As we have reported, the use of information technology (IT) to electronically collect, store, retrieve, and transfer clinical, administrative, and financial health information has great potential to help improve the quality and efficiency of health care and is critical to improving the performance of the U.S. health care system. Critical health information for a patient seeking treatment (such as allergies, current treatments or medications, and prior diagnoses) has, historically, 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 makes it challenging for a clinician to make the most informed decisions on treatment options, potentially putting the patient’s health at greater risk. The use of electronic health records can help provide this access and improve clinical decisions. Electronic health records are particularly crucial for optimizing the health care provided to military personnel and veterans. While in military status and later as veterans, many DOD and VA patients tend to be highly mobile and may have health records residing at multiple medical facilities within and outside the United States. Making such records electronic can help ensure that complete health care information is available for most military service members and veterans at the time and place of care, no matter where it originates. Key to making health care information electronically available is the ability to share that data among health care providers—that is, interoperability. Interoperability is the ability for different information systems or components to exchange information and to use the information that has been exchanged. This capability is important because it allows patients’ electronic health information to move with them from provider to provider, regardless of where the information originated. If electronic health records conform to interoperability standards, they 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 necessary information required for optimal care. (Paper-based health records—if available—also provide necessary information, but unlike electronic health records, paper records do not provide decision support capabilities, such as automatic alerts about a particular patient’s health, or other advantages of automation.) Interoperability can be achieved at different levels. At the highest level, data are in a format that a computer can understand and operate on, whereas at the minimum type of interoperability, the data are in a format that is viewable, so that information is available for a human being to read and interpret. Figure 1 shows various levels of interoperability and examples of the types of data that can be shared at each level. As the figure shows, paper records can be considered interoperable in that they allow data to be read and interpreted by a human being. In the remainder of this report, however, we do not discuss interoperability in this sense; instead, we focus on electronic interoperability, for which the first level of interoperability is unstructured, viewable electronic data. With unstructured data, a clinician would have to find needed or relevant information by scanning uncategorized information. The value of viewable data is increased if the data are structured so that information is categorized and easier to find. At the highest level, as shown, the computer can interpret and act on the data. Not all data require the same level of interoperability. For example, in their initial efforts to implement computable data, VA and DOD focused on outpatient pharmacy and drug allergy data because clinicians gave priority to the need for automated alerts to help medical personnel avoid administering inappropriate drugs to patients. On the other hand, for such narrative data as clinical notes, viewability may be sufficient. Achieving even a minimal level of interoperability is valuable for potentially making all relevant information available to clinicians. Any type of interoperability depends on the use of agreed-upon standards to ensure that information can be shared and used. In health IT, standards govern areas ranging from technical issues, such as file types and interchange systems, to content issues, such as medical terminology. Developing, coordinating, and agreeing on standards are only part of the processes involved in achieving interoperability for electronic health records systems or capabilities. In addition, specifications are needed for implementing the standards, as well as criteria and a process for verifying compliance with the standards. In December 2001, an effort to establish federal health information standards was initiated as an Office of Management and Budget (OMB) e- government project to enable federal agencies to build interoperable health data systems. This project, the Consolidated Health Informatics initiative, was a collaborative agreement among federal agencies, including DOD and VA, to adopt a common set of health information standards for the electronic exchange of clinical health information. Under the Consolidated Health Informatics initiative, DOD, VA, and other participating agencies agreed to endorse 20 sets of standards to make it easier for information to be shared across agencies and to serve as a model for the private sector. For example, standard medication terminologies were agreed upon, which DOD and VA then began to adopt in developing their data repositories. Recognizing the need for public and private sector collaboration to achieve a national interoperable health IT infrastructure, the President issued an executive order in April 2004 that called for widespread adoption of interoperable electronic health records by 2014. This order established the Office of the National Coordinator for Health Information Technology within the Department of Health and Human Services (HHS) with responsibility, among other things, for developing, maintaining, and directing the implementation of a strategic plan to guide the nationwide implementation of interoperable health IT in both the public and private health care sectors. Among its responsibilities as the chief advisor to the Secretary of HHS in this area, the Office of the National Coordinator is to report progress on the implementation of this strategic plan. Under the direction of HHS (through the Office of the National Coordinator), three primary organizations were designated to play major roles in expanding the implementation of health