Veterans Affairs: Posthearing Questions Concerning the		 
Departments of Defense and Veterans Affairs Providing Seamless	 
Health Care Coverage to Transitioning Veterans (24-NOV-03,	 
GAO-04-292R).							 
                                                                 
On October 16, 2003, GAO testified before Congress at a hearing  
on whether DOD and VA are providing seamless health care coverage
to transitioning veterans. This letter responds to a request thst
we provide answers to follow-up questions from the hearing.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-292R					        
    ACCNO:   A08941						        
  TITLE:     Veterans Affairs: Posthearing Questions Concerning the   
Departments of Defense and Veterans Affairs Providing Seamless	 
Health Care Coverage to Transitioning Veterans			 
     DATE:   11/24/2003 
  SUBJECT:   Data base management systems			 
	     Information technology				 
	     Strategic planning 				 
	     Systems evaluation 				 
	     Systems management 				 
	     Interagency relations				 
	     Computer matching					 
	     Medical records					 
	     Military personnel records 			 
	     Medical information systems			 
	     Military personnel 				 
	     Veterans						 
	     Records management 				 
	     DOD/IHS/VA Government Computer-Based		 
	     Patient Record Project				 
                                                                 
	     Federal Health Information Exchange		 
	     Program						 
                                                                 

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GAO-04-292R

______________________________________________________________________________________________

United States General Accounting Office Washington, DC 20548

November 24, 2003

The Honorable Christopher H. Smith
Chairman
Committee on Veterans' Affairs
House of Representatives

Subject: Veterans Affairs: Posthearing Questions Concerning the
Departments of Defense and Veterans Affairs Providing Seamless Health Care
Coverage to Transitioning Veterans

Dear Mr. Chairman:

On October 16, 2003, I testified before your Subcommittee at a hearing on
Hand-off or Fumble: Are DOD and VA Providing Seamless Health Care Coverage
to Transitioning Veterans?1 This letter responds to your request that we
provide answers to follow-up questions from the hearing. Your questions,
along with my responses, follow.

1. "GAO, at the request of this Committee, has examined VA's Information
Technology (IT) needs a number of times. Also, GAO has studied DOD's IT
infrastructure. VA and DOD have pledged over the years to be working
toward common solutions to their IT challenges, most particularly in the
area of computerized patient care records and the portability of these
records across the several systems involved. Yet, they soldier on
separately. What are the basic problems in the view of GAO, that prevent
or obstruct the accomplishment of this goal of a single patient care
record that can accompany a military servicemember from active duty to
veteran status?"

Answer: VA and DOD have been pursuing ways to share data in their health
information systems and create electronic records since 1998, when the
Government Computer-Based Patient Record (GCPR) project was initiated.
GCPR was envisioned as an electronic interface that would allow physicians
and other authorized users at VA, DOD, and Indian Health Service (IHS)
health facilities to access data from any of the other agencies' health
facilities.2 The interface was expected to compile requested patient
information in a "virtual" record that could be displayed on a user's
computer screen.

1U.S. General Accounting Office, Defense Health Care: DOD Needs to Improve
Force Health Protection And Surveillance Processes, GAO-04-158T
(Washington, D.C.: Oct. 16, 2003).

2The Indian Health Service became involved in GCPR because of its
expertise in population-based research and its longstanding relationship
with VA in caring for the American Indian veteran population.

                     Page 1 GAO-04-292R Defense Health Care

Since undertaking this mission, however, VA and DOD have faced
considerable challenges, leading to repeated changes in the focus of their
initiative and the target dates for its accomplishment. Our prior reports
discussing the initiative3 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
reported on the initiative in September 2002,4 VA and DOD had taken some
actions aimed at strengthening their joint efforts. For example, they had
clarified key roles and responsibilities for the initiative and begun
executing revised near- and long-term strategies for achieving the
electronic information exchange capability.

The near-term initiative-the Federal Health Information Exchange-was
completed in July 2002 and enabled the one-way transfer of data from DOD's
existing health care information system to a separate database that VA
hospitals could access. This initiative has shown success in allowing
clinicians in VA medical centers ready access to information-such as
laboratory, pharmacy, and radiology records-on almost 2 million patients.

However, the departments' strategy for an envisioned longer-term, two-way
exchange of clinical information is farther out on the horizon. This
initiative, HealthePeople (Federal), is premised upon the departments'
development of a common health information infrastructure and architecture
comprising standardized data, communications, security, and
high-performance health information systems. VA and DOD anticipated
achieving a limited capability for two-way data exchange by the end of
2005.

Nonetheless, VA and DOD continue to face significant challenges in
realizing this longerterm capability. While the departments have developed
a high-level strategy for the initiative, they face the challenge of
clearly articulating 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. Such an
architecture is necessary for ensuring that the departments have defined a
level of detail and specificity needed to build the exchange capability,
including requirements and design specifications.

In addition, critical to the two-way exchange will be completing the
standardization of the clinical data that these departments plan to share.
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. Currently, VA
and DOD face an enormous task of standardizing their health data. 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 and DOD officials maintain that their
departments, along with the Department of Health and Human Services, are
actively pursuing the development and adoption of data standards.
Nonetheless, they remain uncertain as to when the necessary
standardization will be

3U.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).

4GAO-02-1054T.

                     Page 2 GAO-04-292R Defense Health Care

accomplished. Without standardization, the task of sharing meaningful data
is made more complex and may not prove successful.

2. "Assuming that VA and DOD actually unify their patient care record
keeping, will this accomplishment solve the "seamless transition"
challenge, or will the records problem be supplanted by some other new
one, such as HIPAA [Health Insurance Portability and Accountability Act]
or another cause, and what are your reasons for this conclusion?"

Answer: Achieving the technical capability to unify VA's and DOD's patient
care records in and of itself will not ensure the seamless transition of
health care data. Other issues that the departments need to address
include the following:

o  	Reaching consensus on and implementing data standards. As we pointed
out in our previous response, an essential aspect of making the data
usable will be establishing data standards. Accomplishing this is
particularly challenging, as consensus must be reached with clinicians and
other health care providers to achieve common acceptance of the standards.

o  	Capturing complete and accurate medical information on service
members. The departments must establish and closely adhere to a process
that will ensure the complete and accurate capture of medical information
of service members stored in their respective databases.5 As noted in our
testimony, DOD's database does not currently contain patient health
information (such as health assessments and immunizations) for all service
members.

o  	Ensuring privacy and security compliance. The departments will have to
ensure that the exchange of medical information is compliant with privacy
requirements established in the HIPAA. In addition, given the sensitivity
of patient health information, the departments must ensure that adequate
security is an integral feature of the data exchange capability.

                                       --

We are sending copies of this letter to the Secretary of Veterans Affairs
and the Secretary
of Defense and other interested parties. We will also make copies
available to others upon
request. In addition, this report will be available at no charge on the
GAO Web site at
http://www.gao.gov. Should you or your staff have any questions on matters
discussed in
this letter, please contact me at (757) 552-8100. I can also be reached by
e-mail at
[email protected].

Sincerely yours,

Neal P. Curtin
Director, Operations and Readiness Issues

(350472)

5VA and DOD plan to implement a capability to share patient health
information that will be collected in data repositories that each is
implementing.

                     Page 3 GAO-04-292R Defense Health Care

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