Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Remain Far from Having Comprehensive	 
Electronic Medical Records (18-JUL-07, GAO-07-1108T).		 
                                                                 
The Department of Veterans Affairs (VA) and the Department of	 
Defense (DOD) are engaged in ongoing efforts to share medical	 
information, which is important in helping to ensure high-quality
health care for active-duty military personnel and veterans.	 
These efforts include a long-term program to develop modernized  
health information systems based on computable data: that is,	 
data in a format that a computer application can act on--for	 
example, to provide alerts to clinicians of drug allergies. In	 
addition, the departments are engaged in short-term initiatives  
involving existing systems. GAO was asked to summarize its recent
testimony on the history and current status of these long- and	 
short-term efforts to share health information. To develop that  
testimony, GAO reviewed its previous work, analyzed documents,	 
and interviewed VA and DOD officials about current status and	 
future plans.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-1108T					        
    ACCNO:   A72868						        
  TITLE:     Information Technology: VA and DOD Are Making Progress in
Sharing Medical Information, but Remain Far from Having 	 
Comprehensive Electronic Medical Records			 
     DATE:   07/18/2007 
  SUBJECT:   Data collection					 
	     Data integrity					 
	     Data transmission systems				 
	     Health information architecture			 
	     Information management				 
	     Information systems				 
	     Interagency relations				 
	     Medical information systems			 
	     Strategic planning 				 
	     Systems integration				 
	     Veterans benefits					 
	     Information sharing				 

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GAO-07-1108T

   

     * [1]Results in Brief
     * [2]Background
     * [3]VA and DOD Have Been Working to Exchange Health Information

          * [4]Others Have Recommended Strengthening the Management and Pla

     * [5]VA and DOD Are Exchanging Limited Medical Information, but M

          * [6]VA and DOD Have Begun Deployment of a Modernized Data Interf
          * [7]VA and DOD Are Exchanging Limited Health Information through

               * [8]One-Way Transfer Capability Is Operational
               * [9]Laboratory Interface Initiative Allows VA and DOD to
                 Share L
               * [10]Two-Way Interface Allows Real-Time Viewing of Text
                 Informati

          * [11]Special Procedures Provide Information to VA Polytrauma Cent

     * [12]Contacts and Acknowledgments
     * [13]Attachment 1: Supplementary Tables

          * [14]Types of Data Shared by DOD and VA Are Growing but Remain Li
          * [15]Reported Costs

     * [16]Related GAO Products
     * [17]PDF6-Ordering Information.pdf

          * [18]Order by Mail or Phone

United States Government Accountability Office

GAO

Testimony

Before the Veterans' Disability Benefits Commission

For Release on Delivery
Expected at 10:00 a.m. EDT
Wednesday, July 18, 2007

INFORMATION TECHNOLOGY

VA and DOD Are Making Progress in Sharing Medical Information, but Remain
Far from Having Comprehensive Electronic Medical Records

Statement of Valerie C. Melvin, Director
Human Capital and Management Information Systems Issues

GAO-07-1108T


Members of the Commission:

I am pleased to be here today to discuss the sharing of electronic medical
records between the Department of Defense (DOD) and the Department of
Veterans Affairs (VA). For almost 10 years, the departments have been
engaged in multiple efforts to share electronic medical information, which
is important in helping to ensure that active-duty military personnel and
veterans receive high-quality health care. These include efforts focused
on the long-term vision of a single "comprehensive, lifelong medical
record for each service member" ^1 that would allow a seamless transition
between the two departments, as well as more short-term efforts to meet
immediate needs to exchange health information, including responding to
current military crises.

Each department is developing its own modern health information system to
replace its existing ("legacy") systems, and they are collaborating on a
program to develop an interface to enable these modernized systems to
share data and ultimately to have interoperable^2 electronic medical
records. Unlike the legacy systems, the modernized systems are to be based
on computable data: that is, the data are to be in a format that a
computer application can act on, for example, to provide alerts to
clinicians (of such things as drug allergies) or to plot graphs of changes
in vital signs such as blood pressure. According to the departments, such
computable data contribute significantly to patient safety and the
usefulness of electronic medical records.

While working on this long-term effort, the two departments have also been
pursuing various short-term initiatives to exchange electronic medical
information in their existing systems. These include a completed effort to
allow the one-way transfer of health information from DOD to VA when
service members leave the military, ongoing demonstration projects to
exchange particular types of data at selected sites, and efforts to meet
the immediate needs of facilities treating veterans and service members
with multiple injuries.

^1 In 1996, the Presidential Advisory Committee on Gulf War Veterans'
Illnesses reported on many deficiencies in VA's and DOD's data
capabilities for handling service members' health information. In November
1997, the President called for the two agencies to start developing a
"comprehensive, lifelong medical record for each service member," and in
1998 issued a directive requiring VA and DOD to develop a "computer-based
patient record system that will accurately and efficiently exchange
information."

