VA and DOD Health Care: Efforts to Provide Seamless Transition of
Care for OEF and OIF Servicemembers and Veterans (30-JUN-06,
GAO-06-794R).
As of the end of March 2006, over 1.3 million U.S. military
servicemembers had served or were serving in Operation Enduring
Freedom (OEF) or Operation Iraqi Freedom (OIF). These
servicemembers, including members of the reserves and National
Guard, may be eligible to receive health care from the Department
of Veterans Affairs (VA) while serving on active duty or upon
separating from active duty. Although the Department of Defense
(DOD) provides health care services to servicemembers under
TRICARE, legislation passed by the Congress in May 1982
authorized VA to provide health care services to servicemembers
in time of war or national emergency, when DOD may have
insufficient resources to care for casualties. Through December
16, 2005, DOD had arranged for 193 active duty servicemembers
with serious injuries--traumatic brain injuries and other complex
trauma, such as missing limbs--to receive medical and
rehabilitative care at VA polytrauma rehabilitation centers
(PRC). In addition, about 30 percent (over 144,000) of the
servicemembers who had separated from active duty following
service in OEF or OIF have sought VA health care, including over
4,000 who received inpatient care at VA medical facilities. In
September 2005, we testified on VA's collaboration with DOD to
provide seamless transition of care for servicemembers between
DOD and VA health care systems--that is, no interruption of care
as the person moves from being a DOD patient to being a VA
patient. We reported that VA has developed policies and
procedures that direct its medical facilities to provide OEF and
OIF servicemembers with timely access to care but that the
sharing of health information between DOD and VA was limited.
Congress asked us to update the information we provided in our
testimony by reviewing the efforts VA is making to inform
servicemembers and veterans about VA health care services and to
help ensure that there is a seamless transition of care for
servicemembers from DOD's to VA's health care system. We
addressed the following questions: (1) What outreach efforts has
VA made to inform OEF and OIF servicemembers and veterans about
the VA health care services that may be available to them? (2)
What actions has VA taken to facilitate the seamless transition
of medical and rehabilitation care for seriously injured OEF and
OIF servicemembers who are transferred between DOD medical
treatment facilities (MTF) and PRCs? (3) What special educational
activities or clinical tools is VA using to help ensure its
medical providers are aware of and recognize the needs of
eligible OEF and OIF servicemembers and veterans?
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-06-794R
ACCNO: A56237
TITLE: VA and DOD Health Care: Efforts to Provide Seamless
Transition of Care for OEF and OIF Servicemembers and Veterans
DATE: 06/30/2006
SUBJECT: Electronic data interchange
Electronic health records
Employee training
Government information dissemination
Health care facilities
Health care personnel
Health care planning
Health care services
Interagency relations
Medical information systems
Medical records
Military personnel
Information management
DOD Operation Iraqi Freedom
Operation Enduring Freedom
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GAO-06-794R
* VA Activities Facilitate the Transition of Care for Seriousl
* Agency Comments and Our Evaluation
* PDF6-Ordering Information.pdf
* Order by Mail or Phone
June 30, 2006
The Honorable Michael Bilirakis
Chairman
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives
Subject: VA and DOD Health Care: Efforts to Provide Seamless Transition of
Care for OEF and OIF Servicemembers and Veterans
Dear Mr. Chairman:
As of the end of March 2006, over 1.3 million1 U.S. military
servicemembers had served or were serving in Operation Enduring Freedom
(OEF) or Operation Iraqi Freedom (OIF).2 These servicemembers, including
members of the reserves and National Guard, may be eligible to receive
health care from the Department of Veterans Affairs (VA) while serving on
active duty or upon separating from active duty. Although the Department
of Defense (DOD) provides health care services to servicemembers under
TRICARE,3 legislation passed by the Congress in May 1982 authorized VA to
provide health care services to servicemembers in time of war or national
emergency, when DOD may have insufficient resources to care for
casualties.4 Through December 16, 2005, DOD had arranged for 193 active
duty servicemembers with serious injuries-traumatic brain injuries and
other complex trauma, such as missing limbs-to receive medical and
rehabilitative5 care at VA
1DOD's Contingency Tracking System Deployment File for Operations Enduring
Freedom and Iraqi Freedom reported that as of March 31, 2006, the total
number of servicemembers ever deployed was 1,312,221.
2 OEF, which began in October 2001, supports combat operations in
Afghanistan and other locations, and OIF, which began in March 2003,
supports combat operations in Iraq and other locations.
3DOD provides health care through TRICARE-a regionally structured program
that uses civilian contractors to maintain provider networks to complement
health care services provided at military treatment facilities.
4The Veterans' Administration and Department of Defense Health Resources
Sharing and Emergency Operations Act, Pub. L. No. 97-174, S: 4(a), 96
Stat. 70, 74-75.
5Most servicemembers receive medical care from DOD providers. However, DOD
does not typically provide long-term rehabilitative services and looks to
VA to be a provider of these services.
polytrauma rehabilitation centers (PRC).6 In addition, about 30 percent
(over 144,000) of the servicemembers who had separated from active duty
following service in OEF or OIF have sought VA health care, including over
4,000 who received inpatient care at VA medical facilities.
