Historically, patient health information has been scattered across paper records kept by many different caregivers in many different locations, making it difficult for a clinician to access all of a patient’s health information at the time of care. Lacking access to these critical data, a clinician may be challenged in making the most informed decisions on treatment options, potentially putting the patient’s health at risk. The use of technology to electronically collect, store, retrieve, and transfer clinical, administrative, and financial health information has the potential to improve the quality and efficiency of health care. Electronic health records are particularly crucial for optimizing the health care provided to military personnel and veterans. While in active military status and later as veterans, many DOD and VA personnel, along with their family members, tend to be highly mobile and may have health records residing at multiple medical facilities within and outside the United States. Each department operates separate electronic health record systems that they rely on to create and manage patient health information. In particular, DOD currently relies on AHLTA, which comprises multiple legacy medical information systems that were developed from commercial software products and customized for specific uses. For example, the Composite Health Care System (CHCS), which was formerly DOD’s primary health information system, is used to capture information related to pharmacy, radiology, and laboratory order management. In addition, the department uses Essentris (also called the Clinical Information System), a commercial health information system customized to support inpatient treatment at military medical facilities. For its part, VA currently uses its integrated medical information system— VistA—which was developed in-house by VA clinicians and information technology (IT) personnel. 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. The sharing of health information among organizations is especially important because the health care system is highly fragmented, with care and services provided in multiple settings, such as physician offices and hospitals, that may not be able to coordinate patient medical care records. Thus, a means for sharing information among providers, such as between DOD’s and VA’s health care systems, is achieving interoperability. The Office of the National Coordinator for Health IT (ONC), within the Department of Health and Human Services, has issued draft guidance,describing interoperability as: 1. the ability of systems to exchange electronic health information and 2. the ability to use the electronic health information that has been exchanged from other systems without special effort on the part of the user. Similarly, the fiscal year 2014 NDAA defines interoperability, as used in the provision governing the departments’ electronic health records, as “the ability of different electronic health records systems or software to meaningfully exchange information in real time and provide useful results to one or more systems.” Thus, in these contexts, interoperability allows patients’ electronic health information to be available from provider to provider, regardless of where the information originated. Achieving interoperability depends on, among other things, the use of agreed-upon health data standards to ensure that information can be shared and used. If electronic health records conform to interoperability standards, they potentially can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization, thus providing patients and their caregivers the information needed for optimal care. Information that is electronically exchanged from one provider to another must adhere to the same standards in order to be interpreted and used in electronic health records, thereby permitting interoperability. In the health IT field, standards may govern areas ranging from technical issues, such as file types and interchange systems, to content issues, such as medical terminology. On a national level, ONC has been assigned responsibility for identifying health data standards and technical specifications for electronic health record technology and overseeing the certification of this technology. In addition to exchanging the information, systems must be able to use the information that is exchanged. Thus, electronic health record technology has the potential to improve the quality of care that patients receive and to reduce health care costs, if the technology is used in a way that improves providers’ and patients’ access to critical information. For example, with interoperability, medical providers have the ability to query data from other sources while managing chronically ill patients, regardless of geography or the network on which the data resides. Since 1998, DOD and VA have relied on a patchwork of initiatives involving their health information systems to exchange information and to increase electronic health record interoperability. These have included initiatives to share viewable data in existing (legacy) systems; link and share computable data between the departments’ updated health data repositories; develop a virtual lifetime electronic health record to enable private sector interoperability; implement IT capabilities for the first joint federal health care center; and jointly develop a single integrated system. Table 1 provides a brief description of the history of these various initiatives. In addition to the initiatives mentioned in table 1, DOD and VA previously responded to provisions in the fiscal year 2008 NDAA directing the departments to jointly develop and implement fully interoperable electronic health record systems or capabilities in 2009.called for the departments to set up an interagency program office to be a single point of accountability for their efforts to implement these systems or capabilities by the September 30, 2009, deadline. In January 2009, the IPO completed its charter, articulating, among other things, its mission and functions with respect to attaining interoperable electronic health data. The act also Further, the departments’ Interagency Clinical Informatics Boardestablished the following six interoperability objectives for meeting the departments’ data-sharing needs and facilitating compliance with the fiscal year 2008 NDAA: demonstrate initial network gateway operation, expand questionnaires and self-assessment tools, expand Essentris in DOD, and demonstrate initial document scanning between the departments. refine social history data, share physical exam data, The departments’ officials, including the co-chairs of the group responsible for representing the clinician user community, asserted that they had met the priorities established by the Interagency Clinical Informatics Board and, in conjunction with capabilities previously attained (e.g., the Federal Health Information Exchange and the Bidirectional Health Information Exchange), had met the deadline for achieving full interoperability as required by the act. Nonetheless, in prior reviews, we have identified a number of challenges the departments have faced in managing their efforts in response to the fiscal year 2008 NDAA and to address their common health IT needs. While these initiatives, collectively, have yielded increased data sharing in various capacities, we previously reported that they nonetheless experienced persistent management challenges and did not result in the fully interoperable electronic health record capabilities that the departments had long sought. We have also noted that the manner in which DOD and VA reported progress toward achieving interoperability lacked results-oriented (i.e., objective, quantifiable, and measurable) goals. Specifically, we noted that the departmental plans lacked associated performance goals and measures that are a necessary basis to provide the departments and their stakeholders with a comprehensive picture to effectively manage their progress toward realizing increased interoperability. In March 2011, the Secretaries of Defense and Veterans Affairs committed the two departments to the development of a new, joint integrated electronic health record (iEHR) system. Further, in May 2012, they announced their goal of implementing the integrated health record across both departments by 2017. According to program documentation, pursuing iEHR was expected to enable the departments to align resources and investments with common business needs and programs, resulting in a platform that would replace the two departments’ separate electronic health record systems with a common system. In addition, because it would involve both departments using the same system, this approach was expected to largely sidestep the challenges they had historically encountered in trying to achieve interoperability between separate systems. Toward this end, initial development plans called for the single, joint iEHR system to consist of 54 clinical capabilities that would be delivered in six increments between 2014 and 2017, with all existing applications in VistA and AHLTA continuing uninterrupted until full delivery of the new capabilities. The initiative was to deliver several common infrastructure components—an enterprise architecture;user interface; data centers; and system interface and data exchange standards. The system was to be primarily built by purchasing commercially available solutions for joint use, with noncommercial solutions developed or adopted only when a commercial alternative was unavailable. However, in February 2013, about 2 years after initiating iEHR, the departments’ Secretaries announced changes to their approach— essentially abandoning their effort to develop a single, integrated electronic health record system for both departments. This decision resulted from an assessment of the iEHR program that the Secretaries had requested in December 2012 because of their concerns about the program facing challenges in meeting deadlines, costing too much, and taking too long to deliver capabilities. The IPO reported spending about $564 million on iEHR between October 2011 and June 2013. In place of the iEHR initiative, DOD determined that it would buy a commercially available system to replace its existing AHLTA system and VA decided that it would modernize its existing VistA health information system. In this regard, DOD is pursuing the acquisition of a replacement system for its multiple legacy electronic health record systems under a new program—the DHMSM program. For its part, VA intends to enhance and modernize its existing VistA system under a new program called VistA Evolution. The departments indicated that they would ensure interoperability between their two new systems, and with other public and private health care providers. In December 2013, the IPO was re-chartered and recognized as the single point of accountability in the development and implementation of electronic health records systems or capabilities that allow for full interoperability of health care information between DOD and VA.