IT: the American Health Information Community, the Healthcare Information Technology Standards Panel, and the Certification Commission for Healthcare Information Technology. All three are involved in various processes related to electronic health records interoperability standards. The functions of these organizations are described in the following. The community is a federal advisory body created by the Secretary of HHS to make recommendations on how to accelerate the development and adoption of health IT, including advancing interoperability, identifying health IT standards, advancing nationwide health information exchange, and protecting personal health information. Formed in September 2005, the community is made up of representatives from both the public and private sectors. The American Health Information Community determines specific health care areas of high priority and develops “use cases” for these areas, which provide the context in which standards would be applicable. For example, the community has developed a use case regarding the creation of standardized, secure records of past and current laboratory test results for access by health professionals. The use case conveys how health care professionals would use such records and what standards would apply. Developed in October 2005, the Healthcare Information Technology Standards Panel (HITSP) is a public-private partnership, sponsored by the American National Standards Institute and funded by the Office of the National Coordinator. (HITSP is the successor to the Consolidated Health Informatics initiative, which was dissolved and absorbed into the panel on September 30, 2006.) The panel was established to identify competing standards for the use cases developed by the American Health Information Community and “harmonize” the standards. (Harmonization is the process of identifying overlaps and gaps in relevant standards and developing recommendations to address these overlaps and gaps.) For example, for the three initial use cases developed by the American Health Information Community, HITSP identified competing standards by converting the use cases into detailed requirements documents; it then examined and assessed more than 700 existing standards that would meet those requirements. From those 700 standards, the panel identified 30 named standards and produced detailed implementation guidance describing the specific transactions and use of these named standards. This guidance is codified in an interoperability specification for each use case that integrates the standards. Each of the interoperability specifications developed by HITSP includes references to the identified standards or parts of standards and explains how they should be applied to specific topics. For example, among the standards referred to in one interoperability specification is the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT). This standard is to be used in the “Lab Result Terminology Component” of the specification. Once developed, the specifications are presented to the American Health Information Community, which assesses them for recommendation to the Secretary of HHS. The Secretary publicly “accepts” recommended specifications for a 1-year period of implementation testing, after which the Secretary can formally “recognize” the specifications and associated guidance as interoperability standards. This two-step process is intended to ensure that software developers have adequate time to implement recognized standards in their software. The year between acceptance and recognition allows the panel to refine its implementation guidance based on feedback from actual software implementation. Table 1 shows the current status of the interoperability specifications developed by HITSP. Each of the interoperability specifications in the table is associated with one of the seven use cases developed by the American Health Information Community in 2006 and 2007. The community is also developing six use cases for 2008, for which interoperability specifications have not yet been released: Consultation and Transfers of Care, Public Health Case Reporting, and Immunizations & Response Management. The commission is an independent, nonprofit organization that certifies health IT products. HHS entered into a contract with the commission in October 2005 to develop and evaluate the certification criteria and inspection process for electronic health records. According to HHS, certification is to be the process by which the IT systems of federal health contractors are established to meet federal interoperability standards. Certification helps assure purchasers and other users of health IT systems that the systems will provide needed capabilities (including ensuring security and confidentiality) and will work with other systems without reprogramming. Certification also encourages adoption of health IT by assuring providers that their systems can participate in nationwide health information exchange in the future. In 2006, the commission certified the first 37 ambulatory—or clinician office-based—electronic health record products as meeting baseline criteria for functionality, security, and interoperability. In 2007, the commission expanded certification to inpatient—or hospital—electronic health record products, which could significantly increase patients’ and providers’ access to the health information generated during a hospitalization. To date, the commission has certified over 100 electronic health record products. Since 2005, we have reported and testified on the various actions that HHS and the Office of the National Coordinator have taken to advance nationwide implementation of health IT, which include the establishment of the American Health Information Community and related activities, selection of initial standards to address specific health areas, and the release in July 2004 of a framework for strategic action. We pointed out in 2005 that this framework did not constitute a comprehensive national strategy with detailed plans, milestones, and performance measures needed to ensure that the outcomes of the department’s various initiatives are integrated and its goals are met. As a result, we recommend that HHS establish detailed plans and milestones for each phase of the framework for strategic action and take steps to ensure that those plans are followed and milestones met. In this regard, in June 2008, the Office