Information Technology: VA and DOD Face Challenges in Completing Key Efforts
Published: 2006-06-22T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA) is engaged in an ongoing effort to share electronic medical information with the Department of Defense (DOD), which is important in helping to ensure high-quality health care for active duty military personnel and veterans. Also important, in the face of current military responses to national and foreign crises, is ensuring effective and efficient delivery of veterans' benefits, which is the focus of VA's development of the Veterans Service Network (VETSNET), a modernized system to support benefits payment processes. GAO is testifying on (1) VA's efforts to exchange medical information with DOD, including both near-term initiatives involving existing systems and the longer term program to exchange data between the departments' new health information systems, and (2) VA's ongoing project to develop VETSNET. To develop this testimony, GAO relied on its previous work and followed up on agency actions to respond to GAO recommendations.
section_title: What GAO Found
paragraphs: VA and DOD are implementing near-term demonstration projects that exchange limited electronic medical information between their existing systems, and they are making progress in their longer term effort to share information between the new health information systems that each is developing. Two demonstration projects have been implemented at selected sites: (1) a project to achieve the two-way exchange of health information on patients who receive care from both departments and (2) an application to electronically transfer laboratory work orders and results. According to VA and DOD, these projects have enabled lower costs and improved service to patients by saving time and avoiding errors. In their longer term effort, VA and DOD have made progress, in response to earlier GAO recommendations, by designating a lead entity with final decision-making authority and establishing a project management structure. However, VA and DOD have not yet developed a clearly defined project management plan that gives a detailed description of the technical and managerial processes necessary to satisfy project requirements, as GAO previously recommended. Moreover, the departments have experienced delays in their efforts to begin exchanging patient health data; they have not yet fully populated the repositories that will store the data for their future health systems. As a result, much work remains to be done before the departments achieve their ultimate goal of sharing virtual medical records. VA has also been working to modernize the delivery of benefits through its development of VETSNET, but the pace of progress has been discouraging. Originally initiated in 1986, this program was prompted by the need to modernize VA's Benefits Delivery Network--parts of which are now 40-year-old technology--on which the department relies to make benefits payments, including compensation and pension, education, and vocational rehabilitation and employment. In 1996, after experiencing numerous false starts and spending approximately $300 million, VBA revised its strategy and narrowed its focus to modernizing the compensation and pension system. In earlier reviews, GAO has made numerous recommendations to improve the program's management, including the development of an integrated project plan. In response to GAO's recommendations as well as those of an independent evaluator, VA is now developing an integrated master plan for the compensation and pension system, which it intends to complete in August. Until VA addresses the managerial and program weaknesses that have hampered the program, it is uncertain when VA will be able to end its reliance on its aging benefits technology.

section_title: Letter
paragraphs: I am pleased to participate in today’s hearing on health information  technology. As you know, the Departments of Veterans Affairs (VA)  and Defense (DOD) are engaged in efforts to share electronic  medical information, which is important in helping to ensure that  active duty military personnel and veterans receive high-quality  health care. Also important, in the face of current military responses  to national and foreign crises, is ensuring effective and efficient  delivery of veterans’ benefits, which is the focus of VA’s  development of the Veterans Service Network (VETSNET), a  modernized system to support benefits payment processes.
For the past 8 years, VA and DOD have been working to develop the  ability to exchange patient health information electronically. As part  of their efforts, each department is developing its own modern  health information system—VA’s HealtheVet VistA and DOD’s  Armed Forces Health Longitudinal Technology Application  (AHLTA), and they are collaborating on a program to develop an  interface to enable these future systems to share data and ultimately  to have interoperable electronic medical records with computable  data. That is, the data would be in a format that a computer  application can act on: for example, to provide alerts to clinicians  (of such things as drug allergies) or to plot graphs of changes in vital  signs such as blood pressure. According to the departments, the  availability of computable medical data contributes significantly to  patient safety and the usefulness of electronic medical records.
In addition, responding to a congressional mandate, VA and DOD  initiated information technology demonstration projects in 2004 that  focus on near-term goals: the exchange of electronic medical  information between the departments’ existing health information  systems. These projects are to help in the evaluation of the  feasibility, advantages, and disadvantages of measures to improve  sharing and coordination of health care and health care resources.  The two demonstration projects (Bidirectional Health Information  Exchange and Laboratory Data Sharing Interface) are limited,  interim initiatives that are separate from the departments’ ongoing  long-term efforts in sharing data and developing health information  systems.
