Information Technology: Challenges Remain for VA's Sharing of Electronic Health Records with DOD
Published: 2009-03-12T00:00:00

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 engaged in efforts to improve their ability to share electronic health information. These efforts are vital for making patient information readily available to health care providers in both departments, reducing medical errors, and streamlining administrative functions. In addition, Congress has mandated that VA and DOD jointly develop and implement, by September 30, 2009, electronic health record systems or capabilities that are fully interoperable and compliant with applicable federal interoperability standards. (Interoperability is the ability of two or more systems or components to exchange information and to use the information that has been exchanged.) The experience of VA and DOD in this area is also relevant to broader efforts to advance the nationwide use of health information technology (IT) in both the public and private health care sectors--a goal of both current and past administrations. In this statement, GAO describes VA's and DOD's achievements and challenges in developing interoperable electronic health records, including brief comments on how these apply to the broader national health IT effort.
section_title: What GAO Found
paragraphs: Through their long-running electronic health information sharing initiatives, VA and DOD have succeeded in increasing their ability to share and use health information. In particular, they are sharing certain clinical information (pharmacy and drug allergy data) in computable form--that is, in a format that a computer can understand and act on. This permits health information systems to provide alerts to clinicians on drug allergies, an important feature that was given priority by the departments' clinicians. The departments are now exchanging this type of data on over 27,000 shared patients--an increase of about 9,000 patients between June 2008 and January 2009. Sharing computable data is considered the highest level of interoperability, but other levels also have value. That is, data that are only viewable still provide important information to clinicians, and much of the departments' shared information is of this type. However, the departments have more to do: not all electronic health information is yet shared, and although VA's health data are all captured electronically, information is still captured on paper at many DOD medical facilities. To share and use health data has required, among other things, that VA and DOD agree on standards. At the same time, they are participating in federal standards-related initiatives, which is important both because of the experience that the departments bring to the national effort, and also because their involvement helps ensure that their adopted standards are compliant with federal standards. However, these federal standards are still emerging, which could complicate the departments' efforts to maintain compliance. Finally, the departments' efforts face management challenges. Specifically, the effectiveness of the departments' planning for meeting the deadline for fully interoperable electronic health records is reduced because their plans did not consistently identify results-oriented performance goals (i.e., goals that are objective, quantifiable, and measurable) or measures that would permit progress toward the goals to be assessed. Further constraining VA's and DOD's planning effectiveness is their inability to complete all necessary activities to set up the interagency program office, which is intended to be accountable for fulfilling the departments' interoperability plans. Defining goals and ensuring that these are met would be an important part of the task of the program office. Without a fully established office that can manage the effort to meet these goals, the departments increase the risk that they will not be able to share interoperable electronic health information to the extent and in the manner that most effectively serves military service members and veterans. Accordingly, GAO has recommended that the departments give priority to fully establishing the interagency program office and develop results-oriented performance goals and measures to be used as the basis for reporting interoperability progress. The departments concurred with these recommendations.

section_title: Letter
paragraphs: I am pleased to be here today to discuss the efforts of the  Department of Veterans Affairs (VA) to advance the use of health  information technology to achieve interoperable electronic health  records with the Department of Defense (DOD). VA has been  working with DOD for over a decade to pursue initiatives to share  data between the two departments’ health information systems. To  expedite the departments’ 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. Such systems and capabilities are  important for making patient information more readily available to  health care providers in both departments, reducing medical errors,  and streamlining administrative functions.
The experience of VA and DOD in this area is also relevant to  broader efforts to advance the nationwide use of health information  technology (IT) in both the public and private health care sectors — a goal of both current and past administrations. As you are aware, a  nationwide effort is currently under way to promote the use of  health IT to help improve the efficiency and quality of health care. In  April 2004 an executive order called for widespread adoption of  interoperable electronic health records by 2014, and it set up the  Office of the National Coordinator for Health Information  Technology within the Department of Health and Human Services  (HHS) to help guide efforts leading to this goal. Most recently, in  February, the American Recovery and Reinvestment Act of 2009  established the office in law, giving the National Coordinator  responsibility for coordinating health IT policy and standards,  among other things.
Since 2001, we have been reviewing aspects of the various federal  efforts undertaken to implement IT for health care and public health  solutions. We have reported on VA’s and DOD’s electronic health  information sharing initiatives, as well as on HHS’s national health  IT initiatives. Overall, our studies have recognized progress made  by these departments, but we have also pointed out challenges and  other areas of concern. At your request, in this statement, we will  describe some of VA’s and DOD’s achievements and challenges in  developing interoperable electronic health records, including brief  comments on how these apply to the broader national health IT  effort.
