Computer-Based Patient Records: Improved Planning and Project Management Are Critical to Achieving Two-Way VA-DOD Health Data Exchange
Released: 2004-05-19T00:00:00

Letter

Background

In 1998, following a Presidential call for VA and DOD to start developing a “comprehensive, life-long medical record for each service member,” the two departments began a joint course of action toward achieving the capability to share patient health information for active duty military personnel and veterans. As their first initiative, undertaken in that year, the Government Computer- Based Patient Record (GCPR) project was envisioned as an electronic interface that would allow physicians and other authorized users at VA and DOD health facilities to access data from any of the other agencies’ health information systems. The interface was expected to compile requested patient information in a virtual record that could be displayed on a user’s computer screen.

Our prior reviews of the GCPR project determined that the lack of a lead entity, clear mission, and detailed planning to achieve that mission made it difficult to monitor progress, identify project risks, and develop appropriate contingency plans. Accordingly, reporting on this project in April 2001 and again in June 2002, we made several recommendations to help strengthen the management and oversight of GCPR. Specifically, in 2001 we recommended that the participating agencies (1) designate a lead entity with final decision- making authority and establish a clear line of authority for the GCPR project, and (2) create comprehensive and coordinated plans that included an agreed-upon mission and clear goals, objectives, and performance measures, to ensure that the agencies could share comprehensive, meaningful, accurate, and secure patient health care data. In 2002 we recommended that the participating agencies revise the original goals and objectives of the project to align with their current strategy, commit the executive support necessary to adequately manage the project, and ensure that it followed sound project management principles. VA and DOD took specific measures in response to our recommendations for enhancing overall management and accountability of the project.

By July 2002, VA and DOD had revised their strategy and had made progress toward electronically sharing patient health data. The two departments had renamed the project the Federal Health Information Exchange (FHIE) program and, consistent with our prior recommendation, had finalized a memorandum of agreement designating VA as the lead entity for implementing the program. This agreement also established FHIE as a joint activity that would allow the exchange of health care information in two phases. The first phase, completed in mid-July 2002, enabled the one-way transfer of data from DOD’s existing health information system (the Composite Health Care System) to a separate database that VA clinicians could access. A second phase, finalized this past March, completed VA’s and DOD’s efforts to add to the base of patient health information available to VA clinicians via this one-way sharing capability. According to program officials, FHIE is now fully operational and is showing positive results by providing a wide range of health care information to enable clinicians to make more informed decisions regarding the care of veterans and to facilitate processing disability claims. The officials stated that the departments have now begun leveraging the FHIE infrastructure to achieve interim exchanges of health information on a limited basis, using existing health systems at joint VA/DOD facilities. The departments reported total GCPR/FHIE costs of about $85 million through fiscal year 2003.

The revised strategy also envisioned achieving a longer term, two- way exchange of health information between DOD and VA. Known as HealthePeople (Federal), this initiative is premised upon the departments’ development of a common health information architecture comprising standardized data, communications, security, and high-performance health information systems. The joint effort is expected to result in the secured sharing of health data required by VA’s and DOD’s health care providers between systems that each department is currently developing—DOD’s Composite Health Care System (CHCS) II and VA’s HealtheVet VistA.

DOD began developing CHCS II in 1997 and has completed its associated clinical data repository—a key component for the planned electronic interface. The department expects to complete deployment of all of its major system capabilities by September 2008. It reported expenditures of about $464 million for the system through fiscal year 2003. VA began work on HealtheVet VistA and its associated health data repository in 2001, and expects to complete all six initiatives comprising this system in 2012. VA reported spending about $120 million on HealtheVet VistA through fiscal year 2003.

Under the HealthePeople (Federal) initiative, VA and DOD envision that, upon entering military service, a health record for the service member will be created and stored in DOD’s CHCS II clinical data repository. The record will be updated as the service member receives medical care. When the individual separates from active duty and, if eligible, seeks medical care at a VA facility, VA will then create a medical record for the individual, which will be stored in its health data repository. Upon viewing the medical record, the VA clinician would be alerted and provided with access to the individual’s clinical information residing in DOD’s repository. In the same manner, when a veteran seeks medical care at a military treatment facility, the attending DOD clinician would be alerted and provided with access to the health information in VA’s repository. According to the departments, this planned approach would make virtual medical records displaying all available patient health information from the two repositories accessible to both departments’ clinicians. VA officials anticipated being able to exchange some degree of health information through an interface of their health data repository with DOD’s clinical data repository by the end of 2005.

Progress Toward Achieving HealthePeople (Federal) Faces Continued Challenges and Risks

As we have noted, achieving the longer term capability to exchange health data in a secure, two-way electronic format between new health information systems that VA and DOD are developing is a challenging and complex undertaking, in which success depends on having a clearly articulated architecture, or blueprint, defining how specific technologies will be used to deliver the capability. Developing, maintaining, and using an architecture is a best practice in engineering information systems and other technological solutions, articulating, for example, the systems and interface requirements, design specifications, and database descriptions for the manner in which the departments will electronically store, update, and transmit their data.

Successfully carrying out the initiative also depends on the departments’ instituting a highly disciplined approach to the project’s management. Industry best practices and information technology project management principles stress the importance of accountability and sound planning for any project, particularly an interagency effort of the magnitude and complexity of this one. Such planning involves developing and using a project management plan that describes, among other factors, the project’s scope, implementation strategy, lines of responsibility, resources, and estimated schedules for development and implementation.

