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Exchange Health Data Could Benefit from Improved Planning and Project 
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Report to the Chairman, Subcommittee on Oversight and Investigations, 
Committee on Veterans' Affairs, House of Representatives:

United States General Accounting Office:

GAO:

June 2004:

Computer-Based Patient Records:

VA and DOD Efforts to Exchange Health Data Could Benefit from Improved 
Planning and Project Management:

GAO-04-687:

GAO Highlights:

Highlights of GAO-04-687, a report to the Subcommittee on Oversight and 
Investigations, House Committee on Veterans' Affairs 

Why GAO Did This Study:

A critical element of the Department of Veterans Affairs’ (VA) 
information technology program is its continuing work with the 
Department of Defense (DOD) to achieve the ability to exchange patient 
health care information and create electronic medical records for use 
by veterans, active-duty military personnel, and their health care 
providers.

This report provides an assessment of the departments’ recent progress 
toward achieving an electronic two-way exchange of health care data, 
along with recommendations based on GAO’s work.

What GAO Found:

While VA and DOD continue to move forward in agreeing to and adopting 
standards for clinical data, they have made little progress since last 
winter toward defining how they intend to achieve an electronic 
medical record based on the two-way exchange of patient health data. 
The departments continue to face significant challenges in achieving 
this capability. 

* VA and DOD lack an explicit architecture—a blueprint—that provides 
details on what specific technologies will be used to achieve the 
electronic medical record by the end of 2005.
* The departments have not fully implemented a project management 
structure that establishes lead decision-making authority and ensures 
the necessary day-to-day guidance of and accountability for their 
investment in and implementation of this project.
* They are operating without a project management plan describing the 
specific responsibilities of each department in developing, testing, 
and deploying the electronic interface.

In seeking to provide a two-way exchange of health information between 
their separate health information systems, VA and DOD have chosen a 
complex and challenging approach—one that necessitates the highest 
levels of project discipline. Yet critical project components are 
currently lacking. As such, the departments risk investing in a 
capability that could fall short of what is expected and what is 
needed. Until a clear approach and sound planning are made integral 
parts of this initiative, concerns about exactly what capabilities VA 
and DOD will achieve—and when—will remain.

What GAO Recommends:

To help ensure progress by the departments in achieving the two-way 
exchange of health information, GAO recommends that the Secretaries of 
Veterans Affairs and Defense develop an architecture for the systems’ 
electronic interface, establish a project management structure that 
designates a lead decision-making entity, and create and implement a 
coordinated project plan for developing the interface between the 
departments’ health information systems. In commenting on a draft of 
this report, the departments agreed with our recommendations and 
identified actions planned or undertaken to address them.

www.gao.gov/cgi-bin/getrpt?GAO-04-687.

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Linda D. Koontz at (202) 
512-6240 or koontzl@gao.gov.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

The Two-Way Exchange Could Benefit from Improved Planning and Project 
Management:

Conclusions:

Recommendations for Executive Action:

Agency Comments:

Appendix I: Comments from the Secretary of Veterans Affairs:

Appendix II: Comments from the Director, Interagency Program 
Integration & External Liaison for Health Affairs:

United States General Accounting Office:

Washington, DC 20548:

June 7, 2004:

The Honorable Steve Buyer: 
Chairman, Subcommittee on Oversight and Investigations: 
Committee on Veterans' Affairs: 
House of Representatives:

Dear Mr. Chairman:

As you know, the Departments of Veterans Affairs (VA) and Defense (DOD) 
are currently pursuing the ability to exchange patient health care data 
and create an electronic medical record for veterans and active-duty 
military personnel. While in military status and later as veterans, 
many patients tend to be highly mobile and may have health records 
residing at multiple medical facilities within and outside of the 
United States. Having readily accessible medical data on these 
individuals is important to providing high-quality health care to them 
and to adjudicating any disability claims that they may have. This goal 
of having electronic medical records that display all available 
clinical information in each department's health information system is 
a positive and necessary step. However, as we have previously 
reported,[Footnote 1] the lack of progress the departments have made in 
accomplishing this two-way exchange of health care data raises doubts 
as to when and to what extent a true electronic medical record will be 
achieved.

