DOD and VA: Systematic Data Sharing Would Help Expedite 	 
Servicemembers' Transition to VA Services (19-MAY-05,		 
GAO-05-722T).							 
                                                                 
Since the onset of Operation Enduring Freedom (OEF) and Operation
Iraqi Freedom (OIF), the Department of Defense (DOD) reported	 
that more than 12,000 servicemembers have been injured in combat.
While many return to active duty, others with more serious	 
injuries are likely to be discharged from the military. To ensure
the continuity of medical care and access to all other Department
of Veterans Affairs' (VA) benefits, such as vocational		 
rehabilitation, VA formed its Seamless Transition Task Force. In 
January 2005, GAO reported that VA had given high priority to	 
OEF/OIF servicemembers, but faced challenges in identifying,	 
locating, and following up with seriously injured servicemembers.
GAO recommended that VA and DOD reach an agreement for VA to	 
obtain systematic data from DOD, and the departments concurred.  
However, DOD raised privacy concerns. GAO was asked to review	 
VA's efforts to expedite vocational rehabilitation services to	 
seriously injured servicemembers and to determine the status of  
an agreement between DOD and VA to share health data. GAO relied 
on its prior work; interviewed VA and DOD officials; and reviewed
the Health Insurance Portability and Accountability Act of 1996  
(HIPAA) and the HIPAA Privacy Rule, which govern the sharing of  
individually identifiable health data.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-722T					        
    ACCNO:   A24417						        
  TITLE:     DOD and VA: Systematic Data Sharing Would Help Expedite  
Servicemembers' Transition to VA Services			 
     DATE:   05/19/2005 
  SUBJECT:   Data collection					 
	     Health care services				 
	     Interagency relations				 
	     Military personnel 				 
	     Veterans						 
	     Veterans benefits					 
	     Vocational rehabilitation				 
	     Health policies					 
	     Information sharing				 
	     Military health services				 
	     Standards (health care)				 
	     DOD Operation Iraqi Freedom			 
	     Operation Enduring Freedom 			 

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GAO-05-722T

Testimony

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

United States Government Accountability Office

GAO

For Release on Delivery Expected at 10:00 a.m. EDT

Thursday, May 19, 2005

DOD AND VA

Systematic Data Sharing Would Help Expedite Servicemembers' Transition to
VA Services

Statement of Cynthia A. Bascetta

Director, Health Care-Veterans'

Health and Benefits Issues

GAO-05-722T

Mr. Chairman and Members of the Subcommittee:

Thank you for inviting me to share our perspectives on seriously injured
servicemembers who could benefit from services offered by the Department
of Veterans Affairs (VA), such as vocational rehabilitation, disability
compensation, and health care, as they transition from servicemember to
veteran status. Since the onset of Operation Enduring Freedom (OEF) in
October 2001 and Operation Iraqi Freedom (OIF) in March 2003, the
Department of Defense (DOD) has reported that more than 12,000
servicemembers have been injured in combat. While many return to active
duty after they are treated, others who are more seriously injured are
likely to be discharged from their military obligations and return to
civilian life with disabilities. To ensure the continuity of medical care
as a first priority as well as to coordinate efforts to ensure access to
all other VA benefits, such as vocational rehabilitation, VA formed its
Seamless Transition Task Force in August 2003.

In January 2005, we reported that while VA has given high priority to
providing services to OEF/OIF servicemembers, it was challenged in its
efforts to identify, locate, and follow up with seriously injured
servicemembers.1 One key problem has been the lack of systematic data from
DOD about who is seriously injured, the nature of their injuries, and
where the servicemembers received treatment. As DOD and VA have worked
toward a seamless transition, DOD raised concerns about privacy issues and
the sharing of individually identifiable health data. We recommended that
VA and DOD collaborate to reach an agreement for VA to have access to DOD
data for seriously injured servicemembers that both departments agree are
needed to promote recovery and return to work and both departments
concurred.