Another ongoing VA project is the development of VETSNET, which  was prompted by the need to modernize VA’s Benefits Delivery  Network, parts of which are now 40-year-old technology. This  project, which was originally initiated in 1986, is essential to ensure  the continued accurate processing of benefits payments.
At your request, my testimony today will summarize our previous  work and describe agency actions to respond to our  recommendations in two areas.   ●  First, I will discuss VA’s continued efforts to exchange medical  information with DOD, including (1) near-term initiatives to  exchange data between the agencies’ existing systems and  (2) progress in achieving the longer term goal of exchanging data  between the departments’ new systems, to be built around  electronic patient health records.   ●  Second, I will discuss VA’s ongoing project to modernize its Benefits  Delivery Network and develop VETSNET.
To describe the current status of VA and DOD efforts to exchange  medical information, we reviewed our previous work in this area,  analyzed VA and DOD documentation to determine the  implementation status of our open recommendations, and consulted  with VA and DOD officials responsible for key decisions and actions  on the health data-sharing initiatives. To describe VA’s efforts on the  VETSNET initiative, we reviewed our previous work in this area,  analyzed documentation to determine the implementation status of  our open recommendations—most specifically, the Carnegie Mellon  Software Engineering Institute’s Technical Assessment of the  VETSNET project—and consulted with the Veterans Benefits  Administration officials responsible for key decisions and actions on  the project. The costs that has been incurred for the various projects  were provided by cognizant VA and DOD officials. We did not audit  the reported costs and thus cannot attest to their accuracy or  completeness. All work on which this testimony is based was  conducted in accordance with generally accepted government  auditing standards.
subsections: section_title: Background
paragraphs: VA’s mission is to promote the health, welfare, and dignity of all  veterans in recognition of their service to the nation by ensuring  they receive medical care, benefits, social support, and lasting  memorials. The information technology programs that I will be  discussing today are primary concerns of two of VA’s major  components: the Veterans Health Administration, which manages  one of the largest health care systems in the United States, with 157 hospitals nationwide, and the Veterans Benefits Administration,  which provides benefits and services to veterans and their  dependents that include compensation and pension, educat guaranty, and insurance.
subsections: section_title: VA and DOD Have Been Working on Electronic Medical Records Since 1998
paragraphs: In 1998, following a presidential call for VA and DOD to start  developing a “comprehensive, life-long medical record for eac service member,” the two departments began a joint course of  action aimed at achieving the capability to share patient health  h  information for active duty military personnel and veterans. Their  first initiative, undertaken in that year, was known as the  Government Computer-Based Patient Record (GCPR) project; the  goal of this project was an electronic interface that would allow  physicians and other authorized users at VA and DOD health  facilities to access data from any of the other agency’s health  information systems. The interface was expected to compile  requested patient information in a virtual record that could be  displayed on a user’s computer screen.
In our reviews of the GCPR project, we determined that the lack of a  lead entity, clear mission, and detailed planning to achieve that  mission made it difficult to monitor progress, identify project risks,  and develop appropriate contingency plans. In April 2001 and in  June 2002, we made recommendations to help strengthen the  management and oversight of the project. In 2001, we recommended  that the participating agencies (1) designate a lead entity with final  decision-making 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. In 2002, we recommended that the  participating agencies 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.
VA and DOD took specific measures in response to our  recommendations for enhancing overall management and  accountability of the project. By July 2002, VA and DOD had revised  their strategy and had made progress toward being able to  electronically share patient health data. The two departments had  refocused the project and named it 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. This  agreement also established FHIE as a joint activity that would allow  the transfer from DOD to VA 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 (the  Composite Health Care System or CHCS) to a separate database  that VA clinicians could access.  ●  A second phase, finalized in March 2004, 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.
According to the December 2004 VA/DOD Joint Executive Council  Annual Report, FHIE was fully operational, and providers at all VA  medical centers and clinics nationwide had access to data on  separated service members. According to the report, the FHIE data  repository at that time contained historical clinical health data on  2.3 million unique patients from 1989 on, and the repository made a  significant contribution to the delivery and continuity of care and  adjudication of disability claims of separated service members as  they transitioned to veteran status. The departments reported total  GCPR/FHIE costs of about $85 million through fiscal year 2003.
In addition, officials stated that in December 2004, the departments  began to plan for using the FHIE framework to transfer pre- and  postdeployment health assessment data from DOD to VA. According  to these officials, transferring of this information began in July 2005,  and VA has now received about 1.3 million of these records on more  than 560,000 separated service members.
