Information Technology: VA and DOD Continue to Expand Sharing of Medical Information, but Still Lack Comprehensive Electronic Medical Records

Information Technology: VA and DOD Continue to Expand Sharing of
Medical Information, but Still Lack Comprehensive Electronic
Medical Records (24-OCT-07, GAO-08-207T).

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 testify on the
history and current status of the departments' efforts to share
health information. To develop this testimony, GAO reviewed its
previous work, analyzed documents about current status and future
plans and interviewed VA and DOD officials.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-08-207T
ACCNO: A77587
TITLE: Information Technology: VA and DOD Continue to Expand
Sharing of Medical Information, but Still Lack Comprehensive
Electronic Medical Records
DATE: 10/24/2007
SUBJECT: Access to health care
Data collection
Government information dissemination
Health care programs
Health data repository
Health information architecture
Information disclosure
Information management
Information systems
Interagency relations
Medical records
Military health services
Military personnel
Veterans benefits
Veterans' medical care

******************************************************************
** This file contains an ASCII representation of the text of a **
** GAO Product. **
** **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced. Tables are included, but **
** may not resemble those in the printed version. **
** **
** Please see the PDF (Portable Document Format) file, when **
** available, for a complete electronic file of the printed **
** document's contents. **
** **
******************************************************************
GAO-08-207T

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

* [4]Other Evaluations Have Recommended Strengthening the Managem

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

* [6]VA and DOD Have Begun Deployment of a Modernized Data Interf
* [7]Short-Term Projects Are Allowing VA and DOD to Exchange Limi

* [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]Types of Data Shared by DOD and VA Are Growing but Remain Li
* [12]Special Procedures Provide Information to VA Polytrauma Cent

* [13]Contacts and Acknowledgments
* [14]GAO's Mission
* [15]Obtaining Copies of GAO Reports and Testimony

* [16]Order by Mail or Phone

* [17]To Report Fraud, Waste, and Abuse in Federal Programs
* [18]Congressional Relations
* [19]Public Affairs

Testimony

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

United States Government Accountability Office

GAO

For Release on Delivery
Expected at 10:00 a.m. EDT
Wednesday, October 24, 2007

INFORMATION TECHNOLOGY

VA and DOD Continue to Expand Sharing of Medical Information, but Still
Lack Comprehensive Electronic Medical Records

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

GAO-08-207T

Mr. Chairman and Members of the Subcommittee:

I am pleased to be a part of today's continuing dialogue on efforts by the
Department of Veterans Affairs (VA) and the Department of Defense (DOD) to
share electronic medical information. Over most of the past decade, the
departments have been pursuing initiatives to share electronic medical
information to help ensure that active-duty military personnel and
veterans receive high-quality health care. The departments' efforts have
included working towards a long-term vision of a single "comprehensive,
lifelong medical record"^1 that would allow each service member to
transition seamlessly between the two departments, as well as more
short-term efforts focused on meeting immediate needs to exchange health
information, including responding to current military crises.

Since 2001, we have reported or testified numerous times on the various
initiatives undertaken by the departments to develop the capability to
share health information. Our last testimony before this Subcommittee on
May 8, 2007, highlighted key projects that the departments have pursued in
this regard and the progress of their activities.^2 At your request, my
statement today further discusses the history and current status of the
departments' efforts.

The information in my testimony is based largely on our previous work in
this area. To describe the history and current status of the departments'
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. We conducted our
work in support of this testimony during October 2007 in the Washington,
D.C., area. Information on costs that have been incurred for the various
projects was provided by responsible officials at each department. 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.

^1In 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."

^2GAO, Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Are Far from Comprehensive Electronic Medical
Records, [20]GAO-07-852T (Washington, D.C.: May 8, 2007).

