Computer-Based Patient Records: VA and DOD Made Progress, but	 
Much Work Remains to Fully Share Medical Information (28-SEP-05, 
GAO-05-1051T).							 
                                                                 
For the past 7 years, the Departments of Veterans Affairs (VA)	 
and Defense (DOD) have been working to exchange patient health	 
information electronically and ultimately to have interoperable  
electronic medical records. Sharing medical information helps (1)
promote the seamless transition of active duty personnel to	 
veteran status and (2) ensure that active duty military personnel
and veterans receive high-quality health care and assistance in  
adjudicating their disability claims. This is especially critical
in the face of current military responses to national and foreign
crises. In testimony before the Veterans' Affairs Subcommittee on
Oversight and Investigations in March and May 2004, GAO discussed
the progress being made by the departments in this endeavor. In  
June 2004, at the Subcommittee's request, GAO reported on its	 
review of the departments' progress toward the goal of an	 
electronic two-way exchange of patient health records. GAO is	 
providing an update on the departments' efforts, focusing on (1) 
the status of ongoing, near-term initiatives to exchange data	 
between the agencies' existing systems and (2) progress in	 
achieving the longer term goal of exchanging data between the	 
departments' new systems.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-1051T					        
    ACCNO:   A38557						        
  TITLE:     Computer-Based Patient Records: VA and DOD Made Progress,
but Much Work Remains to Fully Share Medical Information	 
     DATE:   09/28/2005 
  SUBJECT:   Data transmission systems				 
	     Electronic health records				 
	     Health care planning				 
	     Health care services				 
	     Interagency relations				 
	     Medical information systems			 
	     Medical records					 
	     Strategic planning 				 
	     Systems analysis					 
	     Systems evaluation 				 
	     Systems management 				 
	     Information sharing				 
	     DOD/IHS/VA Government Computer-Based		 
	     Patient Record Project				 
                                                                 
	     VA HealtheVet VistA				 

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GAO-05-1051T

                 United States Government Accountability Office

GAO	Testimony before the Committee on Veterans' Affairs, House of
Representatives

For Release on Delivery Expected at 10:00 a.m. EDT September 28, 2005

                                 COMPUTER-BASED
                                PATIENT RECORDS:

     VA and DOD Made Progress, but Much Work Remains to Fully Share Medical
                                  Information

Statement of Linda D. Koontz
Director, Information Management Issues

GAO-05-1051T

[IMG]

September 28, 2005

COMPUTER-BASED PATIENT RECORDS

VA and DOD Have Made Progress, but Much Work Remains to Fully Share Medical
Information

                                 What GAO Found

In the past year, VA and DOD have begun to implement applications that
exchange limited electronic medical information between the departments'
existing health information systems. These applications are (1)
Bidirectional Health Information Exchange, a project to achieve the
two-way exchange of health information on patients who receive care from
both VA and DOD, and (2) Laboratory Data Sharing Interface, an application
used to electronically transfer laboratory work orders and results between
the departments. The Bidirectional Health Information Exchange application
has been implemented at five sites, at which it is being used to rapidly
exchange information such as pharmacy and allergy data. Also, the
Laboratory Data Sharing Interface application has been implemented at six
sites, at which it is being used for real-time entry of laboratory orders
and retrieval of results. According to the departments, these systems
enable lower costs and improved service to patients by saving time and
avoiding errors.

VA and DOD are continuing with activities to support their longer term
goal of sharing health information between their systems (see figure), but
the goal of two-way electronic exchange of patient records remains far
from being realized. Each department is developing its own modern health
information system-VA's HealtheVet VistA and DOD's Composite Health Care
System II-and they have taken steps to respond to GAO's June 2004
recommendations regarding the program to develop an electronic interface
that will enable these systems to share information. That is, they have
developed an architecture for the interface, established project
accountability, and implemented a joint project management structure.
However, they have not yet developed a clearly defined project management
plan to guide their efforts, as GAO previously recommended. Further, they
have not yet fully populated the repositories that will store the data for
their future health systems, and they have experienced delays in their
efforts to begin a limited data exchange. Lacking a detailed project
management plan increases the risk that the departments will encounter
further delays and be unable to deliver the planned capabilities on time
and at the cost expected.

