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United States General Accounting Office:

GAO:

Testimony:

Before the Subcommittee on Oversight and Investigations, Committee on 
Veterans' Affairs, House of Representatives:

For Release on Delivery:

Expected at 10:00 a.m. EDT:

Wednesday, May 19, 2004:

COMPUTER-BASED PATIENT RECORDS:

Improved Planning and Project Management Are Critical to Achieving Two-
Way VA-DOD Health Data Exchange:

Statement of Linda D. Koontz:

Director, Information Management Issues:

GAO-04-811T:

GAO Highlights:

Highlights of GAO-04-811T, testimony before the Subcommittee on 
Oversight and Investigations, House Committee on Veterans' Affairs 

Why GAO Did This Study:

Providing readily accessible health information on veterans and active 
duty military personnel is highly essential to ensuring that these 
individuals are given quality health care and assistance in 
adjudicating disability claims. Moreover, ready access to health 
information is consistent with the President’s recently announced 
intention to provide electronic health records for most Americans 
within 10 years. In an attempt to improve the sharing of health 
information, the Departments of Veterans Affairs (VA) and Defense (DOD) 
have been working, since 1998, toward the ability to exchange 
electronic health records for use by veterans, military personnel, and 
their health care providers. 

In testimony before the Subcommittee last November and again this past 
March, GAO discussed the progress being made by the departments in this 
endeavor. While a measure of success has been achieved—the one-way 
transfer of health data from DOD to VA health care facilities—
identifying the technical solution for a two-way exchange, as part of a 
longer term HealthePeople (Federal) initiative, has proven elusive.

At the Subcommittee’s request, GAO reported on its continuing review of 
the departments’ progress toward this goal of an electronic two-way 
exchange of patient health records. 

What GAO Found:

VA and DOD are continuing with activities to support the sharing of 
health data; nonetheless, achieving the two-way electronic exchange of 
patient health information, as envisioned in the HealthePeople 
(Federal) strategy, remains far from being realized. Each department is 
proceeding with the development of its own health information system—
VA’s HealtheVet VistA and DOD’s Composite Health Care System (CHCS) II; 
these are critical components for the eventual electronic data exchange 
capability. The departments are also proceeding with the essential task 
of defining data and message standards that are important for 
exchanging health information between their disparate systems. In 
addition, a pharmacy data prototype initiative begun this past March, 
which the departments stated is an initial step to defining the 
technology for the two-way data exchange, is ongoing. However, VA and 
DOD have not yet defined an architecture to guide the development of 
the electronic data exchange capability, and lack a strategy to explain 
how the pharmacy prototype will contribute toward determining the 
technical solution for achieving HealthePeople (Federal). As such, 
there continues to be no clear vision of how this capability will be 
achieved, and in what time period.

Compounding the challenge faced by the departments is that they 
continue to lack a fully established project management structure for 
the HealthePeople (Federal) initiative. As a result, the relationships 
between the departments’ managers is not clearly defined, a lead entity 
with final decision-making authority has not been designated, and a 
coordinated, comprehensive project plan that articulates the joint 
initiative’s resource requirements, time frames, and respective roles 
and responsibilities of each department has not yet been established. 
In discussing the need for these components, VA and DOD program 
officials stated this week that the departments had begun actions to 
develop a project plan and define the management structure for 
HealthePeople (Federal). In the absence of such components, the 
progress that VA and DOD have achieved is at risk of compromise, as is 
assurance that the ultimate goal of a common, exchangeable two-way 
health record will be reached.

Given the importance of readily accessible health data for improving 
the quality of health care and disability claims processing for
military members and veterans, we currently have a draft report at the 
departments for comment, in which we are making recommendations to the 
Secretaries of Veterans Affairs and Defense for addressing the 
challenges to, and improving the likelihood of successfully achieving 
the electronic two-way exchange of patient health information. 

www.gao.gov/cgi-bin/getrpt?GAO-04-811T.

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

[End of section]

Mr. Chairman and Members of the Subcommittee:

I am pleased to participate in today's continuing discussion of 
electronic health records and the Department of Veterans Affairs' (VA) 
and Department of Defense's (DOD) actions toward developing the 
capability to electronically exchange patient health information. In 
the face of terrorism, related military responses, and a general call 
for improved health care delivery, providing readily accessible medical 
data on active duty military personnel and veterans is more essential 
than ever to ensuring that these individuals receive high-quality 
health care and assistance in adjudicating any disability claims that 
they may have. The President's recently announced proclamation to 
provide electronic health records for most Americans within the next 10 
years further highlights the significance and potential contributions 
of the departments' actions in pointing the way toward the delivery of 
more effective health care services.

