
Given the importance of the HealtheVet project to the department’s efforts  to deliver high-quality health care to veterans, you requested that we  review the department’s continuing efforts to develop and implement the  modernized system. Specifically, our objectives were to determine (1) the  status of the HealtheVet initiative, (2) VA’s overall plan for completing the  initiative, and (3) how the department is providing oversight to ensure the  success of the initiative.
To achieve our objectives, we analyzed documentation including project  schedules, development plans, technical approach descriptions, funding,  transition plans, information technology governance plans, and  information technology (IT) governance board charters and meeting  minutes. To supplement our analysis, we interviewed officials responsible  for department information technology and the HealtheVet initiative,  including managers of individual HealtheVet projects. The information on  costs that have been incurred for the HealtheVet projects were provided  by VA officials. We did not audit the reported costs and thus cannot attest  to their accuracy or completeness.
We conducted this performance audit from July 2007 through June 2008 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. For more details on our objectives, scope,  and methodology, see appendix I.
subsections: section_title: Background
paragraphs: The current health information system used by VA clinicians is VistA.  Since the inception of this system in 1983, VHA has made numerous  enhancements to its functionality. A significant example was the release  in 1996 of the Computerized Patient Record System, which enabled the  department to provide an individual electronic medical record for each VA  patient. By fiscal year 2007, the implementation of an imaging capability  (VistA Imaging) at all the department’s facilities further enhanced the  system by enabling multimedia data, such as radiology images, to be  linked to a patient’s electronic medical record. These collective  enhancements to VistA resulted in a comprehensive, integrated, electronic  medical record for each patient that is viewable by all of the department’s  clinicians at all of its health care facilities, thus eliminating the need for  paper medical records.
According to VHA officials, VistA was developed based on close  collaboration between staff in the medical facilities and VHA’s IT  personnel, with the intention of providing a system that met the clinicians’  needs. In this regard, clinicians and IT personnel in the various medical  facilities collaborated to define the system’s requirements and, in certain  cases, carry out its development and implementation. For example,  development of VistA Imaging resulted from a clinician building a  prototype at home before it was fielded at a medical facility. Although  system enhancements to VistA were disseminated through a central office,  staff at a medical center could develop and implement applications at the  local level to facilitate the potentially different functions at each location.
According to the department, as a result of VHA’s decentralized  development approach, VistA now consists of 104 separate computer  applications. These include 56 health provider applications; 19  management and financial applications; 13 crosscutting applications such  as patient data exchange; 8 registration, enrollment, and eligibility  applications; 5 health data applications; and 3 information and education  applications (app. III contains a complete list of these applications).
Besides being numerous, these applications have been customized at all  128 VA sites. According to VA, this customization increases the cost of  maintaining the system, as it requires that maintenance also be  customized. VA has reported expending significant resources  (approximately $2.5 billion) to maintain the system between 2001 and  2007.
Further, according to the department, limitations in the system need to be  addressed for the system to remain effective. As mentioned, some VistA  applications are more than 20 years old, and VistA does not standardize  data, which is a prerequisite to making data computable. In addition,  according to VA, VistA stores data in an organizational format based on  the location where care is provided, rather than maintaining a global  record for each individual patient, and it is programmed in a language for  which there is a continually decreasing supply of qualified software  developers.
Accordingly, in 2001, VHA undertook the HealtheVet initiative in order to  standardize its health care system and eliminate the approximately 128  different systems used by its field locations. As we reported in 2003, it  planned to develop or enhance specific areas of system functionality  through six projects, which were to be completed between 2006 and 2012  (shown in table 1). These six projects did not represent all the  functionality provided by the 104 VistA applications; rather, they were  high-priority projects that were under way at the time.
In 2004, VA contracted with the Software Engineering Institute (SEI) for a  technical review of the HealtheVet program. As a result of this review,  SEI concluded, among other things, that VA needed to improve and  integrate the governance of the HealtheVet program, develop an  organizational structure for the program, define the program’s vision, and  define the path for transition from VistA to HealtheVet.
In 2005, VA began to take action on the SEI recommendations. For  example, the department began to develop a HealtheVet organizational  structure, including defining the responsibilities of a project management  office. In addition, it developed an initial draft for HealtheVet governance  that defined decision-making processes, established guidelines for issue  identification and escalation, defined areas of control and levels of  authority, and established accountability. However, the effort to develop a  governance plan and structure was superseded by a major realignment of  the department’s overall IT management structure.
This realignment, initiated in October 2005, was undertaken with the goal  of providing greater authority and accountability over VA resources by  centralizing IT management under the department’s CIO; an additional  goal was to standardize operations and systems development across the  department using new management processes based on industry best  practices. Under the department’s realigned structure, the Assistant  Secretary for Information and Technology serves as VA’s CIO.  The CIO is  assisted by one Principal Deputy Assistant Secretary and five Deputy  CIOs. In particular, the Deputy CIO  for Enterprise Development serves  as the chief advisor to the CIO for all enterprise applications development  activities, including HealtheVet; this official heads the Office for  Enterprise Development, which is responsible for performing enterprise  applications development.
