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. 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 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, 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, 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. Figure 1 shows the distinctions between the various levels of interoperability and examples of the types of data that can be shared at each level. According to DOD and VA officials, not all data require the same level of interoperability. For example, in their initial efforts to implement computable data, DOD and VA 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, unstructured, viewable data may be sufficient. Achieving even a minimal level of electronic interoperability is valuable for potentially making all relevant information available to clinicians. Interoperability depends on adherence to common standards to promote the exchange of health information between participating agencies and with nonfederal entities in supporting quality and efficient health care. In the health IT field, 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 record 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 April 2004, the President called for widespread adoption of interoperable electronic health records by 2014. Health Information established the Office of the National Coordinator for Technology within the Department of Health and Human Services (HHS). This office has been tasked to, among other things, develop, ma direct the implementation of a strategic plan to guide the nationwide implementation of interoperable health IT in both the public and private health care sectors. 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 was created by the Secretary of HHS as a federal advisory body to make recommendatio on how to accelerate the development and adoption of healt including advancing interoperability, identifying health IT standards, advancing a nationwide health information exchange, and protecti ng personal health information. Formed in September 2005, the community is made up of representatives from both the public and private sectors, including high-level DOD and VA officials. The community determines specific health care areas of high priority and develops “use cases” for these areas, which provide the cont ext in which standards would be applicable. The use cases convey how he care professionals would use such records and what standards w apply. Executive Order 13335, Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator (Washington, D.C.: Apr. 27, 2004). The Healthcare Information Technology Standards Panel, sponsored byerican National Standards Institute and funded by the Office of the Am the National Coordinator, was established in October 2005 as a public- private partnership to identify competing standards for the use cases being developed by the American Health Information Community and to “harmonize” the standards. The panel also develops the interoperability specifications that are needed for implementing the standards. Interoperability specifications were developed fo the seven use cases developed by the American Health Information Community in 2006 and 2007. The community also developed six use cases for 2008. The Healthcare Information Technology Standards Panel is made up of representatives from both the public and private sectors, including DOD and VA officials who serve as members and a actively working on several committees and groups within the panel. DOD and VA have been working to exchange patient health data electronically since 1998. As we have previously noted, their effo included both short-term initiatives to share information in existing (legacy) systems, as well as a long-term initiative to develop moderni zed health information systems—replacing their legacy systems—that would be able to share data and, ultimately, use interoperable electronic health records. In their short-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 Systemsand 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, all of which are commercial software products that are customized for specific uses. For example, the Composite Health Care System (CHCS), which was formerly DOD’s primary health information system, is still in use to capture pharmacy, radiology, and laboratory information. In addition, the Clinical Information System (CIS), a commercial health information system customized for DOD, is used to support inpatient treatment at military medical facilities. The departments’ short-term initiatives to share information in their existing systems have included the following projects: The Federal Health Information Exchange (FHIE), completed in 2004, enables DOD to electronically transfer service members’ electronic health information to VA when the members leave active duty. he Bidirectional Health Information Exchange (BHIE), also T established in 2004, was aimed at allowing clinicians at both departments viewable access to records on shared patients (t those who receive care from both departments—for example, vetera ns may receive outpatient care from VA clinicians and be hospitalized at a hat is, military treatment facility). The interface also allows DOD sites to see previously inaccessible data at other DOD sites. As part of the long-term initiative, 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, in September 2006 the departments implemented an interface named CHDR, to link the two repositories. Beyond these initiatives, in January 2007, the departments announced 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. In December 2008, the contractor provide the departments with a recommended strategy for jointly developing an inpatient solution. In reporting on the departments’ progress toward developing fully interoperable electronic health records in July 2008, we highlighted several findings: DOD and VA had established and implemented mechanisms to achieve sharing of electronic health information at different levels of interoperability. As of June 2008, pharmacy and drug allergy data on about 18,300 shared patients were being exchanged at the highest level of interoperability—that is, in computable form, a standardized format that a computer application can act on (for example, to provide alerts to clinicians of drug allergies).