^2 Interoperability is the ability of two or more systems or components to
exchange information and to use the information that has been exchanged.

On May 8, 2007, we testified before the House Veterans Affairs
Subcommittee on Oversight and Investigations on the history of the two
departments' efforts to develop the capability to share health
information, and the current status of the long- and short-term efforts
that the departments are undertaking in this regard.^3 At your request, my
statement today presents information discussed in that testimony.

The information in my testimony is based largely on our previous work in
this area. To describe the current status of VA and DOD efforts to
exchange patient health information, we reviewed our previous work,
analyzed documents on various health initiatives, and interviewed VA and
DOD officials about current status and future plans. The costs that have
been incurred for the various projects were provided by cognizant VA and
DOD officials. We did not audit the reported costs and thus cannot attest
to their accuracy or completeness. All work on which this testimony is
based was conducted in accordance with generally accepted government
auditing standards.

Results in Brief

VA and DOD have been pursuing ways to share data in their health
information systems and create comprehensive electronic medical records
since 1998, following the call for the development of a comprehensive
integrated system to allow the two departments to share patient health
information. However, the departments have faced considerable challenges,
leading to repeated changes in the focus of their initiatives and target
dates. In prior reviews of the departments' efforts, we noted management
weaknesses and made recommendations for improvement, including the
development of a detailed project management plan to guide their efforts.
Currently, VA and DOD are pursuing both long- and short-term initiatives
to share health information. The long-term initiative is to develop a
common health information architecture that would allow the two-way
exchange of health information through the development of modern health
information systems. Among various short-term initiatives are a completed
effort (the Federal Health Information Exchange) that enables DOD to
electronically transfer to VA health information on service members when
they leave the military, as well as two demonstration projects established
in 2004 in response to a congressional mandate, to exchange limited data
in existing systems at selected sites.

^3 GAO, VA and DOD Are Making Progress in Sharing Medical Information, but
Are Far from Comprehensive Electronic Medical Records, GAO-07-852T
(Washington, D.C.: May 8, 2007).

VA and DOD have made progress in both their long-term and short-term
initiatives to share health information, but much work remains to achieve
the goal of a shared electronic medical record and seamless transition
between the two departments. In the long-term project to develop
modernized health information systems, the departments have begun to
implement the first release of the interface between their modernized data
repositories, and computable outpatient pharmacy and drug allergy data are
being exchanged at seven VA and DOD sites. However, significant work
remains including agreeing to standards for the remaining categories of
medical information and populating the data repositories with all this
information. The two departments have also made progress in their
short-term projects to share information in existing systems. Besides
completing the Federal Health Information Exchange, the departments have
made progress on two demonstration projects: (1) the Laboratory Data
Sharing Interface, deployed at 9 localities, allows DOD and VA to
communicate orders for lab tests and their results electronically; and (2)
the Bidirectional Health Information Exchange allows a real-time, two-way
view of outpatient health data from existing systems^4 at all VA sites and
25 DOD sites, and certain inpatient discharge summary data ^5 at all VA
sites and 5 DOD sites. In addition, the two departments have undertaken ad
hoc activities to accelerate the transmission of health information on
severely wounded patients from DOD to VA's four polytrauma centers, which
care for veterans and service members with disabling injuries to more than
one physical region or organ system. These ad hoc processes include manual
workarounds, such as scanning paper records and individually transmitting
radiological images, that are generally feasible only because the number
of polytrauma patients is small (about 350 in all to date).

Through all these efforts, VA and DOD are achieving exchanges of health
information. However, these exchanges are as yet limited, and it is not
clear how they are to be integrated into an overall strategy toward
achieving the departments' long-term goal of comprehensive, seamless
exchange of health information. Consequently, it remains essential for the
departments to develop a comprehensive project plan to guide their efforts
to completion, in line with our earlier recommendations.

Background

In their efforts to modernize their health information systems and share
medical information, VA and DOD begin from different positions. As shown
in table 1, VA has one integrated medical information system, VistA
(Veterans Health Information Systems and Technology Architecture), which
uses all electronic records. All 128 VA medical sites thus have access to
all VistA information.^6 (Table 1 also shows, for completeness, VA's
planned modernized system and its associated data repository.)

^4 DOD's Composite Health Care System (CHCS) and VA's VistA (Veterans
Health Information Systems and Technology Architecture).

^5 Specifically, inpatient discharge summary data stored in VA's VistA and
DOD's Clinical Information System (CIS), a commercial health information
system customized for DOD.

^6 A site represents one or more facilities--medical centers, hospitals,
or outpatient clinics--that store their electronic health data in a single
database.

Table 1: VA Medical Information Systems

System name                               Description                      
Legacy systems                                                             
VistA Veterans Health Information Systems Existing integrated health       
and Technology Architecture               information system.              
Modernized system and repository          
HealtheVet VistA                          Modernized health information    
                                             system based on computable data. 
HDR Health Data Repository                Data repository associated with  
                                             modernized system.               

