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 important to improving the performance of the U.S. health care system. 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 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. As we have previously noted, 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 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 interoperability—that is, the ability to share data among health care providers. Interoperability enables 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, do not provide decision support capabilities, such as automatic alerts about a particular patient’s health, or other advantages of automation. Interoperability depends on the use of agreed-upon standards to ensure that information can be shared and used. 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. DOD and VA have agreed upon numerous common standards that allow them to share health data. They have also participated in numerous standards- setting organizations tasked to reach consensus on the definition and use of standards. For example, DOD and VA officials serve as members and are actively working on several committees and groups within the Healthcare Information Technology Standards Panel. The panel identifies and harmonizes competing standards and develops interoperability specifications that are needed for implementing the standards. Interoperability can be achieved at different levels. At the highest level, electronic data are computable (that is, in a format that a computer can understand and act on to, for example, provide alerts to clinicians on drug allergies). At a lower level, electronic data are structured and viewable, but not computable. The value of data at this level is that they are structured so that data of interest to users are easier to find. At still a lower level, electronic data are unstructured and viewable, but not computable. With unstructured electronic data, a user would have to find needed or relevant information by searching uncategorized data. Beyond these, paper records also can be considered interoperable (at the lowest level) because they allow data to be shared, read, and interpreted by human beings. According to DOD and VA officials, not all data require the same level of interoperability, nor is interoperability at the highest level achievable in all cases. For example, unstructured, viewable data may be sufficient for such narrative information as clinical notes. Figure 1 shows the distinction between the various levels of interoperability and examples of the types of data that can be shared at each level. DOD and VA have been working to exchange patient health information electronically since 1998. We have previously noted their efforts on three key projects: The Federal Health Information Exchange (FHIE), begun in 2001 and enhanced through its completion in 2004, enables DOD to electronically transfer service members’ electronic health information to VA when the members leave active duty. The Bidirectional Health Information Exchange (BHIE), 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. The interface also allows DOD sites to see previously inaccessible data at other DOD sites. The Clinical Data Repository/Health Data Repository (CHDR) interface, implemented in September 2006, linked the departments’ separate repositories of standardized data to enable a two-way exchange of computable health information. These repositories are a part of the modernized health information systems that the departments have been developing—DOD’s AHLTA and VA’s HealtheVet. In their ongoing initiatives to share information, VA uses its integrated medical information system—the Veterans Health Information Systems and Technology Architecture (VistA)—which was developed in-house by VA clinicians and IT personnel. All VA medical facilities have access to all VistA information. DOD currently relies on its AHLTA, which is comprised of multiple legacy medical information systems that the department developed from commercial software products that were customized for specific uses. For example, CHCS, which was formerly DOD’s primary health information system, is still in use to capture 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. Not all of DOD’s medical facilities yet have this inpatient medical system. To facilitate compliance with the act, the Interagency Clinical Informatics Board, made up of senior clinical leaders from both departments who represent the user community, began establishing priorities for interoperable health data between DOD and VA. In this regard, the board is responsible for determining clinical priorities for electronic data sharing between the departments, as well as what data should be viewable and what data should be computable. Based on its work, the board established six interoperability objectives for meeting the departments’ data sharing needs. According to the former acting director of the interagency program office, DOD and VA consider achievement of these six objectives, in conjunction with capabilities previously achieved (e.g., FHIE, BHIE, CHDR), to be sufficient to satisfy the requirement for full interoperability by September 2009. The six objectives are listed in table 1. Our prior reports on DOD’s and VA’s efforts to develop fully interoperable electronic health records noted their progress and highlighted issues that they needed to address to achieve electronic health record interoperability. Specifically, our July 2008 report noted that the departments were sharing some, but not all, electronic health information at different levels of interoperability. At that time the departments’ efforts to set up the interagency program office were in the early stages. Leadership positions in the office were not permanently filled, staffing was not complete, and facilities to house the office had not been designated. Accordingly, we recommended that the Secretaries of Defense and Veterans Affairs expedite efforts to put in place permanent leadership, staff, and facilities for the program office. The departments agreed with our recommendations and stated that they would take actions to address them. Our January 2009 report noted that the departments had defined plans to further increase their sharing of electronic health information; however, the plans did not contain results-oriented (i.e., objective, quantifiable, and measurable) performance goals and measures that could be used as a basis to track and assess progress. We recommended the departments develop and document such goals and performance measures for the six interoperability objectives, to use as the basis for future assessments and reporting of interoperability progress. DOD and VA agreed with our recommendation and stated that the departments intended to include results-oriented goals in their future plans. DOD and VA continue to take steps toward achieving full interoperability in compliance with applicable standards by September 30, 2009. In this regard, the departments have achieved planned capabilities for three of the interoperability objectives—refine social history data, share physical exam data, and demonstrate initial network gateway operation. The following information further explains DOD’s and VA’s activities with respect to these three objectives. Refine social history data: The departments established this objective to enable DOD to share social history data captured in its electronic health record with VA. These data describe, for example, patients’ involvement in hazardous activities and tobacco and alcohol use. Our review of DOD and VA project documentation confirmed that the departments have achieved sharing of viewable social history data, thus providing VA with additional clinical information on shared patients that clinicians could not previously view. Share physical exam data: The departments established this objective to implement an initial capability for DOD to share with VA the electronic health record information that supports the physical exam process when a service member separates from active military duty. To this end, the departments achieved the capability for VA to view DOD’s medical exam data through the BHIE interface, allowing VA to view outpatient treatment records, pre- and postdeployment health assessments, and postdeployment health reassessments, which are compiled for the DOD physical exam. Demonstrate initial network gateway operation: DOD and VA want to demonstrate the operation of secure network gateways to support health information sharing between the departments. These gateways are to support health record data exchange, thus facilitating future growth in data sharing. As of early July 2009, the departments reported that five network gateways were operational and that data migration to two of the operational gateways had begun.