Computer-Based Patient Records: Subcommittee Questions Concerning
VA and DOD Efforts to Achieve a Two-Way Exchange of Health Data  
(14-MAY-04, GAO-04-691R).					 
                                                                 
This letter responds to a request by the Chairman of the	 
Subcommittee on Oversight and Investigations, House Committee on 
Veterans' Affairs, that we provide answers to questions relating 
to our March 17, 2004, testimony. At that hearing, we discussed  
the Department of Veterans Affairs' (VA) and Department of	 
Defense's (DOD) progress toward defining a detailed strategy and 
developing the capability for a two-way exchange of patient	 
health information.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-691R					        
    ACCNO:   A10091						        
  TITLE:     Computer-Based Patient Records: Subcommittee Questions   
Concerning VA and DOD Efforts to Achieve a Two-Way Exchange of	 
Health Data							 
     DATE:   05/14/2004 
  SUBJECT:   Information disclosure				 
	     Information resources management			 
	     Interagency relations				 
	     Medical information systems			 
	     Medical records					 
	     Military personnel records 			 
	     Strategic information systems planning		 
	     Enterprise architecture				 
	     DOD Composite Health Care System II		 
	     DOD/IHS/VA Government Computer-Based		 
	     Patient Record Project				 
                                                                 
	     VA HealtheVet System				 
	     VA/DOD HealthePeople (Federal)			 
	     Initiative 					 
                                                                 

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GAO-04-691R

United States General Accounting Office Washington, DC 20548

May 14, 2004

The Honorable Steve Buyer
Chairman, Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives

Subject: Computer-Based Patient Records: Subcommittee Questions Concerning
VA and DOD Efforts to Achieve a Two-Way Exchange of Health Data

Dear Mr. Chairman:

This letter responds to your April 7, 2004, request that we provide
answers to questions relating to our March 17, 2004, testimony.1 At that
hearing, we discussed the Department of Veterans Affairs' (VA) and
Department of Defense's (DOD) progress toward defining a detailed strategy
and developing the capability for a two-way exchange of patient health
information. Your questions, along with our responses, follow.

1. How many times has the GAO testified on VA-DOD sharing of medical
information in the last 10 years?

In the last 10 years we have testified seven times on matters pertaining
to VA's and DOD's efforts toward achieving the capability to
electronically exchange patient health information. VA and DOD have been
working to achieve this capability since 1998. Our testimony was delivered
between October 2001 and March of this year, and is summarized in
enclosure I.

Our statements at these hearings have highlighted significant challenges
that VA and DOD have faced in pursuing ways to share data in their health
information systems and create electronic medical records. Although noting
the departments' ultimate success in sharing data through the one-way
transfer of health information from DOD to VA health care facilities, as
part of the Federal Health Information Exchange,2 we

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.: Mar. 17, 2004).

2When undertaken in 1998, the initiative to share patient health care
information was called the Government Computer-Based Patient Record
project. The project was renamed the Federal Health Information Exchange
in 2002.

also detailed persistent weaknesses in the departments' actions toward
achieving a two-way health data exchange-the focus of the HealthePeople
(Federal) initiative. For example, our most recent testimony highlighted
the limited progress that the departments had made toward establishing
sound project management and defining a specific architecture and
technological solution for developing the electronic interface that is
fundamental to exchanging data between the individual health information
systems that VA and DOD are developing.

2. What recommendations have either VA or DOD implemented independently or
cooperatively?

VA and DOD have taken action on several recommendations that we have made
over the past 3 years. These recommendations were aimed at improving the
coordination and management of the departments' initial efforts to achieve
electronic information sharing via the Government Computer-Based Patient
Record (GCPR) project, and furthering DOD's development of its new health
information system, the Composite Health Care System II. Our
recommendations, along with the departments' actions to implement them,
are summarized in enclosure II.

In particular, our prior reviews of the project to develop a government
computerbased patient record determined that the lack of a lead entity,
clear mission, and detailed planning to achieve that mission had made it
difficult to monitor progress, identify project risks, and develop
appropriate contingency plans. As a result, in reporting on GCPR in April
20013 and again in June 2002,4 we made several recommendations to help
strengthen the management and oversight of this project. VA and DOD agreed
with and took actions that addressed all of these recommendations,
including designating VA as the lead entity for the initiative,
reevaluating and revising its original goals and objectives, and assigning
a full-time project manager and supporting staff to oversee its
implementation.