For the past 6 years, VA and DOD have been working to achieve an 
electronic medical record and patient health information-sharing 
capability, beginning with a joint project in 1998 to develop a 
government computer-based patient record. As we noted in previous 
testimony,[Footnote 1] the departments have achieved a measure of 
success in sharing data through the one-way transfer of health 
information from DOD to VA health care facilities. However, they have 
been severely challenged in their pursuit of a longer term objective--
providing a virtual medical record based on the two-way exchange of 
patient health care information, as part of their HealthePeople 
(Federal) initiative. This past March, we reported that VA and DOD had 
made little progress in identifying a technological solution for 
achieving a two-way exchange of patient health data and lacked 
discipline in their approach to managing this initiative.

At your request, my testimony today will discuss our continuing 
assessment of VA's and DOD's progress in realizing the HealthePeople 
(Federal) goal of an electronic patient health record and two-way data 
exchange capability. In conducting this work, we reviewed the 
departments' documentation describing VA's and DOD's actions to develop 
new health information systems and determine a strategy for developing 
a secure, electronic two-way data exchange capability, including 
project schedules, project status reports, and conversion and 
deployment plans. We also reviewed documentation identifying the costs 
that the departments have incurred in developing technology to support 
the sharing of health data, including costs associated with achieving 
the one-way transfer of data from DOD to VA health care facilities, and 
ongoing projects to develop new health information systems. We did not 
audit the reported costs, and thus cannot attest to their accuracy or 
completeness. We supplemented our analyses of the agencies' 
documentation with interviews of VA and DOD officials responsible for 
key decisions and actions on the health data-sharing initiatives. We 
conducted our work in accordance with generally accepted government 
auditing standards, during May of this year.

Results In Brief:

VA and DOD are proceeding with actions intended to support the sharing 
of health data, but continue to be far from achieving the two-way 
electronic data exchange capability envisioned in the HealthePeople 
(Federal) strategy. The departments are continuing to take actions to 
develop their individual health information systems that are critical 
to exchanging patient health information and to define data standards 
that are essential to the common sharing of health information. In 
addition, department officials stated that they are proceeding with a 
pharmacy data prototype initiative, begun in March, to satisfy a 
mandate of the Bob Stump National Defense Authorization Act for Fiscal 
Year 2003,[Footnote 2] as an initial step toward achieving 
HealthePeople (Federal). At this stage, however, they have not 
developed a strategy to explain how this project will contribute to 
defining the technological solution for the data exchange capability. 
As such, VA and DOD continue to lack a clearly defined architecture and 
technological solution for developing the electronic interface and 
associated capability for exchanging patient health information between 
their new systems. Moreover, the departments remain challenged to 
articulate a clear vision of how this capability will be achieved, and 
in what time frame.

Further compounding the challenge and uncertainty that VA and DOD face 
is that they continue to lack a fully established project management 
structure for this undertaking. The relationships among management 
entities involved with the HealthePeople (Federal) initiative have not 
been clearly established and the departments have not designated a lead 
entity with final decision-making authority for the initiative to 
ensure that decision making and oversight will not be blurred across 
management entities. In addition, while the departments have designated 
a manager for the pharmacy data prototype project that they view as an 
initial step toward defining electronic data exchange technology, they 
do not yet have a comprehensive and coordinated project plan for the 
HealthePeople (Federal) initiative to articulate the time frames, 
resource requirements, and roles and responsibilities of VA and DOD 
officials charged with designing, developing, and implementing the 
electronic interface capability. The departments also have not 
instituted project review milestones and measures that provide a basis 
for comprehensive management, progressive decision making, and 
authorization of funding for each step in the development process. In 
discussing their management of HealthePeople (Federal), VA and DOD 
program officials stated this week that the departments had begun 
developing a project plan and defining the management structure for 
this initiative.

Absent a comprehensive and coordinated approach to implementing and 
conveying information about HealthePeople (Federal), VA and DOD risk 
compromising their progress and lack assurance that the goals of this 
initiative will be successfully realized. Given the importance of 
readily accessible health data for improving the quality of health care 
and disability claims processing for military members and veterans, we 
currently have a draft report at the departments for comment, in which 
we are making recommendations to the Secretaries of Veterans Affairs 
and Defense for addressing the challenges to and improving the 
likelihood of successfully achieving the electronic two-way exchange of 
patient health information.

