Computer-Based Patient Records: Sound Planning and Project Management Are Needed to Achieve a Two-Way Exchange of VA and DOD Health Data
Published: 2004-03-17T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: A critical component of the Department of Veterans Affairs' (VA) information technology program is its ongoing work with the Department of Defense (DOD) to achieve the ability to exchange patient health care data and create electronic records for use by veterans, active military personnel, and their health care providers. GAO testified before Congress last November that one-way sharing of data, from DOD to VA medical facilities, had been realized. At the Congress's request, GAO assessed, among other matters, VA's and DOD's progress since that time toward defining a detailed strategy for and developing the capability of a twoway exchange of patient health information.
section_title: What GAO Found
paragraphs: Since November, VA and DOD have made little progress in determining their approach for achieving the two-way exchange of patient health data. Department officials recognize the importance of an architecture to articulate how they will electronically interface their health systems, but continue to rely on a nonspecific, high-level strategy--in place since September 2002--to guide their development and implementation of this capability. VA officials stated that an initiative begun this month to satisfy a mandate of the Bob Stump National Defense Authorization Act for Fiscal Year 2003 will be used to better define the electronic interface needed to exchange patient health data. However, this project is at an early stage, and the departments have not yet fully identified the approach or requirements for this undertaking. Given these uncertainties, there is little evidence of how this project will contribute to defining a specific architecture and technological solution for achieving the two-way health data exchange. These uncertainties are further complicated by the absence of sound project management to guide the departments' actions. At present, neither department has the authority to make final decisions binding on the other, and day-to-day oversight of the joint initiative to develop an electronic interface is limited. Progress toward defining data standards continues, but delays have occurred in the development and deployment of the agencies' individual health information systems.

section_title: Letter
paragraphs: I am pleased to be here today to participate in continuing discussions of  the Department of Veterans Affairs’ (VA) information technology program.  My testimony focuses on a critical aspect of that program—VA’s work  with the Department of Defense (DOD) to achieve the ability to exchange  patient health care data and create an electronic medical record for  veterans and active duty military personnel. As you are well aware, having  readily accessible medical data on these individuals—many of whom are  highly mobile and may have health records at multiple medical facilities  within and outside of the United States—is important to providing high- quality health care to them and to adjudicating any disability claims that  they may have. VA and DOD have been pursuing ways to share data in  their health information systems and create electronic records since 1998,  yet accomplishing a two-way health data exchange has been elusive.
When we testified on this initiative last November, VA and DOD had  achieved a measure of success in sharing data through the one-way  transfer of health information from DOD to VA health care facilities. Yet  VA and DOD faced significant challenges and were far from realizing a  longer term objective: providing a virtual medical record based on the two- way exchange of data, as part of their HealthePeople (Federal) initiative.  The departments had not clearly articulated a common health information  architecture, and lacked the details and specificity essential to determining  how they would achieve this capability.
At your request, my testimony will discuss our review of VA’s and DOD’s  actions since November toward defining a detailed strategy and  developing the capability for a two-way exchange of patient health  information. In addition, I will provide an update on actions that the  departments have taken to address recommendations resulting from prior  reviews of their efforts to share medical data, including those articulated  in the May 2003 report of the President’s task force on the development of  electronic medical records.
In conducting this work, we analyzed key documentation supporting VA’s  and DOD’s strategy for developing and implementing the two-way  electronic exchange of health data, including deployment and conversion  plans, project schedules, and status reports for their individual health  information systems. In addition, we reviewed documentation to identify  the costs incurred by VA and DOD in developing technology to support the  sharing of health data, including costs associated with the government  computer-based patient record and federal health information exchange  initiatives, and with VA’s and DOD’s ongoing projects to develop new  health information systems. We supplemented our analyses with  interviews of VA and DOD officials responsible for key decisions and  actions on the initiatives. Further, we analyzed documentation and  interviewed relevant VA and DOD officials to determine actions that have  been taken to address our previous recommendations related to the  government computer-based patient record initiative and those contained  in the President’s task force report. We did not verify the departments’  reported actions in response to the President’s task force  recommendations. We performed our work in accordance with generally  accepted government auditing standards, from December 2003 through  March of this year.
