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 (19-NOV-03, GAO-04-271T).		 
                                                                 
For the past 5 years, the Departments of Veterans Affairs and	 
Defense have been working to exchange health care data and create
electronic records for veterans and active duty personnel. Such  
exchange is seen as a means of reducing the billions of dollars  
that the departments spend annually on health care services and  
making such data more readily accessible to those treating our	 
country's approximately 13 million veterans, military personnel, 
and dependents. This is especially critical when military	 
personnel are engaged in conflicts all over the world, and their 
health records can reside at multiple locations. GAO has reported
on these efforts several times, most recently in September 2002. 
At the request of the Subcommittee, GAO is updating its 	 
observations on the departments' efforts, focusing on (1) the	 
reported status of the ongoing, one-way exchange of data, the	 
Federal Health Information Exchange, and (2) progress toward	 
achieving the longer term two-way exchange under the		 
HealthePeople (Federal) initiative.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-271T					        
    ACCNO:   A08890						        
  TITLE:     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					 
     DATE:   11/19/2003 
  SUBJECT:   Health care facilities				 
	     Health care services				 
	     Medical records					 
	     Military personnel 				 
	     Veterans						 
	     Health care cost control				 
	     Electronic data interchange			 
	     Information resources management			 
	     DOD Composite Health Care System			 
	     Federal Health Information Exchange		 
	     Program						 
                                                                 
	     VA Computerized Patient Record System		 

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GAO-04-271T

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 10:30 a.m. EST

Wednesday, November 19, 2003	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

Statement of Linda D. Koontz, Director Information Management Issues

GAO-04-271T

November 19, 2003

COMPUTER-BASED PATIENT RECORDS

Short-Term Progress Made, But Much

Highlights of GAO-04-271T, a report to the Work Remains to Achieve A
Two-Way
Subcommittee on Oversight and
Investigations, House Committee on Data Exchange Between VA and DOD
Veterans' Affairs

                                 Health Systems

For the past 5 years, the Access to medical data that includes information
on the entire lives of Departments of Veterans Affairs veterans and active
duty military personnel represents an enormous step and Defense have been
working to toward enhanced and more effective medical care. VA and DOD are
pursuing

exchange health care data and this goal in two stages.

create electronic records for

veterans and active duty personnel.  o  Federal Health Information
Exchange. This current, one-way

Such exchange is seen as a means transfer of health care data from DOD to
VA is already allowing
of reducing the billions of dollars
that the departments spend clinicians in VA medical centers to make
faster, more informed decisions
annually on health care services through ready access to information on
almost 2 million patients,
and making such data more readily thereby improving their level of health
care delivery. The program's
accessible to those treating our fiscal year 2003 cost was just over $11
million.
country's approximately 13 million

veterans, military personnel, and  o  HealthePeople (Federal). The
realization of this longer term strategy

dependents. This is especially to enable electronic, two-way information
sharing is farther out on the

critical when military personnel are horizon. The departments are
proceeding with projects that are expectedengaged in conflicts all over
the

world, and their health records can to result in a limited two-way
exchange of health data by the end of 2005.

reside at multiple locations. However, VA and DOD face significant
challenges in implementing a full

data exchange capability. Although a high-level strategy exists, the

GAO has reported on these efforts departments have not yet clearly
articulated a common health

several times, most recently in information infrastructure and
architecture to show how they intend to

September 2002. At the request of achieve the data exchange capability or
what they will be able to

the Subcommittee, GAO is exchange by the end of 2005. In addition,
critical to achieving the two

updating its observations on the way exchange will be completing the
standardization of the clinical data

departments' efforts, focusing on that these departments plan to share.
Without standardization, the task

(1) the reported status of the of sharing meaningful data could be more
complex and may not prove ongoing, one-way exchange of data, successful.

the Federal Health Information Exchange, and (2) progress toward achieving
the longer term two-way

exchange under the HealthePeople VA, DOD Systems to Support Two-Way Data
Exchange Strategy

(Federal) initiative. 	VA Projected DOD Initiatives Completion Initiatives

Graphical User Interface, 2005 General Dentistry

             Health Data Repository,             Pharmacy, Laboratory,        
                 Billing Replacement  2006      Radiology, Immunizations      
                          Laboratory  2007      Inpatient and Scheduling      
                            Pharmacy  2008 Additional Capabilities as Defined 
                             Imaging  2011 
              Appointment Scheduling       
                         Replacement  2012 

Source: VA and DOD.

www.gao.gov/cgi-bin/getrpt?GAO-04-271T.