In September 2005, we testified on VA's collaboration with DOD to provide
seamless transition of care for servicemembers between DOD and VA health
care systems-that is, no interruption of care as the person moves from
being a DOD patient to being a VA patient.7 We reported that VA has
developed policies and procedures that direct its medical facilities to
provide OEF and OIF servicemembers with timely access to care but that the
sharing of health information between DOD and VA was limited. You asked us
to update the information we provided in our testimony by reviewing the
efforts VA is making to inform servicemembers and veterans about VA health
care services and to help ensure that there is a seamless transition of
care for servicemembers from DOD's to VA's health care system. We
addressed the following questions:
1. What outreach efforts has VA made to inform OEF and OIF
servicemembers and veterans about the VA health care services that
may be available to them?
2. What actions has VA taken to facilitate the seamless transition
of medical and rehabilitation care for seriously injured OEF and
OIF servicemembers who are transferred between DOD medical
treatment facilities (MTF) and PRCs?
3. What special educational activities or clinical tools is VA
using to help ensure its medical providers are aware of and
recognize the needs of eligible OEF and OIF servicemembers and
veterans?
To determine outreach efforts VA has made to inform OEF and OIF
servicemembers and veterans about the VA health care services that may be
available to them, we interviewed, and collected supporting documentation
from, VA officials on their efforts and programs that have been
established to inform servicemembers and veterans about VA health care
services. We also observed briefings given by VA representatives at two
military installations8 to active duty and reserve servicemembers about VA
health care services for which they may be eligible.
6The Veterans Health Programs Improvement Act of 2004, Pub. L. No.
108-422, S: 302, 118 Stat. 2379, 2383-86, mandated that VA establish
centers for research, education, and clinical activities related to
complex multiple trauma associated with combat injuries. In response to
that mandate, VA established PRCs at four VA medical facilities with
expertise in traumatic amputation, spinal cord injury, traumatic brain
injury, and blind rehabilitation. The PRCs address the rehabilitation
needs of the combat injured in one setting and in a coordinated manner.
7GAO, VA and DOD Health Care: VA Has Policies and Outreach Efforts to
Smooth Transition from DOD Health Care, but Sharing of Health Information
Remains Limited, GAO-05-1052T (Washington, D.C.: Sept. 28, 2005). Also see
Related GAO Products at the end of this report.
8VA provides briefings at hundreds of MTFs. We attended briefings at two
judgmentally selected installations-the Naval Station Norfolk, Norfolk,
Virginia, and Fort Benning Army Base, Columbus, Georgia.
To identify actions VA has taken to facilitate the seamless transition of
care between MTFs and PRCs for servicemembers seriously injured in OEF and
OIF, we reviewed VA directives, policies, and handbooks governing access
to VA health care by OEF and OIF servicemembers and veterans. We also
visited the two MTFs that treat most of the seriously injured OEF and OIF
servicemembers-Walter Reed Army Medical Center and the National Naval
Medical Center, both located in the Washington, D.C., area-and the four
PRCs that treat them. The PRCs are located at VA Medical Centers in Palo
Alto, California; Tampa, Florida; Minneapolis, Minnesota; and Richmond,
Virginia. During those visits, we interviewed medical providers and
reviewed the VA electronic medical records of the 193 seriously injured
servicemembers who were admitted to the PRCs from January 7, 2002,9
through December 16, 2005. In addition, we attended a discharge planning
conference for an OIF servicemember being discharged from a PRC to
document the information provided to the servicemember about his follow-up
health care from VA and DOD. We made subsequent visits to the Richmond and
Tampa PRCs to observe the capability of PRC providers to access DOD
electronic medical records.
To identify the special educational activities or clinical tools that VA
is using to help ensure its medical providers are aware of and recognize
the needs of eligible OEF and OIF servicemembers and veterans, we
interviewed, and collected supporting documentation from, VA officials.
While we were at the Naval Station Norfolk conducting audit work, we also
visited the VA Medical Center in Hampton, Virginia, to obtain information
on the educational activities and clinical tools VA uses when treating OEF
and OIF servicemembers and veterans. We also obtained this information
from the four PRCs. Further, we determined the number of VA medical
providers and other staff who completed online educational courses
developed by VA.
Our review was conducted from May 2005 through June 2006 in accordance
with generally accepted government auditing standards.
Results in Brief
VA has made a variety of outreach efforts to provide OEF and OIF
servicemembers and veterans and their families with information on VA
health care services. VA reported that from October 1, 2000, through May
31, 2006, it provided about 36,000 briefings to almost 1.4 million active
duty, reserve, and National Guard servicemembers about VA health care
services that may be available to them. In some cases, family members also
attended these briefings, which were provided at over 200 sites, including
70 sites outside the United States. VA also maintains a Web site
containing health information focused on OEF and OIF servicemembers and
veterans, distributes brochures and pamphlets to provide information about
topics of interest to OEF and OIF servicemembers and veterans and their
families, and sends letters and newsletters to veterans about VA health
care services and health issues specific to veterans.
9Although OEF began in October 2001, the earliest recorded date that a
servicemember injured in OEF was admitted to a PRC for treatment was
January 7, 2002.
