Electronic Health Records: Program Office Improvements Needed to Strengthen Management of VA and DOD Efforts to Achieve Full Interoperability
Published: 2009-07-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: For over a decade, the Department of Veterans Affairs (VA) and the Department of Defense (DOD) have been working on initiatives to share electronic health information. To expedite their efforts, Congress mandated in the National Defense Authorization Act for Fiscal Year 2008 that VA and DOD establish a joint interagency program office to act as a single point of accountability in the development of electronic health records systems or capabilities that allow for full interoperability (generally, the ability of systems to exchange data) by September 30, 2009. In this statement, GAO summarizes findings from its upcoming report, focusing on progress in setting up the interagency program office and the departments' actions to achieve fully interoperable capabilities by September 30, 2009. To do so, GAO analyzed agency documentation on project status and conducted interviews with agency officials.
section_title: What GAO Found
paragraphs: VA and DOD have made progress in setting up the interagency program office; however, the office is not yet effectively positioned to be accountable for the departments' efforts to achieve fully interoperable electronic health record systems or capabilities. The departments have taken the important steps of completing personnel descriptions and hiring necessary staff to perform the office's functions, but key leadership positions (for the Director and Deputy Director) continue to be filled on an interim basis. In addition, the office has established a charter and begun to demonstrate responsibilities outlined within this document. Nonetheless, the office is not yet fulfilling key information technology management responsibilities in the areas of performance measurement, project planning, and scheduling--all of which are essential to establishing the office as a single point of accountability for the departments' interoperability efforts. VA and DOD continue to take steps toward achieving full interoperability by the September deadline. In this regard, the departments have achieved planned capabilities for three of six interoperability objectives (see table) that they identified to meet their data sharing needs--refine social history data, share physical exam data, and demonstrate initial network gateway operation. For the remaining three objectives--expand questionnaires and self assessment tools, expand DOD inpatient medical records system, and demonstrate initial document scanning--the departments have partially achieved planned capabilities, with additional work needed to fully meet clinicians' needs for health information.

section_title: Letter
paragraphs: I am pleased to be here today to discuss the Departments of  Veterans Affairs’ (VA) and Defense’s (DOD) interagency program  office and efforts toward advancing the use of health information  technology to achieve interoperable electronic health records. As  you know, VA and DOD have been working for over a decade on  initiatives to share data between their health information systems;  yet, while they have made progress in a number of areas, questions  have persisted concerning when and to what extent the intended  electronic sharing capabilities of the two departments will be fully  achieved. To expedite their efforts, the National Defense  Authorization Act for Fiscal Year 2008 included provisions directing  VA and DOD to jointly develop and implement, by September 30,  2009, fully interoperable electronic health record systems or  capabilities that are compliant with applicable federal  interoperability standards. It further established an interagency  program office to be a single point of accountability for the  departments’ efforts.
Also, the act directed us to report semiannually on VA’s and DOD’s  progress in implementing their electronic health record systems. In  this regard, we have previously issued two reports (in July 2008 and  January 2009). We plan to issue a third report near the end of this  month—a draft of which is currently with the departments for their  review and comments. At your request, my testimony today  summarizes findings from this latest draft report, focusing on the  departments’ progress in setting up the interagency program office  as a point of accountability for the implementation of interoperable  electronic health records, and actions being taken to achieve these  capabilities by September 30, 2009.
In developing this testimony, we relied on our previous work  supporting the draft report. We conducted our work from April 2009  through July 2009, in the Washington, D.C. metropolitan area. All  work on which this testimony is based was performed 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.
subsections: section_title: Background
paragraphs: The use of information technology (IT) to electronically collect,  store, retrieve, and transfer clinical, administrative, and financial  health information has great potential to help improve the quality  and efficiency of health care and is important to improving the  performance of the U.S. health care system. Historically, patient  health information has been scattered across paper records kept by  many different caregivers in many different locations, making it  difficult for a clinician to access all of a patient’s health information  at the time of care. Lacking access to these critical data, a clinician  may be challenged to make the most informed decisions on  treatment options, potentially putting the patient’s health at greater  risk. The use of electronic health records can help provide this  access and improve clinical decisions.
Key to making health care information electronically available is  interoperability—that is, the ability to share data among health care  providers. Interoperability enables different information systems or  components to exchange information and to use the information  that has been exchanged. This capability is important because it  allows patients’ electronic health information to move with them  from provider to provider, regardless of where the information  originated. If electronic health records conform to interoperability  standards, they can be created, managed, and consulted by  authorized clinicians and staff across more than one health care  organization, thus providing patients and their caregivers the  necessary information required for optimal care. In the health IT  field, standards may govern areas ranging from technical issues,  such as file types and interchange systems, to content issues, such  as medical terminology. Unlike paper-based documents, electronic  health records can also provide automatic alerts about a particular  patient’s health, or other advantages of automation.