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 [email protected].

Mr. Chairman and Members of the Subcommittee:

Thank you for inviting us to testify on actions of the Department of
Veterans Affairs (VA) and the Department of Defense (DOD) to achieve the
ability to exchange patient health care data and create an electronic
record for veterans and active duty personnel. VA and DOD, collectively,
provided health care services to approximately 13 million veterans,
military personnel, and dependents at a cost of about $47 billion in
fiscal year 2002. While in military status and later as veterans, many
patients tend to be highly mobile and, consequently, their health records
may be at multiple federal and nonfederal medical facilities, both in and
outside of the United States. Thus, having readily accessible data on
active duty personnel and veterans is important to facilitate providing
quality health care to them.

VA and DOD have been pursuing ways to share data in their health
information systems and create electronic records since 1998, their
actions following the President's call for the development of an interface
to allow the two departments to share patient health information.1 Since
undertaking this mission, however, the departments have faced considerable
challenges, leading to repeated changes in the focus of their initiative
and the target dates for its accomplishment. Our prior reports supporting
the initiative2 noted disappointing progress, exacerbated in large part by
inadequate accountability and poor planning and oversight, which raised
doubts about the departments' ability to achieve an electronic interface
among their health information systems. When we last reported on the
initiative in September 2002,3 VA and DOD had taken some actions aimed at
strengthening their joint efforts. For example, they had

1In 1996, the Presidential Advisory Committee on Gulf War Veterans'
Illnesses reported on many deficiencies in VA's and DOD's data
capabilities for handling service members' health information. In November
1997, the President called for the two agencies to start developing a
"comprehensive, life-long medical record for each service member," and in
1998 issued a directive requiring VA and DOD to develop a "computer-based
patient record system that will accurately and efficiently exchange
information."

2U.S. General Accounting Office, Computer-Based Patient Records: Better
Planning and Oversight by VA, DOD, and IHS [Indian Health Service] Would
Enhance Health Data Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001);
VA Information Technology: Progress Made, but Continued Management
Attention Is Key to Achieving Results, GAO-02-369T (Washington, D.C.: Mar.
13, 2002); and VA Information Technology: Management Making Important
Progress in Addressing Key Challenges GAO-02-1054T (Washington, D.C.:
Sept. 26, 2002).

3GAO-02-1054T.

clarified key roles and responsibilities for the initiative and begun
executing revised near-and long-term strategies for achieving the
electronic information exchange capability.

My statement today will discuss our observations regarding VA's and DOD's
continued actions over the past year to further their implementation of
the electronic information exchange, including an update on (1) the status
and reported benefits of the ongoing near-term initiative, the Federal
Health Information Exchange (FHIE), and (2) the departments' progress and
challenges in achieving the longer term, twoway exchange of data under the
HealthePeople (Federal) initiative.

In conducting this work, we obtained and reviewed relevant documentation
and interviewed key agency officials regarding VA's decisions and actions,
in conjunction with DOD, to develop an electronic medical record for
exchanging patient information. We analyzed the departments' plans and
strategies for the HealthePeople (Federal) initiative and data on patient
information that is currently being transmitted by DOD to VA. In addition,
to observe data retrieval capabilities of the Federal Health Information
Exchange, we conducted a site visit at the VA medical center in
Washington, D.C. We performed our work in accordance with generally
accepted government auditing standards, from March through November 2003.

