Computer-Based Patient Records: Improved Planning and Project	 
Management Are Critical to Achieving Two-Way VA-DOD Health Data  
Exchange (19-MAY-04, GAO-04-811T).				 
                                                                 
Providing readily accessible health information on veterans and  
active duty military personnel is highly essential to ensuring	 
that these individuals are given quality health care and	 
assistance in adjudicating disability claims. Moreover, ready	 
access to health information is consistent with the President's  
recently announced intention to provide electronic health records
for most Americans within 10 years. In an attempt to improve the 
sharing of health information, the Departments of Veterans	 
Affairs (VA) and Defense (DOD) have been working, since 1998,	 
toward the ability to exchange electronic health records for use 
by veterans, military personnel, and their health care providers.
In testimony before the Subcommittee last November and again this
past March, GAO discussed the progress being made by the	 
departments in this endeavor. While a measure of success has been
achieved--the one-way transfer of health data from DOD to VA	 
health care facilities--identifying the technical solution for a 
two-way exchange, as part of a longer term Health ePeople	 
(Federal) initiative, has proven elusive. At the Subcommittee's  
request, GAO reported on its continuing review of the		 
departments' progress toward this goal of an electronic two-way  
exchange of patient health records.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-811T					        
    ACCNO:   A10130						        
  TITLE:     Computer-Based Patient Records: Improved Planning and    
Project Management Are Critical to Achieving Two-Way VA-DOD	 
Health Data Exchange						 
     DATE:   05/19/2004 
  SUBJECT:   Computer security					 
	     Defense capabilities				 
	     Health care facilities				 
	     Health care programs				 
	     Health resources utilization			 
	     Information systems				 
	     Information technology				 
	     Medical information systems			 
	     Medical records					 
	     Military personnel 				 
	     Patient care services				 
	     Veterans benefits					 

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GAO-04-811T

United States General Accounting Office

GAO Testimony

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

For Release on Delivery Expected at 10:00 a.m. EDT Wednesday, May 19, 2004

                                 COMPUTER-BASED
                                PATIENT RECORDS

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

Statement of Linda D. Koontz
Director, Information Management Issues

GAO-04-811T

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

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

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

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

May 19, 2004

COMPUTER-BASED PATIENT RECORDS

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

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

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

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

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

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

Mr. Chairman and Members of the Subcommittee:

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

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

1U.S. General Accounting Office, Computer-BasedPatient
Records:SoundPlanningand ProjectManagementAre
NeededtoAchieveaTwo-WayExchangeofVA andDOD Health Data,GAO-04-402T
(Washington, D.C.: March 17, 2004) and Computer-BasedPatient
Records:Short-TermProgressMade,but Much Work Remainsto Achievea
Two-WayData ExchangeBetweenVAandDOD HealthSystems,GAO-04-271T (Washington,
D.C.: November 19, 2003).

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

  Results In Brief

VA and DOD are proceeding with actions intended to support the sharing of
health data, but continue to be far from achieving the two-way electronic
data exchange capability envisioned in the HealthePeople (Federal)
strategy. The departments are continuing to take actions to develop their
individual health information systems that are critical to exchanging
patient health information and to define data standards that are essential
to the common sharing of health information. In addition, department
officials stated that they are proceeding with a pharmacy data prototype
initiative, begun in March, to satisfy a mandate of the Bob Stump National
Defense Authorization Act for Fiscal Year 2003,2 as an

2P.L. 107-314, sec. 724 (2002).

initial step toward achieving HealthePeople (Federal). At this stage,
however, they have not developed a strategy to explain how this project
will contribute to defining the technological solution for the data
exchange capability. As such, VA and DOD continue to lack a clearly
defined architecture and technological solution for developing the
electronic interface and associated capability for exchanging patient
health information between their new systems. Moreover, the departments
remain challenged to articulate a clear vision of how this capability will
be achieved, and in what time frame.

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

Absent a comprehensive and coordinated approach to implementing and
conveying information about HealthePeople (Federal), VA and DOD risk
compromising their progress and lack assurance that the goals of this
initiative will be successfully realized. Given the importance of readily
accessible health data for improving the

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

Background In 1998, following a Presidential call for VA and DOD to start
developing a "comprehensive, life-long medical record for each service
member," the two departments began a joint course of action toward
achieving the capability to share patient health information for active
duty military personnel and veterans.3 As their first initiative,
undertaken in that year, the Government Computer-Based Patient Record
(GCPR) project was envisioned as an electronic interface that would allow
physicians and other authorized users at VA and DOD health facilities to
access data from any of the other agencies' health information systems.
The interface was expected to compile requested patient information in a
virtual record that could be displayed on a user's computer screen.

Our prior reviews of the GCPR project determined that the lack of a lead
entity, clear mission, and detailed planning to achieve that mission made
it difficult to monitor progress, identify project risks, and develop
appropriate contingency plans. Accordingly, reporting on this project in
April 2001 and again in June 2002,4 we made several recommendations to
help strengthen the management and

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

4U.S. General Accounting Office, VeteransAffairs:Sustained Management
AttentionIs Key to AchievingInformation Technology Results,GAO-02-703
(Washington, D.C.: June 12, 2002) and Computer-BasedPaient
Records:BetterPlanningandOversight ByVA,DOD, and IHS Would Enhance
HealthDataSharing,GAO-01-459 (Washington, D.C.: April 30, 2001).

oversight of GCPR. Specifically, in 2001 we recommended that the
participating agencies (1) designate a lead entity with final
decisionmaking authority and establish a clear line of authority for the
GCPR project, and (2) create comprehensive and coordinated plans that
included an agreed-upon mission and clear goals, objectives, and
performance measures, to ensure that the agencies could share
comprehensive, meaningful, accurate, and secure patient health care data.
In 2002 we recommended that the participating agencies revise the original
goals and objectives of the project to align with their current strategy,
commit the executive support necessary to adequately manage the project,
and ensure that it followed sound project management principles. VA and
DOD took specific measures in response to our recommendations for
enhancing overall management and accountability of the project.