of the National Coordinator released a four-year strategic plan. Although we have not yet fully assessed this plan, if its milestones and measures for achieving an interoperable national infrastructure for health IT are appropriate, the plan could provide a useful roadmap to support the goal of widespread adoption of interoperable electronic health records. DOD and VA have been working to exchange patient health data electronically since 1998. However, the departments have faced considerable challenges in project planning and management, leading to repeated changes in the focus of their initiatives and target completion dates. In reviews in 2001 and 2002, we noted management weaknesses, such as inadequate accountability and poor planning and oversight, and recommended that the departments apply principles of sound project management. In response, by July 2002, DOD and VA had revised their strategy to pursue two initiatives: (1) sharing information in existing systems and (2) developing modernized health information systems— replacing their existing (legacy) systems—that would be able to share data and, ultimately, use interoperable electronic health records. In their shorter-term initiatives to share information from existing systems, the departments began from different positions. VA has one integrated medical information system—the Veterans Health Information Systems and Technology Architecture (VistA)—which uses all electronic records and was developed in-house by VA clinicians and IT personnel. All VA medical facilities have access to all VistA information. In contrast, DOD uses multiple legacy medical information systems (table 1 illustrates selected systems), all of which are commercial software products that are customized for specific uses. Until recently, these systems could not share information. In addition, not all of DOD’s medical information is electronic: certain records are paper-based. As we have reported, the departments’ efforts to share information in their existing systems eventually included several sharing initiatives and exchange projects: The Federal Health Information Exchange (FHIE), completed in 2004, enabled DOD to electronically transfer service members’ electronic health information to VA when the members left active duty. The Laboratory Data Sharing Interface (LDSI), a project established in 2004, allows DOD and VA facilities to share laboratory resources. This interface, now deployed at nine locations, allows the departments to communicate orders for lab tests and their results electronically. The Bidirectional Health Information Exchange (BHIE), also established in 2004, was aimed at allowing clinicians at both departments viewable access to records on shared patients (that is, those who receive care from both departments—for example, veterans may receive outpatient care from VA clinicians and be hospitalized at a military treatment facility). Another benefit of the interface is that it allows DOD sites to see previously inaccessible data at other DOD sites. In the long term, each of the departments aims to develop a modernized system in the context of a common health information architecture that would allow a two-way exchange of health information. The common architecture is to include standardized, computable data; communications; security; and high-performance health information systems: DOD’s Armed Forces Health Longitudinal Technology Application (AHLTA) and VA’s HealtheVet. The departments’ modernized systems are to store information (in standardized, computable form) in separate data repositories: DOD’s Clinical Data Repository (CDR) and VA’s Health Data Repository (HDR). For the two-way exchange of health information, the two repositories are to be linked through an interface named CHDR, which the departments began to develop in March 2004; implementation of the first release of the interface (at one site) occurred in September 2006. Beyond these initiatives, in January 2007, the departments announced a further change to their information-sharing strategy: their intention to jointly determine an approach for inpatient health records. On July 31, 2007, they awarded a contract for a feasibility study and exploration of alternatives. According to the departments, one of the options would be adopting a joint solution, which would be expected to facilitate the seamless transition of active-duty service members to veteran status, and make inpatient health care data on shared patients more readily accessible to both DOD and VA. In addition, the departments believe that a joint development effort could enable them to realize cost savings; however, no decision on a joint system has yet been made. According to the departments, they expect to receive recommendations on possible approaches at the end of July 2008. In our previous work (see Related GAO Products), we pointed out that in view of the many tasks and challenges associated with the departments’ long-term goal of seamless sharing of health information, it was essential that the departments develop a comprehensive project plan to guide these efforts to completion. Accordingly, in 2004, we recommended that the departments develop such a plan for the CHDR interface and that it include a work breakdown structure and schedule for all development, testing, and implementation tasks. Subsequently, the departments began work on the short-term initiatives described, and we raised concerns regarding how all these initiatives were to be incorporated into an overall strategy toward achieving the departments’ goal of a comprehensive, seamless exchange of health information. In response to our concerns, the departments began to develop such a comprehensive plan, which they called the DOD/VA Information Interoperability Plan. To provide input to the plan and determine priorities, in December 2007, the departments established the Joint Clinical Information Board, made up of senior clinical leaders from both departments. The board is responsible for establishing clinical priorities for electronic data sharing between the departments, determining essential health information to be shared, and further identifying and prioritizing data that should be viewable and data that should be computable. The departments produced a draft DOD/VA Information Interoperability Plan in March 2008. According to DOD and VA officials, the draft defines the technical and managerial processes