Computer-Based Patient Records: VA and DOD Efforts to Exchange	 
Health Data Could Benefit from Improved Planning and Project	 
Management (07-JUN-04, GAO-04-687).				 
                                                                 
A critical element of the Department of Veterans Affairs' (VA)	 
information technology program is its continuing work with the	 
Department of Defense (DOD) to achieve the ability to exchange	 
patient health care information and create electronic medical	 
records for use by veterans, active-duty military personnel, and 
their health care providers.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-687 					        
    ACCNO:   A10398						        
  TITLE:     Computer-Based Patient Records: VA and DOD Efforts to    
Exchange Health Data Could Benefit from Improved Planning and	 
Project Management						 
     DATE:   06/07/2004 
  SUBJECT:   Data bases 					 
	     Data collection					 
	     Electronic data interchange			 
	     Electronic government				 
	     Health care services				 
	     Information technology				 
	     Medical records					 
	     Military personnel 				 
	     Program management 				 
	     Veterans						 
	     DOD Composite Health Care System II		 
	     DOD/IHS/VA Government Computer-Based		 
	     Patient Record Project				 
                                                                 
	     VA HealtheVet VistA				 
	     VA/DOD HealthePeople (Federal)			 
	     Initiative 					 
                                                                 
	     Federal Health Information Exchange		 
	     Program						 
                                                                 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-04-687

United States General Accounting Office

GAO	Report to the Chairman, Subcommittee on Oversight and Investigations,

            Committee on Veterans' Affairs, House of Representatives

June 2004

                                 COMPUTER-BASED
                                PATIENT RECORDS

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

                                       a

GAO-04-687

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

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

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

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

June 2004

COMPUTER-BASED PATIENT RECORDS

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

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

o  	VA and DOD lack an explicit architecture-a blueprint-that provides
details on what specific technologies will be used to achieve the
electronic medical record by the end of 2005.

o  	The departments have not fully implemented a project management
structure that establishes lead decision-making authority and ensures the
necessary day-to-day guidance of and accountability for their investment
in and implementation of this project.

o  	They are operating without a project management plan describing the
specific responsibilities of each department in developing, testing, and
deploying the electronic interface.

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

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

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Linda D. Koontz at (202)
512-6240 or [email protected].

Contents

      Letter                                                                1 
                                     Results in Brief                       2 
                                        Background                          3 
                The Two-Way Exchange Could Benefit from Improved Planning  
                                  and Project Management                    6 
                                       Conclusions                          9 
                           Recommendations for Executive Action            10 
                                     Agency Comments                       11 
    Appendix I             Comments from the Secretary of Veterans Affairs 
Appendix II             Comments from the Director, Interagency Program 
                         Integration & External Liaison for Health Affairs 

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

United States General Accounting Office Washington, DC 20548

June 7, 2004

The Honorable Steve Buyer

Chairman, Subcommittee on Oversight and Investigations Committee on
Veterans' Affairs House of Representatives

Dear Mr. Chairman:

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

As requested, our objective was to assess VA's and DOD's recent progress
toward achieving an electronic two-way exchange of health care data. In
conducting our work, we analyzed key documentation supporting VA's and
DOD's strategy for developing and implementing the two-way electronic
exchange of health data. In addition, we reviewed documentation to
identify the costs incurred by VA and DOD in developing technology to
support the sharing of health data, including costs for the

1U.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).

Government Computer-Based Patient Record/Federal Health Information
Exchange (GCPR/FHIE) initiatives, DOD's Composite Health Care System II,
and VA's HealtheVet VistA. We did not audit the reported costs, and thus,
cannot attest to their accuracy or completeness. We supplemented our
analyses with interviews of VA and DOD officials responsible for key
decisions and actions on the initiatives. Our work was performed at VA and
DOD offices located in the Washington, D.C., area in accordance with
generally accepted government auditing standards, from December 2003 to
May of this year.