Source: GAO analysis of VA data.

In contrast, DOD has multiple medical information systems (see table 2).
DOD's various systems are not integrated, and its 138 sites do not
necessarily communicate with each other. In addition, not all of DOD's
medical information is electronic: some records are paper-based.

Table 2: Selected DOD Medical Information Systems

System name                  Description                                   
Legacy systems                                                             
CHCS Composite Health Care   Primary existing DOD health information       
System                       system.                                       
CIS Clinical Information     Commercial health information system          
System                       customized for DOD; used by some DOD          
                                facilities for inpatients.                    
ICDB Integrated Clinical     Health information system used by many Air    
Database                     Force facilities.                             
TMDS Theater Medical Data    Database to collect electronic medical        
Store                        information in combat theater for both        
                                outpatient care and serious injuries.         
JPTA Joint Patient Tracking  Web-based application primarily used to track 
Application                  the movement of patients as they are          
                                transferred from location to location, but    
                                may include text-based medical information.   
Modernized system and repository
AHLTA Armed Forces Health    Modernized health information system,         
Longitudinal Technology      integrated and based on computable data.      
Application ^a                                                             
CDR Clinical Data Repository Data repository associated with modernized    
                                system.                                       

Source: GAO analysis of DOD data.

^a Formerly CHCS II.

VA and DOD Have Been Working to Exchange Health Information Since 1998

For almost a decade, VA and DOD have been pursuing ways to share data in
their health information systems and create comprehensive electronic
records.^7 However, the departments have faced considerable challenges,
leading to repeated changes in the focus of their initiatives and target
dates for accomplishment.

As shown in figure 1, the departments' efforts have involved a number of
distinct initiatives, both long-term initiatives to develop future
modernized solutions, and short-term initiatives to respond to more
immediate needs to share information in existing systems. As the figure
shows, these initiatives often proceeded in parallel.

^7 Initially, the Indian Health Service (IHS) was also 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.

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

The departments' first initiative, known as the Government Computer-Based
Patient Record (GCPR) project, aimed to develop an electronic interface
that would let physicians and other authorized users at VA and DOD health
facilities access data from each other's health information systems. The
interface was expected to compile requested patient information in a
virtual record (that is, electronic as opposed to paper) that could be
displayed on a user's computer screen.

In 2001 and 2002, we reviewed the GCPR project and noted disappointing
progress, exacerbated in large part by inadequate accountability and poor
planning and oversight, which raised doubts about the departments' ability
to achieve a virtual medical record. 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. ^8 We made recommendations in both years
that the departments enhance the project's overall management and
accountability. In particular, we recommended that the departments
designate a lead entity and a clear line of authority for the project;
create comprehensive and coordinated plans that include an agreed-upon
mission and clear goals, objectives, and performance measures; revise the
project's original goals and objectives to align with the current
strategy; commit the executive support necessary to adequately manage the
project; and ensure that it followed sound project management principles.

In response, the two departments revised their strategy in July 2002,
refocusing the project and dividing it into two initiatives. A short-term
initiative (the Federal Health Information Exchange or FHIE) was to enable
DOD, when service members left the military, to electronically transfer
their health information to VA. VA was designated as the lead entity for
implementing FHIE, which was successfully completed in 2004.  A longer
term initiative was to develop a common health information architecture
that would allow the two-way exchange of health information. The common
architecture is to include standardized, computable data, communications,
security, and high-performance health information systems (these systems,
DOD's CHCS II and VA's HealtheVet VistA, were already in development, as
shown in the figure).^9 The departments' modernized systems are to store
information (in standardized, computable form) in separate data
repositories: DOD's Clinical Data Repository (CDR) and VA's Health Data
Repository (HDR). The two repositories are to exchange information through
an interface named CHDR.^10

^8 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).

^9 DOD's existing Composite Health Care System (CHCS) was being modernized
as CHCS II, now renamed AHLTA (Armed Forces Health Longitudinal Technology
Application). VA's existing VistA system was being modernized as
HealtheVet VistA.

^10 The name CHDR, pronounced "cheddar," combines the names of the two
repositories.

In March 2004, the departments began to develop the CHDR interface, and
they planned to begin implementation by October 2005.^11 However,
implementation of the first release of the interface (at one site)
occurred in September 2006, almost a year later. In a review in June 2004,
we identified a number of management weaknesses that could have
contributed to this delay^12 and made a number of recommendations,
including creation of a comprehensive and coordinated project management
plan. In response, the departments agreed to our recommendations and
improved the management of the CHDR program by designating a lead entity
with final decision-making authority and establishing a project management
structure. As we noted in later testimony, however, the program did not
develop a project management plan that would give a detailed description
of the technical and managerial processes necessary to satisfy project
requirements (including a work breakdown structure and schedule for all
development, testing, and implementation tasks), as we had recommended.^13

