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United States Government Accountability Office: 
GAO: 

Testimony: 

Before the Senate Committee on Veterans' Affairs: 

For Release on Delivery: 
Expected at 9:30 a.m. EDT: 
Wednesday, September 24, 2008: 

Information Technology: 

DOD and VA Have Increased Their Sharing of Health Information, but 
Further Actions Are Needed: 

Statement of Valerie C. Melvin, Director: 
Human Capital and Management Information Systems Issues: 

GAO-08-1158T: 

GAO Highlights: 

Highlights of GAO-08-1158T, a testimony before the Senate Committee on 
Veterans' Affairs. 

Why GAO Did This Study: 

The National Defense Authorization Act for Fiscal Year 2008 required 
the Department of Defense (DOD) and the Department of Veterans Affairs 
(VA) to accelerate the exchange of health information between the 
departments and to develop systems or capabilities that allow for full 
interoperability (generally, the ability of systems to use data that 
are exchanged) and that are compliant with federal standards. The act 
also established an interagency program office to function as a single 
point of accountability for the effort and whose role is to implement 
such systems or capabilities by September 30, 2009. 

Further, the act required that GAO semi-annually report on the progress 
made in achieving these goals; its first report was issued in July 
2008. In that report, GAO described the departments’ progress in 
sharing electronic health information, developing electronic health 
records that comply with federal standards, and establishing the 
interagency program office. In this testimony, GAO discusses its July 
2008 report and updated information obtained from the departments. 

What GAO Found: 

DOD and VA are sharing some, but not all, electronic health 
information. This includes exchanging some information in computable 
form, which is the highest level of interoperability. In other cases, 
data can be viewed only—a lower level of interoperability that still 
provides clinicians with important information. The departments have 
undertaken a number of initiatives, resulting in varied sharing 
capabilities (see table below). However, information is still being 
captured in paper records at many DOD medical facilities, and not all 
electronic health information is being shared. 

Table: Sharing Capabilities of DOD and VA Initiatives: 

Initiative: DOD’s Clinical Data Repository/VA’s Health Data Repository 
Interface[A]; 
Sharing Capabilities: Bidirectional (or two-way) real-time exchange of 
computable pharmacy and drug allergy data. 

Initiative: Bidirectional Health Information Exchange; 
Sharing Capabilities: Bidirectional real-time sharing of viewable 
health data[B]. 

Initiative: Federal Health Information Exchange; 
Sharing Capabilities: One-way transfer of viewable health data[B] from 
DOD to VA. 

Initiative: Laboratory Data Sharing Interface; 
Sharing Capabilities: Bidirectional sharing of viewable lab tests and 
results. 

Source: DOD and VA. 

[A] Known as CHDR, pronounced “cheddar,” this interface combines the 
names of the two repositories. 

[B] See attachment 1 for a list of the data elements that are made 
available and are planned for these initiatives. 

[End of table] 

Further enhancing sharing and interoperability depends on adherence to 
common standards. The two departments have agreed on numerous common 
standards and are working with federal groups and each other to ensure 
adherence to such standards and to align their initiatives with 
emerging standards. These efforts, led by the Office of the National 
Coordinator for Health Information Technology (within the Department of 
Health and Human Services), include identifying relevant existing 
standards, identifying and addressing overlaps and gaps in the 
standards, and developing interoperability specifications and 
certification criteria based on these standards. 

The departments are also in the process of setting up a new interagency 
program office that will play a crucial role in accelerating their 
efforts to achieve electronic health records and capabilities that 
allow for full interoperability. However, the program office is not 
expected to be fully operational until the end of the year, which will 
allow the departments only 9 months to meet the deadline for full 
interoperability between the departments by September 2009. While DOD 
and VA have produced a plan for achieving interoperability within this 
time period, many milestones have yet to be determined. In view of the 
short timeframe and without a fully established program office and a 
complete plan with fully established milestones, the departments may be 
challenged in achieving interoperable electronic health records and 
capabilities that most effectively serve military service members and 
veterans. 

What GAO Recommends: 

In the report covered by this testimony, GAO made recommendations that 
the departments give priority to fully establishing the interagency 
program office and finalizing the implementation plan. DOD and VA 
concurred with GAO’s recommendations. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-1158T]. For more 
information, contact Valerie Melvin at (202) 512-6304 or 
melvinv@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to participate in today’s hearing on the exchange of 
electronic medical information between the Department of Defense (DOD) 
and the Department of Veterans Affairs (VA). As you know, the two 
departments have been pursuing initiatives to share data between their 
health information systems for the last decade. However, while progress 
has been made, questions have remained concerning when and to what 
extent the intended electronic sharing capabilities will be fully 
achieved. 

To expedite the departments’ efforts to exchange electronic medical 
information, the National Defense Authorization Act for Fiscal Year 
2008[Footnote 1] included provisions directing DOD and VA to jointly 
develop and implement, by September 30, 2009, electronic health record 
systems or capabilities. The act required that these systems or 
capabilities be compliant with applicable interoperability[Footnote 2] 
standards, and it established an interagency program office to be a 
single point of accountability for the departments’ efforts. 

Further, the act directed GAO to assess DOD’s and VA’s progress in 
implementing the electronic health record systems and to report semi-
annually its results to the appropriate congressional committees. 
Accordingly, on July 28, 2008, we issued the first of our reports in 
response to the act, in which we highlighted the departments’ progress 
in (1) sharing electronic health information, (2) developing electronic 
records that comply with national standards, and (3) establishing the 
interagency program office. [Footnote 3] At your request, my testimony 
today summarizes our findings in these three areas, as presented in 
that report. 