Results in Brief

VA and DOD have been pursuing initiatives to share data between their
health information systems and create comprehensive electronic medical
records since 1998, following a 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 in project planning and management, leading to
repeated changes in the focus of their initiatives and target completion
dates. In prior reviews of their efforts, we noted management weaknesses
such as inadequate accountability and poor planning and oversight and made
recommendations for improvement, including the development of a
comprehensive and coordinated project management plan that defines the
technical and managerial processes necessary to satisfy project
requirements and to guide their activities. In response, by July 2002, VA
and DOD revised their strategy, refocusing the project and dividing it
into long-term and short-term initiatives. For the long term, both
departments are modernizing their health information systems to replace
their existing (legacy) systems and enable the new systems to share data
and, ultimately, to have interoperable^3 electronic medical records.
Unlike the legacy systems, the modernized systems are to be based on
computable data--data that can be automatically processed in a healthcare
system to, for example, provide alerts to clinicians on drug allergies, or
to plot graphs of changes in vital signs such as blood pressure. For the
short-term initiative, the departments focused on sharing information in
existing systems.

VA and DOD have made progress in both their long-term and short-term
initiatives, but much work remains to achieve the goal of interoperable
electronic medical records and a 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. Regarding
their short-term projects to share information in existing systems, the
departments completed the Federal Health Information Exchange in 2004, and
as of this month reported transferring clinical data on more than 4
million veterans. In addition, they have made progress on two
demonstration projects: (1) the Laboratory Data Sharing Interface,
deployed at 9 localities, allows the departments 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 certain
outpatient health data from existing systems^4 at all VA and DOD sites,
and certain inpatient discharge summary data^5 at all VA sites and 13
large DOD sites. Further, 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 severe traumatic brain injuries
or 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, which are
generally feasible only because the number of polytrauma patients is small
(according to VA officials, about 460 with traumatic brain injuries to
date).

^3Interoperability is the ability of two or more systems or components to
exchange information and to use the information that has been exchanged.

Through all of these efforts, VA and DOD are exchanging health
information. However, these exchanges have been limited, and it is not yet
clear how they are to be integrated into an overall strategy to reach the
departments' long-term goal of a comprehensive, seamless exchange of
health information. Accordingly, as we have previously recommended, it
remains critical for the departments to develop a comprehensive project
plan that can guide their efforts to completion.

Background

In their efforts to modernize their health information systems and share
medical information, VA and DOD start from different positions. As shown
in table 1, VA has one integrated medical information system--the Veterans
Health Information Systems and Technology Architecture (VistA)--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.)

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

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

Table 1: VA Medical Information Systems and Data Base

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 (table 2
illustrates certain selected systems). 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.

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

Table 2: Selected DOD Medical Information Systems and Data Bases

System name Description
Legacy systems
CHCS Composite Health Care System Primary existing DOD health information
system
CIS Clinical Information System Commercial health information system
customized for DOD; used by some DOD
facilities for inpatients
ICDB Integrated Clinical Database Health information system used by many
Air Force facilities
TMDS Theater Medical Data Store Database to collect electronic medical
information in combat theater for both
outpatient care and serious injuries
JPTA Joint Patient Tracking Web-based application primarily used to
Application track 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.

aFormerly CHCS II.

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

For nearly a decade, VA and DOD have been undertaking initiatives to
exchange data between their health information systems and create
comprehensive electronic records.^7 However, the departments have faced
considerable challenges in project planning and management, leading to
repeated changes in the focus and target completion dates of the
initiatives.

As shown in figure 1, the departments' efforts have involved both
long-term initiatives to modernize their health information systems^8 and
short-term initiatives to respond to more immediate information-sharing
needs.

^7Initially, the Indian Health Service (IHS) was also a party to this
effort, having been included because of its population-based research
expertise and its longstanding relationship with VA. However, IHS was not
included in a later revised strategy for electronically sharing patient
health information.

^8DOD began efforts to modernize its existing health information system
(CHCS) in 1997 and VA began efforts to modernize its existing health
information system (VistA) in 2001.

