Veterans Affairs: Health Information System Modernization Far from Complete; Improved Project Planning and Oversight Needed
Released: 2008-07-30T00:00:00

Letter

Background

The current health information system used by VA clinicians is VistA. Since the inception of this system in 1983, VHA has made numerous enhancements to its functionality. A significant example was the release in 1996 of the Computerized Patient Record System, which enabled the department to provide an individual electronic medical record for each VA patient. By fiscal year 2007, the implementation of an imaging capability (VistA Imaging) at all the department’s facilities further enhanced the system by enabling multimedia data, such as radiology images, to be linked to a patient’s electronic medical record. These collective enhancements to VistA resulted in a comprehensive, integrated, electronic medical record for each patient that is viewable by all of the department’s clinicians at all of its health care facilities, thus eliminating the need for paper medical records.

According to VHA officials, VistA was developed based on close collaboration between staff in the medical facilities and VHA’s IT personnel, with the intention of providing a system that met the clinicians’ needs. In this regard, clinicians and IT personnel in the various medical facilities collaborated to define the system’s requirements and, in certain cases, carry out its development and implementation. For example, development of VistA Imaging resulted from a clinician building a prototype at home before it was fielded at a medical facility. Although system enhancements to VistA were disseminated through a central office, staff at a medical center could develop and implement applications at the local level to facilitate the potentially different functions at each location.

According to the department, as a result of VHA’s decentralized development approach, VistA now consists of 104 separate computer applications. These include 56 health provider applications; 19 management and financial applications; 13 crosscutting applications such as patient data exchange; 8 registration, enrollment, and eligibility applications; 5 health data applications; and 3 information and education applications (app. III contains a complete list of these applications).

Besides being numerous, these applications have been customized at all 128 VA sites. According to VA, this customization increases the cost of maintaining the system, as it requires that maintenance also be customized. VA has reported expending significant resources (approximately $2.5 billion) to maintain the system between 2001 and 2007.

Further, according to the department, limitations in the system need to be addressed for the system to remain effective. As mentioned, some VistA applications are more than 20 years old, and VistA does not standardize data, which is a prerequisite to making data computable. In addition, according to VA, VistA stores data in an organizational format based on the location where care is provided, rather than maintaining a global record for each individual patient, and it is programmed in a language for which there is a continually decreasing supply of qualified software developers.

Accordingly, in 2001, VHA undertook the HealtheVet initiative in order to standardize its health care system and eliminate the approximately 128 different systems used by its field locations. As we reported in 2003, it planned to develop or enhance specific areas of system functionality through six projects, which were to be completed between 2006 and 2012 (shown in table 1). These six projects did not represent all the functionality provided by the 104 VistA applications; rather, they were high-priority projects that were under way at the time.

In 2004, VA contracted with the Software Engineering Institute (SEI) for a technical review of the HealtheVet program. As a result of this review, SEI concluded, among other things, that VA needed to improve and integrate the governance of the HealtheVet program, develop an organizational structure for the program, define the program’s vision, and define the path for transition from VistA to HealtheVet.

In 2005, VA began to take action on the SEI recommendations. For example, the department began to develop a HealtheVet organizational structure, including defining the responsibilities of a project management office. In addition, it developed an initial draft for HealtheVet governance that defined decision-making processes, established guidelines for issue identification and escalation, defined areas of control and levels of authority, and established accountability. However, the effort to develop a governance plan and structure was superseded by a major realignment of the department’s overall IT management structure.

This realignment, initiated in October 2005, was undertaken with the goal of providing greater authority and accountability over VA resources by centralizing IT management under the department’s CIO; an additional goal was to standardize operations and systems development across the department using new management processes based on industry best practices. Under the department’s realigned structure, the Assistant Secretary for Information and Technology serves as VA’s CIO. The CIO is assisted by one Principal Deputy Assistant Secretary and five Deputy CIOs. In particular, the Deputy CIO for Enterprise Development serves as the chief advisor to the CIO for all enterprise applications development activities, including HealtheVet; this official heads the Office for Enterprise Development, which is responsible for performing enterprise applications development.

Before the realignment, funding and approval of IT was controlled by each medical center director, this enabled local IT personnel to make changes to VistA applications that were specific to the local medical facility. As a result of the realignment, the funding for all IT development projects, including both VistA and HealtheVet projects, was moved under the control of the department’s CIO. The business owners (that is, VHA for VistA and HealtheVet) retain responsibility for development and prioritization of requirements and program oversight, while staff in the Office of Enterprise Development are responsible for planning and execution of information technology development projects.

