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June 30, 2006: The Honorable Michael Bilirakis: Chairman: Subcommittee on Oversight and Investigations: Committee on Veterans' Affairs: House of Representatives: Subject: VA and DOD Health Care: Efforts to Provide Seamless Transition of Care for OEF and OIF Servicemembers and Veterans: Dear Mr. Chairman: As of the end of March 2006, over 1.3 million[Footnote 1] U.S. military servicemembers had served or were serving in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF).[Footnote 2] These servicemembers, including members of the reserves and National Guard, may be eligible to receive health care from the Department of Veterans Affairs (VA) while serving on active duty or upon separating from active duty. Although the Department of Defense (DOD) provides health care services to servicemembers under TRICARE,[Footnote 3] legislation passed by the Congress in May 1982 authorized VA to provide health care services to servicemembers in time of war or national emergency, when DOD may have insufficient resources to care for casualties.[Footnote 4] Through December 16, 2005, DOD had arranged for 193 active duty servicemembers with serious injuries--traumatic brain injuries and other complex trauma, such as missing limbs--to receive medical and rehabilitative[Footnote 5] care at VA polytrauma rehabilitation centers (PRC).[Footnote 6] In addition, about 30 percent (over 144,000) of the servicemembers who had separated from active duty following service in OEF or OIF have sought VA health care, including over 4,000 who received inpatient care at VA medical facilities. In September 2005, we testified on VA's collaboration with DOD to provide seamless transition of care for servicemembers between DOD and VA health care systems--that is, no interruption of care as the person moves from being a DOD patient to being a VA patient.[Footnote 7] We reported that VA has developed policies and procedures that direct its medical facilities to provide OEF and OIF servicemembers with timely access to care but that the sharing of health information between DOD and VA was limited. You asked us to update the information we provided in our testimony by reviewing the efforts VA is making to inform servicemembers and veterans about VA health care services and to help ensure that there is a seamless transition of care for servicemembers from DOD's to VA's health care system. We addressed the following questions: 1. What outreach efforts has VA made to inform OEF and OIF servicemembers and veterans about the VA health care services that may be available to them? 2. What actions has VA taken to facilitate the seamless transition of medical and rehabilitation care for seriously injured OEF and OIF servicemembers who are transferred between DOD medical treatment facilities (MTF) and PRCs? 3. What special educational activities or clinical tools is VA using to help ensure its medical providers are aware of and recognize the needs of eligible OEF and OIF servicemembers and veterans? To determine outreach efforts VA has made to inform OEF and OIF servicemembers and veterans about the VA health care services that may be available to them, we interviewed, and collected supporting documentation from, VA officials on their efforts and programs that have been established to inform servicemembers and veterans about VA health care services. We also observed briefings given by VA representatives at two military installations[Footnote 8] to active duty and reserve servicemembers about VA health care services for which they may be eligible. To identify actions VA has taken to facilitate the seamless transition of care between MTFs and PRCs for servicemembers seriously injured in OEF and OIF, we reviewed VA directives, policies, and handbooks governing access to VA health care by OEF and OIF servicemembers and veterans. We also visited the two MTFs that treat most of the seriously injured OEF and OIF servicemembers--Walter Reed Army Medical Center and the National Naval Medical Center, both located in the Washington, D.C., area--and the four PRCs that treat them. The PRCs are located at VA Medical Centers in Palo Alto, California; Tampa, Florida; Minneapolis, Minnesota; and Richmond, Virginia. During those visits, we interviewed medical providers and reviewed the VA electronic medical records of the 193 seriously injured servicemembers who were admitted to the PRCs from January 7, 2002,[Footnote 9] through December 16, 2005. In addition, we attended a discharge planning conference for an OIF servicemember being discharged from a PRC to document the information provided to the servicemember about his follow-up health care from VA and DOD. We made subsequent visits to the Richmond and Tampa PRCs to observe the capability of PRC providers to access DOD electronic medical records. To identify the special educational activities or clinical tools that VA is using to help ensure its medical providers are aware of and recognize the needs of eligible OEF and OIF servicemembers and veterans, we interviewed, and collected supporting documentation from, VA officials. While we were at the Naval Station Norfolk conducting audit work, we also visited the VA Medical Center in Hampton, Virginia, to obtain information on the educational activities and clinical tools VA uses when treating OEF and OIF servicemembers and veterans. We also obtained this information from the four PRCs. Further, we determined the number of VA medical providers and other staff who completed online educational courses developed by VA. Our review was conducted from May 2005 through June 2006 in accordance with generally accepted government auditing standards. Results in Brief: VA has made a variety of outreach efforts to provide OEF and OIF servicemembers and veterans and their families with information on VA health care services. VA reported that from October 1, 2000, through May 31, 2006, it provided about 36,000 briefings to almost 1.4 million active duty, reserve, and National Guard servicemembers about VA health care services that may be available to them. In some cases, family members also attended these briefings, which were provided at over 200 sites, including 70 sites outside the United States. VA also maintains a Web site containing health information focused on OEF and OIF servicemembers and veterans, distributes brochures and pamphlets to provide information about topics of interest to OEF and OIF servicemembers and veterans and their families, and sends letters and newsletters to veterans about VA health care services and health issues specific to veterans. VA has taken several actions to facilitate the transition of medical and rehabilitative care for seriously injured servicemembers who are being transferred from MTFs to PRCs. In April 2003, the Secretary of VA authorized VA medical facilities to give priority to OEF and OIF servicemembers over veterans, except those with service-connected disabilities. In April 2004, VA signed a memorandum of agreement (MOA) with DOD that established the referral procedures for transferring injured servicemembers from DOD to VA medical facilities. VA and DOD also established joint programs to ease the transfer of injured servicemembers to VA medical facilities, including a program that assigned VA social workers to selected MTFs to coordinate patient transfers to VA medical facilities. Nevertheless, problems remain in the process for electronically sharing the medical records VA needs to determine whether servicemembers are medically stable enough to participate in vigorous rehabilitation activities. According to VA