Before the realignment, funding and approval of IT was controlled by each  medical center director, this enabled local IT personnel to make changes  to VistA applications that were specific to the local medical facility. As a  result of the realignment, the funding for all IT development projects,  including both VistA and HealtheVet projects, was moved under the  control of the department’s CIO. The business owners (that is, VHA for  VistA and HealtheVet) retain responsibility for development and  prioritization of requirements and program oversight, while staff in the  Office of Enterprise Development are responsible for planning and  execution of information technology development projects.
section_title: HealtheVet Projects Are Under Way, but Time Frames Have Slipped
paragraphs: As of June 2008, the HealtheVet program has eight major software  development projects under way. One of these is to continue  development and population of an operational database that currently  contains health data. Five are applications development projects, of which  four are health care applications currently in development and one is a  financial application in the planning stage. The remaining two projects are  to enhance current VistA systems, prepare them for transition to  HealtheVet, and develop new applications. However, since 2003, the time  frames for completing the projects and the HealtheVet system as a whole  have been extended from 2012 to 2018. Department officials acknowledge  that VA has experienced significant delays in developing and implementing  HealtheVet and attribute the delays to various factors, and stated that they  are working to address the delays by using an incremental development  life-cycle approach and establishing more realistic time frames, among  other things.
Of the eight projects in progress, one is currently operational though not  yet completed. The Health Data Repository (HDR) database, which  became operational in 2006, currently contains standardized health data in  three areas: vital signs, allergies, and outpatient pharmacy. These data  were addressed first because they were given high priority by clinicians.  As we have previously reported, the department is currently using HDR  to help achieve interoperability with DOD to support the exchange of  computable electronic patient information. The HDR project is currently  standardizing and converting laboratory data so that they can be added to  the repository next, with further types of health data (for example,  inpatient pharmacy, dental, and ophthalmology) to be added as the  development of the HealtheVet system continues.
Four projects are developing health care information applications:  The Scheduling application is planned for initial deployment at one site (a  VA medical center in Muskogee, Oklahoma) in September 2008 (full  deployment to all medical facilities is planned for 2011).
For the Pharmacy project, final testing of one function (order checking) is  scheduled to begin in September 2008, and new drug file and pharmacy  data management systems are scheduled to be implemented in January  2009. Remaining system functions to be developed include inventory,  order entry and clinical monitoring, medication dispensing, and  medication administration. Further development of the Pharmacy  application depends on the results of an ongoing analysis and evaluation  of the costs of building and deploying these functions. This analysis, for  which a contract was issued in February 2008, is due July 2008.
The new Laboratory system is scheduled for independent verification and  validation in October 2008. National deployment is planned to begin in  2010, with a phased implementation across the department expected to  take place over the next 5 years.
The initial implementation of the Enrollment application is scheduled for  August 2008. This project is to provide an enrollment workflow for use at  VA’s Health Eligibility Center. An enhancement is scheduled for  implementation by July 2009 for communicating to veterans and providing  operational efficiencies for VA staff at the Health Eligibility Center and  medical centers to coordinate changes in veterans’ eligibility. Finally, in  December 2011, the department expects to complete a modernized  registration capability.
A fifth project (Billing) is for a new financial system, which is in the  planning stage. The current Billing project is a second attempt to  modernize the billing system. Under the first attempt, VA awarded a  contract in July 2003 to implement a commercial product to provide an  updated billing capability for the department (called at that time the  Patient Financial Services System); however, after about $107 million was  spent on this effort, the contract was terminated in September 2006 by  mutual agreement between the department and the contractor. The  department expects to complete national deployment of the current  project (called the Revenue Improvements and System Enhancement  project) at the end of fiscal year 2015.
Finally, the program has two ongoing projects that are focused on  activities to develop and implement required enhancements to existing  VistA applications and lay the foundation for transitioning these  applications to HealtheVet:    The focus of the VistA application development project in the near term is  to develop the critical enhancements and fixes to the VistA system that are  necessary to ensure compliance with changes to patient enrollment and  billing requirements and accomplish other critical data updates. In fiscal  year 2010, the emphasis for this initiative will shift from fixes and  enhancements to new development work aimed at the transition to  HealtheVet. The initiative will then encompass building many of the  replacement systems within HealtheVet.
The VistA foundations modernization project includes work on  architecture and testing services, including a comprehensive testing suite  and strategy for all VistA and HealtheVet applications. In fiscal year 2009,  several common services—the deployment toolkit, business rules engine,  and workflow engine—are expected to be delivered, along with new  testing services capabilities and updates to the overall architecture. This  work is expected to be ongoing until the completion of the HealtheVet  initiative.
Table 2 summarizes the status of these projects.
From the inception of the initiative in 2001 through fiscal year 2007, VA  reported spending almost $600 million for the development of these eight  projects. The department estimates that it will incur additional  development costs of approximately $535 million for the initiative during  fiscal years 2008 and 2009, with the estimated total development cost of  HealtheVet being $11 billion when completed in 2018. Table 3 shows the  reported development costs through fiscal year 2007 and estimated  development costs for fiscal years 2008 and 2009.