As requested, our objective was to assess VA's and DOD's recent 
progress toward achieving an electronic two-way exchange of health care 
data. In conducting our work, we analyzed key documentation supporting 
VA's and DOD's strategy for developing and implementing the two-way 
electronic exchange of health data. In addition, we reviewed 
documentation to identify the costs incurred by VA and DOD in 
developing technology to support the sharing of health data, including 
costs for the Government Computer-Based Patient Record/Federal Health 
Information Exchange (GCPR/FHIE) initiatives, DOD's Composite Health 
Care System II, and VA's HealtheVet VistA. We did not audit the 
reported costs, and thus, cannot attest to their accuracy or 
completeness. We supplemented our analyses with interviews of VA and 
DOD officials responsible for key decisions and actions on the 
initiatives. Our work was performed at VA and DOD offices located in 
the Washington, D.C., area in accordance with generally accepted 
government auditing standards, from December 2003 to May of this year.

Results in Brief:

While VA and DOD have continued to define data standards that are 
essential to facilitating the exchange of data, they have made little 
progress toward defining just how they intend to achieve the two-way 
exchange of patient health data between their two health information 
systems currently under development. Although VA officials recognize 
the importance of having an architecture that describes in detail how 
they plan to develop an electronic interface between those systems, 
they acknowledge that the departments' efforts continue to be guided by 
a less specific, high-level strategy that has been in place since 
September 2002. Compounding the challenge and uncertainties of 
developing the electronic interface is that VA and DOD have not fully 
established a project management structure to ensure the necessary day-
to-day guidance of and accountability for the departments' investment 
in and implementation of this capability. Although maintaining that 
they were collaborating on this initiative through a joint working 
group and receiving oversight from executive-level councils, neither 
department has the authority to make final project decisions binding on 
the other. Further, the departments are operating without a project 
management plan describing the specific responsibilities of VA and DOD 
in developing, testing, and deploying the interface. In the absence of 
an explicit architecture and critical project management, VA and DOD 
are progressing slowly in their development of the interface and their 
limited progress to date calls into question the departments' ability 
to begin exchanging patient health information by their targeted date 
of the end of 2005.

Given the implications that readily accessible medical data can have 
for improving the quality of health care and disability claims 
processing for military members and veterans, we are recommending that 
the Secretaries of Veterans Affairs and Defense take a number of 
actions to improve the likelihood of successfully achieving the two-way 
exchange of medical data.

In commenting on a draft of this report, the Secretary of Veterans 
Affairs and DOD's Interagency Program Integration and External Liaison 
for Health Affairs agreed with the report's recommendations. In their 
comments, they provided information on actions planned or undertaken to 
improve program management.

Background:

Since 1998 VA and DOD have been trying to achieve the capability to 
share patient health care data electronically. The original effort--the 
government computer-based patient record (GCPR) project--included the 
Indian Health Service (IHS) and was envisioned as an electronic 
interface that would allow physicians and other authorized users at VA, 
DOD, and IHS health facilities to access data from any of the other 
agencies' health information systems. The interface was expected to 
compile requested patient information in a virtual record that could be 
displayed on a user's computer screen.

Our prior reviews of the GCPR project 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. Accordingly, reporting on 
this project[Footnote 2] in April 2001 and again in June 2002, we made 
several recommendations to help strengthen the management and oversight 
of GCPR. Specifically, in 2001 we recommended that the participating 
agencies (1) designate a lead entity with final decision-making 
authority and establish a clear line of authority for the GCPR project, 
and (2) create comprehensive and coordinated plans that included an 
agreed-upon mission and clear goals, objectives, and performance 
measures, to ensure that the agencies could share comprehensive, 
meaningful, accurate, and secure patient health care data. In 2002, we 
recommended that the participating agencies revise the original goals 
and objectives of the project to align with their current strategy, 
commit the executive support necessary to adequately manage the 
project, and ensure that it followed sound project management 
principles. VA and DOD took specific measures in response to our 
recommendations for enhancing overall management and accountability of 
the project.