In developing this testimony, we relied largely on our previous  work. We conducted our work in support of this testimony during  February 2009 and March 2009, in Washington, D.C. 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 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 critical 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.
Electronic health records are particularly crucial for optimizing the  health care provided to military personnel and veterans. While in  military status and later as veterans, many VA and DOD patients  tend to be highly mobile and may have health records residing at  multiple medical facilities within and outside the United States.  Making such records electronic can help ensure that complete  health care information is available for most military service  members and veterans at the time and place of care, no matter  where it originates.
subsections: section_title: VA Has Been Working with DOD to Exchange Health Information for Over a Decade
paragraphs: VA and DOD have been working to exchange patient health data  electronically since 1998. As we have previously noted, their efforts  have included both short-term initiatives to share information in  existing (legacy) systems, as well as a long-term initiative to develop  modernized health information systems—replacing their legacy  systems—that would be able to share data and, ultimately, use  interoperable electronic health records.
In their short-term initiatives to share information from existing  systems, the departments began from different positions. VA has  one integrated medical information system—the Veterans Health  Information Systems and Technology Architecture (VistA)—which  uses all electronic records and was developed in-house by VA  clinicians and IT personnel. All VA medical facilities have access to  all VistA information.
In contrast, DOD uses multiple legacy medical information systems,  all of which are commercial software products that are customized  for specific uses. For example, the Composite Health Care System  (CHCS) which was formerly DOD’s primary health information  system, is still in use to capture pharmacy, radiology, and laboratory  information. In addition, the Clinical Information System (CIS), a  commercial health information system customized for DOD, is used  to support inpatient treatment at military medical facilities.
The departments’ short-term initiatives to share information in their  existing systems have included several projects. Most notable are  two information exchange projects:  ●  The Federal Health Information Exchange (FHIE), completed in  2004, enables DOD to electronically transfer service members’  electronic health information to VA when the members leave active  duty.  ●  The Bidirectional Health Information Exchange (BHIE), also  established in 2004, was aimed at allowing clinicians at both  departments viewable access to records on shared patients (that is,  those who receive care from both departments—veterans may  receive outpatient care from VA clinicians and be hospitalized at a  military treatment facility). The interface also allows DOD sites to  see previously inaccessible data at other DOD sites.
As part of the long-term initiative, each of the departments aims to  develop a modernized system in the context of a common health  information architecture that would allow a two-way exchange of  health information. The common architecture is to include  standardized, computable data; communications; security; and high- performance health information systems: DOD’s AHLTA and VA’s  HealtheVet. The departments’ modernized systems are to store  information (in standardized, computable form) in separate data  repositories: DOD’s Clinical Data Repository (CDR) and VA’s Health  Data Repository (HDR). For the two-way exchange of health  information, in September 2006 the departments implemented an  interface named CHDR, to link the two repositories.
Beyond these initiatives, in January 2007, the departments  announced their intention to jointly determine an approach for  inpatient health records. On July 31, 2007, they awarded a contract  for a feasibility study and exploration of alternatives. In December  2008, the contractor provided the departments with a recommended  strategy for jointly developing an inpatient solution.
section_title: VA and DOD Have Increased Information Sharing, but Continue to Face Challenges in Developing and Implementing Interoperable Health Records
paragraphs: VA and DOD have increased their ability to share and use health  information, sharing both computable and viewable data. This  achievement has required years of effort by the two departments,  involving, among other things, agreeing on standards and setting  priorities for the kind of information to be shared and the  appropriate level of interoperability to work toward.
Interoperability—the ability to share data among health care  providers—is key to sharing health care information electronically.  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. (Paper-based  health records—if available—also provide necessary information,  but unlike electronic health records, do not provide decision  support capabilities, such as automatic alerts about a particular  patient’s health, or other advantages of automation.)
Interoperability can be achieved at different levels. 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. The value of data at  this level is that they are structured so that data of interest to users  are easier to find. 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 can also be considered interoperable (at the lowest level)  because they allow data to be shared, read, and interpreted by  human beings. Figure 1 shows the distinction between the various  levels of interoperability and examples of the types of data that can  be shared at each level.
VA and DOD have adopted a classification framework like the one in  the figure to define what level of interoperability they are aiming to  achieve in various information areas. For example, in their initial  efforts to implement computable data, VA and DOD focused on  outpatient pharmacy and drug allergy data because clinicians gave  priority to the need for automated alerts to help medical personnel  avoid administering inappropriate drugs to patients. As of January  31, 2009, the departments were exchanging computable outpatient  pharmacy and drug allergy data through the CHDR interface on over  27,000 shared patients—an increase of about 9,000 patients since  June 2008.