Background:

In 1998, following a Presidential call for VA and DOD to start 
developing a "comprehensive, life-long medical record for each service 
member," the two departments began a joint course of action toward 
achieving the capability to share patient health information for active 
duty military personnel and veterans.[Footnote 3] As their first 
initiative, undertaken in that year, the Government Computer-Based 
Patient Record (GCPR) project was envisioned as an electronic interface 
that would allow physicians and other authorized users at VA and DOD 
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 in April 2001 and again in June 2002,[Footnote 4] 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 
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 activity 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 (the Composite Health Care 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. According to program officials, FHIE is now fully 
operational and is showing positive results by providing a wide range 
of health care information to enable clinicians to make more informed 
decisions regarding the care of veterans and to facilitate processing 
disability claims. The officials stated that the departments have now 
begun leveraging the FHIE infrastructure to achieve interim exchanges 
of health information on a limited basis, using existing health systems 
at joint VA/DOD facilities.[Footnote 5] The departments reported total 
GCPR/FHIE costs of about $85 million through fiscal year 2003.

The revised strategy also envisioned achieving a longer term, two-way 
exchange of health information between DOD and VA. 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 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 6] 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 7] 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 with 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 anticipated 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 2005.

Progress Toward Achieving HealthePeople (Federal) Faces Continued 
Challenges and Risks:

As we have noted,[Footnote 8] achieving the longer term capability to 
exchange health data in a secure, two-way electronic format between new 
health information systems that VA and DOD are developing is a 
challenging and complex undertaking, in which success depends on having 
a clearly articulated architecture, or blueprint, defining how specific 
technologies will be used to deliver the capability. Developing, 
maintaining, and using an architecture is a best practice in 
engineering information systems and other technological solutions, 
articulating, for example, the systems and interface requirements, 
design specifications, and database descriptions for the manner in 
which the departments will electronically store, update, and transmit 
their data.

Successfully carrying out the initiative also depends on the 
departments' instituting a highly disciplined approach to the project's 
management. 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 this one. Such planning involves developing 
and using a project management plan that describes, among other 
factors, the project's scope, implementation strategy, lines of 
responsibility, resources, and estimated schedules for development and 
implementation.

Currently, VA and DOD are proceeding with the development of their new 
health information systems and with the identification of standards 
that are essential to sharing common health data. DOD is deploying its 
first release of CHCS II functionality (a capability for integrating 
DOD clinical outpatient processes into a single patient record), with 
scheduled completion in June 2006. For its part, VA continues to work 
toward completing a prototype for the department's health data 
repository, scheduled for completion at the end of next month. In 
addition, as we reported in March, the departments have continued 
essential steps toward standardizing clinical data, having adopted data 
and message standards that are important for exchanging health 
information between disparate systems.[Footnote 9] Department 
officials also stated that they were proceeding with a pharmacy data 
prototype initiative, begun in March to satisfy a mandate of the Bob 
Stump National Defense Authorization Act for Fiscal Year 2003,[Footnote 
10] as an initial step toward achieving HealthePeople (Federal). The 
officials maintain that they expect to be positioned to begin 
exchanging patient health information between their new systems on a 
limited basis in the fall of 2005, identifying four categories of data 
that they expect to be able to exchange: outpatient pharmacy data, 
laboratory results, allergies, and patient demographics.

However, VA's and DOD's approach to meeting this HealthePeople 
(Federal) goal is fraught with uncertainty and lacks a solid foundation 
for ensuring that this mission can be successfully accomplished. As we 
reported in March, the departments continue to lack an architecture 
detailing how they intend to use technology to achieve the two-way 
electronic data exchange capability. In discussing their intentions for 
developing such an architecture, VA's Deputy Chief Information Officer 
for Health stated last week that the departments do not expect to have 
an established architecture until a future unspecified date. He added 
that VA and DOD planned to take an incremental approach to determining 
the architecture and technological solution for the data exchange 
capability. He explained, for example, that they hope to gain from the 
pharmacy data prototype project an understanding of what technology is 
necessary and how it should be deployed to enable the two-way exchange 
of patient health records between their data repositories. VA and DOD 
reported approval of the contractor's technical requirements for the 
prototype last month and have a draft architecture for the prototype. 
They expect to complete the prototype in mid-September of this year.

Although department officials consider the pharmacy data prototype to 
be an initial step toward achieving HealthePeople (Federal), how and to 
what extent the prototype will contribute to defining the electronic 
interface for a two-way data exchange between VA's and DOD's new health 
information systems are unclear. Such prototypes, if accomplished 
successfully, can offer valuable contributions to the process of 
determining the technological solution for larger, more encompassing 
initiatives. However, ensuring the effective application of lessons 
learned from the prototype requires that VA and DOD have a well-defined 
strategy to show how this project will be integrated with the 
HealthePeople (Federal) initiative. Yet VA and DOD have not developed a 
strategy to articulate the integration approach, time frames, and 
resource requirements associated with implementing the prototype 
results to define the technological features of the two-way data 
exchange capability under HealthePeople (Federal). Until VA and DOD are 
able to determine the architecture and technological solution for 
achieving a secure electronic systems interface, they will lack 
assurance that the capability to begin electronically exchanging 
patient health information between their new systems in 2005 can be 
successfully accomplished.