necessary to satisfy the departments’ requirements and guide their activities to completion. According to these officials, review of this draft by senior DOD and VA officials is currently ongoing and is scheduled to be completed by August 2008. DOD and VA have established and implemented mechanisms for electronic sharing of health information, some of which is exchanged in computable form, while other information is viewable only. However, not all electronic health information is yet shared (for example, immunization records and history, data on exposure to health hazards, and psychological health treatment and care records). Further, although VA’s health information is all captured electronically, not all health data collected by DOD are electronic—many DOD medical facilities use paper-based health records. Computable data. Data in computable form are exchanged through the CHDR interface, which links the modernized health data repositories for the new systems that each department is developing. Implementing the interface required the departments to agree on standards for various types of data, put the data into the agreed standard formats, and populate the repositories with the standardized data. Currently, the types of computable health data being exchanged are limited to outpatient pharmacy and drug allergy data. The next type of data to be standardized, included in the repositories, and exchanged is laboratory data. These data are not shared for all patients—only those who are seen at both DOD and VA medical facilities, identified as shared patients, and then “activated.” Once a patient is activated, all DOD and VA sites can access information on that patient and receive alerts on allergies and drug interactions for that patient. According to DOD and VA officials, outpatient pharmacy and drug allergy data were being exchanged on more than 18,300 shared patients as of June 2008; however, officials stated that they are unable to track the number of shared patients currently receiving care from both departments, so the number of patients for whom data could potentially be shared is unknown. Viewable data. Data in viewable form are shared through the BHIE interface. Through BHIE, clinicians can query selected health information on patients from all VA and DOD sites and view current data onscreen almost immediately. Because the BHIE interface provides access to up-to- date information, the departments’ clinicians expressed strong interest in expanding its use. As a result, the departments decided to broaden the capability and expand its implementation. For example, the departments completed a BHIE interface with DOD’s Clinical Data Repository in July 2007, and they began sharing viewable patient vital signs information through BHIE in June 2008. Extending BHIE connectivity could provide both departments with the ability to view additional data in DOD’s legacy systems, until such time as the departments’ modernized systems are fully developed and implemented. According to a DOD/VA annual report and program officials, the departments now consider BHIE an interim step in their overall strategy to create a two-way exchange of electronic health records. Table 1 summarizes the types of health data currently shared via the departments’ various initiatives (including FHIE and LDSI), as well as additional types of data that are currently planned for sharing. As depicted in table 3, DOD and VA are sharing or plan to share a wide range of health information; however, other health information that the departments currently capture has not yet been addressed (for example, immunization records and history and data on exposure to health hazards). Further, although VA’s health information is all captured electronically, many DOD medical facilities continue to rely on paper records. Also, clinical encounters for those enrolled in the military’s TRICARE health care program are not captured in DOD’s electronic health system unless care is received at a military treatment facility. According to the departments’ officials, the DOD/VA Information Interoperability Plan (targeted for approval in August 2008) is to address these and other issues and define tasks required to guide the development and implementation of interoperable, bidirectional, and standards-based electronic health records and capabilities for military and veteran beneficiaries. DOD and VA are in the process of finalizing the plan, and we have not yet performed an assessment. However, if it includes the essential elements needed to guide the departments in achieving their long-term goal of seamless sharing of health information, it could improve the prospects for the successful achievement of this goal. DOD and VA have agreed upon numerous common standards that allow them to share health data, which include standards that are part of current and emerging federal interoperability specifications. The foundation built by this collaborative process has allowed DOD and VA to begin sharing computable health data (the highest level of interoperability). Continuing their historical involvement in efforts to agree upon standards for the electronic exchange of clinical health information, the departments are also participating in recent ongoing standards-related initiatives led by the Office of the National Coordinator for Health Information Technology (within the Department of Health and Human Services). In addition, DOD is taking steps to arrange for certification of its modernized health information system (a customized commercial system) against current standards. The standards agreed to by the two departments are listed in a jointly published common set of interoperability standards called the Target DOD/VA Health Standards Profile. This profile resulted from an effort that took place beginning in 2001, in which the two departments compared their individual standards profiles for compatibility and began converging them. First developed in 2004, the Target Standards Profile is updated annually and is used for reviewing joint DOD/VA initiatives to ensure standards compliance. According to the departments, they anticipate continued updates and revisions to the Target Standards Profile as additional federal standards emerge and are in varying stages of recognition and acceptance by HHS (as previously presented in table 1). The current version of the profile, dated September 2007, includes federal standards (such