officials, the transfer could be more efficient if PRC medical personnel had real-time access to the servicemembers' complete DOD electronic medical records from the referring MTFs. VA and DOD reported that as of December 2005 only two of the PRCs had requested and been granted real-time access to the electronic medical records maintained at Walter Reed Army Medical Center. One of these PRCs had also been granted access to the electronic medical records at the National Naval Medical Center. However, problems continue to exist with the PRCs' ability to access DOD electronic medical records. During a visit to the two PRCs in April 2006, we found that neither facility could access the DOD electronic medical records at Walter Reed Army Medical Center because of technical difficulties. Furthermore, while VA's electronic medical record system captures a wide range of patient information, we found that at the time we conducted our audit work it did not always contain a complete record of information related to the patient's discharge from the PRC, such as dates and times of follow-up medical appointments--information that could be useful for maintaining continuity of care or responding to a patient inquiry about future appointments. In response to our concerns about this problem, VA has taken corrective action. The department has developed a template that identifies the information given to servicemembers at discharge from PRCs. The template has been included in VA's electronic medical record for use systemwide. VA has developed a number of educational activities and online clinical tools to help ensure that VA medical providers and other staff are aware of and recognize the health care needs of OEF and OIF servicemembers and veterans. Examples of VA's educational efforts include developing online courses on infectious diseases of Southwest Asia; holding conferences on brain injuries; conducting conference calls, each of which provided more than 100 VA staff with information on transferring servicemembers from DOD to VA health care services; and developing publications on the long-term effects of using an antimalarial drug. VA has also provided educational activities at two East Coast centers targeting medical professionals (such as physicians, nurses, and social workers), including conferences on topics such as physical and mental health issues, infectious disease issues, and health care services provided by VA. Furthermore, VA has developed clinical tools to help its staff be aware of and responsive to the needs of OEF and OIF servicemembers and veterans. For example, it has added reminder screens to its electronic medical records that pop up when staff are accessing patients' records and prompt them to ask questions about OEF-and OIF-related medical and psychological conditions, such as infectious diseases and depression. VA and DOD have also developed guidelines to assist clinicians in providing medical care to OEF and OIF veterans. We provided a draft of this report to VA and DOD for comment. VA concurred with the information presented in our draft report. DOD commented that the report portrays the numerous efforts that have been made to improve the efficacy of programs designed to ensure a smooth transition and continuity of care as servicemembers transition back and forth between DOD and VA health care systems. DOD also stated that the report contained several inaccuracies; however, we maintain that the information contained in the report accurately presents the results of our audit work. Background: DOD has reported that as of June 26, 2006, over 19,000 servicemembers have been wounded in action since the onset of OEF and OIF. Some of these servicemembers are surviving injuries that would have been fatal in past conflicts. In World War II, about 30 percent of American servicemembers wounded in combat died. Because of medical advances, this proportion has dropped to 3 percent for OEF and OIF servicemembers, but many of them are returning home with severe disabilities, including traumatic brain injuries and missing limbs. In 2005, DOD reported that about 65 percent of the OEF and OIF servicemembers wounded in action were injured by blasts and fragments from improvised explosive devices, land mines, and other explosive devices. More recently, DOD estimated in 2006 that the percentage of those injured by blasts and fragments who have some degree of trauma to the brain ranged from less than 20 percent to 28 percent. These injuries may require comprehensive inpatient rehabilitation services to address complex cognitive, physical, and mental health impairments.[Footnote 10] While servicemembers are on active duty, DOD manages where they receive their care--at an MTF, a TRICARE civilian provider, or a VA medical facility.Once discharged from the military or demobilized from the reserves or National Guard, veterans may be eligible to receive care from VA's health care system. From the OEF and OIF conflict areas, seriously injured servicemembers are usually brought to Landstuhl Regional Medical Center in Germany for treatment. From there, they are usually transported to MTFs located in the United States, with most of the seriously injured admitted to Walter Reed Army Medical Center or the National Naval Medical Center. Once seriously injured servicemembers are medically stabilized, DOD can elect to send those with traumatic brain injuries and other complex trauma, such as missing limbs, to one of the four PRCs for rehabilitative services. The transfer of injured servicemembers from MTFs to VA medical facilities for medical care requires the exchange of health information between DOD and VA. In August 1998, the President issued a directive requiring VA and DOD to develop a computer-based patient record system that would accurately and efficiently exchange information between the departments. The directive stated that VA and DOD should define, acquire, and implement a fully integrated computer-based patient record available across the entire spectrum of health care delivery over the lifetime of the patient.[Footnote 11] Since receiving the President's directive, VA and DOD have been working to exchange patient health information electronically and ultimately to have interoperable electronic medical records. VA and DOD have begun to implement applications that exchange limited electronic medical information between the departments' existing health information systems. One of these applications--the Bidirectional Health Information Exchange--is a project to achieve the two-way exchange of health information on patients who receive care from both VA and DOD. The application has been implemented at all VA sites and at 14 DOD sites to exchange information such as pharmacy and allergy data, but as we testified in September 2005, the goal of systemwide two-way electronic exchange of patient records remains far from being realized.