In prior reports, we have discussed the different levels of  interoperability that agencies can achieve. At the highest level,  electronic data are computable (that is, in a format that a computer  can understand and act on to, for example, provide alerts to  clinicians on drug allergies). At a lower level, electronic data are  structured and viewable, but not computable. At still a lower level,  electronic data are unstructured and viewable, but not computable.  With unstructured electronic data, a user would have to find needed  or relevant information by searching uncategorized data. Beyond  these, paper records also can be considered interoperable (at the  lowest level) because they allow data to be shared, read, and  interpreted by human beings. According to VA and DOD officials,  not all data require the same level of interoperability, nor is  interoperability at the highest level achievable in all cases. For  example, unstructured, viewable data may be sufficient for such  narrative information as clinical notes.
subsections: section_title: VA and DOD Are Required by Law to Establish an Interagency Program Office and Achieve Full Interoperability
paragraphs: As previously noted, the National Defense Authorization Act for  Fiscal Year 2008 called for VA and DOD to jointly develop and  implement fully interoperable electronic health record systems or  capabilities by September 30, 2009, and established an interagency  program office to be accountable for the departments’ efforts in this  regard. The departments have been working to set up this office  since April 2008. In January 2009, the office completed its charter,  articulating, among other things, its mission and functions with  respect to attaining interoperable electronic health data. The charter  further identified the office’s responsibilities in carrying out its  mission, in areas such as oversight and management, stakeholder  communication, and decision-making.
Further, to help meet the intent of the act, the Interagency Clinical  Informatics Board, made up of senior clinical leaders from both  departments who represent the user community, began establishing  priorities for health data sharing between VA and DOD. The board  subsequently identified six interoperability objectives for meeting  the departments’ data sharing needs, as reflected in table 1.
According to the former acting director of the interagency program  office, VA and DOD consider achievement of these six objectives, in  conjunction with data sharing capabilities previously achieved (e.g.,  the Federal Health Information Exchange (FHIE), the Bidirectional  Health Information Exchange (BHIE), and the interface between  DOD’s Clinical Data Repository (CDR) and VA’s Health Data  Repository (HDR), known as CHDR), to be sufficient to satisfy the  requirement for full interoperability by September 2009.
section_title: DOD/VA Interagency Program Office Has Made Progress in Becoming Operational, but Is Not Fully Functioning as a Single Point of Accountability
paragraphs: As our report later this month will note, VA and DOD have taken  important steps to make the interagency program office operational.  However, more work is needed to solidify its leadership and  management capabilities if the office is to effectively function as a  single point of accountability for achieving interoperable electronic  health data.
In particular, the departments have completed personnel  descriptions and recruited and hired staff for government positions  and obtained necessary contractor staff to perform the office’s  functions. As of early July, the departments reported that they had  selected staff members for 10 of 14 government positions and that  recruitment efforts were underway to fill the remaining 4 positions  by late September 2009. Further, all of the 16 designated contractor  positions had been filled.
Nonetheless, VA and DOD continue to fill the office’s key leadership  positions—that of director and deputy director—on an interim  basis. To their credit, the departments have taken steps to hire a  full-time permanent director and a deputy director to lead the office.  Earlier this month, DOD selected a candidate for the director  position, VA concurred with the selection, and the candidate’s  application was sent to the Office of Personnel Management for  approval. In the meantime, the departments requested and received  an extension of the interim director’s appointment until September  30, 2009, or until a permanent official is hired. Further, as of late  June, interagency program officials stated that actions were  underway to fill the deputy director position and that VA was  interviewing candidates for this position. The interim director stated  that the departments anticipate making a selection for the deputy  director position by the end of this month.
Beyond the need to appoint these key permanent leaders, the office  needs to fulfill a number of responsibilities identified in its January  2009 charter that are critical to its effectiveness. To this end, the  office has taken several steps. For example, it submitted its first  annual report to Congress that summarized the departments’ efforts  toward achieving full interoperability and the status of key activities  completed to set up the office. Further, the office developed 11  standard operating procedures in areas such as program  management oversight, strategic communications, and process  improvement.
However, the office has not yet carried out other key responsibilities  identified in its charter that are fundamental to effective IT program  management and that would be essential to effectively serving as  the single point of accountability. For example, the office has not  yet established results-oriented (i.e., objective, quantifiable, and  measurable) goals and performance measures for all six of the  interoperability objectives discussed previously.