Currently, VA and DOD are proceeding with the development of their new health information systems and with the identification of standards that are essential to sharing common health data. DOD is deploying its first release of CHCS II functionality (a capability for integrating DOD clinical outpatient processes into a single patient record), with scheduled completion in June 2006. For its part, VA continues to work toward completing a prototype for the department’s health data repository, scheduled for completion at the end of next month. In addition, as we reported in March, the departments have continued essential steps toward standardizing clinical data, having adopted data and message standards that are important for exchanging health information between disparate systems. Department officials also stated that they were proceeding with a pharmacy data prototype initiative, begun in March to satisfy a mandate of the Bob Stump National Defense Authorization Act for Fiscal Year 2003, as an initial step toward achieving HealthePeople (Federal). The officials maintain that they expect to be positioned to begin exchanging patient health information between their new systems on a limited basis in the fall of 2005, identifying four categories of data that they expect to be able to exchange: outpatient pharmacy data, laboratory results, allergies, and patient demographics.

However, VA’s and DOD’s approach to meeting this HealthePeople (Federal) goal is fraught with uncertainty and lacks a solid foundation for ensuring that this mission can be successfully accomplished. As we reported in March, the departments continue to lack an architecture detailing how they intend to use technology to achieve the two-way electronic data exchange capability. In discussing their intentions for developing such an architecture, VA’s Deputy Chief Information Officer for Health stated last week that the departments do not expect to have an established architecture until a future unspecified date. He added that VA and DOD planned to take an incremental approach to determining the architecture and technological solution for the data exchange capability. He explained, for example, that they hope to gain from the pharmacy data prototype project an understanding of what technology is necessary and how it should be deployed to enable the two-way exchange of patient health records between their data repositories. VA and DOD reported approval of the contractor’s technical requirements for the prototype last month and have a draft architecture for the prototype. They expect to complete the prototype in mid-September of this year.

Although department officials consider the pharmacy data prototype to be an initial step toward achieving HealthePeople (Federal), how and to what extent the prototype will contribute to defining the electronic interface for a two-way data exchange between VA’s and DOD’s new health information systems are unclear. Such prototypes, if accomplished successfully, can offer valuable contributions to the process of determining the technological solution for larger, more encompassing initiatives. However, ensuring the effective application of lessons learned from the prototype requires that VA and DOD have a well-defined strategy to show how this project will be integrated with the HealthePeople (Federal) initiative. Yet VA and DOD have not developed a strategy to articulate the integration approach, time frames, and resource requirements associated with implementing the prototype results to define the technological features of the two-way data exchange capability under HealthePeople (Federal). Until VA and DOD are able to determine the architecture and technological solution for achieving a secure electronic systems interface, they will lack assurance that the capability to begin electronically exchanging patient health information between their new systems in 2005 can be successfully accomplished.

In addition to lacking an explicit architecture and technological solution to guide the development of the electronic data exchange capability, VA and DOD continue to be challenged in ensuring that this undertaking will be managed in a sound, disciplined manner. As was the situation in March, VA and DOD continue to lack a fully established project management structure for the HealthePeople (Federal) initiative. The relationships among the management entities involved with the initiative have not been clearly established, and no one entity has authority to make final project decisions binding on the other. As we noted during the March hearing, the departments’ implementation of our recommendation that it establish a lead entity for the Government Computer-Based Patient Record project helped strengthen the overall accountability and management of that project and contributed to its successful accomplishment.

Further, although the departments have designated a project manager and established a project plan defining the work tasks and management structure for the pharmacy prototype, they continue to lack a comprehensive and coordinated project plan for HealthePeople (Federal), to explain the technical and managerial processes that have been instituted to satisfy project requirements for this broader initiative. Such a plan would include, among other information, details on the authority and responsibility of each organizational unit; the work breakdown structure and schedule for all of the tasks to be performed in developing, testing, and deploying the electronic interface; as well as a security plan. The departments also have not instituted necessary project review milestones and measures to provide a basis for comprehensive management of the project at critical intervals, progressive decision making, or authorization of funding for each step in the development process. As a result, current plans for the development of the electronic data exchange capability between VA’s and DOD’s new health information systems do not offer a clear vision for the project or demonstrate sufficient attention to the effective day-to-day guidance of and accountability for the investments in and implementation of this capability. In discussing their management of HealthePeople (Federal), VA and DOD program officials stated this week that the departments had begun actions to develop a project plan and define the management structure for this initiative.

Given the significance of readily accessible health data for improving the quality of health care and disability claims processing for military members and veterans, we currently have a draft report at the departments for comment, in which we are recommending to the Secretaries of Veterans Affairs and Defense, a number of actions for addressing the challenges to, and improving the likelihood of, successfully achieving the electronic two-way exchange of patient health information.

In summary, VA’s and DOD’s pursuit of various initiatives to achieve the electronic sharing of patient health data represents an important step toward providing more high-quality health care for active duty military personnel and veterans. Moreover, in undertaking HealthePeople (Federal), the departments have an opportunity to help lead the nation to a new frontier of health care delivery. However, the continued absence of an architecture and defined technological solution for an electronic interface for their new health information systems, coupled with the need for more comprehensive and coordinated management of the projects supporting the development of this capability, elevates the uncertainty about how VA and DOD intend to achieve this capability and in what time frame. Until these critical components have been put into place, the departments will continue to lack a convincing position regarding their approach to and progress toward achieving the HealthePeople (Federal) goals and, ultimately, risk jeopardizing the initiative’s overall success.

Mr. Chairman, this concludes my statement. I would be pleased to respond to any questions that you or other members of the Subcommittee may have at this time.

Contacts and Acknowledgments

For information about this testimony, please contact Linda D. Koontz, Director, Information Management Issues, at (202) 512-6240 or at koontzl@gao.gov, or Valerie C. Melvin, Assistant Director, at (202) 512-6304 or at melvinv@gao.gov. Other individuals making key contributions to this testimony include Barbara S. Oliver, J. Michael Resser, and Eric L. Trout.

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