In October 2004, the two departments established two more short-term
initiatives in response to a congressional mandate.^14 These were two
demonstration projects: the Laboratory Data Sharing Interface, aimed at
allowing VA and DOD facilities to share laboratory resources, and the
Bidirectional Health Information Exchange (BHIE), aimed at allowing both
departments' clinicians access to records on shared patients (that is,
those who receive care from both departments).^15 As demonstration
projects, both initiatives were limited in scope, with the intention of
providing interim solutions to the departments' need for more immediate
health information sharing. However, because BHIE provided access to
up-to-date information, the departments' clinicians expressed strong
interest in increasing its use. As a result, the departments began
planning to broaden BHIE's capabilities and expand its implementation
considerably. Until the departments' modernized systems are fully
developed and implemented, extending BHIE connectivity could provide each
department with access to most data in the other's legacy systems.
According to a VA/DOD annual report^16  and program officials, the
departments now consider BHIE an interim step in their overall strategy to
create a two-way exchange of electronic medical records.

^11 December 2004 VA and DOD Joint Strategic Plan.

^12 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).

^13 GAO, 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) and Information Technology: VA and DOD
Face Challenges in Completing Key Efforts, GAO-06-905T (Washington, D.C.:
June 22, 2006).

^14 The Bob Stump National Defense Authorization Act for Fiscal Year 2003
(Pub. L. No.107-314, SS 721, 724, Dec. 2, 2002) mandated that the
departments conduct demonstration projects to test 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.

Most recently, the departments have announced a further change to their
information-sharing strategy. In January 2007, they announced their
intention to jointly develop a new inpatient medical record system.
According to the departments, adopting this joint solution will facilitate
the seamless transition of active-duty service members to veteran status,
as well as making inpatient health-care data on shared patients
immediately accessible to both DOD and VA. In addition, the departments
consider that a joint development effort could allow them to realize
significant cost savings. We have not evaluated the departments' plans or
strategy in this area.

Others Have Recommended Strengthening the Management and Planning of the
Departments' Health Information Initiatives

Throughout the history of these initiatives, evaluations beyond ours have
also found deficiencies in the departments' efforts, especially with
regard to the need for comprehensive planning. For example, in fiscal year
2006, the Congress did not provide all the funding requested for
HealtheVet VistA because it did not consider that the funding had been
adequately justified. In addition, a recent presidential task force
identified the need for VA and DOD to improve their long-term planning.^17
This task force, reporting on gaps in services provided to returning
veterans, noted problems with regard to sharing information on wounded
service members, including the inability of VA providers to access paper
DOD inpatient health records. According to the report, although
significant progress has been made on sharing electronic information, more
needs to be done. The task force recommended that VA and DOD continue to
identify long-term initiatives and define scope and elements of a joint
inpatient electronic health record.

^15 To create BHIE, the departments drew on the architecture and framework
of the information transfer system established by the FHIE project. Unlike
FHIE, which provides a one-way transfer of information to VA when a
service member separates from the military, the two-way system allows
clinicians in both departments to view, in real time, limited health data
(in text form) from the departments' current health information systems.

^16 December 2004 VA and DOD Joint Strategic Plan.

VA and DOD Are Exchanging Limited Medical Information, but Much Work Remains to
Achieve Seamless Sharing

VA and DOD have made progress in both their long-term and short-term
initiatives to share health information. In the long-term project to
develop modernized health information systems, the departments have begun
to implement the first release of the interface between their modernized
data repositories, among other things. The two departments have also made
progress in their short-term projects to share information in existing
systems, having completed two initiatives and making important progress on
another. In addition, the two departments have undertaken ad hoc
activities to accelerate the transmission of health information on
severely wounded patients from DOD to VA's four polytrauma centers.
However, despite the progress made and the sharing achieved, the tasks
remaining to achieve the goal of a shared electronic medical record remain
substantial.

^17 Task Force on Returning Global War on Terror Heroes, Report to the
President (Apr. 19, 2007).

VA and DOD Have Begun Deployment of a Modernized Data Interface

In their long-term effort to share health information, VA and DOD have
completed the development of their modernized data repositories, agreed on
standards for various types of data, and begun to populate the
repositories with these data.^18 In addition, they have now implemented
the first release of the CHDR interface, which links the two departments'
repositories, at seven sites. The first release has enabled the seven
sites to share limited medical information: specifically, computable
outpatient pharmacy and drug allergy information for shared patients.

According to DOD officials, in the third quarter of 2007 the department
will send out instructions to its remaining sites so that they can all
begin using CHDR. According to VA officials, the interface will be
available across the department when necessary software updates are
released, which is expected this July.^19

Besides being a milestone in the development of the departments'
modernized systems, the interface implementation provides benefits to the
departments' current systems. Data transmitted by CHDR are permanently
stored in the modernized data repositories, CDR and HDR. Once in the
repositories, these computable data can be used by DOD and VA at all sites
through their existing systems. CHDR also provides terminology mediation
(translation of one agency's terminology into the other's). VA and DOD
plans call for developing the capability to exchange computable laboratory
results data through CHDR during fiscal year 2008.

