Health Care: National Strategy Needed to Accelerate the 	 
Implementation of Information Technology (14-JUL-04,		 
GAO-04-947T).							 
                                                                 
Health care is an information-intensive industry that remains	 
highly fragmented and inefficient. Hence, the uses of information
technology (IT)--in delivering clinical care, performing	 
administrative functions, and supporting the public health	 
infrastructure--have the potential to yield both cost savings and
improvements in the care itself. In 2003, GAO reported on	 
benefits to health care that could result from using IT--both	 
cost savings and measurable improvements in the delivery and	 
quality of care. GAO also reported on federal agencies' existing 
and planned information systems intended to support our nation's 
preparedness for and ability to respond to public health	 
emergencies and the status of health care standards setting	 
initiatives. Congress has asked GAO to summarize our work on	 
reported benefits of the use of IT for health care delivery and  
on IT initiatives supporting public health preparedness and	 
response.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-947T					        
    ACCNO:   A10970						        
  TITLE:     Health Care: National Strategy Needed to Accelerate the  
Implementation of Information Technology			 
     DATE:   07/14/2004 
  SUBJECT:   Disease detection or diagnosis			 
	     Diseases						 
	     Emergency preparedness				 
	     Health care planning				 
	     Health care programs				 
	     Health resources utilization			 
	     Hospital care services				 
	     Information technology				 
	     Medical records					 
	     Intergovernmental relations			 
	     Interagency relations				 
	     Health care cost control				 
	     Electronic data interchange			 
	     National preparedness				 
	     Medical information systems			 
	     Computer matching					 

******************************************************************
** 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-04-947T

United States Government Accountability Office

GAO Testimony

Before the Committee on Government Reform, Subcommittee on Technology,
Information Policy, Intergovernmental Relations and the Census, House of
Representatives

For Release on Delivery 2:00 p.m. EDT July 14, 2004

HEALTH CARE

    National Strategy Needed to Accelerate the Implementation of Information
                                   Technology

Statement of David A. Powner,
Director, Information Technology Management Issues

GAO-04-947T

Highlights of GAO-04-947T, testimony before the Subcommittee on
Technology, Information Policy, Intergovernmental Relations and the
Census, Committee on Government Reform, House of Representatives

Health care is an informationintensive industry that remains highly
fragmented and inefficient. Hence, the uses of information technology
(IT)-in delivering clinical care, performing administrative functions, and
supporting the public health infrastructure-have the potential to yield
both cost savings and improvements in the care itself.

In 2003, GAO reported on benefits to health care that could result from
using IT-both cost savings and measurable improvements in the delivery and
quality of care. GAO also reported on federal agencies' existing and
planned information systems intended to support our nation's preparedness
for and ability to respond to public health emergencies and the status of
health care standards setting initiatives.

The subcommittee has asked GAO to summarize our work on reported benefits
of the use of IT for health care delivery and on IT initiatives supporting
public health preparedness and response.

www.gao.gov/cgi-bin/getrpt?GAO-04-947T.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact David A. Powner at
202-512-9286 or [email protected].

July 14, 2004

HEALTH CARE

National Strategy Needed to Accelerate the Implementation of Information
Technology

The use of IT can yield benefits in clinical care and associated
administrative functions as well as in public health. Health care
organizations reported that electronic medical records (EMR) improved the
delivery of care because, among other reasons, more complete medical
documentation was available to support the provider's diagnosis. In
addition, EMRs could greatly facilitate the reporting of public health
information associated with the early detection of and response to disease
outbreaks. One hospital replaced outpatients' paper medical charts with
EMRs, realizing about $8.6 million in annual savings. This hospital also
established electronic access to laboratory results and reports, replacing
its manual process for handling medical records and saving another $2.8
million a year. In addition, the lessons learned that were reported to us
by health care organizations that have successfully implemented solutions
could be used by other organizations to accelerate the adoption of health
IT. These lessons recognize the importance of reengineering business
processes, gaining users' acceptance of IT, providing adequate training,
and making systems secure.