HealtheVet Projects Are Under Way, but Time Frames Have Slipped

As of June 2008, the HealtheVet program has eight major software development projects under way. One of these is to continue development and population of an operational database that currently contains health data. Five are applications development projects, of which four are health care applications currently in development and one is a financial application in the planning stage. The remaining two projects are to enhance current VistA systems, prepare them for transition to HealtheVet, and develop new applications. However, since 2003, the time frames for completing the projects and the HealtheVet system as a whole have been extended from 2012 to 2018. Department officials acknowledge that VA has experienced significant delays in developing and implementing HealtheVet and attribute the delays to various factors, and stated that they are working to address the delays by using an incremental development life-cycle approach and establishing more realistic time frames, among other things.

Of the eight projects in progress, one is currently operational though not yet completed. The Health Data Repository (HDR) database, which became operational in 2006, currently contains standardized health data in three areas: vital signs, allergies, and outpatient pharmacy. These data were addressed first because they were given high priority by clinicians. As we have previously reported, the department is currently using HDR to help achieve interoperability with DOD to support the exchange of computable electronic patient information. The HDR project is currently standardizing and converting laboratory data so that they can be added to the repository next, with further types of health data (for example, inpatient pharmacy, dental, and ophthalmology) to be added as the development of the HealtheVet system continues.

Four projects are developing health care information applications: The Scheduling application is planned for initial deployment at one site (a VA medical center in Muskogee, Oklahoma) in September 2008 (full deployment to all medical facilities is planned for 2011).

For the Pharmacy project, final testing of one function (order checking) is scheduled to begin in September 2008, and new drug file and pharmacy data management systems are scheduled to be implemented in January 2009. Remaining system functions to be developed include inventory, order entry and clinical monitoring, medication dispensing, and medication administration. Further development of the Pharmacy application depends on the results of an ongoing analysis and evaluation of the costs of building and deploying these functions. This analysis, for which a contract was issued in February 2008, is due July 2008.

The new Laboratory system is scheduled for independent verification and validation in October 2008. National deployment is planned to begin in 2010, with a phased implementation across the department expected to take place over the next 5 years.

The initial implementation of the Enrollment application is scheduled for August 2008. This project is to provide an enrollment workflow for use at VA’s Health Eligibility Center. An enhancement is scheduled for implementation by July 2009 for communicating to veterans and providing operational efficiencies for VA staff at the Health Eligibility Center and medical centers to coordinate changes in veterans’ eligibility. Finally, in December 2011, the department expects to complete a modernized registration capability.

A fifth project (Billing) is for a new financial system, which is in the planning stage. The current Billing project is a second attempt to modernize the billing system. Under the first attempt, VA awarded a contract in July 2003 to implement a commercial product to provide an updated billing capability for the department (called at that time the Patient Financial Services System); however, after about $107 million was spent on this effort, the contract was terminated in September 2006 by mutual agreement between the department and the contractor. The department expects to complete national deployment of the current project (called the Revenue Improvements and System Enhancement project) at the end of fiscal year 2015.

Finally, the program has two ongoing projects that are focused on activities to develop and implement required enhancements to existing VistA applications and lay the foundation for transitioning these applications to HealtheVet: The focus of the VistA application development project in the near term is to develop the critical enhancements and fixes to the VistA system that are necessary to ensure compliance with changes to patient enrollment and billing requirements and accomplish other critical data updates. In fiscal year 2010, the emphasis for this initiative will shift from fixes and enhancements to new development work aimed at the transition to HealtheVet. The initiative will then encompass building many of the replacement systems within HealtheVet.

The VistA foundations modernization project includes work on architecture and testing services, including a comprehensive testing suite and strategy for all VistA and HealtheVet applications. In fiscal year 2009, several common services—the deployment toolkit, business rules engine, and workflow engine—are expected to be delivered, along with new testing services capabilities and updates to the overall architecture. This work is expected to be ongoing until the completion of the HealtheVet initiative.

Table 2 summarizes the status of these projects.

From the inception of the initiative in 2001 through fiscal year 2007, VA reported spending almost $600 million for the development of these eight projects. The department estimates that it will incur additional development costs of approximately $535 million for the initiative during fiscal years 2008 and 2009, with the estimated total development cost of HealtheVet being $11 billion when completed in 2018. Table 3 shows the reported development costs through fiscal year 2007 and estimated development costs for fiscal years 2008 and 2009.

In addition, the time frames for completing the projects and the HealtheVet system as a whole have been extended since the inception of the HealtheVet initiative. As shown in table 1, the time frames as of 2003 envisioned completion by 2012. Current time frames extend the completion date to 2018.

Officials from VA’s Office of Information and Technology acknowledged that VA had experienced significant delays in developing and implementing HealtheVet. These officials attribute the delays to various factors, including changes in technical and deployment approaches, lack of management continuity, and loss of experienced contractor staff.