History of Selected VA/DOD Efforts on Electronic Medical Records and Data
Sharing

                 United States Government Accountability Office

Mr. Chairman and Members of the Committee:

I am pleased to participate in today's discussion on the actions taken by
the Departments of Veterans Affairs (VA) and Defense (DOD) to promote the
seamless transition of active duty personnel to veteran status. Among the
two departments' goals for seamless transition is to be able to exchange
patient health information electronically and ultimately to have
interoperable1 electronic medical records. Sharing of medical information
is an important tool to help ensure that active duty military personnel
and veterans receive high-quality health care and assistance in
adjudicating their disability claims-goals that, in the face of current
military responses to national and foreign crises, are more essential than
ever.

For the past 7 years, VA and DOD have been working to achieve these
capabilities, beginning with a joint project in 1998 to develop a
government computer-based patient record. As we have noted in previous
testimony,2 the departments had 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 the longer term objective-providing a virtual medical
record in which data are computable. That is, rather than data being
provided as text for viewing only, data would be in a format that the
health information application can act on: for example, providing alerts
to clinicians (of such things as drug allergies) and plotting graphs of
changes in vital signs such as blood pressure. According to the
departments, the use

1 Interoperability is the ability of two or more systems or components to
exchange information and to use the information that has been exchanged.

2 GAO,Computer-Based Patient Records: Improved Planning and Project
Management Are Critical to Achieving Two-Way VA-DOD Health Data Exchange,
GAO-04-811T (Washington, D.C.: May 19, 2004); 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); and Computer-Based Patient Records: Short-Term Progress
Made, but Much Work Remains to Achieve a Two-Way Data Exchange Between VA
and DOD Health Systems, GAO-04-271T (Washington, D.C.: Nov. 19, 2003).

of such computable medical data contributes significantly to the
usefulness of electronic medical records.

As of June 2004, when we last reported on this topic,3 VA and DOD were
continuing to define the data standards that are essential both for the
exchange of data and for the development of interoperable electronic
medical records. At that time, we identified weaknesses in the planning
and management structure of the departments' program, and we recommended
that the departments take a number of actions to address these weaknesses.

Also in 2004, in response to a mandate in the Bob Stump National Defense
Authorization Act for Fiscal Year 2003,4 VA and DOD initiated information
technology demonstration projects focusing on near-term goals: the
exchange of electronic medical information between the departments'
existing health information systems. These projects are to help in the
evaluation of the feasibility, advantages, and disadvantages of measures
to improve sharing and coordination of health care and health care
resources. The two demonstration projects (Bidirectional Health
Information Exchange and Laboratory Data Sharing Interface) are interim
initiatives that are separate from the departments' ongoing long-term
efforts in sharing data and developing health information systems.

At your request, my testimony today will discuss the two departments'
continued efforts to exchange medical information, with a specific focus
on (1) the status of ongoing, near-term initiatives to exchange data
between the agencies' existing systems and (2) progress in achieving the
longer term goal of exchanging data between the departments' new systems,
still in development, which are to be built around electronic patient
health records.

3 GAO, Computer-Based Patient Records: VA and DOD Efforts to Exchange
Health Data Could Benefit from Improved Planning and Project Management,
GAO-04-687 (Washington, D.C.: June 7, 2004).

4 Pub. L. No. 107-314, S:721 (a)(1), 116 Stat. 2589,2595 (2002). To
further encourage on-going collaboration, section 721 directed the
Secretary of Defense and the Secretary of Veterans Affairs to establish a
joint program to identify and provide incentives to implement, fund, and
evaluate creative health care coordination and sharing initiatives between
DOD and VA.

In conducting this work, we reviewed the departments' documentation
describing the two demonstration projects, including business plans,
budget summaries, and project status reports. 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 reviewed draft system
requirements, design specifications, and software descriptions for the
electronic interface between the departments' new health systems. 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. In addition, to observe the Bidirectional
Health Information Exchange and Laboratory Data Sharing Interface
capabilities, we conducted site visits to military treatment facilities
and VA medical centers in El Paso and San Antonio, Texas, and Puget Sound,
Washington. We conducted our work from June through September 2005, in
accordance with generally accepted government auditing standards.