VA has taken several actions to facilitate the transition of medical and
rehabilitative care for seriously injured servicemembers who are being
transferred from MTFs to PRCs. In April 2003, the Secretary of VA
authorized VA medical facilities to give priority to OEF and OIF
servicemembers over veterans, except those with service-connected
disabilities. In April 2004, VA signed a memorandum of agreement (MOA)
with DOD that established the referral procedures for transferring injured
servicemembers from DOD to VA medical facilities. VA and DOD also
established joint programs to ease the transfer of injured servicemembers
to VA medical facilities, including a program that assigned VA social
workers to selected MTFs to coordinate patient transfers to VA medical
facilities. Nevertheless, problems remain in the process for
electronically sharing the medical records VA needs to determine whether
servicemembers are medically stable enough to participate in vigorous
rehabilitation activities. According to VA officials, the transfer could
be more efficient if PRC medical personnel had real-time access to the
servicemembers' complete DOD electronic medical records from the referring
MTFs. VA and DOD reported that as of December 2005 only two of the PRCs
had requested and been granted real-time access to the electronic medical
records maintained at Walter Reed Army Medical Center. One of these PRCs
had also been granted access to the electronic medical records at the
National Naval Medical Center. However, problems continue to exist with
the PRCs' ability to access DOD electronic medical records. During a visit
to the two PRCs in April 2006, we found that neither facility could access
the DOD electronic medical records at Walter Reed Army Medical Center
because of technical difficulties. Furthermore, while VA's electronic
medical record system captures a wide range of patient information, we
found that at the time we conducted our audit work it did not always
contain a complete record of information related to the patient's
discharge from the PRC, such as dates and times of follow-up medical
appointments-information that could be useful for maintaining continuity
of care or responding to a patient inquiry about future appointments. In
response to our concerns about this problem, VA has taken corrective
action. The department has developed a template that identifies the
information given to servicemembers at discharge from PRCs. The template
has been included in VA's electronic medical record for use systemwide.
VA has developed a number of educational activities and online clinical
tools to help ensure that VA medical providers and other staff are aware
of and recognize the health care needs of OEF and OIF servicemembers and
veterans. Examples of VA's educational efforts include developing online
courses on infectious diseases of Southwest Asia; holding conferences on
brain injuries; conducting conference calls, each of which provided more
than 100 VA staff with information on transferring servicemembers from DOD
to VA health care services; and developing publications on the long-term
effects of using an antimalarial drug. VA has also provided educational
activities at two East Coast centers targeting medical professionals (such
as physicians, nurses, and social workers), including conferences on
topics such as physical and mental health issues, infectious disease
issues, and health care services provided by VA. Furthermore, VA has
developed clinical tools to help its staff be aware of and responsive to
the needs of OEF and OIF servicemembers and veterans. For example, it has
added reminder screens to its electronic medical records that pop up when
staff are accessing patients' records and prompt them to ask questions
about OEF- and OIF-related medical and psychological conditions, such as
infectious diseases and depression. VA and DOD have also developed
guidelines to assist clinicians in providing medical care to OEF and OIF
veterans.
We provided a draft of this report to VA and DOD for comment. VA concurred
with the information presented in our draft report. DOD commented that the
report portrays the numerous efforts that have been made to improve the
efficacy of programs designed to ensure a smooth transition and continuity
of care as servicemembers transition back and forth between DOD and VA
health care systems. DOD also stated that the report contained several
inaccuracies; however, we maintain that the information contained in the
report accurately presents the results of our audit work.
Background
DOD has reported that as of June 26, 2006, over 19,000 servicemembers have
been wounded in action since the onset of OEF and OIF. Some of these
servicemembers are surviving injuries that would have been fatal in past
conflicts. In World War II, about 30 percent of American servicemembers
wounded in combat died. Because of medical advances, this proportion has
dropped to 3 percent for OEF and OIF servicemembers, but many of them are
returning home with severe disabilities, including traumatic brain
injuries and missing limbs. In 2005, DOD reported that about 65 percent of
the OEF and OIF servicemembers wounded in action were injured by blasts
and fragments from improvised explosive devices, land mines, and other
explosive devices. More recently, DOD estimated in 2006 that the
percentage of those injured by blasts and fragments who have some degree
of trauma to the brain ranged from less than 20 percent to 28 percent.
These injuries may require comprehensive inpatient rehabilitation services
to address complex cognitive, physical, and mental health impairments.10
While servicemembers are on active duty, DOD manages where they receive
their care-at an MTF, a TRICARE civilian provider, or a VA medical
facility. Once discharged from the military or demobilized from the
reserves or National Guard, veterans may be eligible to receive care from
VA's health care system.
From the OEF and OIF conflict areas, seriously injured servicemembers are
usually brought to Landstuhl Regional Medical Center in Germany for
treatment. From there, they are usually transported to MTFs located in the
United States, with most of the seriously injured admitted to Walter Reed
Army Medical Center or the National Naval Medical Center. Once seriously
injured servicemembers are medically stabilized, DOD can elect to send
those with traumatic brain injuries and other complex trauma, such as
missing limbs, to one of the four PRCs for rehabilitative services.
10Traumatic brain injuries may cause problems with cognition
(concentration, memory, judgment, and mood), movement (strength,
coordination, and balance), sensation (tactile sensation and vision), and
emotion (instability and impulsivity).
The transfer of injured servicemembers from MTFs to VA medical facilities
for medical care requires the exchange of health information between DOD
and VA. In August 1998, the President issued a directive requiring VA and
DOD to develop a computer-based patient record system that would
accurately and efficiently exchange information between the departments.