For example, changes in technical and deployment approaches delayed the development of the Scheduling, Health Data Repository, Pharmacy, Laboratory, and Enrollment projects. In particular, for Scheduling, Health Data Repository, Laboratory, and Enrollment, VHA has alternated between developing the systems in-house and using a commercial off-the-shelf product. In addition, programming languages for the Scheduling and Enrollment projects changed. Finally, VHA changed the deployment approach for Pharmacy annually between 2003 and 2007.

Several projects experienced management turnover. For example, the Enrollment project has had multiple program managers since it began, and the VistA application development and VistA foundations modernization projects have seen more than one change in program management.

Finally, the Scheduling, Health Data Repository, Laboratory, Vista Application Development, and Vista Foundations Modernization projects were delayed by the loss of experienced contractor staff. These initiatives were supported by an overall contract for HealtheVet. When this contract expired in September 2006, it was renewed on a monthly basis to ensure continuity of work until a new contract was awarded. However, task orders from the new contract, which was signed in November 2006, were not issued until June, July, and September 2007. According to department officials, as a result of these delays, the experienced contractor staff who supported the initiatives had moved to other work, corporate knowledge for these initiatives was lost, and new contractor staff had to be hired and educated.

Department officials stated that they are working to address the delays experienced by using an incremental, development life-cycle approach and establishing more realistic time frames for the effort. In addition, to address future contracting issues, the department is establishing an integrated product team composed of IT, program, and acquisition personnel.

VA Has Developed an Overall Strategy for HealtheVet, but It Lacks a Project Management Plan

Under VA’s current strategy for HealtheVet, developed in August 2006, the department is taking an incremental approach to the remainder of the initiative, based on six phases (referred to as “blocks”) that are to be completed in 2018. Under this strategy, the department plans to replace the 104 VistA applications that are currently in use (see app. III) with 67 applications, 3 databases, and 10 common services. Figure 1 provides a high-level overview of the strategy, and table 4 lists all the planned software development applications by block.

As table 4 shows, work has not yet been initiated on many applications that are planned for the final system. Further, although the department has established interim dates for completing projects that are under way, as of mid-June 2008, the department had not developed a detailed schedule or approach for completing the HealtheVet initiative, including the remaining 62 software applications, other than to state that it intends to complete all six blocks of the initiative by 2018.

Industry best practices and IT project management principles stress the importance of accountability and sound planning for any project, particularly an effort of the magnitude and complexity of HealtheVet. Inherent in such planning is the development and use of a project management plan that describes, among other factors, the project’s scope, implementation strategy, lines of responsibility, security requirements, resources, and estimated schedule for development and implementation. Specifically, an effective project management plan incorporates all the critical areas of system development and is to be used as a means of determining what needs to be done and when, and should measure progress. Such a plan also includes an integrated schedule that considers all dependencies and includes subtasks so that deadlines are realistic, and it incorporates reviews to allow oversight and approval by high-level managers.

A key component of planning is determining the resources necessary to accomplish the myriad tasks needed throughout the life cycle of the initiative. In April 2008, VA provided an $11 billion cost estimate to complete HealtheVet; however, it has not yet independently validated these estimates. We stress in our Cost Assessment Guide that having a validated cost estimate is essential to improve the accuracy of cost, schedule, and performance management. Validated cost estimates are also important to facilitate program approval and determine the necessary funding needed for HealtheVet.

Without an integrated plan that includes independently validated cost estimates, VA increases the risk that HealtheVet could incur schedule slippages and cost increases and not achieve what it intends to achieve.

VA Has Not Fully Established an Oversight Structure for HealtheVet

In the wake of the realignment of IT resources under central, department- level control, VA leadership endorsed an approach to the oversight and governance of IT development projects that is based on ensuring the involvement of senior management from both the user and the developer organizations. Under this approach, business owners establish IT requirements, business benefits, and priorities and oversee full life-cycle execution of IT programs. The department’s CIO organization provides the developers who devise technology solutions for the users. In addition, CIO officials chair a set of IT governance boards that review progress and recommend funding for IT projects; these boards include executive-level representation from business owners.

For the HealtheVet initiative, various levels and types of oversight are currently provided by the business owner (the Veterans Health Administration), the developers (the Office of Enterprise Development within the department’s CIO organization), and departmental IT governance boards. However, the business unit has not yet finalized a governance plan or implemented a complete governance structure, several key leadership positions within the developers’ organization are either vacant or filled with acting personnel, and the IT governance boards have not yet scheduled critical reviews of HealtheVet projects. Until all elements of governance and oversight are in place, the risk is increased that the HealtheVet initiative may experience cost overruns and continued schedule slippages and may not achieve what it intends to achieve.

