Electronic Health Records: Clear Definition of the Interagency Program Office's Role in VA's New Modernization Effort Would Strengthen Accountability
Released: 2018-09-13T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: The National Defense Authorization Act for Fiscal Year 2008 included provisions that VA and DOD jointly develop and implement electronic health record systems or capabilities and accelerate the exchange of health care information. The act also required that these systems be compliant with applicable interoperability standards. Further, the act established a joint Interagency Program Office to act as a single point of accountability for the efforts, with the function of implementing, by September 30, 2009, electronic health record systems that allow for full interoperability.

This testimony discusses GAO's previously reported findings on the establishment and evolution of the Interagency Program Office over the last decade. In developing this testimony, GAO summarized findings from its reports issued in 2008 through 2018, and information on the departments' actions in response to GAO's recommendations.

section_title: What GAO Found
paragraphs: Since its establishment in 2008, the Department of Defense (DOD) and Department of Veterans Affairs (VA) Interagency Program Office has been involved in various approaches to increase health information interoperability. However, the office has not been effectively positioned to function as the single point of accountability for the departments' electronic health record system interoperability efforts. For example,

Between July 2008 and January 2010, GAO issued reports on VA's and DOD's efforts to set up the office, which highlighted steps the departments had taken, but also identified deficiencies, such as vacant leadership positions and a lack of necessary plans. GAO recommended that the departments improve management of their interoperability efforts by developing a project plan and results-oriented performance goals and measures.

In April 2009, the Interagency Program Office was assigned responsibility for establishing a lifetime electronic record for servicemembers and veterans, called the Virtual Lifetime Electronic Record. GAO reported in February 2011 that, among other things, the office had not developed and approved an integrated master schedule, a master program plan, or performance metrics for the initiative, as outlined in the office's charter. Accordingly, GAO recommended that the departments correct these deficiencies to strengthen their efforts to establish the Virtual Lifetime Electronic Record.

In March 2011, VA and DOD committed to jointly developing a new, common integrated electronic health record system and empowered the Interagency Program Office with increased authority, expanded responsibilities, and increased staffing levels for leading the integrated system effort. However, in February 2013, the departments abandoned their plan to develop the integrated system and stated that they would again pursue separate modernization efforts. In February 2014, GAO reported on this decision and recommended that VA and DOD take steps to better position the office to function as the single point of accountability for achieving interoperability between the departments' electronic health record systems.

VA and DOD stated that they agreed with the above GAO recommendations. However, in several cases the departments' subsequent actions were incomplete and did not fully address all recommendations.

In June 2017 VA announced that it planned to acquire the same electronic health record system that DOD has been acquiring. GAO testified in June 2018 that a governance structure had been proposed that would be expected to leverage existing joint governance facilitated by the Interagency Program Office. At that time, VA's program officials had stated that the department's governance plans for the new program were expected to be finalized in October 2018. However, the officials have not yet indicated what role, if any, the Interagency Program Office is to have in the governance process. Ensuring that the role and responsibilities of the office are clearly defined within these governance plans is essential to VA successfully acquiring and implementing the same system as DOD.

section_title: What GAO Recommends
paragraphs: GAO recommends that VA clearly define the role and responsibilities of the Interagency Program Office in the governance plans for acquisition of the department's new electronic health record syst

section_title: Letter
paragraphs: Thank you for the opportunity to participate in today’s hearing on the  Department of Defense (DOD) and Department of Veterans Affairs (VA)  Interagency Program Office and the office’s role regarding VA’s Electronic  Health Record Modernization (EHRM) program. As you know, these  departments operate two of the nation’s largest health care systems,  which provide coverage to millions of veterans and active duty service  members and their beneficiaries. The use of information technology (IT) is  crucial to helping the departments effectively serve the nation’s veterans  and, each year, the departments spend billions of dollars on information  systems and assets.

Both VA and DOD have long recognized the importance of advancing the  use of shared health information systems and capabilities to make patient  information more readily available to their health care providers, reduce  medical errors, and streamline administrative functions. Toward this end,  the two departments have an extensive history of working to achieve  shared health care resources. Over many years, however, the  departments have experienced challenges in managing a number of  critical initiatives related to modernizing major systems. Such initiatives  include modernizing VA’s electronic health information system—the  Veterans Health Information Systems and Technology Architecture  (VistA).