[Footnote 12] As a separate effort, VA and DOD have undertaken an initiative to allow the four PRCs to electronically access medical records at Walter Reed Army Medical Center and the National Naval Medical Center to obtain information on seriously injured OEF and OIF servicemembers. The capability for electronic access was requested by the Richmond and Tampa PRCs in 2005 and by the Palo Alto and Minneapolis PRCs in 2006. This capability will be limited to a small number of providers at each of the PRCs. Apart from joint efforts to share medical information, VA and DOD separately have developed electronic systems for recording and accessing patient health information. VA's electronic medical records are maintained in a system that captures a wide range of patient information, including doctors' progress notes, vital signs, laboratory results, medications dispensed, drug allergies, radiological images, and clinical reminders. VA's system also allows the patient's complete medical record to be accessed from any VA medical facility. While DOD's electronic medical record system also captures information such as doctors' progress notes, vital signs, medications dispensed, and laboratory results, it does not include radiological images, vision and hearing tests, or anesthesia notes. In addition, DOD does not have a systemwide approach to electronic medical record management since the information is maintained and stored at individual MTFs or, in some locations, in networks that service multiple MTFs within a small geographic area. Under DOD's approach, all medical information cannot be electronically accessed by providers throughout DOD's health care system. For example, providers at Walter Reed Army Medical Center and the National Naval Medical Center can access each other's electronic medical records but cannot access medical records from Landstuhl Regional Medical Center in Germany. VA's Outreach Includes Briefings, Web Sites, and Newsletters: VA has taken a number of actions to provide OEF and OIF servicemembers and their families with information about VA health care services, such as the cost of the services, how to register for VA health care, and where to obtain VA health care. VA reported that from October 1, 2000, through May 31, 2006, it held about 36,000 briefings for almost 1.4 million active duty, reserve, and National Guard servicemembers. These briefings were held at over 200 sites, including 70 sites located outside the United States. VA reported that over 8,000 family members attended some of these briefings from October 1, 2005, through May 31, 2006. In addition, under a May 2005 MOA between VA and the National Guard, VA has trained staff hired by the National Guard to provide VA health and benefit information to National Guard units in each state. For both servicemembers and veterans, VA has also created a Web site[Footnote 13] that provides information for those who served in OEF and OIF, such as information on VA health and medical services, dependents' benefits and services, and transition assistance from military to civilian life. The Web site contains information about VA benefits available to active duty military personnel, including a page that briefly describes these benefits. VA has also developed a variety of informational materials, including a wallet-sized card with relevant toll-free telephone numbers and Web site addresses, fact sheets and pamphlets summarizing VA benefits, and a monthly video magazine called The American Veteran. VA reported that almost 1.4 million of the wallet- sized cards have been distributed during briefings. Fact sheets and pamphlets are sent to VA medical facilities for distribution to veterans and are also available on VA's Web site. The video magazine reports information about VA services on a VA Web site[Footnote 14] and on the Pentagon Channel, which is available online[Footnote 15] and on cable television. VA also has outreach efforts designed specifically for active duty, reserve, and National Guard OEF and OIF veterans. The Secretary of VA sends new veterans a letter thanking them for their service to the country and informing them about VA health care services and assistance in their transition to civilian life. As of May 15, 2006, the Secretary had sent letters to over 530,000 OEF and OIF servicemembers who had left active duty. These letters include information about the VA health care services available to veterans and a toll-free number for obtaining additional health care information. In addition, from December 2003 through March 2006 VA sent four newsletters to OEF and OIF veterans with information on health issues of interest to these veterans. VA Activities Facilitate the Transition of Care for Seriously Injured OEF and OIF Servicemembers Transferred to PRCs: VA has taken a number of actions to facilitate the transition of medical and rehabilitation care for servicemembers who have been seriously injured in OEF and OIF and are being transferred between DOD and VA medical facilities. These actions focus on establishing and expanding internal initiatives for providing care to this population as well as VA's efforts to electronically share medical records with DOD. In April 2003, when the President declared a national emergency with respect to the Iraq conflict, the Secretary of VA issued a memorandum authorizing VA medical facilities to give priority to servicemembers who sustained injuries in OEF and OIF over veterans and others eligible for VA health care, except those with service-connected disabilities. In October 2003, VA issued a directive requiring its medical facilities to designate a point of contact to receive and expedite transfers of servicemembers from DOD to VA medical facilities. In April 2004, VA signed an MOA with DOD to provide health care and rehabilitation services to servicemembers who sustain spinal cord injury, traumatic brain injury, or visual impairment. The MOA established the referral procedures for transferring active duty inpatient servicemembers from DOD to VA medical facilities.[Footnote 16] In June 2005, VA issued a directive expanding the scope of care it would provide to include psychological treatment for family members and intensive clinical and social work case management services[Footnote 17] at its four regional traumatic brain injury rehabilitation centers and renamed these facilities PRCs. VA has also established joint programs with DOD to ease the transfer of injured servicemembers to VA medical facilities. In August 2003, VA and DOD established a program that assigned VA social workers to selected MTFs[Footnote 18] to coordinate patient transfers between DOD and VA medical facilities. The social workers make appointments for care, ensure continuity of therapy and medications, and follow up with patients after discharge. By late February 2006, VA reported that the social workers had received requests for transfer of care for over 6,000 patients, and over three-fourths of them had been transferred to VA facilities; the rest of the requests were pending.[Footnote 19] Under another program, a uniformed servicemember was stationed at each PRC beginning in March 2005 to assist servicemembers being admitted to the PRC. The uniformed servicemembers serve as liaisons among injured servicemembers and their families, the MTFs, the PRCs, and the servicemembers' units. For example, they assist with reimbursement for travel and lodging costs for immediate family members. In January 2005, VA established the Seamless Transition Office to enhance servicemembers' transition back to civilian life by improving coordination within the Veterans Benefits Administration and the Veterans Health Administration,[Footnote 20] as well as between DOD and VA. The goals of the Seamless Transition Office related to health care include improving communication, coordination, and collaboration within VA and with DOD concerning health care, educating VA staff about OEF and OIF veterans' health care, and other needs. The office has been active in areas such as coordinating efforts of the VA social workers assigned to MTFs to help servicemembers transfer their health care from MTFs to VA health care facilities and issuing a handbook on the policy and procedures for PRCs, including recommended staffing levels for the different types of medical providers caring for patients. There are also