By July 2002, VA and DOD had revised their strategy and had made some 
progress toward electronically sharing patient health data. The two 
departments had renamed the project the Federal Health Information 
Exchange (FHIE) program and, consistent with our prior recommendation, 
had finalized a memorandum of agreement designating VA as the lead 
entity for implementing the program. This agreement also established 
FHIE as a joint effort that would allow the exchange of health care 
information in two phases. The first phase, completed in mid-July 2002, 
enabled the one-way transfer of data from DOD's existing health 
information system to a separate database that VA clinicians could 
access. A second phase, finalized this past March, completed VA's and 
DOD's efforts to add to the base of patient health information 
available to VA clinicians via this one-way sharing capability. The 
departments reported total GCPR/FHIE costs of about $85 million through 
fiscal year 2003.

The revised strategy also envisioned the pursuit of a longer term, two-
way exchange of health information between DOD and VA.[Footnote 3] 
Known as HealthePeople (Federal), this initiative is premised upon the 
departments' development of a common health information architecture 
comprising standardized data, communications, security, and high-
performance health information systems. The joint effort is expected to 
result in the secured sharing of health data required by VA's and DOD's 
health care providers between systems that each department is currently 
developing--DOD's Composite Health Care System (CHCS) II and VA's 
HealtheVet VistA.

DOD began developing CHCS II in 1997 and has completed the development 
of its associated clinical data repository--a key component for the 
planned electronic interface. The department expects to complete 
deployment of all of its major system capabilities by September 
2008.[Footnote 4] It reported expenditures of about $464 million for 
the system through fiscal year 2003. VA began work on HealtheVet VistA 
and its associated health data repository in 2001, and expects to 
complete all six initiatives comprising this system in 2012.[Footnote 
5] VA reported spending about $120 million on HealtheVet VistA through 
fiscal year 2003.

Under the HealthePeople (Federal) initiative, VA and DOD envision that, 
upon entering military service, a health record for the service member 
will be created and stored in DOD's CHCS II clinical data repository. 
The record will be updated as the service member receives medical care. 
When the individual separates from active duty and, if eligible, seeks 
medical care at a VA facility, VA will then create a medical record for 
the individual, which will be stored in its health data repository. 
Upon viewing the medical record, the VA clinician would be alerted and 
provided access to the individual's clinical information residing in 
DOD's repository. In the same manner, when a veteran seeks medical care 
at a military treatment facility, the attending DOD clinician would be 
alerted and provided with access to the health information in VA's 
repository. According to the departments, this planned approach would 
make virtual medical records displaying all available patient health 
information from the two repositories accessible to both departments' 
clinicians. VA officials have stated that they anticipate being able to 
exchange some degree of health information through an interface of 
their health data repository with DOD's clinical data repository by the 
end of calendar year 2005.

The Two-Way Exchange Could Benefit from Improved Planning and Project 
Management:

While VA and DOD are making progress in agreeing to and adopting 
standards for clinical data,[Footnote 6] they continue to face 
significant challenges in providing a virtual medical record based on 
the two-way exchange of data as part of their HealthePeople (Federal) 
initiative. Specifically, VA and DOD do not have:

* an explicit architecture that provides details on what specific 
technologies they will use to achieve the exchange capability;

* a fully established project management structure that will ensure the 
necessary day-to-day guidance of and accountability for the 
departments' investment in and implementation of the exchange; and:

* a project management plan describing the specific responsibilities of 
each department in developing, testing, and deploying the interface and 
addressing security requirements.

System Architecture Not Developed:

VA's and DOD's ability to exchange data between their separate health 
information systems is crucial to achieving the goals of HealthePeople 
(Federal). Yet, successfully sharing health data between the 
departments via a secure electronic interface between each of their 
data repositories can be complex and challenging, and depends 
significantly on the departments' having a clearly articulated 
architecture, or blueprint, defining how specific technologies will be 
used to achieve the interface. Developing, maintaining, and using an 
architecture is a best practice in engineering information systems and 
other technological solutions. An architecture would articulate, for 
example, the system requirements and design specifications, database 
descriptions, and software descriptions that define the manner in which 
the departments will electronically store, update, and transmit their 
data.

VA and DOD lack an explicit architecture that provides details on what 
specific technologies they will use to achieve the exchange capability, 
or just what they will be able to exchange by the end of 2005--their 
projected date for having this capability operational. While VA 
officials stated that they recognize the importance of a clearly 
defined architecture, they acknowledged that the departments' actions 
were continuing to be driven by the less specific, high-level strategy 
that has been in place since September 2002.