Although implementing this interface is an important accomplishment, the
departments are still a long way from completion of the modernized health
information systems and comprehensive longitudinal health records. While
DOD and VA had originally projected completion dates for their modernized
systems of 2011 and 2012, respectively, department officials told us that
there is currently no scheduled completion date for either system.
Further, both departments have still to identify the next types of data to
be stored in the repositories. The two departments will then have to
populate the repositories with the standardized data, which involves
different tasks for each department. Specifically, although VA's medical
records are already electronic, it still has to convert these into the
interoperable format appropriate for its repository. DOD, in addition to
converting current records from its multiple systems, must also address
medical records that are not automated. As pointed out by a recent Army
Inspector General's report, some DOD facilities are having problems with
hard-copy records.^20 In the same report, inaccurate and incomplete health
data were identified as a problem to be addressed. Before the departments
can achieve the long-term goal of seamless sharing of medical information,
all these tasks and challenges will have to be addressed. Consequently, it
is essential for the departments to develop a comprehensive project plan
to guide these efforts to completion, as we have previously recommended.

^18 DOD has populated CDR with information for outpatient encounters, drug
allergies, and order entries and results for outpatient pharmacy/lab
orders. VA has populated HDR with patient demographics, vital signs
records, allergy data, and outpatient pharmacy data; this summer, the
department plans to include chemistry and hematology laboratory data.

^19 The Remote Data Interoperability software upgrade provides the
capability for the automated checks and alerts allowed by computable data.

VA and DOD Are Exchanging Limited Health Information through Short-Term Projects

In addition to the long-term effort described above, the two departments
have made some progress in meeting immediate needs to share information in
their respective legacy systems by setting up short-term projects, as
mentioned earlier, which are in various stages of completion. In addition,
the departments have set up special processes to transfer data from DOD
facilities to VA's polytrauma centers, which treat traumatic brain
injuries and other especially severe injuries.

  One-Way Transfer Capability Is Operational

DOD has been using FHIE to transfer information to VA since 2002.
According to department officials, over 184 million clinical messages on
more than 3.8 million veterans had been transferred to the FHIE data
repository as of March 2007. Data elements transferred are laboratory
results, radiology results, outpatient pharmacy data, allergy information,
consultation reports, elements of the standard ambulatory data record, and
demographic data. Further, since July 2005, FHIE has been used to transfer
pre- and post-deployment health assessment and reassessment data; as of
March 2007, VA had access to data for more than 681,000 separated service
members and demobilized Reserve and National Guard members who had been
deployed. Transfers are done in batches once a month, or weekly for
veterans who have been referred to VA treatment facilities.

^20 Inspector General, Army, Army Physical Disability Evaluation System
Inspection (March 2007).

According to a joint DOD/VA report,^21 FHIE has made a significant
contribution to the delivery and continuity of care of separated service
members as they transition to veteran status, as well as to the
adjudication of disability claims.

  Laboratory Interface Initiative Allows VA and DOD to Share Lab Resources

One of the departments' demonstration projects, the Laboratory Data
Sharing Interface (LDSI), is now fully operational and is deployed when
local agencies have a business case for its use and sign an agreement. It
requires customization for each locality and is currently deployed at nine
locations. LDSI currently supports a variety of chemistry and hematology
tests, and work is under way to include microbiology and anatomic
pathology.

Once LDSI is implemented at a facility, the only nonautomated action
needed for a laboratory test is transporting the specimens. If a test is
not performed at a VA or DOD doctor's home facility, the doctor can order
the test, the order is transmitted electronically to the appropriate lab
(the other department's facility or in some cases a local commercial lab),
and the results are returned electronically.

Among the benefits of LDSI, according to VA and DOD, are increased speed
in receiving laboratory results and decreased errors from manual entry of
orders. The LDSI project manager in San Antonio stated that another
benefit of the project is 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 no longer has to
contract out some of its laboratory work to private companies, but instead
uses the DOD laboratory.

^21 December 2004 VA and DOD Joint Strategic Plan.

  Two-Way Interface Allows Real-Time Viewing of Text Information

Developed under a second demonstration project, the BHIE interface is now
available throughout VA and partially deployed at DOD. It is currently
deployed at 25 DOD sites, providing access to 15 medical centers, 18
hospitals, and over 190 outpatient clinics associated with these sites.
DOD planned to make current BHIE capabilities available departmentwide by
June 2007.

The interface permits a medical care provider to query patient data from
all VA sites and any DOD site where it is installed and to view that data
onscreen almost immediately. It not only allows DOD and VA to view each
other's information, it also allows DOD sites to see previously
inaccessible data at other DOD sites.