  Results in Brief

In the past year, VA and DOD have begun to implement applications that
exchange limited electronic medical information between the departments'
existing health information systems. These applications were developed
through two information technology demonstration projects: (1)
Bidirectional Health Information Exchange is a project to achieve the
two-way exchange of health information on shared patients,5 and (2)
Laboratory Data Sharing Interface is an application used to facilitate the
electronic transfer/sharing of orders for laboratory work and the results
of the

5 Shared patients receive care from both VA and DOD clinicians. For
example, veterans may receive outpatient care from VA clinicians and be
hospitalized at a military treatment facility.

work. The departments have implemented the Bidirectional Health
Information Exchange application at five sites, at which it is being used
for the rapid exchange of specific types of information (pharmacy data,
drug and food allergy information, patient demographics, and laboratory
results6 on shared patients). Also, the Laboratory Data Sharing Interface
application has been implemented at six sites, at which it is being used
for real-time entry of laboratory orders and retrieval of laboratory
results. Although the data exchanged by these demonstration projects are
in text form only (that is, they are not computable), the systems have
significant benefits, according to the two departments, because they
enable lower costs and improved service to patients by saving time and
avoiding errors.

Since our last report on the departments' efforts to achieve a virtual
medical record, VA and DOD have taken several actions, but the departments
continue to be far from achieving the two-way electronic data exchange
capability originally envisioned. The departments have implemented three
recommendations that we made in June 2004: They have developed an
architecture for the electronic interface between DOD's Clinical Data
Repository and VA's Health Data Repository; they have established the
VA/DOD Health Executive Council7 as the lead entity for the project; and
they have established a joint project management structure to provide
day-to-day guidance for this initiative. Additionally, the Health
Executive Council established working groups to provide programmatic
oversight and to facilitate interagency collaboration on sharing
initiatives between DOD and VA. However, VA and DOD have not yet developed
a clearly defined project management plan that gives a detailed
description of the technical and managerial processes necessary to satisfy
project requirements, as we previously recommended. Moreover, the
departments have

6 These data are text files providing surgical, pathology, cytology,
microbiology, chemistry, and hematology test results and descriptions of
radiology results.

7 The VA/DOD Health Executive Council is composed of senior leaders from
VA and DOD, who work to institutionalize sharing and collaboration of
health services and resources. The council is cochaired by the VA
Undersecretary for Health and DOD Assistant Secretary of Defense for
Health Affairs, and meets every 2 months.

experienced delays in their efforts to begin exchanging computable patient
health data; they have not yet fully populated the data repositories that
are to store the medical data for their future health systems. As a
result, much work remains before the departments achieve their ultimate
goal-interoperable electronic health records and two-way electronic
exchange of computable 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 aimed at achieving the
capability to share patient health information for active duty military
personnel and veterans.8 Their first initiative, undertaken in that year,
was the Government Computer-Based Patient Record (GCPR) project, whose
goal was 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 agency's 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.

In our reviews of the GCPR project, we 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. In April 2001 and in June 2002,9 we made
recommendations to help strengthen the management and oversight of the
project. In 2001, we recommended

8 Initially, 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.

9 GAO, Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results, GAO-02-703 (Washington, D.C.:
June 12, 2002); and Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing,
GAO-01-459 (Washington, D.C.: Apr. 30, 2001).

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

VA and DOD took specific measures in response to our recommendations for
enhancing overall management and accountability of the project. By July
2002, VA and DOD had revised their strategy and had made progress toward
being able to electronically share patient health data. The two
departments had refocused the project and named it 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.

0M	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, CHCS) to a separate database that VA
clinicians could access.

0M	A second phase, finalized in March 2004, 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 the December 2004 VA/DOD Joint Executive Council10 Annual
Report, FHIE was fully operational, and VA providers at all

10 The Joint Executive Council is composed of the Deputy Secretary of
Veterans Affairs, the Undersecretary of Defense for Personnel and
Readiness, and the cochairs of joint councils on health, benefits, and
capital planning. The council meets on a quarterly basis to recommend
strategic direction of joint coordination and sharing efforts.

VA medical centers and clinics nationwide had access to data on separated
service members. According to the report, the FHIE data repository at that
time contained historical clinical health data on 2.3 million unique
patients from 1989 on, and the repository made a significant contribution
to the delivery and continuity of care and adjudication of disability
claims of separated service members as they transitioned to veteran
status. The departments reported total GCPR/FHIE costs of about $85
million through fiscal year 2003.

In addition, officials stated that in December 2004, the departments began
to use the FHIE framework to transfer pre- and postdeployment health
assessment data from DOD to VA. According to these officials, VA has now
received about 400,000 of these records.