The directive stated that VA and DOD should define, acquire, and implement
a fully integrated computer-based patient record available across the
entire spectrum of health care delivery over the lifetime of the
patient.11
Since receiving the President's directive, VA and DOD have been working to
exchange patient health information electronically and ultimately to have
interoperable electronic medical records. VA and DOD have begun to
implement applications that exchange limited electronic medical
information between the departments' existing health information systems.
One of these applications-the Bidirectional Health Information Exchange-is
a project to achieve the two-way exchange of health information on
patients who receive care from both VA and DOD. The application has been
implemented at all VA sites and at 14 DOD sites to exchange information
such as pharmacy and allergy data, but as we testified in September 2005,
the goal of systemwide two-way electronic exchange of patient records
remains far from being realized.12 As a separate effort, VA and DOD have
undertaken an initiative to allow the four PRCs to electronically access
medical records at Walter Reed Army Medical Center and the National Naval
Medical Center to obtain information on seriously injured OEF and OIF
servicemembers. The capability for electronic access was requested by the
Richmond and Tampa PRCs in 2005 and by the Palo Alto and Minneapolis PRCs
in 2006. This capability will be limited to a small number of providers at
each of the PRCs.
Apart from joint efforts to share medical information, VA and DOD
separately have developed electronic systems for recording and accessing
patient health information. VA's electronic medical records are maintained
in a system that captures a wide range of patient information, including
doctors' progress notes, vital signs, laboratory results, medications
dispensed, drug allergies, radiological images, and clinical reminders.
VA's system also allows the patient's complete medical record to be
accessed from any VA medical facility. While DOD's electronic medical
record system also captures information such as doctors' progress notes,
vital signs, medications dispensed, and laboratory results, it does not
include radiological images, vision and hearing tests, or anesthesia
notes. In addition, DOD does not have a systemwide approach to electronic
medical record management since the information is maintained and stored
at individual MTFs or, in some locations, in networks that service
multiple MTFs within a small geographic area. Under DOD's approach, all
medical information cannot be electronically accessed by providers
throughout DOD's health care system. For example, providers at Walter Reed
Army Medical Center and the National Naval Medical Center can access each
other's electronic medical records but cannot access medical records from
Landstuhl Regional Medical Center in Germany.
11National Science and Technology Council, A National Obligation: Planning
for Health Preparedness for and Readjustment of the Military, Veterans,
and Their Families After Future Deployments, Presidential Review Directive
5 (Washington, D.C.: Executive Office of the President, Office of Science
and Technology Policy, August 1998).
12GAO, Computer-Based Patient Records: VA and DOD Made Progress, but Much
Work Remains to Fully Share Medical Information, GAO-05-1051T (Washington,
D.C.: Sept. 28, 2005).
VA's Outreach Includes Briefings, Web Sites, and Newsletters
VA has taken a number of actions to provide OEF and OIF servicemembers and
their families with information about VA health care services, such as the
cost of the services, how to register for VA health care, and where to
obtain VA health care. VA reported that from October 1, 2000, through May
31, 2006, it held about 36,000 briefings for almost 1.4 million active
duty, reserve, and National Guard servicemembers. These briefings were
held at over 200 sites, including 70 sites located outside the United
States. VA reported that over 8,000 family members attended some of these
briefings from October 1, 2005, through May 31, 2006. In addition, under a
May 2005 MOA between VA and the National Guard, VA has trained staff hired
by the National Guard to provide VA health and benefit information to
National Guard units in each state.
For both servicemembers and veterans, VA has also created a Web site13
that provides information for those who served in OEF and OIF, such as
information on VA health and medical services, dependents' benefits and
services, and transition assistance from military to civilian life. The
Web site contains information about VA benefits available to active duty
military personnel, including a page that briefly describes these
benefits. VA has also developed a variety of informational materials,
including a wallet-sized card with relevant toll-free telephone numbers
and Web site addresses, fact sheets and pamphlets summarizing VA benefits,
and a monthly video magazine called The American Veteran. VA reported that
almost 1.4 million of the wallet-sized cards have been distributed during
briefings. Fact sheets and pamphlets are sent to VA medical facilities for
distribution to veterans and are also available on VA's Web site. The
video magazine reports information about VA services on a VA Web site14
and on the Pentagon Channel, which is available online15 and on cable
television.
VA also has outreach efforts designed specifically for active duty,
reserve, and National Guard OEF and OIF veterans. The Secretary of VA
sends new veterans a letter thanking them for their service to the country
and informing them about VA health care services and assistance in their
transition to civilian life. As of May 15, 2006, the Secretary had sent
letters to over 530,000 OEF and OIF servicemembers who had left active
duty. These letters include information about the VA health care services
available to veterans and a toll-free number for obtaining additional
health care information. In addition, from December 2003 through March
2006 VA sent four newsletters to OEF and OIF veterans with information on
health issues of interest to these veterans.
13See http://www.seamlesstransition.va.gov .
14See http://www1.va.gov/opa/feature/amervet/index.htm .
15See http://www.pentagonchannel.mil .
VA Activities Facilitate the Transition of Care for Seriously Injured OEF and
OIF Servicemembers Transferred to PRCs
VA has taken a number of actions to facilitate the transition of medical
and rehabilitation care for servicemembers who have been seriously injured
in OEF and OIF and are being transferred between DOD and VA medical
facilities. These actions focus on establishing and expanding internal
initiatives for providing care to this population as well as VA's efforts
to electronically share medical records with DOD.