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

The departments' first initiative was the Government Computer-Based
Patient Record (GCPR) project, which aimed to develop an electronic
interface that would allow physicians and other authorized users at VA and
DOD health facilities to 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.

We reviewed the GCPR project in 2001 and 2002, noting disappointing
progress exacerbated in large part by inadequate accountability and poor
planning and oversight, which raised questions about the departments'
abilities 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.^9 In both years, we recommended
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, by July 2002, the two departments had revised their strategy,
refocusing the project and dividing it into two initiatives. A short-term
initiative, the Federal Health Information Exchange (FHIE), was to enable
DOD to electronically transfer service members' health information to VA
when the members left active duty. VA was designated as the lead entity
for implementing FHIE, which was completed in 2004. A longer-term
initiative was to develop a common health information architecture that
would allow a 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 Composite Health Care System II and VA's HealtheVet VistA, were
already in development, as shown in the figure).^10 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.^11

In March 2004, the departments began to develop the CHDR interface. They
planned to begin implementation by October 2005;^12 however,
implementation of the first release of the interface (at one site)
occurred in September 2006, almost a year beyond the target date. In a
report in June 2004,^13 we identified a number of management weaknesses
that could have contributed to this delay and made a number of
recommendations, including creation of a comprehensive and coordinated
project management plan. The departments agreed with our recommendations
and took steps to improve the management of the CHDR initiative,
designating a lead entity with final decision-making authority and
establishing a project management structure. However, as we noted in
subsequent testimony,^14 the initiative did not have a detailed project
management plan that described 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.

^9GAO, Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results, [21]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,
[22]GAO-01-459 (Washington, D.C.: Apr. 30, 2001).

^10DOD'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.

^11The name CHDR, pronounced "cheddar," combines the names of the two
repositories.

^12December 2004 VA and DOD Joint Strategic Plan.

In October 2004, responding to a congressional mandate,^15 the departments
established two more short-term initiatives: 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 giving both departments' clinicians access to records on shared
patients (that is, those who receive care from both departments).^16 As
demonstration projects, these initiatives were limited in scope, with the
intention of providing interim solutions to the departments' needs for
more immediate health information sharing. However, because BHIE provided
access to up-to-date information, the departments' clinicians expressed
strong interest in expanding its use. As a result, the departments began
planning to broaden this capability and expand its implementation
considerably. Extending BHIE connectivity could provide each department
with access to most data in the other's legacy systems, until such time as
the departments' modernized systems are fully developed and implemented.
According to a VA/DOD annual report^17 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.

^13GAO, Computer-Based Patient Records: VA and DOD Efforts to Exchange
Health Data Could Benefit from Improved Planning and Project Management,
[23]GAO-04-687 (Washington, D.C.: June 7, 2004).

^14GAO, Computer-Based Patient Records: VA and DOD Made Progress, but Much
Work Remains to Fully Share Medical Information, [24]GAO-05-1051T
(Washington, D.C.: Sept. 28, 2005) and Information Technology: VA and DOD
Face Challenges in Completing Key Efforts, [25]GAO-06-905T (Washington,
D.C.: June 22, 2006).

^15The Bob Stump National Defense Authorization Act for Fiscal Year 2003
(Pub. L. No.107-314, S 721, 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.

^16To 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.

The departments' reported costs for the various sharing initiatives and
the modernization of their health information systems through fiscal year
2007 are shown in table 3.

Table 3: Reported Costs of VA and DOD Initiatives since inception

Project VA expenditure DOD expenditure
HealtheVet VistA $681.7 million through FY --
2006
AHLTA -- $954.3 million through FY
2007 (estimated)
Joint initiatives:
CHDR 4.1 million DOD does not account for
FHIE 65.5 million these projects separately.
LDSI 2.8 million
BHIE 6.3 million
Total $78.7 million $89.7 million though FY 2007

Source: VA and DOD data.