Regarding public health, federal agencies identified 72 existing and
planned information systems-34 surveillance systems, 18 supporting
technologies, 10 communications systems, and 10 detection systems. For
example, the Centers for Disease Control and Prevention is currently
implementing its Public Health Information Network comprised of a number
of disease surveillance and communications systems, including the Health
Alert Network. This network is an early warning and response system that
is intended to facilitate communication among federal, state, and local
agencies during public health emergencies. GAO also reported that
identification and implementation of health care data, communications, and
security standards-which are necessary to support compatibility and
interoperability of agencies' various IT systems-remained incomplete
across the health care sector. To address the challenges of coordinating
the many IT initiatives and implementing a consistent set of standards,
GAO recommended last year that the Secretary of Health and Human Services
develop a strategy for public health preparedness and response, to include
setting priorities for IT initiatives and establishing mechanisms to
monitor the implementation of standards throughout the health care
industry. Since that time, progress has been made in identifying
standards. The Office of Management and Budget's e-government initiative,
the Consolidated Health Informatics initiative, has identified a number of
standards to be applied to new federal development efforts and
modifications of existing systems. This initiative is intended to promote
the interoperability of information systems. However, implementing these
standards across the federal government is still a work in progress. Until
these standards are implemented, informationsharing challenges will
remain. In April of this year, Executive Order 13335 established a
National Health IT Coordinator and called for a strategic plan to guide
the nationwide implementation of interoperable health IT. As this plan
moves forward, it will be essential to have continued leadership, clear
direction, measurable goals, and mechanisms to monitor progress.

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today to discuss the benefits that effective
implementation of information technology (IT) can bring to the health care
industry. According to the Institute of Medicine and others, health care
is an information-intensive industry that remains highly fragmented and
inefficient. Hence, the uses of IT-in delivering clinical care, performing
administrative functions, and supporting the public health
infrastructure1-have the potential to yield both cost savings and
improvements in the care itself.

However, effectively implementing IT has historically been a major
challenge for this industry. Currently there is inconsistent use of IT in
exchanging data and delivering care. In addition, implementing information
security measures that resist cyber attacks also remains a challenge.

At your request, today I will summarize our previously issued reports on
(1) the reported benefits of using IT for health care delivery, including
lessons learned from health care organizations that have implemented IT
and (2) IT initiatives that support the public health infrastructure,
including the status of standards setting initiatives that are necessary
to support greater information sharing.2 In preparing this testimony, we
summarized our prior reports and updated progress on our recommendations
in accordance with generally accepted government auditing standards.

1The public health infrastructure is the foundation that supports the
planning, delivery, and evaluation of public health activities and is
comprised of a well-trained workforce, effective program and policy
evaluation, sufficient epidemiology and surveillance capability to detect
outbreaks and monitor incidence of diseases, appropriate response capacity
for public health emergencies, effective laboratories, secure information
systems, and advanced communications systems.

2U.S. General Accounting Office, Bioterrorism:
InformationTechnologyStrategy Could Strengthen Federal Agencies'Abilities
toRespond to PublicHealth Emergencies, GAO-03139 (Washington, D.C.: May
30, 2003) and U.S. General Accounting Office, Information
Technology:BenefitsRealized forSelected Health Care Functions,GAO-04-224
(Washington, D.C.: October 31, 2003).

  Results in Brief

As we reported last year, cost savings and other benefits realized by
health care organizations that have implemented IT can be significant both
in providing clinical health care and in performing the administrative
functions associated with health care delivery. For example, using bar
code technology and wireless scanners to verify both the identities of
patients and their correct medications, a community hospital prevented the
administration of over 1,200 wrong drugs or dosages and almost 2,000 early
or extra doses. The monetary value of the errors that were prevented was
almost $850,000. Another example is a teaching hospital, which replaced
paper medical charts with electronic medical records (EMR) for
outpatients, realizing about $8.6 million in annual savings.3 This
hospital also established electronic access to laboratory results and
reports, replacing its manual process for handling medical records and
saving $2.8 million a year. Health care organizations also told us that
EMRs improved the delivery of care because, among other reasons, more
complete medical documentation was available to support the provider's
diagnosis. In addition, these electronic records could greatly facilitate
the reporting of public health information associated with the early
detection and response to disease outbreaks. Additionally, the lessons
learned that were reported to us by health care organizations that have
successfully implemented solutions could be used by other organizations to
accelerate the adoption of health IT. These lessons recognize the
importance of reengineering business processes, gaining users' acceptance
of IT, providing adequate training, and making systems secure.