VHA Has Not Fully Implemented a HealtheVet Governance Structure

VHA has not yet established a governance structure for HealtheVet in accordance with the approach endorsed by the department. Under this approach, business unit governance for IT initiatives is provided at several levels. An Executive Steering Committee, chaired by the head of the business unit, provides executive oversight. Reporting to the Executive Steering Committee is an Oversight Board that is responsible for ensuring that all stakeholders are represented in defining requirements, monitoring progress, and determining that the initiative is meeting their needs. Finally, a Program Director is responsible for day-to-day oversight activities to ensure that the technical solution provided by the developers meets business needs (such as requirements development and testing) and for coordinating with the developers’ program office.

According to senior management officials, VHA has not yet established a governance structure for HealtheVet in accordance with this approach, but it has developed a plan to do so. According to these officials, they worked with the departmental CIO organization to develop this plan. Officials told us that the plan had been approved by the Under Secretary for Health and was under review and awaiting approval by the Secretary of Veterans Affairs (we anticipate reviewing the plan upon its approval by the Secretary). VHA officials expect the plan to be approved next month. However, the officials did not provide a schedule for finalizing the plan and implementing the structure.

Until the governance structure is implemented, VHA is providing oversight of the HealtheVet initiative through various means. For example, according to officials, the former VHA CIO (now the Chief Officer of VHA’s Office of Information) briefs the VHA head (the Under Secretary for Health) twice weekly. In addition, the Office of Information holds formal meetings every two weeks with the developers (the Office of Enterprise Development in the department’s CIO organization) on three or four IT projects (which may include HealtheVet projects). Further, VHA’s Office of Information holds meetings with VHA managers who act as business liaisons between VHA and the departmental CIO organization. VHA also has an Information Data Management Committee that establishes priorities for VHA IT investments (including HealtheVet) and makes funding recommendations to the Under Secretary. This committee includes major VHA stakeholders, including headquarters and regional executives, as well as the Chief Officer, who co-chairs the council.

These means fulfill some of the functions of the governance model endorsed by the department. That is, the Information Data Management Committee performs some of the oversight functions of an Oversight Board, and the Chief Officer coordinates with the developers’ program office. However, there is currently no equivalent to an Executive Steering Committee, and there is no Program Director. If the draft governance plan follows the model endorsed by the department, its approval and implementation would include these elements.

Without a complete governance structure in place, the business owners’ ability to perform appropriate oversight of the HealtheVet projects may be decreased.

Key Positions within the Office of Enterprise Development Are Vacant

The Office of Enterprise Development within the departmental CIO organization is responsible for development of the HealtheVet projects. This office provides day-to-day oversight and management of the technical development activities. However, currently several key leadership positions within the Office of Enterprise Development are either vacant or are filled with acting personnel. That is, positions within Program Management and Software Development are vacant, and the Assistant Deputy CIO for Software Engineering is acting (see fig. 2 for an organizational chart showing these positions).

The position of Assistant Deputy CIO for Program Management is currently vacant; this position is responsible for activities such as managing a program’s portfolio of IT applications during its entire life cycle, as well as for developing and managing project plans and schedules and managing risk. In addition, the position of head of Software Engineering is filled by an acting Assistant Deputy CIO; this position has responsibility for overseeing the architecture of an application’s technical solution. Another Assistant Deputy CIO position (head of Software Development) is vacant; this position is responsible for ensuring that software deliverables meet their expected requirements. In commenting on a draft of this report, the department noted that a vacancy announcement for the Assistant Deputy CIO for Program Management position has been posted with a closing date of July 7, 2008. Until these key leadership positions are permanently staffed, the risk is increased that the department’s management and control of the HealtheVet initiative will not be efficient and effective.

IT Governance Boards Have Been Established, but No Milestone Reviews Have Been Scheduled

In 2007, three VA governance boards for IT investment projects were established; they have the following general responsibilities: The Business Needs and Investment Board (chaired by the Principal Deputy Assistant Secretary) is to evaluate whether proposed IT investment projects meet business needs.

The Planning, Architecture, Technology, and Services Board (chaired by a Deputy CIO) determines whether IT projects meet technical standards by, among other things, performing milestone reviews.

The Information Technology Leadership Board (chaired by the CIO) uses input from the two other boards to make recommendations to the department’s Strategic Management Council for funding the major categories of IT projects.

Although the boards are chaired by officials in the CIO’s office, they all include high-level executives from the user organizations. For example, the VHA representative on the Information Technology Leadership Board is the head of VHA—the Under Secretary for Health.

Since being established, the three governance boards have begun providing oversight to ensure that investments align with the department’s strategic plan and that business and budget requirements for ongoing and new initiatives meet user demands. In 2007, the three boards evaluated the HealtheVet projects that were proposed for fiscal year 2009, and the Information Technology Leadership Board made funding recommendations to the department’s Strategic Management Council. As a result of these deliberations, the department requested about $330 million for HealtheVet development projects for fiscal year 2009.