In addition, in September 2002 we reported on DOD's acquisition of the
Composite Health Care System II.5 DOD envisioned achieving a
state-of-the-art automated medical information system that would lead to
improved health-care decisions and lower medical and system costs through
creating computer-based patient records that doctors and other health
service providers would be able to access from any military treatment
facility, irrespective of location. However, our review of the initiative
noted, among other concerns, DOD's limited progress during early stages of

3U.S. General Accounting Office, Computer-Based Patient Records: Better
Planning and Oversight by VA, DOD, and IHS Would Enhance Health Data
Sharing, GAO-01-459 (Washington, D.C.: Apr. 30, 2001).

4U.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).

5U.S. General Accounting Office, Information Technology: Greater Use of
Best Practices Can Reduce Risks in Acquiring Defense Health Care System,
GAO-02-345 (Washington, D.C.: Sept. 26, 2002).

the system's development that led to a change in its redesign and
development/deployment schedule. We recommended five actions aimed at
increasing the project's likelihood of success, three of which have been
implemented. DOD is in various stages of implementing the remaining two
recommendations.

3. What is the total dollars spent by DOD and VA on their individual or
collective efforts on the development of an interoperable medical record?

From fiscal year 1998, when VA and DOD began pursuing ways to share data
in their health information systems and create electronic records for
active duty personnel and veterans, through fiscal year 2003, the
departments reported spending a total of about $670 million on their
individual and collective efforts. As shown in table 1, this amount is
attributable to the departments' joint actions on the Government
Computer-Based Patient Record (GCPR) project and subsequently the Federal
Health Information Exchange (FHIE) initiative, which have resulted in the
one-way transfer of data from DOD's existing health information system
(the Composite Health Care System) to a separate database that VA
hospitals can access. The amount also includes the departments' reported
expenditures for individual health information systems-VA's HealtheVet
(VistA) and DOD's Composite Health Care System II-that each is currently
developing and anticipates using to support the two-way exchange of health
data as part of the HealthePeople (Federal) initiative.6 However, through
fiscal year 2003, VA and DOD did not report any costs associated with the
critical tasks of defining and developing the electronic interface that is
essential to achieving the two-way exchange of patient health information
between these systems.

Table 1: Dollars (in millions) Spent by VA and DOD to Develop Electronic
Health Information Systems and Sharing Capabilities through Fiscal Year
2003

                            HealthePeople (Federal)

                                   HealtheVet    Composite Health   
     Agency     GCPR      FHIE           VistAa   Care System II        Total 
       VA         $27.8   $20.4          $120.0                 0.0    $168.2 
      DOD          17.7   18.8              0.0              $464.0     500.5 
     Total        $45.5   $39.2          $120.0              $464.0    $668.7 

Source: VA and DOD data.

a Veterans Health Information Systems and Technology Architecture

6DOD began developing CHCS II in 1997 and has completed its associated
clinical data repository that is key to achieving the electronic
interface. DOD expects to complete deployment of all of its major system
capabilities by September 2008. VA began work on HealtheVet (VistA) and
its associated health data repository in 2001, and expects to complete the
six initiatives that make up this system in 2012.

4.	GAO testified that there had been very little progress since our last
hearing in November 2003. How did VA and DOD explain this to you? When
Congress scheduled its March 17, 2004, hearing, did GAO get the sense that
this provided an incentive for the two departments to move forward on this
issue?

In discussing with VA and DOD their actions since last November toward
achieving a two-way exchange of patient health information under the
HealthePeople (Federal) initiative, officials in both departments
expressed their belief that progress was being made. In response to our
finding that the departments had not yet defined an architecture to
describe in detail how specific technologies will be used to achieve the
capability to electronically exchange data between their health
information systems-a significant concern that we also raised in our
November testimony-the officials stated that they had recently taken an
important first step toward accomplishing this task.

In particular, VA and DOD officials referred to a pharmacy prototype
project, undertaken in response to the Bob Stump National Defense
Authorization Act for Fiscal Year 2003, to develop a real-time interface,
data exchange, and capability to check prescription drug data for
outpatients by October 1, 2004. According to VA's Deputy Chief Information
Officer for Health, the departments hope to determine from the prototype,
planned for completion by September 2004, whether the interface technology
developed to meet this mandate can be used to facilitate the exchange of
data between the health information systems that VA and DOD are currently
developing. However, as our testimony noted, the departments had not fully
defined their approach or requirements for developing and demonstrating
the capabilities of the planned prototype. Further, since VA and DOD have
not yet completed their new health information systems that are intended
to be used under HealthePeople (Federal), the demonstration may only test
the ability to exchange data in VA's and DOD's existing health systems-the
Veterans Health Information Systems and Technology Architecture (VistA)
and the Composite Health Care System (CHCS), respectively. Consequently,
the early stage of the prototype and the uncertainties regarding what
capabilities it will demonstrate provided little evidence or assurance as
to how or whether this project would contribute to defining the
architecture and technological solution for the two-way exchange of
patient health information.