To expedite the departments’ efforts to exchange electronic health care  information, Congress included in the National Defense Authorization Act  for Fiscal Year 2008, provisions that required VA and DOD to jointly  develop and implement electronic health record systems or capabilities  and to accelerate the exchange of health care information. The act also  required that these systems or capabilities be compliant with applicable  interoperability standards, implementation specifications, and  certification criteria of the federal government.

Further, the act established a joint Interagency Program Office to act as a  single point of accountability for the electronic health care exchange  efforts. The office was given the function of implementing, by September  30, 2009, electronic health record systems or capabilities that would allow  for full interoperability of personal health care information between the  departments.

In addition, the act included a provision that GAO report on the progress  that VA and DOD have made in achieving the goal of fully interoperable  personal health care information. Our reports in response to this  requirement included information on the departments’ efforts to set up the  joint Interagency Program Office. We also subsequently produced  reports that have discussed the Interagency Program Office in relation to  VA’s efforts to develop a lifetime electronic health record capability for  servicemembers and veterans, develop a joint electronic record  capability with DOD, and promote increased electronic health record  system interoperability.

At your request, my testimony today summarizes findings from our prior  work that examined the establishment and evolution of the Interagency  Program Office over the last decade. The testimony also discusses the  roles this office has played in VA’s and DOD’s efforts to increase  interoperability and electronic health record capabilities, and any  challenges the office has faced in doing so.

In developing this testimony, we relied on our previous reports and  testimonies related to the Interagency Program Office, as well as VA’s  and DOD’s electronic health record system programs and modernization  efforts. We also incorporated information on the departments’ actions in  response to recommendations we made in our previous reports. In  addition, we discussed this testimony with the Executive Director of VA’s  EHRM office. The reports cited throughout this statement include detailed  information on the scope and methodology of our prior reviews.

We conducted the work on which this statement is based 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: 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 in making the most informed decisions on  treatment options, potentially putting the patient’s health at risk.

The use of technology to electronically collect, store, retrieve, and transfer  clinical, administrative, and financial health information has the potential  to improve the quality and efficiency of health care. Electronic health  records are particularly crucial for optimizing the health care provided to  military personnel and veterans. While in active military status and later  as veterans, many DOD and VA personnel, along with their family  members, tend to be highly mobile and may have health records residing  at multiple medical facilities within and outside the United States.

VA and DOD operate separate electronic health record systems that they  rely on to create and manage patient health information. In particular, VA  currently uses its integrated medical information system—VistA—which  was developed in-house by the department’s clinicians and IT personnel  and has been in operation since the early 1980s. Over the last several  decades, VistA has evolved into a technically complex system comprised  of about 170 modules that support health care delivery at 170 VA Medical  Centers and over 1,200 outpatient sites. In addition, customization of  VistA, such as changes to the modules by the various medical facilities,  has resulted in about 130 versions of the system—referred to as  instances.

For its part, DOD relies on its Armed Forces Health Longitudinal  Technology Application (AHLTA), which comprises multiple legacy  medical information systems that were developed from commercial  software products and customized for specific uses. For example, the  Composite Health Care System (CHCS), which was formerly DOD’s  primary health information system, is used to capture information related  to pharmacy, radiology, and laboratory order management. In addition,  the department uses Essentris (also called the Clinical Information  System), a commercial health information system customized to support  inpatient treatment at military medical facilities.

In July 2015, DOD awarded a contract for a new commercial electronic  health record system to be developed by the Cerner Corporation. Known  as MHS GENESIS, this system is intended to replace DOD’s existing  AHLTA system. The transition to MHS GENESIS began in February 2017  and implementation is expected to be complete throughout the  department in 2022.
subsections: section_title: Interoperability: An Overview
paragraphs: The sharing of health information among organizations is especially  important because the health care system is highly fragmented, with care  and services provided in multiple settings, such as physician offices and  hospitals, that may not be able to coordinate patient medical care  records. Thus, a means for sharing information among providers, such as  between DOD’s and VA’s health care systems, is by achieving  interoperability.