a number of routinely scheduled teleconferences and videoconferences within VA and between VA and the military medical facilities to coordinate medical care for injured servicemembers and to discuss and resolve medical issues. Topics include issues that are general in nature and would apply to a number of servicemembers or that are specific to individual servicemembers. For example, monthly, and as needed, VA's Seamless Transition Office and PRC staff hold teleconferences to discuss such issues as obtaining DOD medical records and how to provide follow-up medical care once the servicemember is discharged from the PRC. Further, on a bimonthly basis, PRCs hold teleconferences or videoconferences with Walter Reed Army Medical Center and the National Naval Medical Center to discuss issues arising during the transfer of injured servicemembers from their facilities to the PRCs, such as obtaining military medical records. Servicemembers and their families sometimes participate in the videoconference to meet PRC staff prior to transfer. Also on a monthly basis, VA and DOD hold videoconferences to discuss medical and logistical issues that arise with injured servicemembers. These videoconferences include DOD medical providers from Landstuhl Regional Medical Center in Germany and combat medical units located in Iraq. For example, during one videoconference, VA and DOD staff discussed the blood filters[Footnote 21] that were being surgically implanted in injured servicemembers in Iraq.[Footnote 22] Medical providers in Baghdad asked if there was a different type of blood filter that they could use that would make removal easier at the stateside MTF or PRC. Despite coordination, we found that the departments are having problems exchanging health care information electronically between the four PRCs and the two MTFs--Walter Reed Army Medical Center and the National Naval Medical Center. While our current review focused on the electronic transfer of information among these six facilities, over 5 years ago we recommended that VA and DOD create comprehensive and coordinated plans to ensure that the departments can share comprehensive, meaningful, accurate, and secure patient health data.[Footnote 23] Both VA and DOD concurred with this recommendation and are in the process of implementing it. From a systemwide perspective, we testified over 2 years ago and again last September on the need for VA and DOD to intensify their efforts to implement the capability to share health care information electronically. In those testimonies, we recognized the actions VA and DOD had taken to electronically exchange health information but also acknowledged that much work remains to attain this goal.[Footnote 24] During our visits to the PRCs from October through December 2005, we observed that none of the PRCs had real-time access to the injured servicemembers' DOD electronic medical records from the transferring MTFs. Instead, the MTF faxed copies of some of the medical information, such as the servicemember's medical history and physical and doctor's progress notes from these records, to the PRC. Because this information did not always provide enough data for the PRC provider to determine if the servicemember was medically stable enough to be admitted to the PRC and to engage in vigorous rehabilitation activities and because the PRC did not have access to the complete medical records (paper or electronic), VA developed a standardized list of the minimum types of health care information needed about each servicemember transferring from an MTF. However, after they reviewed this basic medical information PRC providers stated that they frequently needed additional information and had to ask the PRC social worker to obtain it from the VA social worker at the MTF. For example, if the PRC provider noticed that the servicemember was on a particular antibiotic therapy, the provider might request the results of the most recent blood and urine cultures to determine if the servicemember was medically stable enough to participate in strenuous rehabilitation activities. According to PRC officials, obtaining additional medical information in this way rather than electronically was very time consuming and often required multiple phone calls and faxes between the facilities. According to VA officials, the main barrier to PRC medical providers' getting real-time access to medical records was DOD's interpretation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)[Footnote 25] and the HIPAA Privacy Rule.[Footnote 26] The HIPAA Privacy Rule permits VA and DOD to share servicemembers' health information under certain circumstances, such as for purposes of treatment or if the individual signs a proper authorization. However, DOD officials told us they initially were reluctant to provide this access to VA because they were concerned that VA would have access to health information of all servicemembers, not only the information of those being transferred to the PRC for treatment. Since we initiated our review, the four PRCs and Walter Reed Army Medical Center and the National Naval Medical Center have reached separate agreements on the records VA would be able to access and have begun to take action to share medical records.[Footnote 27] During our initial visits, two PRCs--Richmond and Tampa--were in the process of separately negotiating with Walter Reed Army Medical Center to obtain real-time access to injured servicemembers' electronic medical records. VA reported that as of December 27, 2005, PRC providers in Richmond and Tampa have real-time access to these records. The Tampa PRC also gained access to the National Naval Medical Center's electronic medical records on February 21, 2006. VA and DOD officials have not established a date when all PRCs would have real-time access to electronic records at Walter Reed Army Medical Center and the National Naval Medical Center. In April 2006, we revisited the Tampa and Richmond PRCs and found that problems continued with access to DOD electronic medical records. Providers at both PRCs that had been granted electronic access by DOD to obtain medical information stated that they could not always access the DOD electronic records. For example, during our visits neither facility could access the DOD electronic medical records at Walter Reed Army Medical Center because of a technical problem. Furthermore, while a nurse practitioner at the Tampa PRC was able to access the electronic medical records at the National Naval Medical Center, the admitting PRC provider for rehabilitative services could not. While VA's electronic medical records offer ready access to VA medical information for its medical providers, we found that during our site visits some information related to servicemembers' and veterans' discharge from PRCs was not always entered into the records. When servicemembers and veterans are discharged from PRCs, many still require follow-up medical care at VA, DOD, or private-sector facilities. The social worker at the PRC is responsible for arranging follow-up appointments prior to the patient's discharge from the PRC. Information on follow-up appointments and points of contact is provided to the servicemember or veteran during the discharge planning conference, along with a large amount of other medical information and discharge instructions. Our review of 193 servicemembers' VA electronic medical records showed that 126 patients required follow-up medical appointments after discharge from the PRC[Footnote 28]. An examination of the 126 records indicated that appointments were made for 122 of the patients, with the remaining 4 patients