as data standards established by the Food and Drug Administration and security standards established by the National Institute of Standards and Technology); industry standards (such as wireless communications standards established by the Institute of Electrical and Electronics Engineers and Web file sharing standards established by the American National Standards Institute); and international standards (such as SNOMED CT, which was mentioned earlier, and security standards established by the International Organization for Standardization). The profile also indicates which of these standards support the HHS- recognized use cases and HITSP interoperability specifications. For example, for clinical data on allergy reactions, the departments agreed to use SNOMED CT codes (mentioned previously), which are included as part of HITSP interoperability specifications. In particular, for the two kinds of data now being exchanged in computable form through CHDR (pharmacy and allergy data), DOD and VA adopted National Library of Medicine data standards for medications and drug allergies, as well as SNOMED CT codes for allergy reactions. According to officials, the departments rely on published versions of the library standards, and they can also submit new terms to the National Library of Medicine for inclusion in the standards. Also, the departments can exchange a standardized allergy reaction as long as it is mapped to a SNOMED CT code in each department’s allergy reaction file. If a coded term is not available in the files, clinicians can exchange descriptions of allergy reactions in free text. This standardization was a prerequisite for exchanging computable medical information—an accomplishment that, according to the National Coordinator for Health IT, has not yet been achieved in any other sector. Continuing the departments’ historical involvement in efforts to agree upon standards for the electronic exchange of clinical health information, health officials from both DOD and VA participate as members of the American Health Information Community and HITSP. For example, the 18- member community includes high-level representatives from both DOD (the Assistant Secretary of Defense for Health Affairs) and VA (the Director, Health Data and Informatics, Veterans Health Administration). DOD and VA are members of the HITSP Board and are actively working on several committees and groups (Provider Perspective Technical Committee; Population Perspective Technical Committee; Security, Privacy and Infrastructure Domain Technical Committee; Care Management and Health Records Domain Technical Committee; Administrative and Financial Domain Technical Committee; Harmonization Committee; and Foundation Committee). The National Coordinator indicated that such participation is important and stated that it would not be advisable for DOD and VA to move significantly ahead of the national standards initiative; if they did, the departments might have to change the way their systems share information by adjusting them to the national standards later, as the standards continue to evolve. In addition, according to DOD officials, the department is taking steps to ensure that the electronic health records produced by its modernized health information system, AHLTA, which is a customized commercial software application, are compliant with standards by arranging for certification through the Certification Commission for Healthcare Information Technology. Specifically, version 3.3 of AHLTA, which is still undergoing beta testing, was conditionally certified in April 2007 against 2006 outpatient electronic health record criteria established by the commission. DOD officials stated that AHLTA version 3.3 has been installed at three DOD locations for beta testing and has met specific functionality, interoperability, and security requirements. The commission cannot fully certify this version of AHLTA until it has verified that the system has been in operational use at a medical site. The departments’ efforts to share data and to be involved in standardization activities are important mechanisms for ensuring that their electronic health records are both interoperable and aligned with emerging standards and specifications. To accelerate the departments’ ongoing interoperability efforts, Congress included provisions establishing a joint interagency program office in the National Defense Authorization Act for Fiscal Year 2008. Under the act, the Secretary of Defense and the Secretary of Veterans Affairs were required to jointly develop schedules and benchmarks for setting up the DOD/VA Interagency Program Office, as well as for other activities for achieving interoperable health information (that is, establishing system requirements, acquisition and testing, and implementation of interoperable electronic health records or capabilities). The schedules and benchmarks were due 30 days after passage of the act (February 28, 2008). The departments developed a draft implementation plan defining fiscal years 2008 and 2009 schedules and milestones; the date of the draft was April 25—almost 2 months after the due date. In the effort to set up the program office, the departments appointed an Acting Director from DOD and an Acting Deputy Director from VA on April 17, 2008. According to the Acting Director, they have also detailed staff and provided temporary space and equipment to a transition team. According to this official, through the efforts of the transition team, the departments are currently developing a charter for the office, defining and approving an organizational structure, and preparing to begin recruiting permanent staff for the office, who are expected to number about 30. According to the implementation plan, the departments expect to appoint a permanent Director and Deputy and begin recruiting staff by October 2008. According to the Acting Director, program staff are expected to be in place, and the office is expected to be fully operational by December 2008. According to the departments, $4.94 million was requested to fund the office for fiscal year 2008, which is expected to be received this July. Funding requirements of $6.94 million for fiscal year 2009 were submitted in June. The draft implementation plan includes schedules and milestones for achieving interoperable health information in two stages. The first stage— Interoperability I, to be completed by September 2008—is to address