However, not all DOD medical information is captured in CHCS. For example,
according to DOD officials, as of September 6, 2005, 1.7 million patient
stay records were stored in the Clinical Information System (a commercial
product customized for DOD). In addition, many Air Force facilities use a
system called the Integrated Clinical Database for their medical
information.

The revised DOD/VA strategy also envisioned achieving a longer term,
two-way exchange of health information between DOD and VA, which may also
address systems outside of CHCS. Known as HealthePeople (Federal), this
initiative is premised on 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 between
the new systems that each department is currently developing and beginning
to implement-VA's HealtheVet VistA and DOD's CHCS II.

0M	DOD began developing CHCS II in 1997 and had completed a key component
for the planned electronic interface-its Clinical Data Repository. When we
last reported in June 2004, the department expected to complete deployment
of all of its major system

capabilities by September 2008.11 DOD reported expenditures of about $600
million for the system through fiscal year 2004.12

0M	VA began work on HealtheVet VistA and its associated Health Data
Repository in 2001 and expected to complete all six initiatives comprising
this system in 2012. VA reported spending about $270 million on
initiatives that comprise HealtheVet VistA through fiscal year 2004. 13

Under the HealthePeople (Federal) initiative, VA and DOD envision that, on
entering military service, a health record for the service member would be
created and stored in DOD's Clinical Data Repository. The record would be
updated as the service member receives medical care. When the individual
separated from active duty and, if eligible, sought medical care at a VA
facility, VA would then create a medical record for the individual, which
would be stored in its Health Data Repository. On 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 sought 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

11 DOD's CHCS II capabilities are being deployed in five increments. The
first provides a graphical user interface for clinical outpatient
processes, thus providing an electronic medical record capability; the
second supports general dentistry; the third provides pharmacy,
laboratory, radiology, and immunizations capabilities; the fourth provides
inpatient and scheduling capabilities; and the fifth will provide
additional capabilities as defined. According to DOD, the first increment
has been deployed to 64 of the 139 DOD health facilities, representing
over 6.9 million beneficiaries, or about 75 percent of the total 9.2
million beneficiaries.

12 These expenditures represent acquisition costs for software
development, test and evaluation, hardware acquisition, system
implementation, and associated contractor personnel costs. They do not
include government personnel or operations and maintenance costs.

13 The six initiatives that make up HealtheVet VistA are the Health Data
Repository, billing replacement, laboratory, pharmacy, imaging, and
appointment scheduling replacement. This amount includes investments in
these six initiatives by VA as reported in their submission to the Office
of Management and Budget for fiscal year 2004.

information from the two repositories accessible to both departments'
clinicians.

To achieve this goal requires the departments to be able to exchange
computable health information between the data repositories for their
future health systems: that is, VA's Health Data Repository (a component
of HealtheVet VistA) and DOD's Clinical Data Repository (a component of
CHCS II). In March 2004, the departments began an effort to develop an
interface linking these two repositories, known as CHDR (a name derived
from the abbreviations for DOD's Clinical Data Repository-CDR-and VA's
Health Data Repository-HDR). According to the departments,14 they planned
to be able to exchange selected health information through CHDR by October
2005. Developing the two repositories, populating them with data, and
linking them through the CHDR interface would be important steps toward
the two departments' long-term goals as envisioned in HealthePeople
(Federal). Achieving these goals would then depend on completing the
development and deployment of the associated health information
systems-HealtheVet VistA and CHCS II.

In our most recent review of the CHDR program, issued in June 2004,15 we
reported that the efforts of DOD and VA in this area demonstrated a number
of management weaknesses. Among these were the lack of a well-defined
architecture for describing the interface for a common health information
exchange; an established project management lead entity and structure to
guide the investment in the interface and its implementation; and a
project management plan defining the technical and managerial processes
necessary to satisfy project requirements. With these critical components
missing, VA and DOD increased the risk that they would not achieve their
goals. Accordingly, we recommended that the departments

14 December 2004 VA and DOD Joint Strategic Plan.

15 GAO, Computer-Based Patient Records: VA and DOD Efforts to Exchange
Health Data Could Benefit from Improved Planning and Project Management,
GAO-04-687 (Washington, D.C.: June 7, 2004).