In developing this testimony, we relied largely on our previous work 
supporting the July 2008 report. Where available, we also obtained and 
analyzed updated information about the departments’ exchange 
activities. We conducted our work in support of this testimony during 
August 2008 and September 2008, in Washington, D.C. All work on which 
this testimony is based was performed in accordance with generally 
accepted government auditing standards. Those standards require that we 
plan and perform the audit to obtain sufficient, appropriate evidence 
to provide a reasonable basis for our findings and conclusions based on 
our audit objectives. We believe that the evidence obtained provides a 
reasonable basis for our findings and conclusions based on our audit 
objectives. 

Results in Brief: 

DOD and VA are sharing some, but not all, electronic health information 
at different levels of interoperability. Specifically, pharmacy and 
drug allergy data on almost 19,000 shared patients are exchanged at the 
highest level of interoperability—that is, in computable form; at this 
level, the data are in a standardized format that a computer 
application can act on. In other cases, data can be viewed only—a lower 
level of interoperability that still provides clinicians with important 
information. However not all health information is shared 
electronically; information is still being captured in paper records at 
many DOD medical facilities. According to the departments, the 
September 2008 DOD/VA Information Interoperability Plan is intended to 
address these and other issues and define tasks required to guide the 
development and implementation of an interoperable electronic health 
record capability. If properly executed, the plan could help the 
departments fully achieve the goal of seamless sharing of health 
information. 

Further enhancing interoperability depends on adherence to common 
standards. The two departments have agreed upon numerous standards that 
allow them to share health data and are participating in initiatives 
led by the Office of the National Coordinator for Health Information 
Technology (within the Department of Health and Human Services) that 
are aimed at promoting the adoption of federal standards and broader 
use of electronic health records. The involvement of the departments in 
the federal initiatives is an important mechanism for aligning their 
electronic health records with emerging federal standards. 

Once fully established, a new interagency program office is expected to 
play a crucial role in accelerating the departments’ efforts to develop 
and implement electronic health records and capabilities that allow for 
full interoperability. However, the program office is not expected to 
be fully operational until the end of the year, after which only 9 
months will remain to meet the deadline for full interoperability 
between the departments by September 2009. The program office’s plan 
for achieving interoperability within this time period includes 
milestones that are yet to be determined. In view of the short 
timeframe, without a fully established program office and a complete 
plan with established milestones, the departments may be challenged in 
meeting the required date for achieving interoperable electronic health 
records and capabilities. 

To better ensure the successful attainment of interoperable electronic 
health record systems or capabilities, we recommended that the 
departments give priority to fully establishing the interagency program 
office and finalizing their implementation plan. The departments 
concurred with our recommendations. 

Background: 

The use of information technology (IT) to electronically collect, 
store, retrieve, and transfer clinical, administrative, and financial 
health information has great potential to help improve the quality and 
efficiency of health care and is critical to improving the performance 
of the U.S. health care system. Historically, patient health 
information has been scattered across paper records kept by many 
different caregivers in many different locations, making it difficult 
for a clinician to access all of a patient’s health information at the 
time of care. Lacking access to these critical data, a clinician may be 
challenged to make the most informed decisions on treatment options, 
potentially putting the patient’s health at greater risk. The use of 
electronic health records can help provide this access and improve 
clinical decisions.[Footnote 4] 

Electronic health records are particularly crucial for optimizing the 
health care provided to military personnel and veterans. While in 
military status and later as veterans, many DOD and VA patients tend to 
be highly mobile and may have health records residing at multiple 
medical facilities within and outside the United States. Making such 
records electronic can help ensure that complete health care 
information is available for most military service members and veterans 
at the time and place of care, no matter where it originates. 

Key to making health care information electronically available is 
interoperability—that is, the ability to share data among health care 
providers. Interoperability enables different information systems or 
components to exchange information and to use the information that has 
been exchanged. This capability is important because it allows 
patients’ electronic health information to move with them from provider 
to provider, regardless of where the information originated. If 
electronic health records conform to interoperability standards, they 
can be created, managed, and consulted by authorized clinicians and 
staff across more than one health care organization, thus providing 
patients and their caregivers the necessary information required for 
optimal care. (Paper-based health records—if available—also provide 
necessary information, but unlike electronic health records, do not 
provide decision support capabilities, such as automatic alerts about a 
particular patient’s health, or other advantages of automation.) 

Interoperability can be achieved at different levels.[Footnote 5] At 
the highest level, electronic data are computable (that is, in a format 
that a computer can understand and act on to, for example, provide 
alerts to clinicians on drug allergies). At a lower level, electronic 
data are structured and viewable, but not computable. The value of data 
at this level is that they are structured so that data of interest to 
users are easier to find. At still a lower level, electronic data are 
unstructured and viewable, but not computable. With unstructured 
electronic data, a user would have to find needed or relevant 
information by searching uncategorized data. Beyond these, paper 
records can also be considered interoperable (at the lowest level) 
because they allow data to be shared, read, and interpreted by human 
beings. However, my discussion today focuses only on the three levels 
of electronic interoperability. Figure 1 shows the distinction between 
the various levels of interoperability and examples of the types of 
data that can be shared at each level. 

Figure 1: Levels of Data Interoperability: 

[Refer to PDF for image] 

This figure is an illustration of the levels of data interoperability, 
as follows: 

Level 1: Nonelectronic data (i.e., paper forms); 
Level 2: Unstructured, viewable electronic data (i.e., scans of paper 
forms); 
Level 3: Structured, viewable electronic data (i.e., electronically 
entered data that cannot be computed by other systems); 
Level 4: Computable electronic data (i.e., electronically entered data 
that can be computed by other systems. 