You asked us to testify on VA's and DOD's efforts to provide a seamless
transition for seriously injured OEF/OIF servicemembers. Specifically, we
(1) reviewed VA's efforts to expedite vocational rehabilitation services
to seriously injured servicemembers and (2) determined the status of an
agreement between DOD and VA to share health data. My comments today
highlight the findings of our earlier work on VA's vocational
rehabilitation services for seriously injured servicemembers returning
from OEF/OIF and our ongoing work on DOD's and VA's data sharing
agreement.2

1GAO, Vocational Rehabilitation: More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers, GAO-05-167
(Washington, D.C.: Jan. 14, 2005).

Our January 2005 report on VA's efforts to expedite vocational
rehabilitation services to OEF/OIF servicemembers was based on interviews
with officials at VA headquarters and at 12 of VA's 57 regional offices.
Five of the 12 regional offices are located near the five major Army
military treatment facilities (MTF) treating the majority of seriously
injured OEF/OIF servicemembers during our review. We visited Walter Reed
Army Medical Center where most seriously injured Army servicemembers are
initially treated. To do our work on the status of DOD's and VA's data
sharing agreement, we reviewed a draft memorandum of understanding for the
sharing of data between DOD and VA, pertinent provisions of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA
Privacy Rule, which govern the sharing of individually identifiable health
data.3 We also spoke with officials responsible for the implementation of
the Privacy Rule at DOD and VA. We discussed the information contained in
this statement with DOD and VA officials who agreed with our findings. We
did our work from March through May 2005 in accordance with generally
accepted government auditing standards.

In summary, while VA has taken steps to expedite services to seriously
injured OEF/OIF servicemembers, VA does not have systematic data from DOD
on those servicemembers who may need vocational rehabilitation and other
benefits from VA. As a result, VA has had to rely on its regional offices
to develop informal data sharing arrangements with local MTF staff to
identify servicemembers who may need vocational rehabilitation services.
However, VA staff have no official data source from DOD from which to
confirm the completeness and reliability of the data obtained through
these informal, local arrangements. Furthermore, VA staff cannot provide
reasonable assurance that some seriously injured servicemembers who may
have benefited from early intervention by a vocational rehabilitation
counselor have not been overlooked. Unresolved issues between DOD and VA
continue to delay the systematic sharing of data. To obtain systematic
data from DOD on seriously injured OEF/OIF servicemembers who may need VA
services, DOD and VA have been working on an agreement to exchange
servicemembers' health data for over 2 years. DOD and VA differ in their
understanding of HIPAA Privacy Rule provisions that govern the sharing of
individually identifiable health data for seriously injured servicemembers
receiving treatment in MTFs, and the extent to which the Privacy Rule
would permit that exchange. DOD's and VA's inability to resolve these
differences has impeded coming to an agreement on exchanging seriously
injured servicemembers' individually identifiable health data. We continue
to believe that an agreement between DOD and VA to share health data would
expedite the delivery of VA services to OEF/OIF servicemembers, as well as
help ensure a seamless transition.

2See related GAO products listed at the end of this testimony.

3Pub. L. No. 104-191, S: 264, 110 Stat. 1936, 2033-34; 45 C.F.R. S:
164.500, et seq. (2004).

                                   Background

Servicemembers deployed to Afghanistan and Iraq are surviving injuries
that would have been fatal in past conflicts due, in part, to advances in
battlefield medicine and protective equipment. However, the severity of
their injuries can result in a lengthy transition from injured
servicemember to veteran. Initially, most seriously injured servicemembers
are brought to Landstuhl Regional Medical Center in Germany for treatment.
From there, they are usually transported to major MTFs in the United
States. According to DOD officials, once stabilized and discharged from
MTFs, servicemembers usually relocate closer to their homes or military
bases and are treated as outpatients. At this point, the military
generally begins to assess whether the servicemember will be able to
remain in the military, a process that could take months to complete.

Faced with the need to provide benefits and services to a new generation
of veterans with disabilities, VA formed an internal task force-the
Seamless Transition Task Force-in August 2003 to develop and implement
policies to improve the transition of injured servicemembers back to
civilian life. Although the task force's initial priority was to ensure
the continuity of medical care for injured servicemembers as they
transitioned from military to VA health care, it also coordinated efforts
to ensure access to all other VA benefits, including vocational
rehabilitation.