0Mdevelop an architecture for the electronic interface between their
health systems that includes system requirements, design specifications,
and software descriptions;

0Mselect a lead entity with final decision-making authority for the
initiative;

0Mestablish a project management structure to provide day-to-day guidance
of and accountability for their investments in and implementation of the
interface capability; and

0Mcreate and implement a comprehensive and coordinated project management
plan for the electronic interface that defines the technical and
managerial processes necessary to satisfy project requirements and
includes (1) the authority and responsibility of each organizational unit;
(2) a work breakdown structure for all of the tasks to be performed in
developing, testing, and implementing the software, along with schedules
associated with the tasks; and (3) a security policy.

Besides pursuing their long-term goals for future systems through the
HealthePeople (Federal) strategy, the departments are working on two
demonstration projects that focus on exchanging information between
existing systems: (1) Bidirectional Health Information Exchange, a project
to exchange health information on shared patients, and (2) Laboratory Data
Sharing Interface, an application used to transfer laboratory work orders
and results. These demonstration projects were planned in response to
provisions of the Bob Stump National Defense Authorization Act of 2003,
which mandated that VA and DOD conduct demonstration projects that
included medical information and information technology systems to be used
as a test for evaluating the feasibility, advantages, and disadvantages of
measures and programs designed to improve the sharing and coordination of
health care and health care resources between the departments.

Figure 1 is a time line showing initiation points for the VA and DOD
efforts discussed here, including strategies, major programs, and the
recent demonstration projects.

Figure 1: History of Selected VA/DOD Electronic Medical Records and Data
Sharing Efforts

  VA and DOD Are Exchanging Limited Medical Information between Existing
  Health Systems

VA and DOD have begun to implement applications developed under two
demonstration projects that focus on the exchange of electronic medical
information. The first-the Bidirectional Health Information Exchange-has
been implemented at five VA/DOD locations and the second-Laboratory Data
Sharing Interface-has been implemented at six VA/DOD locations.

Bidirectional Health Information Exchange

According to a VA/DOD annual report and program officials, Bidirectional
Health Information Exchange (BHIE) is an interim step in the departments'
overall strategy to create a two-way exchange of electronic medical
records. BHIE builds on the architecture and framework of FHIE, the
current application used to transfer health data on separated service
members from DOD to VA. As discussed earlier, FHIE provides an interface
between VA's and DOD's current health information systems that allows
one-way transfers only, which do not occur in real time: VA clinicians do
not

have access to transferred information until about 6 weeks after
separation. In contrast, BHIE focuses on the two-way, near-real-time
exchange of information (text only) on shared patients (such as those at
sites jointly occupied by VA and DOD facilities). This application
exchanges data between VA's VistA system and DOD's CHCS system (and CHCS
II where implemented). To date, the departments reported having spent $2.6
million on BHIE.

The primary benefit of BHIE is the near-real-time access to patient
medical information for both VA and DOD, which is not available through
FHIE. During a site visit to a VA and DOD location in Puget Sound, we
viewed a demonstration of this capability and were told by a VA clinician
that the near-real-time access to medical information has been very
beneficial in treating shared patients.

As of August 2005, BHIE was tested and deployed at VA and DOD facilities
in Puget Sound, Washington, and El Paso, Texas, where the exchange of
demographic, outpatient pharmacy, radiology, laboratory, and allergy data
(text only) has been achieved. The application has also been deployed to
three other locations this month (see table 1). According to the program
manager, a plan to export BHIE to additional locations has been approved.
The additional locations were selected based on a number of factors,
including the number and types of VA and DOD medical facilities in the
area, FHIE usage, and retiree population at the locations. The program
manager stated that implementation of BHIE requires training of staff from
both departments. In addition, implementation at DOD facilities requires
installation of a server; implementation at VA facilities requires
installation of a software patch (downloaded from a VA computer center),
but no additional equipment. As shown in table 1, five additional
implementations are scheduled for the first quarter of fiscal year 2006.

Table 1: Scheduled Rollout of BHIE at Selected DOD Facilities

Facility Implementation date

Madigan Army Medical Center, Washington October 2004

William Beaumont Army Medical Center, Texas October 2004

Eisenhower Army Medical Center, Georgia September 2005

Naval Hospital Great Lakes, Illinois September 2005

Naval Medical Center, California September 2005

Brooke Army Medical Center, Texas First quarter, fiscal year 2006

Landstuhl Regional Medical Center, Germany First quarter, fiscal year 2006

Bassett Army Community Hospital, Alaska First quarter, fiscal year 2006

Walter Reed Army Medical Center, Maryland First quarter, fiscal year 2006

Bethesda Naval Medical Center, Maryland First quarter, fiscal year 2006
Sources: VA and DOD.