The information collected during our review of the HealthePeople (Federal)
initiative suggests that the Subcommittee's scheduled hearing may have
provided an incentive for VA and DOD to move forward on this issue. In
conducting our review from December 2003 through March 2004, we observed
that the level of activity undertaken by the departments to support the
initiative increased significantly in the month preceding the hearing. For
example, the departments' officials first informed us of their intent to
rely on the planned pharmacy prototype to determine the technology
interface for the two-way data exchange capability in early February; a
contract for development of the prototype was finalized on February 27.
Beyond

these actions, VA and DOD began steps toward designating a program manager
for the pharmacy prototype project and establishing an overall project
plan in the week before the hearing.

5. GAO stated that success lies with the highest levels of project
discipline, including a well-defined architecture and an established
project management structure. At the present time, these criteria are
absent. Is that correct? Please provide your recommendations on the top
five priorities that need to be addressed in 2004.

At the time of our testimony, these critical project components were
absent from VA's and DOD's initiative to develop a two-way exchange of
patient health information. Specifically, VA and DOD lacked a clearly
defined architecture to describe how they planned to develop the
electronic interface needed to exchange data between their health
information systems. In addition, the departments had not fully
established a project management structure to ensure the necessary
day-to-day guidance of and accountability for their investments in and
implementation of this capability.

Given the implications that an electronic interface can have for improving
the quality of health care and disability claims processing for military
members and veterans, the top five priorities that VA and DOD need to
address in 2004 to increase the likelihood of a successful outcome are

o  	development of an architecture for the electronic interface that
articulates system requirements, design specifications, and software
descriptions;

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

o  	establishment of a project management structure (i.e., project manager
and supporting staff) to provide day-to-day guidance of and accountability
for the investments in and implementation of the electronic interface
capability;

o  	development and implementation of a comprehensive and coordinated
project plan that defines the technical and managerial processes necessary
to satisfy project requirements and that includes the authority and
responsibility of each organizational unit; a work breakdown structure and
schedule for all of the tasks to be performed in developing, testing, and
deploying the electronic interface; and a security plan; and

o  	implementation of project review milestones and measures to provide
the basis for comprehensive management, progressive decision making, and
authorization of funding for each step in the development process.

VA and DOD officials stated at the conclusion of our review that they had
begun discussions to establish an overall project plan and finalize roles
and responsibilities for managing the joint initiative to develop an
electronic interface.

6. To your knowledge, has any major VA or DOD IT project ever been
initiated with such criteria firmly established from the beginning?

To date, we have evaluated only a small portion of VA's and DOD's
respective portfolios of information technology investments. Based on our
work, we cannot point to any instances in which either department has
initiated a major information technology project with a clearly defined
architecture and sound project management having been established. At the
same time, we are generally aware that DOD has held out certain projects
undertaken by its component organizations as examples in which
well-defined architectures and sound project management existed. However,
we did not participate in, and therefore cannot comment on, the validity
of those representations.

During our reviews of the Government Computer-Based Patient Record
project, we did see evidence that implementing critical project management
processes after a project has been undertaken can positively affect its
outcome. As our testimony noted,7 VA's and DOD's designation of clear
lines of authority and a manager to provide day-to-day oversight helped
strengthen overall project management and accountability and contributed
to successfully achieving the transfer of patient health information from
DOD to VA's medical facilities.

Agency Comments and Our Evaluation

We received comments orally and via e-mail on a draft of this
correspondence from VA's Assistant Secretary for Information and
Technology and DOD's Interagency Program Integration and External Liaison
for Health Affairs. In commenting on our responses, these officials
offered additional perspectives and suggested clarifications, which have
been incorporated where appropriate. Both departments' officials disagreed
with the way in which our response to question 4 characterized their
progress toward developing a two-way electronic data exchange capability.

Regarding our response to question 1, VA and DOD officials commented that
they have now designated a single manager for the electronic interface
initiative. They have not yet, however, provided for our analysis any
documentation on the project management structure and the manager's and
supporting staff's roles and responsibilities for overseeing and ensuring
accountability for this initiative.