Level 4 leads to increasingly sophisticated and standardized data. 

Source: GAO analysis based on data for the Center for Information 
Technology Leadership. 

[End of figure] 

It is important to note that not all data require the same level of 
interoperability. For example, in their initial efforts to implement 
computable data, DOD and VA focused on outpatient pharmacy and drug 
allergy data because clinicians gave priority to the need for automated 
alerts to help medical personnel avoid administering inappropriate 
drugs to patients. On the other hand, for such narrative data as 
clinical notes, unstructured, viewable data may be sufficient. 
Achieving even a minimal level of electronic interoperability is 
valuable for potentially making all relevant information available to 
clinicians. 

Efforts to Adopt and Implement Federal Interoperability Standards Are 
Ongoing: 

Any level of interoperability depends on the use of agreed-upon 
standards to ensure that information can be shared and used. In the 
health IT field, standards govern areas ranging from technical issues, 
such as file types and interchange systems, to content issues, such as 
medical terminology. Developing, coordinating, and agreeing on 
standards are only part of the processes involved in achieving 
interoperability for electronic health records systems or capabilities. 
In addition, specifications are needed for implementing the standards, 
as well as criteria and a process for verifying compliance with the 
standards. 

The President’s executive order of April 2004 that called for 
widespread adoption of interoperable electronic health records by 
2014,[Footnote 6] established the Office of the National Coordinator 
for Health Information Technology within the Department of Health and 
Human Services (HHS) to, among other things, develop, maintain, and 
direct the implementation of a strategic plan to guide the nationwide 
implementation of interoperable health IT in both the public and 
private health care sectors. Under the direction of HHS (through the 
Office of the National Coordinator), three primary organizations were 
designated to play major roles in expanding the implementation of 
health IT: 

* The American Health Information Community was created by the 
Secretary of Health and Human Services as a federal advisory body to 
make recommendations on how to accelerate the development and adoption 
of health IT, including advancing interoperability, identifying health 
IT standards, advancing nationwide health information exchange, and 
protecting personal health information. Formed in September 2005, the 
community is made up of representatives from both the public and 
private sectors, including high-level DOD and VA officials. The 
community determines specific health care areas of high priority and 
develops “use cases”[Footnote 7] for these areas, which provide the 
context in which standards would be applicable. The use cases convey 
how health care professionals would use such records and what standards 
would apply. 

* The Healthcare Information Technology Standards Panel, sponsored by 
the American National Standards Institute[Footnote 8] and funded by the 
Office of the National Coordinator, was established in October 2005 as 
a public-private partnership to identify competing standards for the 
use cases being developed by the American Health Information Community 
and to “harmonize”[Footnote 9] the standards. The panel also develops 
the interoperability specifications that are needed for implementing 
the standards. Interoperability specifications were developed for each 
of the seven use cases developed by the American Health Information 
Community in 2006 and 2007.[Footnote 10] The community is also 
developing six use cases for 2008 for which interoperability 
specifications have not yet been released.[Footnote 11] The Healthcare 
Information Technology Standards Panel is made up of representatives 
from both the public and private sectors, including DOD and VA 
officials who serve as members and are actively working on several 
committees and groups within the panel. This panel is the successor to 
the Consolidated Health Informatics[Footnote 12] initiative, which was 
dissolved and absorbed into the panel on September 30, 2006. 

* The Certification Commission for Healthcare Information Technology is 
an independent, nonprofit organization that certifies health IT 
products. HHS entered into a contract with the commission in October 
2005 to develop and evaluate the certification criteria and inspection 
process for electronic health records. According to HHS, certification 
is to be the process by which the IT systems of federal health 
contractors are established to meet federal interoperability standards. 
Certification helps assure purchasers and other users of health IT 
systems that the systems will provide needed capabilities (including 
ensuring security and confidentiality) and will work with other systems 
without reprogramming. Certification also encourages adoption of health 
IT by assuring providers that their systems can participate in 
nationwide health information exchange in the future. In 2006, the 
commission certified the first 37 ambulatory—or clinician office-
based—electronic health record products as meeting baseline criteria 
for functionality, security, and interoperability. In 2007, the 
commission expanded certification to inpatient—or hospital—electronic 
health record products, which could significantly increase patients’ 
and providers’ access to the health information generated during a 
hospitalization. To date, the commission has certified over 100 
electronic health record products. 

DOD and VA Have Been Pursuing Efforts to Exchange Health Information 
for a Decade: 

DOD and VA have been working to electronically exchange patient health 
data since 1998. As we have reported previously,[Footnote 13] their 
efforts have included both short-term initiatives to share information 
in existing (legacy) systems, as well as a long-term initiative to 
develop modernized health information systems—replacing their legacy 
systems—that would be able to share data and, ultimately, use 
interoperable electronic health records. 

In their short-term initiatives to share information from existing 
systems, the departments began from different positions. VA has one 
integrated medical information system—the Veterans Health Information 
Systems and Technology Architecture (VistA)—which uses all electronic 
records and was developed in-house by VA clinicians and IT personnel. 
All VA medical facilities have access to all VistA information. 

In contrast, DOD uses multiple legacy medical information systems, all 
of which are commercial software products that are customized for 
specific uses. For example, the Composite Health Care System (CHCS) 
which was formerly DOD’s primary health information system is still in 
use to capture pharmacy, radiology, and laboratory information. 
[Footnote 14] In addition, the Clinical Information System (CIS), a 
commercial health information system customized for DOD, is used by 
some facilities for inpatients. The departments’ short-term initiatives 
to share information in their existing systems have included several 
projects: 

* The Federal Health Information Exchange (FHIE), completed in 2004, 
enables DOD to electronically transfer service members’ electronic 
health information to VA when the members leave active duty. 