Also last year, we reported that multiple federal agencies had a large
number of both existing and planned information systems that are intended
to support our nation's preparedness for and ability to

3For electronic medical records (EMRs)-also known as electronic health
records, automated medical records, and computer-based patient records,
among other names- multiple definitions exist, depending on the functions
that are included. They can be used simply as a passive tool to store
patient information or can include multiple decision support functions,
such as individualized patient reminders and prescribing alerts.

respond to public health emergencies, including bioterrorism.4
Specifically, these agencies identified 72 systems-34 surveillance
systems, 18 supporting technologies, 10 communications systems, and 10
detection systems.5 For example, the Centers for Disease Control and
Prevention is currently implementing its Public Health Information
Network, which consists of a number of disease surveillance and
communication systems, including the Health Alert Network. This network is
an early warning and response system that is intended to facilitate better
communication among federal, state, and local agencies during public
health emergencies. We also reported that identification and
implementation of health care data, communications, and security
standards-which are necessary to support compatibility and
interoperability of agencies' various IT systems-remained incomplete
across the health care sector. A major consequence of not implementing
such standards is that federal agencies and others associated with public
health cannot exchange data. For example, in responding to the anthrax
events, one of the major IT challenges that public health officials faced
was the issue of how to exchange data among all participants. During this
event, participants accumulated dissimilar data and principally exchanged
it manually.

To address the challenges of coordinating the many IT initiatives and
implementing a consistent set of standards, we recommended last year that
the Secretary of Health and Human Services develop a strategy for public
health preparedness and response, to include setting priorities for IT
initiatives, establishing milestones for defining and implementing all
standards, and establishing mechanisms to monitor the implementation of
standards throughout

4Bioterrorism is the threat or intentional release of biological agents
(viruses, bacteria, or their toxins) for the purpose of influencing the
conduct of government, or intimidating or coercing a civilian population.

5Surveillancesystems facilitate the performance of ongoing collection,
analysis, and interpretation of disease-related data. Supporting
technologiesare tools or systems that provide information for the other
categories of systems. Communicationssystems facilitate the secure and
timely delivery of information to the relevant responders and decision
makers. Detectionsystems consist of devices for the collection and
identification of potential biological agents from environmental samples
that include an IT component that facilitates the collection of data for
surveillance.

the health care industry. Since then, progress has been made in
identifying standards. For example, the Office of Management and Budget's
Consolidated Health Informatics (CHI) e-government initiative has
identified a number of standards that are to be applied to new federal
development efforts and modifications of existing systems to promote the
interoperability of information across federal agencies. However,
implementing these standards across the federal government remains a work
in progress. Further progress in leadership has occurred with the
President's recently issued Executive Order6, which calls for the
establishment of a National Health Information Technology Coordinator and
the issuance of a broader strategic plan to guide the nationwide
implementation of interoperable health care information systems. Although
it is encouraging that the Coordinator plans to present this strategic
plan next week, as health IT initiatives are pursued it will be essential
to have continued leadership, clear direction, measurable goals, and
mechanisms to monitor progress.

Background

The United States health care system is a large sector of the economy
comprised of clinicians, health care delivery organizations, insurers,
consumers, and government health agencies. According to the Medicare
Payment Advisory Commission, the health care industry generally uses less
IT than other industries, and the extent and types of IT deployed vary by
setting and institution. The health care industry has recognized that IT
can improve the quality of care, promote patient safety, reduce costs of
both care and administrative functions, and expedite response to public
health emergencies.

Public health officials are increasingly concerned about our exposure and
susceptibility to infectious disease and food-borne illness because of
global travel, increased volume of food imports,

6Executive Order 13335-Incentives for the Use of Health Information
Technology and Establishing the Position of the National Health
Information Technology Coordinator, April 27, 2004.

and the evolution of antibiotic-resistant pathogens. Public health experts
maintain that a strong infrastructure could provide the capacity to
prepare for and respond to both acute and chronic threats to the nation's
health, whether they are bioterrorism attacks, emerging infections,
disparities in health status, or increases in chronic disease and injury
rates.