In addition, the time frames for completing the projects and the  HealtheVet system as a whole have been extended since the inception of  the HealtheVet initiative. As shown in table 1, the time frames as of 2003  envisioned completion by 2012. Current time frames extend the  completion date to 2018.
Officials from VA’s Office of Information and Technology acknowledged  that VA had experienced significant delays in developing and  implementing HealtheVet. These officials attribute the delays to various  factors, including changes in technical and deployment approaches, lack  of management continuity, and loss of experienced contractor staff.
For example, changes in technical and deployment approaches delayed  the development of the Scheduling, Health Data Repository, Pharmacy,  Laboratory, and Enrollment projects. In particular, for Scheduling, Health  Data Repository, Laboratory, and Enrollment, VHA has alternated between  developing the systems in-house and using a commercial off-the-shelf  product. In addition, programming languages for the Scheduling and  Enrollment projects changed. Finally, VHA changed the deployment  approach for Pharmacy annually between 2003 and 2007.
Several projects experienced management turnover. For example, the  Enrollment project has had multiple program managers since it began, and  the VistA application development and VistA foundations modernization  projects have seen more than one change in program management.
Finally, the Scheduling, Health Data Repository, Laboratory, Vista  Application Development, and Vista Foundations Modernization projects  were delayed by the loss of experienced contractor staff. These initiatives  were supported by an overall contract for HealtheVet. When this contract  expired in September 2006, it was renewed on a monthly basis to ensure  continuity of work until a new contract was awarded. However, task  orders from the new contract, which was signed in November 2006, were  not issued until June, July, and September 2007. According to department  officials, as a result of these delays, the experienced contractor staff who  supported the initiatives had moved to other work, corporate knowledge  for these initiatives was lost, and new contractor staff had to be hired and  educated.
Department officials stated that they are working to address the delays  experienced by using an incremental, development life-cycle approach and  establishing more realistic time frames for the effort. In addition, to  address future contracting issues, the department is establishing an  integrated product team composed of IT, program, and acquisition  personnel.
section_title: VA Has Developed an Overall Strategy for HealtheVet, but It Lacks a Project Management Plan
paragraphs: Under VA’s current strategy for HealtheVet, developed in August 2006, the  department is taking an incremental approach to the remainder of the  initiative, based on six phases (referred to as “blocks”) that are to be  completed in 2018. Under this strategy, the department plans to replace  the 104 VistA applications that are currently in use (see app. III) with 67  applications, 3 databases, and 10 common services. Figure 1 provides a  high-level overview of the strategy, and table 4 lists all the planned  software development applications by block.
As table 4 shows, work has not yet been initiated on many applications  that are planned for the final system. Further, although the department has  established interim dates for completing projects that are under way, as of  mid-June 2008, the department had not developed a detailed schedule or  approach for completing the HealtheVet initiative, including the remaining  62 software applications, other than to state that it intends to complete all  six blocks of the initiative by 2018.
Industry best practices and IT project management principles stress the  importance of accountability and sound planning for any project,  particularly an effort of the magnitude and complexity of HealtheVet.  Inherent in such planning is the development and use of a project  management plan that describes, among other factors, the project’s scope,  implementation strategy, lines of responsibility, security requirements,  resources, and estimated schedule for development and implementation.  Specifically, an effective project management plan incorporates all the  critical areas of system development and is to be used as a means of  determining what needs to be done and when, and should measure  progress. Such a plan also includes an integrated schedule that considers  all dependencies and includes subtasks so that deadlines are realistic, and  it incorporates reviews to allow oversight and approval by high-level  managers.
A key component of planning is determining the resources necessary to  accomplish the myriad tasks needed throughout the life cycle of the  initiative. In April 2008, VA provided an $11 billion cost estimate to  complete HealtheVet; however, it has not yet independently validated  these estimates. We stress in our Cost Assessment Guide that having a  validated cost estimate is essential to improve the accuracy of cost,  schedule, and performance management. Validated cost estimates are also  important to facilitate program approval and determine the necessary  funding needed for HealtheVet.
Without an integrated plan that includes independently validated cost  estimates, VA increases the risk that HealtheVet could incur schedule  slippages and cost increases and not achieve what it intends to achieve.
section_title: VA Has Not Fully Established an Oversight Structure for HealtheVet
paragraphs: In the wake of the realignment of IT resources under central, department- level control, VA leadership endorsed an approach to the oversight and  governance of IT development projects that is based on ensuring the  involvement of senior management from both the user and the developer  organizations. Under this approach, business owners establish IT  requirements, business benefits, and priorities and oversee full life-cycle  execution of IT programs. The department’s CIO organization provides the  developers who devise technology solutions for the users. In addition, CIO  officials chair a set of IT governance boards that review progress and  recommend funding for IT projects; these boards include executive-level  representation from business owners.