                                Results in Brief

The current one-way transfer of health information resulting from the
departments' near-term solution-the Federal Health Information
Exchange-represents a positive undertaking that has begun enabling
information sharing between DOD and VA. As part of the initiative,
electronic health data from separated (retired or discharged) service
members contained in DOD's Military Health System Composite Health Care
System are being transmitted monthly to a VA FHIE repository,4 which VA
clinicians access through the department's current health system, the
Veterans Health Information Systems and Technology Architecture. As a
result, VA clinicians now have more readily accessible DOD health data,
such as laboratory, pharmacy, and radiology records, on almost 2 million
patients and have noted the benefits of this current capability in
improving health care delivery. Further, although not

4A repository is an information system used to store and access data.

originally included in the FHIE plan, VA officials have stated that
efforts are underway to provide access to outpatient and retail pharmacy
data.

Realizing the departments' longer term strategy-HealthePeople (Federal)-is
farther out on the horizon. VA officials have stated that the departments
are on schedule to provide a limited capability for an electronic, two-way
exchange of patient health information by the end of 2005. However, VA and
DOD face significant challenges in implementing a full data exchange
capability. Although a high-level strategy exists, the departments have
not yet clearly articulated a common health information infrastructure and
architecture to show how they intend to achieve the data exchange
capability or what exactly they will be able to exchange by the end of
2005. In addition, critical to achieving the two-way exchange will be
completing the standardization of the clinical data that these departments
plan to share. Without standardization, the task of sharing meaningful
data is made more complex, and may not prove successful. Until these
essential issues are resolved, the departments cannot be assured that the
HealthePeople (Federal) initiative will deliver expected benefits within
established time frames.

In 1998, VA and DOD, along with the Indian Health Service (IHS), began the
Government Computer-Based Patient Record (GCPR) project-an initiative to
share patient health care data. At that time, each agency collected and
maintained patient health information in separate systems, and their
health facilities could not electronically share patient health
information across agency lines. GCPR 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 facilities. The interface was expected to compile
requested patient information in a "virtual" record that could be
displayed on a user's computer screen.

In reporting on the initiative in April 2001,5 we raised doubts about
GCPR's ability to provide expected benefits. We noted that the project was
experiencing schedule and cost overruns and was operating without clear
goals, objectives, and consistent leadership. We recommended that the
participating agencies (1) designate a lead entity with final
decisionmaking authority and establish a clear line of authority for the
GCPR

Background

5GAO-01-459.

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. VA, DOD, and
IHS agreed with our findings and recommendations.

In March 2002, however, we again reported that the project was continuing
to operate without clear lines of authority or a lead entity responsible
for final decision-making.6 Further, the project continued to move forward
without comprehensive and coordinated plans, including an agreed-upon
mission and clear goals, objectives, and performance measures. In
addition, the participating agencies had announced a revised strategy that
was considerably less encompassing than the project was originally
intended to be. For example, rather than serve as an interface to allow
data sharing across the three agencies' disparate systems, as originally
envisioned, the revised strategy initially called only for a one-way
transfer of data from DOD's current health care information system to a
separate database that VA hospitals could access. In further reporting on
this initiative in June 2002, we recommended that VA, DOD, and IHS 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.7

When we last testified on the initiative in September 2002,8 VA had
reported some progress toward achieving shared patient health care data
and the two departments had formally revised both the name and the
strategy for the initiative. Specifically, the two departments had renamed
the project the Federal Health Information Exchange (FHIE) Program. In
addition, consistent with our prior recommendation, they had finalized a
memorandum of agreement designating VA as the lead entity in implementing
FHIE.

With this agreement, FHIE became a joint effort between VA and DOD to
achieve the exchange of health care information in two phases. The first

6GAO-02-369T.

7U.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).

8GAO-02-1054T.

  VA AND DOD Continue to Report Success in Implementing the Feeral Health
  Information Exchange Near-Term Solution

phase, completed in mid-July 2002, enabled the one-way transfer of data
from DOD's existing health care information system to a separate database
that VA hospitals could access.