IT can play an essential role in supporting federal, state, local, and
tribal governments in public health activities and clinical care delivery.
For public health emergencies in particular, the ability to quickly
exchange data from provider to public health agency-or from provider to
provider-is crucial in detecting and responding to naturally occurring or
intentional disease outbreaks. It allows physicians to share individually
identifiable information with public health agencies for use in performing
public health activities.

The Centers for Disease Control and Prevention (CDC) has previously
acknowledged several IT limitations in the public health infrastructure.
For example, basic capability for disease surveillance systems to detect
and analyze disease outbreaks is lacking for several reasons. First,
health care providers have traditionally used paper- or telephone-based
systems to report disease outbreaks to approximately 3,000 public health
agencies. This is a labor-intensive, burdensome process for local health
care providers and public health officials, often resulting in incomplete
and untimely data. Second, not all public health agencies have access to
the Internet or to secure channels for electronically transmitting
sensitive data.

Several types of systems can play vital roles in identifying and
responding to public health emergencies, including acts of bioterrorism.
These types of systems-described in a technology assessment for the
Department of Health and Human Services (HHS) that was completed by the
University of California San Francisco-Stanford Evidence-based Practice
Center-serve different but related functions and include the following:7

7University of California San Francisco-Stanford Evidence-based Practice
Center, Bioterrorism Preparedness and Response:Useof Information
Technologies and Decision SupportSystems(Stanford, CA: June 2002).

o   o Detection-systems that consist of devices for the collection and
identification of potential biological agents from environmental samples,
making use of IT to record and send data to a network.

o   o Surveillance-systems that facilitate the performance of ongoing
collection, analysis, and interpretation of disease-related data to plan,
implement, and evaluate public health actions.

o   o Diagnostic and clinical management-systems with potential utility
for enhancing the likelihood that clinicians will consider the possibility
of bioterrorism-related illness. These systems are generally designed to
assist clinicians in developing a differential diagnosis for a patient who
has an unusual clinical presentation.

o   o Communications-systems that facilitate the secure and timely
delivery of information to the relevant responders and decision makers so
that appropriate action can be taken.

In April of this year, the President issued an Executive Order, which
recognizes the importance of IT to the improvement of the health care
system to address problems with high costs, medical errors, and
administrative inefficiencies. The order establishes the position of a
National Health Information Technology Coordinator. This new position has
been tasked with providing leadership for the development and nationwide
implementation of interoperable health IT in both the public and private
health care sectors. The President also announced a goal of having EMRs
available for most Americans within the next 10 years.

  Information Technology Can Provide Benefits for Delivery of Care

IT can provide significant benefits in providing clinical health care and
in the administrative functions associated with health care delivery. Last
October, we identified 20 examples of reported cost savings or other
benefits at 14 health care organizations that had implemented IT solutions
in their clinical care environments. The

rapidly rising costs of health care, along with an increasing concern for
the quality of care and the safety of patients, are driving health care
organizations to use IT to automate clinical care operations and their
associated administrative functions. IT is now being used for, among other
things, EMRs, order management, Internet access for patient and provider
communications, and automated billing and financial management.

Health care delivery organizations identified instances that resulted in
cost savings from the use of IT as a result of reductions in costs
associated with medication errors, communication and documentation of
clinical care and test results, staffing and paper storage, and processing
of information. Specific examples included:

o   o A teaching hospital reported that it realized about $8.6 million in
annual savings by replacing paper medical charts with EMRs for
outpatients. It also reported saving over $2.8 million annually by
replacing its manual process for handling medical records with electronic
access to laboratory results and reports.

o   o A teaching hospital reported that it saved $5 million annually on
drug substitutions, based on automated prompts that recommended
alternatives resulting in increased quality and decreased cost.

o   o A community hospital prevented the administration of over 1,200
wrong drugs or dosages and almost 2,000 early or extra doses by using bar
code technology and wireless scanners to verify both the identities of
patients and their correct medications. The reported monetary value of the
errors prevented was almost $850,000.

o   o An integrated health care delivery organization reduced the overall
number of daily chart pulls, estimating that about $5.7 million in medical
record staffing costs were avoided or saved annually.