However, not all DOD medical information is captured in CHCS. For  example, according to DOD officials, as of September 2005, 1.7  million patient stay records were stored in the Clinical Information  System (a commercial product customized for DOD). In addition,  many Air Force facilities use a system called the Integrated Clinical  Database for their medical information.
The revised DOD/VA strategy also envisioned achieving a longer  term, two-way exchange of health information between DOD and  VA, which may also address systems outside of CHCS. Known as  HealthePeople (Federal), this initiative is premised on 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 hea between the new systems that each department is currently  developing and beginning to implement—DOD’s AHLTA and VA’s HealtheVet VistA.
DOD began developing AHLTA in 1997. component for the planned electronic interface—its Clinical Data  Repository, and it expects to complete deployment of all of its major  system capabilities by 2011. (When we reported in June 2004, this  deployment was expected in September 2008.) DOD expects to  spend about $783 million for the system through fiscal year 2006.
At that time it was known as CHCS II. In November 2005, DOD renamed CHCS II the  Armed Forces Health Longitudinal Technology Application (AHLTA). million on initiatives that comprise HealtheVet VistA through fiscal  year 2005.
Under the HealthePeople (Federal) initiative, VA and DOD envision  that, on entering military service, a health record for the service  member would be created and stored in DOD’s Clinical Data  Repository. The record would be updated as the service member  receives medical care. When the individual separated from activeduty and, if eligible, sought medical care at a VA facility, VA w then create a medical record for the individual, which would be  stored in its Health Data Repository. On viewing the medical recor the VA clinician would be alerted and provided with access to the  individual’s clinical information residing in DOD’s repository. In  same manner, when a veteran sought medical care at a military  treatment facility, the attending DOD clinician would be alerted an provided with access to the health information in VA’s repository.  According to the departments, this planned approach would mak e  virtual medical records displaying all available patient health  information from the two repositories accessible to both  departments’ clinicians.
December 2004 VA and DOD Joint Strategic Plan.
Developing the two repositories, populating them with data, a linking them through the CHDR interface would be important steps  toward the two departments’ long-term goals as envisioned in  HealthePeople (Federal). Achieving these goals would then depend  on completing the development and deployment of the associated  health information systems—HealtheVet VistA and AHLTA.
In a review of the CHDR program in June 2004, we reported that  the efforts of DOD and VA in this area demonstrated a number of  management weaknesses. Among these were the lack of a well- defined architecture for describing the interface for a common  health information exchange; an established project management  lead entity and structure to guide the investment in the interface a its implementation; and a project management plan defining thetechnical and managerial processes necessary to satisfy project  requirements. With these critical components missing, VA and DOD increased the risk that they would not achieve their goals.  Accordingly, we recommended that the departments   develop an architecture for the electronic interface between their  health systems that includes system requirements, design  specifications, and software descriptions;  ● select a lead entity with final decision-making authority for the  establish a project management structure to provide day-to guidance of and accountability for their inv estments in and  implementation of the interface capability; and  create and management plan for the electronic interface that defines the  technical and managerial processes necessary to satisfy project  requirements and includes (1) the authority and responsibility of  each organizational unit; (2) a work breakdown structure for all o the tasks to be performed in developing, testing, and implemen the software, along with schedules associated with the tasks; and  (3) a security policy.   implement a comprehensive and coordinated project  f  ting  In September 2005, we testified that VA and DOD had made  progress in the electronic sharing of patient health data in their  near-term demonstration projects. We noted that with regard to  their long-term goals, the departments had improved the  management of the CHDR program, but that this program continued  to face significant challenges—in particular, developing a project  management plan of sufficient specificity to be an effective guide for  the program.
Besides pursuing their long-term goals for future systems through  the HealthePeople (Federal) strategy, the departments are working  on two demonstration projects that focus on exchanging  information between existing systems: (1) Bidirectional Health  Information Exchange, a project to exchange health information on  shared patients, and (2) Laboratory Data Sharing Interface, an  application used to transfer laboratory work orders and results.  These demonstration projects were planned in response to  provisions of the Bob Stump National Defense Authorization Act of  2003, which mandated that VA and DOD conduct demonstration  projects that included medical information and information  technology systems to be used as a test for evaluating the feasibi advantages, and disadvantages of measures and programs designed  to improve the sharing and coordination of health care and health  care resources between the departments.