instructed to call their local VA medical centers for appointments. However, while the date and time for the appointment was in the electronic medical record, it was not clearly summarized in 96 of 122 of these records, nor was there evidence that it was given to the patient. In addition, 75 of the 122 records did not clearly indicate the points of contact, nor was there evidence that this information was given to the patient. If this information were clearly documented in patients' electronic medical records, it would be available to VA providers who may need it to manage future care. In February 2006, in response to questions we raised during our review, VA developed a template for PRC social workers to complete when a patient is discharged. The social worker includes on the template information on follow-up medical appointments, contact names and telephone numbers for the medical facilities where the servicemember is going to obtain follow-up medical care, military contacts, and PRC contacts. This template is entered into the electronic medical record. During our visit to the Tampa and Richmond PRCs in April 2006, we found that the social workers had been using the templates for patients discharged since mid-March 2006. VA Is Using Courses, Conferences, and Online Clinical Tools to Help Ensure Medical Providers Are Aware of and Recognize Needs of Eligible OEF and OIF Servicemembers and Veterans: VA has developed activities to educate its medical providers and other staff on the health care needs of those who are or have been deployed in OEF and OIF. As part of its Veterans Health Initiatives, VA produced 14 educational courses that address OEF-and OIF-related topics, such as traumatic brain injuries and infectious diseases of Southwest Asia. These courses are available on VA's intranet, over the Internet, and on compact discs. As of December 31, 2005, VA reported that nearly 2,000 courses had been completed by VA staff, including nearly 1,200 courses that were completed by physicians. Also over 12,000 courses were completed by non-VA staff, such as veterans, family members, and staff from veterans service organizations. VA medical centers have also used conferences and in-house presentations to train staff on the needs of OEF and OIF servicemembers and veterans. For example, the Tampa PRC sponsored blast injury conferences in 2004 and 2005 that were attended by physicians, nurses, psychologists, and social workers. In addition, from April 2005 through April 2006, VA held five 1½-hour conference calls for VA social workers that focused on the transfer of care for servicemembers from DOD to VA medical facilities, including information such as ways to be proactive in working with military families as they transition from active duty to veteran status and recognizing the signs and symptoms of stress and post-traumatic stress disorder in returning OEF and OIF veterans. VA reported that attendance for the conference calls ranged from 105 to 360 social workers. VA's educational efforts have also included publications. VA's Under Secretary for Health has issued five informational letters to VA's medical providers offering guidance on OEF-and OIF-related topics. The topics of these letters include the long-term effects of heat-related illnesses and the long-term effects of using an antimalarial drug. In addition, VA's War-Related Illness and Injury Study Centers have produced publications providing information for combat veterans and providers on topics such as management of chronic pain and the effects of exposure to depleted uranium.[Footnote 29] VA's War-Related Illness and Injury Study Centers have also provided educational activities and clinical tools to help medical professionals treat OEF and OIF servicemembers and veterans. In 2004 and 2005 the centers reported that they held three conferences, with a total attendance of more that 450 health care providers, including physicians, nurses, and social workers, that addressed such topics as physical and mental health issues, infectious disease issues, and health care services provided by VA. They also held six workshops from 2003 through 2005 on topics such as patient-provider communication and the recognition and treatment of undiagnosed illnesses, and established Web sites that provide links to their publications and to other sources of education for medical providers. VA has also developed various clinical tools to enhance the ability of its providers and other staff to be aware of and responsive to the needs of OEF and OIF servicemembers and veterans. For example, VA has added reminder screens to its electronic medical records that pop up when a patient's record is opened if the veteran served in the military after September 11, 2001. These screens prompt providers to ask questions about medical and psychological issues related to OEF and OIF veterans, such as infectious diseases and depression. The screens continue to pop up each time the patient's medical record is opened until the information requested is entered into that record. The pop-up reminder screens were the subject of one of the informational letters issued to VA staff. Further, VA and DOD developed 25 guidelines for clinical practice,[Footnote 30] which can be viewed on a VA Web site.[Footnote 31] VA officials stated that any of the guidelines may be used for OEF and OIF servicemembers and veterans depending on their needs. Finally, VA's National Center for Post- Traumatic Stress Disorder and DOD developed the Iraq War Clinician Guide. It addresses the needs of veterans of the Iraq war and is available on a VA Web site.[Footnote 32] Agency Comments and Our Evaluation: VA and DOD reviewed a draft of this report and provided written comments, which appear in enclosures I and II respectively. VA concurred with the information presented in our draft report. It also stated that PRCs' access to DOD's electronic medical records has been a significant challenge for VA in accomplishing its mission. VA further commented that it is justifiably proud of the accomplishments of its dedicated staff in successfully responding to the often overwhelming transitional needs of these young servicemembers and their families. DOD commented that the report portrays the numerous efforts that have been made to improve the efficacy of programs designed to ensure a smooth transition and continuity of care as servicemembers transition back and forth between DOD and VA health care systems. DOD commented that the statements in the draft report concerning its lack of a systemwide approach to electronic medical record management and the inability of providers throughout DOD's health care system to access medical records is completely inaccurate. Our statements are not inaccurate. While our draft report recognizes DOD's long-standing ongoing efforts to achieve the capability to electronically share the complete medical record, we did not find that this capability exists yet at DOD. For example, in March 2006 the Chief Information Officer at the National Naval Medical Center explained to us that MTFs did not have access to electronic medical records at other MTFs across the United States. He told us that while information could be shared among providers linked by a local area network, those providers could not electronically access medical records from other local area networks. Specifically, he noted that providers at Walter Reed Army Medical Center and the National Naval Medical Center can access each other's medical records electronically, but they cannot access medical records from Landstuhl Regional Medical Center in Germany or from MTFs in San