Officials in both departments stated that a planned pharmacy prototype 
initiative, begun this past March in response to requirements of the 
National Defense Authorization Act of 2003,[Footnote 7] would assist 
them in defining the electronic interface technology needed to exchange 
patient health information. The act mandated that VA and DOD develop a 
real-time interface, data exchange, and capability to check 
prescription drug data for outpatients by October 1, 2004. In late 
February, VA hired a contractor to develop the planned prototype but 
the departments had not yet fully determined the approach or 
requirements for it. DOD officials stated that the contractor was 
expected to more fully define the technical requirements for the 
prototype. In late April, the departments reported approval of the 
contractor's requirements and technical design for the prototype.

While the pharmacy prototype may help define a technical solution for 
the two-way exchange of health information between the two departments' 
existing systems, there is no assurance that this same solution can be 
used to interface the new systems under development. Because the 
departments' new health information systems--major components of 
HealthePeople (Federal)--are scheduled for completion over the next 4 
to 9 years, the prototype may only test the ability to exchange data in 
VA's and DOD's existing health systems. Thus, given the uncertainties 
regarding what capabilities the pharmacy prototype will demonstrate, it 
is difficult to predict how or whether the prototype initiative will 
contribute to defining the architecture and technological solution for 
the two-way exchange of patient health information for the 
HealthePeople (Federal) initiative.

Fully Established Project Management Structure Not in Place:

Industry best practices and information technology project management 
principles stress the importance of accountability and sound planning 
for any project, particularly an interagency effort of the magnitude 
and complexity of HealthePeople (Federal). Based on our past work, we 
have found that a project management structure should establish 
relationships between managing entities with each entity's roles and 
responsibilities clearly articulated.[Footnote 8] Further, it is 
important to establish final decision-making authority with one entity.

However, VA and DOD have not fully established a project management 
structure that will ensure the necessary day-to-day guidance of and 
accountability for the departments' investment in and implementation of 
the two-way capability. According to officials in both departments a 
joint working group and oversight by the Joint Executive Council and 
VA/DOD Health Executive Council has provided the collaboration 
necessary for HealthePeople (Federal).[Footnote 9] However, this 
oversight by the executive councils is at a very high level, occurs 
either bimonthly or quarterly, and encompasses all of the joint 
coordination and sharing efforts for health services and resources. 
Since a lead entity has not been designated, neither department has had 
the authority to make final project decisions binding on the other. 
Further, the roles and responsibilities for each department have not 
been clearly articulated. Without a clearly defined project management 
structure, accountability and a means to monitor progress are difficult 
to establish.

In early March, VA officials stated that the departments had designated 
a program manager for the planned pharmacy prototype and were 
establishing roles and responsibilities for managing the joint 
initiative to develop an electronic interface. Just this month, 
officials from both departments told us that this individual would be 
the program manager for the electronic interface. However, they had not 
yet designated a lead entity or provided documentation for the project 
management structure or their roles and responsibilities for the 
HealthePeople (Federal) initiative.

Project Management Plan Lacking:

An equally important component necessary for guiding the development of 
the electronic interface is a project management plan. Information 
technology project management principles and industry best 
practices[Footnote 10] emphasize that a project management plan is 
needed to define the technical and managerial processes necessary to 
satisfy project requirements. Specifically, the plan should include, 
among other things, the authority and responsibility of each 
organizational unit; a work breakdown structure for all of the tasks to 
be performed in developing, testing, and deploying the software, along 
with schedules associated with the tasks; and a security policy.

However, the departments are currently operating without a project 
management plan for HealthePeople (Federal) that describes the specific 
responsibilities of each department in developing, testing, and 
deploying the interface and addressing security requirements. This 
month, officials from both departments stated that a pharmacy prototype 
project management plan that includes a work breakdown structure and 
schedule was developed in mid-March. They further stated that a work 
group that reports to the integrated project team has been given 
responsibility for the development of security and information 
assurance provisions. While these actions should prove useful in 
guiding the development of the prototype, they do not address the 
larger issue of how the departments will develop and implement an 
interface to exchange health care information between their systems by 
2005.