* The Laboratory Data Sharing Interface (LDSI), a project established 
in 2004, allows DOD and VA facilities to share laboratory resources. 
This interface, now deployed at nine locations, allows the departments 
to communicate orders for lab tests and their results electronically. 

* The Bidirectional Health Information Exchange (BHIE), also 
established in 2004, was aimed at allowing clinicians at both 
departments viewable access to records on shared patients (that is, 
those who receive care from both departments—for example, veterans may 
receive outpatient care from VA clinicians and be hospitalized at a 
military treatment facility).[Footnote 15] The interface also allows 
DOD sites to see previously inaccessible data at other DOD sites. 

As part of the long-term initiative, each of the departments aims to 
develop a modernized system in the context of a common health 
information architecture that would allow a two-way exchange of health 
information. The common architecture is to include standardized, 
computable data; communications; security; and high-performance health 
information systems: DOD’s Armed Forces Health Longitudinal Technology 
Application (AHLTA)[Footnote 16] and VA’s HealtheVet. The departments’ 
modernized systems are to store information (in standardized, 
computable form) in separate data repositories: DOD’s Clinical Data 
Repository (CDR) and VA’s Health Data Repository (HDR). For the two-way 
exchange of health information, the two repositories are to be linked 
through an interface named CHDR,[Footnote 17] which the departments 
began developing in March 2004 (with implementation beginning in 
September 2006). 

Beyond these initiatives, in January 2007, the departments announced an 
addition to their information-sharing strategy: their intention to 
jointly determine an approach for inpatient health records. On July 31, 
2007, they awarded a contract for a feasibility study and exploration 
of alternatives.[Footnote 18] According to the departments, one of the 
options would be adopting a joint solution, which would be expected to 
facilitate the seamless transition of active-duty service members to 
veteran status, and make inpatient health care data on shared patients 
more readily accessible to both DOD and VA. In addition, the 
departments believe that a joint development effort could enable them 
to realize cost savings. However, no decision on a joint inpatient 
health records system has yet been made. The departments’ officials 
stated that they received recommendations from the contractor on the 
possible approaches for the joint inpatient electronic health record in 
August, but added that they would not be prepared to release the 
findings from the study until senior leadership has fully reviewed and 
considered the recommendations—a step for which no date was provided. 

We have previously pointed out that the many tasks and challenges 
associated with the departments’ long-term goal of seamless sharing of 
health information made it essential that the departments develop a 
comprehensive project plan to guide these efforts to completion. 
Therefore, in 2004, we recommended that the departments develop such a 
plan for the CHDR interface and that it include a work breakdown 
structure and schedule for all development, testing, and implementation 
tasks.[Footnote 19] Further, as the departments undertook work on their 
short-term initiatives, we raised concerns regarding how all of these 
initiatives were to be incorporated into an overall strategy toward 
achieving the departments’ goal of a comprehensive, seamless exchange 
of health information. In response to our concerns, the departments 
began developing a comprehensive plan, which they called the DOD/VA 
Information Interoperability Plan. To provide input to the plan and 
determine priorities, in December 2007, the departments established the 
Joint Clinical Information Board, made up of senior clinical leaders 
from both departments. The board is responsible for establishing 
clinical priorities for electronic data sharing between the 
departments, determining essential health information to be shared, and 
further identifying and prioritizing data that should be viewable and 
data that should be computable. 

The departments produced the DOD/VA Information Interoperability Plan 
(Version 1.0) this month. While the scope of the plan includes health 
information interoperability, it also addresses interoperability of 
personnel and benefits information. According to the plan, it describes 
the scope and milestones necessary to achieve and measure progress 
toward interoperability goals. To this end, the plan identifies over 20 
initiatives, including, for example, enhancing health information 
exchange between clinical information systems. The plan also 
incorporates information intended to address requirements in the 
National Defense Authorization Act for Fiscal Year 2008 that require 
schedules for establishing the interagency program office; establishing 
requirements for electronic health record systems; and acquiring, 
testing, and implementing electronic health record systems. 

DOD and VA Are Sharing Some, but Not All, Health Information at 
Different Levels of Interoperability: 

DOD and VA are electronically sharing health information as a result of 
their long- and short-term initiatives to achieve interoperability; 
some of this information is exchanged in computable form, while other 
information is viewable only. However, not all electronic health 
information is yet shared. Further, although VA’s health information is 
all captured electronically, not all health data collected by DOD are 
electronic—many DOD medical facilities use paper-based health records. 

Long-Term Initiative Provides Computable Data: 

Data in computable form are exchanged as a result of the departments’ 
long-term initiative to develop the CHDR interface, which links the 
modernized health data repositories for the new systems that each 
department is developing. Implementing the interface required the 
departments to agree on standards for various types of data, put the 
data into the agreed standard formats, and populate the repositories 
with the standardized data.[Footnote 20] Currently, the types of 
computable health data being exchanged are limited to outpatient 
pharmacy and drug allergy data. According to the departments, the next 
type of data to be standardized, included in the repositories, and 
exchanged in computable form is laboratory data (i.e., chemistry and 
hematology laboratory results).[Footnote 21] However, DOD and VA 
officials told us that this data exchange is expected to be achieved by 
October 31, 2009. 

Currently, these computable data are not shared for all patients—rather 
only for those who are seen at both DOD and VA medical facilities, 
identified as shared patients, and then “activated.”[Footnote 22] Once 
a patient is activated, all DOD and VA sites can access information on 
that patient and receive alerts on allergies and drug interactions for 
that patient. According to DOD and VA officials, outpatient pharmacy 
and drug allergy data were being exchanged on almost 19,000 shared 
patients as of July 31, 2008; however, officials stated that they are 
unable to track the number of shared patients currently receiving care 
from both departments, so the number of patients for whom data could 
potentially be shared is unknown. 