Further, the revised strategy envisioned VA and DOD pursuing a longer
term, two-way exchange of clinical information.9 This initiative, known as
HealthePeople (Federal), is premised upon the departments' development of
a common health information infrastructure and architecture comprising
standardized data, communications, security, and highperformance health
information systems. The departments developed the strategy for achieving
the two-way exchange in September 2002 and anticipated achieving a limited
capability by the end of 2005.

Over the past year, VA and DOD have continued to realize success in the
implementation and use of FHIE. In achieving the exchange of health care
information, electronic data from separated (retired or discharged)
service members contained in DOD's Military Health System Composite Health
Care System (CHCS) are being transmitted monthly to a VA FHIE repository,
which VA clinicians access through the Computerized Patient Record System
(CPRS) in the Veterans Health Information Systems and Technology
Architecture (VistA), VA's current health care system. This information
exchange capability is currently available to all VA medical centers and
has given VA clinicians the ability to access and display the data through
CPRS remote data views10 about 6 weeks after the service member's
separation. VA and DOD reported spending about $11 million in fiscal year
2003 to cover completion and maintenance of FHIE.

According to program officials, FHIE is showing positive results by
providing a wide range of health care information to enable clinicians to
make faster and more informed decisions regarding the care of veterans.
The officials stated that the repository presently contains data on almost
2 million patients. This includes clinical data on almost 1.8 million
personnel who separated from the military between 1987 and June 2003. The
data consist of over 23 million laboratory records, 24 million pharmacy
records, and over 4 million radiology records. A second phase of the FHIE

9IHS, which had been a part of the early efforts, was not included in
FHIE, but was expected to assume a role in the longer term
project-HealthePeople (Federal).

10CPRS remote data views is an application that allows authorized users to
access patient health care data from any VA medical facility.

initiative, completed in September 2003, added to the base of health
information available to VA clinicians by including discharge summaries;11
allergy information; admissions, disposition, and transfer information;
and consultation results. A clinician at VA's Washington, D.C. medical
center noted that the information provided through FHIE has proved
particularly valuable for treating emergency-room and first-time patients
by providing ready access to information on patients' existing medical
conditions and current drug prescriptions.

The program manager added that FHIE is providing ready access to health
information. It is currently capable of accommodating up to 800 queries
per hour, with an average response rate of 4 seconds per query. For the
month of September 2003, VA clinicians made over 1,900 authorized queries
to the database. Further, as we observed during an FHIE demonstration at
the medical center, the capability has resulted in an almost instantaneous
display of DOD patient data in the same format as other data residing in
CPRS, thus facilitating its use.

Although nearing completion, VA officials indicated, additional patient
information from DOD will be added to the FHIE database. For example, they
stated that efforts are currently under way to add, by the end of
December, outpatient pharmacy data (such as mail order and retail pharmacy
profiles) that are housed in DOD's Pharmacy Data Transaction Service, and
by the end of February 2004, other outpatient records.

Beyond FHIE, VA and DOD are proceeding with a joint, long-term strategy
involving the two-way exchange of clinical information. Under this
strategy, VA and DOD plan to seek opportunities for sharing existing
systems and technology and explore the convergence of VA and DOD health
information applications consistent with mission requirements. According
to the Veterans Health Administration's Acting Deputy Chief Information
Officer (CIO) for Health, and the Military Health System's CIO, this joint
VA/DOD initiative is expected to allow the secured sharing of health data
required by their health care providers between systems that each is
currently developing-DOD's Composite Health Care System II (CHCS II) and
VA's HealtheVet VistA. Critical to achieving this capability is an
interface to allow the exchange of patient health information between each
system's data repository.

  Actions Toward a Common Health Information Infrastructure Are Progressing, but
  Significant Challenges Remain

11Discharge summaries will include inpatient histories, diagnoses, and
procedures.