For the HealtheVet initiative, various levels and types of oversight are  currently provided by the business owner (the Veterans Health  Administration), the developers (the Office of Enterprise Development  within the department’s CIO organization), and departmental IT  governance boards. However, the business unit has not yet finalized a  governance plan or implemented a complete governance structure, several  key leadership positions within the developers’ organization are either  vacant or filled with acting personnel, and the IT governance boards have  not yet scheduled critical reviews of HealtheVet projects. Until all  elements of governance and oversight are in place, the risk is increased  that the HealtheVet initiative may experience cost overruns and continued  schedule slippages and may not achieve what it intends to achieve.
subsections: section_title: VHA Has Not Fully Implemented a HealtheVet Governance Structure
paragraphs: VHA has not yet established a governance structure for HealtheVet in  accordance with the approach endorsed by the department. Under this  approach, business unit governance for IT initiatives is provided at several  levels. An Executive Steering Committee, chaired by the head of the  business unit, provides executive oversight. Reporting to the Executive  Steering Committee is an Oversight Board that is responsible for ensuring  that all stakeholders are represented in defining requirements, monitoring  progress, and determining that the initiative is meeting their needs. Finally,  a Program Director is responsible for day-to-day oversight activities to  ensure that the technical solution provided by the developers meets  business needs (such as requirements development and testing) and for  coordinating with the developers’ program office.
According to senior management officials, VHA has not yet established a  governance structure for HealtheVet in accordance with this approach, but  it has developed a plan to do so. According to these officials, they worked  with the departmental CIO organization to develop this plan. Officials told  us that the plan had been approved by the Under Secretary for Health and  was under review and awaiting approval by the Secretary of Veterans  Affairs (we anticipate reviewing the plan upon its approval by the  Secretary). VHA officials expect the plan to be approved next month.  However, the officials did not provide a schedule for finalizing the plan  and implementing the structure.
Until the governance structure is implemented, VHA is providing oversight  of the HealtheVet initiative through various means. For example,  according to officials, the former VHA CIO (now the Chief Officer of VHA’s  Office of Information) briefs the VHA head (the Under Secretary for  Health) twice weekly. In addition, the Office of Information holds formal  meetings every two weeks with the developers (the Office of Enterprise  Development in the department’s CIO organization) on three or four IT  projects (which may include HealtheVet projects). Further, VHA’s Office  of Information holds meetings with VHA managers who act as business  liaisons between VHA and the departmental CIO organization. VHA also  has an Information Data Management Committee that establishes  priorities for VHA IT investments (including HealtheVet) and makes  funding recommendations to the Under Secretary. This committee  includes major VHA stakeholders, including headquarters and regional  executives, as well as the Chief Officer, who co-chairs the council.
These means fulfill some of the functions of the governance model  endorsed by the department. That is, the Information Data Management  Committee performs some of the oversight functions of an Oversight  Board, and the Chief Officer coordinates with the developers’ program  office. However, there is currently no equivalent to an Executive Steering  Committee, and there is no Program Director. If the draft governance plan  follows the model endorsed by the department, its approval and  implementation would include these elements.
Without a complete governance structure in place, the business owners’  ability to perform appropriate oversight of the HealtheVet projects may be  decreased.
section_title: Key Positions within the Office of Enterprise Development Are Vacant
paragraphs: The Office of Enterprise Development within the departmental CIO  organization is responsible for development of the HealtheVet projects.  This office provides day-to-day oversight and management of the technical  development activities. However, currently several key leadership  positions within the Office of Enterprise Development are either vacant or  are filled with acting personnel. That is, positions within Program  Management and Software Development are vacant, and the Assistant  Deputy CIO for Software Engineering is acting (see fig. 2 for an  organizational chart showing these positions).
The position of Assistant Deputy CIO for Program Management is  currently vacant; this position is responsible for activities such as  managing a program’s portfolio of IT applications during its entire life  cycle, as well as for developing and managing project plans and schedules  and managing risk. In addition, the position of head of Software  Engineering is filled by an acting Assistant Deputy CIO; this position has  responsibility for overseeing the architecture of an application’s technical  solution. Another Assistant Deputy CIO position (head of Software  Development) is vacant; this position is responsible for ensuring that  software deliverables meet their expected requirements. In commenting  on a draft of this report, the department noted that a vacancy  announcement for the Assistant Deputy CIO for Program Management  position has been posted with a closing date of July 7, 2008. Until these  key leadership positions are permanently staffed, the risk is increased that  the department’s management and control of the HealtheVet initiative will  not be efficient and effective.
section_title: IT Governance Boards Have Been Established, but No Milestone Reviews Have Been Scheduled
paragraphs: In 2007, three VA governance boards for IT investment projects were  established; they have the following general responsibilities:    The Business Needs and Investment Board (chaired by the Principal  Deputy Assistant Secretary) is to evaluate whether proposed IT  investment projects meet business needs.
The Planning, Architecture, Technology, and Services Board (chaired by a  Deputy CIO) determines whether IT projects meet technical standards  by, among other things, performing milestone reviews.
The Information Technology Leadership Board (chaired by the CIO) uses  input from the two other boards to make recommendations to the  department’s Strategic Management Council for funding the major  categories of IT projects.