Beyond these initiatives, in January 2007, the departments announced a
further change to their information-sharing strategy: their intention to
jointly develop a new inpatient medical record system. On July 31, 2007,
they awarded a contract for a feasibility study.^18 According to the
departments, adopting this joint solution is expected to facilitate the
seamless transition of active-duty service members to veteran status, and
make inpatient health care data on shared patients immediately accessible
to both DOD and VA. In addition, the departments believe that a joint
development effort could enable them to realize significant cost savings.
We have not evaluated the departments' plans or strategy for this new
system.

^17December 2004 VA and DOD Joint Strategic Plan.

^18The contract is for a 6-month base period, with a follow-on 6-month
option period. The cost for the 6-month base period is about $2 million.

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

Throughout the history of these initiatives, evaluations besides our own
have found deficiencies in the departments' efforts, especially with
regard to the lack of comprehensive planning. For example, a recent
presidential task force identified the need for VA and DOD to improve
their long-term planning.^19 This task force, reporting on gaps in
services provided to returning veterans, noted problems in sharing
information on wounded service members, including the inability of VA
providers to access paper DOD inpatient health records. The task force
stated that although significant progress has been made towards sharing
electronic information, more needs to be done, and recommended that VA and
DOD continue to identify long-term initiatives and define the scope and
elements of a joint inpatient electronic health record. In addition, in
fiscal year 2006, Congress did not provide all the funding requested for
HealtheVet VistA because it did not consider that the funding had been
adequately justified.

VA and DOD Are Exchanging Limited Medical Information, but a Seamlessly Shared
Medical Record Will Require Much More Work

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
modernize their health information systems, the departments have begun,
among other things, to implement the first release of the interface
between their modernized data repositories. The departments have also made
progress in their short-term projects to share information in existing
systems, having completed two initiatives, and are making important
progress on another. In addition, the 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 reach the goal of a shared electronic medical record are
substantial.

^19Task 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.^20 In addition, they have now implemented
the first release of the CHDR interface. According to the departments'
officials, all DOD sites can now access the interface, and it is expected
to be available across VA when necessary software updates are released.
(Currently 103 of 128 VA sites have received these updates.)^21 At 7
sites, VA and DOD are now exchanging limited medical information for
shared patients: specifically, computable outpatient pharmacy and drug
allergy information.

CHDR is the conduit for exchanging computable medical information between
the departments. Data transmitted via the interface are permanently stored
in each department's new data repository, 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). The
departments' plans call for further developing the capability to exchange
computable laboratory results data through the interface during fiscal
year 2008.

Although implementing this interface is an important accomplishment, the
departments are still a long way from completing the modernized health
information systems and comprehensive longitudinal health records. While
DOD and VA had originally projected completion dates of 2011 and 2012,
respectively, for their modernized systems, the departments' officials
told us that there is currently no scheduled completion date for either
system. VA is evaluating a proposal that would result in completion of its
system in 2015; DOD is evaluating the impact of the new study on a joint
inpatient medical record and has not indicated a new completion date.

Further, both departments have still to identify the next types of data to
be stored in the repositories. The departments will then have to populate
the repositories with the standardized data. This involves different tasks
for each department. Specifically, while VA's medical records are already
electronic, it must still convert them 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.^22
The report also identified inaccurate and incomplete health data as a
problem to be addressed. Before the departments can achieve the long-term
goal of seamless sharing of medical information, all of these tasks and
challenges will have to be addressed. Accordingly, it is essential that
the departments develop a comprehensive project plan to guide these
efforts to completion, as we have previously recommended.

^20DOD 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; in July, the
department added chemistry and hematology, and in September, microbiology.

^21The Remote Data Interoperability software upgrade provides the
capability for the automated checks and alerts allowed by computable data.