Short-Term Initiatives Provide Viewable Data: 

Data in viewable form are shared as a result of the various short-term 
initiatives previously mentioned. Through BHIE, clinicians can query 
selected health information on patients from all DOD and VA sites and 
view current data onscreen almost immediately. Because the BHIE 
interface provides access to up-to-date information, clinicians at both 
departments have expressed strong interest in expanding its use, and 
DOD and VA have taken steps in this regard. For example, the 
departments completed a BHIE interface with DOD’s Clinical Data 
Repository in July 2007, and they began sharing viewable patient vital 
signs information through BHIE in June 2008. Extending BHIE 
connectivity could provide both departments with the ability to view 
additional data in DOD’s legacy systems, until such time as the 
departments’ modernized systems are fully developed and implemented. 
According to a DOD/VA annual report[Footnote 23] and program officials, 
the departments now consider BHIE an interim step in their overall 
strategy to create a two-way exchange of electronic health records. 

DOD has been using another short-term initiative, FHIE, to transfer 
information to VA since 2002, allowing VA clinicians to view service 
members’ electronic health information when the members leave active 
duty. Among the data elements transferred are laboratory results, 
radiology results, outpatient pharmacy data, allergy information, 
consultation reports, and demographic data. Further, since July 2005, 
FHIE has been used to transfer pre- and post-deployment health 
assessment and reassessment data. Transfers are done in batches once a 
month, or weekly for veterans who have been referred to VA treatment 
facilities. 

Another initiative that provides viewable data, LDSI, is deployed when 
local agencies have a business case for its use and sign an agreement 
to share laboratory resources. LDSI currently supports a variety of 
chemistry, hematology, toxicology, and serology laboratory results. If 
a test is not performed at a DOD or VA doctor’s home facility, the 
doctor can order the test, the order is transmitted electronically to 
the appropriate lab (the other department’s facility or in some cases a 
local commercial lab), and the results are returned electronically. 
Among the benefits of LDSI, according to DOD and VA, are increased 
speed in receiving laboratory results and decreased errors from manual 
entry of orders. 

Attachment 1 summarizes the types of health data currently shared via 
the DOD and VA initiatives, as well as additional types of data that 
are currently planned for sharing via these initiatives. 

While DOD and VA are sharing or plan to share a wide range of health 
information, questions nonetheless exist regarding when and to what 
extent electronic sharing capabilities will be fully achieved. Beyond 
the initiatives and types of data already discussed, the electronic 
sharing of health information between the departments has not been 
fully addressed. Although VA’s health information is all captured 
electronically, many DOD medical facilities continue to rely on paper 
records. Also, clinical encounters for those enrolled in the military’s 
TRICARE health care program[Footnote 24] are not captured in DOD’s 
electronic health system unless care is received at a military 
treatment facility.[Footnote 25] Addressing these conditions will be 
important to determining the outcome of the departments’ joint efforts. 

DOD and VA Have Adopted Standards to Allow Sharing and Are Engaged in 
Efforts to Establish Standards: 

As previously discussed, interoperability standards are an essential 
element in the exchange of electronic health information. In this 
regard, DOD and VA have agreed upon numerous common standards that 
allow them to share health data, which include standards that are part 
of current and emerging federal interoperability specifications. The 
foundation built by this collaborative process has allowed the two 
departments to begin sharing computable health data (the highest level 
of interoperability). 

The standards agreed to by the two departments are listed in a jointly 
published common set of interoperability standards called the Target 
DOD/VA Health Standards Profile.[Footnote 26] The current version of 
the profile, dated September 2007, includes federal standards (such as 
data standards established by the Food and Drug Administration and 
security standards established by the National Institute of Standards 
and Technology); industry standards (such as wireless communications 
standards established by the Institute of Electrical and Electronics 
Engineers and Web file sharing standards established by the American 
National Standards Institute); international standards (such as the 
Systematized Nomenclature of Medicine Clinical Terms, or SNOMED CT, and 
security standards established by the International Organization for 
Standardization). According to the departments, they anticipate 
continued updates and revisions to the profile as additional federal 
standards emerge. 

For the two kinds of data now being exchanged in computable form 
through CHDR (pharmacy and drug allergy data), DOD and VA adopted the 
National Library of Medicine data standards for medications and drug 
allergies,[Footnote 27] as well as the SNOMED CT codes for allergy 
reactions.[Footnote 28] This standardization was a prerequisite for 
exchanging computable medical information—an accomplishment that, 
according to the Department of Health and Human Services’ National 
Coordinator for Health IT, has not been widely achieved. 

Further, DOD and VA are continuing their historical involvement in 
efforts to agree upon standards for the electronic exchange of clinical 
health information by participating in ongoing initiatives led by the 
Office of the National Coordinator that are aimed at promoting the 
adoption of federal standards and broader use of electronic health 
records. Health officials from both departments participate as members 
of the American Health Information Community and the Healthcare 
Information Technology Standards Panel. For example, high-level 
representatives of the 18-member Community include the Assistant 
Secretary of Defense for Health Affairs and the Director, Health Data 
and Informatics, Veterans Health Administration. DOD and VA are also 
members of the Healthcare Information Technology Standards Panel Board 
and are actively working on several committees and groups, including 
the Provider Perspective Technical Committee; Population Perspective 
Technical Committee; and Security, Privacy and Infrastructure Domain 
Technical Committee. The National Coordinator indicated that such 
participation is important and stated it would not be advisable for DOD 
and VA to move significantly ahead of the national standards 
initiative; if they did, the departments might have to change the way 
their systems share information by adjusting them to the national 
standards later, as the standards continue to evolve. 