Regarding our response to question 2, VA and DOD officials stated that
both departments have cooperatively implemented our recommendations. Our
response has been clarified to reflect that VA and DOD took actions that
addressed all of our recommendations for improving management of the
Government Computer-Based Patient Record project, and to reflect that DOD
has implemented three of five recommendations that we made to improve its
CHCS II project.

7GAO-04-402T.

In commenting on our response to question 3, which addressed the total
dollars spent by VA and DOD on developing an electronic medical record
through fiscal year 2003 (the latest time frame for which we had complete
information reported by the departments), both VA and DOD referred to
initiatives other than GCPR, FHIE, and their individual health information
systems, which they believed reflected work on developing the electronic
data exchange capability. For example, both departments identified the
pharmacy prototype as a critical effort toward developing an electronic
interface for which resources were being expended. Our testimony, as well
as this correspondence, acknowledges that the departments had taken action
related to the pharmacy prototype. However, this initiative was not
undertaken until late February of this year, which was outside of the time
frame of the reported costs reflected in our response to the question. We
have revised our response to more clearly reflect our use of cost
information reported through fiscal year 2003.

Beyond the pharmacy prototype, VA stated that a number of other
initiatives had also demonstrated progress toward achieving an electronic
interface. It stated, for example, that the departments had contributed
"in-kind" resources to efforts supporting the Consolidated Health
Informatics initiative and internal standards boards within each
department. However, VA did not provide any specific cost information for
these actions.

Finally, in commenting on the reported costs, DOD suggested that we
clarify the title of our table identifying the departments' expenditures,
to better reflect that not all costs reported through fiscal year 2003
were directly attributable to achieving the two-way electronic health data
exchange. We have revised the table to more clearly reflect the reported
expenditures for GCPR, FHIE, and the departments' individual health
information system initiatives.

Regarding our response to question 4, VA and DOD stated that they did not
agree with our assessment that the departments' progress since November
2003 had been limited, or that most progress had been apparent just before
the March hearing. Both departments cited their work related to the
pharmacy prototype project as evidence of their progress toward developing
the electronic interface. For example, DOD stated that although the
departments may not have informed us, before last February, of their
intent to rely on the pharmacy prototype to determine the technology for
the electronic interface, a memorandum discussing the pharmacy data
exchange strategy had been signed in October 2003. However, we were not
provided with copies of any such documentation, and without information on
such an activity, we cannot offer an assessment of any actions taken by VA
and DOD on the pharmacy prototype earlier than February 2004-the point at
which we were made aware that this prototype would be used to help define
the electronic interface. Further, in its comments, VA said it continued
to anticipate that the prototype would assist in determining an
appropriate architecture for the electronic interface. Given the stage of
the pharmacy project and the supporting documentation available to us when
our review ended, our analysis determined that the departments lacked
evidence as to how or whether the

project would contribute to defining the architecture and technological
solution for a two-way exchange of patient health information.

Beyond the pharmacy prototype, VA cited numerous other initiatives
involving the departments' existing health information systems (VistA and
CHCS) and infrastructure that it considered to be evidence of progress.
These included a project aimed at automatically sending to VA relevant
electronic health information for patients sent to DOD for VA-paid care as
veterans; and a data-sharing interface project, involving the use of VA's
and DOD's existing health information systems to produce real-time,
bidirectional exchange of clinically relevant data, including outpatient
pharmacy, allergy, and patient demographic information at VA and DOD
locations with medical sharing agreements. During our review, VA and DOD
did not offer information on these initiatives or identify them as being
part of the HealthePeople (Federal) strategy for an electronic two-way
data exchange capability. Therefore, we are unable to make an assessment
of these initiatives or how they relate to VA's and DOD's progress toward
achieving the intended capability to electronically exchange patient data
between the new health information systems- HealtheVet (VistA) and CHCS
II-that the departments are developing.

In commenting on the response to question 5, the departments identified
various actions that, in their views, addressed our identified priorities
for disciplined project management. Regarding the development of an
architecture to define the electronic interface, the departments
anticipated that the pharmacy prototype would assist them in determining
the appropriate architecture and emphasized their continued work on
developing standards that will affect the interface requirements. Our
testimony acknowledged the departments' actions on developing data
standards, and also noted their plans for using the pharmacy prototype to
determine the architecture for the electronic interface. As we pointed
out, however, the early stage of the prototype and the uncertainties
regarding what capabilities it would demonstrate provided little evidence
or assurance as to how or whether the project would contribute to defining
the architecture and technological solution for a two-way exchange of
patient health information.