Antonio, Texas. He acknowledged that DOD's Armed Forces Health Longitudinal Technology Application (AHLTA)--a comprehensive electronic health record--will allow providers to access medical information. In its comments, DOD also cited the access that AHLTA will provide. However, DOD documentation that describes the system states that it is for outpatient care--only one part of the complete medical record. VA providers treating OEF and OIF servicemembers are in need of information concerning the inpatient care--not just the outpatient care--that servicemembers received at DOD. Furthermore, AHLTA cannot be accessed by all of DOD's providers. In its comments on our draft report DOD stated that AHLTA is not operational at 19 percent of DOD's MTFs and that full deployment is not expected until December 2006. In comparison, VA's system allows the patient's complete medical record to be accessed from any VA medical facility. In its comments, DOD also mentioned that a section of our draft report that described the actions VA has taken to facilitate the transition of care from DOD to VA is misleading. However, the section is an accurate presentation of VA initiatives as presented to us by VA and as observed during our audit work. Furthermore, DOD stated that it transmits certain medical information to VA on a monthly basis, although VA providers told us they need ready electronic access to current medical record information for the seriously injured OEF and OIF servicemembers. We believe that in order to plan and begin appropriate treatment immediately upon a servicemember's arrival at a PRC, medical record information is best provided through direct electronic access, not through monthly transmissions. Our draft report recognized the technical advances that VA has made in that it has the capability to electronically share the complete medical record of each of its beneficiaries among all its providers at all its medical facilities. This means that all medical services provided by VA to its beneficiaries--including information such as outpatient or inpatient procedures, pharmacy, or radiology notes--are included in VA's electronic record. VA and DOD provided technical comments that we incorporated where appropriate. As agreed with your office, unless you publicly announced its contents earlier, we plan no further distribution of this report until 30 days after its report date. We will then send copies of this report to the Secretaries of Veterans Affairs and Defense and appropriate congressional committees. We will also make copies available to others on request. In addition, the report will be available at no charge on GAO's Web site at [Hyperlink, http://www.gao.gov]. If you or your staff have any questions, please contact me at (202) 512- 7101 or bascettac@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are Michael T. Blair, Jr., Assistant Director; Cynthia Forbes; Roseanne Price; Shannon Slawter; and Cherie' Starck. Sincerely yours, Signed by: Cynthia A. Bascetta: Director, Health Care: Enclosures - 2: Comments from the Department of Veterans Affairs: The Deputy Secretary Of Veterans Affairs: Washington, D.C.: June 19, 2006: Ms. Cynthia A. Bascetta: Director: Health Care Team: U. S. Government Accountability Office: 441 G Street, NW: Washington, DC 20548: Dear Ms. Bascetta: The Department of Veterans Affairs (VA) has reviewed the Government Accountability Office's (GAO) draft report, VA AND DOD HEALTH CARE: Efforts to Provide Seamless Transition of Care for OEF and OIF Servicemembers and Veterans (GAO 06-794R) and concurs with the information as presented. Your report cites many of the initiatives that VA has implemented to assure that Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) servicemembers receive timely access to benefits and high quality health care and that their transition from the military to VA is efficient and compassionate. VA and the Department of Defense (DoD) have established a collaborative relationship to respond to the special needs of these soldiers and their families. As GAO reports, seamless transition efforts, particularly for seriously injured combat veterans, rank among VA's highest priorities. The Veterans Health Administration (VHA) has taken the lead in expanding outreach and case management efforts, to facilitate medical treatment and rehabilitation in our polytrauma rehabilitation centers (PRCs). VHA is also developing educational activities and clinical tools to assure that VA clinical staff has the information it requires to recognize the complex challenges inherent in the types of injuries these veterans sustain. Nevertheless, VHA's emphasis continues to focus on ongoing improvement recognizing that VHA must maintain the flexibility necessary to adapt to changing demand. As part of VHA's efforts to monitor its effectiveness, the Office of Seamless Transition is implementing a quality assurance program designed to assess VHA's program through in-depth review of medical records for patients transferred from military facilities to VA facilities. Because the program is still in the early developmental stages, data collection, aggregation and reporting processes are still being refined. We anticipate that valuable trend information will eventually be generated to prompt follow-up corrective actions as indicated at the national and local levels. I agree with GAO that our PRCs' access to DoD electronic medical records has been a significant challenge for VA in accomplishing our mission. Our program managers continue to work in close coordination with DoD to resolve remaining obstacles. As reported, both the Richmond and Tampa PRCs can now access the electronic records from Walter Reed Army Medical Center and Bethesda National Naval Medical Center. The Minneapolis and Palo Alto PRCs have requested the same access, and VHA is pursuing vigorously full record sharing capability with appropriate Army and Navy officials. I anticipate that successful data transfer will be available in the near future. VHA is justifiably proud of the accomplishments of its dedicated staff in successfully responding to the often overwhelming transitional needs of these young servicemembers and their families. I am personally committed to assure that every resource will be used to maintain the highest levels of support in any way that is needed. GAO's report has been very helpful in highlighting our strengths and priorities, and I appreciate the opportunity to comment on it. VA is also providing technical comments separately. Sincerely yours, Signed by: Gordon H. Mansfield: Comments from the Department of Defense: The Assistant Secretary Of Defense: Washington, D. C. 20301-1200: Ms. Cynthia Bascetta: Director, Health Care: U.S. Government Accountability Office: 441 G. Street, N.W. Washington, DC 20548: Jun 15 2006: Dear Ms. Bascetta: This is the Department of Defense (DoD) response to the Government Accountability Office (GAO) draft report, GAO 06-749R, "VA And DOD Health Care: Efforts to Provide Seamless Transition of Care for OEF and OIF Servicemembers and Veterans," dated June 2, 2006 (GAO Code 290463). The Department appreciates the opportunity to provide the attached comments on the draft report. Please direct any questions to my points of contact on this matter, Mr. Kenneth Cox (functional) at (703) 681-0039, ext. 3602 and Mr. Gunther J. Zimmerman (Audit Liaison) at (703) 681-3492, ext. 4065. Sincerely, Signed by: William Winkenwerder, Jr., MD: Enclosures: 1. Overall Comments 2. Technical Comments: GAO Draft Report -Dated June 2, 2006 GAO Code - 290463/GAO-06-794R: "VA And Dod Health Care: Efforts to Provide Seamless