However, there is one oversight function that has not yet been exercised for the HealtheVet projects: milestone reviews. Milestone reviews, which are a responsibility of the Planning, Architecture, Technology, and Services Board, afford an opportunity for progressive decision making about the program under review and are coupled with authorization for funding. The VA milestone review process includes concept definition, requirements development, system design and prototype, system development and testing, system deployment, and operations and maintenance. Each step in the process has specific and organizationally required exit criteria that must be satisfied before the program can proceed to the next stage.

The Planning, Architecture, Technology, and Services Board has performed one milestone review since being established (this was a system design and prototype review for another IT development project). However, the board has not yet developed a schedule for any milestone reviews for HealtheVet projects. In particular, although the Enrollment project is scheduled for initial implementation in August 2008, no system deployment milestone review has been scheduled. According to the chair of this board, although no HealtheVet milestone reviews have been scheduled, the board has scheduled an operational test readiness review for another HealtheVet project (the Scheduling project) in June 2008 to verify that the application functions as designed are ready for initial deployment. Doing such a review should provide the board with useful information for oversight of this project. Nonetheless, it is important to hold milestone reviews on all projects that are moving from one phase of development to the next. Without milestone reviews of project progress, the governance boards cannot effectively measure progress or determine the funding needed for HealtheVet.

Conclusions

Although VA has made progress on its $11 billion HealtheVet initiative, it has also experienced significant delays, and none of the associated development projects have been completed. Moreover, VA is proceeding with this complex initiative without a project management plan and validated cost estimates to coordinate and guide the effort.

At the same time, a governance structure for HealtheVet has not yet been established, and key leadership positions that are responsible for providing day-to-day oversight have not been permanently staffed. Further, several IT governance boards with oversight responsibility for HealtheVet have not yet performed essential reviews of HealtheVet projects to gauge progress and funding requirements and the department lacks a time frame for doing so. Until the department takes the necessary actions to fully address these matters, it will face the risk that HealtheVet may experience cost overruns and continued schedule slippages, and may not achieve the outcome it intends to achieve.

Recommendations for Executive Action

To better ensure the success of HealtheVet, we recommend that the Secretary of Veterans Affairs direct the Chief Information Officer to take the following four actions: Develop a project management plan that encompasses all six blocks of HealtheVet.

Validate cost estimates for all six blocks of HealtheVet.

Expedite efforts to permanently staff the position of the Director of the Program Management office and fill other critical leadership positions in the Office of Enterprise Development.

Develop a schedule for and conduct milestone reviews of the HealtheVet projects.

In addition, to ensure proper oversight of HealtheVet, we recommend that the Secretary of Veterans Affairs direct the Veterans Health Administration Under Secretary to take the following action: Finalize and implement the plan to establish the HealtheVet governance structure.

Agency Comments and Our Evaluation

In providing written comments on a draft of this report, the Deputy Secretary of Veterans Affairs agreed with our conclusions and concurred with our recommendations. (The department’s comments are reproduced in app. II.) The comments described actions planned or being taken that respond to our recommendations. For example, according to the department, the Office of Information and Technology is developing a comprehensive, integrated HealtheVet project management plan to be completed within 6 months that is to reflect dependencies between resources and establish a single schedule for all VA medical information technology projects. As part of this plan, the department noted that it will include the format and schedule for conducting milestone reviews for HealtheVet projects. In addition, the department stated that it has hired a contractor to conduct an independent financial validation of the HealtheVet preliminary cost estimate that includes three phases and is to be completed by February 2009. To address staffing within the Office of Enterprise Development, the department stated that it had posted a vacancy announcement to fill the leadership position for the Program Management Office. Lastly, the department said it expects final review and approval of the HealtheVet governance plan by July 2008. If the actions that the department has planned or undertaken are properly implemented, they should help ensure success with the development and implementation of HealtheVet. The department also provided technical comments on the draft report, which we have incorporated as appropriate.

As agreed, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we are sending copies of this report to interested congressional committees and the Secretary of Veterans Affairs. Copies of this report will also be made available to other interested parties on request. This report will also be available at no charge on our Web site at http://www.gao.gov.

Should you or your staffs have any questions on matters discussed in this report, please contact me at (202) 512-6304 or melvinv@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix IV.

Appendix I: Objectives, Scope, and Methodology

As requested, the objectives of our review were to determine (1) the status of the HealtheVet initiative, (2) VA’s overall plan for completing the initiative, and (3) how VA is providing oversight to ensure the success of the initiative. We conducted our review by reviewing relevant HealtheVet project and budget documentation and validated our analyses through interviews with knowledgeable VA officials.