The Office of the National Coordinator for Health IT, within the  Department of Health and Human Services, has issued guidance,  describing interoperability as:  the ability of systems to exchange electronic health information and  the ability to use the electronic health information that has been  exchanged from other systems without special effort on the part of the  user.

Similarly, the National Defense Authorization Act for Fiscal Year 2014  defines interoperability, per its use in the provision governing VA’s and  DOD’s electronic health records, as “the ability of different electronic  health records systems or software to meaningfully exchange information  in real time and provide useful results to one or more systems.” Thus, in  these contexts, interoperability allows patients’ electronic health  information to be available from provider to provider, regardless of where  the information originated.

Achieving interoperability depends on, among other things, the use of  agreed-upon health data standards to ensure that information can be  shared and used. If electronic health records conform to interoperability  standards, they potentially 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 information  needed for optimal care. Information that is electronically exchanged from  one provider to another must adhere to the same standards in order to be  interpreted and used in electronic health records, thereby permitting  interoperability.

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. On a national level, the Office of the  National Coordinator has been assigned responsibility for identifying  health data standards and technical specifications for electronic health  record technology and overseeing the certification of this technology.

In addition to exchanging the information, systems must be able to use  the information that is exchanged. Thus, if used in a way that improves  providers’ and patients’ access to critical information, electronic health  record technology has the potential to improve the quality of care that  patients receive and to reduce health care costs. For example, with  interoperability, medical providers have the ability to query data from  other sources while managing chronically ill patients, regardless of  geography or the network on which the data reside.

section_title: VA and DOD Have a Long History of Efforts to Achieve Electronic Health Record Interoperability
paragraphs: Since 1998, DOD and VA have relied on a patchwork of initiatives  involving their health information systems to exchange information and  increase electronic health record interoperability. These have included  initiatives to share viewable data in existing (legacy) systems; link and  share computable data between the departments’ updated health data  repositories; develop a virtual lifetime electronic health record to enable  private sector interoperability; implement IT capabilities for the first joint  federal health care center; and jointly develop a single integrated system.  Table 1 provides a brief description of the history of these various  initiatives.

In addition to the initiatives mentioned in table 1, DOD and VA previously  responded to provisions in the National Defense Authorization Act for  Fiscal Year 2008 directing the departments to jointly develop and  implement fully interoperable electronic health record systems or  capabilities in 2009. The act also called for the departments to set up  the Interagency Program Office to be a single point of accountability for  their efforts to implement these systems or capabilities by the September  30, 2009, deadline.

section_title: The Interagency Program Office Has Not Functioned as the Single Point of Accountability for VA and DOD’s Efforts to Increase Electronic Health Record Interoperability
paragraphs: The Interagency Program Office has been involved in the various  approaches taken by VA and DOD to increase health information  interoperability and modernize their respective electronic health record  systems. These approaches have included development of the Virtual  Lifetime Electronic Record (VLER) and a new, common integrated  electronic health record (iEHR) system. However, although the  Interagency Program Office has led efforts to identify data standards that  are critical to interoperability between systems, the office has not been  effectively positioned to be the single point of accountability as called for  in the National Defense Authorization Act for Fiscal Year 2008. Moreover,  the future role of the office with respect to VA’s current electronic health  record modernization program is uncertain.
subsections: section_title: The Interagency Program Office Became Operational, but Was Not Positioned to Be the Single Point of Accountability for Achieving Interoperability
paragraphs: Although VA and DOD took steps to set up the Interagency Program  Office, the office was not positioned to be the single point of  accountability for the departments’ efforts to achieve electronic health  record interoperability by September 30, 2009. When we first reported in  July 2008 on its establishment, VA and DOD’s efforts to set up the office  were still in their early stages. Leadership positions in the office were  not yet permanently filled, staffing was not complete, and facilities to  house the office had not been designated. Further, the implementation  plan for setting up the office was in draft and, although the plan included  schedules and milestones, the dates for several activities (such as  implementing a capability to share immunization records) had not yet  been determined, even though all capabilities were to be achieved by  September 2009.

We concluded that without a fully established program office and a  finalized implementation plan with set milestones, the departments could  be challenged in meeting the required date for achieving interoperability.  Accordingly, we recommended that the departments give priority to fully  establishing the office by putting in place permanent leadership and staff,  as well as finalizing the draft implementation plan. Both departments  agreed with this recommendation.