those health data most commonly required by health care providers, as validated by the Joint Clinical Information Board. The first milestone for Interoperability I, sharing vital signs information, has been achieved. The remaining milestones (sharing questionnaires and forms, family history, social history, and other history) are all due September 2008. The second stage—Interoperability II, to be completed by September 2009—is to address additional health information enhancements. However, the information to be covered by these enhancements has not yet been fully defined, and milestone dates are not fully established: According to the plan, the requirements for the Interoperability II enhancements are to be validated by the Joint Clinical Information Board, which sets the clinical priorities for what electronic health information should be shared next. This validation, followed by approval by senior department leadership, was to be complete by June 2008. However, according to department officials, the completion date is now expected to be the end of July 2008. Of 52 milestone dates for Interoperability II, 19 are yet to be determined. For example, milestone dates have not been identified regarding capabilities to share data on exposures to health hazards, immunization records and history, family history, and psychological health treatment and care records. Officials stated that decisions on these milestone dates will depend on clinical priorities, technical considerations, and policy decisions. For example, the exchange of psychological health treatment and care records requires policy decisions regarding appropriate access. Further, according to the implementation plan draft, the plan is intended to serve as a “living document” that will be updated and refined as more detailed information becomes known on planned fiscal year 2008 and fiscal year 2009 initiatives, and as health care information needs change. According to the Acting Director, the draft implementation plan has not been finalized because of remaining uncertainties regarding such issues as space and staffing needs. For example, although the scope of the office’s responsibility is to be for electronic health records and capabilities, the departments’ leadership may broaden its scope to include sharing of personnel and benefits data, which would affect the number of staff required. However, although the implementation plan (as a planning tool) is appropriately a living document, it is nonetheless important to complete the planning and make the decisions needed to finalize the initial plan, particularly in view of the fast approaching September 2009 deadline. Further, according to department officials, the joint interagency program office will play a crucial role in coordinating the departments’ efforts to accelerate their interoperability efforts. An important aspect of this coordination will be managing the further development and implementation of the DOD/VA Information Interoperability Plan, currently under review by senior management. According to these officials, having a centralized office to take on this role will be a primary benefit. However, the effort to set up the program office is still in its early stages. The positions of Director and Deputy Director are not yet permanently filled, permanent staff have not yet been hired, and facilities have not yet been designated for housing the office. Until the program office is fully established, it will not be able to play this crucial role effectively. DOD and VA are currently sharing more health information than ever before, including exchanging some at the highest level of interoperability, that is, in computable form. The departments also have efforts under way to share additional information. Additional issues remaining to be addressed include electronic sharing of the information in paper-based health records and the completion of their long-range plans to develop fully interoperable health information systems. According to the departments, the DOD/VA Information Interoperability Plan is to address these and other issues. Once the plan is finalized and approved by DOD and VA officials, we intend to perform an assessment of the plan. However, if the plan includes the essential elements needed to guide the departments in achieving their long-term goal of seamless sharing of health information, it could improve the prospects for the successful achievement of this goal. Further enhancing interoperability depends on adherence to common standards. The two departments have agreed on standards and are working with each other and federal groups to help ensure that their systems are both interoperable and compliant with current and emerging federal standards. The joint interagency program office is to play a crucial role in accelerating the departments’ efforts to achieve electronic health records and capabilities that allow for full interoperability. However, it is not expected to be fully set up until the end of the year, after which only 9 months will remain to meet the goal of full interoperability between the departments by September 2009. The implementation plan, which was almost 2 months late, remains in draft, with many milestone dates yet to be determined. In view of the short timeframes, without a fully established program office and a finalized implementation plan with set milestones, the departments may be challenged in meeting the required date for achieving interoperable electronic health records and capabilities. To better ensure that the effort by DOD and VA to achieve fully interoperable electronic health record systems or capabilities is accelerated, we recommend that the Secretaries of Defense and Veterans Affairs give priority to fully establishing the Joint Interagency Program Office by expediting efforts to put in place permanent leadership, staff, and facilities and make the necessary decisions to finalize the draft implementation plan. In providing written comments on a draft of this report, the Assistant Secretary of Defense for Health Affairs and the Secretary of Veterans Affairs agreed with our recommendations. (The departments’ comments are reproduced in app.II and app. III, respectively.) DOD stated that high priority will be given to fully establishing the Joint Interagency Program Office, with specific focus on expanding efforts related to permanent leadership, staff, and facilities. DOD also provided