Short-Term Projects Are Allowing VA and DOD to Exchange Limited Health
Information

In addition to the long-term effort previously described, the two
departments have made some progress in meeting immediate needs to share
information in their respective legacy systems through short-term projects
which, as mentioned earlier, are in various stages of completion. They
have also set up special processes to transfer data from DOD facilities to
VA's polytrauma centers in a further effort to more effectively 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 DOD officials, 194 million clinical messages on more than 4
million veterans had been transferred to the FHIE data repository as of
September 2007, including 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 September
2007, VA had access to data for more than 793,000 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. According to a
joint VA/DOD report,^23 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.

^22Inspector General, Army, Army Physical Disability Evaluation System
Inspection (March 2007).

^23December 2004,VA and DOD Joint Strategic Plan.

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, at one of the nine locations, anatomic pathology and
microbiology tests.

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 the LDSI interface, 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.

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

Developed under a second demonstration project, the BHIE interface permits
a medical care provider to query selected health information on patients
from all VA and DOD sites and to view that data onscreen almost
immediately. It not only allows the two departments to view each other's
information, but it also allows DOD sites to see previously inaccessible
data at other DOD sites.

VA and DOD have been making progress on expanding the BHIE interface. As
initially developed, the interface provided access to information in VA's
VistA and DOD's Composite Health Care System, but it is currently being
expanded to query data in other DOD systems and databases. In particular,
the interface has been expanded to DOD's:

o Modernized data repository, CDR, which has enabled
department-wide access to outpatient data for pharmacy and
inpatient and outpatient allergy, radiology, chemistry, and
hematology data since July 2007, and to microbiology data since
September 2007.
o Clinical Information System (CIS), an inpatient system used by
some DOD facilities; the interface enables bidirectional views of
discharge summaries and is currently deployed at 13 large DOD
sites.
o Theater Medical Data Store, which became operational in October
2007, enabling access to inpatient and outpatient clinical
information from combat theaters.

The departments are also taking steps to make more data elements
available through BHIE. VA and DOD staff told us that by the end
of the first quarter of 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, a VA/DOD demonstration site in El
Paso began sharing radiological images between the VA and DOD
facilities in September 2007 using the BHIE/FHIE
infrastructure.^24

^24To create BHIE, the departments drew on the architecture and framework
of the information transfer system established by the FHIE project.

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

Although VA and DOD are sharing various types of health data, the
type of data being shared has been limited and significant work
remains to expand the data shared and integrate the various
initiatives. Table 4 summarizes the types of health data currently
shared via the long- and short-term initiatives we have described,
as well as additional types of data that are currently planned for
sharing. 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
the health information systems at VA and DOD.

Table 4: 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, hematology
and microbiology at 2
localities)
BHIE Outpatient pharmacy Provider notes Data are not
data transferred but can
Procedures be viewed.
Drug and food allergy
information Problem lists

Surgical pathology Vital signs
reports
Scanned images and
Microbiology results documents

Cytology reports Family history

Chemistry and Social history
hematology reports
Other history
Laboratory orders questionnaires

Radiology text reports Radiology images

Inpatient discharge
summaries and/or
emergency room notes
from CIS at 13 DOD and
all VA sites

Source: GAO analysis of VA and DOD data.

Special Procedures Provide Information to VA Polytrauma Centers

In addition to the information technology initiatives described, DOD and
VA have set up special procedures to transfer medical information to VA's
four polytrauma centers, which treat active duty service members and
veterans severely wounded in combat.^25 Some examples of polytrauma
include traumatic brain injury, amputations, and loss of hearing or
vision.^26

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.^27

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. According to DOD officials, when patients are
referred to VA for care, DOD sends copies of medical records documenting
treatment provided by the referring DOD facility along with them. The DOD
medical information is currently collected in several different systems:

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. As mentioned earlier, the BHIE
interface to this database became operational in October.
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. DOD officials told us that the paper record is the
official DOD medical record, although AHLTA is used extensively to
provide outpatient encounter information for medical records
purposes.