We later reported in January 2009 that VA and DOD had continued to  take steps to set up the Interagency Program Office. For example, the  departments had developed descriptions for key positions within the  office. In addition, the departments had developed a document that  depicted the Interagency Program Office’s organizational structure; they  also had approved a program office charter to describe, among other  things, the mission and functions of the office.

However, we pointed out that VA and DOD had not yet fully executed  their plan to set up the office. For example, among other activities, they  had not filled key positions for the Director and Deputy Director, or for 22  of 30 other positions identified for the office.

Our report stressed that, in the continued absence of a fully established  Interagency Program Office, the departments would remain ineffectively  positioned to assure that interoperable electronic health records and  capabilities would be achieved by the required date. Thus, we  recommended that the departments develop results-oriented performance  goals and measures to be used as the basis for reporting interoperability  progress. VA and DOD agreed with our recommendation.

Nevertheless, in a subsequent July 2009 report, we noted that the  Interagency Program Office was not effectively positioned to function as a  single point of accountability for the implementation of fully interoperable  electronic health record systems or capabilities between VA and DOD.  While the departments had made progress in setting up the office by  hiring additional staff, they continued to fill key leadership positions on an  interim basis. Further, while the office had begun to demonstrate  responsibilities outlined in its charter, it was not yet fulfilling key IT  management responsibilities in the areas of performance measurement (as we previously recommended), project planning, and scheduling,  which were essential to establishing the office as a single point of  accountability for the departments’ interoperability efforts. Thus, we  recommended that the departments improve the management of their  interoperability efforts by developing a project plan and a complete and  detailed integrated master schedule. VA and DOD stated that they agreed  with this recommendation.

In our January 2010 final report in response to the National Defense  Authorization Act for Fiscal Year 2008, we noted that VA and DOD  officials believed they had satisfied the act’s September 30, 2009,  requirement for full interoperability by meeting specific interoperability- related objectives that the departments had established. These  objectives included: refine social history data, share physical exam data,  and demonstrate initial document scanning between the departments.

Additionally, the departments had made progress in setting up their  Interagency Program Office by hiring additional staff, including a  permanent director. In addition, consistent with our recommendations in  the three previously mentioned reports, the office had begun to  demonstrate responsibilities outlined in its charter in the areas of  scheduling, planning, and performance measurement.

Nevertheless, the office’s efforts in these areas did not fully satisfy the  recommendations and were incomplete. Specifically, the office did not  have a schedule that included information about tasks, resource needs,  or relationships between tasks associated with ongoing activities to  increase interoperability. Also, key IT management responsibilities in the  areas of planning and performance measurement remained incomplete.  We reiterated that, by not having fulfilled key management  responsibilities, as we had previously recommended, the Interagency  Program Office continued to not be positioned to function as a single  point of accountability for the delivery of the future interoperable  capabilities that the departments were planning.

section_title: The Interagency Program Office Was to Be the Single Point of Accountability for Establishing a Lifetime Electronic Record for Servicemembers and Veterans, but VA and DOD Did Not Develop Complete Plans for the Effort
paragraphs: Although the Interagency Program Office charter named the office as the  single point of accountability for the initiative, the office did not have key  plans to define and guide the effort. In April 2009, the President  announced that VA and DOD would work together to define and build  VLER to streamline the transition of electronic medical, benefits, and  administrative information between the two departments. VLER was  intended to enable access to all electronic records for service members  as they transition from military to veteran status, and throughout their  lives. Further, the initiative was to expand the departments’ health  information sharing capabilities by enabling access to private sector  health data.

Shortly after the April 2009 announcement, VA, DOD, and the  Interagency Program Office began working to define and plan for the  VLER initiative. Further, the office was rechartered in September 2009  and named as the single point of accountability for the coordination and  oversight of jointly approved IT projects, data, and information sharing  activities, including VLER.