DOD has also supported transition assistance in various ways. For example,
the VA/DOD Joint Executive Committee was established in February 2002 to
promote collaboration between the two departments, including resolving
obstacles to information sharing. The committee is chaired by the Deputy
Secretary of Veterans Affairs and the Under Secretary of Defense for
Personnel and Readiness. In addition, the Army-in cooperation with
VA-established the Disabled Soldier Support System in April 2004 as an
advocacy group and information clearinghouse to clarify the services
available to disabled soldiers as they transition to civilian life. In
addition, DOD participated at times on VA's Seamless Transition Task
Force.

Separation from the military and return to civilian life often entail the
exchange of individually identifiable health data between DOD and VA. The
exchange of these data must comply with the HIPAA Privacy Rule, which
became effective April 14, 2001.4 The Privacy Rule permits VA and DOD to
share servicemembers' health data under certain circumstances.

 VA Has Taken Steps to Expedite Vocational Rehabilitation Services, but Lack of
                   Systematic Data from DOD Poses a Challenge

VA has given priority consideration and assistance to seriously injured
servicemembers returning from Afghanistan and Iraq. In a September 2003
letter, VA asked its regional offices to coordinate with staff at MTFs in
their areas to ascertain the identities, medical conditions, and military
status of the seriously injured OEF/OIF servicemembers. VA specifically
instructed regional offices to focus on servicemembers whose disabilities
were definitely or likely to result in military separation. Minimally,
this included servicemembers with injuries that had been classified as
"very serious," "serious," or in a "special category."5 In this letter, VA
instructed its regional offices to assign a case manager to each seriously
injured servicemember who applied for disability compensation. In
addition, VA noted the particular importance of early intervention for
those who were seriously injured and emphasized that seriously injured
servicemembers applying for vocational rehabilitation should receive the
fastest possible service. Moreover, VA reminded vocational rehabilitation
staff that they can initiate evaluation and counseling and, in some cases,
authorize training before a servicemember was discharged.6

4The Privacy Rule applies to covered entities and specifies how
individually identifiable health data may be used and disclosed by covered
entities. See 45 C.F.R. S:S: 164.500(a), 164.502 (2004). Covered entities
are defined in the Privacy Rule as health plans, clearinghouses, and
certain health care providers. Both the DOD health care system and the VA
health care system are covered entities. See 45 C.F.R. S: 160.103 (2004).
All covered entities had to comply with the Privacy Rule by April 14,
2003, with the exception of small health plans.

5Army regulations classify illnesses and injuries as "very serious" when
life is imminently endangered; as "serious" when there is a cause for
immediate concern but there is no imminent danger to life; and as "special
category" when the patient has a particular condition, such as loss of
limb or sight, a psychiatric condition, paralysis, or a permanent
disfigurement.

Since most seriously injured servicemembers are initially treated at major
MTFs, VA has detailed staff to these facilities to identify and educate
these servicemembers about VA services.7 These staff include VA social
workers and disability compensation benefits counselors. At Walter Reed
Army Medical Center, where the largest number of seriously injured
servicemembers has been treated, VA's Washington, D.C. regional office has
since 2001 also provided a vocational rehabilitation counselor to work
with hospitalized patients, specifically to offer and provide vocational
counseling and evaluation. The counselor reported attempting to contact
all patients within 48 hours of their arrival and visited them routinely
thereafter to establish rapport. Her primary mission is to work with
servicemembers who will need to prepare for civilian employment, although
she told us that her early intervention efforts could also help
servicemembers who are able to remain in the military.

Staff at another regional office noted that they also advocate early
intervention. These staff said that they try to contact servicemembers as
soon as possible to establish rapport and provide vocational
rehabilitation program information even before the servicemembers are
physically ready to begin vocational rehabilitation. We previously
reported on the importance of early intervention to maximize the work
potential of individuals with disabilities. We reported, for example, that
rehabilitation offered as close as possible to the onset of disabling
impairments has the greatest likelihood of success.8

6Servicemembers can receive vocational rehabilitation services prior to
separation from the military under certain circumstances. For example,
hospitalized servicemembers pending discharge may receive all VA
vocational rehabilitation benefits-such as counseling, evaluation, and
training-except for the monthly subsistence allowance. 38 U.S.C. S:S:
3102, 3104, and 3113.