subsections: section_title: Background
paragraphs: In 1998 VA and DOD, along with the Indian Health Service (IHS), began an  initiative to share patient health care data, called the government  computer-based patient record (GCPR) project. At that time, each agency  collected and maintained patient health information in separate systems,  and their health facilities could not electronically share patient health  information across agency lines. GCPR was envisioned as an electronic  interface that would allow physicians and other authorized users at VA,  DOD, and IHS health facilities to access data from any of the other  agencies’ health facilities. The interface was expected to compile  requested patient information in a “virtual” record that could be displayed  on a user’s computer screen.
In reporting on the initiative in April 2001, we raised doubts about GCPR’s  ability to provide expected benefits. We noted that the project was  experiencing schedule and cost overruns and was operating without clear  goals, objectives, and consistent leadership. We recommended that the  participating agencies (1) designate a lead entity with final decisionmaking  authority and establish a clear line of authority for the GCPR project, and  (2) create comprehensive and coordinated plans that included an agreed- upon mission and clear goals, objectives, and performance measures, to  ensure that the agencies could share comprehensive, meaningful,  accurate, and secure patient health care data. VA, DOD, and IHS agreed  with our findings and recommendations.
In March 2002, however, we again reported that the project was continuing  to operate without clear lines of authority or a lead entity responsible for  final decisionmaking. Further, the project continued to move forward  without comprehensive and coordinated plans and an agreed-upon  mission and clear goals and measures. In addition, the participating  agencies had announced a revised strategy that was considerably less  encompassing than the project was originally intended to be. For example,  rather than serve as an interface to allow data sharing across the three  agencies’ disparate systems, as originally envisioned, the revised strategy  initially called only for a one-way transfer of data from DOD’s current  health care information system to a separate database that VA hospitals  could access. In further reporting on this initiative in June 2002, we  recommended that VA, DOD, and IHS revise the original goals and  objectives of the project to align with their current strategy, commit the  executive support necessary to adequately manage the project, and ensure  that it followed sound project management principles.
In September 2002 we reported that VA and DOD had made some progress  toward electronically sharing patient health data. The two departments  had renamed the project the Federal Health Information Exchange (FHIE)  program and, consistent with our prior recommendation, had finalized a  memorandum of agreement designating VA as the lead entity for  implementing the program. With this agreement, FHIE became a joint  effort between VA and DOD to achieve the exchange of health care  information in two phases. The first phase, completed in mid-July 2002,  enabled the one-way transfer of data from DOD’s existing health  information system to a separate database that VA hospitals could access.  A second phase, finalized earlier this month, completed VA’s and DOD’s  efforts to add to the base of patient health information available to VA  clinicians via this one-way sharing capability. VA and DOD reported total  FHIE costs of about $85 million through fiscal year 2003.
The revised strategy also envisioned VA and DOD pursuing a longer term,  two-way exchange of health information. This initiative, known as  HealthePeople (Federal), is premised upon the departments’ development  of a common health information architecture comprising standardized  data, communications, security, and high-performance health information  systems. The joint effort is expected to result in the secured sharing of  health data required by VA’s and DOD’s health care providers between  systems that each department is currently developing—DOD’s Composite  Health Care System II (CHCS II) and VA’s HealtheVet VistA.
DOD began developing CHCS II in 1997 and has completed its associated  clinical data repository that is key to achieving an electronic interface.  DOD expects to complete deployment of all of its major system  capabilities by September 2008. The department reported expenditures of  about $464 million for the system through fiscal year 2003. VA began work  on HealtheVet VistA and its associated health data repository in 2001, and  expects to complete all six initiatives that make up this system in 2012.  VA reported spending about $120 million on HealtheVet VistA through  fiscal year 2003.