In our February 2011 report on the departments’ efforts to address their  common health IT needs, we noted that, among other things, the  Interagency Program Office had not developed an approved integrated  master schedule, master program plan, or performance metrics for the  VLER initiative, as outlined in the office’s charter. We noted that if the  departments did not address these issues, their ability to effectively  deliver capabilities to support their joint health IT needs would be  uncertain. Thus, we recommended that the Secretaries of VA and DOD  strengthen their efforts to establish VLER by developing plans that would  include scope definition, cost and schedule estimation, and project plan  documentation and approval. Although the departments stated they  agreed with this recommendation, they did not implement it.

section_title: The Interagency Program Office Was Responsible for the Development of a Joint Electronic Health Record System for VA and DOD, but the Office Was Not Positioned for Effective Collaboration
paragraphs: The Interagency Program Office was assigned responsibility for the  development of an electronic health record system that VA and DOD  were to share. However, the departments did not provide the office with  control over the resources (i.e., funds and staff) it needed to facilitate  effective collaboration.

In March 2011, the Secretaries of VA and DOD committed the two  departments to developing the iEHR system, and in May 2012 announced  their goal of implementing it across the departments by 2017. To oversee  this new effort, in October 2011, VA and DOD re-chartered the  Interagency Program Office to give it increased authority, expanded  responsibilities, and increased staffing levels for leading the integrated  system effort. The new charter also gave the office responsibility for  program planning and budgeting, acquisition and development, and  implementation of clinical capabilities. However, in February 2013, the  Secretaries of VA and DOD announced that they would not continue with  their joint development of a single electronic health record system.

In February 2014, we reported on the departments’ decision to abandon  their plans for iEHR. Specifically, we reported that VA and DOD had not  addressed management barriers to effective collaboration on their joint  health IT efforts. For example, the Interagency Program Office was  intended to better position the departments to collaborate, but the  departments had not implemented the office in a manner consistent with  effective collaboration. Specifically, the Interagency Program Office  lacked effective control over essential resources such as funding and  staffing. In addition, decisions by the departments had diffused  responsibility for achieving integrated health records, potentially  undermining the office’s intended role as the single point of accountability.

We concluded that providing the Interagency Program Office with control  over essential resources and clearer lines of authority would better  position it for effective collaboration. Further, we recommended that VA  and DOD better position the office to function as the single point of  accountability for achieving interoperability between the departments’  electronic health record systems by ensuring that the office has authority  (1) over dedicated resources (e.g., budget and staff), (2) to develop  interagency processes, and (3) to make decisions over the departments’  interoperability efforts. Although VA and DOD stated that they agreed with  this recommendation, they did not implement it.

section_title: The Interagency Program Office Subsequently Took Steps to Improve Interoperability Measurement and Additional Actions Are Planned
paragraphs: In light of the departments’ not having implemented a solution that  allowed for seamless electronic sharing of medical health care data, the  National Defense Authorization Act for Fiscal Year 2014 included  requirements pertaining to the implementation, design, and planning for  interoperability between VA and DOD’s separate electronic health record  systems. Among other things, the departments were each directed to (1)  ensure that all health care data contained in VA’s VistA and DOD’s  AHLTA systems complied with national standards and were computable  in real time by October 1, 2014, and (2) deploy modernized electronic  health record software to support clinicians while ensuring full standards- based interoperability by December 31, 2016.

In August 2015, we reported that VA and DOD, with guidance from the  Interagency Program Office, had taken actions to increase interoperability  between their electronic health record systems. Among other things, the  departments had initiated work focused on near-term objectives, including  standardizing their existing health data and making them viewable by  both departments’ clinicians in an integrated format. The departments  also developed longer-term plans to modernize their respective electronic  health record systems. For its part, the Interagency Program Office  issued guidance outlining the technical approach for achieving  interoperability between the departments’ systems.

However, even with the actions taken, VA and DOD did not certify by the  October 1, 2014, deadline established in the National Defense  Authorization Act for Fiscal Year 2014 for compliance with national data  standards that all health care data in their systems complied with national  standards and were computable in real time.

We also reported that the departments’ system modernization plans  identified a number of key activities to be implemented beyond December  31, 2016—the deadline established in the act for the two departments to  deploy modernized electronic health record software to support clinicians  while ensuring full standards-based interoperability. Specifically, DOD  had issued plans and announced the contract award for acquiring a  modernized system to include interoperability capabilities across military  operations. VA had issued plans describing an incremental approach to  modernizing its existing electronic health records system. These plans—if  implemented as described—indicated that deployment of the new  systems with interoperability capabilities would not be completed across  the departments until after 2018.