Figure 1 is a time line showing initiation points for the VA and DOD  efforts discussed here, including strategies, major programs, and the recent demonstration projects.
section_title: Work on VETSNET Dates to 1986
paragraphs: The VETSNET effort grew out of an initiative begun by the Veterans  Benefits Administration (VBA) in 1986 to replace its outdated  Benefits Delivery Network. The Benefits Delivery Network, parts of  which were developed in the 1960s, contains over 3 million veterans  benefits records, including compensation and pension, education,  and vocational rehabilitation and employment. Originally, the plan  was to modernize all of these systems and in so doing provide a rich  source for answering questions about veterans’ benefits and enable  faster processing of benefits. As envisioned in the 1980s, the  modernization would produce a faster, more flexible, higher  capacity system that would be both an information system and a  payment system. In 1996, after experiencing numerous false starts  and spending approximately $300 million on the overall  modernization of BDN, VBA revised its strategy and narrowed its  focus to modernizing the compensation and pension payment  system.
At that time, we undertook an assessment of the department’s  software development capability and determined that it was  immature. In our assessment, we specifically examined the  VETSNET effort and concluded that VBA could not reliably develop  and maintain high-quality software on any major project within  existing cost and schedule constraints. VBA showed significant  weaknesses in requirements management, software project  planning, and software subcontract management, with no  identifiable strengths. We also testified that (1) VBA did not follow  sound systems development practices on VETSNET, such as  validation and verification of systems requirements; (2) it employed  for the project a new systems development methodology and  software development language not previously used; and (3) it did  not develop the cost-benefit information necessary to track progress  or assess return on investment (for example, total software to be  developed and cost estimates). As a result, we concluded that  VBA’s modernization efforts had inherent risks.
Between 1996 and 2002 we reported several more times on  VETSNET, highlighting concerns in several areas. (See attachment 1  for a description of the conclusions and findings of our products on  this topic.) In these products, we made several recommendations  aimed at improving VA’s software development capabilities,  including that the department take steps to achieve greater maturity  in its software development processes and that it delay any major  investment in software development (beyond that needed to sustain  critical day-to-day operations) until it had done so. In addition, we  made recommendations aimed specifically at VETSNET  development, including that VBA assess and validate users’  requirements for the new system; complete testing of the system’s  functional business capability, as well as end-to-end testing to  ensure that payments are made accurately; and establish an  integrated project plan to guide its transition from the old to the  new system.
Although VBA took various actions in response to these  recommendations, we continued to identify the department’s weak  software development capability as a significant factor contributing  to VBA’s persistent problems in developing and implementing the  system—the same condition that we identified in 1996. We also  reported that VBA continued to work on VETSNET without an  integrated project plan. As a result, the development of VETSNET  continued to suffer from problems in several areas, including  project management, requirements development, and testing.
section_title: VA and DOD Are Working to Share Medical Information
paragraphs: VA and DOD have made progress in sharing patient health data by  implementing applications developed under two demonstration  projects that focus on the exchange of electronic medical  information. The first—the Bidirectional Health Information  Exchange—has been implemented at 16 VA/DOD locations, and the  second—Laboratory Data Sharing Interface—has been implemented  at 6 VA/DOD locations.
Bidirectional Health Information Exchange. According to a  VA/DOD annual report and program officials, Bidirectional Health  Information Exchange (BHIE) is an interim step in the departments’  overall strategy to create a two-way exchange of electronic medical  records. BHIE builds on the architecture and framework of FHIE,  the application used to transfer health data on separated service  members from DOD to VA. As discussed earlier, FHIE provides an  interface between VA’s and DOD’s existing health information  systems that allows one-way transfers only, which do not occur in  real time: VA clinicians do not have access to transferred  information until about 6 weeks after separation. In contrast, BHIE  focuses on the two-way, near-real-time exchange of information  (text only) on shared patients (such as those at sites jointly  occupied by VA and DOD facilities). This application exchanges  data between VA’s VistA system and DOD’s CHCS system (and  AHLTA where implemented). As of September 2005, the  departments reported having spent $2.6 million on BHIE.
The primary benefit of BHIE is near-real-time access to patient  medical information for both VA and DOD, which is not available  through FHIE. During a site visit to a VA and DOD location in Puget  Sound in 2005, we viewed a demonstration of this capability and  were told by a VA clinician that the near-real-time access to medical  information was very beneficial in treating shared patients.
As of June 2006, BHIE was deployed at VA and DOD facilities at 16  sites, where the exchange of demographic, outpatient pharmacy,  radiology, laboratory, and allergy data (text only) has been  achieved. In addition, according to officials, over 120 outpatient  military clinics associated with these sites also have access to this  information through BHIE. According to VA and DOD, BHIE will be  implemented at two more sites in July 2006. Table 1 presents a  schedule for implementation of BHIE; the sites listed are all DOD  sites with nearby VA facilities.