                                Results in Brief

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

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

Background

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

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

Our prior reviews of the GCPR project determined that the lack of a lead
entity, clear mission, and detailed planning to achieve that mission made
it difficult to monitor progress, identify project risks, and develop
appropriate contingency plans. Accordingly, reporting on this project2 in
April 2001 and again in June 2002, we made several recommendations to help
strengthen the management and oversight of GCPR. Specifically, in 2001 we
recommended that the participating agencies (1) designate a lead entity
with final decision-making authority and establish a clear line of
authority for the GCPR project, and (2) create comprehensive and
coordinated plans that included an agreed-upon mission and clear goals,
objectives, and performance measures, to ensure that the agencies could
share comprehensive, meaningful, accurate, and secure patient health care
data. In 2002, we recommended that the participating agencies revise the
original goals and objectives of the project to align with their current
strategy, commit the executive support necessary to adequately manage the
project, and ensure that it followed sound project management principles.
VA and DOD took specific measures in response to our recommendations for
enhancing overall management and accountability of the project.

2U.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).

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

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

DOD began developing CHCS II in 1997 and has completed the development of
its associated clinical data repository-a key component for the planned
electronic interface. The department expects to complete deployment of all
of its major system capabilities by September 2008.4 It reported
expenditures of about $464 million for the system through fiscal year
2003. VA began work on HealtheVet VistA and its associated health data
repository in 2001, and expects to complete all six initiatives

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

4DOD'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.

comprising this system in 2012.5 VA reported spending about $120 million
on HealtheVet VistA through fiscal year 2003.

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

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

The Two-Way Exchange Could Benefit from Improved Planning

o

  and Project Management

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

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

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

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

    System Architecture Not Developed

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

VA and DOD lack an explicit architecture that provides details on what
specific technologies they will use to achieve the exchange capability, or

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

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

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

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

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

    Fully Established Project Management Structure Not in Place

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

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

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

8GAO-01-459.

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

or provided documentation for the project management structure or their
roles and responsibilities for the HealthePeople (Federal) initiative.

    Project Management Plan Lacking

Conclusions

An equally important component necessary for guiding the development of
the electronic interface is a project management plan. Information
technology project management principles and industry best practices10
emphasize that a project management plan is needed to define the technical
and managerial processes necessary to satisfy project requirements.
Specifically, the plan should include, among other things, the authority
and responsibility of each organizational unit; a work breakdown structure
for all of the tasks to be performed in developing, testing, and deploying
the software, along with schedules associated with the tasks; and a
security policy.

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

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

Achieving an electronic interface that will enable VA and DOD to exchange
patient medical records is an important goal, with substantial

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

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

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

  Recommendations for Executive Action

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

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

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

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

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

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

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

Sincerely yours,

Linda D. Koontz
Director, Information Management Issues

                 Page 12 GAO-04-687 VA/DOD Health Data Exchange

                 Page 13 GAO-04-687 VA/DOD Health Data Exchange

                 Page 14 GAO-04-687 VA/DOD Health Data Exchange

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

  GAO's Mission

Obtaining Copies of GAO Reports and Testimony

The General Accounting Office, the audit, evaluation and investigative arm
of Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability of
the federal government for the American people. GAO examines the use of
public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO's commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no cost
is through the Internet. GAO's Web site (www.gao.gov) contains abstracts
and fulltext files of current reports and testimony and an expanding
archive of older products. The Web site features a search engine to help
you locate documents using key words and phrases. You can print these
documents in their entirety, including charts and other graphics.

Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as "Today's Reports," on its
Web site daily. The list contains links to the full-text document files.
To have GAO e-mail this list to you every afternoon, go to www.gao.gov and
select "Subscribe to e-mail alerts" under the "Order GAO Products"
heading.

Order by Mail or Phone 	The first copy of each printed report is free.
Additional copies are $2 each. A check or money order should be made out
to the Superintendent of Documents. GAO also accepts VISA and Mastercard.
Orders for 100 or more copies mailed to a single address are discounted 25
percent. Orders should be sent to:

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

To order by Phone: 	Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061

To Report Fraud,	Contact: Web site: www.gao.gov/fraudnet/fraudnet.htm

  Waste, and Abuse in E-mail: [email protected]

Federal Programs Automated answering system: (800) 424-5454 or (202)
512-7470

Jeff Nelligan, Managing Director, [email protected] (202) 512-4800

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