In April 2003, when the President declared a national emergency with
respect to the Iraq conflict, the Secretary of VA issued a memorandum
authorizing VA medical facilities to give priority to servicemembers who
sustained injuries in OEF and OIF over veterans and others eligible for VA
health care, except those with service-connected disabilities. In October
2003, VA issued a directive requiring its medical facilities to designate
a point of contact to receive and expedite transfers of servicemembers
from DOD to VA medical facilities. In April 2004, VA signed an MOA with
DOD to provide health care and rehabilitation services to servicemembers
who sustain spinal cord injury, traumatic brain injury, or visual
impairment. The MOA established the referral procedures for transferring
active duty inpatient servicemembers from DOD to VA medical facilities.16
In June 2005, VA issued a directive expanding the scope of care it would
provide to include psychological treatment for family members and
intensive clinical and social work case management services17 at its four
regional traumatic brain injury rehabilitation centers and renamed these
facilities PRCs.
VA has also established joint programs with DOD to ease the transfer of
injured servicemembers to VA medical facilities. In August 2003, VA and
DOD established a program that assigned VA social workers to selected
MTFs18 to coordinate patient transfers between DOD and VA medical
facilities. The social workers make appointments for care, ensure
continuity of therapy and medications, and follow up with patients after
discharge. By late February 2006, VA reported that the social workers had
received requests for transfer of care for over 6,000 patients, and over
three-fourths of them had been transferred to VA facilities; the rest of
the requests were pending.19 Under another program, a uniformed
servicemember was stationed at each PRC beginning in March 2005 to assist
servicemembers being admitted to the PRC. The uniformed servicemembers
serve as liaisons among injured servicemembers and their families, the
MTFs, the PRCs, and the servicemembers' units. For example, they assist
with reimbursement for travel and lodging costs for immediate family
members.
16In addition to outlining DOD's and VA's responsibilities in the transfer
process, the MOA also established the reimbursement rate between the two
departments for inpatient care that VA would provide.
17Case management includes assessment of the individual's health care
needs, care planning and implementation, referral coordination,
monitoring, and periodic reassessment of the individual's health care
needs.
18Five MTFs were originally selected because they received most of the OEF
and OIF casualties. These facilities were Walter Reed Army Medical Center
(Washington, D.C.), Brooke Army Medical Center (San Antonio, Texas),
Dwight David Eisenhower Army Medical Center (Augusta, Georgia), Madigan
Army Medical Center (Tacoma, Washington), and the National Naval Medical
Center (Bethesda, Maryland). In 2004 and 2005, three additional
MTFs-Darnall Army Community Hospital (Fort Hood, Texas), Evans Army
Community Hospital (Fort Carson, Colorado), and the Naval Hospital Camp
Pendleton (Camp Pendleton, California)-were added to care for returning
OEF and OIF servicemembers.
In January 2005, VA established the Seamless Transition Office to enhance
servicemembers' transition back to civilian life by improving coordination
within the Veterans Benefits Administration and the Veterans Health
Administration,20 as well as between DOD and VA. The goals of the Seamless
Transition Office related to health care include improving communication,
coordination, and collaboration within VA and with DOD concerning health
care, educating VA staff about OEF and OIF veterans' health care, and
other needs. The office has been active in areas such as coordinating
efforts of the VA social workers assigned to MTFs to help servicemembers
transfer their health care from MTFs to VA health care facilities and
issuing a handbook on the policy and procedures for PRCs, including
recommended staffing levels for the different types of medical providers
caring for patients.
There are also a number of routinely scheduled teleconferences and
videoconferences within VA and between VA and the military medical
facilities to coordinate medical care for injured servicemembers and to
discuss and resolve medical issues. Topics include issues that are general
in nature and would apply to a number of servicemembers or that are
specific to individual servicemembers. For example, monthly, and as
needed, VA's Seamless Transition Office and PRC staff hold teleconferences
to discuss such issues as obtaining DOD medical records and how to provide
follow-up medical care once the servicemember is discharged from the PRC.
Further, on a bimonthly basis, PRCs hold teleconferences or
videoconferences with Walter Reed Army Medical Center and the National
Naval Medical Center to discuss issues arising during the transfer of
injured servicemembers from their facilities to the PRCs, such as
obtaining military medical records. Servicemembers and their families
sometimes participate in the videoconference to meet PRC staff prior to
transfer. Also on a monthly basis, VA and DOD hold videoconferences to
discuss medical and logistical issues that arise with injured
servicemembers. These videoconferences include DOD medical providers from
Landstuhl Regional Medical Center in Germany and combat medical units
located in Iraq. For example, during one videoconference, VA and DOD staff
discussed the blood filters21 that were being
19According to VA, patients remain in pending status until DOD determines
that the patient is ready for transfer to a VA facility and VA determines
the patient's medical condition is stable.
20The Veterans Benefits Administration provides benefits and services,
such as disability compensation, to veterans. The Veterans Health
Administration's primary responsibility is the delivery of health care to
veterans.
21Blood filters are filters that screen blood to remove clots that could
result in death.
surgically implanted in injured servicemembers in Iraq.22 Medical
providers in Baghdad asked if there was a different type of blood filter
that they could use that would make removal easier at the stateside MTF or
PRC.