In particular, early development and use of results-oriented metrics  is an important IT program management activity. Performance goals  and measures, if effectively implemented, can provide a meaningful  baseline against which to measure the progress of a program and  the outcomes associated with its implementation. VA and DOD  agreed with our previous recommendation calling for the  development of such goals and measures. Further, the interagency  program office charter identified the development of metrics to  monitor the departments’ performance against interoperability  objectives as a responsibility of the office. Nevertheless, the office  has developed performance goals for only one of the six identified  interoperability objectives—the expansion of DOD’s medical  records system (Essentris) to share inpatient discharge summaries  with VA. Department officials have stated that results-oriented goals  and measures for the other five interoperability objectives will be  included in the next version of the DOD/VA Joint Executive Council  Joint Strategic Plan, expected to be completed by December 2009.  To the extent that the departments establish and effectively use  results-oriented goals and measures for their interoperability  objectives, they will be better positioned to gauge their progress  toward achieving fully interoperable capabilities and improving  veterans’ health care.
Further, development of an integrated master schedule is a key IT  program management activity, especially given the magnitude and  complexity of the departments’ efforts to achieve full  interoperability. According to DOD guidance, an integrated master  schedule should identify detailed project tasks and the associated  start, completion, and interim milestone dates; resource needs; and  relationships (e.g., sequence and dependencies) between tasks.
While the program office has begun to develop an integrated master  schedule as required by its charter, the current version does not  include the attributes of an effective schedule. For example, the  schedule included limited information—only the name of the  objective and a completion date of September 30, 2009—for three of  the six interoperability objectives (i.e., refine social history data,  share physical exam data, and expand questionnaires and self  assessment tools). The schedule did not include information on  tasks to be performed to meet the objectives, nor start dates,  resource needs, or relationships between tasks for any of the six  objectives. Without a complete and detailed integrated master  schedule, the departments are devoid of critical information that  could be vital to their ability to appropriately respond to project  needs and guide project efforts.
Similarly, development of a project plan is an important activity for  IT program management. Industry best practices and IT program  management principles stress the importance of sound planning for  any project. Inherent in such planning is the development and use of  a project management plan that describes, among other things, the  project’s scope, resource needs, and key milestones. The  interagency program office charter identified the need to develop a  project plan but, as of late June, the office had not yet done so. As  we have noted in our prior work, without a project plan, the  departments lack a key tool that could be used to guide their efforts  in achieving full interoperability.
In discussing these activities, the interagency program office’s  interim director and former acting director cited three reasons for  why performance measurement, scheduling, and project planning  responsibilities had not been accomplished. First, they stated that  because it has taken longer than anticipated to hire staff, the office  has not been able to perform all of its responsibilities. Second, the  office’s interim leadership and staff have focused their efforts on  providing interested parties (e.g., federal agencies and military  organizations) with briefings, presentations, and status information  on activities the office is undertaking to achieve interoperability, in  addition to participating in efforts to develop a strategy for  implementation of the Virtual Lifetime Electronic Record, which the  President announced in April 2009. Finally, according to the  officials, the office waited until June to begin the process of  developing performance metrics so that it could do so in  conjunction with the departments’ annual update to the Joint  Strategic Plan that is scheduled for completion in December 2009.
In the absence of sufficient metrics to monitor progress, a complete  integrated master schedule, and a project plan, the interagency  program office’s ability to effectively provide oversight and  management, including meaningful reporting on the progress and  delivery of interoperable capabilities, is jeopardized. As importantly,  the absence of these critical management tools calls into question  the effectiveness of this office in functioning as the single point of  accountability for achieving full interoperability, and the  departments’ overall success in meeting this goal.
section_title: VA and DOD Are Taking Steps to Meet their Objectives, but Activities to Meet Clinicians’ Needs Are Expected to Remain After the Deadline for Achieving Full Interoperability
paragraphs: VA and DOD continue to take steps toward achieving full  interoperability by September 30, 2009. In this regard, the  departments have achieved planned capabilities for three of the  objectives—refine social history data, share physical exam data, and  demonstrate initial network gateway operation. Specifically, with  regard to these objectives, the departments have accomplished the  following capabilities:  ●  The sharing of viewable social history data captured in DOD’s  electronic health record, thus providing VA with additional clinical  information on shared patients that clinicians could not previously  view. These data describe, for example, patients’ involvement in  hazardous activities and tobacco and alcohol use.   ●  The sharing of physical exam data, allowing VA to view DOD’s  medical exam data through the BHIE interface, which supports the  physical exam process when a service member separates from  active military duty. VA clinicians are able to view outpatient  treatment records, pre- and post- deployment health assessments,  and post deployment health reassessments.   ●  The operation of secure network gateways to support health  information sharing between the departments, thus facilitating  future growth in data sharing. As of early July, the departments  reported that five network gateways were operational and that data  migration to two of the operational gateways had begun. The  departments believed these five gateways satisfy the intent of the  objective and will provide sufficient capacity to support health  information sharing between VA and DOD as of September 2009.