Additionally, because DOD stores electronic medical information in  systems other than CHCS (such as the Clinical Information System  and the Integrated Clinical Database), work is currently under way  to allow BHIE to have the ability to exchange information with  those systems. Currently, one site is testing the use of BHIE as an  interface allowing both departments’ staff to view discharge  summaries stored in the Clinical Information System. DOD and VA  plan to perform a side-by-side comparison to ensure that this  capability maintains data quality. When they are satisfied, the  capability will be provided to those DOD locations that currently  use the Clinical Information System and have BHIE implemented.  Doing so will permit all VA sites access to the information in the  Clinical Information System on shared patients at DOD sites running  BHIE.
In addition, at the VA/DOD site in El Paso, a prototype is being  designed for exchanging radiological images using the BHIE/FHIE  infrastructure. If the prototype is successful, this capability will be  extended to the rest of the sites.
Laboratory Data Sharing Interface. The Laboratory Data Sharing  Interface (LDSI) initiative enables the two departments to share  laboratory resources. Through LDSI, a VA provider can use VA’s  health information system to write an order for laboratory tests, and  that order is electronically transferred to DOD, which performs the  test. The results of the laboratory tests are electronically transferred  back to VA and included in the patient’s medical record. Similarly, a  DOD provider can choose to use a VA lab for testing and receive the  results electronically. Once LDSI is fully implemented at a facility,  the only nonautomated action in performing laboratory tests is the  transport of the specimens.
Among the benefits of LDSI are increased speed in receiving  laboratory results and decreased errors from manual entry of  orders. However, according to the LDSI project manager in San  Antonio, a primary benefit of the project will be the time saved by  eliminating the need to rekey orders at processing labs to input the  information into the laboratories’ systems. Additionally, the San  Antonio VA facility will no longer have to contract out some of its  laboratory work to private companies, but instead use the DOD  laboratory. As of September 2005, the departments reported having  spent about $3.3 million on LDSI.
An early version of what is now LDSI was originally tested and  implemented at a joint VA and DOD medical facility in Hawaii in  May 2003. The demonstration project built on this application and  enhanced it; the resulting application was tested in San Antonio and  El Paso. It has now been deployed to six sites. According to the  departments, a plan to export LDSI to two additional locations has  been approved. Table 2 shows the locations at which it has been or  is to be implemented.
subsections: section_title: VA and DOD Are Taking Action to Achieve a Virtual Medical Record, but Much Work Remains
paragraphs: Besides the near-term initiatives just discussed, VA and DOD  continue their efforts on the longer term goal: to achieve a virtual  medical record based on the two-way exchange of computable data  between the health information systems that each is currently  developing. The cornerstone for this exchange is CHDR, the planned  electronic interface between the data repositories for the new  systems.
The departments have taken important actions on the CHDR  initiative. As we testified in September 2005, they successfully  completed Phase I of CHDR in September 2004 by demonstrating  the two-way exchange of pharmacy information with a prototype in  a controlled laboratory environment. According to department  officials, the pharmacy prototype provided invaluable insight into  each other’s data repository systems, architecture, and the work  that is necessary to support the exchange of computable  information. These officials stated that lessons learned from the  development of the prototype were documented and being applied  to Phase II of CHDR, the production phase, which is to implement  the two-way exchange of patient health records between the  departments’ data repositories. Further, the same DOD and VA  teams that developed the prototype were developing the production  version.
In addition, the departments developed an architecture for the  CHDR electronic interface, as we recommended in June 2004. The  architecture for CHDR includes major elements required in a  complete architecture. For example, it defines system requirements  and allows these to be traced to the functional requirements, it  includes the design and control specifications for the interface  design, and it includes design descriptions for the software.
Also in response to our recommendations, the departments  established project accountability and implemented a joint project  management structure. Specifically, the Health Executive Council  was established as the lead entity for the project. The joint project  management structure consists of a Program Manager from VA and  a Deputy Program Manager from DOD to provide day-to-day  guidance for this initiative. Additionally, the Health Executive  Council established the DOD/VA Information  Management/Information Technology Working Group and the  DOD/VA Health Architecture Interagency Group, to provide  programmatic oversight and to facilitate interagency collaboration  on sharing initiatives between DOD and VA.
To build on these actions and successfully carry out the CHDR  initiative, however, the departments still have a number of  challenges to overcome. The success of CHDR will depend on the  departments’ instituting a highly disciplined approach to the  project’s management. 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.