3. At the DOD treatment facility (Walter Reed, Bethesda, or
Brooke), additional inpatient information is recorded in CIS and
outpatient pharmacy and drug information are 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:

^25In particular, clinicians require access to discharge notices, which
describe the treatment given at previous medical facilities and the status
of patients when they left those facilities.

^26Polytrauma 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 result in physical, cognitive,
psychological, or psychosocial impairments and functional disability.

^27The four Polytrauma Rehabilitation Centers are in Richmond, Virginia;
Tampa, Florida; Minneapolis, Minnesota; and Palo Alto, California.

o 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.
o Staff at Walter Reed, Brooke, and Bethesda medical centers
collect paper records, print records from CIS, scan all these, and
transmit the scanned data to the four polytrauma centers. DOD
staff pointed out that this laborious process is feasible only
because the number of polytrauma patients is small. According to
VA officials, 460 severe traumatic brain injury patients had been
treated at the polytrauma centers through fiscal year 2007.
According to DOD officials, the medical records for 81 patients
planned for transfer or already at a VA polytrauma center were
scanned and provided to VA between April 1 and October 11 of this
year. Digital radiology images were also provided for 48 patients.
o Staff at Walter Reed and Bethesda are transmitting radiology
images electronically to the four polytrauma centers. 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.
o VA has access to outpatient data (via BHIE) from all DOD sites,
including Landstuhl.

These special efforts to transfer medical information on seriously
wounded patients represent important additional steps to
facilitate the sharing of information that is vital to providing
polytrauma patients with quality health care.

In summary, VA and DOD are exchanging health information via their
long- and short-term initiatives and continue to expand sharing of
medical information via BHIE. However, these exchanges have been
limited, and significant work remains to fully achieve the goal of
exchanging interoperable, computable data. Work still to be done
includes 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
this work and achieve the departments' ultimate goal of a
maintaining a lifelong electronic medical record that will follow
service members as they transition from active to veteran status,
a comprehensive and coordinated project management plan that
defines the technical and managerial processes necessary to
satisfy project requirements and to guide their activities
continues to be of vital importance. We have previously
recommended that the departments develop such a plan and that it
include a work breakdown structure and schedule for all
development, testing, and implementation tasks. Without such a
detailed plan, 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 a
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
[26]melvinv@gao.gov . Other individuals who made key contributions
to this testimony are Barbara Oliver (Assistant Director), Nancy
Glover, Glenn Spiegel, and Amos Tevelow.

Related GAO Products

Computer-Based Patient Records: Better Planning and Oversight by
VA, DOD, and IHS Would Enhance Health Data Sharing. [27]GAO-01-459
. Washington, D.C.: April 30, 2001.

Veterans Affairs: Sustained Management Attention Is Key to
Achieving Information Technology Results. [28]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. [29]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. [30]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. [31]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. [32]GAO-05-1051T
. Washington, D.C.: September 28, 2005.

Information Technology: VA and DOD Face Challenges in Completing
Key Efforts. [33]GAO-06-905T . Washington, D.C.: June 22, 2006.

DOD and VA Exchange of Computable Pharmacy Data. [34]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, [35]GAO-07-852T . Washington, D.C.: May 8, 2007.

Information Technology: VA and DOD Are Making Progress in Sharing
Medical Information, but Remain Far from Having Comprehensive
Electronic Medical Records, [36]GAO-07-1108T . Washington, D.C.:
July 18, 2007.

GAO's Mission

The Government Accountability Office, the audit, evaluation, and
investigative arm of Congress, exists to support Congress in
meeting its constitutional responsibilities and to help improve
the performance and accountability of the federal government for
the American people. GAO examines the use of public funds;
evaluates federal programs and policies; and provides analyses,
recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO's
commitment to good government is reflected in its core values of
accountability, integrity, and reliability.