Under the HealthePeople (Federal) strategy, VA and DOD envision that,  upon entering military service, a health record for the service member will  be created and stored in DOD’s CHCS II clinical data repository. The  record will remain in the clinical data repository and be updated as the  service member receives medical care. When the individual separates from  active duty and, if eligible, seeks medical care at a VA facility, VA will then  create a medical record for the individual, which will be stored in its  health data repository. Upon viewing the medical record, the VA clinician  would be alerted and provided access to clinical information on the  individual also residing in DOD’s repository. In the same manner, when a  veteran seeks medical care at a military treatment facility, the attending  DOD clinician would be alerted and provided with access to the health  information existing in VA’s repository. According to VA and DOD, the  planned approach would make virtual medical records displaying all  available patient health information from the two repositories accessible  to both departments’ clinicians. VA officials have stated that they  anticipate being able to exchange some degree of health information  through an interface of their health data repository with DOD’s clinical  data repository by the end of calendar year 2005.
section_title: Lacking A Defined Strategy, VA And DOD Have Made Limited Progress Toward A Common Health Information Exchange
paragraphs: VA’s and DOD’s ability to exchange data between their separate health  information systems is crucial to achieving the goals of HealthePeople  (Federal). Yet successfully sharing patient health information via a secure  electronic interface between each of their data repositories can be  complex and challenging, and depends on their having a clearly articulated  architecture, or blueprint, defining how specific technologies will be used  to achieve the interface. Developing, maintaining, and using an  architecture is a best practice in engineering information systems and  other technological solutions. An architecture would articulate, for  example, the system requirements and design specifications, database  descriptions, and software descriptions that define the manner in which  the departments will electronically store, update, and transmit their data.
Equally critical is an established project management structure to guide  project development. Industry best practices and information technology  project management principles stress the importance of accountability  and sound planning for any project, particularly an interagency effort of  the magnitude and complexity of this one. 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.
As was the situation when we testified last November, VA and DOD  continue to lack an explicit architecture detailing how they intend to  achieve the data exchange capability, or just what they will be able to  exchange by the end of 2005—their projected time frame for putting this  capability into operation. VA officials stated that they recognize the  importance of a clearly defined architecture, but acknowledged that the  departments’ actions were continuing to be driven by the less-specific,  high-level strategy that has been in place since September 2002.
The officials added that just this month, the departments had taken a first  step toward trying to determine how their separate data repositories  would interface to enable the two-way exchange of patient health records.  Specifically, officials in both departments pointed to a project that they  are undertaking in response to requirements of the National Defense  Authorization Act for Fiscal Year 2003, which mandated that VA and DOD  develop a real-time interface, data exchange, and capability to check  prescription drug data for outpatients by October 1, 2004. VA’s Deputy  Chief Information Officer for Health stated that they hope to determine  from a prototype planned for completion by next September whether the  interface technology developed to meet this mandate can be used to  facilitate the exchange of data between the health information systems  that they are currently developing.
By late February, VA had hired a supporting contractor to develop the  planned prototype, but the departments had not yet fully defined their  approach or requirements for developing and demonstrating its  capabilities. DOD officials stated that the departments would rely on the  contractor to more fully define the technical requirements for the  prototype. Further, according to VA officials, since the departments’ new  health information systems that are intended to be used under  HealthePeople (Federal) have not yet been completed, the demonstration  may only test the ability to exchange data in VA’s and DOD’s existing  health systems—the Veterans Information Systems and Technology  Architecture and the Composite Health Care System, respectively. Thus,  given the early stage of the prototype and the uncertainties regarding what  capabilities it will demonstrate, there is little evidence and assurance as to  how or whether this project will contribute to defining the architecture  and technological solution for the two-way exchange of patient health  information.
Further compounding the challenges and uncertainty that VA and DOD  face is the lack of a fully established project management structure to  ensure the necessary day-to-day guidance of and accountability for the  departments’ investments in and implementation of the electronic  interface between their systems. Officials in both departments maintain  that they are collaborating on this initiative through a joint working group  and with oversight provided by the Joint Executive Council and VA/DOD  Health Executive Council. However, neither department has had the  authority to make final project decisions binding on the other, and there  has been a visible absence of day-to-day project oversight for the joint  initiative to develop an electronic interface between the departments’  planned information systems. Further, VA and DOD are operating without  a project management plan describing the overall development and  implementation of the interface, including the specific roles and  responsibilities of each department in developing, testing, and deploying  the interface and addressing security requirements. In discussing these  matters last week, VA officials stated that the departments had recently  designated a program manager for the planned prototype. Further, VA and  DOD officials added that they had begun discussions to establish an  overall project plan and finalize roles and responsibilities for managing the  joint initiative to develop an electronic interface. Until these essential  project management elements are fully established, VA and DOD will lack  assurance that they can successfully develop and implement an electronic  interface and the associated capability for exchanging health information  within the time frames that they have established.