However, 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. According to the departments, much of the information being  shared today is currently at the structured, viewable level. For  example, through BHIE, the departments exchange surgical  pathology reports, microbiology results, cytology reports, chemistry  and hematology reports, laboratory orders, vital signs, and other  data in structured, viewable form. Some of this information is from  scanned documents that are viewable but unstructured. With this  format, a clinician would have to find needed or relevant  information by scanning uncategorized information. The value of  viewable data is increased if the data are structured so that  information is categorized and easier to find. Nonetheless, achieving  even a minimal level of electronic interoperability is valuable for  potentially making all relevant information available to clinicians.
However, the departments have more to do: not all electronic health  information is yet shared. In addition, although VA’s health data are  all captured electronically, information is still captured on paper at  many DOD medical facilities.
subsections: section_title: VA and DOD Have Adopted Standards to Allow Sharing and Are Taking Steps to Follow Evolving Federal Standards
paragraphs: Any level of interoperability depends on the use of agreed-upon  standards to ensure that information can be shared and used. 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.  ●  For example, vocabulary standards provide common definitions  and codes for medical terms and determine how information will be  documented for diagnoses and procedures. These standards are  intended to lead to consistent descriptions of a patient’s medical  condition by all practitioners. Without such standards, the terms  used to describe the same diagnoses and procedures may vary (the  condition known as hepatitis, for example, may be described as a  liver inflammation). The use of different terms to indicate the same  condition or treatment complicates retrieval and reduces the  reliability and consistency of data.  ●  Another example is messaging standards, which establish the order  and sequence of data during transmission and provide for the  uniform and predictable electronic exchange of data. For example,  they might require the first segment to include the patient’s name,  hospital number, and birth date. A series of subsequent segments  might transmit the results of a complete blood count, dictating one  result (e.g., iron content) per segment. Messaging standards can be  adopted to enable intelligible communication between organizations  via the Internet or some other communications pathway. Without  them, the interoperability of health IT systems may be limited,  reducing the data that can be shared.
VA and DOD have agreed upon numerous common standards that  allow them to share health data. These are listed in a jointly  published common set of interoperability standards called the  Target DOD/VA Health Standards Profile, updated annually. The  profile includes federal standards (such as data standards  established by the Food and Drug Administration and security  standards established by the National Institute of Standards and  Technology); industry standards (such as wireless communications  standards established by the Institute of Electrical and Electronics  Engineers and Web file sharing standards established by the  American National Standards Institute); and international standards  (such as the Systematized Nomenclature of Medicine Clinical  Terms, or SNOMED CT, and security standards established by the  International Organization for Standardization).
For the two kinds of data now being exchanged in computable form  through CHDR (pharmacy and drug allergy data), VA and DOD  adopted the National Library of Medicine data standards for  medications and drug allergies, as well as the SNOMED CT codes  for allergy reactions. This standardization was a prerequisite for  exchanging computable medical information—an accomplishment  that, according to the Department of Health and Human Services’  National Coordinator for Health IT, has not been widely achieved.
Further, VA and DOD are continuing their historical involvement in  efforts to agree upon standards for the electronic exchange of  clinical health information by participating in ongoing initiatives led  by the Office of the National Coordinator under the direction of  HHS. These initiatives have included the designation of standards- setting organizations tasked to reach consensus on the definition  and use of standards. For example, these organizations have been  responsible for, among other things,   ●  developing use cases, which provide the context in which  standards would be applicable;   identifying competing standards for the use cases and harmonizing  the standards;   ●  developing interoperability specifications that are needed for  implementing the standards; and   ●  creating certification criteria to determine whether health IT  systems meet standards accepted or recognized by the Secretary of  HHS, and then certifying systems that meet those criteria.
The involvement of the two departments in these initiatives is  important both because of the experience that the departments can  offer the national effort, and also because their involvement helps  ensure that the standards they adopt are consistent with the  emerging federal standards. DOD and VA have made progress  toward adopting health data interoperability standards that are  newly recognized and accepted by the Secretary of HHS. The  departments have identified these new standards, which relate to  three HHS-recognized use cases, in their most recent Target  Standards Profile.
Nonetheless, the need to be consistent with the emerging federal  standards adds complexity to the task faced by the two departments  of extending their standards efforts to additional types of health  information. The National Coordinator recognized the importance of  their participation and stated it would not be advisable for VA and  DOD to move significantly ahead of the national standards initiative;  if they did, the departments might have to change the way their  systems share information by adjusting them to the national  standards later, as the standards continue to evolve.
section_title: VA and DOD Plans Lack Results-Oriented Performance Goals and Measures, and Interagency Program Office Is Not Fully Set Up
paragraphs: Using interoperable health IT to help improve the efficiency and  quality of health care is a complex goal that requires the  involvement of multiple stakeholders in both departments, as well  as numerous activities taking place over an expanse of time. In view  of this complexity, it is important to develop comprehensive plans  that cover the full scope of the activities needed to reach the goal of  interoperable health capabilities or systems. To be effective, these  plans should be grounded in results-oriented goals and performance  measures that allow the results of the activities to be monitored and  assessed, so that the departments can take corrective action if  needed.