Despite coordination, we found that the departments are having problems
exchanging health care information electronically between the four PRCs
and the two MTFs-Walter Reed Army Medical Center and the National Naval
Medical Center. While our current review focused on the electronic
transfer of information among these six facilities, over 5 years ago we
recommended that VA and DOD create comprehensive and coordinated plans to
ensure that the departments can share comprehensive, meaningful, accurate,
and secure patient health data.23 Both VA and DOD concurred with this
recommendation and are in the process of implementing it. From a
systemwide perspective, we testified over 2 years ago and again last
September on the need for VA and DOD to intensify their efforts to
implement the capability to share health care information electronically.
In those testimonies, we recognized the actions VA and DOD had taken to
electronically exchange health information but also acknowledged that much
work remains to attain this goal.24
During our visits to the PRCs from October through December 2005, we
observed that none of the PRCs had real-time access to the injured
servicemembers' DOD electronic medical records from the transferring MTFs.
Instead, the MTF faxed copies of some of the medical information, such as
the servicemember's medical history and physical and doctor's progress
notes from these records, to the PRC. Because this information did not
always provide enough data for the PRC provider to determine if the
servicemember was medically stable enough to be admitted to the PRC and to
engage in vigorous rehabilitation activities and because the PRC did not
have access to the complete medical records (paper or electronic), VA
developed a standardized list of the minimum types of health care
information needed about each servicemember transferring from an MTF.
However, after they reviewed this basic medical information PRC providers
stated that they frequently needed additional information and had to ask
the PRC social worker to obtain it from the VA social worker at the MTF.
For example, if the PRC provider noticed that the servicemember was on a
particular antibiotic therapy, the provider might request the results of
the most recent blood and urine cultures to determine if the servicemember
was medically stable enough to participate in strenuous rehabilitation
activities.
22VA officials in attendance included staff from the PRCs and the Seamless
Transition Office. DOD officials in attendance included staff from Walter
Reed Army Medical Center; the National Naval Medical Center; Brooke Army
Medical Center; Wilford Hall Medical Center; Army Institute for Surgical
Research; Landstuhl Regional Medical Center in Germany; and combat medical
units located in Balad and Baghdad, Iraq.
23GAO, 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).
24GAO, 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); 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); and GAO-05-1051T.
According to PRC officials, obtaining additional medical information in
this way rather than electronically was very time consuming and often
required multiple phone calls and faxes between the facilities.
According to VA officials, the main barrier to PRC medical providers'
getting real-time access to medical records was DOD's interpretation of
the Health Insurance Portability and Accountability Act of 1996 (HIPAA)25
and the HIPAA Privacy Rule.26 The HIPAA Privacy Rule permits VA and DOD to
share servicemembers' health information under certain circumstances, such
as for purposes of treatment or if the individual signs a proper
authorization. However, DOD officials told us they initially were
reluctant to provide this access to VA because they were concerned that VA
would have access to health information of all servicemembers, not only
the information of those being transferred to the PRC for treatment.
Since we initiated our review, the four PRCs and Walter Reed Army Medical
Center and the National Naval Medical Center have reached separate
agreements on the records VA would be able to access and have begun to
take action to share medical records.27 During our initial visits, two
PRCs-Richmond and Tampa-were in the process of separately negotiating with
Walter Reed Army Medical Center to obtain real-time access to injured
servicemembers' electronic medical records. VA reported that as of
December 27, 2005, PRC providers in Richmond and Tampa have real-time
access to these records. The Tampa PRC also gained access to the National
Naval Medical Center's electronic medical records on February 21, 2006. VA
and DOD officials have not established a date when all PRCs would have
real-time access to electronic records at Walter Reed Army Medical Center
and the National Naval Medical Center.
In April 2006, we revisited the Tampa and Richmond PRCs and found that
problems continued with access to DOD electronic medical records.
Providers at both PRCs that had been granted electronic access by DOD to
obtain medical information stated that they could not always access the
DOD electronic records. For example, during our visits neither facility
could access the DOD electronic medical records at Walter Reed Army
Medical Center because of a technical problem. Furthermore, while a nurse
practitioner at the Tampa PRC was able to access the electronic medical
records at the National Naval Medical Center, the admitting PRC provider
for rehabilitative services could not.
25Pub. L. No. 104-191, 110 Stat. 1936 (1996).
26The Privacy Rule, which became effective on April 14, 2001, specifies
how individually identifiable health information may be used and disclosed
by covered entities, which include health plans, health care
clearinghouses, and certain health care providers. See 45 C.F.R. S:S:
164.500(a), 164.502 (2005). Both TRICARE and the VA health care system are
health plans. See 45 C.F.R. S: 160.103 (2005).
27This initiative is a unique undertaking by the four PRCs, Walter Reed
Army Medical Center, and the National Naval Medical Center. It is distinct
from VA's and DOD's Bidirectional Health Information Exchange.