With regard to its role, the Interagency Program Office had taken steps to  develop process metrics intended to monitor progress related to the data  standardization and exchange of health information consistent with its  responsibilities. For example, it had issued guidance that calls for tracking  metrics, such as the percentage of data domains within the departments’  current health information systems that are mapped to national standards.

However, the office had not yet specified outcome-oriented metrics and  established related goals that are important to gauging the impact that  interoperability capabilities have on improving health care services for  shared patients. As a result, we recommended that VA and DOD, working  with the Interagency Program Office, take actions to establish a time  frame for identifying outcome-oriented metrics, define goals to provide a  basis for assessing and reporting on the status of interoperability-related  activities and the extent to which interoperability is being achieved by the  departments’ modernized electronic health record systems, and update  Interagency Program Office guidance to reflect the metrics and goals  identified.

Subsequently, we reported that VA and DOD had certified in April 2016  that all health care data in their systems complied with national standards  and were computable in real time.  However, VA acknowledged that it  did not expect to complete a number of key activities related to its  electronic health record system until sometime after the December 31,  2016, statutory deadline for deploying modernized electronic health  record software with interoperability.

Further, in following up on implementation of the recommendations in our  August 2015 report, we found that VA, DOD, and the Interagency  Program Office had addressed the recommendations in full by updating  guidance to include goals and objectives and an approach to developing  metrics that would improve the departments’ ability to report on the status  of interoperability activities.

section_title: The Interagency Program Office’s Role in Governing VA’s New Electronic Health Record System Acquisition Is Uncertain
paragraphs: In June 2017, the former VA Secretary announced a significant shift in the  department’s approach to modernizing the department’s electronic health  record system. Specifically, rather than continue to use VistA, the  Secretary stated that the department planned to acquire the same Cerner  electronic health record system that DOD has been acquiring.

Accordingly, the department awarded a contract to Cerner in May 2018  for a maximum of $10 billion over 10 years. Cerner is to replace VistA  with a commercial electronic health record system. This new system is to  support a broad range of health care functions that include, for example,  acute care, clinical decision support, dental care, and emergency  medicine. When implemented, the new system will be expected to  provide access to authoritative clinical data sources and become the  authoritative source of clinical data to support improved health, patient  safety, and quality of care provided by VA.

Deployment of the new electronic health record system at three initial  sites is planned for within 18 months of October 1, 2018, with a phased  implementation of the remaining sites over the next decade. Each VA  medical facility is expected to continue using VistA until the new system  has been deployed at that location.

As we testified in June 2018, VA has taken steps to establish a program  management office and has drafted a structure for technology, functional,  and joint governance of the electronic health record implementation.  Specifically, in January 2018, the former VA Secretary established the  Electronic Health Record Modernization (EHRM) program office that  reports directly to the VA Deputy Secretary.

Further, VA has drafted a memorandum that describes the role of  governance bodies within VA, as well as governance intended to facilitate  coordination between the department and DOD. According to EHRM  program documentation, VA is in the process of establishing a Functional  Governance Board, a Technical Governance Board, and a Governance  Integration Board comprised of program officials intended to provide  guidance and coordinate with DOD, as appropriate. Further, a joint  governance structure between VA and DOD has been proposed that  would be expected to leverage existing joint governance facilitated by the  Interagency Program Office.

Nevertheless, while VA’s plans for governance of the EHRM program  provide a framework for high-level oversight for program decisions  moving forward, EHRM officials have noted that the governance bodies  will not be finalized until October 2018. Accordingly, the officials have not  yet indicated what role, if any, the Interagency Program Office is to have  in the governance process.

section_title: Conclusions
paragraphs: The responsibilities of the Interagency Program Office have been  intended to support the numerous approaches taken by VA and DOD to  increase health information interoperability and modernize their  respective electronic health record systems. Yet, while the office has led  key efforts to identify data standards that are critical to interoperability  between systems, the office has not been effectively positioned to be the  single point of accountability originally described in the National Defense  Authorization Act for Fiscal Year 2008. Further, the future role of the  Interagency Program Office remains unclear despite the continuing need  for VA and DOD to share the electronic health records of servicemembers  and veterans. In particular, what role, if any, that the office is to have in  VA’s acquisition of the same electronic health record system that DOD is  currently acquiring is uncertain.