Although the boards are chaired by officials in the CIO’s office, they all  include high-level executives from the user organizations. For example,  the VHA representative on the Information Technology Leadership Board  is the head of VHA—the Under Secretary for Health.
Since being established, the three governance boards have begun  providing oversight to ensure that investments align with the department’s  strategic plan and that business and budget requirements for ongoing and  new initiatives meet user demands. In 2007, the three boards evaluated the  HealtheVet projects that were proposed for fiscal year 2009, and the  Information Technology Leadership Board made funding  recommendations to the department’s Strategic Management Council. As a  result of these deliberations, the department requested about $330 million  for HealtheVet development projects for fiscal year 2009.
However, there is one oversight function that has not yet been exercised  for the HealtheVet projects: milestone reviews. Milestone reviews, which  are a responsibility of the Planning, Architecture, Technology, and  Services Board, afford an opportunity for progressive decision making  about the program under review and are coupled with authorization for  funding. The VA milestone review process includes concept definition,  requirements development, system design and prototype, system  development and testing, system deployment, and operations and  maintenance. Each step in the process has specific and organizationally  required exit criteria that must be satisfied before the program can  proceed to the next stage.
The Planning, Architecture, Technology, and Services Board has  performed one milestone review since being established (this was a  system design and prototype review for another IT development project).  However, the board has not yet developed a schedule for any milestone  reviews for HealtheVet projects. In particular, although the Enrollment  project is scheduled for initial implementation in August 2008, no system  deployment milestone review has been scheduled. According to the chair  of this board, although no HealtheVet milestone reviews have been  scheduled, the board has scheduled an operational test readiness review  for another HealtheVet project (the Scheduling project) in June 2008 to  verify that the application functions as designed are ready for initial  deployment. Doing such a review should provide the board with useful  information for oversight of this project. Nonetheless, it is important to  hold milestone reviews on all projects that are moving from one phase of  development to the next. Without milestone reviews of project progress,  the governance boards cannot effectively measure progress or determine  the funding needed for HealtheVet.
section_title: Conclusions
paragraphs: Although VA has made progress on its $11 billion HealtheVet initiative, it  has also experienced significant delays, and none of the associated  development projects have been completed. Moreover, VA is proceeding  with this complex initiative without a project management plan and  validated cost estimates to coordinate and guide the effort.
At the same time, a governance structure for HealtheVet has not yet been  established, and key leadership positions that are responsible for  providing day-to-day oversight have not been permanently staffed.  Further, several IT governance boards with oversight responsibility for  HealtheVet have not yet performed essential reviews of HealtheVet  projects to gauge progress and funding requirements and the department  lacks a time frame for doing so. Until the department takes the necessary  actions to fully address these matters, it will face the risk that HealtheVet  may experience cost overruns and continued schedule slippages, and may  not achieve the outcome it intends to achieve.
section_title: Recommendations for Executive Action
paragraphs: To better ensure the success of HealtheVet, we recommend that the  Secretary of Veterans Affairs direct the Chief Information Officer to take  the following four actions:    Develop a project management plan that encompasses all six blocks of  HealtheVet.
Validate cost estimates for all six blocks of HealtheVet.
Expedite efforts to permanently staff the position of the Director of the  Program Management office and fill other critical leadership positions in  the Office of Enterprise Development.
Develop a schedule for and conduct milestone reviews of the HealtheVet  projects.
In addition, to ensure proper oversight of HealtheVet, we recommend that  the Secretary of Veterans Affairs direct the Veterans Health Administration  Under Secretary to take the following action:    Finalize and implement the plan to establish the HealtheVet governance  structure.
section_title: Agency Comments and Our Evaluation
paragraphs: In providing written comments on a draft of this report, the Deputy  Secretary of Veterans Affairs agreed with our conclusions and concurred  with our recommendations. (The department’s comments are reproduced  in app. II.) The comments described actions planned or being taken that  respond to our recommendations. For example, according to the  department, the Office of Information and Technology is developing a  comprehensive, integrated HealtheVet project management plan to be  completed within 6 months that is to reflect dependencies between  resources and establish a single schedule for all VA medical information  technology projects. As part of this plan, the department noted that it will  include the format and schedule for conducting milestone reviews for  HealtheVet projects. In addition, the department stated that it has hired a  contractor to conduct an independent financial validation of the  HealtheVet preliminary cost estimate that includes three phases and is to  be completed by February 2009. To address staffing within the Office of  Enterprise Development, the department stated that it had posted a  vacancy announcement to fill the leadership position for the Program  Management Office. Lastly, the department said it expects final review and  approval of the HealtheVet governance plan by July 2008. If the actions  that the department has planned or undertaken are properly implemented,  they should help ensure success with the development and  implementation of HealtheVet. The department also provided technical  comments on the draft report, which we have incorporated as appropriate.
As agreed, unless you publicly announce the contents of this report earlier,  we plan no further distribution until 30 days from the report date. At that  time, we are sending copies of this report to interested congressional  committees and the Secretary of Veterans Affairs. Copies of this report  will also be made available to other interested parties on request. This  report will also be available at no charge on our Web site at  http://www.gao.gov.