While VA's electronic medical records offer ready access to VA medical
information for its medical providers, we found that during our site
visits some information related to servicemembers' and veterans' discharge
from PRCs was not always entered into the records. When servicemembers and
veterans are discharged from PRCs, many still require follow-up medical
care at VA, DOD, or private-sector facilities. The social worker at the
PRC is responsible for arranging follow-up appointments prior to the
patient's discharge from the PRC. Information on follow-up appointments
and points of contact is provided to the servicemember or veteran during
the discharge planning conference, along with a large amount of other
medical information and discharge instructions. Our review of 193
servicemembers' VA electronic medical records showed that 126 patients
required follow-up medical appointments after discharge from the PRC.28 An
examination of the 126 records indicated that appointments were made for
122 of the patients, with the remaining 4 patients instructed to call
their local VA medical centers for appointments. However, while the date
and time for the appointment was in the electronic medical record, it was
not clearly summarized in 96 of 122 of these records, nor was there
evidence that it was given to the patient. In addition, 75 of the 122
records did not clearly indicate the points of contact, nor was there
evidence that this information was given to the patient. If this
information were clearly documented in patients' electronic medical
records, it would be available to VA providers who may need it to manage
future care.
In February 2006, in response to questions we raised during our review, VA
developed a template for PRC social workers to complete when a patient is
discharged. The social worker includes on the template information on
follow-up medical appointments, contact names and telephone numbers for
the medical facilities where the servicemember is going to obtain
follow-up medical care, military contacts, and PRC contacts. This template
is entered into the electronic medical record. During our visit to the
Tampa and Richmond PRCs in April 2006, we found that the social workers
had been using the templates for patients discharged since mid-March 2006.
VA Is Using Courses, Conferences, and Online Clinical Tools to Help Ensure
Medical Providers Are Aware of and Recognize Needs of Eligible OEF and OIF
Servicemembers and Veterans
VA has developed activities to educate its medical providers and other
staff on the health care needs of those who are or have been deployed in
OEF and OIF. As part of its Veterans Health Initiatives, VA produced 14
educational courses that address OEF- and OIF-related topics, such as
traumatic brain injuries and infectious diseases of Southwest Asia. These
courses are available on VA's intranet, over the Internet, and on compact
discs. As of December 31, 2005, VA reported that nearly 2,000 courses had
been completed by VA staff, including nearly 1,200 courses that were
completed by physicians. Also over 12,000 courses were completed by non-VA
staff, such as veterans, family members, and staff from veterans service
organizations.
28The remaining 67 patients did not need follow-up outpatient appointments
because they were still patients in the PRC; had been transferred to
another inpatient facility, such as an MTF or VA long-term care facility;
or did not need follow-up medical care.
VA medical centers have also used conferences and in-house presentations
to train staff on the needs of OEF and OIF servicemembers and veterans.
For example, the Tampa PRC sponsored blast injury conferences in 2004 and
2005 that were attended by physicians, nurses, psychologists, and social
workers. In addition, from April 2005 through April 2006, VA held five 1
1/2-hour conference calls for VA social workers that focused on the
transfer of care for servicemembers from DOD to VA medical facilities,
including information such as ways to be proactive in working with
military families as they transition from active duty to veteran status
and recognizing the signs and symptoms of stress and post-traumatic stress
disorder in returning OEF and OIF veterans. VA reported that attendance
for the conference calls ranged from 105 to 360 social workers.
VA's educational efforts have also included publications. VA's Under
Secretary for Health has issued five informational letters to VA's medical
providers offering guidance on OEF- and OIF-related topics. The topics of
these letters include the long-term effects of heat-related illnesses and
the long-term effects of using an antimalarial drug. In addition, VA's
War-Related Illness and Injury Study Centers have produced publications
providing information for combat veterans and providers on topics such as
management of chronic pain and the effects of exposure to depleted
uranium.29
VA's War-Related Illness and Injury Study Centers have also provided
educational activities and clinical tools to help medical professionals
treat OEF and OIF servicemembers and veterans. In 2004 and 2005 the
centers reported that they held three conferences, with a total attendance
of more that 450 health care providers, including physicians, nurses, and
social workers, that addressed such topics as physical and mental health
issues, infectious disease issues, and health care services provided by
VA. They also held six workshops from 2003 through 2005 on topics such as
patient-provider communication and the recognition and treatment of
undiagnosed illnesses, and established Web sites that provide links to
their publications and to other sources of education for medical
providers.
VA has also developed various clinical tools to enhance the ability of its
providers and other staff to be aware of and responsive to the needs of
OEF and OIF servicemembers and veterans. For example, VA has added
reminder screens to its electronic medical records that pop up when a
patient's record is opened if the veteran served in the military after
September 11, 2001. These screens prompt providers to ask questions about
medical and psychological issues related to OEF and OIF veterans, such as
infectious diseases and depression. The screens continue to pop up each
time the patient's medical record is opened until the information
requested is entered into that record. The pop-up reminder screens were
the subject of one of the informational letters issued to VA staff.
Further, VA and DOD developed
29In May 2001, VA established the two War-Related Illness and Injury Study
Centers, one in Washington, D.C., and one in East Orange, New Jersey. The
mission of these centers includes providing health-related educational
services to veterans and health care professionals.
25 guidelines for clinical practice,30 which can be viewed on a VA Web
site.31 VA officials stated that any of the guidelines may be used for OEF
and OIF servicemembers and veterans depending on their needs. Finally,
VA's National Center for Post-Traumatic Stress Disorder and DOD developed
the Iraq War Clinician Guide. It addresses the needs of veterans of the
Iraq war and is available on a VA Web site.32
Agency Comments and Our Evaluation
VA and DOD reviewed a draft of this report and provided written comments,
which appear in enclosures I and II respectively. VA concurred with the
information presented in our draft report. It also stated that PRCs'
access to DOD's electronic medical records has been a significant
challenge for VA in accomplishing its mission. VA further commented that
it is justifiably proud of the accomplishments of its dedicated staff in
successfully responding to the often overwhelming transitional needs of
these young servicemembers and their families. DOD commented that the
report portrays the numerous efforts that have been made to improve the
efficacy of programs designed to ensure a smooth transition and continuity
of care as servicemembers transition back and forth between DOD and VA
health care systems.