In the course of their health IT efforts, VA and DOD have faced  considerable challenges in project planning and management. As far  back as 2001 and 2002, we reported management weaknesses, such  as inadequate accountability and poor planning and oversight, and  recommended that the departments apply principles of sound  project management. The departments’ efforts to meet the recent  requirements of the National Defense Authorization Act for Fiscal  Year 2008 provide additional examples of such challenges, raising  concerns regarding their ability to most effectively meet the  September 2009 deadline for developing and implementing  interoperable electronic health record systems or capabilities.
The departments have identified key documents as defining their  planned efforts to meet this deadline: the November 2007 VA/DOD  Joint Executive Council Strategic Plan for Fiscal Years 2008–2010  (known as the VA/DOD Joint Strategic Plan) and the September  2008 DOD/VA Information Interoperability Plan (Version 1.0).  These plans identify various objectives and activities that, according  to the departments, are aimed at increasing health information  sharing and achieving full interoperability. However, of the 45  objectives and activities identified in their plans, we previously  reported that only 4 were documented with results-oriented (i.e.,  objective, quantifiable, and measurable) performance goals and  measures that are characteristic of effective planning.   ●  An example of an objective, quantifiable, and measurable  performance goal is DOD’s objective of increasing the percentage  for inpatient discharge summaries that it shares with VA from 51  percent as of March 2009, to 70 percent by September 30, 2009.  ●  However, other goals in the plans are not measurable: For example,  one objective is the development of a plan for interagency sharing of  essential health images. Another objective is to review national  health IT standards. In neither case are tangible deliverables  described that would permit the departments to determine progress  in achieving these goals.
In view of the complexity and scale of the tasks required for the two  departments to develop interoperable electronic health records, the  lack of documented results-oriented performance goals and  measures hinder their ability to measure and report their progress  toward delivering new capabilities. Both departments agreed with  our January 2009 recommendation that they develop results- oriented goals and associated performance measures to help them  manage this effort. Until they develop these goals and measures,  the departments will be challenged to effectively assess their  progress.
In addition, we previously reported that the departments had not  fully set up the interagency program office that was established in  the National Defense Authorization Act for Fiscal Year 2008.  According to department officials, this office will play a crucial role  in coordinating the departments’ efforts to accelerate their  interoperability efforts. These officials stated that having a  centralized office to take on this role will be a primary benefit.  Further, defining results-oriented performance goals and ensuring  that these are met would be an important part of the task of the  program office. However, the effort to set up the program office was  still in its early stages. The departments had taken steps to set up  the program office, such as developing descriptions for key  positions and beginning to hire personnel, but they had not  completed all necessary activities to meet their December 2008  deadline for the office to be fully operational. Both departments  agreed with our July 2008 recommendation that the departments  give priority to fully establishing the interagency program office.  Since we last reported, the departments have continued their efforts  to hire staff for the office with 18 of 30 positions filled as of March 5,  2009, but the positions of Director and Deputy Director are not yet  filled with permanent hires.
Until the departments complete key activities to set up the program  office, it will not be positioned to be fully functional, or accountable  for fulfilling the departments’ interoperability plans. Coupled with  the lack of results-oriented plans that establish program  commitments in measurable terms, the absence of a fully  operational interagency program office leaves VA and DOD without  a clearly established approach for ensuring that their actions will  achieve the desired purpose of the act.
In closing, Mr. Chairman, VA and DOD have made important  progress in achieving electronic health records that are  interoperable, but the departments continue to face challenges in  managing the activities required to achieve this inherently complex  goal. These include the need to continue to agree on standards for  their own systems while ensuring that they maintain compliance  with federal standards, which are still emerging as part of the effort  to promote the nationwide adoption of health IT. In addition, the  departments’ efforts face managerial challenges in defining goals  and measures and setting up the interagency program office. Until  these challenges are addressed, the risk is increased that the  departments will not achieve the ability to share interoperable  electronic health information to the extent and in the manner that  most effectively serves military service members and veterans.
This concludes my statement. I would be pleased to respond to any  questions that you or other members of the subcommittee may have.
section_title: Contacts and Acknowledgements
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; Barbara Collier; Neil Doherty;  Rebecca LaPaze; J. Michael Resser; Kelly Shaw; and Eric Trout.
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