In addition, according to DOD officials, their department is taking 
steps to ensure that the electronic health records produced by its 
modernized health information system, AHLTA (which is a customized 
commercial software application), are compliant with standards by 
arranging for certification through the Certification Commission for 
Healthcare Information Technology. AHLTA version 3.3 has been installed 
at three DOD locations[Footnote 29] for beta testing and has met 
specific functionality, interoperability, and security requirements. 
However, the officials stated that the commission cannot fully certify 
this version of AHLTA until it has verified that the system has been in 
operational use at a medical site. 

The departments’ efforts to share data and to be involved in 
standardization activities are important mechanisms for ensuring that 
their electronic health records are both interoperable and aligned with 
emerging standards. 

Further Actions Needed to Fully Establish the Interagency Program 
Office: 

To accelerate the departments’ ongoing interoperability efforts, 
Congress included in the National Defense Authorization Act for Fiscal 
Year 2008 provisions establishing an interagency program office. Under 
the act, the Secretary of Defense and the Secretary of Veterans Affairs 
were required to jointly develop schedules and benchmarks for setting 
up the DOD/VA Interagency Program Office, and for other activities to 
achieve interoperable health information (that is, establishing system 
requirements, acquisition and testing, and implementation of 
interoperable electronic health records or capabilities). The schedules 
and benchmarks were due 30 days after passage of the act, or the end of 
February 2008. 

The departments did not meet the February 2008 date; however, just this 
month they produced the DOD/VA Information Interoperability Plan, which 
incorporates fiscal year 2008 and 2009 schedules and milestones that 
DOD and VA previously referred to in a draft implementation plan. 
Further, in an effort to set up the program office, the departments 
appointed an Acting Director from DOD and an Acting Deputy Director 
from VA.[Footnote 30] According to the Acting Director, the departments 
also have detailed staff and provided temporary space and equipment to 
a transition team. The official stated that, through the efforts of the 
transition team, the departments are currently developing a charter for 
the office, defining and approving an organizational structure, and 
preparing to begin recruiting permanent staff for the office, which is 
expected to number about 30. According to the plan, the departments 
expect to appoint a permanent Director and Deputy Director and begin 
recruiting staff by October 2008. The Acting Director added that 
program staff are expected to be in place, and the office is expected 
to be fully operational by December 2008. To fund the office, the 
departments have reported requesting $4.94 million for fiscal year 2008 
and $6.94 million for fiscal year 2009. 

Within the plan, milestones and schedules have been included for 
achieving interoperable health information in two stages. The first 
stage—Interoperability I— is to be completed this month and is to make 
available those health data most commonly required by health care 
providers, as validated by the Joint Clinical Information Board, 
[Footnote 31] which sets the clinical priorities for what electronic 
health information should be shared. The first milestone for this 
stage, sharing vital signs information, was already achieved this past 
June as part of the BHIE initiative. According to department officials, 
the remaining milestones related to sharing questionnaires and forms, 
family history, social history, and other history are all due during 
this month. 

The second stage—Interoperability II— is to be completed by September 
2009, and is to address additional health information enhancements. 
Department officials stated that the information to be covered by these 
enhancements is being defined, and that validation of the requirements 
for the enhancements by the Joint Clinical Information Board was 
completed in July 2008. 

Nevertheless, milestones for this stage have not been fully 
established. Specifically, of 52 activities identified for 
Interoperability II, 11 do not yet have defined milestones. For 
example, milestones have not been identified for completing 
requirements validation, acquisition, and testing for the scanning of 
service members’ paper medical records into DOD’s electronic health 
record system in order to share these records electronically with VA; a 
capability expected to be implemented by September 30, 2009. Department 
officials stated that decisions on these milestones will depend on 
clinical priorities, technical considerations, and policy decisions. 
Further, according to the plan, it is intended to serve as a “living 
document” that will be updated and refined as more detailed information 
becomes known on planned fiscal year 2008 and fiscal year 2009 
initiatives, and as health care information needs change. However, 
although the plan (as a planning tool) is a living document, it is 
nonetheless important to complete the planning and make the decisions 
needed to finalize the plan, particularly in view of the fast 
approaching September 2009 deadline. 

In addition, according to department officials, the interagency program 
office will play a crucial role in coordinating the departments’ 
efforts to accelerate their interoperability efforts. An important 
aspect of this coordination will be managing implementation of the 
DOD/VA Information Interoperability Plan, which the departments 
recently finalized. According to these officials, having a centralized 
office to take on this role will be a primary benefit. However, the 
effort to set up the program office is still in its early stages. As 
has been noted, the positions of Director and Deputy Director are not 
yet permanently filled, permanent staff have not yet been hired, and 
facilities have not yet been designated for housing the office. In 
addition, the departments have not completed an interagency program 
office charter because the departments’ leadership broadened its scope 
to include sharing of personnel and benefits data instead of only 
health information. Until the program office is fully established, it 
will not be able to play this crucial role effectively. Thus, it 
remains vital that the Secretaries of Defense and Veterans Affairs 
fully establish the Interagency Program Office by expediting efforts to 
put in place permanent leadership, staff, and facilities. 

To better ensure that the effort by DOD and VA to achieve fully 
interoperable electronic health record systems or capabilities is 
accelerated, our July report included recommendations that the 
departments give priority to fully establishing the interagency program 
office and finalizing the implementation plan. Prompt action by the 
departments to address these recommendations is critical to developing 
and implementing electronic health record systems or capabilities that 
allow for full interoperability of personal health care information by 
September 30, 2009, as specified in the National Defense Authorization 
Act for Fiscal Year 2008. In their comments on our report, both 
departments concurred with these recommendations. 