Regarding the selection of a lead entity with final decision-making
authority for the electronic interface initiative, the departments stated
that the VA/DOD Health Executive Council was serving in this capacity. VA
added that this council provides a fully integrated body in which
decisions are made and accountability for progress is provided for both
departments. We agree that the Health Executive Council plays an important
role in helping to ensure full accountability for the HealthePeople
(Federal) initiative. Nonetheless, as established, this council meets on a
bimonthly basis and is composed of senior VA and DOD leaders who work from
a high-level, departmentwide perspective, to institutionalize all of VA's
and DOD's sharing and collaboration on health services and resources. As
our testimony noted, there is no one entity dedicated to making binding
decisions for the HealthePeople (Federal) project. Our prior work on GCPR
noted the importance of a lead entity to exercise final authority over the
project, and VA and DOD demonstrated improvements in

managing GCPR as a result of implementing our recommendation that it
establish such an entity.

On establishing a project manager and supporting staff to provide
day-to-day guidance for the electronic interface initiative, VA and DOD
cited their designation of a single manager with accountability and
day-to-day responsibility for project implementation. However, as
discussed, the departments have not yet provided documentation of the
management structure that they have implemented, including information on
the roles and responsibilities that the manager and supporting staff will
have for the joint electronic interface initiative.

Regarding the development and implementation of a comprehensive and
coordinated project plan for the electronic interface initiative, the
departments stated that a project management plan had been developed for
the pharmacy prototype. We agree that such a plan is necessary for the
pharmacy prototype. However, it is also essential that the departments
have a project management plan for the electronic interface initiative to
define the technical and managerial processes needed to satisfy project
requirements, and assign responsibilities, tasks, and schedules associated
with developing, testing, and deploying the electronic interface between
the new health information systems that VA and DOD are developing.

Further, regarding the implementation of project review milestones and
measures for the electronic interface initiative, VA and DOD stated that
the departments provide updates to the Health Executive Council and the
Joint Executive Council. VA added that performance measures for
interoperability are built into the joint strategic plan managed by the
Joint Executive Council. As our March testimony noted, the Health
Executive Council meets bimonthly to institutionalize sharing and
collaboration of health services and resources, and the Joint Executive
Council meets quarterly to recommend strategic direction of joint
coordination and sharing efforts. VA and DOD did not provide any evidence
to explain the levels of update being provided to these councils or how
the councils' reviews address critical milestones and measures of the
initiative's progress. In addition, our review of the joint strategic plan
found that this high-level strategy established broad time frames and a
general approach for achieving a health data exchange between VA and DOD,
but did not articulate specific details regarding the incremental design
and development of the electronic interface capability. For example, the
strategy lacked specific milestones or measures that would enable the
departments to track the status of their actions toward developing the
interface at critical intervals in the project's life cycle.

Finally, in commenting on our response to question 6, VA officials stated
that the department has implemented all of its major health information
initiatives under the Veterans Health Information Systems and Technology
Architecture. For its part, DOD stated that it is guided by a rigorous
project management system, and cited our September 2002 report8 in which
we stated that the CHCS II initiative was generally

8GAO-02-345.

aligned with the Military Health System's (MHS) enterprise architecture.
As noted, our evaluations have not identified any major initiatives that
VA and DOD have begun with both a clearly defined architecture and sound
project management already established. While our report on DOD's CHCS II
noted that this system and the MHS architecture were generally aligned, it
also highlighted deficiencies in the project's management during its early
years. For example, performance-based contracting methods were not used to
ensure contractor accountability.

In responding to these questions, we relied on past work related to our
review of VA's
and DOD's actions since last November toward defining a detailed strategy
and
developing the capability for a two-way exchange of patient health
information. We
reviewed our prior analyses of key documentation supporting the
departments'
strategy, including deployment and conversion plans, project schedules,
and status
reports for their individual health information systems. In addition, we
reviewed
documentation identifying the costs incurred by VA and DOD in developing
technology to support the sharing of health data, including costs for the
Government
Computer-Based Patient Record and Federal Health Information Exchange
initiatives, and with their 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 conducted our work in accordance with generally
accepted
government auditing standards, during April 2004.

We are sending copies of this letter to the Secretaries of Veterans
Affairs and
Defense, and to other interested parties. Copies will also be available at
no charge at
our Web site at www.gao.gov.

Should you or your office have any questions on matters discussed in this
letter,
please contact me at (202) 512-6240 or Valerie Melvin, Assistant Director,
at (202)
512-6304. We can also be reached by e-mail at [email protected] and
[email protected], respectively. Key contributors to this correspondence
include
Barbara S. Oliver, J. Michael Resser, and Eric Trout.