As initially developed, the BHIE interface provides access to information
in VA's VistA and DOD's CHCS, but it is currently being expanded to query
data in other DOD databases (in addition to CHCS). In particular, DOD has
developed an interface to the Clinical Information System (CIS), an
inpatient system used by many DOD facilities, which will provide
bidirectional views of discharge summaries. The BHIE-CIS interface is
currently deployed at five DOD sites and planned for eight others.
Further, interfaces to two additional systems are planned for June and
July 2007: An interface to DOD's modernized data repository, CDR, will
give access to outpatient data from combat theaters. An interface to
another DOD database, the Theater Medical Data Store, will give access to
inpatient information from combat theaters.

The departments also plan to make more data elements available. Currently,
BHIE enables text-only viewing of patient identification, outpatient
pharmacy, microbiology, cytology, radiology, laboratory orders, and
allergy data from its interface with DOD's CHCS. Where it interfaces with
CIS, it also allows viewing of discharge summaries from VA and the five 
DOD sites. DOD staff told us that in early fiscal year 2008, they plan to
add provider notes, procedures, and problem lists. Later in fiscal year
2008, they plan to add vital signs, scanned images and documents, family
history, social history, and other history questionnaires. In addition, at
the VA/DOD site in El Paso, a trial is under way of a process for
exchanging radiological images using the BHIE/FHIE infrastructure.^22 Some
images have successfully been exchanged.

Through their efforts on these long- and short-term initiatives, VA and
DOD are achieving exchanges of various types of health information (see
attachment 1 for a summary of all the types of data currently being shared
and those planned for the future, as well as cost data on the
initiatives). However, these exchanges are as yet limited, and significant
work remains to be done to expand the data shared and integrate the
various initiatives.

Special Procedures Provide Information to VA Polytrauma Centers

In addition to the information technology initiatives described, DOD and
VA have set up special activities to transfer medical information to VA's
four polytrauma centers, which are treating active-duty service members
severely wounded in combat.^23 Polytrauma centers care for veterans and
returning service members with injuries to more than one physical region
or organ system, one of which may be life threatening, and which results
in physical, cognitive, psychological, or psychosocial impairments and
functional disability. Some examples of polytrauma include traumatic brain
injury (TBI), amputations, and loss of hearing or vision.

When service members are seriously injured in a combat theater overseas,
they are first treated locally. They are then generally evacuated to
Landstuhl Medical Center in Germany, after which they are transferred to a
military treatment facility in the United States, usually Walter Reed Army
Medical Center in Washington, D.C.; the National Naval Medical Center in
Bethesda, Maryland; or Brooke Army Medical Center, at Fort Sam Houston,
Texas. From these facilities, service members suffering from polytrauma
may be transferred to one of VA's four polytrauma centers for
treatment.^24

22 To create BHIE, the departments drew on the architecture and framework
of the information transfer system established by the FHIE project.

^23 In particular, clinicians required access to discharge notices, which
describe the treatment given at previous medical facilities and the status
of patients when they left those facilities.

At each of these locations, the injured service members will accumulate
medical records, in addition to medical records already in existence
before they were injured. However, the DOD medical information is
currently collected in many different systems and is not easily accessible
to VA polytrauma centers. Specifically:

           1. In the combat theater, electronic medical information may be
           collected for a variety of reasons, including routine outpatient
           care, as well as serious injuries. These data are stored in the
           Theater Medical Data Store, which can be accessed by unit
           commanders and others. (As mentioned earlier, the departments have
           plans to develop a BHIE interface to this system by July 2007.
           Until then, VA cannot access these data.) In addition, both
           inpatient and outpatient medical data for patients who are
           evacuated are entered into the Joint Patient Tracking Application.
           (A few VA polytrauma center staff have been given access to this
           application.)
           2. At Landstuhl, inpatient medical records are paper-based (except
           for discharge summaries). The paper records are sent with a
           patient as the individual is transferred for treatment in the
           United States.
           3. At the DOD treatment facility (Walter Reed, Bethesda, or
           Brooke), additional information will be recorded in CIS and
           CHCS/CDR.^25

^24 The four Polytrauma Rehabilitation Centers are in Richmond, Tampa,
Minneapolis, and Palo Alto.

^25 Pharmacy and drug information would be stored in CDR; other health
information continues to be stored in local CHCS databases.

When service members are transferred to a VA polytrauma center, VA and DOD
have several ad hoc processes in place to electronically transfer the
patients' medical information:

           0M DOD has set up secure links to enable a limited number of
           clinicians at the polytrauma centers to log directly into CIS at
           Walter Reed and Bethesda Naval Hospital to access patient data.
           0M Staff at Walter Reed collect paper records, print records from
           CIS, scan all these, and transmit the scanned data to three of the
           four polytrauma centers. DOD staff said that they are working on
           establishing this capability at the Brooke and Bethesda medical
           centers, as well as the fourth VA polytrauma center. According to
           VA staff, although the initiative began several months ago, it has
           only recently begun running smoothly as the contractor became more
           skilled at assembling the records. DOD staff also pointed out that
           this laborious process is feasible only because the number of
           polytrauma patients is small (about 350 in all to date); it would
           not be practical on a large scale.
           0M Staff at Walter Reed and Bethesda are transmitting radiology
           images electronically to three polytrauma centers. (A fourth has
           this capability, but at this time no radiology images have been
           transferred there.) Access to radiology images is a high priority
           for polytrauma center doctors, but like scanning paper records,
           transmitting these images requires manual intervention: when each
           image is received at VA, it must be individually uploaded to
           VistA's imagery viewing capability. This process would not be
           practical for large volumes of images.
           0M VA has access to outpatient data (via BHIE) from 25 DOD sites,
           including Landstuhl.