7In our January 2005 report, we focused on five MTFs, which treated the
majority of seriously injured OEF/OIF servicemembers: Brooke Army Medical
Center in Texas; Walter Reed Army Medical Center in Washington, D.C.;
Madigan Army Medical Center in Washington; Eisenhower Army Medical Center
in Georgia; and Darnall Army Community Hospital in Texas. VA also has
placed staff at Evans Army Community Hospital in Colorado and Bethesda
Naval Medical Center in Maryland.

8GAO, Vocational Rehabilitation: VA Has Opportunities to Improve Services,
but Faces Significant Challenges, GAO-05-572T (Washington, D.C.: Apr. 20,
2005), and SSA Disability: Program Redesign Necessary to Encourage Return
to Work, GAO/HEHS-96-62 (Washington, D.C.: Apr. 24, 1996).

Despite efforts by VA's regional offices to identify and obtain medical
information on seriously injured OEF/OIF servicemembers, lack of
systematic data from DOD poses a challenge. Although VA requested in the
spring of 2004 that DOD provide on a systematic basis personal identifying
data, medical data, and DOD's injury classification for seriously injured
servicemembers, DOD and VA have not developed a data sharing agreement. In
the absence of a data sharing agreement with DOD, VA cannot reliably
identify all seriously injured servicemembers or know with certainty when
they are medically stabilized, when they may be undergoing evaluation for
a medical discharge, or when they are discharged from the military. As a
result, VA cannot provide reasonable assurance that some seriously injured
servicemembers who may benefit from vocational rehabilitation services
have not been overlooked.

In our review of 12 VA regional offices, we found that the nature of the
local relationship between VA staff and MTF staff was a key factor in the
completeness and reliability of the information that the MTF provided on
seriously injured servicemembers. For example, at one location, the MTF
staff provided VA regional office staff with the names of new patients but
no indication of the severity of their conditions or the combat theater
from which they were returning. Another regional office reported receiving
lists of servicemembers for whom the Army had initiated a medical
separation in addition to lists of patients with information on the
severity of their injuries. Some regional offices were able to capitalize
on long-standing informal relationships. For example, the VA coordinator
responsible for identifying and monitoring the seriously injured
servicemembers at one regional office had served as an Army nurse at the
local MTF and was provided all pertinent information.

VA staff at the 12 regional offices generally expressed confidence that
the data sources they developed enabled them to identify most seriously
injured servicemembers. However, we noted that informal data sharing
relationships could break down with changes in personnel at either the MTF
or the VA regional office. Several VA headquarters' officials and regional
office staff we interviewed said that systematic data from DOD would
provide them with a way to reliably identify and follow up with seriously
injured servicemembers. Additionally, VA officials said these data would
help them plan for projected increases in services for newly returning
OEF/OIF servicemembers.

          Unresolved Issues Continue to Delay a Data Sharing Agreement

After more than 2 years of discussion, DOD and VA have not developed a
data sharing agreement. Although DOD and VA officials agree that the HIPAA
Privacy Rule permits the exchange of individually identifiable health data
if the individual signs a proper authorization, the departments have not
pursued this as an alternative to a data sharing agreement. DOD and VA
officials said the departments want to pursue options under other
provisions of the Privacy Rule that may permit them to exchange data
without individual authorizations. However, DOD and VA differ in their
understanding of HIPAA Privacy Rule provisions that govern the sharing of
individually identifiable health data for servicemembers currently
receiving treatment in MTFs without an authorization, and the extent to
which the Privacy Rule would permit that exchange. DOD's and VA's
inability to resolve these differences has impeded coming to an agreement
on exchanging servicemembers' individually identifiable health data.