Should you or your staffs have any questions on matters discussed in 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. GAO staff who made major  contributions to this report are listed in appendix IV.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: As requested, the objectives of our review were to determine (1) the status  of the HealtheVet initiative, (2) VA’s overall plan for completing the  initiative, and (3) how VA is providing oversight to ensure the success of  the initiative. We conducted our review by reviewing relevant HealtheVet  project and budget documentation and validated our analyses through  interviews with knowledgeable VA officials.
To determine the status of the HealtheVet initiative, we reviewed  individual HealtheVet documents on system operation and development,  time frames, and activities planned. Additionally, we researched the  department’s expenditures on HealtheVet initiatives through fiscal year  2007 and the department’s current estimate of how much it plans to spend  in fiscal years 2008 and 2009. We did not assess the accuracy of the cost  data provided to us. We supplemented our analyses with interviews of VA  personnel involved in the initiative. We also observed demonstrations of  scheduling and enrollment prototypes to better understand how  HealtheVet initiatives could provide enhanced service to patients and  better support VA’s medical care providers. Finally, to gain user  perspective on moving from VistA to HealtheVet, we visited the VA  Medical Center in Salem, Virginia, because it had recently installed  customized enhancements to VistA.
To determine VA’s plan for completing HealtheVet, we reviewed the  department’s strategy and transition plan. We supplemented this review  with responsible officials at the Office of Information and Technology,  including the Deputy CIO for Enterprise Development and the Acting  Deputy Director of the Program Management Office within the Office of  Enterprise Development, to identify the department’s current strategy for  the completion of HealtheVet. We summarized information obtained  through interviews and reviews of HealtheVet documents to illustrate VA’s  approach to completing the initiative.
To determine how VA is providing oversight for HealtheVet, we reviewed  department information technology (IT) governance documents, including  the IT Governance Plan, as well as the charters of the three VA IT  governance boards, to determine the boards’ roles and responsibilities for  oversight of VA IT initiatives such as HealtheVet. In addition, we reviewed  minutes of the three VA IT governance boards to determine the extent of  their oversight of HealtheVet to date. We interviewed the chairman of the  Planning, Architecture, Technology, and Services Board to determine that  board’s plans for conducting future milestone reviews for HealtheVet. We  also reviewed the Office of Enterprise Development organizational  structure and responsibilities. We interviewed the Chief Officer of VHA’s  Office of Information and members of his staff to obtain information on  the plan under development to provide governance for HealtheVet.
We conducted this performance audit at the Department of Veterans  Affairs headquarters in Washington, D.C., and the VA medical center in  Salem, Virginia, from July 2007 through June 2008, 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: Comments from the Department of Veterans Affairs
section_title: Appendix III: Existing VistA Applications Overview
paragraphs: According to VA, all of the functionality delivered by the VistA  applications described below will be either rehosted or replaced as part of  HealtheVet.
Offers a convenient way for healthcare providers to view information about  multiple patients on a single screen. Users can see at a glance multiple patients  for whom they have items that require attention.
Passes final patient results between vendor clinical information systems and  VistA.
Enables clinicians to enter, review, and continuously update all order-related  information connected with any patient.
Provides a common and consistent data structure for adverse reaction data.
Provides a method for identifying who is authorized to perform various actions on  clinical documents.
Assists clinical decision-making and educate providers about appropriate care.  The primary goal is to provide relevant information to providers at the point of  care, for improving care for veterans.
Provides an efficient way for clinicians to order consultations and procedures from  other providers or services within the hospital site, at their own facility or another  facility.
A clinically oriented, structured report that extracts many kinds of data from VistA  and displays it in a standard format.
Provides the clinician with a current and historical view of the patient’s health care  problems across clinical specialties and allows each identified problem to be  traceable through the VistA system in terms of treatment, test results, and  outcome.
Simplifies the use and management of clinical documents for both clinical and  administrative medical facility personnel.
A menu-based system incorporating features necessary for the maintenance of  medical center dental records.
Contains important demographic and clinical data on VHA patients identified with  Hepatitis C infection.
Designed to allow for the local entry and verification of patient-related data at an  individual medical center.
Contains important demographic and clinical data on VHA patients identified with  Human Immunodeficiency Virus infection.
Designed to store, in the patient’s electronic medical record, all patient intake and  output information associated with a hospital stay or outpatient visit.
Supports General Laboratory, Microbiology, Histology, Cytology, Surgical  Pathology, Electron Microscopy, Blood Donors, and Blood Bank for managing and  automating the workload and reporting process.
Automates record keeping and reporting for all areas of Anatomic Pathology.
Uses data that can be tied primarily to a donor, a patient, or a unit of blood/blood  component.
Reduces or eliminates the need for manual ordering and reporting of laboratory  results to interface laboratories.
Allows entry, edit, and viewing of data for many medical tests and procedures.
Provides computer support for both clinical and administrative patient care  activities associated with mental health care.