subsections: section_title: Progress Toward Achieving a Two-Way Data Exchange Has Been Limited
paragraphs: In the absence of an architecture and project management structure for  the initiative, VA and DOD have continued to make only limited progress  toward developing the technological solution essential to interfacing their  patient health information. To their credit, the departments have  continued essential steps toward standardizing clinical data—important  for exchanging health information between disparate systems. The  Institute of Medicine’s Committee on Data Standards for Patient Safety has  reported the lack of common data standards as a key factor preventing  information sharing within the health care industry. Over the past 4  months, VA and DOD have agreed to adopt additional data standards for  uniformly presenting in any system data related to demographics,  immunizations, medications, names of laboratory tests ordered, and  laboratory result contents.
Nonetheless, as reflected in figure 1, the technology needed to achieve a  two-way exchange of patient health information remains far from  complete, with only DOD’s data repository having been fully developed.
Since November, both departments have delayed key milestones  associated with the development and deployment of their individual health  information systems. VA program officials told us that completion of a  prototype for the department’s health data repository has been delayed  approximately a year, until the end of this June. The officials explained  that earlier testing of the prototype had slowed clinicians’ use of the  clinical applications, necessitating a revised approach to populating the  repository. In addition, while DOD officials previously stated that the  department planned to complete the deployment of its first release of  CHCS II functionality (a capability for integrating DOD clinical outpatient  processes into a single patient record) in September 2005, the agency has  now extended its completion date to June 2006. According to DOD  officials, the schedule for completing this deployment was revised because  of a later than anticipated decision on when the department could proceed  with its worldwide deployment. Collectively, the lack of an architecture  and project management structure, coupled with delays in the  departments’ completion of key projects, places VA and DOD at increased  risk of being unable to successfully accomplish the HealthePeople  (Federal) initiative and the overall goal of more effectively meeting service  members’ and veterans’ health care and disability needs.
section_title: VA and DOD Could Benefit From Current And Past Recommendations On Sharing Electronic Medical Records
paragraphs: Mr. Chairman, as part of our review, you asked that we update the status  of VA’s and DOD’s actions to address prior recommendations related to  sharing electronic medical information. In this regard, both the President’s  task force and we have made a number of recommendations to VA and  DOD for improving health care delivery to beneficiaries through better  coordination and management of their electronic health sharing initiatives.  In its final report of May 2003, the President’s task force recommended  specific actions for providing timely, high-quality care through effective  electronic sharing of health information, such as the development and  deployment, by fiscal year 2005, of electronic medical records that are  interoperable, bidirectional, and standards-based. The departments  reported that they are in various stages of acting on these  recommendations, with anticipated completion dates ranging from June of  this year to September 2005. Our attachment to this statement summarizes  these specific recommendations, and the departments’ reported actions to  address them. Giving full consideration to these recommendations could  provide VA and DOD with relevant information for determining how to  proceed with the HealthePeople (Federal) initiative.
Also, as mentioned earlier, our prior reviews of the departments’ project to  develop a government computer-based patient record determined that the  lack of a lead entity, clear mission, and detailed planning to achieve that  mission had made it difficult to monitor progress, identify project risks,  and develop appropriate contingency plans. As a result, in reporting on  this initiative in April 2001 and again in June 2002, we made several  recommendations to help strengthen the management and oversight of  this project. VA and DOD have taken specific measures in response to our  recommendations for enhancing overall management and accountability  of the project, with demonstrated improvements and outcomes. Extending  these practices to current activities supporting the development of  HealthePeople (Federal) could strengthen the departments’ approach to  successfully accomplishing a two-way health information exchange.