To determine the status of the HealtheVet initiative, we reviewed individual HealtheVet documents on system operation and development, time frames, and activities planned. Additionally, we researched the department’s expenditures on HealtheVet initiatives through fiscal year 2007 and the department’s current estimate of how much it plans to spend in fiscal years 2008 and 2009. We did not assess the accuracy of the cost data provided to us. We supplemented our analyses with interviews of VA personnel involved in the initiative. We also observed demonstrations of scheduling and enrollment prototypes to better understand how HealtheVet initiatives could provide enhanced service to patients and better support VA’s medical care providers. Finally, to gain user perspective on moving from VistA to HealtheVet, we visited the VA Medical Center in Salem, Virginia, because it had recently installed customized enhancements to VistA.

To determine VA’s plan for completing HealtheVet, we reviewed the department’s strategy and transition plan. We supplemented this review with responsible officials at the Office of Information and Technology, including the Deputy CIO for Enterprise Development and the Acting Deputy Director of the Program Management Office within the Office of Enterprise Development, to identify the department’s current strategy for the completion of HealtheVet. We summarized information obtained through interviews and reviews of HealtheVet documents to illustrate VA’s approach to completing the initiative.

To determine how VA is providing oversight for HealtheVet, we reviewed department information technology (IT) governance documents, including the IT Governance Plan, as well as the charters of the three VA IT governance boards, to determine the boards’ roles and responsibilities for oversight of VA IT initiatives such as HealtheVet. In addition, we reviewed minutes of the three VA IT governance boards to determine the extent of their oversight of HealtheVet to date. We interviewed the chairman of the Planning, Architecture, Technology, and Services Board to determine that board’s plans for conducting future milestone reviews for HealtheVet. We also reviewed the Office of Enterprise Development organizational structure and responsibilities. We interviewed the Chief Officer of VHA’s Office of Information and members of his staff to obtain information on the plan under development to provide governance for HealtheVet.

We conducted this performance audit at the Department of Veterans Affairs headquarters in Washington, D.C., and the VA medical center in Salem, Virginia, from July 2007 through June 2008, 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.

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: Existing VistA Applications Overview

According to VA, all of the functionality delivered by the VistA applications described below will be either rehosted or replaced as part of HealtheVet.

Offers a convenient way for healthcare providers to view information about multiple patients on a single screen. Users can see at a glance multiple patients for whom they have items that require attention.

Passes final patient results between vendor clinical information systems and VistA.

Enables clinicians to enter, review, and continuously update all order-related information connected with any patient.

Provides a common and consistent data structure for adverse reaction data.

Provides a method for identifying who is authorized to perform various actions on clinical documents.

Assists clinical decision-making and educate providers about appropriate care. The primary goal is to provide relevant information to providers at the point of care, for improving care for veterans.

Provides an efficient way for clinicians to order consultations and procedures from other providers or services within the hospital site, at their own facility or another facility.

A clinically oriented, structured report that extracts many kinds of data from VistA and displays it in a standard format.

Provides the clinician with a current and historical view of the patient’s health care problems across clinical specialties and allows each identified problem to be traceable through the VistA system in terms of treatment, test results, and outcome.

Simplifies the use and management of clinical documents for both clinical and administrative medical facility personnel.

A menu-based system incorporating features necessary for the maintenance of medical center dental records.

Contains important demographic and clinical data on VHA patients identified with Hepatitis C infection.

Designed to allow for the local entry and verification of patient-related data at an individual medical center.

Contains important demographic and clinical data on VHA patients identified with Human Immunodeficiency Virus infection.

Designed to store, in the patient’s electronic medical record, all patient intake and output information associated with a hospital stay or outpatient visit.

Supports General Laboratory, Microbiology, Histology, Cytology, Surgical Pathology, Electron Microscopy, Blood Donors, and Blood Bank for managing and automating the workload and reporting process.

Automates record keeping and reporting for all areas of Anatomic Pathology.

Uses data that can be tied primarily to a donor, a patient, or a unit of blood/blood component.

Reduces or eliminates the need for manual ordering and reporting of laboratory results to interface laboratories.

Allows entry, edit, and viewing of data for many medical tests and procedures.

Provides computer support for both clinical and administrative patient care activities associated with mental health care.

Generates management reports on employees; accumulates daily statistics on the number of patients treated; generates reports on patients by bed section and ward; allows users to enter vital signs, height, and weight for patients; and allows users to generate intake and output reports.

Integrates the automation of many Clinical Nutrition, Food Management, and Management Reports functions.

Automates the tumor registry and supports tumor registrars in abstracting cancer cases, following up on cancer patients and producing the Hospital Annual Report.

Provides a method to track drug distribution and inventory management within a medical center.