Obtaining Copies of GAO Reports and Testimony

The fastest and easiest way to obtain copies of GAO documents at
no cost is through GAO's Web site ( [37]www.gao.gov ). Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of
newly posted products every afternoon, go to [38]www.gao.gov and
select "E-mail Updates."

Order by Mail or Phone

The first copy of each printed report is free. Additional copies
are $2 each. A check or money order should be made out to the
Superintendent of Documents. GAO also accepts VISA and Mastercard.
Orders for 100 or more copies mailed to a single address are
discounted 25 percent. Orders should be sent to:

U.S. Government Accountability Office 441 G Street NW, Room LM
Washington, DC 20548

To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax:
(202) 512-6061

To Report Fraud, Waste, and Abuse in Federal Programs

Contact:

Web site: [39]www.gao.gov/fraudnet/fraudnet.htm E-mail:
[40]fraudnet@gao.gov Automated answering system: (800) 424-5454 or
(202) 512-7470

Congressional Relations

Gloria Jarmon, Managing Director, [41]JarmonG@gao.gov , (202)
512-4400 U.S. Government Accountability Office, 441 G Street NW,
Room 7125 Washington, DC 20548

Public Affairs

Susan Becker, Acting Manager, [42]BeckerS@gao.gov , (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548

(310912)

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

[43]www.gao.gov/cgi-bin/getrpt?GAO-08-207T .

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
melvinv@gao.gov.

Highlights of [44]GAO-08-207T , a testimony before the Subcommittee on
Oversight and Investigations, Committee on Veterans' Affairs, House of
Representatives

October 24, 2007

INFORMATION TECHNOLOGY

VA and DOD Continue to Expand Sharing of Medical Information, but Still
Lack Comprehensive Electronic Medical Records

GAO was asked to testify on the history and current status of the
departments' efforts to share health information. To develop this
testimony, GAO reviewed its previous work, analyzed documents about
current status and future plans and interviewed VA and DOD officials.

[45]What GAO Recommends

GAO has previously made several recommendations on this topic, including
that VA and DOD develop a detailed project management plan to guide their
efforts to share patient health data. While the departments agreed with
these recommendations, a comprehensive overall strategy that incorporates
all of the ongoing activities still needs to be implemented.

For almost a decade, VA and DOD have been pursuing ways to share health
information and to 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
completion dates. 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, which builds 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 expanding the sharing of additional medical information by using
this interface to link other systems and databases. 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. While these
multiple initiatives and ad hoc processes have facilitated degrees of data
sharing, they nonetheless highlight the need for continued efforts to
integrate information systems and automate information exchange. At
present, 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.

References

Visible links
1. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_268
2. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_275
3. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_290
4. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_319
5. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_323
6. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_624
7. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_334
8. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_339
9. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_343
10. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_347
11. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_580
12. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_360
13. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_1119
14. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_1154
15. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_1135
16. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_1136
17. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_1139
18. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_1141
19. file:///home/webmaster/infomgt/d08207t.htm#LinkTarget_257
20. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-07-852T
21. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-02-703
22. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-01-459
23. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-04-687
24. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-05-1051T
25. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-06-905T
26. file:///home/webmaster/infomgt/d08207t.htm#mailto:melvinv@gao.gov
27. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-01-459
28. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-02-703
29. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-04-271T
30. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-04-402T
31. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-04-687
32. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-05-1051T
33. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-06-905T
34. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-07-554R
35. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-07-852T
36. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-07-1108T
37. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/
38. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/
39. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/fraudnet/fraudnet.htm
40. file:///home/webmaster/infomgt/d08207t.htm#mailto:fraudnet@gao.gov
41. file:///home/webmaster/infomgt/d08207t.htm#mailto:JarmonG@gao.gov
42. file:///home/webmaster/infomgt/d08207t.htm#mailto:BeckerS@gao.gov
43. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-08-207T
44. file:///home/webmaster/infomgt/d08207t.htm#http://www.gao.gov/cgi-bin/getrpt?GAO-08-207T
*** End of document. ***