By July 2002, VA and DOD had revised their strategy and had made progress
toward electronically sharing patient health data. The two departments had
renamed the project the Federal Health Information Exchange (FHIE) program
and, consistent with our prior recommendation, had finalized a memorandum
of agreement designating VA as the lead entity for implementing the
program. This agreement also established FHIE as a joint activity that
would allow the exchange of health care information in two phases. The
first phase, completed in mid-July 2002, enabled the one-way transfer of
data from DOD's existing health information system (the Composite Health
Care System) to a separate database that VA clinicians could access. A
second phase, finalized this past March, completed VA's and DOD's efforts
to add to the base of patient health information available to VA
clinicians via this one-way sharing capability. According to program
officials, FHIE is now fully operational and is showing positive results
by providing a wide range of health care information to enable clinicians
to make more informed decisions regarding the care of veterans and to
facilitate processing disability claims. The officials stated that the
departments have now begun leveraging the FHIE infrastructure to achieve
interim exchanges of health information on a limited basis, using existing
health systems

at joint VA/DOD facilities.5 The departments reported total GCPR/FHIE
costs of about $85 million through fiscal year 2003.

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

DOD began developing CHCS II in 1997 and has completed its associated
clinical data repository-a key component for the planned electronic
interface. The department expects to complete deployment of all of its
major system capabilities by September 2008.6 It reported expenditures of
about $464 million for the system through fiscal year 2003. VA began work
on HealtheVet VistA and its associated health data repository in 2001, and
expects to complete all six initiatives comprising this system in 2012.7
VA reported spending about $120 million on HealtheVet VistA through fiscal
year 2003.

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

6DOD'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.

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

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

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

As we have noted,8 achieving the longer term capability to exchange health
data in a secure, two-way electronic format between new health information
systems that VA and DOD are developing is a challenging and complex
undertaking, in which success depends on having a clearly articulated
architecture, or blueprint, defining how specific technologies will be
used to deliver the capability. Developing, maintaining, and using an
architecture is a best practice in engineering information systems and
other technological

8GAO-04-402T.

solutions, articulating, for example, the systems and interface
requirements, design specifications, and database descriptions for the
manner in which the departments will electronically store, update, and
transmit their data.

Successfully carrying out the initiative also depends on the departments'
instituting a highly disciplined approach to the project's management.
Industry best practices and information technology project management
principles stress the importance of accountability and sound planning for
any project, particularly an interagency effort of the magnitude and
complexity of this one. Such planning involves developing and using a
project management plan that describes, among other factors, the project's
scope, implementation strategy, lines of responsibility, resources, and
estimated schedules for development and implementation.

Currently, VA and DOD are proceeding with the development of their new
health information systems and with the identification of standards that
are essential to sharing common health data. DOD is deploying its first
release of CHCS II functionality (a capability for integrating DOD
clinical outpatient processes into a single patient record), with
scheduled completion in June 2006. For its part, VA continues to work
toward completing a prototype for the department's health data repository,
scheduled for completion at the end of next month. In addition, as we
reported in March, the departments have continued essential steps toward
standardizing clinical data, having adopted data and message standards
that are important for exchanging health information between disparate
systems.9 Department officials also stated that they were proceeding with
a pharmacy data prototype initiative, begun in March to satisfy a mandate
of the Bob Stump National Defense Authorization Act for

9VA 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.

Fiscal Year 2003, 10 as an initial step toward achieving HealthePeople
(Federal). The officials maintain that they expect to be positioned to
begin exchanging patient health information between their new systems on a
limited basis in the fall of 2005, identifying four categories of data
that they expect to be able to exchange: outpatient pharmacy data,
laboratory results, allergies, and patient demographics.

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

Although department officials consider the pharmacy data prototype to be
an initial step toward achieving HealthePeople (Federal), how

10Sec. 724 of the act mandates that the Secretaries of Veterans Affairs
and Defense seek to ensure that, on or before October 1, 2004, the two
departments' pharmacy data systems are interoperable for VA and DOD
beneficiaries by achieving real-time interface, data exchange, and
checking of prescription drug data of outpatients and using national
standards for the exchange of outpatient medication information. The act
further states that if the specified interoperability is not achieved by
that date, then the Secretary of Veterans Affairs shall adopt DOD's
Pharmacy Data Transaction System for VA's use.

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

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

Further, although the departments have designated a project manager and
established a project plan defining the work tasks and management
structure for the pharmacy prototype, they continue to lack a
comprehensive and coordinated project plan for

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

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

In summary, VA's and DOD's pursuit of various initiatives to achieve the
electronic sharing of patient health data represents an important step
toward providing more high-quality health care for active duty military
personnel and veterans. Moreover, in undertaking HealthePeople (Federal),
the departments have an opportunity to help lead the nation to a new
frontier of health care delivery. However, the continued absence of an
architecture and defined technological solution for an electronic
interface for their new health information systems, coupled with the need
for more comprehensive and coordinated management of the projects

supporting the development of this capability, elevates the uncertainty
about how VA and DOD intend to achieve this capability and in what time
frame. Until these critical components have been put into place, the
departments will continue to lack a convincing position regarding their
approach to and progress toward achieving the HealthePeople (Federal)
goals and, ultimately, risk jeopardizing the initiative's overall success.

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

  Contacts and Acknowledgments

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

(310716)

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