Provides a real-time, point-of-care solution for validating the administration of Unit Dose and intravenous medications to inpatients in medical centers.

Provides a regional system resource to expedite the distribution of mail-out prescriptions to veteran patients.

Provides functionality to monitor and track the receipt, inventory, and dispensing of all controlled substances.

Works toward perpetual inventory for each VA medical facility pharmacy by tracking all drugs through pharmacy locations.

Provides the ability to create and distribute electronic Outpatient Pharmacy claims to insurance companies on behalf of VHA pharmacy prescription beneficiaries in a real-time environment.

Integrates functions from the Intravenous and Unit Dose modules to provide a comprehensive record of medications utilized during hospitalization of the veteran.

Provides pharmacists and their staff with IV labels, manufacturing worksheets, ward lists for order updates, and management report.

Provides a standard computerized system for dispensing and managing inpatient medications.

Provides standardization of the local drug files in all VA medical facilities.

Provides a way to manage the medication regimen of veterans seen in outpatient clinics and to monitor and manage the workload and costs in the Outpatient Pharmacy.

Makes data extraction reports available at the medical centers and allows local management to use the data to project local drug usage and identify potential drug accountability problem areas.

Provides tools for managing site configurable data in pharmacy files.

Provides medical centers with the ability to determine whether a patient has been seen at other VA facilities and to request current pharmacy information from those facilities prior to the patient appearing for a scheduled outpatient visit.

In the outpatient setting, patients are assigned a primary care team and provider who are responsible for delivering essential health care, coordinating all health care services, and serving as the point of access for specialty care. This application allows a user to create, set up, and define teams; create and assign positions to the team; assign staff to the positions; assign patients to the team; and assign patient to providers’ positions.

Automates purchasing, provides control and auditing of expenditures, and generates management reports.

Used to enter, edit, and retrieve data for each episode of care.

Automates the entire range of diagnostic functions performed in imaging departments, including order entry of requests, registration of patients for exams, processing of exams, recording of reports/results, verification of reports on-line, displaying/printing results for clinical staff, automatic tracking of requests/exams/reports, and generation of management statistics/reports, both recurring and ad hoc.

Used by clinicians to place orders for certain types of medical products and services that are maintained under contract by the Denver Distribution Center. The most substantial product line is custom hearing aids.

Automates all aspects of the outpatient appointment process.

Is designed to facilitate the Social Work Service functions within a medical facility and is composed of Case Management, Clinical Assessment, and Community Resources.

Permits the identification and tracking of patients with a spinal cord dysfunction due to trauma or disease and the medical resources utilized during their treatment.

Integrates scheduling surgical cases and tracking clinical patient data to provide a variety of administrative and clinical reports.

Provides medical facilities a mechanism to track information relating to both surgical risk and operative mortality.

Facilitates medical decision-making by delivering complete multimedia patient information to the clinician’s desktop in an integrated manner.

Includes the components used to capture, store, and display all types of images.

Allows scanned and electronically generated documents to be associated with the online patient record and displayed on clinical workstations.

Allows radiology departments to operate without generating X-ray film.

Captures, stores, and displays images for a particular service or specialty.

Enables the Visual Impairment Service Team to easily manage and track activities and services provided to blinded veterans in their service areas.

Designed to store, in the patient’s electronic medical record, all vital signs and various measurements associated with a patient’s hospital stay or outpatient clinic visit.

To establish a computerized tracking system that generates aggregate data at the facility level. It would assist in the assessment of various aspects of care provided to women veterans.

Automates the debt collection process and a billing module is available to create non-medical care debts.

Creates and prints encounter forms that display relevant clinical information, and provides for the entry of clinical encounter data for local and national needs.

Provides the ability to perform the functions involved in issuing beneficiary travel pay.

Provides on-line access to medical data to Veterans Benefits Administration Rating Veteran Service Representatives and Decision Review Officers. It also creates a more efficient means of requesting compensation and pension examinations.

CPT codes are used for reporting medical services and procedures performed by physicians. The software includes all CPT codes to code outpatient services for reimbursement and workload purposes.

Provides a means of exporting data from selected VistA applications and transmitting it to a Decision Support System at the Austin Automation Center.

Is based on the Medicare Grouper requirements as defined by the Health Care Financing Administration. Each DRG represents a class of patients who are deemed medically comparable and who require approximately equal amounts of health care resources.

Facilitates the management of information needed to effectively discharge key operations responsibilities normally assigned to VA engineering organizations.

Provides additional functionality within the Integrated Funds Distribution, Control Point Activity, Accounting and Procurement package.

Provides a mechanism to track and account for procedures and delivered services that are not handled in any other VistA package.

