In their efforts to modernize their health information systems and share medical information, VA and DOD start from different positions. As shown in table 1, VA has one integrated medical information system—the Veterans Health Information Systems and Technology Architecture (VistA)—which uses all electronic records. All 128 VA medical sites thus have access to all VistA information. (Table 1 also shows, for completeness, VA’s planned modernized system and its associated data repository.) In contrast, DOD has multiple medical information systems (table 2 illustrates certain selected systems). DOD’s various systems are not integrated, and its 138 sites do not necessarily communicate with each other. In addition, not all of DOD’s medical information is electronic: some records are paper-based. For nearly a decade, VA and DOD have been undertaking initiatives to exchange data between their health information systems and create comprehensive electronic records. However, the departments have faced considerable challenges in project planning and management, leading to repeated changes in the focus and target completion dates of the initiatives. As shown in figure 1, the departments’ efforts have involved both long- term initiatives to modernize their health information systems and short- term initiatives to respond to more immediate information-sharing needs. The departments’ first initiative was the Government Computer-Based Patient Record (GCPR) project, which aimed to develop an electronic interface that would allow physicians and other authorized users at VA and DOD health facilities to access data from each other’s health information systems. The interface was expected to compile requested patient information in a virtual record (that is, electronic as opposed to paper) that could be displayed on a user’s computer screen. We reviewed the GCPR project in 2001 and 2002, noting disappointing progress exacerbated in large part by inadequate accountability and poor planning and oversight, which raised questions about the departments’ abilities to achieve a virtual medical record. We determined that the lack of a lead entity, clear mission, and detailed planning to achieve that mission made it difficult to monitor progress, identify project risks, and develop appropriate contingency plans. In both years, we recommended that the departments enhance the project’s overall management and accountability. In particular, we recommended that the departments designate a lead entity and a clear line of authority for the project; create comprehensive and coordinated plans that include an agreed-upon mission and clear goals, objectives, and performance measures; revise the project’s original goals and objectives to align with the current strategy; commit the executive support necessary to adequately manage the project; and ensure that it followed sound project management principles. In response, by July 2002, the two departments had revised their strategy, refocusing the project and dividing it into two initiatives. A short-term initiative, the Federal Health Information Exchange (FHIE), was to enable DOD to electronically transfer service members’ health information to VA when the members left active duty. VA was designated as the lead entity for implementing FHIE, which was completed in 2004. A longer-term initiative was to develop 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 (these systems, DOD’s Composite Health Care System II and VA’s HealtheVet VistA, were already in development, as shown in the figure). 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). The two repositories are to exchange information through an interface named CHDR. In March 2004, the departments began to develop the CHDR interface. They planned to begin implementation by October 2005; however, implementation of the first release of the interface (at one site) occurred in September 2006, almost a year beyond the target date. In a report in June 2004, we identified a number of management weaknesses that could have contributed to this delay and made a number of recommendations, including creation of a comprehensive and coordinated project management plan. The departments agreed with our recommendations and took steps to improve the management of the CHDR initiative, designating a lead entity with final decision-making authority and establishing a project management structure. However, as we noted in subsequent testimony, the initiative did not have a detailed project management plan that described the technical and managerial processes necessary to satisfy project requirements (including a work breakdown structure and schedule for all development, testing, and implementation tasks), as we had recommended. In October 2004, responding to a congressional mandate, the departments established two more short-term initiatives: the Laboratory Data Sharing Interface, aimed at allowing VA and DOD facilities to share laboratory resources, and the Bidirectional Health Information Exchange (BHIE), aimed at giving both departments’ clinicians access to records on shared patients (that is, those who receive care from both departments). As demonstration projects, these initiatives were limited in scope, with the intention of providing interim solutions to the departments’ needs for more immediate health information sharing. However, because BHIE provided access to up-to-date information, the departments’ clinicians expressed strong interest in expanding its use. As a result, the departments began planning to broaden this capability and expand its implementation considerably. Extending BHIE connectivity could provide each department with access to most data in the other’s legacy systems, until such time as the departments’ modernized systems are fully developed and implemented. According to a VA/DOD 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 medical records. The departments’ reported costs for the various sharing initiatives and the modernization of their health information systems through fiscal year 2007 are shown in table 3. Beyond these initiatives, in January 2007, the departments announced a further change to their information-sharing strategy: their intention to jointly develop a new inpatient medical record system. On July 31, 2007, they awarded a contract for a feasibility study. According to the departments, adopting this joint solution is expected to facilitate the seamless transition of active-duty service members to veteran status, and make inpatient health care data on shared patients immediately accessible to both DOD and VA. In addition, the departments believe that a joint development effort could enable them to realize significant cost savings. We have not evaluated the departments’ plans or strategy for this new system. Throughout the history of these initiatives, evaluations besides our own have found deficiencies in the departments’ efforts, especially with regard to the lack of comprehensive planning. For example, a recent presidential task force identified the need for VA and DOD to improve their long-term planning. This task force, reporting on gaps in services provided to returning veterans, noted problems in sharing information on wounded service members, including the inability of VA providers to access paper DOD inpatient health records. The task force stated that although significant progress has been made towards sharing electronic information, more needs to be done, and recommended that VA and DOD continue to identify long-term initiatives and define the scope and elements of a joint inpatient electronic health record. In addition, in fiscal year 2006, Congress did not provide all the funding requested for HealtheVet VistA because it did not consider that the funding had been adequately justified. VA and DOD have made progress in both their long-term and short-term initiatives to share health information. In the long-term project to modernize their health information systems, the departments have begun, among other things, to implement the first release of the interface between their modernized data repositories. The departments have also made progress in their short-term projects to share information in existing systems, having completed two initiatives, and are making important progress on another. In addition, the departments have undertaken ad hoc activities to accelerate the transmission of health information on severely wounded patients from DOD to VA’s four polytrauma centers. However, despite the progress made and the sharing achieved, the tasks remaining to reach the goal of a shared electronic medical record are substantial. In their long-term effort to share health information, VA and DOD have completed the development of their modernized data repositories, agreed on standards for various types of data, and begun to populate the repositories with these data. In addition, they have now implemented the first release of the CHDR interface. According to the departments’ officials, all DOD sites can now access the interface, and it is expected to be available across VA when necessary software updates are released. (Currently 103 of 128 VA sites have received these updates.) At 7 sites, VA and DOD are now exchanging limited medical information for shared patients: specifically, computable outpatient pharmacy and drug allergy information. CHDR is the conduit for exchanging computable medical information between the departments. Data transmitted via the interface are permanently stored in each department’s new data repository, CDR, and HDR. Once in the repositories, these computable data can be used by DOD and VA at all sites through their existing systems. CHDR also provides terminology mediation (translation of one agency’s terminology into the other’s). The departments’ plans call for further developing the capability to exchange computable laboratory results data through the interface during fiscal year 2008. Although implementing this interface is an important accomplishment, the departments are still a long way from completing the modernized health information systems and comprehensive longitudinal health records. While DOD and VA had originally projected completion dates of 2011 and 2012, respectively, for their modernized systems, the departments’ officials told us that there is currently no scheduled completion date for either system. VA is evaluating a proposal that would result in completion of its system in 2015; DOD is evaluating the impact of the new study on a joint inpatient medical record and has not indicated a new completion date. Further, both departments have still to identify the next types of data to be stored in the repositories. The departments will then have to populate the repositories with the standardized data.