IT also contributed to other benefits, such as shorter hospital stays,
faster communication of test results, improved management of chronic
disease, and improved accuracy in capturing charges associated with
diagnostic and procedure codes. For example,

o   o A teaching hospital reported a decrease in average length of stay
from 7.3 to 5 days when it implemented an integrated EMR system that
resulted in improvements in health care efficiency and practice changes.

o   o A teaching hospital reported improved patient scheduling using a
rules-based electronic scheduling system that accommodated travel time to
the appointment, fasting requirements, and providers' availability.

o   o An integrated health care delivery organization reported
improvements in diabetes control for members with the disease, decreases
in upper gastrointestinal studies ordered, and increases in the number of
Pap smears performed by using alerts and reminders, automated patient care
guidelines, and data warehouse reports.

o   o A teaching hospital reported that 4 percent of radiology orders that
had been entered into the order entry system were cancelled and 55 percent
were changed when an embedded alert warned that an order was inappropriate
for specified clinical reasons.

Health care organizations also told us that EMRs could also improve the
delivery of care because, among other reasons, more complete medical
documentation was available to support the provider's diagnosis. In
addition, EMRs greatly facilitate the reporting of public health
information associated with the early detection of and response to disease
outbreaks.

The lessons learned that were reported to us by health care organizations
that have successfully implemented IT may prove useful for other
organizations as they implement solutions-such as recognizing the
importance of reengineering business processes, gaining users' acceptance,
providing adequate training, and making systems available and secure. For
example, organizations reported that business process changes were key in
effectively implementing the technology and that users, including
physicians, should be involved in systems design and implementation.

  Many IT Initiatives Address the Public Health Infrastructure, Although
  Standards Implementation Challenges Remain

In May 2003, we reported that six federal agencies involved in
bioterrorism preparedness and response had a large number of existing and
planned information systems associated with supporting a public health
emergency. Specifically, these agencies identified 72 information systems
and supporting technologies. Of the 72 systems, 34 are surveillance
systems, 18 are supporting technologies, 10 are communications systems,
and 10 are detection systems. In spite of these many initiatives, the key
ones that are intended to facilitate greater information sharing are still
being developed and implemented. For example, CDC is currently
implementing its Public Health Information Network, which consists of a
number of disease surveillance and communications systems, including the
Health Alert Network. This network is an early warning and response system
intended to provide federal, state, and local agencies with better
communications during public health emergencies. The Department of Defense
is using its Electronic Surveillance System for the Early Notification of
Community-based Epidemics (ESSENSE) to support early identification of
infectious disease outbreaks in the military by comparing analyses of data
collected daily with historical trends. We also found that agencies varied
in the extent to which they interacted and coordinated with other agencies
in planning and operating each of these initiatives.

The October 2001 anthrax attacks and the subsequent emergence of new
infectious diseases have highlighted the importance of data standards for
real-time data exchange across the public health infrastructure. During
the anthrax attack, participants accumulated dissimilar data and
principally exchanged it manually.

Since 1993, we have called for federal leadership to expedite the
standards development process in order to accelerate the use of EMRs.8
Most recently, in May 2003, we again reported that the

8U.S. General Accounting Office, Automated MedicalRecords:LeadershipNeeded
to Expedite StandardsDevelopment, GAO/IMTEC-93-17 (Washington, D.C.: April
30, 1993).

identification and implementation of health care data, communications, and
security standards-which are necessary to support the compatibility and
interoperability of agencies' various IT systems-remains incomplete across
the health care industry. We also identified other standards setting
initiatives (e.g., CHI and HIPPA9) and raised concerns about coordinating
these initiatives.

To address the challenges of coordinating the many IT initiatives and
implementing a consistent set of standards, we recommended that the
Secretary of Health and Human Services (HHS), in coordination with other
key stakeholders, establish a national IT strategy for public health
preparedness and response, including specific steps toward improving the
nation's ability to use IT in support of the public health infrastructure.
Specifically, we recommended, among other things, that the Secretary

o  	set priorities for information systems, supporting technologies, and
other IT initiatives;

o  	define activities for ensuring that the various standards-setting
organizations coordinate their efforts and reach further consensus on the
definition and use of standards;

o  	establish milestones for defining and implementing all standards; and

o  	create a mechanism-consistent with HIPAA requirements-to monitor the
implementation of standards throughout the health care industry.