In addition to lacking an explicit architecture and technological 
solution to guide the development of the electronic data exchange 
capability, VA and DOD continue to be challenged in ensuring that this 
undertaking will be managed in a sound, disciplined manner. As was the 
situation in March, VA and DOD continue to lack a fully established 
project management structure for the HealthePeople (Federal) 
initiative. The relationships among the management entities involved 
with the initiative have not been clearly established, and no one 
entity has authority to make final project decisions binding on the 
other. As we noted during the March hearing, the departments' 
implementation of our recommendation that it establish a lead entity 
for the Government Computer-Based Patient Record project helped 
strengthen the overall accountability and management of that project 
and contributed to its successful accomplishment.

Further, although the departments have designated a project manager and 
established a project plan defining the work tasks and management 
structure for the pharmacy prototype, they continue to lack a 
comprehensive and coordinated project plan for HealthePeople (Federal), 
to explain the technical and managerial processes that have been 
instituted to satisfy project requirements for this broader initiative. 
Such a plan would include, among other information, details on the 
authority and responsibility of each organizational unit; the work 
breakdown structure and schedule for all of the tasks to be performed 
in developing, testing, and deploying the electronic interface; as well 
as a security plan. The departments also have not instituted necessary 
project review milestones and measures to provide a basis for 
comprehensive management of the project at critical intervals, 
progressive decision making, or authorization of funding for each step 
in the development process. As a result, current plans for the 
development of the electronic data exchange capability between VA's and 
DOD's new health information systems do not offer a clear vision for 
the project or demonstrate sufficient attention to the effective day-
to-day guidance of and accountability for the investments in and 
implementation of this capability. In discussing their management of 
HealthePeople (Federal), VA and DOD program officials stated this week 
that the departments had begun actions to develop a project plan and 
define the management structure for this initiative.

Given the significance of readily accessible health data for improving 
the quality of health care and disability claims processing for 
military members and veterans, we currently have a draft report at the 
departments for comment, in which we are recommending to the 
Secretaries of Veterans Affairs and Defense, a number of actions for 
addressing the challenges to, and improving the likelihood of, 
successfully achieving the electronic two-way exchange of patient 
health information.

In summary, VA's and DOD's pursuit of various initiatives to achieve 
the electronic sharing of patient health data represents an important 
step toward providing more high-quality health care for active duty 
military personnel and veterans. Moreover, in undertaking HealthePeople 
(Federal), the departments have an opportunity to help lead the nation 
to a new frontier of health care delivery. However, the continued 
absence of an architecture and defined technological solution for an 
electronic interface for their new health information systems, coupled 
with the need for more comprehensive and coordinated management of the 
projects supporting the development of this capability, elevates the 
uncertainty about how VA and DOD intend to achieve this capability and 
in what time frame. Until these critical components have been put into 
place, the departments will continue to lack a convincing position 
regarding their approach to and progress toward achieving the 
HealthePeople (Federal) goals and, ultimately, risk jeopardizing the 
initiative's overall success.

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

Contacts and Acknowledgments:

For information about this testimony, please contact Linda D. Koontz, 
Director, Information Management Issues, at (202) 512-6240 or at 
koontzl@gao.gov, or Valerie C. Melvin, Assistant Director, at (202) 
512-6304 or at melvinv@gao.gov. Other individuals making key 
contributions to this testimony include Barbara S. Oliver, J. Michael 
Resser, and Eric L. Trout.

(310716):

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] P.L. 107-314, sec. 724 (2002).

[3] Initially, the Indian Health Service (IHS) also was a party to this 
effort, having been included because of its population-based research 
expertise and its long-standing relationship with VA. However, IHS was 
not included in a later revised strategy for electronically sharing 
patient health information. 

[4] 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).



[5] VA and DOD officials stated that these efforts were not expected to 
contribute to determining the technological solution for a two-way data 
exchange between VA's and DOD's new health information systems but, 
instead, constituted attempts toward facilitating the sharing of health 
data in the absence of the longer term capabilities that HealthePeople 
(Federal) is expected to provide. 

[6] 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.

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



[8] GAO-04-402T.



[9] 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. 

[10] 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, then the Secretary of Veterans Affairs shall 
adopt DOD's Pharmacy Data Transaction System for VA's use.