In summary, Mr. Chairman, achieving an electronic interface to enable VA  and DOD to exchange patient medical records between their health  information systems is an important goal, with substantial implications for  improving the quality of health care and disability claims processing for  our nation’s military members and veterans. However, in seeking a virtual  medical record based on the two-way exchange of data between their  separate health information systems, VA and DOD have chosen an  approach that necessitates the highest levels of project discipline,  including a well-defined architecture for describing the interface for a  common health information exchange and an established project  management structure to guide the investment in and implementation of  this electronic capability. At this time, the departments lack these critical  components, and thus risk investing in a capability that could fall short of  their intended goals. The continued absence of a clear approach and  sound planning for the design of this new electronic capability elevates  concerns and skepticism about exactly what capabilities VA and DOD will  achieve as part of HealthePeople (Federal), and in what time frame.
Mr. Chairman, this concludes my statement. I would be pleased to respond  to any questions that you or other members of the Subcommittee may  have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For information about this testimony, please contact Linda D. Koontz,  Director, Information Management Issues, at (202) 512-6240 or at  koontzl@gao.gov, or Valerie C. Melvin, Assistant Director, at (202) 512- 6304 or at melvinv@gao.gov. Other individuals making key contributions to  this testimony include Nabajyoti Barkakati, Michael P. Fruitman, Carl L.  Higginbotham, Barbara S. Oliver, J. Michael Resser, Sylvia L. Shanks, and  Eric L. Trout.
section_title: Appendix: VA’s and DOD’s Reported Actions to Address Recommendations in the President’s Task Force Report of May 26, 2003
paragraphs: Department of Veterans Affairs (VA)
Department of Defense (DOD)
The VA/DOD Joint Strategic Plan and the Joint  Electronic Health Records Plan have set  September 2005 as the target date by which VA  and DOD will achieve interoperability of health  data. The VA/DOD Health Executive Council  Information Management/ Information Technology  Work Group is on track to complete this capability  by the end of fiscal year 2005. In March 2004, the  departments awarded a contract to develop a bi- directional pharmacy solution that will  demonstrate interoperability in a prototype  environment. The departments are on track to  complete the prototype by October 2004.
Operational interoperability is planned  for fiscal year 2005.The pharmacy  prototype is the initial effort within the  Clinical Health Data Repositories  (CHDR) framework. This framework is  the effort to develop software component  services that will be used by the VA and  DOD data repositories. The prototype  has a planned completion date of  October 2004.
This issue remains under review by the Veterans  Health Administration’s HIPAA Program Office. It  is VA’s understanding that VA and DOD have  concluded that this is not necessary in order to  share information on patients that both  departments are treating.
DOD believes that it and VA can achieve  the appropriate sharing of protected  health information within the guidelines  of the current regulations. The HIPAA  privacy rule has a specific exception  authorizing one-way sharing of health  data at the time of a service member’s  separation. This supports the “seamless  transition to veteran status.”
The Joint Strategic Plan has set June 2004 as the  target date for the departments to develop an  implementation plan for the one physical exam  protocol. VA and DOD are currently piloting the  single separation physical exam that meets DOD  needs and VA’s rating criteria at 16 Benefits  Delivery at Discharge sites.
The departments are currently testing an  advanced technological demonstration  project that transfers images of paper  personnel documents to VA from official  military personnel file repositories in the  Army, Navy, and Marine Corps, with Air  Force integration into the program in  process (including the DD214). When  fully operational, this system will send  digital images of any personnel record to  the VA within 48 hours of the request.
Department of Veterans Affairs (VA)
Department of Defense (DOD)
Both the Health Executive Council (through the  Deployment Health Work Group) and the VA/DOD  Benefits Executive Council are currently  developing and implementing processes to  address these issues.
DOD is already providing VA with daily  information on personnel separating  from active duty, which includes  assignment history, location, and  occupational duties through the DD214.  DOD’s TRICARE On Line provides  health care professionals with access to  the individual service member’s pre- and  post-deployment health assessments  The Defense Occupational and  Environmental Health Readiness System  with CHCS II, is capturing data on  occupational exposures and transferring  it to the clinical data repository. When  these systems are fully operational,  appropriate information will be able to be  shared via a two-way exchange with VA.
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