Since our May 2003 report, HHS has continued its efforts to identify
applicable standards throughout the health care industry and across
federal health care programs. For example, in May 2004, the CHI

9In August 1996, Congress recognized the need for standards to improve the
Medicare and Medicaid programs in particular and the efficiency and
effectiveness of the health care system in general. It passed the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), which calls
for the industry to control the distribution and exchange of health care
data and begin to adopt electronic data exchange standards to uniformly
and securely exchange patient information.

initiative-one of OMB's e-government projects-announced fifteen additional
standards that build on the initial five announced in March 2003. Federal
agencies are expected to include the standards in their architectures and
when they build, acquire, or modify systems. Current plans for the CHI
initiative call for it to be incorporated into HHS's Federal Health
Architecture by September 2004.10 This architecture is still evolving, and
many issues-such as coordination of the various standards setting efforts
and implementation of the standards that have been identified-are still
works in progress. Until these standards are more fully implemented,
federal agencies and others associated with the public health
infrastructure cannot ensure that their systems will be capable of
exchanging data with other systems when needed and consequently cannot
ensure effective preparation for and response to public health
emergencies, including acts of bioterrorism.

In addition, in April of this year, the President issued an Executive
Order, which calls for the establishment of a National Health Information
Technology Coordinator and the issuance of a broader strategic plan to
guide the nationwide implementation of interoperable health care
information systems. The coordinator is also specifically tasked with
creating incentives for the use of health IT and accelerating the adoption
of EMRs, among other things. The Coordinator plans to present the
strategic plan next week. Such a plan, if properly crafted, should help to
move the health care industry towards interoperable information systems.
As health IT initiatives are pursued, it will be essential to have
continued leadership, clear direction, measurable goals, and mechanisms to
monitor progress.

____________________________________________________________

In summary, there are many opportunities and challenges associated with
the implementation of IT for clinical care delivery and public health. The
federal government, namely HHS, has taken a leadership role in
establishing a strategy and identifying data and

10Initiated in July 2003, the Federal Health Architecture is expected to
define an overarching framework and methodology for establishing targets
and standards for interoperability and communication across the federal
health community.

communications standards, which are critical for sharing data across the
health care industry-both to improve the quality of patient care in the
United States and to strengthen the public health infrastructure. However,
much more work remains to more fully utilize IT for the delivery of care
and to identify and respond to public health emergencies. HHS needs to
provide continued leadership, sustained and focused attention, clear
direction, and mechanisms to monitor progress in order to bring about
measurable improvements and achieve the President's goals.

Mr. Chairman, this concludes my statement. I would be happy to answer any
questions that you or members of the subcommittee may have at this time.

If you should have any questions about this testimony, please contact me
at (202) 512-9286 or M. Yvonne Sanchez, Assistant Director, at (202)
512-6274. We can also be reached by e-mail at [email protected] and
[email protected], respectively. Other individuals who made key
contributions to this testimony include Joanne Fiorino, M. Saad Khan, and
Mary Beth McClanahan.

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.

GAO's Mission	The Government Accountability 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.

Obtaining Copies of The fastest and easiest way to obtain copies of GAO
documents at no cost

is through GAO's Web site (www.gao.gov). Each weekday, GAO postsGAO
Reports and newly released reports, testimony, and correspondence on its
Web site. To Testimony have GAO e-mail you a list of newly posted products
every afternoon, go to

www.gao.gov and select "Subscribe to Updates."

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. Government Accountability 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:
    Waste, and Abuse in Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: [email protected] Programs Automated answering system: (800)
424-5454 or (202) 512-7470

Congressional 	Gloria Jarmon, Managing Director, [email protected] (202)
512-4400 U.S. Government Accountability Office, 441 G Street NW, Room 7125

Relations Washington, D.C. 20548

Public Affairs Jeff Nelligan, Managing Director, [email protected] (202)
512-4800 U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548
*** End of document. ***