Two examples help illustrate the different views of DOD and VA regarding
the HIPAA Privacy Rule. First, the Privacy Rule permits covered entities
that are also government agencies providing public benefits to disclose
individually identifiable health data to each other when the programs
serve the same or similar populations, and the disclosure is necessary to
coordinate the covered functions of such programs or to improve
administration and management related to the covered functions of the
programs.9,10 VA officials have said they believe that this provision
allows DOD to share servicemembers' health data with VA because the
departments serve the same or similar populations-active duty
servicemembers who transition to veteran status. VA officials also said
they believe that DOD and VA provide public benefits. In contrast, a DOD
official who is responsible for implementation of the Privacy Rule does
not agree that DOD and VA serve the same or similar populations or that
DOD provides public benefits. This official said he believes that serving
the same or similar populations means that servicemembers have a dual
eligibility for both DOD and VA services. Although the official said that
while some former servicemembers are dually eligible for DOD and VA
services, not all qualify for both services simultaneously. This official
also said that the services that DOD provides are not public benefits
because they are unlike the examples of public benefits programs provided
in the preamble to the Privacy Rule.11 The Privacy Rule does not define
public benefits.

9See 45 C.F.R S: 164.512(k)(6) (2004).

10Covered functions in general are a health plan's or health care
provider's activities of providing or arranging for health care services.
See 45 C.F.R. S: 164.103 (2004).

In the second example, the Privacy Rule explicitly permits the disclosure
of individually identifiable health data by DOD to VA upon the separation
or discharge of a servicemember in order to determine eligibility for VA
benefits.12 DOD views "upon the separation or discharge" as referring to
the separation process that varies by servicemember, but which begins with
the decision by DOD that the servicemember will separate. According to VA
officials, the HIPAA Privacy Rule would allow DOD to share data sooner
than the decision by DOD that the servicemember will separate. However,
DOD is reluctant to provide individually identifiable health data to VA
until DOD is certain that a servicemember will separate from the military.
DOD is concerned that VA's outreach to servicemembers who are still on
active duty could work at cross-purposes to the military's retention
goals. According to DOD officials, it would be premature for VA to begin
working with servicemembers who may eventually return to active duty. VA
contends that DOD could define the specific point of separation or
discharge earlier in the process. In commenting on our January 2005
report, VA said that a memorandum of understanding was then being
negotiated that would allow VA to obtain from DOD the servicemember's
medical information prior to discharge from military service. VA added
that its Office of General Counsel was confident that there are exceptions
in the Privacy Rule that would permit military service medical information
to be disclosed for VA benefits purposes and that it had pressed the case
with DOD's General Counsel. As of May 17, 2005, the memorandum of
understanding between DOD and VA has not been finalized.

Despite being unable to agree on an exchange of individually identifiable
health data, DOD and VA are currently reviewing a draft memorandum of
understanding. DOD and VA officials told us they believe that the
memorandum of understanding will move the two departments closer to a data
sharing agreement. However, we found that the draft memorandum of
understanding restates many of the legal authorities contained in the
Privacy Rule for the use and disclosure of individually identifiable
health data. For example, the draft memorandum of understanding does not
specify that individually identifiable health data of OEF/OIF
servicemembers shall be disclosed and restates that data will be shared
upon separation or discharge without further defining the specific point
during the separation or discharge process when data can be shared. As a
result, even if the memorandum of understanding is finalized, DOD and VA
will still not have a data sharing agreement that specifies what types of
individually identifiable health data can be exchanged and when the data
can be shared.

11See 65 Fed. Reg. 82462, 82541-42 (2000).

12See 45 C.F.R. S: 164.512(k)(1)(ii) (2004).

Mr. Chairman, this completes my prepared remarks. I will be pleased to
answer any questions you or other Members of the Subcommittee may have at
this time.

                          Contact and Acknowledgments

For further information, please contact Cynthia A. Bascetta at (202)
512-7101. Also contributing to this statement were Mary Ann Curran, Marcia
Mann, Kevin Milne, and Janet Overton.