Sincerely yours,

Linda D. Koontz
Director, Information Management Issues

Enclosure I: GAO Testimony on VA-DOD Sharing of Patient Health Information

Testimony
date/number Summary of results

March 17, 2004 GAO-04-402T VA and DOD had made little progress since
November 2003 toward defining how they intended to achieve the two-way
exchange of patient health information under the HealthePeople (Federal)
initiative. While VA officials recognized the importance of an
architecture to describe in detail how the departments would
electronically interface their health systems, they continued to rely on a
lessspecific, high-level strategy-in place since September 2002-to guide
the development and implementation of this capability. The departments
intended to rely on a pharmacy prototype project undertaken in March 2004
to better define the electronic interface needed to exchange patient
health data, but had not fully determined the approach or requirements for
this undertaking. Thus, there was little evidence of how this project
would contribute to defining a specific architecture and technological
solution for achieving a two-way exchange of patient health information.
These uncertainties were further complicated by the absence of sound
project management to guide the departments' actions on the HealthePeople
(Federal) initiative. Although progress toward defining data standards
continued, delays had occurred in VA's and DOD's development and
deployment of their individual health information systems, critical for
achieving the electronic interface. November 19, 2003 GAO-04-271T The
one-way transfer of health information resulting from VA's and DOD's
nearterm solution-the Federal Health Information Exchange
(FHIE)-represented a positive undertaking and had enabled electronic
health data from separated (retired or discharged) service members
contained in DOD's Military Health System Composite Health Care System to
be transmitted monthly to a VA FHIE repository, giving VA clinicians more
ready access to DOD health data, such as laboratory, pharmacy, and
radiology records, on almost 2 million patients. The departments' longer
term strategy to enable electronic, two-way information
sharing-HealthePeople (Federal)-was farther out on the horizon, and VA and
DOD faced significant challenges in implementing a full data exchange
capability. Although a high-level strategy existed, the departments had
not clearly articulated a common health information infrastructure and
architecture to show how they intended to achieve the data exchange
capability or what they would be able to exchange by the end of 2005.
Critical to achieving the two-way exchange was completing the
standardization of the clinical data that the departments planned to
share.

September 26, 2002 VA and DOD reported some progress in achieving the
capability to share patient

GAO-02-1054T 	health care data under the Government Computer-Based Patient
Record (GCPR) initiative. The agencies had, since March 2002, formally
renamed the initiative the Federal Health Information Exchange and begun
implementing a more narrowly defined strategy involving the one-way
transfer of patient health data from DOD to VA; a two-way exchange was
planned by 2005.

March 13, 2002 VA had achieved limited progress in its joint efforts with
DOD and the Indian

GAO-02-369T 	Health Service to create an interface for sharing data in
their health information systems, as part of GCPR. Strategies for
implementing the project continued to be revised, its scope had been
substantially narrowed from its original objectives, and it continued to
operate without clear lines of authority or comprehensive, coordinated
plans. Consequently, the future success of this project remained
uncertain, raising questions as to whether it would ever fully achieve its
original objective of allowing health care professionals to share clinical
information via a comprehensive, lifelong medical record.