DOD commented that the statements in the draft report concerning its lack
of a systemwide approach to electronic medical record management and the
inability of providers throughout DOD's health care system to access
medical records is completely inaccurate. Our statements are not
inaccurate. While our draft report recognizes DOD's long-standing ongoing
efforts to achieve the capability to electronically share the complete
medical record, we did not find that this capability exists yet at DOD.
For example, in March 2006 the Chief Information Officer at the National
Naval Medical Center explained to us that MTFs did not have access to
electronic medical records at other MTFs across the United States. He told
us that while information could be shared among providers linked by a
local area network, those providers could not electronically access
medical records from other local area networks. Specifically, he noted
that providers at Walter Reed Army Medical Center and the National Naval
Medical Center can access each other's medical records electronically, but
they cannot access medical records from Landstuhl Regional Medical Center
in Germany or from MTFs in San Antonio, Texas. He acknowledged that DOD's
Armed Forces Health Longitudinal Technology Application (AHLTA)-a
comprehensive electronic health record-will allow providers to access
medical information. In its comments, DOD also cited the access that AHLTA
will provide. However, DOD documentation that describes the system states
that it is for outpatient care-only one part of the complete medical
record. VA providers treating OEF and OIF servicemembers are in need of
information concerning the inpatient care-not just the outpatient
care-that servicemembers received at DOD. Furthermore, AHLTA cannot be
accessed by all of DOD's providers. In its comments on our draft report
DOD stated that AHLTA is not operational at 19 percent of DOD's MTFs and
that full deployment is not expected until December 2006. In comparison,
VA's system allows the patient's complete medical record to be accessed
from any VA medical facility.
30Clinical practice guidelines are recommendations for treating specific
diseases or conditions.
31See http://www.oqp.med.va.gov/cpg/cpg.htm .
32See http://www.ncptsd.va.gov/war/guide/index.html .
In its comments, DOD also mentioned that a section of our draft report
that described the actions VA has taken to facilitate the transition of
care from DOD to VA is misleading. However, the section is an accurate
presentation of VA initiatives as presented to us by VA and as observed
during our audit work. Furthermore, DOD stated that it transmits certain
medical information to VA on a monthly basis, although VA providers told
us they need ready electronic access to current medical record information
for the seriously injured OEF and OIF servicemembers. We believe that in
order to plan and begin appropriate treatment immediately upon a
servicemember's arrival at a PRC, medical record information is best
provided through direct electronic access, not through monthly
transmissions. Our draft report recognized the technical advances that VA
has made in that it has the capability to electronically share the
complete medical record of each of its beneficiaries among all its
providers at all its medical facilities. This means that all medical
services provided by VA to its beneficiaries-including information such as
outpatient or inpatient procedures, pharmacy, or radiology notes-are
included in VA's electronic record.
VA and DOD provided technical comments that we incorporated where
appropriate.
- - - - -
As agreed with your office, unless you publicly announced its contents
earlier, we plan no further distribution of this report until 30 days
after its report date. We will then send copies of this report to the
Secretaries of Veterans Affairs and Defense and appropriate congressional
committees. We will also make copies available to others on request. In
addition, the report will be available at no charge on GAO's Web site at
http://www.gao.gov .
If you or your staff have any questions, please contact me at (202)
512-7101 or bascettac@gao.gov . Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this report. GAO staff who made major contributions to this report are
Michael T. Blair, Jr., Assistant Director; Cynthia Forbes; Roseanne Price;
Shannon Slawter; and Cherie' Starck.
Sincerely yours,
Cynthia A. Bascetta
Director, Health Care
Enclosures - 2
Comments from the Department of Veterans Affairs
Comments from the Department of Defense
Related GAO Products
Information Technology: VA and DOD Face Challenges in Completing Key
Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.
VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth
Transition from DOD Health Care, but Sharing of Health Information Remains
Limited. GAO-05-1052T. Washington, D.C.: September 28, 2005.
Computer-Based Patient Records: VA and DOD Made Progress, but Much Work
Remains to Fully Share Medical Information. GAO-05-1051T. Washington,
D.C.: September 28, 2005.
Military and Veterans' Benefits: Improvements Needed in Transition
Assistance Services for Reserves and National Guard. GAO-05-844T.
Washington, D.C.: June 29, 2005.
Military and Veterans' Benefits: Enhanced Services Could Improve
Transition Assistance for Reserves and National Guard. GAO-05-544.
Washington, D.C.: May 20, 2005.
DOD and VA: Systematic Data Sharing Would Help Expedite Servicemembers'
Transition to VA Services. GAO-05-722T. Washington, D.C.: May 19, 2005.
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.
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.: March 17, 2004.
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.: November 19, 2003.
Computer-Based Patient Records: Better Planning and Oversight by VA, DOD,
and IHS Would Enhance Health Data Sharing. GAO-01-459. Washington, D.C.:
April 30, 2001.
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