technical comments on the draft report, which we incorporated as appropriate. VA’s comments described actions planned or being taken that respond to our recommendations. For example, according to VA, the Deputy Director of the Interagency Program Office is expected to be appointed by October 2008. In addition, VA stated that the departments collaboratively determined the number and type of staff required for the new office and expect to hire permanent staff by December 2008. In this regard, DOD has taken the lead on securing permanent facilities for the program office and is currently working with the General Services Administration to find suitable space. In addition, VA stated the departments are in the process of finalizing the implementation plan and that by October 31, 2008, they expect to identify the milestones and timelines for defining requirements to support interoperable health records. The department noted that the Joint Clinical Information Board is expected to identify, by July 31, 2008, the specific data types and format for sharing that must be achieved by September 2009. If the actions planned or currently under way are properly implemented, they should help ensure that DOD and VA will be successful in meeting their goals for sharing interoperable health information. We are sending copies of this report to the Secretaries of Veterans Affairs and Defense, appropriate congressional committees, and other interested parties. We will also make copies available to others upon request. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov. If you or your staffs have questions about 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. Key contributors to this report are listed in appendix IV. To describe the progress of the Department of Defense (DOD) and Department of Veterans Affairs (VA) to date on developing electronic health records systems or capabilities that allow for full interoperability of personal health care information between the departments, we reviewed our previous work on DOD and VA efforts to develop health information systems, interoperable health records, and interoperability standards to be implemented in federal health care programs. Additionally, we reviewed information gathered from agency documentation and interviews with cognizant DOD and VA officials relating to the departments’ efforts to share electronic health information. Further, we visited a DOD military treatment facility and a VA medical center (Walter Reed Army Medical Center and the Washington, D.C., VA Medical Center), chosen because they were accessible and allowed us to observe the sharing capabilities and functionality of the two departments’ electronic health information systems. To describe steps taken by the departments to ensure that their health records comply with applicable interoperability standards, implementation specifications, and certification criteria of the federal government, we analyzed information gathered from DOD and VA documentation and interviews pertaining to the interoperability standards and implementation specifications that the two departments have agreed to for exchanging health information via their health care information systems. We reviewed documentation and interviewed agency officials from the Department of Health and Human Services’ Office of the National Coordinator for Health Information technology to obtain information regarding the defined federal interoperability standards, implementation specifications, and certification criteria. We also reviewed documentation and interviewed DOD and VA officials from the Joint Clinical Information Board to determine the extent to which the departments have adopted federal interoperability standards, implementation specifications, and certification criteria. To describe efforts to set up the joint interagency program office, we analyzed documentation regarding the establishment of the office and interviewed responsible officials. We conducted this performance audit at VA and DOD sites in the greater Washington, D.C., metropolitan area from March 2008 through July 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. In addition to the contact named above, key contributions were made to this report by Barbara S. Oliver (Assistant Director), Barbara Collier, Kelly Shaw, and Robert Williams, Jr. VA and DOD Health Care: Progress Made on Implementation of 2003 President’s Task Force Recommendations on Collaboration and Coordination, but More Remains to Be Done. GAO-08-495R. Washington, D.C.: April 30, 2008. Health Information Technology: HHS Is Pursuing Efforts to Advance Nationwide Implementation, but Has Not Yet Completed a National Strategy. GAO-08-499T. Washington, D.C.: February 14, 2008. Information Technology: VA and DOD Continue to Expand Sharing of Medical Information, but Still Lack Comprehensive Electronic Medical Records. GAO-08-207T. Washington, D.C.: October 24, 2007. Veterans Affairs: Progress Made in Centralizing Information Technology Management, but Challenges Persist. GAO-07-1246T. Washington, D.C.: September 19, 2007. Information Technology: VA and DOD Are Making Progress in Sharing Medical Information, but Remain Far from Having Comprehensive Electronic Medical Records. GAO-07-1108T. Washington, D.C.: July 18, 2007. Health Information Technology: Efforts Continue but Comprehensive Privacy Approach Needed for National Strategy. GAO-07-988T. Washington, D.C.: June 19, 2007. Information Technology: VA and DOD Are Making Progress in Sharing Medical Information, but Are Far from Comprehensive Electronic Medical Records. GAO-07-852T. Washington, D.C.: May 8, 2007. DOD and VA Outpatient Pharmacy Data: Computable Data Are Exchanged for Some Shared Patients, but Additional Steps Could Facilitate Exchanging These Data for All Shared Patients. GAO-07- 554R.Washington, D.C.: April 30, 2007. Health Information Technology: Early Efforts Initiated but Comprehensive Privacy Approach Needed for National Strategy. GAO-07- 400T. Washington, D.C.: February 1, 2007. Health Information Technology: Early Efforts Initiated, but Comprehensive Privacy Approach Needed for National Strategy. GAO-07- 238. Washington, D.C.: January 10, 2007. Health Information Technology: HHS is Continuing Efforts to Define Its National Strategy. GAO-06-1071T. Washington, D.C.: September 1, 2006. Information Technology: VA and DOD Face Challenges in Completing Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006. Health Information Technology: HHS Is Continuing Efforts to Define a National Strategy. GAO-06-346T. Washington, D.C.: March 15, 2006. Computer-Based Patient Records: VA and DOD Made Progress, but Much Work Remains to Fully Share Medical Information. GAO-05-1051T. Washington, D.C.: September 28, 2005. Health Information Technology: HHS Is Taking Steps to Develop a National Strategy. GAO-05-628. Washington, D.C.: May 27, 2005. Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project Management. GAO-04-687. Washington, D.C.: June 7, 2004. Computer-Based Patient Records: Improved Planning and Project Management Are Critical to Achieving Two-Way VA-DOD Health Data Exchange. GAO-04-811T. Washington, D.C.: May 19, 2004. Computer-Based Patient Records: Sound Planning and Project Management Are Needed to Achieve a Two-Way Exchange of VA and DOD Health Data. GAO-04-402T. Washington, D.C.: March 17, 2004. Computer-Based Patient Records: Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health Systems. GAO-04-271T. Washington, D.C.: November 19, 2003. VA Information Technology: Management Making Important Progress in Addressing Key Challenges. GAO-02-1054T. Washington, D.C.: September 26, 2002. Veterans Affairs: Sustained Management Attention Is Key to Achieving Information Technology Results. GAO-02-703. Washington, D.C.: June 12, 2002. VA Information Technology: Progress Made, but Continued Management Attention Is Key to Achieving Results. GAO-02-369T. Washington, D.C.: March 13, 2002. VA and Defense Health Care: Military Medical Surveillance Policies in Place, but Implementation Challenges Remain. GAO-02-478T. Washington, D.C.: February 27, 2002. VA and Defense Health Care: Progress Made, but DOD Continues to Face Military Medical Surveillance System Challenges. GAO-02-377T. Washington, D.C.: January 24, 2002. VA and Defense Health Care: Progress and Challenges DOD Faces in Executing a Military Medical Surveillance System. GAO-02-173T. Washington, D.C.: October 16, 2001. Computer-Based Patient Records: Better Planning and Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing. GAO-01-459. Washington, D.C.: April 30, 2001.

Summary: Under the National Defense Authorization Act for Fiscal Year 2008, the Department of Defense (DOD) and the Department of Veterans Affairs (VA) are required to accelerate the exchange of health information between the departments and to develop systems or capabilities that allow for full interoperability (generally, the ability of systems to use data that are exchanged) and that are compliant with federal standards. The act also established a joint interagency program office to act as a single point of accountability for the effort, whose function is to implement such systems or capabilities by September 30, 2009. Further, the act required that GAO semi-annually report on the progress made in achieving these goals. For this first report, GAO describes the departments' progress to date in sharing electronic health information, developing electronic health records that comply with federal standards, and setting up the joint interagency program office. To do so, GAO reviewed its past work, analyzed agency documentation, and conducted interviews with agency officials. DOD and VA are sharing some, but not all, electronic health information at different levels of interoperability. Specifically, pharmacy and drug allergy data on about 18,300 patients who receive care from both departments are exchanged at the highest level of interoperability--that is, in computable form; at this level, the data are in a standardized format that a computer application can act on (for example, to provide alerts to clinicians of drug allergies). In other cases, data can be viewed only--a lower level of interoperability that still provides clinicians with important information. However, not all electronic health information is yet shared, and information is still captured on paper at many DOD medical facilities. According to the departments, a DOD/VA Information Interoperability Plan (targeted for approval in August 2008) is to address these and other issues and define tasks required to guide the development and implementation of an interoperable electronic health record capability. If properly developed and implemented, the plan could help the departments achieve the goal of seamless sharing of health information. DOD and VA have agreed upon numerous common standards that allow them to share health data, which include standards that are part of current and emerging federal interoperability specifications. This collaboration provided the essential foundation for the departments to begin sharing computable health data. The departments are currently participating in recent initiatives led by the Office of the National Coordinator for Health Information Technology (within the Department of Health and Human Services) that are aimed at promoting the adoption of federal standards and broader use of electronic health records. These initiatives include identifying relevant existing standards, identifying and addressing overlaps and gaps in the standards, and developing interoperability specifications and certification criteria based on these standards. The involvement of the departments in these activities is an important mechanism for aligning their electronic health records with emerging federal standards. In establishing the joint interagency program office, Congress directed the departments to develop an implementation plan for setting up the office and carrying out related activities (such as validating and establishing requirements for interoperable health capabilities). The departments' effort to set up the program office is still in its early stages. Leadership positions in the office are not yet permanently filled, staffing is not complete, and facilities to house the office have not been designated. Further, the implementation plan is currently in draft, and although it includes schedules and milestones, dates for several activities have not yet been determined (such as implementing a capability to share immunization records), even though all capabilities are to be achieved by September 2009. Without a fully established program office and a finalized implementation plan with set milestones, the departments may be challenged in meeting the required date for achieving interoperable electronic health records and capabilities.