For the remaining three objectives—expand questionnaires and self  assessment tools, expand Essentris in DOD, and demonstrate initial  document scanning—the departments have partially achieved  planned capabilities, with additional work needed to fully meet  clinicians’ needs.
Specifically, for the objective to expand questionnaires and self  assessment tools, the departments intend to provide all periodic  health assessment data stored in the DOD electronic health record  to VA in a format that associates questions with responses. Health  assessment data is collected from two sources: questionnaires  administered at military treatment facilities and a DOD health  assessment reporting tool that enables patients to answer questions  about their health upon entry into the military. Questions relate to a  wide range of personal health information, such as dietary habits,  physical exercise, and tobacco and alcohol use. While the  departments have established the capability for VA to view  questions and answers from the questionnaires collected by DOD at  military treatment facilities, they have not yet established the  additional capability for VA to view information from DOD’s health  assessment reporting tool. Department officials stated that they  intend to provide this capability by September 2009.
However, the other two objectives—expand Essentris in DOD and  demonstrate initial document scanning—are expected to require  substantial additional work beyond September to meet clinicians’  needs. By September 30, DOD intends to expand its Essentris  system to at least one additional site for each military medical  service and to increase the percentage of inpatient discharge  summaries that it shares electronically with VA to 70 percent.  According to the interim director of the interagency program office,  as of late June 2009, the departments had expanded the system to  two Army sites (but not yet to an Air Force or Navy site) and were  sharing 58 percent of inpatient discharge summaries. The interim  director stated that the departments expect to share 70 percent of  inpatient discharge summaries and expand the system to an Air  Force and a Navy site by the September deadline. Nevertheless, the  official added that to better meet clinicians’ needs, DOD will need to  further expand the inpatient medical records system. In this regard,  the department has established a future goal of making the inpatient  system operational for 92 percent of DOD’s inpatient beds by  September 2010.
The departments also expect to demonstrate an initial capability to  scan service members’ medical documents into the DOD electronic  health record and share the documents electronically with VA by  September 2009. According to the program office interim director,  the departments were in the process of setting up an interagency  test environment to test the initial capability to query medical  documents associated with specific patients as of late June 2009. He  stated that the departments expect to begin user testing at up to  nine sites by September 2009. According to this official, these  activities are expected to demonstrate an initial document scanning  capability. However, after September 2009, the departments  anticipate needing to perform additional work to expand their initial  document scanning capability (e.g., completion of user testing and  establishment of the scanning capability at all DOD sites).
In conclusion, VA and DOD have continued to increase electronic  health information interoperability, and have taken steps to meet  the six objectives that they identified as necessary to achieve full  interoperability by September 30, 2009. However, for two of the six  interoperability objectives, the departments subsequently plan to  perform significant additional activities that are necessary to meet  clinicians’ needs. Further, the departments’ lack of progress in  establishing fundamental IT management capabilities that are the  specific responsibilities of the interagency program office  contributes to uncertainty about the extent to which they will  achieve full interoperability by the deadline. Although the  departments have generally made progress toward making the  program office operational, the absence of performance metrics,  and a complete integrated master schedule and a project plan, limits  the office’s ability to effectively manage and provide meaningful  progress reporting on the delivery of interoperable capabilities that  are deemed critical to improving the quality of health care for our  nation’s veterans.
To better improve the management of VA’s and DOD’s efforts to  achieve fully interoperable electronic health record systems, our  draft report recommends that the Secretaries of Defense and  Veterans Affairs emphasize the interagency program office’s  establishment of a project plan and a complete and detailed  integrated master schedule.
Mr. Chairman, this concludes my prepared statement. I would be  pleased to respond to any questions that you or other members of  the subcommittee may have.
section_title: Contact and Acknowledgments
paragraphs: If you have any questions on matters discussed in this testimony,  please contact Valerie C. Melvin, Director, Information Management  and Human Capital Issues, at (202) 512-6304 or melvinv@gao.gov.  Other individuals who made key contributions to this testimony are  Mark Bird, Assistant Director; Rebecca Eyler; Michael Redfern; J.  Michael Resser; Kelly Shaw; Eric Trout; and Merry Woo.
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