           Although these various efforts to transfer medical information on
           seriously wounded patients are working, and the departments are to
           be commended on their efforts, the multiple processes and
           laborious manual tasks illustrate the effects of the lack of
           integrated health information systems and the difficulties of
           exchanging information in their absence.

           In summary, through the long- and short-term initiatives
           described, as well as efforts such as those at the polytrauma
           centers, VA and DOD are achieving exchanges of health information.
           However, these exchanges are as yet limited, and significant work
           remains to be done to fully achieve the goal of exchanging
           interoperable, computable data, including agreeing to standards
           for the remaining categories of medical information, populating
           the data repositories with all this information, completing the
           development of HealtheVet VistA and AHLTA, and transitioning from
           the legacy systems. To complete these tasks, a detailed project
           management plan continues to be of vital importance to the
           ultimate success of the effort to develop a lifelong virtual
           medical record. We have previously recommended that the
           departments develop a clearly defined project management plan that
           describes the technical and managerial processes necessary to
           satisfy project requirements, including a work breakdown structure
           and schedule for all development, testing, and implementation
           tasks. Without a plan of sufficient detail, VA and DOD increase
           the risk that the long-term project will not deliver the planned
           capabilities in the time and at the cost expected. Further, it is
           not clear how all the initiatives we have described today are to
           be incorporated into an overall strategy toward achieving the
           departments' goal of comprehensive, seamless exchange of health
           information.

           This concludes my statement. I would be pleased to respond to any
           questions that you may have.

Contacts and Acknowledgments

If you have any questions concerning this testimony, please contact
Valerie C. Melvin, Director, Human Capital and Management Information
Systems Issues, at (202) 512-6304 or [19][email protected] . Other
individuals who made key contributions to this testimony are Barbara
Oliver, Assistant Director; Barbara Collier; and Glenn Spiegel.

Attachment 1: Supplementary Tables

Types of Data Shared by DOD and VA Are Growing but Remain Limited

Table 3 summarizes the types of health data currently shared through the
long- and short-term initiatives we have described, as well as types of
data that are currently planned for addition. While this gives some
indication of the scale of the tasks involved in sharing medical
information, it does not depict the full extent of information that is
currently being captured in health information systems and that remains to
be addressed.

Table 3: Data Elements Made Available and Planned by DOD-VA Initiatives

                            Data elements                                     
Initiative Available              Planned            Comments              
CHDR       Outpatient pharmacy    Laboratory data    Computable data are   
                                                        exchanged between one 
              Drug allergy                              department's data     
                                                        repository and the    
                                                        other's.              
FHIE       Patient demographics   None               One-way batch         
                                                        transfer of text data 
              Laboratory results                        from DOD to VA occurs 
                                                        weekly if discharged  
              Radiology reports                         patient has been      
                                                        referred to VA for    
              Outpatient pharmacy                       treatment; otherwise  
              information                               monthly.              
                                                                              
              Admission discharge                                             
              transfer data                                                   
                                                                              
              Discharge summaries                                             
                                                                              
              Consult reports                                                 
                                                                              
              Allergies                                                       
                                                                              
              Data from the DoD                                               
              Standard Ambulatory                                             
              Data Record                                                     
                                                                              
              Pre- and                                                        
              post-deployment                                                 
              assessments                                                     
LDSI       Laboratory orders      Microbiology       Noncomputable text    
                                                        data are transferred. 
              Laboratory results     Anatomic pathology                       
              (chemistry and                                                  
              hematology only)                                                
BHIE       Outpatient pharmacy    Provider notes     Data are not          
              data                                      transferred but can   
                                     Procedures         be viewed.            
              Drug & food allergy                                             
              information            Problem lists                            
                                                                              
              Surgical pathology     Vital signs                              
              reports                                                         
                                     Scanned images and                       
              Microbiology results   documents                                
                                                                              
              Cytology reports       Family history                           
                                                                              
              Chemistry & hematology Social history                           
              reports                                                         
                                     Other history                            
              Laboratory orders      questionnaires                           
                                                                              
              Radiology text reports Radiology images                         
                                                                              
              Inpatient discharge                                             
              summaries and/or                                                
              emergency room notes                                            
              from CIS at five DOD                                            
              and all VA sites                                                

Source: GAO analysis of VA and DOD data.