In summary, through numerous efforts, DOD and VA are sharing electronic 
health information at different levels of interoperability. Moreover, 
as a result of their efforts, the departments are sharing more data 
than ever before. However, significant work remains to plan and 
implement new capabilities that could further increase the sharing of 
electronic health information between the departments and to determine 
the desired level of data interoperability. Recognizing the importance 
of timely implementation of such capabilities, Congress established a 
requirement for an interagency program office as a single point of 
accountability, and a deadline of about one year from now to achieve 
full interoperability of personal health care information between the 
departments. In view of this short timeframe and as we have 
recommended, a fully functioning program office and a finalized plan 
with set milestones are critical steps toward achieving interoperable 
electronic health records and capabilities. Although completion of the 
DOD/VA Information Interoperability Plan is an important and positive 
accomplishment, without permanent program office leadership, staff, and 
facilities or fully established milestones, the departments may 
nonetheless remain challenged in achieving interoperable electronic 
health information to the extent and in the manner that most 
effectively serves military service members and veterans. 

Mr. Chairman, this concludes my statement. I would be pleased to 
respond to any questions that you or other members of the committee may 
have. 

Contacts and Acknowledgements: 

If you have any questions on matters discussed in this testimony, 
please contact Valerie C. Melvin, Director, Human Capital and 
Management Information Systems Issues, at (202) 512-6304 or 
melvinv@gao.gov. Other individuals who made key contributions to this 
testimony are Mark Bird, Assistant Director; Barbara Collier; Neil 
Doherty; Rebecca LaPaze; Lee McCracken; Barbara Oliver; Kelly Shaw; 
Eric Trout; and Robert Williams, Jr. 

[End of section] 

Attachment 1: Current and Planned Health Data Sharing: 

Table 1 summarizes the types of health data currently shared through 
the long- and short-term initiatives we have described, as well as 
types of data that are currently planned for addition. 

Table 1: Data Elements Made Available and Planned by DOD/VA 
Initiatives: 

Initiative: CHDR; 
Data elements: Available: Outpatient pharmacy; Drug allergy; 
Data elements: Planned: Laboratory data; 
Interoperability level: Computable data; 
Comments: Data are exchanged between one department’s data repository 
and the other’s. As of July 31, 2008, computable pharmacy and 
medication allergy data were being exchanged on almost 19,000 shared 
patients. The departments are prioritizing their current needs to 
determine what, if any, additional data elements need to be exchanged 
at the computable data level. 

Initiative: BHIE, Bidirectional Health Information Exchange; 
Data elements: Available: Outpatient pharmacy data; Drug and food 
allergy information; Surgical pathology reports; Microbiology results; 
Cytology reports; Chemistry and hematology reports; Laboratory orders; 
Radiology text reports; Inpatient discharge summaries, emergency room 
notes, inpatient consultation, operative reports, and history and 
physical reports from CIS at 17 DOD sites (about 40% of inpatient beds) 
and all VA sites; Provider notes; Procedures; Problem lists; Vital 
signs; 
Data elements: Planned: Scanned images and documents; Family history; 
Social history; Other history questionnaires; Radiology images; 
Psychological health treatment and care records; Rollout of CIS at 
additional DOD sites; expansion to include additional CIS 
documentation: initial evaluation notes, procedure notes, evaluation 
and management notes, preoperative and postoperative evaluation notes; 
Interoperability level: Structured, viewable data; Unstructured, 
viewable data from scanned documents; 
Comments: Data are not transferred but can be viewed. Limitations: 
Inpatient data are available only from a portion of DOD inpatient 
hospitals, not all military hospitals. 

Initiative: FHIE, Federal Health Information Exchange; 
Data elements: Available: Patient demographics; Laboratory results 
;Radiology reports; Outpatient pharmacy information; Admission 
discharge transfer data; Discharge summaries from CHCS; Consult 
reports; Allergies; Data from the DOD Standard Ambulatory Data Record; 
Pre- and postdeployment health assessments; Postdeployment health 
reassessments; 
Data elements: Planned: None; 
Interoperability level: Structured, viewable data; 
Comments: Noncomputable text data are transferred to VA and stored in 
VA’s FHIE database, making it accessible to all VA clinicians. One-way 
batch transfer of text data from DOD to VA occurs weekly if discharged 
patient has been referred to VA for treatment; otherwise monthly. 
Limitations: Discharge summaries from CHCS only[A] are transferred, not 
from other DOD systems. 

Initiative: LDSI, Laboratory Data Sharing Interface; 
Data element: Available: Laboratory orders; Laboratory results 
(chemistry, hematology, toxicology, and serology at all LDSI sites; 
anatomic pathology and microbiology at two localities); 
Data element: Planned: Additional sites as business need arises; 
Interoperability level: Structured, viewable data; 
Comments: Noncomputable text data are transferred and captured in the 
individual’s health record. 

Source: GAO analysis of DOD and VA data. 

[A] According to department officials, the discharge summary module of 
CHCS is used at a limited number of sites. 

[End of table] 

[End of section] 

Footnotes: 

[1] The National Defense Authorization Act for Fiscal Year 2008, Pub. 
L. No. 110-181, Section 1635, required “Fully Interoperable Electronic 
Personal Health Information for the Department of Defense and the 
Department of Veterans Affairs.” 

[2] Interoperability is the ability of two or more systems or 
components to exchange information and to use the information that has 
been exchanged. Further discussion of levels of interoperability is 
provided later in this testimony. 