Without a project management plan, VA and DOD lack assurance that they 
can successfully develop and implement an electronic interface and the 
associated capability for exchanging health information within the time 
frames that they have established. VA and DOD officials stated that 
they have begun discussions to establish an overall project plan.

Conclusions:

Achieving an electronic interface that will enable VA and DOD to 
exchange patient medical records is an important goal, with substantial 
implications for improving the quality of health care and disability 
claims processing for the nation's military members and veterans. In 
seeking a virtual medical record based on the two-way exchange of data 
between their separate health information systems, VA and DOD have 
chosen a complex and challenging approach that necessitates the highest 
levels of project discipline, including a well-defined architecture for 
describing the interface for a common health information exchange; an 
established project management structure to guide the investment in and 
implementation of this electronic capability; and a project management 
plan that defines the technical and managerial processes necessary to 
satisfy project requirements. These critical components are currently 
lacking; thus, the departments risk investing in a capability that 
could fall short of expectations. The continued absence of these 
components elevates concerns about exactly what capabilities VA and DOD 
will achieve--and when.

Recommendations for Executive Action:

To encourage significant progress on achieving the two-way exchange of 
health information, we recommend that the Secretaries of Veterans 
Affairs and Defense instruct the Acting Chief Information Officer for 
Health and the Chief Information Officer for the Military Health 
System, respectively, to:

* develop an architecture for the electronic interface between their 
health systems that includes system requirements, design 
specifications, and software descriptions;

* select a lead entity with final decision-making authority for the 
initiative;

* establish a project management structure to provide day-to-day 
guidance of and accountability for their investments in and 
implementation of the interface capability; and:

* create and implement a comprehensive and coordinated project 
management plan for the electronic interface that defines the technical 
and managerial processes necessary to satisfy project requirements and 
includes (1) the authority and responsibility of each organizational 
unit; (2) a work breakdown structure for all of the tasks to be 
performed in developing, testing, and implementing the software, along 
with schedules associated with the tasks; and (3) a security policy.

Agency Comments:

The Secretary of Veterans Affairs provided written comments on a draft 
of this report and we received comments via e-mail from DOD's 
Interagency Program Integration and External Liaison for Health 
Affairs; both concurred with the recommendations. Each department's 
comments are reprinted in their entirety as appendixes I and II, 
respectively. In their comments, the officials also provided 
information on actions taken or underway that, in their view, address 
our recommendations.

We are sending copies of this report to the Secretaries of Veterans 
Affairs and Defense and to the Director, Office of Management and 
Budget. Copies will also be available at no charge on GAO's Web site at 
www.gao.gov.

Should you have any question on matters contained in this report, 
please contact me at (202) 512-6240, or Barbara Oliver, Assistant 
Director, at (202) 512-9396. We can also be reached by e-mail at 
koontzl@gao.gov and oliverb@gao.gov, respectively. Other key 
contributors to this report were Michael P. Fruitman, Valerie C. 
Melvin, J. Michael Resser, and Eric L. Trout.

Sincerely yours,

Signed by: 

Linda D. Koontz: 
Director, Information Management Issues:

[End of section]

Appendix I: Comments from the Secretary of Veterans Affairs:

THE SECRETARY OF VETERANS AFFAIRS 
WASHINGTON:

May 28, 2004:

Ms. Linda Koontz: 
Director:
Information Technology Team: 
U. S. General Accounting Office: 
441 G Street, NW:
Washington, DC 20548:

Dear Ms. Koontz:

The Department of Veterans Affairs (VA) has reviewed your draft report 
COMPUTER-BASED PATIENT RECORDS: VA and DOD Efforts to Exchange Health 
Data Could Benefit from Improved Planning and Project Management, (GAO-
04-687) and agrees with your conclusions and concurs with your 
recommendations. As outlined in the enclosure, VA and the Department of 
Defense (DoD) are actively engaged in a number of endeavors that 
address the intent of each recommendation.

Developing the technology to provide the ability to exchange patient 
health care data and the creation of an electronic medical record for 
both veterans and active duty personnel remains a priority for VA. The 
Department believes the plan VA and DoD are pursuing, although 
challenging and complex, will provide the necessary flexibility while 
achieving the desired interface between VA and DoD.

