Electronic Health Records: VA's Efforts Raise Concerns about Interoperability Goals and Measures, Duplication with DOD, and Future Plans
Released: 2016-07-13T00:00:00

Letter

Background

VA operates one of the largest health care systems in America, providing care to millions of veterans and their families each year. The department’s health information system—VistA—serves an essential role in helping the department to fulfill its health care delivery mission. Specifically, VistA is an integrated medical information system that was developed in-house by the department’s clinicians and information technology (IT) personnel, and has been in operation since the early 1980s. The system consists of 104 separate computer applications, including 56 health provider applications; 19 management and financial applications; 8 registration, enrollment, and eligibility applications; 5 health data applications; and 3 information and education applications. Within VistA, an application called the Computerized Patient Record System enables the department to create and manage an individual electronic health record for each VA patient.

Electronic health records are particularly crucial for optimizing the health care provided to veterans, many of whom may have health records residing at multiple medical facilities within and outside the United States. Taking these steps toward interoperability—that is, collecting, storing, retrieving, and transferring veterans’ health records electronically—is significant to improving the quality and efficiency of care. One of the goals of interoperability is to ensure that patients’ electronic health information is available from provider to provider, regardless of where it originated or resides.

Since 1998, VA has undertaken a patchwork of initiatives with DOD to allow the departments’ health information systems to exchange information and increase interoperability. Among others, these have included initiatives to share viewable data in the two departments’ existing (legacy) systems, link and share computable data between the departments’ updated heath data repositories, and jointly develop a single integrated system that would be used by both departments. Table 1 summarizes a number of these key initiatives.

In addition to the initiatives mentioned in table 1, VA has worked in conjunction with DOD to respond to provisions in the National Defense Authorization Act for Fiscal Year 2008, which required the departments to jointly develop and implement fully interoperable electronic health record systems or capabilities in 2009. Yet, even as the departments undertook numerous interoperability and modernization initiatives, they faced significant challenges and slow progress. For example, VA’s and DOD’s success in identifying and implementing joint IT solutions has been hindered by an inability to articulate explicit plans, goals, and time frames for meeting their common health IT needs.

In March 2011, the secretaries of VA and DOD announced that they would develop a new, joint integrated electronic health record system (referred to as iEHR). This was intended to replace the departments’ separate systems with a single common system, thus sidestepping many of the challenges they had previously encountered in trying to achieve interoperability. However, in February 2013, about 2 years after initiating iEHR, the secretaries announced that the departments were abandoning plans to develop a joint system, due to concerns about the program’s cost, schedule, and ability to meet deadlines. The Interagency Program Office (IPO), put in place to be accountable for VA’s and DOD’s efforts to achieve interoperability, reported spending about $564 million on iEHR between October 2011 and June 2013.

In light of VA and DOD not implementing a solution that allowed for the seamless electronic sharing of health care data, the National Defense Authorization Act for Fiscal Year 2014 included requirements pertaining to the implementation, design, and planning for interoperability between the departments’ electronic health record systems. Among other actions, provisions in the act directed each department to (1) ensure that all health care data contained in their systems (VA’s VistA and DOD’s Armed Forces Health Longitudinal Technology Application, referred to as AHLTA) 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, in conjunction with DOD, had engaged in several near-term efforts focused on expanding interoperability between their existing electronic health record systems. For example, the departments had analyzed data related to 25 “domains” identified by the Interagency Clinical Informatics Board and mapped health data in their existing systems to standards identified by the IPO. The departments also had expanded the functionality of their Joint Legacy Viewer—a tool that allows clinicians to view certain health care data from both departments in a single interface.

More recently, in April 2016, VA and DOD certified 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. Specifically, the department stated that deployment of a modernized VistA system at all locations and for all users is not planned until 2018.