Reported Costs

Table 4 shows costs expended on these information sharing initiatives
since their inception.

Table 4: Costs of DOD and VA Initiatives Since Inception

Project                   VA expenditure         DOD expenditure           
HealtheVet VistA    $514 million through FY 2005 --                        
AHLTA                         --                 $755 million through FY   
                                                    2006 (estimated)          
Joint initiatives:                                                         
CHDR                 5.3 million through about   DOD does not account for  
FHIE                62.4 million April 2007      these projects            
LDSI                 1.5 million                 separately.               
BHIE                 7.0 million                                           
Total              $76.2 million                 $72.6 million though FY   
                                                    2006                      

Source: GAO analysis of DOD and VA data.

Related GAO Products

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.

Veterans Affairs: Sustained Management Attention Is Key to Achieving
Information Technology Results. GAO-02-703. Washington, D.C.: June 12,
2002.

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: 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: 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.

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.

Information Technology: VA and DOD Face Challenges in Completing Key
Efforts. GAO-06-905T. Washington, D.C.: June 22, 2006.

DOD and VA Exchange of Computable Pharmacy Data. GAO-07-554R. Washington,
D.C.: April 30, 2007.

Information Technology: VA and DOD Are Making Progress in Sharing Medical
Information, but Are Far from Comprehensive Electronic Medical Records,
GAO-07-852T. Washington, D.C.: May 8, 2007.

(310900)

www.gao.gov/cgi-bin/getrpt? [20]GAO-07-1108T .

To view the full product, including the scope

and methodology, click on the link above.

For more information, contact Valerie Melvin at (202) 512-6304 or
[email protected].

Highlights of [21]GAO-07-1108T , testimony to the Veterans' Disability
Benefits Commission

July 18, 2007

INFORMATION TECHNOLOGY

VA and DOD Are Making Progress in Sharing Medical Information, but Remain
Far from Having Comprehensive Electronic Medical Records

The Department of Veterans Affairs (VA) and the Department of Defense
(DOD) are engaged in ongoing efforts to share medical information, which
is important in helping to ensure high-quality health care for active-duty
military personnel and veterans. These efforts include a long-term program
to develop modernized health information systems based on computable data:
that is, data in a format that a computer application can act on--for
example, to provide alerts to clinicians of drug allergies. In addition,
the departments are engaged in short-term initiatives involving existing
systems.

GAO was asked to summarize its recent testimony on the history and current
status of these long- and short-term efforts to share health information.
To develop that testimony, GAO reviewed its previous work, analyzed
documents, and interviewed VA and DOD officials about current status and
future plans.

[22]What GAO Recommends

GAO has previously made several recommendations on these topics, including
that VA and DOD develop a detailed project management plan to guide their
efforts to share patient health data. The departments agreed with these
recommendations.

For almost a decade, VA and DOD have been pursuing ways to share health
information and create comprehensive electronic medical records. However,
they have faced considerable challenges in these efforts, leading to
repeated changes in the focus of their initiatives and target dates. In
prior reviews of the departments' efforts, GAO noted management
weaknesses, including the lack of a detailed project management plan to
guide their efforts. Currently, the two departments are pursuing both
long- and short-term initiatives to share health information. Under their
long-term initiative, the modern health information systems being
developed by each department are to share standardized computable data
through an interface between data repositories associated with each
system. The repositories have now been developed, and the departments have
begun to populate them with limited types of health information. In
addition, the interface between the repositories has been implemented at
seven VA and DOD sites, allowing computable outpatient pharmacy and drug
allergy data to be exchanged. Implementing this interface is a milestone
toward the departments' long-term goal, but more remains to be done.
Besides extending the current capability throughout VA and DOD, the
departments must still agree to standards for the remaining categories of
medical information, populate the data repositories with this information,
complete the development of the two modernized health information systems,
and transition from their existing systems.

While pursuing their long-term effort to develop modernized systems, the
two departments have also been working to share information in their
existing systems. Among various short-term initiatives are a completed
effort to allow the one-way transfer of health information from DOD to VA
when service members leave the military, as well as ongoing demonstration
projects to exchange limited data at selected sites. One of these
projects, building on the one-way transfer capability, developed an
interface between certain existing systems that allows a two-way view of
current data on patients receiving care from both departments. VA and DOD
are now working to link other systems via this interface and extend its
capabilities. The departments have also established ad hoc processes to
meet the immediate need to provide data on severely wounded service
members to VA's polytrauma centers, which specialize in treating such
patients. These processes include manual workarounds (such as scanning
paper records) that are generally feasible only because the number of
polytrauma patients is small. These multiple initiatives and ad hoc
processes highlight the need for continued efforts to integrate
information systems and automate information exchange. However, it is not
clear how all the initiatives are to be incorporated into an overall
strategy focused on achieving the departments' goal of comprehensive,
seamless exchange of health information.

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