Generates management reports on employees; accumulates daily statistics on the  number of patients treated; generates reports on patients by bed section and  ward; allows users to enter vital signs, height, and weight for patients; and allows  users to generate intake and output reports.
Integrates the automation of many Clinical Nutrition, Food Management, and  Management Reports functions.
Automates the tumor registry and supports tumor registrars in abstracting cancer  cases, following up on cancer patients and producing the Hospital Annual Report.
Provides a method to track drug distribution and inventory management within a  medical center.
Provides a real-time, point-of-care solution for validating the administration of Unit  Dose and intravenous medications to inpatients in medical centers.
Provides a regional system resource to expedite the distribution of mail-out  prescriptions to veteran patients.
Provides functionality to monitor and track the receipt, inventory, and dispensing  of all controlled substances.
Works toward perpetual inventory for each VA medical facility pharmacy by  tracking all drugs through pharmacy locations.
Provides the ability to create and distribute electronic Outpatient Pharmacy claims  to insurance companies on behalf of VHA pharmacy prescription beneficiaries in a  real-time environment.
Integrates functions from the Intravenous and Unit Dose modules to provide a  comprehensive record of medications utilized during hospitalization of the veteran.
Provides pharmacists and their staff with IV labels, manufacturing worksheets,  ward lists for order updates, and management report.
Provides a standard computerized system for dispensing and managing inpatient  medications.
Provides standardization of the local drug files in all VA medical facilities.
Provides a way to manage the medication regimen of veterans seen in outpatient  clinics and to monitor and manage the workload and costs in the Outpatient  Pharmacy.
Makes data extraction reports available at the medical centers and allows local  management to use the data to project local drug usage and identify potential  drug accountability problem areas.
Provides tools for managing site configurable data in pharmacy files.
Provides medical centers with the ability to determine whether a patient has been  seen at other VA facilities and to request current pharmacy information from those  facilities prior to the patient appearing for a scheduled outpatient visit.
In the outpatient setting, patients are assigned a primary care team and provider  who are responsible for delivering essential health care, coordinating all health  care services, and serving as the point of access for specialty care. This  application allows a user to create, set up, and define teams; create and assign  positions to the team; assign staff to the positions; assign patients to the team;  and assign patient to providers’ positions.
Automates purchasing, provides control and auditing of expenditures, and  generates management reports.
Used to enter, edit, and retrieve data for each episode of care.
Automates the entire range of diagnostic functions performed in imaging  departments, including order entry of requests, registration of patients for exams,  processing of exams, recording of reports/results, verification of reports on-line,  displaying/printing results for clinical staff, automatic tracking of  requests/exams/reports, and generation of management statistics/reports, both  recurring and ad hoc.
Used by clinicians to place orders for certain types of medical products and  services that are maintained under contract by the Denver Distribution Center.  The most substantial product line is custom hearing aids.
Automates all aspects of the outpatient appointment process.
Is designed to facilitate the Social Work Service functions within a medical facility  and is composed of Case Management, Clinical Assessment, and Community  Resources.
Permits the identification and tracking of patients with a spinal cord dysfunction  due to trauma or disease and the medical resources utilized during their  treatment.
Integrates scheduling surgical cases and tracking clinical patient data to provide a  variety of administrative and clinical reports.
Provides medical facilities a mechanism to track information relating to both  surgical risk and operative mortality.
Facilitates medical decision-making by delivering complete multimedia patient  information to the clinician’s desktop in an integrated manner.
Includes the components used to capture, store, and display all types of images.
Allows scanned and electronically generated documents to be associated with the  online patient record and displayed on clinical workstations.
Allows radiology departments to operate without generating X-ray film.
Captures, stores, and displays images for a particular service or specialty.
Enables the Visual Impairment Service Team to easily manage and track activities  and services provided to blinded veterans in their service areas.
Designed to store, in the patient’s electronic medical record, all vital signs and  various measurements associated with a patient’s hospital stay or outpatient clinic  visit.
To establish a computerized tracking system that generates aggregate data at the  facility level. It would assist in the assessment of various aspects of care provided  to women veterans.
Automates the debt collection process and a billing module is available to create  non-medical care debts.
Creates and prints encounter forms that display relevant clinical information, and  provides for the entry of clinical encounter data for local and national needs.
Provides the ability to perform the functions involved in issuing beneficiary travel  pay.
Provides on-line access to medical data to Veterans Benefits Administration  Rating Veteran Service Representatives and Decision Review Officers. It also  creates a more efficient means of requesting compensation and pension  examinations.
CPT codes are used for reporting medical services and procedures performed by  physicians. The software includes all CPT codes to code outpatient services for  reimbursement and workload purposes.
Provides a means of exporting data from selected VistA applications and  transmitting it to a Decision Support System at the Austin Automation Center.
Is based on the Medicare Grouper requirements as defined by the Health Care  Financing Administration. Each DRG represents a class of patients who are  deemed medically comparable and who require approximately equal amounts of  health care resources.
Facilitates the management of information needed to effectively discharge key  operations responsibilities normally assigned to VA engineering organizations.