Attached are specific actions VA is taking and planning on each 
recommendation. Due to the limited comment period the General 
Accounting Office (GAO) has provided for responding to this report, the 
Department is unable to develop extensive information on these 
activities at this time. VA will provide additional information as well 
as updates on planned actions in its response to your final report.

The Department appreciates the opportunity to comment on your draft 
report.

Sincerely yours,

Signed by: 

Anthony J. Principi: 

Enclosure:

Enclosure:

The Department of Veterans Affairs (VA) Comments on the General 
Accounting Office's (GAO) Draft Report: COMPUTER-BASED PATIENT RECORDS: 
VA and DOD Efforts to Exchange Health Data Could Benefit from Improved 
Planning and Project Management (GAO-04-687):

GAO recommends that the Secretaries of Veterans Affairs and Defense 
instruct the Acting Chief Information Officer for Health and the Chief 
Information Officer for the Military Health System respectively to:

* Develop an architecture for the electronic interface between their 
health systems that includes system requirements, design 
specifications, and software descriptions.

Concur-The Departments are actively engaged in several activities that 
relate to development of a final architecture for the electronic 
interface between the agencies' health information systems. VA and DoD 
expect to have developed the final architecture by the 1STQuarter, FY 
2005. The Departments anticipate that the current work to develop a 
pharmacy prototype to demonstrate the bi-directional exchange of 
pharmacy data will provide important technical information, and have 
significant impact on the final definition of an architecture.

* Select a lead entity with final decision-making authority for the 
initiative.

Concur-The Veterans Health Administration (VHA) Acting Under Secretary 
for Health and DoD's Assistant Secretary of Defense for Health Affairs, 
have agreed that the VA/DoD Health Executive Council (HEC) will 
continue to serve as the lead entity with final decision-making 
authority for the initiative. Co-chaired by the Assistant Secretary of 
Defense Health Affairs and the Under Secretary for Health the HEC is an 
executive body that provides single and final decision making authority 
for the initiative.

* Establish a project management structure to provide day-to-day 
guidance of and accountability for their investments in and 
implementation of the interface capability.

Concur - The Departments have implemented a joint project management 
structure that includes a single Program Manager from VA and a single 
Deputy Program Manager from DoD. This structure ensures joint 
accountability and day-to-day responsibility for project 
implementation. VA provided formal documentation of this project 
management structure and the appointments as part of its response to 
GAO's document request on May 14, 2004.

* Create and implement a comprehensive and coordinated project 
management plan for the electronic interface that defines the technical 
and managerial processes necessary to satisfy project requirements and 
includes (1) the authority and responsibility of each organizational 
unit; (2) a work breakdown structure for all of the tasks to be 
performed in developing, testing, and implementing the software, along 
with schedules associated with the tasks; and (3) a security policy.

Concur -The Departments have developed a comprehensive draft "DoDNA 
Joint Electronic Medical Records (JEMR) Interoperability Program 
Management Plan" that updates the previously provided project 
management plan. This draft document is in coordination between the 
Departments. VA anticipates approval of this plan in June 2004. As part 
of its response to GAO's document request and in earlier responses, VA 
provided GAO with an initial project management plan and GANTT chart/
work breakdown structure for the high-level tasks that comprise the 
work to achieve interoperability. A final security policy will be 
completed once the final technical architecture is identified. It is 
current practice to ensure that all patient data exchanges are done in 
compliance with all regulatory and congressional privacy and security 
mandates, including the Privacy Act and the Privacy Regulations 
contained within the Health Insurance Portability and Accountability 
Act.

[End of section]

Appendix II: Comments from the Director, Interagency Program 
Integration & External Liaison for Health Affairs:

Comments on the General Accounting Office (GAO) draft report GAO-04-
687, COMPUTER-BASED PATIENT RECORDS: "VA and DoD Efforts to Exchange 
Health Data Could Benefit from Improved Planning and Project 
Management", dated June 2004, (GAO Code 310710):

The GAO recommended that the Under Secretary for Health for the 
Veterans Health Administration and Assistant Secretary of Defense, 
Health Affairs instruct the Acting Chief Information Officer for Health 
and the Chief Information Officer for the Military Health System 
respectively, to:

* GAO Recommendation 1: Develop an architecture for the electronic 
interface between their health systems that includes system 
requirements, design specifications, and software descriptions;

* DoD Response to 1: Concur: The Departments are refining the 
appropriate architecture to be used for the electronic exchange of data 
between DoD's Clinical Data Repository and VA's Health Data Repository.