Accordingly, in 2004 we recommended that the departments develop  a clearly defined project management plan that describes the  technical and managerial processes necessary to satisfy project  requirements and includes (1) the authority and responsibility of  each organizational unit; (2) a work breakdown structure for all of  the tasks to be performed in developing, testing, and implementing  the software, along with schedules associated with the tasks; and  (3) a security policy. As of September 2005, the departments had an  interagency project management plan that provided the program  management principles and procedures to be followed by the  project. However, this plan did not specify the authority and  responsibility of organizational units for particular tasks; the work  breakdown structure was at a high level and lacked detail on  specific tasks and time frames; and security policy was still being  drafted. No more recent plan has yet been provided. Without a plan  of sufficient detail, VA and DOD increase the risk that the CHDR  project will not deliver the planned capabilities in the time and at  the cost expected.
In addition, officials did not meet a previously established  milestone: by October 2005, the departments had planned to be able  to exchange outpatient pharmacy data, laboratory results, allergy  information, and patient demographic information on a limited  basis. However, according to officials, the work required to  implement standards for pharmacy and medication allergy data was  more complex than originally anticipated and would result in a  delay. The new target date for the limited exchange of medication  allergy, outpatient pharmacy, and patient demographic data has  been postponed from February to June 2006.
Currently, the departments report that they are close to finishing the  development of a pilot to perform this data exchange at their joint  facility in El Paso. They expect to be able to begin the pilot by the  end of this month, which will allow them to share outpatient  pharmacy and medication allergy information that can support drug- drug interaction checking and drug-allergy alerts. If the pilot is  successful, it will enable for the first time the exchange of  computable information between the departments’ two data  repositories.
Finally, the health information currently in the data repositories has  various limitations.  ●  Although DOD’s Clinical Data Repository includes data in the  categories that were to be exchanged at the missed milestone  described above (outpatient pharmacy data, laboratory results,  allergy information, and patient demographic information), these  data are not yet complete. First, the information in the Clinical Data  Repository is limited to those locations that have implemented the  first increment of AHLTA, DOD’s new health information system. As  of June 15, 2006, according to DOD officials, 115 of 138 medical  treatment facilities worldwide have implemented this increment,  and officials expect that the remaining facilities will receive the  increment by the end of this year. Second, at present, health  information in systems other than CHCS (such as the Clinical  Information System and the Integrated Clinical Database) is not yet  being captured in the Clinical Data Repository. However, work is  currently under way to allow BHIE to have the ability to exchange  information with those systems.  ●  The information in VA’s Health Data Repository is also limited:  although all VA medical records are currently electronic, VA has to  convert these into the interoperable format appropriate for the  Health Data Repository. So far, the data in the Health Data  Repository consist of patient demographics, vital signs records,  allergy data, and outpatient pharmacy data for the 6 million veterans  who have electronic medical records in VA’s current system, VistA  (this system contains all the department’s medical records in  electronic form). VA officials told us that they are currently  converting lab results data.
section_title: VA Has Been Severely Challenged by VETSNET Project
paragraphs: Since its inception, the VETSNET program has been plagued by  problems. In 2002, we offered a number of recommendations  regarding the ongoing compensation and pension (C&P)  replacement program. We testified that VBA should assess and  validate users’ requirements for the new system and complete  testing of the system’s functional business capability, including end- to-end testing. We also recommended that VA appoint a project  manager, thoroughly analyze its current initiative, and develop a  number of plans, including a revised C&P replacement strategy and  an integrated project plan. We also noted that VBA had much work  to do before it could fully implement the VETSNET C&P system by  its target date (at that time) of 2005, and thus it would have to  ensure that the aging Benefits Delivery Network (BDN) would be  available to continue accurately processing benefits payments until  a new system could be deployed. Accordingly, we recommended  that VBA develop action plans to move from the current to the  replacement system and to ensure the availability of BDN to provide  the more than 3.5 million payments made to veterans each month.
VA concurred with our recommendations and took several actions  to address them. For example, it appointed a full-time project  manager. Also, the project team reported that to ensure that  business needs were met, certification had been completed of users’  requirements for the system’s applications.
In addition, VA reported that a revised strategy for the replacement  system was completed. This revised strategy included the business  case, described the methodology used to identify system  development alternatives, displayed the cost/benefit analysis results  of the viable alternatives that could be used to develop the system,  and provided a description of the recommended development plan.  Based on this strategy, the Secretary of Veterans Affairs, Assistant  Secretary for Information and Technology, the Under Secretary for  Benefits, and the Deputy Chief Information Officer for Benefits  approved continuation of the VETSNET development in September  2002.