Under the HealthePeople (Federal) strategy, 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 remain in the
clinical data repository and 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 clinical information on the individual also
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 access to the clinical information existing
in VA's repository. According to VA and DOD, the planned approach would
make virtual medical records displaying all available clinical information
from the two repositories accessible to both departments' clinicians.

VA and DOD Are Making Progress, but Full Implementation of Joint Strategy
Is Years Away

VA's and DOD's joint strategy for accomplishing the two-way exchange of
health information, developed in September 2002, depends on successfully
implementing and achieving an electronic interface between individual
health information systems that each department is currently developing.
These systems development efforts began as separate, department-specific
initiatives in which VA aimed to enhance its existing health information
system utilizing modern tools and languages, and DOD aimed to replace
several of its health information systems to achieve cost efficiencies and
a computer-based patient record. Work on modernizing VA's new system,
HealtheVet (VistA), began in 2001, and development of DOD's new system,
CHCS II, began in 1997.

Since establishing the strategy, VA and DOD have made some progress on
systems development efforts that will support achieving health data
exchange. Currently, VA and DOD are in different stages of completing
their systems. As shown in table 1, VA began work on one of the key
initiatives intended to support HealthePeople (Federal)-the health data
repository-in June 2001; it is currently testing the design of this
database. VA plans to complete the repository by July 2006; it projects
completing all six initiatives comprising HealtheVet (VistA) over the next
9 years, with a final module on scheduling replacement expected in May
2012.

Table 1: HealtheVet (VistA) Initiatives

Health Data Repository Establish a repository of clinical information 2006 
                          normally June 2001                             
(HDR)                  residing on one or more independent platforms  
                          Obtain a modern, high- performance billing     2006 
Billing Replacement    system that April 2002                         
                          will support an increase to third- party       
                          payments                                       
                          Clinically oriented system designed to provide 2007 
Laboratory             data to February 2003                          
                          health care personnel                          
                          Facilitate improved VA pharmacy operations,    2008 
Pharmacy               customer April 2002                            
                          service, and patient safety, concurrent with   
                          the pursuit                                    
                          of full reengineering of VA pharmacy           
                          applications                                   
                          Provide complete online data to healthcare     2011 
Imaging                providers, to October 2002                     
                          increase clinician productivity, facilitate    
                          medical                                        
                          decision-making, and improve quality of care   

Appointment Scheduling Provide VistA users with a redesigned scheduling
May 2001 2012 Replacement capability to better meet the needs of VHA
facility staff

and patients

Source: VA

As table 2 reflects, DOD is incrementally deploying CHCS II in five
blocks, with each block providing additional capabilities to its system.
The department is currently proceeding with limited deployment of its
graphical user interface for clinical outpatient processes. In addition,
DOD has completed its clinical data repository, and a department official
stated that as each site implements CHCS II, data in CHCS will be
converted to the new system. DOD expects to complete deployment of all of
its major system capabilities by September 2008.

                    Table 2: CHCS II Deployment Information

1 (release 1) 	Adds a graphical user interface for Limited deployment
underway September 2005 clinical outpatient processes

2 (release 2) Support for general dentistry	Deployment to Operation, Test
& Evaluation September 2005 sites during the 2nd Qtr of FY04

3 (releases 3&4) 	Provides pharmacy, laboratory, Plan under way to award a
contract for Block September 2006 radiology, and immunizations 3 in 2nd
Qtr FY 04 and begin requirements capabilities analysis by 4th Qtr FY04

4 (releases 5&6) 	Provides inpatient and scheduling Begin requirements
development and September 2007 capabilities analysis in 2nd Qtr FY 04

5 (release 7) Additional Capabilities as Defined 	Begin requirements
development and September 2008 analysis in early 1st Qtr FY05

Source: DOD.

Although VA and DOD officials do not expect their departments' systems to
be fully implemented until 2012 and 2008, respectively, they anticipate
being able to exchange some degree of clinical information through an
interface between DOD's clinical data repository and VA's planned health
data repository by the end of calendar year 2005. VA officials explained
that by that time, they expect to have developed the HealtheVet (VistA)
health data repository to a point at which it will have limited data.
However, the departments have not yet articulated exactly what data will
be available.