Transition of Care for OEF and OIF Service members and Veterans" Department Of Defense Comments: This draft report provides a review of the Department of Veterans Affairs' (VA) and Department of Defense's (DoD) efforts to date to ensure continuity of care for service members injured in Operations Enduring Freedom and Iraqi Freedom. Overall Comments: * The report portrays the numerous efforts that have been made to improve the efficacy of programs designed to ensure a smooth transition and continuity of care as wounded and injured service members transition back and forth between the Military Health System and the Veterans Health Administration. However, the report does contain several inaccuracies that are addressed in the attached technical comments. Key examples are: * The report states that "In addition, DoD does not have a system-wide approach to electronic medical record management since the information is maintained and stored in individual MTFs, or in some locations, in networks that service multiple MTFs within a small geographical area. Under DoD's approach, medical information cannot be accessed by providers throughout DoD's health care system." This statement is completely inaccurate. It does not recognize the current state of DoD's electronic health record development and implementation. DoD began implementation of a standards-based, comprehensive electronic health record, called AHLTA, in January 2004. AHLTA generates, maintains and provides worldwide, secure, round-the- clock online access to health records on our 9.2 million beneficiaries. Authorized health care providers can access patient information regardless of the location where care was provided, as evident during Hurricane Katrina. A key component to AHLTA is the centralized Clinical Data Repository (CDR) which contains electronic clinical records for over 8.04 million beneficiaries. As of June 2, 2006, AHLTA has been implemented at 113 of 139 planned Medical Treatment Facilities with 48,447 of 63,000 total users fully trained to include 16,359 health care providers. Deployment to all planned facilities is scheduled for completion in December 2006. To date, AHLTA has processed over 80,958 patient encounters daily for a cumulative total of over 21 million outpatient encounters, and continues to grow daily. At the time of this study, AHLTA was being implemented at Walter Reed Army Medical Center (September 2005 - April 2006) and National Naval Medical Center Bethesda (September 2005 - May 2006). * The report cites "VA has taken a number of actions to facilitate the transition of medical and rehabilitation care for service members who have been seriously injured in OEF and OIF and are being transferred between DoD and VA medical facilities. These actions focus on establishing and expanding internal initiatives for providing care to this population as well as VA's efforts to electronically share medical records with DoD". This statement is misleading. DoD transmits to VA on a monthly basis: laboratory results, radiology results, outpatient pharmacy data, allergy information, discharge summaries, consult reports, admission, disposition and transfer information, elements of the standard ambulatory data records and demographic data on separated service members. VA providers and benefits specialists access this data daily for use in the delivery of healthcare and claims adjudication. DoD has transmitted messages to the Federal Health Information Exchange (FHIE) data repository on more than 3.5 million unique retired or discharged Service members. This number grows as health information on recently separated Service members is extracted and transferred to VA. Bidirectional Health Information Exchange (BHIE) is a joint DoD and VA initiative which enables real-time sharing of allergy, outpatient pharmacy, demographic, laboratory and radiology data between DoD BHIE sites and all VA Treatment Facilities for patients treated in both DoD and VA. As of May 2006, BHIE is operational at 14 sites (see first technical note, referring to p. 7). DoD also sends electronic pre-and post-deployment health assessment information to the VA. The initial historical data extraction for separated Service members was completed in July 2005 resulting in approximately 400,000 pre-and post-deployment health assessments being sent to the FHIE data repository at the VA Austin Automation Center. Monthly transmission of electronic pre-and post-deployment health assessment data to the FHIE data repository began in September 2005 and has continued each month since then. VA providers began accessing the data in December 2005. Beginning in March 2006, and continuing monthly, pre-and post-deployment health assessment data on Reserve and National Guard members, who were deployed and are now demobilized, is also being transferred to the FHIE data repository. * The report states "According to VA officials, the main barrier to PRC medical providers' getting real-time access to medical records centered on DoD's interpretation of Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA Privacy Rule. The HIPAA Privacy Rule permits DoD and VA to share service members' health information under certain circumstances, such as for purposes of treatment or if the individual signs a proper authorization. However, DoD officials told us they initially were reluctant to provide this access to VA because they were concerned that VA would have access to health information of all service members, not only the information of those being transferred to the PRC for treatment." DoD applies stringent measures to ensure security and privacy of patient health information, to include the use of access control technology, strict role-based password protection, auditing of user actions, encryption, firewalls, de-identification of patient identifiable data during testing, certifications and accreditations, anti-viral software, network and physical security, training and 24 hour intrusion detection monitoring and tracking. Working within these measure's, DoD continues to explore with the VA and other industry partners, such things as the use of virtual private networks and point- to-point networks to securely transmit health information or provision of direct access where appropriate. These issues are not unique to the DoD or VA. The Department of Health and Human Services, Office of National Coordinator, and American Health Information Community are grappling with these very issues regarding the establishment of a national health infrastructure which will support the use of electronic medical records and subsequent data exchange. Security and privacy of data is a key aspect of their considerations. The DoD and VA are actively engaged in these discussions. The recent massive VA information security breach that contained considerable information on active duty military service members highlights the critical importance of getting the appropriate security procedures in place before plunging forward. Related GAO Products: Information Technology: VA and DOD Face Challenges in Completing Key Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006. VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth Transition from DOD Health Care, but Sharing of Health Information Remains Limited. GAO-05-1052T. Washington, D.C.: September 28, 2005. 