* GAO Recommendation 2: Select a lead entity with final decision-making 
authority for the initiative.

* DoD Response to 2 : Concur: The DoD/VA Health Executive Council serves 
as the lead entity with final decision-making authority for the 
initiative.

* GAO Recommendation 3: Establish a project management structure to 
provide day-to-day guidance of and accountability for their investments 
in and implementation of the interface capability; and:

* DoD Response to 3: Concur: The Departments have implemented a joint 
project management structure that includes a single Program Manager and 
a single Deputy Program Manager with joint accountability and day-to-
day responsibility for project implementation.

* Recommendation 4 : Create and implement a comprehensive and 
coordinated project management plan for the electronic interface that 
defines the technical and management plan for the electronic interface 
that defines the technical and managerial processes necessary to 
satisfy project requirements and includes (1) the authority and 
responsibility of each organizational unit; (2) a work breakdown 
structure for all of the tasks to be performed in developing, testing, 
and implementing the software, along with schedules associated with the 
tasks; and (3) a security policy.

* DoD Response to 4: Concur: A comprehensive draft "DoD/VA Joint 
Electronic Medical Records Interoperability Program Management Plan" 
has been prepared and is currently in coordination.

FOOTNOTES

[1] U.S. General Accounting Office, 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) and 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). 

[2] U.S. General Accounting Office, Veterans Affairs: Sustained 
Management Attention Is Key to Achieving Information Technology 
Results, GAO-02-703 (Washington, D.C.: June 12, 2002) and 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).

[3] IHS, was not included in FHIE, but was expected to assume a role in 
the longer-term project--HealthePeople (Federal).

[4] DOD's CHCS II capabilities are being deployed in blocks. Block 1 
provides a graphical user interface for clinical outpatient processes; 
block 2 supports general dentistry; block 3 provides pharmacy, 
laboratory, radiology, and immunizations capabilities; block 4 provides 
inpatient and scheduling capabilities; and block 5 will provide 
additional capabilities as defined.

[5] The six initiatives that make up HealtheVet VistA are health data 
repository, billing replacement, laboratory, pharmacy, imaging, and 
appointment scheduling replacement.

[6] Standardized clinical data is important for exchanging health 
information between disparate systems. The Institute of Medicine's 
Committee on Data Standards for Patient Safety has reported the lack of 
common data standards as a key factor preventing information sharing 
within the health care industry. VA and DOD, along with the Department 
of Health and Human Services, have been active participants in the 
Consolidated Health Informatics initiative. As part of this initiative, 
the Secretary of Health and Human Services announced in early May the 
adoption of 15 new standards to enable the exchange of health 
information.

[7] Sec. 724 of the act mandates that the Secretaries of Veterans 
Affairs and Defense seek to ensure that, on or before October 1, 2004, 
the two departments' pharmacy data systems are interoperable for VA and 
DOD beneficiaries by achieving real-time interface, data exchange, and 
checking of prescription drug data of outpatients, and using national 
standards for the exchange of outpatient medication information. The 
act further states that if the specified interoperability is not 
achieved by that date, the Secretary of Veterans Affairs shall adopt 
DOD's Pharmacy Data Transaction System for VA's use.

[8] GAO-01-459.

[9] The Joint Executive Council is comprised of the Deputy Secretary of 
Veterans Affairs, the Under Secretary of Defense for Personnel and 
Readiness, and the cochairs of joint councils on health, benefits, and 
capital planning. The council meets on a quarterly basis to recommend 
strategic direction of joint coordination and sharing efforts. The VA/
DOD Health Executive Council is comprised of senior leaders from VA and 
DOD, who work to institutionalize sharing and collaboration of health 
services and resources. The council is cochaired by the VA Under 
Secretary for Health and DOD Assistant Secretary of Defense for Health 
Affairs, and meets on a bimonthly basis.

[10] Institute of Electrical and Electronics Engineers, IEEE/EIA Guide 
for Information Technology (IEEE/EIA 12207.1 - 1997), April 1998. 

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