Testimony
date/number Summary of results

February 27, 2002 GAO-02-478T DOD's and VA's numerous databases and
electronic systems for capturing mission-critical data, including health
information, were not linked, and information could not be readily shared.
DOD had several initiatives under way to link many of its information
systems-some with VA. For example, to create a comprehensive, lifelong
medical record for service members and veterans and to allow health care
professionals to share clinical information, the departments, along with
the Indian Health Service, initiated the Government Computer-Based Patient
Record (GCPR) project in 1998. However, several factors, including
planning weaknesses, competing priorities, and inadequate accountability,
made it unlikely that they would achieve a GCPR or realize its benefits in
the near future. To strengthen management and oversight of the project, we
recommended designating a lead entity with clear lines of authority for
the project and the creation of comprehensive and coordinated plans for
sharing meaningful, accurate, and secure patient health data. For the near
term, DOD and VA had decided to reconsider their approach to GCPR and
focus on allowing VA to access selected service members' health data
captured by DOD, such as laboratory and radiology results, outpatient
pharmacy data, and patient demographic information. However, GCPR would
not provide VA with access to information on the health status of
personnel when they entered military service; on medical care provided to
Reservists while not on active duty; or on the care military personnel
received from providers outside DOD, including those from TRICARE.a
January 24, 2002 GAO-02-377T DOD improved its medical surveillance system
under Operation Joint Endeavor. However, system problems included lack of
a single, comprehensive electronic system to document and access medical
surveillance data. Some DOD initiatives to improve information technology
capability were several years away from full implementation. The ability
of VA to fulfill its role in serving veterans and providing backup to DOD
in times of war was to be enhanced as DOD increased its medical
surveillance capability. GCPR was a joint DOD/VA initiative in conjunction
with the Indian Health Service to link information systems. However,
because of planning weaknesses, competing priorities, and inadequate
accountability, it was unlikely that the departments would accomplish GCPR
or realize its benefits in the near future. To strengthen management and
oversight of the initiative, we again recommended designating a lead
entity with clear lines of authority for the project and the creation of
comprehensive and coordinated plans for sharing meaningful, accurate, and
secure patient health data. October 16, 2001 GAO-02-173T DOD and VA were
establishing a medical surveillance system for the health care needs of
military personnel and veterans. The system was to collect and analyze
uniform information on deployments, environmental health threats, disease
monitoring, medical assessments, and medical encounters. We identified
weaknesses in DOD's medical surveillance capability and performance in the
Gulf War and Operation Joint Endeavor, and uncovered deficiencies in its
ability to collect, maintain, and transfer accurate data. The department
had several initiatives under way to improve the reliability of deployment
information and to enhance its information technology capabilities,
although some initiatives were several years away from full
implementation. VA's ability to serve veterans and provide backup to DOD
in times of war was to be enhanced as DOD increased its medical
surveillance capability. GCPR was one initiative to link the departments'
information systems. However, because of planning weaknesses, competing
priorities, and inadequate accountability, it was unlikely that they would
accomplish GCPR or realize its benefits in the near future. To strengthen
management and oversight of the initiative, we recommended designating a
lead entity with clear lines of authority for the project and the creation
of comprehensive and coordinated plans for sharing meaningful, accurate,
and secure patient health data.

Source: GAO.
aTRICARE is the Department of Defense's worldwide health care program for
active duty and retired uniformed services
members and their families.

Enclosure II: Actions Taken by VA and DOD on GAO Recommendations

Report date/number Recommendations Actions taken by VA and/or DOD

June 12, 2002 The Secretary of Veterans Affairs, to make The Department of
Veterans Affairs (VA), in

GAO-02-703 	significant progress beyond the current conjunction with DOD,
implemented this strategy for the government computer-based
recommendation. The departments reevaluated patient record, should
instruct the Veterans and revised the original goals and objectives of
Health Administration (VHA) undersecretary the GCPR initiative. A May 3,
2002, and VHA chief information officer, in memorandum of agreement
between VA and cooperation with DOD and the Indian Health DOD established
the Federal Health Information Service (IHS), to revisit the original
goals and Exchange (FHIE), which replaced the GCPR objectives of the
Government Computer-initiative. As of mid-July 2002, all VA medical Based
Patient Record (GCPR) initiative to centers had access to FHIE data on
over 1 determine if they remain valid, and where million service personnel
who separated necessary, revise the goals and objectives to between 1987
and 2001. be aligned with the current strategy and direction of the
project.

June 12, 2002 The Secretary of Veterans Affairs, to make

GAO-02-703 	significant progress beyond the current strategy for GCPR,
should instruct the VHA undersecretary and VHA chief information officer,
in cooperation with DOD and IHS, to commit the executive support necessary
for adequately managing the project, and ensure that sound project
management principles are followed in carrying out the initiative.

VA, in conjunction with DOD, implemented this recommendation. The
departments committed the executive support necessary for adequately
managing the GCPR project. They also ensured that project management
principles were followed in carrying out the initiative. Specifically, in
May 2002 VA and DOD signed a memorandum of agreement that designated VA as
the lead entity in implementing the project (formally renamed FHIE). VA
committed executive support for the project by way of monthly updates,
given by the FHIE program manager, to the VA chief information officer, as
well as quarterly updates to the joint VA/DOD Executive Council. In
addition, VA procured and implemented project management software to
better track the assignment and status of project tasks and initiatives.