section_title: Recommendation for Executive Action
paragraphs: We are making the following recommendation to VA:  The Secretary of Veterans Affairs should ensure that the role and  responsibilities of the Interagency Program Office are clearly defined  within the governance plans for acquisition of the department’s new  electronic health record system. (Recommendation 1)

Chairman Banks, Ranking Member Lamb, and Members of the  Subcommittee, this completes my prepared statement. I would be  pleased to respond to any questions that you may have at this time.

section_title: GAO Contact and Staff Acknowledgments
paragraphs: If you or your staffs have any questions about this testimony, please  contact Carol C. Harris, Director, Information Technology Management  Issues, at (202) 512-4456 or harrisc@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this testimony statement. GAO staff who made key  contributions to this testimony are Mark Bird (Assistant Director), Jennifer  Stavros-Turner (Analyst in Charge), Rebecca Eyler, Jacqueline Mai, Scott  Pettis, and Charles Youman.

This is a work of the U.S. government and is not subject to copyright protection in the  United States. The published product may be reproduced and distributed in its entirety  without further permission from GAO. However, because this work may contain  copyrighted images or other material, permission from the copyright holder may be  necessary if you wish to reproduce this material separately.


Question-summary annotations: questions: question: What was the Interagency Program Office assigned responsibility for in 2009?
answer: In April 2009, the Interagency Program Office was assigned responsibility for establishing a lifetime electronic record for servicemembers and veterans, called the Virtual Lifetime Electronic Record.

question: What did GAO report in 2011?
answer: GAO reported in February 2011 that, among other things, the office had not developed and approved an integrated master schedule, a master program plan, or performance metrics for the initiative, as outlined in the office's charter.
child_questions: question: What did GAO recommend to amend these deficiencies?
answer: Accordingly, GAO recommended that the departments correct these deficiencies to strengthen their efforts to establish the Virtual Lifetime Electronic Record.

questions: question: What did VA and DOD commit to in 2011?
answer: In March 2011, VA and DOD committed to jointly developing a new, common integrated electronic health record system and empowered the Interagency Program Office with increased authority, expanded responsibilities, and increased staffing levels for leading the integrated system effort.
child_questions: question: How did this commitment change in 2013?
answer: However, in February 2013, the departments abandoned their plan to develop the integrated system and stated that they would again pursue separate modernization efforts.

question: What did GAO recommend in 2014?
answer: In February 2014, GAO reported on this decision and recommended that VA and DOD take steps to better position the office to function as the single point of accountability for achieving interoperability between the departments' electronic health record systems.

questions: question: What did VA announce in June 2017?
answer: In June 2017 VA announced that it planned to acquire the same electronic health record system that DOD has been acquiring.

question: What did GAO testify to in June 2018?
answer: GAO testified in June 2018 that a governance structure had been proposed that would be expected to leverage existing joint governance facilitated by the Interagency Program Office.
child_questions: question: What had VA's officials stated at the time?
answer: At that time, VA's program officials had stated that the department's governance plans for the new program were expected to be finalized in October 2018.
child_questions: question: What had the VA officials failed to indicate?
answer: However, the officials have not yet indicated what role, if any, the Interagency Program Office is to have in the governance process.

question: What is essential to VA acquiring and implementing the same system as DOD?
answer: Ensuring that the role and responsibilities of the office are clearly defined within these governance plans is essential to VA successfully acquiring and implementing the same system as DOD.

questions: question: What provisions did the National Defense Authorization Act for Fiscal Year 2008 include?
answer: The National Defense Authorization Act for Fiscal Year 2008 included provisions that VA and DOD jointly develop and implement electronic health record systems or capabilities and accelerate the exchange of health care information.
child_questions: question: With what did the National Defense Authorization Act require VA and DOD's systems comply?
answer: The act also required that these systems be compliant with applicable interoperability standards.

question: What did the act establish as a point of accountability?
answer: Further, the act established a joint Interagency Program Office to act as a single point of accountability for the efforts, with the function of implementing, by September 30, 2009, electronic health record systems that allow for full interoperability.