Note: VA facilities are sited near all the DOD facilities shown.

Additionally, because DOD stores electronic medical information in systems
other than CHCS (such as the Clinical Information System and the
Integrated Clinical Database), work is currently under way to allow BHIE
to have the ability to exchange information with those systems. The Puget
Sound Demonstration site is also working on sharing consultation reports
stored in the VA and DOD systems.

Laboratory Data Sharing Interface

The Laboratory Data Sharing Interface (LDSI) initiative enables the two
departments to share laboratory resources. Through LDSI, a VA provider can
use VA's health information system to write an order for laboratory tests,
and that order is electronically transferred to DOD, which performs the
test. The results of the laboratory tests are electronically transferred
back to VA and included in the patient's medical record. Similarly, a DOD
provider can choose to use a VA lab for testing and receive the results
electronically. Once LDSI is fully implemented at a facility, the only
nonautomated action in performing laboratory tests is the transport of the
specimens.

Among the benefits of LDSI is increased speed in receiving laboratory
results and decreased errors from multiple entry of orders. However,
according to the LDSI project manager in San Antonio, a primary benefit of
the project will be the time saved by eliminating the need to rekey orders
at processing labs to input the information into the laboratories'
systems. Additionally, the San

Antonio VA facility will no longer have to contract out some of its
laboratory work to private companies, but instead use the DOD laboratory.
To date, the departments reported having spent about $3.3 million on LDSI.

An early version of what is now LDSI was originally tested and implemented
at a joint VA and DOD medical facility in Hawaii in May 2003. The
demonstration project built on this application and enhanced it; the
resulting application was tested in San Antonio and El Paso. It has now
been deployed to six sites in all. According to the departments, a plan to
export LDSI to additional locations has been approved. Table 2 shows the
locations at which it has been or is to be implemented.

  Table 2: VA/DOD Facilities with LDSI Implementations Facility Implementation
                                      Date

Tripler Army Medical Center and May 2003 VA Spark M. Matsunaga Medical
Center, Hawaii

Kirtland Air Force Base and May 2003 Albuquerque VA Medical Center, New
Mexico

Naval Medical Center and July 2004 San Diego VA Health Care System,
California

Great Lakes Naval Hospital and October 2004 VA Medical Center, Illinois

William Beaumont Army Medical Center, El Paso, Texas October 2004

Brooke Army Medical Center, San Antonio, Texas August 2005

Bassett Army Community Hospital, Alaska Pre-implementation

Nellis Air Force Base, Nevada Pre-implementation

                              Sources: VA and DOD.

  VA and DOD Are Taking Actions to Achieve a Virtual Medical

Record, but Much Work Remains Besides the near-term initiatives just
discussed, VA and DOD continue their efforts on the longer term goal: to
achieve a virtual medical record based on the two-way exchange of
computable data between the health information systems that each is
currently developing. The cornerstone for this exchange is CHDR, the
planned electronic interface between the data repositories for the new
systems.

The departments have taken important actions on the CHDR initiative. In
September 2004 they successfully completed Phase I of CHDR by
demonstrating the two-way exchange of pharmacy information with a
prototype in a controlled laboratory environment.16 According to
department officials, the pharmacy prototype provided invaluable insight
into each other's data repository systems, architecture, and the work that
is necessary to support the exchange of computable information. These
officials stated that lessons learned from the development of the
prototype were documented and are being applied to Phase II of CHDR, the
production phase, which is to implement the two-way exchange of patient
health records between the departments' data repositories. Further, the
same DOD and VA teams that developed the prototype are now developing the
production version.

In addition, the departments developed an architecture for the CHDR
electronic interface, as we recommended in June 2004. The architecture for
CHDR includes major elements required in a complete architecture. For
example, it defines system requirements and allows these to be traced to
the functional requirements, it includes the design and control
specifications for the interface design, and it includes design
descriptions for the software.

Also in response to our recommendations, the departments have established
project accountability and implemented a joint project management
structure. Specifically, the Health Executive Council has been established
as the lead entity for the project. The joint project management structure
consists of a Program Manager from VA and a Deputy Program Manager from
DOD to provide day-to-day guidance for this initiative. Additionally, the
Health Executive Council established the DOD/VA Information
Management/Information Technology Working Group and the DOD/VA Health
Architecture Interagency Group, to provide programmatic oversight and to
facilitate interagency collaboration on sharing initiatives between DOD
and VA.