September 26, 2002 The Secretary of Defense, through the DOD implemented
this recommendation. In late

GAO-02-345 	Assistant Secretary of Health Affairs, should 2002, the
program office produced a direct the Military Health System (MHS) chief
maintenance release for CHCS II that corrected information officer to give
expanded use of many of the remaining bugs that required best practices in
managing CHCS II the workarounds, and the limited deployment sites
attention and priority it deserves. At a have that version. In addition,
MHS has put a minimum, the Assistant Secretary should standard operating
procedure in place to direct the MHS chief information officer to, as
evaluate the effect of all workarounds required part of the CHCS II
deployment decisions, for new systems/versions before consider the
aggregate impact on defense implementation. The standard operating health
affairs mission performance caused by procedure is part of the
configuration control the workarounds needed to compensate for board
procedures and the service components all unresolved defects affecting the
system's have agreed to these procedures. Finally, a test operational
efficiency. and evaluation master plan that addresses the

aggregate impact of workarounds has been completed for the CHCS II release
of functionality supporting general dentistry, and will be used as a
template for future plans.

Report date/number Recommendations Actions taken by VA and/or DOD

September 26, 2002 The Assistant Secretary of Health Affairs

GAO-02-345 	should direct the MHS chief information officer to verify that
the CHCS II inventory of risks is complete and correct, and report this to
the Assistant Secretary for Health Affairs every 6 months, along with a
report on the status of all top priority risks, including each risk's
probability of occurrence and impact on mission.

September 26, 2002 The Secretary of Defense should direct the GAO-02-345
Assistant Secretary of Defense for Command, DOD implemented this
recommendation. The program office updated the risk management plan to
require continuous risk management database updates and monthly risk
reports. An initial 6-month report was provided to the Assistant Secretary
in April 2003 that included the status of all program risks, with details
on priority 1 risks, including probability of occurrence and impact on
mission.

DOD implemented this recommendation. The program office updated its
cost-benefit analysis in September 2002, and the Naval Center for Cost
Analysis validated the cost estimate. This was used to approve the limited
deployment of a graphical user interface for clinical outpatient processes
in January 2003, and is available for use by the milestone decision
authority for the full deployment decision.

Control, Communications, and Intelligence, who is the designated approval
authority for CHCS II, to monitor the project's use of best practices,
including implementation of each of the above recommendations, and use
this information to oversee the project's movement through its acquisition
cycle. To this end, the Assistant Secretary, or other designated CHCS II
approval authority, should not grant any request for deployment approval
of any CHCS II release that is not justified by reliable analysis of the
release's costs, benefits, and risks.

September 26, 2002 The Secretary of Defense, through the Actions to
implement this recommendation are

GAO-02-345 	Assistant Secretary of Health Affairs, should ongoing. MHS has
contracted with the Army direct the MHS CIO to give expanded use of Test
and Evaluation Command and a private best practices in managing CHCS II
the contractor to assess limited deployment sites attention and priority
they deserve. At a and obtain data on initial benefits to support minimum,
the Assistant Secretary should return-on-investment analyses. Deployments
of direct the MHS CIO to define and implement the initial version of the
system were delayed incremental investment management until fiscal year
2004; it is therefore unlikely that processes to include (1) modifying the
CHCS this recommendation will be fully addressed II investment strategy to
define how this before the end of the fiscal year. approach will be
implemented; (2) justifying investment in each system release before
beginning detailed design and development of the release; (3) requiring
that such justification be based on reliable estimates of costs, benefits,
and risks; (4) measuring whether actual return-on-investment for each
deployed release is in line with justification forecasts; and (5) using
actual return-on investment results in deciding whether to begin detailed
design and development of the next system release.

       Report date/number Recommendations Actions taken by VA and/or DOD

September 26, 2002 The Secretary of Defense, through the

GAO-02-345 	Assistant Secretary of Health Affairs, should direct the MHS
CIO to give expanded use of best practices in managing CHCS II the
attention and priority they deserve. At a minimum, the Assistant Secretary
should direct the MHS CIO to employ performancebased contracting practices
on all future CHCS II delivery orders to the maximum extent possible,
including (1) defining performance standards against which deliverables
can be judged, (2) developing and using quality assurance plans that
describe how contractor performance against the standards will be
measured, and (3) defining and using contractor incentives and penalties
tied to the quality plan.

Actions to implement this recommendation are ongoing. The program office
received approval to begin acquiring commercial off-the-shelf software
packages to develop prototype pharmacy/laboratory/radiology capabilities,
and plans to conduct full and open competition contracts for these
packages. A performancebased, firm fixed-price integration contract, with
incentives, is being prepared and is expected to be awarded in the 3rd
quarter of fiscal year 2004. As the program office re-negotiates the
contracts for a graphical user interface for clinical outpatient processes
and general dentistry, they will also be moved to this performance-based
type of contract.

Source: GAO.

(310712)

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