Together with DOD and the Interagency Program Office, VA Needs to Develop Goals and Metrics for Assessing Interoperability

Even as VA has undertaken numerous initiatives with DOD that were intended to advance electronic health record interoperability, a significant concern is that these departments have not identified outcome-oriented goals and metrics to clearly define what they aim to achieve from their interoperability efforts, and the value and benefits these efforts are expected to yield. As we have stressed in our prior work and guidance, assessing the performance of a program should include measuring its outcomes in terms of the results of products or services. In this case, such outcomes could include improvements in the quality of health care or clinician satisfaction. Establishing outcome-oriented goals and metrics is essential to determining whether a program is delivering value.

The IPO is responsible for monitoring and reporting on VA’s and DOD’s progress in achieving interoperability and coordinating with the departments to ensure that these efforts enhance health care services. Toward this end, the office issued guidance that identified a variety of process-oriented metrics to be tracked, such as the percentage of health data domains that have been mapped to national standards. The guidance also identified metrics to be reported that relate to tracking the amounts of certain types of data being exchanged between the departments, using existing capabilities. This would include, for example, laboratory reports transferred from DOD to VA via the Federal Health Information Exchange and patient queries submitted by providers through the Bidirectional Health Information Exchange.

Nevertheless, in our August 2015 report, we noted that the IPO had not specified outcome-oriented metrics and goals that could be used to gauge the impact of the interoperable health record capabilities on the departments’ health care services. At that time, the acting director of the IPO stated that the office was working to identify metrics that would be more meaningful, such as metrics on the quality of a user’s experience or on improvements in health outcomes. However, the office had not established a time frame for completing the outcome-oriented metrics and incorporating them into the office’s guidance.

In the report, we stressed that using an effective outcome-based approach could provide the two departments with a more accurate picture of their progress toward achieving interoperability, and the value and benefits generated. Accordingly, we recommended that the departments, working with the IPO, establish a time frame for identifying outcome- oriented metrics; define related goals as a basis for determining the extent to which the departments’ modernized electronic health record systems are achieving interoperability; and update IPO guidance accordingly.

Both departments concurred with our recommendations. Further, since that time, VA has established a performance architecture program that has begun to define an approach for identifying outcome-oriented metrics focused on health outcomes in selected clinical areas, and it also has begun to establish baseline measurements. We intend to continue monitoring the department’s efforts to determine how these metrics define and report on the results achieved by interoperability between the departments.

VA’s Plan to Modernize VistA Raises Concern about Duplication with DOD’s Electronic Health Record System Acquisition

Following the termination of the iEHR initiative, VA moved forward with an effort to modernize VistA separately from DOD’s planned acquisition of a commercially available electronic health record system. The department took this course of action even though it has many health care business needs in common with those of DOD. For example, in May 2010, VA (and DOD) issued a report on medical IT to Congressional committees that identified 10 areas—inpatient documentation, outpatient documentation, pharmacy, laboratory, order entry and management, scheduling, imaging and radiology, third-party billing, registration, and data sharing—in which the departments have common business needs. Further, the results of a 2008 study pointed out that over 97 percent of inpatient requirements for electronic health record systems are common to both departments.

We also issued several prior reports regarding the plans for separate systems, in which we noted that the departments did not substantiate their claims that VA’s VistA modernization, together with DOD’s acquisition of a new system, would be achieved faster and at less cost than developing a single, joint system. Moreover, we noted that the departments’ plans to modernize their two separate systems were duplicative and stressed that their decisions should be justified by comparing the costs and schedules of alternate approaches.

We recommended that VA and DOD develop cost and schedule estimates that would include all elements of their approach (i.e., modernizing both departments’ health information systems and establishing interoperability between them) and compare them with estimates of the cost and schedule for developing a single, integrated system. If the planned approach for separate systems was projected to cost more or take longer, we recommended that the departments provide a rationale for pursuing such an approach.

VA, as well as DOD, agreed with our recommendations and stated that an initial comparison had indicated that the approach involving separate systems would be more cost effective. However, as of June 2016, the departments had not provided us with a comparison of the estimated costs of their current and previous approaches. Further, with respect to their assertions that separate systems could be achieved faster, both departments had developed schedules which indicated that their separate modernization efforts are not expected to be completed until after the 2017 planned completion date for the previous single-system approach.