Provides additional functionality within the Integrated Funds Distribution, Control  Point Activity, Accounting and Procurement package.
Provides a mechanism to track and account for procedures and delivered services  that are not handled in any other VistA package.
Supports VHA’s Fee for Service program, which is care authorized for veterans  who are legally eligible and are in need of care that cannot feasibly be provided by  a VA facility.
Allows code sheet data to be entered and transmitted electronically from the  medical facility service level to the national database.
Provides the medical center the ability to monitor incomplete records, interim  summaries, discharge summaries, and both inpatient and outpatient operation  reports.
Automates a spectrum of VA financial activities. Provides users the capability to  manage budgets, order goods and services, maintain records of available funds,  determine the status of a request, compare vendors and items to determine the  best purchase, record the receipt of items into the warehouse, and pay vendors.
Automates the mini-banking system that VA provides for patients to manage their  personal funds while hospitalized in a VA medical facility.
Contains all the features necessary to create bills for patients and third party  insurance carriers.
Captures clinical data resulting from ambulatory care patient encounters.
Automates time and attendance for employees, timekeepers, payroll, and  supervisors.
A national-level application replacing the site-based Voluntary Timekeeping  System that tracks and manages the hours of service contributed by volunteers  and volunteer organizations.
Enhances the ability to associate appropriate data with a single patient identifier. It  provides the tools necessary to automatically identify patient records identified as  being duplicates.
This package enables M-based VistA applications running on core facility  computer systems to exchange health care information with other computer  systems. It provides messaging services and a single toolset for M-based VistA  applications to create, send, receive, and process HL7 messages.
A portability layer between the underlying operating system and application code.  This enables the VistA system to be portable among different computers,  operating systems, and M implementations.
Provides Development and Quality Assessment Tools, Capacity Planning Tools,  and System Management Utilities.
Provides an efficient way for applications to present a list of items to the user for  action.
An electronic messaging system that transmits messages, computer programs,  data dictionaries, and data between users and applications located at the same or  at different facilities.
This is a suite of applications that provides the ability to uniquely identify a patient  and the facilities where that patient receives care. It is a foundation for the CPRS  Remote Data Views that allows the clinician to retrieve clinical information from  wherever the patient has received care.
Is a Web-based application that creates a new, on-line environment where  veterans, family, and clinicians may come together to optimize veterans’ health  care.
Provides clinicians quick and easy access to patients’ information from any VA  medical facility where a patient has received care.
Electronically requests and receives patient demographics, episodes of care,  medications, and diagnostic evaluations from other VA facilities.
Provides functionality so that graphical user interface developers can establish a  connection from a client workstation to a VistA Server; fun remote procedure calls  on the VistA M Server; and return data to the client workstation.
The majority of VHA clinical data is stored in VA FileMan files and is retrieved and  accessed through VA FileMan Application Programmer Interfaces and user  interfaces.
Provides a synchronous communication mechanism between M applications and  rehosted applications, supporting VHA’s ongoing transition to HealtheVet.
Provides a comprehensive range of software dedicated to the support of  administrative functions related to patient admission, discharge, transfer, and  registration.
Allows the user to design monitors that capture patient data in support of quality  management efforts.
Facilitates the processing of an application for health benefits, which has been  transmitted to the VHA site from the web-based software.
Provides the capability to request and obtain veteran eligibility data via the VA  national telecommunications network.
Extracts patient-reported Means Test data and transmit it to the Health Eligibility  Center.
Provides for the maintenance and control of medical records and x-ray films to  facilitate availability to a variety of users.
Provides a standardized assessment tool supporting the completion of a  comprehensive accurate and reproducible patient assessment, and serves as the  basis for developing the patient’s plan of care.
Replaces the embossed data card as a means of identifying veteran patients  entitled to care and service at VA health care facilities.
Facilitates the electronic interchange of veteran information between Veteran  Benefits Administration Regional Offices and VA medical facilities.
Supports VHA policy by compiling data on patient incidents.
Used to express diagnostic clinical problems in easy-to-understand terminology  and associate these terms to coding systems such as ICD, DSM, NANDA.
Supports VHA policy by providing for the identification of events requiring follow- up review.
Tracks and trends compliments and complaints and measures the facility’s types  of complaints as they relate to the Customer Services Standards and the National  Patient Satisfaction Survey.
Designed to manage the data from all employee accidents, create a Report of  Accident, and produce the Office of Worker’s Compensation Programs Form CA-1  and the Federal Employee’s Notice of Occupational Disease and Claim for  Compensation Form CA-2.
Automates the entire serials management process in VA Library Services.
Supports the VA Police in their responsibilities of crime prevention, preliminary  investigation of crimes, apprehension, legally correct handling of suspected  offenders, and the transfer of suspected offenders to appropriate authorities.
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributions to this report  were made by Barbara Oliver (Assistant Director), Barbara Collier, Neil  Doherty, Nancy Glover, Michele Mackin, J. Michael Resser, Amos  Tevelow, Eric Trout, and Charles Youman.