16 The completion of the pharmacy prototype project satisfied a mandate of
the 2003 Bob Stump National Defense Authorization Act, Pub. L. 107-314,
sec. 724 (2002).

To build on these actions and successfully carry out the CHDR initiative,
however, the departments still have a number of challenges to overcome.
The success of CHDR will depend 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. We recommended in 2004 that the departments develop a clearly defined
project management plan that describes the technical and managerial
processes necessary to satisfy project requirements and includes (1) the
authority and responsibility of each organizational unit; (2) a work
breakdown structure for all of the tasks to be performed in developing,
testing, and implementing the software, along with schedules associated
with the tasks; and (3) a security policy. Currently, the departments have
an interagency project management plan that provides the program
management principles and procedures to be followed by the project.
However, the plan does not specify the authority and responsibility of
organizational units for particular tasks; the work breakdown structure is
at a high level and lacks detail on specific tasks and time frames; and
security policy is still being drafted. Without a plan of sufficient
detail, VA and DOD increase the risk that the CHDR project will not
deliver the planned capabilities in the time and at the cost expected.

In addition, officials now acknowledge that they will not meet a
previously established milestone: by October 2005, the departments had
planned to be able to exchange outpatient pharmacy data, laboratory
results, allergy information, and patient demographic information on a
limited basis. However, according to officials, the work required to
implement standards for pharmacy and medication allergy data was more
complex than originally anticipated and led to the delay. They stated that
the schedule for CHDR is presently being revised. Development and data
quality testing must be completed and the results reviewed. The new target
date for medication allergy, outpatient pharmacy, and patient demographic
data exchange is now February 2006.

Finally, the health information currently in the data repositories has
various limitations.

0M	Although DOD's Clinical Data Repository includes data in the categories
that were to be exchanged at the missed milestone described above:
outpatient pharmacy data, laboratory results, allergy information, and
patient demographic information, these data are not yet complete. First,
the information in the Clinical Data Repository is limited to those
locations that have implemented the first increment of CHCS II, DOD's new
health information system. As of September 9, 2005, according to DOD
officials, 64 of 139 medical treatment facilities worldwide have
implemented this increment. Second, at present, health information in
systems other than CHCS (such as the Clinical Information System and the
Integrated Clinical Database) is not yet being captured in the Clinical
Data Repository. For example, according to DOD officials, as of September
9, 2005, the Clinical Information System contained 1.7 million patient
stay records.

0M	The information in VA's Health Data Repository is also limited:
although all VA medical records are currently electronic, VA has to
convert these into the interoperable format appropriate for the Health
Data Repository. So far, the data in the Health Data Repository consist of
patient demographics and vital signs records for the 6 million veterans
who have electronic medical records in VA's current system, VistA (this
system contains all the department's medical records in electronic form).
VA officials told us that they plan next to sequentially convert allergy
information, outpatient pharmacy data, and lab results for the limited
exchange that is now planned for February 2006.

In summary, developing an electronic interface that will enable VA and DOD
to exchange computable patient medical records is a highly complex
undertaking that could lead to substantial benefits- improving the quality
of health care and disability claims processing for the nation's military
members and veterans. VA and DOD have made progress in the electronic
sharing of patient health data in their limited, near-term demonstration
projects, and have taken an important step toward their long-term goals by
improving the management of the CHDR program. However, the departments
face considerable work and significant challenges before they can achieve
these long-term goals. While the departments have made

progress in developing a project management plan defining the technical
and managerial processes necessary to satisfy project requirements, this
plan does not specify the authority and responsibility of organizational
units for particular tasks, the work breakdown structure lacks detail on
specific tasks and time frames, and security policy has not yet been
finalized. Without a project management plan of sufficient specificity,
the departments risk further delays in their schedule and continuing to
invest in a capability that could fall short of expectations.

Mr. Chairman, this concludes my statement. I would be pleased to respond
to any questions that you or other members of the Committee 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]. Other individuals making key contributions to this
testimony include Nabajyoti Barkakati, Barbara S. Collier, Nancy E.
Glover, James T. MacAulay, Barbara S. Oliver, J. Michael Resser, and Eric
L. Trout.

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