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. Military and Veterans' Benefits: Improvements Needed in Transition Assistance Services for Reserves and National Guard. GAO-05-844T. Washington, D.C.: June 29, 2005. Military and Veterans' Benefits: Enhanced Services Could Improve Transition Assistance for Reserves and National Guard. GAO-05-544. Washington, D.C.: May 20, 2005. DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers' Transition to VA Services. GAO-05-722T. Washington, D.C.: May 19, 2005. Vocational Rehabilitation: VA Has Opportunities to Improve Services, but Faces Significant Challenges. GAO-05-572T. Washington, D.C.: April 20, 2005. VA Disability Benefits and Health Care: Providing Certain Services to the Seriously Injured Poses Challenges. GAO-05-444T. Washington, D.C.: March 17, 2005. Vocational Rehabilitation: More VA and DOD Collaboration Needed to Expedite Services for Seriously Injured Servicemembers. GAO-05-167. Washington, D.C.: January 14, 2005. 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. 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. (290463): FOOTNOTES [1] DOD's Contingency Tracking System Deployment File for Operations Enduring Freedom and Iraqi Freedom reported that as of March 31, 2006, the total number of servicemembers ever deployed was 1,312,221. [2] OEF, which began in October 2001, supports combat operations in Afghanistan and other locations, and OIF, which began in March 2003, supports combat operations in Iraq and other locations. [3] DOD provides health care through TRICARE--a regionally structured program that uses civilian contractors to maintain provider networks to complement health care services provided at military treatment facilities. [4] The Veterans' Administration and Department of Defense Health Resources Sharing and Emergency Operations Act, Pub. L. No. 97-174, § 4(a), 96 Stat. 70, 74-75. [5] Most servicemembers receive medical care from DOD providers. However, DOD does not typically provide long-term rehabilitative services and looks to VA to be a provider of these services. [6] The Veterans Health Programs Improvement Act of 2004, Pub. L. No. 108-422, § 302, 118 Stat. 2379, 2383-86, mandated that VA establish centers for research, education, and clinical activities related to complex multiple trauma associated with combat injuries. In response to that mandate, VA established PRCs at four VA medical facilities with expertise in traumatic amputation, spinal cord injury, traumatic brain injury, and blind rehabilitation. The PRCs address the rehabilitation needs of the combat injured in one setting and in a coordinated manner. [7] GAO, VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth Transition from DOD Health Care, but Sharing of Health Information Remains Limited, GAO-05-1052T (Washington, D.C.: Sept. 28, 2005). Also see Related GAO Products at the end of this report. [8] VA provides briefings at hundreds of MTFs. We attended briefings at two judgmentally selected installations--the Naval Station Norfolk, Norfolk, Virginia, and Fort Benning Army Base, Columbus, Georgia. [9] Although OEF began in October 2001, the earliest recorded date that a servicemember injured in OEF was admitted to a PRC for treatment was January 7, 2002. [10] Traumatic brain injuries may cause problems with cognition (concentration, memory, judgment, and mood), movement (strength, coordination, and balance), sensation (tactile sensation and vision), and emotion (instability and impulsivity). [11] National Science and Technology Council, A National Obligation: Planning for Health Preparedness for and Readjustment of the Military, Veterans, and Their Families After Future Deployments, Presidential Review Directive 5 (Washington, D.C.: Executive Office of the President, Office of Science and Technology Policy, August 1998). [12] GAO, Computer-Based Patient Records: VA and DOD Made Progress, but Much Work Remains to Fully Share Medical Information, GAO-05-1051T (Washington, D.C.: Sept. 28, 2005). [13] See [Hyperlink, http://www.seamlesstransition.va.gov]. [14] See [Hyperlink, http://www1.va.gov/opa/feature/amervet/index.htm]. [15] See [Hyperlink, http://www.pentagonchannel.mil]. [16] In addition to outlining DOD's and VA's responsibilities in the transfer process, the MOA also established the reimbursement rate between the two departments for inpatient care that VA would provide. [17] Case management includes assessment of the individual's health care needs, care planning and implementation, referral coordination, monitoring, and periodic reassessment of the individual's health care needs. [18] Five MTFs were originally selected because they received most of the OEF and OIF casualties. These facilities were Walter Reed Army Medical Center (Washington, D.C.), Brooke Army Medical Center (San Antonio, Texas), Dwight David Eisenhower Army Medical Center (Augusta, Georgia), Madigan Army Medical Center (Tacoma, Washington), and the National Naval Medical Center (Bethesda, Maryland). In 2004 and 2005, three additional MTFs--Darnall Army Community Hospital (Fort Hood, Texas), Evans Army Community Hospital (Fort Carson, Colorado), and the Naval Hospital Camp Pendleton (Camp Pendleton, California)--were added to care for returning OEF and OIF servicemembers. [19] According to VA, patients remain in pending status until DOD determines that the patient is ready for transfer to a VA facility and VA determines the patient's medical condition is stable. [20] The Veterans Benefits Administration provides benefits and services, such as disability compensation, to veterans. The Veterans Health Administration's primary responsibility is the delivery of health care to veterans. [21] Blood filters are filters that screen blood to remove clots that could result in death. [22] VA officials in attendance included staff from the PRCs and the Seamless Transition Office. DOD officials in attendance included staff from Walter Reed Army Medical Center; the National Naval Medical Center; Brooke Army Medical Center; Wilford Hall Medical Center; Army Institute for Surgical Research; Landstuhl Regional Medical Center in Germany; and combat medical units located in Balad and Baghdad, Iraq. [23] GAO, Computer-Based Patient Records: Better Planning and Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001). [24] GAO, 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.: Mar. 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.: Nov. 19, 2003); and GAO-05-1051T. [25] Pub. L. No. 104-191, 110 Stat. 1936 (1996). [26] The Privacy Rule, which became effective on April 14, 2001, specifies how individually identifiable health information may be used and disclosed by covered entities, which include health plans, health care clearinghouses, and certain health care providers. See 45 C.F.R. §§ 164.500(a), 164.502 (2005). Both TRICARE and the VA health care system are health plans. See 45 C.F.R. § 160.103 (2005). [27] This initiative is a unique undertaking by the four PRCs, Walter Reed Army Medical Center, and the National Naval Medical Center. It is distinct from VA's and DOD's Bidirectional Health Information Exchange. [28] The remaining 67 patients did not need follow-up outpatient appointments because they were still patients in the PRC; had been transferred to another inpatient facility, such as an MTF or VA long- term care facility; or did not need follow-up medical care. [29] In May 2001, VA established the two War-Related Illness and Injury Study Centers, one in Washington, D.C., and one in East Orange, New Jersey. The mission of these centers includes providing health-related educational services to veterans and health care professionals. [30] Clinical practice guidelines are recommendations for treating specific diseases or conditions. [31] See [Hyperlink, http://www.oqp.med.va.gov/cpg/cpg.htm]. [32] See [Hyperlink, http://www.ncptsd.va.gov/war/guide/index.html]. 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