Also critical, VA and DOD have begun adopting data standards. Data
standardization is essential to allowing the exchange of health
information from disparate systems and improving decision-making by
providing health information when and where it is needed. In accordance
with the Consolidated Health Informatics Initiative,12 in March 2003, VA
and DOD, along with the Department of Health and Human Services, announced
the adoption of four standards to allow the transmission of messages and
one standard that allows laboratory results to be presented uniformly in
any system. In addition, VA officials stated that the departments have
examined and concluded that their existing legislation and policies meet
the intent of the Health Insurance Portability and Accountability Act.

VA and DOD Face Challenges in Moving Toward HealthePeople (Federal)

VA and DOD face key challenges to completing HealthePeople (Federal) that
raise doubts as to when and to what extent a true virtual health record
will be achieved. Although a high-level strategy exists, the HealthePeople
(Federal) joint work group faces the challenge of clearly articulating a
common health information infrastructure and architecture to show how they
intend to achieve the data exchange capability, or just what they will be
able to exchange by the end of 2005. Such an architecture is necessary for
ensuring that the departments have defined a level of detail and
specificity needed to build the data repository interface, including
interface requirements and design specifications. For example, having
detailed specifications would assist VA in making critical decisions such
as the manner in which it will store its electronic data. According to VA
officials, they have not yet determined whether one central or several
regional data repositories would best facilitate access to the patient

12The Consolidated Health Informatics Initiative, created under the
President's Management Agenda, identified a portfolio of 24 target areas
for data and messaging standards that would enable all agencies in the
federal health enterprise to more readily exchange clinical health
information.

information and achieve the timely response rates required by clinicians
at its medical facilities.

Another critical challenge to successfully implementing HealthePeople
(Federal) will be completing the standardization of the data elements of
each department's health records. While standards for laboratory results
were adopted in 2003, VA and DOD face a significant undertaking to
standardize the remaining health data. To lend perspective to the enormity
of this task, according to the joint strategy that VA and DOD have
developed, VA will have to migrate over 150 variations of clinical and
demographic data to one standard, and DOD will have to migrate over 100
variations of clinical data to one standard. VA officials have indicated
that as various HealtheVet (VistA) applications are developed, they plan
to incorporate clinical data standards. Further, they and DOD officials
maintain that their departments, along with the Department of Health and
Human Services, are actively pursuing the development and adoption of such
data standards. Nonetheless, they remain uncertain as to what degree of
standardization (beyond the laboratory result standard that has been
adopted) will be achieved by the 2005 milestone for implementing the
twoway exchange of health information.

In summary, in pursuing an electronic exchange of patient health
information, VA and DOD are taking a vital step toward facilitating
services to our nation's active duty personnel and veterans. The ability
to readily access medical records covering the lifecycle of service
members and veterans would enhance the effectiveness of care to these
individuals. In working toward this capability, VA and DOD have achieved a
measure of success in sharing data, as evidenced by VA clinicians now
having access to military health records for veterans through FHIE.
However, a virtual medical record based on the two-way exchange of data
between VA and DOD is far from being achieved. The departments face
significant challenges in realizing this longer term strategy. Without
having clearly articulated a common health information infrastructure and
architecture, the departments lack the details and specificity essential
to determining how they will achieve the data exchange capability.

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

(310362)

For information regarding this testimony, please contact Linda D. Koontz,
Director, or Valerie Melvin, Assistant Director, Information Management
Issues, at (202) 512-6240 or at [email protected] or [email protected],
respectively. Other individuals making key contributions to this testimony
include Barbara S. Oliver, Eric L. Trout, Michael P. Fruitman, and J.
Michael Resser.

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Public Affairs 	U.S. General Accounting Office, 441 G Street NW, Room 7149
Washington, D.C. 20548
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