VA Has Begun to Implement VistA Modernization Plans amid Uncertainty about Its Approach; the Department Is Currently Reconsidering How to Proceed

As VA has proceeded with its program to modernize VistA (known as VistA Evolution), the department has developed a number of plans to support its efforts. These include an interoperability plan and a road map describing functional capabilities to be deployed through fiscal year 2018. Specifically, these documents describe the department’s approach for modernizing its existing electronic health record system through the VistA Evolution program, while helping to facilitate interoperability with DOD’s system and the private sector. For example, the VA Interoperability Plan, issued in June 2014, describes activities intended to improve VistA’s technical interoperability, such as standardizing the VistA software across the department to simplify sharing data.

In addition, the VistA 4 Roadmap, last revised in February 2015, describes four sets of functional capabilities that are expected to be incrementally deployed during fiscal years 2014 through 2018 to modernize the VistA system and enhance interoperability. According to the road map, the first set of capabilities was delivered by the end of September 2014 and included access to the Joint Legacy Viewer and a foundation for future functionality, such as an enhanced graphical user interface and enterprise messaging infrastructure.

Another interoperable capability that is expected to be incrementally delivered over the course of the VistA modernization program is the enterprise health management platform. The department has stated that this platform is expected to provide clinicians with a customizable view of a health record that can integrate data from VA, DOD, and third-party providers. Also, when fully deployed, VA expects the enterprise health management platform to replace the Joint Legacy Viewer.

However, a recent independent assessment of health IT at VA reported that lengthy delays in modernizing VistA had resulted in the system becoming outdated. Further, this study questioned whether the VistA Evolution program to modernize the electronic health record system can overcome a variety of risks and technical issues that have plagued prior VA initiatives of similar size and complexity. For example, the study raised questions regarding the lack of any clear advances made during the past decade and the increasing amount of time needed for VA to release new health IT capabilities. Given the concerns identified, the study recommended that VA assess the cost versus benefits of various alternatives for delivering the modernized capabilities, such as commercially available off-the-shelf electronic health record systems, open source systems, and the continued development of VistA.

In speaking about this matter, VA’s Under Secretary for Health has asserted that the department will follow through on its plans to complete the VistA Evolution program in fiscal year 2018. However, the Chief Information Officer has also indicated that the department is taking a step back in reconsidering how best to meet its electronic health record system needs beyond fiscal year 2018. As such, VA’s approach to addressing its electronic health record system needs remains uncertain.

In summary, VA’s approach to pursuing electronic health record interoperability with DOD has resulted in an increasing amount of standardized health data and has made an integrated view of that data available to department clinicians. Nevertheless, a modernized VA electronic health record system that is fully interoperable with DOD’s system is still years away. Thus, important questions remain about when VA intends to define the extent of interoperability it needs to provide the highest possible quality of care to its patients, as well as how and when the department intends to achieve this extent of interoperability with DOD. In addition, VA’s unsuccessful efforts over many years to modernize its VistA system raise concern about how the department can continue to justify the development and operation of an electronic health record system that is separate from DOD’s system, even though the departments have common system needs. Finally, VA’s recent reconsideration of its approach to modernizing VistA raises uncertainty about how it intends to accomplish this important endeavor.

Chairman Kirk, Ranking Member Tester, and Members of the Subcommittee, this concludes my prepared statement. I would be pleased to respond to any questions that you may have.

Contact and Acknowledgments

If you or your staff have any questions about this testimony, please contact Valerie C. Melvin 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 testimony statement. GAO staff who made key contributions to this statement are Mark T. Bird (Assistant Director), Jennifer Stavros-Turner (Analyst in Charge), Rebecca Eyler, Nancy Glover, Jacqueline Mai, and Scott Pettis.

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