[3] GAO, Electronic Health Records: DOD and VA Have Increased Their 
Sharing of Health Information, but More Work Remains, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-08-954] (Washington, D.C.: July 
28, 2008). 

[4] An electronic health record is a longitudinal collection of 
information about the health of an individual or the care provided, 
such as patient demographics, progress notes, problems, medications, 
vital signs, past medical history, immunizations, laboratory data, and 
radiology reports. 

[5] These levels were identified by the Center for Information 
Technology Leadership, which was chartered in 2002 as a research 
organization established to help guide the health care community in 
making more informed strategic IT investment decisions. According to 
DOD and VA officials, the different levels of interoperability have 
been accepted for use by the Office of the National Coordinator for 
Health Information Technology. 

[6] Executive Order 13335, Incentives for the Use of Health Information 
Technology and Establishing the Position of the National Health 
Information Technology Coordinator (Washington, D.C.: Apr. 27, 2004). 

[7] Use cases are descriptions of events that detail what a system (or 
systems) needs to do to achieve a specific mission or goal; they convey 
how individuals and organizations (actors) interact with the systems. 
For health IT, use cases strive to provide enough detail and context 
for follow-up activities to occur, such as standards harmonization, 
architecture specification, certification consideration, and detailed 
policy discussions to advance the national health IT agenda. 

[8] The American National Standards Institute is a private, nonprofit 
organization whose mission is to promote and facilitate voluntary 
consensus standards and ensure their integrity. 

[9] Harmonization is the process of identifying overlaps and gaps in 
relevant standards and developing recommendations to address these 
overlaps and gaps. 

[10] The seven use cases are Emergency Responder, Consumer Empowerment, 
Medication Management, Quality, Registration and Medication History, 
Laboratory Results Reporting, and Visit, Utilization, and Lab Result 
Data. 

[11] The six use cases are Remote Monitoring, Patient-Provider Secure 
Messaging, Personalized Healthcare, Consultation and Transfers of Care, 
Public Health Case Reporting, and Immunizations & Response Management. 

[12] In December 2001, the Consolidated Health Informatics was 
initiated to enable federal agencies to build interoperable health data 
systems. This project was a collaborative agreement among federal 
agencies, including DOD and VA, to adopt a common set of health 
information standards for the electronic exchange of clinical health 
information. 

[13] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-954]. 

[14] According to DOD, CHCS applications are now accessed through its 
modernized health information system, Armed Forces Health Longitudinal 
Technology Application (AHLTA). The department no longer considers 
AHLTA as an acronym but as the official name of the system. 

[15] To create BHIE, the departments drew on the architecture and 
framework of the information transfer system established by the FHIE 
project. Unlike FHIE, which provides a one-way transfer of information 
to VA when a service member separates from the military, the two-way 
interface allows clinicians in both departments to view, in real time, 
limited health data (in text form) from the departments’ existing 
health information systems. 

[16] AHLTA was formerly known as CHCS II. 

[17] The name CHDR, pronounced “cheddar,” combines the names of the two 
repositories. 

[18] The contract for this study is still ongoing; according to DOD and 
VA officials, a contract option period was exercised and began in July 
2008 and will conclude in December 2008. 

[19] GAO, Computer-Based Patient Records: DOD and VA Efforts to 
Exchange Health Data Could Benefit from Improved Planning and Project 
Management, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-687] 
(Washington, D.C.: June 7, 2004). 

[20] DOD has populated CDR with information for outpatient encounters, 
drug allergies, and order entries and results for outpatient pharmacy 
and lab orders. VA has populated HDR with patient demographics, vital 
signs records, allergy data, and outpatient pharmacy data; in July 
2007, the department added chemistry and hematology, and in September 
2007, added microbiology. 

[21] Standardizing the data involves different tasks for each 
department. That is, although VA’s health records are already 
electronic, it must still convert them into the standardized format 
appropriate for its repository. DOD must convert and standardize 
current records from its multiple systems, but it must also address 
health records that are not automated. 

[22] That is, they are matched on certain identifiers—first name, last 
name, date of birth, Social Security number—in both agencies’ health 
information systems and established as “active” shared patients. 

[23] December 2004 DOD and VA Joint Strategic Plan. 

[24] Those eligible are active-duty service members, National Guard and 
Reserve members, retirees, their families, survivors and certain former 
spouses. 

[25] According to DOD officials, about 7.29 million individuals are 
enrolled in TRICARE. These people can seek care in both the direct care 
system (military medical facilities) and the purchased care system 
(nonmilitary medical facilities). 

[26] First developed in 2004, this profile resulted from an effort in 
which the two departments compared their individual standards profiles 
for compatibility and began converging them. The Target Standards 
Profile is updated annually and is used for reviewing joint DOD/VA 
initiatives to ensure standards compliance. 

[27] These data standards are known as RxNorm and Unified Medical 
Language System (UMLS) for medications and drug allergies. 

[28] SNOMED CT, a comprehensive health and clinical terminology, was 
established by the International Health Terminology Standards 
Development Organisation, a not-for-profit association that develops 
and promotes use of SNOMED CT so as to support safe and effective 
health information exchange. 

[29] These locations are the Naval Medical Center in Portsmouth, Va.; 
Eisenhower Army Medical Center in Fort Gordon, Ga.; and Goodfellow Air 
Force Base in San Angelo, Tex. 

[30] Before these appointments, both the officials had been involved in 
the planning and implementation of the departments’ current sharing 
capabilities. 

[31] These data were defined in response to the recommendation by the 
President’s Commission on Care for America’s Returning Wounded 
Warriors. 

[End of section] 

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