Further, to ensure that the benefits delivery network would be able  to continue accurately processing benefits payment until the new  system was deployed, VBA purchased additional BDN hardware,  hired 11 new staff members to support BDN operations,  successfully tested a contingency plan in the event of disruption of  the system, and provided retention bonuses to staff familiar with  BDN operations.
However, VBA did not develop an integrated project plan for  VETSNET, which is a basic requirement of sound project  management. In addition, it did not develop an action plan for  transitioning from the current to the replacement system. Thus,  although the actions taken addressed some of our specific concerns,  they were not sufficient to establish the program on a sound footing.
In 2005, the VA CIO became concerned by continuing problems with  VETSNET: the project continued to postpone target dates, and costs  continued to increase (VA indicated that by 2005 these costs  exceeded $69 million). Accordingly, he arranged to contract for an  independent assessment of the department’s options for the  VETSNET project, including an evaluation of whether the program  should be terminated. This assessment, conducted by the Carnegie  Mellon Software Engineering Institute (SEI), concluded that the  program faced many risks arising from management, organizational,  and program issues, but no technical barriers that could not be  overcome. According to SEI, terminating the program would not  solve the underlying management and organizational problems,  which would continue to hamper any new or revised effort.
SEI recommended that the department not terminate the program  but take an aggressive approach to dealing with the issues SEI  described while continuing to work on the program at a reduced  pace. According to SEI, this approach would allow VA to make  necessary improvements to its system and software engineering and  program management capabilities while making gradual progress on  the system. SEI also discussed specific concerns about the system’s  management and the organization’s capabilities, presenting areas  that required focus regardless of the particular course that VA chose  for the system. For example:  ●  Setting realistic deadlines. SEI commented that there was no  credible evidence that VETSNET would be complete by the target  date, which at the time of the SEI review was December 2006.  Because this deadline was unrealistic, VBA needed to plan and  budget for supporting BDN so that its ability to pay veterans  benefits would not be disrupted.   ●  Establishing an effective requirements process.  ●  Implementing effective program measurements in order to assess  progress.   ●  Establishing sound program management. According to SEI,  different organizational components had independent schedules and  priorities, which caused confusion and deprived the department of a  program perspective.
These observations are consistent with our long-standing concerns  regarding fundamental deficiencies in VBA’s management of the  project.
In the wake of the SEI assessment and recommendations, VA is in  the process of creating, with contract help, an integrated master  plan that is to cover the C&P replacement project. Because this plan  is in process, no cost or schedule milestones have yet been finalized.  According to VA, the integrated master plan is to be completed by  the end of August 2006.
VA officials told us that they intend to complete this plan before  beginning to plan for modernizing the systems for paying education  benefits or for paying vocational rehabilitation and employment  benefits. Plans for making the transition to VETSNET and ending  VBA’s dependence on BDN are also on hold.
Thus, VA still lacks an integrated project plan or a plan to move  from the current to the replacement system. Until it has an  integrated project plan and schedule incorporating all the critical  areas of the system development effort, VBA will lack the means of  determining what needs to be done and when, and of measuring  progress. Without plans to move from the current to the  replacement system, VBA will lack assurance that it can c pay beneficiaries accurately and on time through the transition  period.
In summary, developing an electronic interface that will enable VA  and DOD to exchange computable patient medical records is a  highly complex undertaking that could lead to substantial benef its— improving the quality of health care and disability claims processing  for the nation’s service members and veterans. VA and DOD have  made progress in the electronic sharing of patient health data in  their limited, near-term demonstration projects, and have taken a important step toward their long-term goals by improving the  management of the CHDR program. However, the departments considerable work and significant challenges before they can  achieve these long-term goals. While the departments have ma progress in developing a project management plan, it is not yet  complete. Having a project management plan of sufficient speci to guide the program—including establishing accountability and  addressing security—would help the departments avoid further  delays in their schedule and ensure that they produce a capabilit that meets their expectations.
VA has also been working to modernize the delivery of benefits  through its development of VETSNET, but the pace of progress has  been discouraging. Much work remains in accomplishing the  original comprehensive goal of modernizing the aging system that  VBA currently depends on to pay veterans benefits. Until VBA  develops an integrated project plan that addresses the long-stan management weaknesses that we and others have identified, it will  be uncertain when and at what cost VETSNET will be delivered.