Supports VHA’s Fee for Service program, which is care authorized for veterans who are legally eligible and are in need of care that cannot feasibly be provided by a VA facility.

Allows code sheet data to be entered and transmitted electronically from the medical facility service level to the national database.

Provides the medical center the ability to monitor incomplete records, interim summaries, discharge summaries, and both inpatient and outpatient operation reports.

Automates a spectrum of VA financial activities. Provides users the capability to manage budgets, order goods and services, maintain records of available funds, determine the status of a request, compare vendors and items to determine the best purchase, record the receipt of items into the warehouse, and pay vendors.

Automates the mini-banking system that VA provides for patients to manage their personal funds while hospitalized in a VA medical facility.

Contains all the features necessary to create bills for patients and third party insurance carriers.

Captures clinical data resulting from ambulatory care patient encounters.

Automates time and attendance for employees, timekeepers, payroll, and supervisors.

A national-level application replacing the site-based Voluntary Timekeeping System that tracks and manages the hours of service contributed by volunteers and volunteer organizations.

Enhances the ability to associate appropriate data with a single patient identifier. It provides the tools necessary to automatically identify patient records identified as being duplicates.

This package enables M-based VistA applications running on core facility computer systems to exchange health care information with other computer systems. It provides messaging services and a single toolset for M-based VistA applications to create, send, receive, and process HL7 messages.

A portability layer between the underlying operating system and application code. This enables the VistA system to be portable among different computers, operating systems, and M implementations.

Provides Development and Quality Assessment Tools, Capacity Planning Tools, and System Management Utilities.

Provides an efficient way for applications to present a list of items to the user for action.

An electronic messaging system that transmits messages, computer programs, data dictionaries, and data between users and applications located at the same or at different facilities.

This is a suite of applications that provides the ability to uniquely identify a patient and the facilities where that patient receives care. It is a foundation for the CPRS Remote Data Views that allows the clinician to retrieve clinical information from wherever the patient has received care.

Is a Web-based application that creates a new, on-line environment where veterans, family, and clinicians may come together to optimize veterans’ health care.

Provides clinicians quick and easy access to patients’ information from any VA medical facility where a patient has received care.

Electronically requests and receives patient demographics, episodes of care, medications, and diagnostic evaluations from other VA facilities.

Provides functionality so that graphical user interface developers can establish a connection from a client workstation to a VistA Server; fun remote procedure calls on the VistA M Server; and return data to the client workstation.

The majority of VHA clinical data is stored in VA FileMan files and is retrieved and accessed through VA FileMan Application Programmer Interfaces and user interfaces.

Provides a synchronous communication mechanism between M applications and rehosted applications, supporting VHA’s ongoing transition to HealtheVet.

Provides a comprehensive range of software dedicated to the support of administrative functions related to patient admission, discharge, transfer, and registration.

Allows the user to design monitors that capture patient data in support of quality management efforts.

Facilitates the processing of an application for health benefits, which has been transmitted to the VHA site from the web-based software.

Provides the capability to request and obtain veteran eligibility data via the VA national telecommunications network.

Extracts patient-reported Means Test data and transmit it to the Health Eligibility Center.

Provides for the maintenance and control of medical records and x-ray films to facilitate availability to a variety of users.

Provides a standardized assessment tool supporting the completion of a comprehensive accurate and reproducible patient assessment, and serves as the basis for developing the patient’s plan of care.

Replaces the embossed data card as a means of identifying veteran patients entitled to care and service at VA health care facilities.

Facilitates the electronic interchange of veteran information between Veteran Benefits Administration Regional Offices and VA medical facilities.

Supports VHA policy by compiling data on patient incidents.

Used to express diagnostic clinical problems in easy-to-understand terminology and associate these terms to coding systems such as ICD, DSM, NANDA.

Supports VHA policy by providing for the identification of events requiring follow- up review.

Tracks and trends compliments and complaints and measures the facility’s types of complaints as they relate to the Customer Services Standards and the National Patient Satisfaction Survey.

Designed to manage the data from all employee accidents, create a Report of Accident, and produce the Office of Worker’s Compensation Programs Form CA-1 and the Federal Employee’s Notice of Occupational Disease and Claim for Compensation Form CA-2.

Automates the entire serials management process in VA Library Services.

Supports the VA Police in their responsibilities of crime prevention, preliminary investigation of crimes, apprehension, legally correct handling of suspected offenders, and the transfer of suspected offenders to appropriate authorities.

Appendix IV: GAO Contact and Staff Acknowledgments

Staff Acknowledgments

In addition to the contact named above, key contributions to this report were made by Barbara Oliver (Assistant Director), Barbara Collier, Neil Doherty, Nancy Glover, Michele Mackin, J. Michael Resser, Amos Tevelow, Eric Trout, and Charles Youman.