Related GAO Products

Vocational Rehabilitation: VA Has Opportunities to Improve Services, but
Faces Significant Challenges. GAO-05-572T. Washington, D.C.: April 20,
2005.

VA Disability Benefits and Health Care: Providing Certain Services to the
Seriously Injured Poses Challenges. GAO-05-444T. Washington, D.C.: March
17, 2005.

Vocational Rehabilitation: More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers. GAO-05-167.
Washington, D.C.: January 14, 2005.

Health Information: First-Year Experiences under the Federal Privacy Rule.
GAO-04-965. Washington, D.C.: September 3, 2004.

(290458)

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www.gao.gov/cgi-bin/getrpt?GAO-05-722T.

To view the full product, including the scope

and methodology, click on the link above.

For more information, contact Cynthia A. Bascetta at (202) 512-7101.

Highlights of GAO-05-722T, a testimony before the Subcommittee on
Oversight and Investigations, Committee on Veterans' Affairs, House of
Representatives

May 19, 2005

DOD AND VA

Systematic Data Sharing Would Help Expedite Servicemembers' Transition to
VA Services

Since the onset of Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF), the Department of Defense (DOD) reported that more than
12,000 servicemembers have been injured in combat. While many return to
active duty, others with more serious injuries are likely to be discharged
from the military. To ensure the continuity of medical care and access to
all other Department of Veterans Affairs' (VA) benefits, such as
vocational rehabilitation, VA formed its Seamless Transition Task Force.

In January 2005, GAO reported that VA had given high priority to OEF/OIF
servicemembers, but faced challenges in identifying, locating, and
following up with seriously injured servicemembers. GAO recommended that
VA and DOD reach an agreement for VA to obtain systematic data from DOD,
and the departments concurred. However, DOD raised privacy concerns.

GAO was asked to review VA's efforts to expedite vocational rehabilitation
services to seriously injured servicemembers and to determine the status
of an agreement between DOD and VA to share health data. GAO relied on its
prior work; interviewed VA and DOD officials; and reviewed the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA
Privacy Rule, which govern the sharing of individually identifiable health
data.

While VA has taken steps to expedite services to seriously injured
servicemembers, VA does not have systematic data from DOD on seriously
injured servicemembers who may need VA vocational rehabilitation and other
benefits. As a result, VA has had to rely on its regional offices to
develop informal data sharing arrangements with local military treatment
facility (MTF) staff to identify servicemembers who may need vocational
rehabilitation services. However, VA staff have no official data source
from DOD from which to confirm the completeness and reliability of the
data they obtain. Furthermore, they cannot provide reasonable assurance
that some seriously injured servicemembers who may have benefited from
vocational rehabilitation services have not been overlooked. Although
several VA headquarters officials and regional office staff GAO
interviewed said that systematic data from DOD would provide them with a
way to reliably identify and follow up with seriously injured
servicemembers, DOD and VA have not developed a data sharing agreement.
Additionally, VA officials said these data would help VA plan for
projected increases in the need for services for newly returning OEF/OIF
servicemembers. VA has requested that DOD provide systematic data on
seriously injured servicemembers who may need vocational rehabilitation.

DOD and VA have been working on a data sharing agreement for over 2 years,
but have not reached an agreement. DOD and VA differ in their
understanding of HIPAA Privacy Rule provisions that govern the sharing of
individually identifiable health data for servicemembers currently
receiving treatment at MTFs, and the extent to which the Privacy Rule
would permit that exchange. DOD's and VA's inability to resolve these
differences has impeded coming to an agreement on exchanging seriously
injured servicemembers' individually identifiable health data. Despite
being unable to agree on an exchange of individually identifiable health
data, DOD and VA are reviewing a draft memorandum of understanding, which
the departments believe will move them closer to a data sharing agreement.
However, GAO found that the draft memorandum restates many of the legal
authorities contained in the Privacy Rule for the use and disclosure of
individually identifiable health data. As a result, even if the memorandum
of understanding is finalized, DOD and VA will still have to agree on what
types of individually identifiable health data can be exchanged and when
the data can be shared. DOD and VA generally agreed with GAO's findings.
*** End of document. ***