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. Other individuals making key contributions  to this testimony include Barbara S. Collier, Martin Katz, Barbara S.  Oliver, Eric L. Trout, Robert Williams Jr., and Charles Youman.
section_title: Attachment 1. Past GAO Products Highlighting VETSNET Concerns
paragraphs: We previously performed several reviews addressing VETSNET and  made numerous recommendations aimed at strengthening the  program and VA’s software development and management  capabilities. The table summarizes the results of these reviews.
GAO Products Highlighting Concerns with VETSNET Project to Replace Compensation and Pension (C&P) Payment System  VETSNET had inherent risks in that (1) it did not follow sound systems development practices, such as  validation and verification of systems requirements; (2) it employed a new systems development  methodology and software development language not previously used; and (3) VBA did not develop the  cost-benefit information necessary to track progress or assess return on investment (for example, total  software to be developed and cost estimates).
VBA’s software development capability was immature and it could not reliably develop and maintain high- quality software on any major project within existing cost and schedule constraints, placing its software  development projects at significant risk. VBA showed significant weaknesses in requirements management,  software project planning, and software subcontract management, with no identifiable strengths.
VETSNET experienced schedule delays and missed deadlines because (1) it employed a new software  development language not previously used by the development team, one that was inconsistent with the  agency’s other systems development efforts; (2) the department’s software development capability was  immature and it had lost critical systems control and quality assurance personnel, and (3) VBA lacked a  complete systems architecture; for example, neither a security architecture nor performance characteristics  had been defined for the project.
VBA’s software development capability remained ad hoc and chaotic, subjecting the agency to continuing  risk of cost overruns, poor quality software, and schedule delays in software development.   $11 million had reportedly been spent on VETSNET C&P; neither the May 1998 completion date nor the  revised completion date of December 1998 were met. Contributing factors included lack of an integrated  architecture defining the business processes, information flows and relationships, business requirements,  and data descriptions, and VBA’s immature software development capability.
VBA’s software development capability remained ad hoc and chaotic. The VETSNET implementation  approach lacked key elements, including a strategy for data conversion and an integrated project plan and  schedule incorporating all critical systems development areas. Further, data exchange issues had not been  fully addressed.
The project’s viability was still a concern. It continued to lack an integrated project plan and schedule  addressing all critical systems development areas, to be used as a means of determining what needs to be  done and when. A pilot test of 10 original claims that did not require significant development work may not  have been sufficient to demonstrate that the product was capable of working as intended in an  organizationwide operational setting.
VBA still had fundamental tasks to accomplish before it could successfully complete development and  implementation. It still had to assess and validate users’ requirements for the new system to ensure that  business needs were met. It needed to complete testing of the system’s functional business capability, as  well as end-to-end testing to ensure that payments would be made accurately. Finally, it needed to establish  an integrated project plan to guide its transition from the old to the new system.
VA still needed to address long-standing concerns regarding development and implementation. VA needed  to appoint a project manager, undertake a complete analysis of the initiative, and develop plans, including a  revised C&P replacement system strategy and an integrated project plan. It also needed to develop and  implement action plans to move VBA from the current to the replacement system and to ensure that the  Benefits Delivery Network would be able to continue accurately processing benefits payments until the new  system was deployed.
Much work remained before VBA could fully implement the VETSNET C&P system, and complete  implementation was not expected until 2005. This meant that VBA had to continue relying on its aging  Benefits Delivery Network to provide the more than 3.5 million payments that VA had to make to veterans  each month.  In late March, a VETSNET executive board and a project control board were established to provide decision  support and oversee implementation, and VBA expected to hire a full-time project manager by the end of  September. VBA also began revalidating functional business requirements for the new system, with  completion planned by January 2003, and it identified actions needed to transition VBA from the current to  the replacement system. VBA also hired a contractor and tasked the contractor with conducting functional,  integration, and linkage testing, as well as software quality assurance for each release of the system  applications.  Despite these actions, completing implementation of the new system could take several years. All but one of  the software applications for the new system still needed to be fully deployed or developed. Specifically, a  rating board automation tool (RBA 2000) was deployed, although VBA did not plan to require all its regional  offices to use it until July 2003. In addition, two others had not been completely deployed: one of these  (Share, used to establish a new claim) was in use by only 6 of the 57 regional offices. The other (Modern  Award Processing–Development, used to develop information on claims) was in pilot testing at two regional  offices—Salt Lake and Little Rock—but was not expected to be implemented at the other 55 regional offices  until October 2003. The remaining three software applications (Award Processing, Finance and Accounting  System, and Correspondence) were still in development.
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